Posted: November 1st, 2015

List the strategies of health promotion as outlined in the Ottawa Charter and provide an example of each of the strategies.

Assignment 5: Scholarly Paper – Strategies for Community Health Promotion | Value 30%
Due Date: Negotiable, however, it is recommended that you work through both Sections I and II, prior to completing work on this assignment.

Purpose

The purpose of this assignment is to provide the student with an opportunity to develop a health promotion program and relate strategies of community planning, implementation and evaluation to the community diagnosis identified in Assignment 2. Please note you are not expected to carry out the health promotion program that you develop.

Choose one of the following to complete this assignment:

Based on the community diagnosis you developed in Assignment 2, (a) develop an outline for a program to meet the identified need, including goals and objectives, and (b) compare and contrast the strengths and limitations of two approaches for influencing community change in the direction of health which would be appropriate in developing the proposed program (e.g., behavioral / lifestyle, socio-environmental approach) and which need to be considered in the planning, implementation and evaluation of the program. Discuss the role of the community health nurse related to each of the approaches and in relation to the planned program.

Or

Based on the community diagnosis you developed in Assignment 2, (a) develop an outline for a program to meet the identified need and (b) develop a proposal for obtaining funding for the program. The proposal should include goals and objectives for the proposed program; a description of the target aggregate/group; rationale for the approach to be utilized (e.g., behavioral / lifestyle, socio-environmental approach); a description of the “players” who will be involved in program planning, implementation and evaluation and their roles: proposed evaluation strategies; and, a budget for the program.

Marking Criteria

All aspects of the assignment as outlined are clearly addressed.

Critical analysis and synthesis of ideas is evident.

Ideas are develop logically and presented in an organized, clear, and concise manner.

Paper will build on course content and will reflect use of resources beyond those included in the course study guide.

APA (6th. ed.) scholarly format – limit of 12 pages (excluding title and reference pages).
Submitting Your Assignment
When you have completed this assignment, send it to your tutor for marking. Always retain a copy of your assignment for your files.
Click the “Browse” button to find your assignment and then “Upload” to move it into Moodle. If you make a mistake, you can delete the uploaded file by clicking the red X next to the file name.

Then, add a note if needed and click the “Submit for Marking” button to send it to your instructor.
Course Textbooks
Stamler, L. L., & Yiu. L. (Eds.). (2012). Community health nursing: A Canadian perspective (3nd ed.). Toronto: Pearson/Prentice Hall.
Vollman, A. R., Anderson, E. T., & McFarlane, J. (2012). Canadian community as partner: Theory and practice in nursing (3nd ed.). Philadelphia: Wolters Kluwer | Lippincott Williams & Wilkins.
References
Butterfield, P.G. (2002). Upstream reflections on environmental health: An abbreviated history and framework for action [Electronic version]. ANS, 25(1), 32-50.
College & Association of Registered Nurses of Alberta. (2008, September). Primary health care. Retrieved fromhttp://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Guidelines/PrimaryHealthCare_Sep2008.pdf
Community Health Nurses Association of Canada. (2011). Community health nursing standards of practice. Retrieved http://www.chnc.ca
Hamilton, N., & Bhatti, T. (1996, February). Population health promotion: An integrated model of population health and health promotion.Retrieved May 31, 2005, from Public Health Agency of Canada Web site: http://www.phac-aspc.gc.ca
Jonas, S. (2003). Talking about health and wellness with patients: Integrating health promotion and disease prevention in your practice.Retrieved May 31, 2005 from http://www.americanhealthandhealing.com/Pages/JONASchap102.html
Ontario Health Promotion Resource System. (n.d.). HP-101 Health promotion on-line course. Retrieved July 12, 2005 from
http://www.ohprs.ca/hp101/main.htm
Public Health Agency of Canada. (1986). Ottawa charter for health promotion: An international conference on health promotion. Retrieved May 03, 2005 from http://www.phac-aspc.gc.ca/
Public Health Agency of Canada. (2002). What is the population health approach? Retrieved May 31, 2005 from
http://www.phac-aspc.gc.ca/
Statistics Canada. (n.d.). Health status, well-being and satisfaction. Retrieved May 31, 2005 fromhttp://www.statcan.ca/english/concepts/definitions/health.htm
World Health Organization: Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Retrieved November 19, 2007 fromhttp://www.who.int/suggestions/faq/en/
Young, L. E., & Wharf Higgins, J. (2008).Concepts of health. In L. L. Stamler & L. Yui (Eds.). Community health nursing: A Canadian perspective (2nd ed.). (pp. 80 – 92). Toronto : Pearson/Prentice Hall.

COURSE CONTENT
Section 1: Concepts Basic to Community Health Nursing
The concepts addressed in Section 1, Units 1, 2, 3, and 4 may represent new material for some learners while being a review for others. Whether new learning or review, it is important to develop or increase one’s understanding of the concepts that form the foundations of community health nursing in order to apply the concepts to community health nursing practice. A quiz, comprising 20% of the overall course composite grade, occurs upon completion of Section 1.
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Learning Outcomes | Focusing | Practicing | Activity 1 | Activity 2 | Activity 3 | Activity 4 | Reflecting | References
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Unit 1: Community Health Nursing
“Key to all community practice is the principle of “doing with” not “to” or “for” the people served”
(Vollman, Anderson, & McFarlane, 2012, p. 3).
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Learning Outcomes
By completing this unit, you will be able to
• discuss the historical underpinnings of community health nursing.
• describe the various roles of the community health nurse in relation to the focus of client.
• identify current health care issues and trends of particular importance to community health nurses.
• discuss the role of professional associations in relation to community health nursing.
• identify the ethical issues particular to community health nursing.
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Focusing
Where do community health nurses work? What are the values and beliefs of community health nurses? What do community health nurses do?
Take a few moments to write your answers to these questions in your course notes. There are no incorrect responses; just list your ideas.
You may wish to consult the website at www.chnac.ca to determine how similar or different your ideas are to those outlined by the Community Health Nurses Association of Canada (2003).
The Community Health Nursing Standards of Practice (2003) are also found as an Appendix in the Stamler and Yiu (2012) text. You will be directed to consult these standards of practice often as you work through this course.
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Practicing
Activity 1: Who is the Community Health Nurse?
List the major differences between the CARNA Standards of Practice (2013) located at Practice Standards for Regulated Members with CNA Code of Ethics for Registered Nurses
http://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Standards/PracticeStandards_CNA_Ethics_2008.pdf
and the Canadian Community Health Nursing Standards of Practice (2011) located at http://www.chnc.ca/documents/CHNC-ProfessionalPracticeModel-EN/index.html
Discuss one example of how nursing practice might differ depending on which standards are being utilized to guide nursing practice. If you like, record your thoughts in your course notes, or post your ideas to the Unit 1 Conference. Feel free to read the postings of other learners and engage in discussion with your peers who have posted their ideas to the Conference.
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Activity 2: Who is the client or recipient of care and what are the common settings of community health nursing practice?
Flash is required for this activity. Flash Player can be downloaded for free from www.adobe.com.
Try the flash cards exercise by clicking here.
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Activity 3: How is community health nursing affected by societal and health care trends?
Beyond consulting the course texts, you might find the following websites of interest:
http://www.von.ca/en/about/history.aspx Victorian Order of Nurses for Canada.
www.capnm.ca/core_competencies¬_standards_print.doc The Canadian Association for Parish Nursing Ministry
http://www.who.int/healthpromotion/en/ World Health Organization.
Test your knowledge of community health nursing history by completing the following statements. To see the answer, drag your mouse (hold the left button down as you move the mouse) over the blank space in the sentence between the arrows.
1) The best known, early community health nurses, called district or visiting nurses were the -> Victorian Order of Nurses (VON)<-, founded in 1897.
2) In 1948 the federal government, through a National Grant Program, matched provincial spending for designated health programs dollar for dollar. By 1957 the -> Hospital Insurance and Diagnostic Services Act <- was passed, and in 1968 the -> Medical Care Insurance Act<- made publicly funded medical care available to all Canadians. The emergence of publicly funded health care brought dramatic changes to the roles of district or visiting nurses.
3) Through 1950 to 1970, hospitals were built in abundance however, by the early 1970’s, it was becoming evident that increasing hospital costs would not be sustainable. The 1974, the -> Lalonde Report <- presented the first vision for health promotion services.
4) A landmark document entitled the -> Declaration of Alma Ata (WHO) <- arose from an International Conference on Primary Health Care in 1978.
5) As diagnostic and hospital costs continued to increase, extra-billing by physicians and user fees by provincial institutions posed a serious threat to Medicare. The -> Canada Health Act <- was passed in April 1984 and provided the federal government with the legal authority to penalize provinces that permitted practices such as extra-billing for insured services.
6) The Epp (1986) framework, entitled -> Achieving Health for All: A Framework for Health Promotion <- expanded on Lalonde’s work and formed the basis for the -> Ottawa Charter for Health Promotion (1986) <-.
7) More recent documents such as Hamilton and Bhatti’s (1996) -> Population Health Promotion Model <- have clearly influenced today’s community health nursing as evidenced by the Community Health Nursing Practice Model (2003).
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Activity 4: Do Community Health Nurses face different ethical issues?
In your course notes provide definitions for the following ethical principles. Drag your mouse below the term, between the arrows, to see the suggested response:
Beneficence
->Requires that potential benefits to individuals and to society be maximized, and that potential harms be minimized” (Coughlin, Soskolne, & Goodman [1997] as cited in Vollman et. al., 2004, p.107).<-
Nonmaleficence
->“Requires that harmful acts not be committed – Primum non nocere – first, do no harm” (Vollman et. al., 2004, p.107).<-
Justice
->“Requires the equitable distribution of potential benefits and burdens” (Vollman et.al., 2004, p. 107).<-
Autonomy
->“Is focused on the right of self-determination that grants importance to individual freedom” (Vollman et. al., 2004, p. 108).<-
Do you believe the nurse-client relationship is different for nurses who work in hospitals and for those who work in the community? Write your response with brief rationale in your course notes.
The following CARNA website may assist you in answering the preceding question and should be of interest to you. Go to Professional Boundaries for Registered Nurses: Guidelines for the Nurse-Client Relationship (May 2011) athttp://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Guidelines/RN_ProfessionalBoundaries_May2011.pdf
You might also find the following article by Jos, Perlmutteer, and Marshall (2003) Substance abuse during pregnancy: Clinical and public health approaches a stimulus for further thinking in relation to community health nursing practice.
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Reflecting
You likely will have noticed in your readings that nurses working in community settings do not all share the same title. Do you believe that there is a difference between community health nurses and public health nurses? If so, in what ways do you believe that they are different? You may choose to write your response in your course notes or initiate a discussion with your fellow learners in the Unit 1 Conference.
Drag your mouse between the arrows to see a hint: ->
Cradduck (2000) states,
Community health nursing is an art and a science that synthesizes knowledge from the public health sciences and professional nursing theories. Its goal is to promote and preserve the health of populations, and it is directed to communities, groups, families, and individuals across the lifespan, in a continuous rather than episodic process…
The terms community health nurse and public health nurse are used synonymously in many jurisdictions. [In this course] the terms will used interchangeably; whichever term is used, it refers to a nurse whose practice focuses on health promotion, illness and injury prevention, and community development, and who uses Primary Health Care as the vehicle for practice. (p. 354)
<-
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References
College and Association of Registered Nurses of Alberta. (2011). Professional boundaries for Registered Nurses: Guidelines for the nurse-client relationship. Retrieved fromhttp://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Guidelines/RN_ProfessionalBoundaries_May2011.pdf
College and Association of Registered Nurses of Alberta. (2013). Retrieved fromhttp://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Standards/PracticeStandards_CNA_Ethics_2008.pdf
Community Health Nurses Association of Canada. (2011). Community health nursing standards of practice. Retrieved May 02, 2005 fromhttp://www.chnc.ca/documents/CHNC-ProfessionalPracticeModel-EN/index.html
Cradduck, G. R. (2000). Primary health care practice. In M. J. Stewart (Ed.), Community nursing: Promotion Canadians’ health (pp. 352-369). Toronto : Saunders.
Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model of population health and health promotion. Retrieved from Public Health Agency of Canada Web site: http://www.phac-aspc.gc.ca/ph-sp/php-psp/index-eng.php
Health Canada – Health Care System – Health and Welfare Canada (1986). Achieving health for all: A framework for health promotion. Retrieved November 19, 2007 from Health Canada Web site: http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/1986-frame-plan-promotion/index_e.html
Parliament of Canada. (2005). The Canada Health Act : Overview and Options. Retrieved September 3, 2015, from fromhttp://www.parl.gc.ca/content/lop/researchpublications/944-e.pdf
Jos, P. H., Perlmutteer, M., & Marshall, M. H. (2003). Substance abuse during pregnancy: Clinical and public health approaches[Electronic Version]. The Journal of Law, Medicine & Ethics, 31(3), 340-350.
Lalonde, M. (1974). A new perspective on the health of Canadians: A working document. Retrieved May 03, 2005 from Public Health Agency of Canada Web site: http://www.phac-aspc.gc.ca/ph-sp/pube-pubf/perintrod-eng.php
Public Health Agency of Canada. (1986). Ottawa charter for health promotion: An international conference on health promotion.Retrieved May 03, 2005 from http://www.phac-aspc.gc.ca/ph-sp/docs/charter-chartre/index-eng.php
Stamler, L. L., & Yiu. L. (Eds.). (2012). Community health nursing: A Canadian perspective (3nd ed.). Toronto: Pearson/Prentice Hall.
The Canadian Association for Parish Nursing Ministry. (2004). Standards of practice parish nursing ministry. Retrieved May 02, 2005 from www.capnm.ca/core_competencies¬_standards_print.doc
Victorian Order of Nurses for Canada. (n.d.). A century of caring. Retrieved September 7, 2010 from http://www.von.ca/about/history.aspx
Vollman, A. R., Anderson, E. T., & McFarlane, J. (2012). Canadian community as partner: Theory and practice in nursing (3nd ed.). Philadelphia: Wolters Kluwer | Lippincott Williams & Wilkins.
World Health Organization. (1978). International conference on primary health care. Retrieved May 03, 2005 fromhttp://www.who.int/hpr/NPH/docs/declaration_almaata.pdf
World Health Organization. (2005). Retrieved July 10, 2005 from http://www.who.int/healthpromotion/en/
Section 1: Basic Concepts of Community Health Nursing
Unit 2: Theoretical Foundations
Fundamental to engaging in community health nursing is the capacity to incorporate the concepts of population health, primary health care and health promotion into one’s practice. Unit 2 is designed to facilitate analysis, understanding and development of meaningful ways to speak about concepts that are foundational to the role of the community health nurse.
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Learning Outcomes
By completing this unit, you will be able to
• articulate meanings of health, primary health care, health promotion, and population health.
• illustrate the associations and differences among health promotion, primary health care and population health.
• discuss the determinants of health.
• provide examples illustrating the principles of primary health care and the strategies of health promotion.
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Focusing
Consider the varying definition of health in a medical model versus a systems/health promotion model?

You may wish to write your response in your course notes or post your ideas to the Unit 2 Conference for discussion with your fellow students.
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Practicing
Activity 1: What is Health?
Using the search engine Google and the search term ‘definition+health’ will yield literally millions of related websites. A somewhat overwhelming result if one is seeking a succinct definition! Perhaps as Young and Wharf Higgins (2008) point out, defining health is not as important as determining “what it means to speak of health in a particular way” (p. 80).
Read about ‘health’ in the course texts and if you wish consult the following websites to determine elements that are common to discussions of health:
World Health Organization definition of health located at http://www.who.int/suggestions/faq/en/
Statistics Canada’s definition of health status located at http://www.statcan.ca/english/concepts/definitions/health.htm
Jonas (2003) offers a further view of health located at http://www.americanhealthandhealing.com/Pages/JONASchap102.html
Make a list in your course notes of the elements that appear in more than one of these discussions on health and develop a brief description of health means to you.
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Activity 2: What is Primary Health Care?
Read about primary health care (PHC) in the course texts and the CARNA (2008) document located athttp://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Guidelines/PrimaryHealthCare_Sep2008.pdf
Based on your readings, complete the following table. Printable version here (in Microsoft Word Doc format).
PHC Principles Example of Principle in Action Role of CHN
1.

2.

3. Health Promotion Prenatal program Develop & deliver program
4.

5.

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Activity 3: What is Health Promotion?
Health promotion is clearly one of the principles of primary health care, but what does it mean to use a community health promotion approach?
Consult the course texts and the 1986 Ottawa Charter for Health Promotion at http://www.phac-aspc.gc.ca/ph-sp/docs/charter-chartre/pdf/charter.pdf to answer the following questions. You may wish to make notes in your course notes.
1. What is the major difference between a behavioral and a socio-environmental approach to health promotion?
2. List the strategies of health promotion as outlined in the Ottawa Charter and provide an example of each of the strategies.
3. Explain in your own words the meaning of health determinants.
If you feel that you do not have a basic understanding of health promotion and would like to engage in further work, the Ontario Health Promotion Resource System offers an online health promotion course located at http://www.ohprs.ca/hp101/main.htm
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Activity 4: What is Population Health Promotion?
Consult the course texts, the following websites and the Butterfield article in completing the following activities in relation to population health promotion. You may wish to write your ideas in your course notes.
Public Health Agency of Canada located at http://www.phac-aspc.gc.ca/
Hamilton and Bhatti (1996) Population Health Promotion Model located http://www.phac-aspc.gc.ca (use web site search tool to find article).
Community Health Nurses Association of Canada located at http://www.chnc.ca
Butterfield (2002) Upstream reflections on environmental health: An abbreviated history and framework for action
1. Explain in your on words what is meant by ‘upstream thinking’ versus ‘downstream thinking’.
2. A mother arrives at the community health clinic where you work as a registered nurse to have her child immunized. As she enters your clinic room she mentions that she noticed a display on the wall referring to population health promotion and questions you as to what that means. How would you respond? Consider posting your response to the Unit 2 Conference for discussion with fellow students.
3. Compare the Hamilton and Bhatti (1996) Population Health Promotion Model to the Community Health Nurses Association of Canada (2003) Community Health Nursing Practice Model. What would you state is the most significant difference between the two? Consider posting your answer to the Unit 2 Conference for discussion.
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Virtual Preceptorship
Assignment 3: Application Exercise 1 – From Theory to Practice
This is the first of the three application exercises in this course. Please spend some time working through this exercise as it should provide you with a chance to utilize the theory you have learned in a practical way that you will take with you into your practice as a community health nurse.
NOTE: To complete this portion of Assignment 3 valued at 15% of your final grade, you need to complete Application Exercise 1 and then submit your work to your tutor.
Please review the Assessment page of the course before you submit your work to your tutor so that you are aware of how your work will be evaluated. Your tutor will be marking your assignment to see if you have summarized the key findings you discovered in completing the application exercise. Your work will achieve the maximum value/grade if it is succinct and insightful and clearly shows how you have applied the theory learned to a practical situation.
Integrating the Concepts of Population Health, Primary Health Care and Health Promotion
Hopefully, what you have learned in Units 1 and 2 has given you a beginning theoretical foundation and practical tools to use in the role of community health nurse. This application exercise is designed to assist you to use what you have learned in applying the concepts of population health, primary health care and health promotion.
You are the community health nurse in the following case study and your objective is to convince the manager of your community health unit to grant you dedicated nursing time to work with this community beyond your day-to-day community health nursing practice routine of working with families in immunization clinics and home visits.
First – read this short case study:
You are a community health nurse employed in a rural Alberta health unit. In your district, the unemployment rate is over 20%, and the incidence of small grocery store theft has increased markedly during the past year. During routine infant and preschool immunization clinics and home visits you have noted signs of fatigue, anemia, and susceptibility to respiratory infections in family members of all ages. In addition you have noticed that many of the parents that you see in their homes seem to be smoking more. During clinic and home visits, many parents express concern about the adequacy of the diet that they are able to provide, and say that the funding they receive from Social Services is insufficient to meet their families’ basic food needs. The largest urban centre where large discount food stores are available is a four-hour-drive away. Most families in the district do their grocery shopping at the local general stores, where prices are higher. Many of these families have large debts. The owners of these stores are unable to extend the credit lines of many of their customers much further, although they are sympathetic to the overall situation. The general tone within the district towards the employment and economic situation is pessimistic, although many parents do comment during clinic and home visits that they are still waiting for things to “turn around.”
Recently a small group of farmers and local businessmen expressed interest in developing a food bank, although no one has any experience in organizing one. The only condition that they have placed on their offer is that “needy families become directly involved in helping themselves and each other, and nobody just gets a free handout.” The provincial nutritionist, a good friend of yours, has indicated her support and is willing to be involved in consultation and teaching. (Adapted from Athabasca University NURS 436, 2000)
Second – Prepare one of the following for submission to your unit manager.
1. Develop a PowerPoint presentation – Using data supplied in the case study indicate how you, the community health nurse, would work with this community integrating the concepts of population health promotion, primary health care and health promotion. Offer to share your presentation with someone or a group in your network.
2. Develop a written proposal – Using data supplied in the case study outline how you, the community health nurse, would work with this community integrating the concepts of population health promotion, primary health care and health promotion. Offer to discuss your proposal with someone or a group in your network.
Submit your PowerPoint presentation or your written proposal to your tutor for marking via the Assignment Dropbox on the home page. (limit of 5 pages or 20 power point slides (excluding title and reference pages).
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Reflecting
Describe in your own words the difference between population health promotion, primary health care and primary care. You may find it beneficial to write your ideas in your course notes.
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References
Butterfield, P.G. (2002). Upstream reflections on environmental health: An abbreviated history and framework for action [Electronic version]. ANS, 25(1), 32-50.
College & Association of Registered Nurses of Alberta. (2008, September). Primary health care. Retrieved fromhttp://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Guidelines/PrimaryHealthCare_Sep2008.pdf
Community Health Nurses Association of Canada. (2011). Community health nursing standards of practice. Retrieved http://www.chnc.ca
Hamilton, N., & Bhatti, T. (1996, February). Population health promotion: An integrated model of population health and health promotion.Retrieved May 31, 2005, from Public Health Agency of Canada Web site: http://www.phac-aspc.gc.ca
Jonas, S. (2003). Talking about health and wellness with patients: Integrating health promotion and disease prevention in your practice.Retrieved May 31, 2005 from http://www.americanhealthandhealing.com/Pages/JONASchap102.html
Ontario Health Promotion Resource System. (n.d.). HP-101 Health promotion on-line course. Retrieved on September 3 fromhttp://www.ohprs.ca/hp101/about_ohprs.htm

Public Health Agency of Canada. (1986). Ottawa charter for health promotion: An international conference on health promotion. Retrieved May 03, 2005 from http://www.phac-aspc.gc.ca/
Public Health Agency of Canada. (2002). What is the population health approach? Retrieved May 31, 2005 from
http://www.phac-aspc.gc.ca/
Statistics Canada. (n.d.). Health status, well-being and satisfaction. Retrieved May 31, 2005 fromhttp://www.statcan.ca/english/concepts/definitions/health.htm
World Health Organization: Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Retrieved November 19, 2007 fromhttp://www.who.int/suggestions/faq/en/
Young, L. E., & Wharf Higgins, J. (2008).Concepts of health. In L. L. Stamler & L. Yui (Eds.). Community health nursing: A Canadian perspective (2nd ed.). (pp. 80 – 92). Toronto : Pearson/Prentice Hall.
Section 1: Basic Concepts of Community Health Nursing
Unit 3: Epidemiology
Community health nursing practice includes the assessment of patterns and trends of health and illness in the community. Unit 3 is designed to facilitate understanding and application of epidemiology concepts, while learning how data about health and illness patterns are generated and used by community health nurses.
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Learning Outcomes
By completing this unit, you will be able to:
• interpret and apply basic epidemiologic measures of community health.
• apply principles of epidemiology to community health nursing practice.
• explain how common epidemiology research study designs are utilized in community health nursing.
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Focusing
Examine the Canadian Community Health Nursing Standards of Practice (2011) located at http://www.chnc.ca/documents/CHNC-ProfessionalPracticeModel-EN/index.html and list in your course notes the epidemiology principles and strategies that community health nurses are expected to incorporate into their practice. Ask yourself are these concepts that you are familiar with? Do you utilize these concepts in your current nursing practice, if so briefly describe how.
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Practicing
Beyond consulting your course texts you might find the following Websites of interest as you complete the following learning activities.
http://www.pitt.edu/~super1/lecture/lec19061/index.htm (Songer, T., 2005, March)
http://www.pitt.edu/~super1/lecture/lec19071/index.htm (Songer, T., 2005, March)
http://www.pitt.edu/~super1/lecture/lec4211/index.htm (Wheeler, F. C., n.d.)
http://www.pitt.edu/~super1/lecture/lec4201/index.htm (Wheeler, F.C., n.d.)
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Activity 1: What is Epidemiology?
You may choose to write your responses in your course notes as you complete the following statements.
1. Epidemiology is the study of __________________.
2. The purposes of epidemiology are to ____________________.
3. The epidemiologic model is most often presented as a triangle consisting of host-agent-environment. Briefly describe what is meant by:
o Host
o Agent
o Environment
You may find the following report to be of interest
Spreading the Bird Flu; Tracking the Virus; Developing a Vaccine; The Flu Over Time
U.S. News & World Report (2005).
4. Complete the following (drag mouse at the end of each line to see the answer):
o An organism’s ability to invade and multiply in a susceptible host is known as
-> infectivity.<-
o An organism’s ability to induce disease in a susceptible host is known as
->pathogenicity.<-
o The severity or degree of the disease induced by an organism is known as
->virulence.<-
o An organism’s ability to induce specific immunity within the host is known as
->immunogencity.<-
5. Explain the difference between natural, acquired, active and passive immunity.
o Why is herd immunity an important concept in relation to community health?
6. The major difference between a host-agent-environment triad model and a web of causation model is _______________.
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Activity 2: Natural History of Disease
Complete the following table demonstrating the relationship between the natural history of disease and the levels of prevention (Primary, Secondary, Tertiary, Death <—> Recovery). Printable version (in Word doc format).
Stage in Natural History Level of Prevention
Pre-pathogenesis
Early pathogenesis with first clinical signs
Advanced disease
Outcome
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Activity 3: Measuring Health and Disease
Measurement of health and disease is required for:
• Preventing disease
• Promoting health
• Planning health services
The central tool of epidemiology is the comparison of rates that are expressed as fractions.
Rate = Numerator / Denominator
Consult your course texts and the Web sites listed at the beginning of this Practicing section in order to increase or develop your basic understanding of measurement in epidemiology. You may choose to make notes in your course notes.
1. Explain the difference between
a. mortality and morbidity rates and
b. incidence and prevalence in relation to disease process within a population?
2. Table 1 depicts the prevalence and incidence rates from disease “ZZ” per 1000 population from 1975 to 2005.
Table 1. Disease “ZZ” Prevalence and Incidence Rates by Year per 1000
Year Prevalence Rate
(per 1000) Incidence Rate
(per 1000)
1975 80 18
1985 79 10
1995 81 4
2005 83 1
Compare the changes in these rates. Suggest reasons that might explain the relative changes in rates.
Suggested Response
3. Assume that the prevalence rate (PR) of coronary heart disease decreases after age 75 years, while its incidence (IR) continues to increase with age. What is the most probable explanation of the divergence of these rates?
Suggested Response
4. Table 2 depicts death rates per year from lung cancer per 1000 for males aged 35 plus years.
Table 2. Death Rates per Year from Lung Cancer per 1000 for Males aged 35+ years
Death Rates per 1000 per year, Males 35+ years
Cigarette smokers 0.96
Non-smokers 0.07
From Table 2, calculate:
1. relative risk for smokers versus non-smokers
2. the attributable risk for smokers.
3. explain your answers to question 4 a) and b) in narrative form.
Suggested Response
5. How can relative risk calculations be used by a community health nurse?
Suggested Response
6. What are the uses of attributable risk to a community health nurse?
Suggested Response
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Activity 4: Surveillance and Screening
Consult your course texts and the following lecture on screening by Dr. Shawky located athttp://www.pitt.edu/~super1/lecture/lec4021/index.htm to complete one or both of the following exercises.
1. You are one of several community health nurses offering a blood pressure testing clinic during Seniors Day at the local mall. It has been previously determined that anyone who has a blood pressure reading of 140/90 or greater and is not currently being treated for hypertension will be referred for follow-up. You and the other community health nurses take blood pressure readings for 250 individuals. According to your results, 75 of the individuals tested are referred for follow-up. Of the 75 individuals identified, 30 require intervention. Calculate the sensitivity, specificity, positive and negative predictive value and explain what these mean. Based on the information from this screen test, would you continue to use it? Why or why not?
Hint: First complete the screening test results table, then do the calculations.
Disease Status Total
Present Absent
Test Positive True + False + Predictive +
Test Negative False – True – Predictive –
Total Sensitivity Specificity 250
Suggested Response
2. You are a community health nurse working in the early maternity discharge program. From your ongoing review of the literature, you obtained a checklist that could be used prior to discharge to identify new mothers who may require more than one home visit post discharge. You received ethical clearance to administer the checklist to 200 women prior to discharge and to the follow those women in the community. You had the staff nurses administer the checklist and a community health nurse visited all of the women within 24 hours of discharge, covering those topics specified by the early maternity discharge program for discussion during the first post-partum visit.
According to the checklist, 25 of the women would require more than 1 home visit following discharge. From the follow-up visits, you found that 20 of those identified by the checklist and 10 not identified by the checklist required extra home visits. Calculate the sensitivity, specificity, positive predictive value, and negative predictive value of the checklist and explain what these values mean.
Suggested Response
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Activity 5: Research in Epidemiology
Consult your course texts and the following web site http://www.pitt.edu/~super1/lecture/lec0571/index.htm (Pearson. R. J., n.d.) as well as the articles provided as examples of each design. Feel free to explore the journal databases through the Athabasca University online library and the MERLOT site located at http://www.pitt.edu/~super1/assist/keysearch.htm for further examples that may be of interest you.
As you read about each design work to understand the circumstances that dictate when a particular design is used, what the strengths and weaknesses are of the design, and how strong the design is in supporting causality. You may choose to make notes on each of the epidemiological research designs in your course notes.
An example that has no disease focus that may be of interest Education as a Determinant of Career Retention and Job Satisfaction Among Registered Nurses (Ramber, et al., 2005).
Case-Control example Escherichia Coli O157:H7 Outbreak; Escherichia coli O157:H7 outbreak associated with ground beef contamination (Medical Letter on the CDC & FDA, 2005)
Cohort Prospective example Pregnant Patients with Lupus Have High Rates of Fetal Loss (Barry, 2005)
Randomized Clinical Trial example Compliance and Satisfaction With Home Exercise: A Comparison of Computer-Assisted Video Instruction and Routine Rehabilitation Practice (Lysack, et al., 2005).
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Virtual Preceptorship
Assignment 4: Application Exercise 2 – From Theory to Practice
This is the second application exercise in this course. Please spend some time working through this exercise as it should provide you with a chance to utilize the theory you have learned in a practical way that you will take with you into your practice as a community health nurse.
NOTE: To complete this portion of Assignment 4 valued at 15% of your final grade, you need to complete Application Exercise 2 and then submit your work to your tutor. Please review the Assignment Overview before you submit your work to your tutor so that you are aware of how your work will be evaluated. Your tutor will be marking your assignment to see if you have summarized the key findings you discovered in doing the application exercise. Your work will achieve the maximum value/grade if it is succinct and insightful and clearly shows how you have applied the theory learned to a practical situation.
Integrating the Concepts of Epidemiology in Community Health Nursing Practice
Hopefully, what you have learned in Unit 3 has given you a beginning foundation and practical tools to use in the role of a community health nurse. This application exercise is designed to assist you to use what you have learned in applying epidemiology concepts.
First – read this short case study.
You are the community health nurse who is responsible for developing and teaching prenatal classes in your community health unit. Recently you have become aware that many women attending the prenatal classes are 30+ years in age and this is their first pregnancy. Further to this demographic fact, you have noticed that many of these women seem to be struggling with their commitment to their career and their desire to remain at home following the birth of their child. You are thinking about including a class to address this concern and begin to seek evidence to support your observations. You begin with a search of the literature.
Second – Read the following study Changes in Maternal Characteristics in Nova Scotia, Canada from 1988 to 2001 (Fell, et al., 2005).
Third – Develop a critique of this research study and submit to your tutor for marking.
Your critique should include, but is not limited to the following:
• What type of study design is it? Provide rationale.
• Are the findings reported consistent with information/knowledge that you have? Do the reported relationships make sense?
• If reported, how strong is the observed association?
• Would you incorporate the findings of this study into your community health nursing practice (i.e., the class that you are planning) or recommend this study to others? Provide rationale.
• What further research question(s) would you develop in relation to this study and/or your observations?
• APA (6th. ed.) scholarly format is required – limit of 5 pages (excluding title and reference pages)
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Reflecting
Refer to the Focusing section of this unit and the list you made of the epidemiology principles and strategies that community health nurses are expected to use, as put forth by the Canadian Community Health Nursing Standards of Practice (2013) located athttp://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Standards/PracticeStandards_CNA_Ethics_2008.pdf
Describe in your own words how using epidemiology principles and strategies relates to population health, primary health care and health promotion. Feel free to discuss your ideas with your fellow learners in the Unit 3 Conference.
You might enjoy reading Dr. Kavasarala’s lecture located at http://www.pitt.edu/~super1/lecture/lec18001/index.htm as your final learning activity in this unit.
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References
Barry, H. (2005). Pregnant patients with Lupus have high rates of fetal loss [Electronic version]. American Family Physician. 71(11), 2174.
College and Association of Registered Nurses of Alberta. (2013). Practice Standards for Regulated Members with CNA Code of Ethics for Registered Nurses Retrieved fromhttp://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Standards/PracticeStandards_CNA_Ethics_2008.pdf
Community Health Nurses Association of Canada. (2011). Community health nursing standards of practice. Retrieved May 02, 2005 fromhttp://www.chnc.ca/documents/CHNC-ProfessionalPracticeModel-EN/index.html
Fell, D. B., Joseph, K. S., Dodds, L., Allen, A. C., et al. (2005). Changes in maternal characteristics in Nova Scotia, Canada from 1988 to 2001 [Electronic version]. Canadian Journal of Public Health, 96(3), 234-239.
Kavasarala, A. K. (2004, December). Epidemiology- its perspectives and applications. Retrieved June 27, 2005 from MERLOT Supercourse: Epidemiology, the internet, and global health Web site: located at http://www.pitt.edu/~super1/lecture/lec18001/index.htm
Lindsay, J. R., Kennedy, L., Atkinson, A. B., Bell, P.M. et al. (2005). Reduced prevalence of limited joint mobility in Type 1 Diabetes in a U.K. clinic population over a 20-year period [Electronic version]. Diabetes Care, 28(3), 658-662.
Lysack, C., Dama, M., Neufeld, S., & Andreassi, E. (2005). Compliance and satisfaction with home exercise: A comparison of computer-assisted video instruction and routine rehabilitation practice [Electronic version]. Journal of Allied Health, 34(2), 76-83.
Medical Letter on CDC & FDA, Atlanta. (2005, July 03). Escherichia Coli O157:H7 outbreak; Escherichia coli O157:H7 outbreak associated with ground beef contamination [Electronic version].
Pearson, R. J. (n.d.). Different kinds of epidemiologic studies. Retrieved June 27, 2005 from MERLOT Supercourse: Epidemiology, internet, and global health Web site: located at http://www.pitt.edu/~super1/lecture/lec0571/index.htm.
Rambur, B., McIntosh, B., Val Palumbo, M., & Reinier, K. (2005). Education as a determinant of career retention and job satisfaction among Registered Nurses [Electronic version]. Journal of Nursing Scholarship, 37(2), 185-193.
Shawky, S. (n.d.). Screening. Retrieved June 27, 2005 from MERLOT Supercourse: Epidemiology, the internet, and global health Web site: located at http://www.pitt.edu/~super1/lecture/lec4021/index.htm
Songer, T. (2005, March). Introduction to fundamentals of epidemiology. Retrieved June 27, 2005 from MERLOT Supercourse: Epidemiology, the internet, and global health Web site: located at http://www.pitt.edu/~super1/lecture/lec19061/index.htm
Songer, T. (2005, March). Web of causation; Exposure and disease outcomes. Retrieved June 27, 2005 from MERLOT Supercourse: Epidemiology, the internet, and global health Web site: located at http://www.pitt.edu/~super1/lecture/lec19071/index.htm
Supercourse: Epidemiology, the internet and global health. Retrieved June 27, 2005 from Multimedial Educational Resource for Learning and Online Teaching (MERLOT) Web site: located at http://www.merlot.org/artifact/ArtifactDetail.po?oid=1010000000000002301
U.S. News & World Report. (2005). Spreading the Bird Flu; Tracking the virus; Developing a vaccine; The flu over time. 138(12), 44-45.
Welsh, J. A., Cogswell, M. E., Rogers, S., Rockett, H., et al. Overweight among low-income preschool children associated with the consumption of sweet drinks: Missouri, 1999-2002 [Electronic version]. Pediatrics, 115(2), 488.
Wheeler, F.C. (n.d.). Epidemiology applications. Retrieved June 27, 2005 from MERLOT Supercourse: Epidemiology, the internet, and global health Web site: located at http://www.pitt.edu/~super1/lecture/lec4211/index.htm.
Wheeler, F.C. (n.d.). Key terms and measures. Retrieved June 27, 2005 from MERLOT Supercourse: Epidemiology, the internet and global health Web site: located at http://www.pitt.edu/~super1/lecture/lec4201/index.htm.
Section 1: Basic Concepts of Community Health Nursing
Unit 4: Affecting Health of Communities
Community health nurses work as one member of a multidisciplinary team in order to affect the overall health of a community. Unit 4 is designed to provide a brief overview of a number of the factors that are important in relation to the overall health of a community. Several methods that may be utilized to promote the health of a community are discussed.
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Learning Outcomes
By completing this unit, you will be able to:
• articulate the importance of environmental factors in relation to health.
• describe the associations between culture and health.
• discuss the need for public policy.
• articulate the principles of change theory in relation to community health nursing.
• provide examples illustrating a behavioral and a socio-environmental approach to health enhancement.
• discuss the theory of harm reduction and its relationship to health promotion.
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Focusing
Think about the concept of health promotion and the determinants of health that were discussed in Section 1, Unit 2. Although not specifically addressed to date in the course, what would you identify as the most significant determinant of health? What evidence do you have to support your answer? You may choose to post your responses to the Unit 4 Conference for discussion with fellow students.
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Practicing
Activity 1: The Environmental Effect
The community environment in which people live is complex and many factors within that environment may contribute to the health of the population.
Consult your course texts and websites of your own choosing in completing the following exercises related to environmental health.
1. Think about the community in which you live. What factors would you list as enhancements to the community’s health and what factors would you list as detriments to the community’s health? Write your ideas in your course notes. How does your list compare with the environmental health factors outlined in the course texts and websites that you have read? You may choose to discuss your community’s environmental enhancements and detriments with your fellow students in the Unit 4 Conference.
2. Review recent local newspaper articles to arrive at a sense of what is currently of importance in relation to the environmental health of your community. When you locate these articles, you may want to cut them out of the paper for future analysis and reference.
In analyzing local newspaper articles related to the environmental health of your community, consider questions such as, are they seasonal factors, like West Nile virus, or do they refer to something more permanent, for example, fluoridation of water? Is one particular group of people affected more than another by the environmental factor discussed?
3. Describe in your own words how environment is related to health promotion, as outlined in the Ottawa Charter for Health Promotion (1986). You may write your response in your course notes.
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Activity 2: The Relationship between Culture and Health
Culture is another factor that may contribute to the health of a population.
Consult your course texts and websites of your own choosing in order to answer the following questions related to culture and health. You may choose to write your ideas in your course notes.
1. Again think of your local community. How would you describe the dominate culture of your community? How would you describe a minority culture in your community?
2. Do you believe that the minority culture you described has different views and access to health care? Can you support your response with evidence?
3. In reviewing your local newspaper for articles related to environmental health did you also notice articles related to health that were culturally based? If so, do you believe that any one culture is better represented in relation to health over another? Provide rationale for your answer.
4. Do you believe that community health nurses need to be more aware of cultural diversity than nurses working in tertiary care centers? Provide rationale for your answer. You may choose to post your ideas to the Unit 4 Conference for discussion with your fellow students.
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Activity 3: The Need for Public Policy
Building healthy public policy is one strategy of health promotion (Ottawa Charter, 1986). What is public policy and how does it relate to politics?
Consult your course texts and the following Health Canada Web sites related to Nursing Policy.
http://www.phac-aspc.gc.ca/
1. How is community health promotion reflected on the Nursing Policy web sites?
Do you believe that nurses in general are in a position to formally address the creation of public policy? Why or why not?
2. Spend some time looking through the Health Canada Office of Nursing Policy website.
Does the site provide you with information as to policy development? Do you believe that the information presented in the site assumes that you understand policy development and the political process? Do you understand policy development and the political process? If your answer to each of these questions is no, do not feel bad — you are not alone.
3. At this time you may choose to gather information beyond the course texts on policy development and the political process by reading one of the following.
Steele, S., Rocchiccioli, J., & Porche, D. (2003). Analyzing and promoting issues in health policy: Nurse manager’s perspective[Electronic version]. Nursing Economics, 21(2), 80-83.
Ennen, K. A. (2001). Shaping the future of practice through political activity: How nurses can influence health care policy [Electronic version]. AAOHN Journal, 49(12), 557-572.
Discuss with your colleagues ways in which community health nurses, as members of the nursing profession, can increase their power or more effectively use the power they already have by virtue of their societal mandate and numbers. In what ways might this be helpful in addressing the need for healthy public policies?
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Activity 4: The Process of Planned Change
Beyond consulting your course texts for information on theories related to a planned change process, you might find the following articles to be of interest.
Cork, A. (2005). A model for successful change management [Electronic version]. Nursing Standard, 19(25), 40-43.
Westley, C., & Briggs, L.A. (2004). Using the stages of change model to improve communication about advance care planning[Electronic version]. Nursing Forum, 39(3), 5-13.
In analyzing the variety of change theories offered in your course texts and the above articles, how would describe the similarities and differences among these theories? You may choose to write your response in your course notes.
Would you state that any one of these change theories is more suitable to a population health promotion approach? Provide rationale for your response.
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Activity 5: Utilizing a Biomedical, Behavioral/Lifestyle, or Socio-environmental Approach to Community Health Promotion
A brief description of the differences between a behavioral and socio-environmental approach to health promotion was discussed in Section 1, Unit 2. You may wish to refer to your course notes for a quick review.
In consulting the Stamler and Yiu (2012) course text for a more detailed description of these three approaches, it is important to ask critical questions such as, “Is any one approach better than the other in relation to overall enhancement of community health?” or “Should the approach utilized be the one that will best produce the desired health change?” As you read, begin to formulate your own response to these questions.
Consider West Nile virus. Can you think of aspects related to this community health issue that would be best addressed from a biomedical approach, a behavioral/lifestyle approach, a socio-environmental approach? Write your ideas in course notes, perhaps share them with your fellow students in the Unit 4 Conference, or discuss your ideas with a work colleague.
Behavioral/lifestyle approaches are representative of health promotion programs that utilize strategies of social marketing and health education.
Read any one of the following articles as an example of a Canadian social marketing program.
Rootman, I., & Edwards, P. (2004). The best laid schemes of mice and men… ParticipACTION’s legacy and the future of physical activity promotion in Canada [Electronic version]. Canadian Journal of Public Health, 95, S37-S44.
Edwards, P. (2004). No country mouse: Thirty years of effective marketing and health communications [Electronic version]. Canadian Journal of Public Health, 95, S6.
Bauman, A., Madill, J., Craig, C.L., & Salmon, A. (2004). ParticipACTION: This mouse roared, but did it get the cheese? [Electronic version]. Canadian Journal of Public Health, 95, S14-S.
Read the following as an example of a Canadian health education program.
McKay, A. (2004). Sexual health education in the schools: Questions and answers [Electronic version]. The Canadian Journal of Human Sexuality, 13(3/4), 129-142.
Socio-environmental approaches are representative of health promotion programs that have evolved beyond behavioral/lifestyle approach strategies.
Read one of the following articles related to utilization of the strategy of harm reduction:
Don, L. (2005). Making plans for Nigella – the cases for, and against, harm reduction [Electronic version]. Drugs and Alcohol Today, 5(1), 17-23.
Reid, J. R. (2002) Harm reduction and injection drug use: Pragmatic lessons from the public health model [Electronic version]. Health & Social Work, 27(3), 223-227.
Refer back to the local community newspaper articles you cut out in Activity 2. Would you argue that any one approach would be best suited to bring about a health enhancement change in your community? Provide rationale. You may choose to write your response in your course notes.
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Reflecting
Define the following terms. Drag your mouse between the arrows to see a suggested response:
Policy
-> A policy is a broad goal statement that deals with “shoulds” and “oughts”, based on values, goals principles and evidence. It is frequently proactive and negotiable and is developed in stages similar to that of nursing process, namely, formation of the problem, through to adoption, implementation and evaluation. Policy is an end or outcome. (Clark, 2003) <-
Politics
-> Politics is a means rather than an end. Politics deals with conditions and involves using power to influence, persuade, or otherwise change. It is mostly reactive and nonnegotiable. Politics shapes the content for policy process and development. (Clarke, 2003) <-
Harm Reduction
-> Harm reduction is a program or policy designed to focus on the harms associated with engaging in particular behaviors rather than on the behaviors themselves. The approach requires strong community stakeholder support and is generally characterized by five principles, namely, pragmatism, harms, prioritization of goals, flexibility, and autonomy. (Wilkinson, 2005) <-
Congratulations on having completed Section 1 Basic Concepts of Community Health Nursing. Take a few days to review the content and (then complete Assignment 1). Assignment 1 is a Quiz, comprising 20% of your overall course composite grade. Review the quiz guidelines outlined in the assessment section.
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References
Bauman, A., Madill, J., Craig, C.L., & Salmon, A. (2004). ParticipACTION: This mouse roared, but did it get the cheese? [Electronic version]. Canadian Journal of Public Health, 95, S14-S.
Clarke, H. F. (2003). Health and nursing policy: A matter of politics, power, and professionalism. In M. McIntyre & E. Thomlinson,Realities of Canadian nursing: Professional, practice and power issues (pp. 60-82). Philadelphia: Lippincott.
Community Health Nurses Association of Canada. (2003, May). Community health nursing standards of practice. Retrieved May 02, 2005 from http://www.chnc.ca/
Cork, A. (2005). A model for successful change management [Electronic version]. Nursing Standard, 19(25), 40-43.
Don, L. (2005). Making plans for Nigella – the cases for, and against, harm reduction [Electronic version]. Drugs and Alcohol Today, 5(1), 17-23.
Edwards, P. (2004). No country mouse: Thirty years of effective marketing and health communications [Electronic version]. Canadian Journal of Public Health, 95, S6.
Ennen, K. A. (2001). Shaping the future of practice through political activity: How nurses can influence health care policy [Electronic version]. AAOHN Journal, 49(12), 557-572.
Health Canada Office of Nursing Policy. Retrieved July 10, 2005 from http://www.hc-sc.gc.ca/ahc-asc/branch-dirgen/spb-dgps/onp-bpsi/index-eng.php
McKay, A. (2004). Sexual health education in the schools: Questions and answers [Electronic version]. The Canadian Journal of Human Sexuality, 13(3/4), 129-142.
Public Health Agency of Canada. (1986). Ottawa charter for health promotion: An international conference on health promotion. Retrieved May 03, 2005 from http://www.phac-aspc.gc.ca/
Reid, J. R. (2002) Harm reduction and injection drug use: Pragmatic lessons from the public health model [Electronic version]. Health & Social Work, 27(3), 223-227.
Rootman, I., & Edwards, P. (2004). The best laid schemes of mice and men… ParticipACTION’s legacy and the future of physical activity promotion in Canada [Electronic version]. Canadian Journal of Public Health, 95, S37-S44.
Steele, S., Rocchiccioli, J., & Porche, D. (2003). Analyzing and promoting issues in health policy: Nurse manager’s perspective[Electronic version]. Nursing Economics, 21(2), 80-83.
Westley, C., & Briggs, L.A. (2004). Using the stages of change model to improve communication about advance care planning[Electronic version]. Nursing Forum, 39(3), 5-13.
Wilkinson, H. P. (2008). Substance abuse. In L.L. Stamler & L. Yiu (Eds.). Community Health Nursing a Canadian Perspective (pp. 385-394). Toronto: Pearson/Prentice Hall.
Section 2: Health Promotion and the Community as Partner
Section 2, Units 5, 6, and 7, includes a discussion of various models that may be utilized when working with communities. Nursing process provides the foundation for learners to develop a health promotion program for an identified aggregate of their choosing.
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Learning Outcomes | Focusing | Practicing | Activity 1 | Activity 2 | Activity 3 | Reflecting | References
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Unit 5: Developing Health Promotion Programs – Assessment
“Community assessment is a systematic process; it is the art of becoming acquainted with a community. The people of the community are your partners and contribute throughout the process; the assessment phase is their point of entry into the process of inquiry, planning, implementing programs, and evaluating their success”(Vollman, Anderson, & McFarlane, 2012, p. 225)
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Learning Outcomes
By completing this unit, you will be able to:
• discuss the use of models to guide community health nursing practice.
• explain the importance of determining population health indicators in relation to community health programming.
• identify an aggregate within a community as a client of community health nursing practice.
• apply the assessment phase of a selected nursing model to an aggregate within a selected community.
• apply various methods of data collection in the assessment of an aggregate within a selected community.
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Focusing
Standard 1: A, 4 of the Community Health Nurses Association Standards of Practice located at http://www.chnc.ca/ states,
The community health nurse: facilitates planned change with the individual/community population through the application of the Population Health Promotion Model.
• Identifies the level of intervention necessary to promote health
• Identifies which determinants of health require action/change to promote health
• Utilizes a comprehensive range of strategies to address health-related issues. (p.11)
The reference for the Health Canada Population Health Promotion Model cited in the above Community Health Nurses Association Standards of Practice is located at http://www.phac-aspc.gc.ca/.
You previously did some analysis of these models in Section 1, Units 1 and 2 and you may find it useful to review the notes that you have already made.
Consider the following situation. You are one of several community health nurses working in the Community Health Centre in your area. Over lunch you comment on the number of moms who have asked you about infant massage and where they might go to take a course. Several of the other community health nurses indicate they have had similar requests. From examining both the Population Health Promotion model and the Community Health Nurses Association Standards of Practice, where might you begin an assessment of this aggregate? If you wish, make a list of what you would assess in your course notes.
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Practicing
Activity 1: What is a community health assessment?
Examine “The Planning-Evaluation Cycle” Figure 14.1, p. 237 of the Stamler and Yui (2012) text. What does this figure remind you of?
Suggested Response
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Activity 2: Determining an Aggregate
As you will have gathered by now, this course does not focus on individuals as clients. Instead the “client” is viewed as being a number of persons with something in common, that is, an aggregate.
Aggregates may be groups or collections of people who meet, who share common purpose, who identify with one another. Alternatively, aggregates may be populations, which are less organized collections of people who have something in common, like a demographic feature such as age, ethnic background, or place of employment; or they may share a common health concern, such as risk of heart disease or promoting relaxation in infants. Aggregates or populations are one way of defining a community.
There are numerous other ways to define community. Consult your course texts to find other definitions of community.
As you read the following definitions of community, try to identify examples of each based on your own experiences with communities.
1. A community can be defined as a geopolitical community ( Clark, 2003), with defined geographical and jurisdictional boundaries, such as towns and cities. The boundary of a geopolitical community generally delineates its periphery (e.g., city limits) and is easily identifiable on a map.
2. A community of interest is another way of defining community. A community of interest is a social system in which people form networks to benefit individuals who have shared interests and goals. A support group is an example of a community of interest (Allender & Spradley, 2005).
3. A community may be defined as a community of problem ecology or of identifiable need ( Clark, 2003). Such a community includes all areas that comprise a health problem and its contributing factors. For example, a river may be polluted by an industry located in one part of the province and residents in another part of the province must deal with the effects on their drinking water. Both areas comprise the community of problem ecology.
4. Alternatively, a community may be defined as a community of solution, understood as the boundaries within which a health concern can be identified and resolved (Allender & Spradley, 2005). Members of a community of solution may have little in common, other than a desire to address the particular concern. This definition has many similarities to the community of problem ecology, but the community of solution may extend further than the community of problem ecology to include, for example, provincial or federal health authorities that can address an issue such as river pollution.
Each of these concepts of community is useful for different purposes. For the purposes of the Nursing 434 Community Health Promotion, you will identify a community aggregate, complete an assessment of that aggregate and develop a nursing diagnosis as requirements for Assignment 2.
Review the definition of “Aggregate”:
Aggregates are populations with some common characteristics and/or concerns, who may or may not interact with each other to address those concerns. Preschool-age children, persons with coronary artery disease and seniors are examples of aggregates. (Clark, 2003)
Consider an aggregate with which you would like to complete your community assessment for Assignment 2.
If you think about the above examples of aggregates, what immediate questions come to mind? If your questions lead you to the conclusion that the above mentioned aggregates are too broad, then you are on the correct path.
In order to make this assessment manageable, you should narrow your focus and develop a clear statement of exactly who the aggregate is that you wish to study. For example, the aggregate of interest may be preschool age children with attention deficit disorder. This would present a narrower focus, however it may still be too broad to be assessed in a meaningful way during this course.
You might want to consider phrasing the question as, “Who exactly represents the population/aggregate or who is the target population that I am interested in?” Hence, the aggregate or target population may be preschool age children diagnosed with attention deficit disorder who attend day care full time.
You may find it helpful to choose an aggregate that you are familiar with and/or have access to. Think of aggregates that exist in your work or social environment. Ideally you should be able to have communication with individuals within the aggregate and these formal or informal conversations may serve to compliment other assessment data.
If you have difficulty selecting an aggregate, you may find it helpful to discuss your thoughts with other learners in the Unit 4 Conference.
It is strongly recommended that you discuss your ideas with your course tutor via Course Mail to facilitate identification of a suitable aggregate prior to beginning your assessment.
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Activity 3: Choosing a Model and Method of Assessment
There is no one correct model or method by which to assess a community. Yiu (2008), in the Stamler and Yiu course text, provides information on a number of different models. Ammerman and Parks (1998) provide further information about the community capacity approach in Preparing students for more effective community interventions: Assets assessment.
Vollman, Anderson, and McFarlane (2012) provide a comprehensive community assessment guide based on Neuman’ systems model in their Canadian Community as Partner course text.
The University of Kansas Community Toolbox provides a “one stop shop” for information on this topic.
Environment Canada’s EcoAction 2000 Program located here, provides interesting discussion related to community assessment, the environment and health.
Often, those completing a community assessment utilize concepts from more than one model. Remember the purpose of a community assessment is to develop a realistic profile of the community’s people and subsystems while allowing for identification of strengths and capacities as well as risks to population aggregates and the environment. (Vollman, Anderson & McFarlane, 2012)
Essential questions to ask are:
• What kind of information is needed?
• How will the information be attained?
• What will be done with the information once it is collected?
Answers to the above questions will guide the type of model and assessment method utilized.
Consult your course texts in order to complete the following table on methods of assessment.
Printable version here (in Word doc format).
Assessment Method Example of when to use Strengths Weaknesses
Secondary Analysis

Windshield Surveys

Surveys & Questionnaires

Informant Interviewing

Now that you have identified an aggregate and have some ideas as to how to conduct a community assessment it is recommended that you begin work on completion of Assignment 2. Please review the Assignment Overview so that you are aware of how your work will be evaluated.
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Reflecting
What is the overall goal of population health and how is it achieved? Feel free to discuss your ideas with other learners in the Unit 4 Conference.
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References
Allender, J. A., & Spradley, B. W. (2005). Community health nursing: Promoting and protecting the public’s health (6 th ed.). Philadephia, PA: Lippincott Williams & Wilkins.
Ammerman, A., & Parks, C. (1998). Preparing students for more effective community interventions: Assets assessment [Electronic version]. Family and Community Health.21(1), 32-46.
Clark, M. J. (2003). Community health nursing: Caring for populations (4 th ed.). Upper Saddle River, NY: Pearson Education.
Environment Canada.(2003). Environment Canada: EcoAction publications from needs assessment to evaluation. Retrieved May 17, 2006.
Public Health Agency of Canada. (2003). What determines health? Retrieved July 14, 2005 from
http://www.phac-aspc.gc.ca/.
Statistics Canada. (2005). Health status well-being .Retrieved July 12, 2005 from
http://www.statcan.ca/english/freepub/82-221-XIE/2005001/tables.htm#health
Vollman, A. R., Anderson, E. T., & McFarlane, J. (2012). Canadian community as partner: Theory and multidisciplinary practice (3rd ed.). Philadelphia: Wolters Kluwer Health | Lippincott Williams & Wilkins.
Work Group on Health Promotion and Community Development (2006). Community Tool Box.
Retrieved January 17, 2008 from the University of Kansas site: http://ctb.ku.edu/en/default.aspx.
Section 2: Health Promotion and the Community as Partner
Unit 6: Developing Health Promotion Programs – Community Diagnosis and Planning
“Planning, like assessment and analysis, is a systematic process completed in partnership with the community”(Vollman, Anderson, & McFarlane, 2012, p. 289)
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Learning Outcomes
By completing this unit, you will be able to
• develop community diagnoses based on analysis of the assessment data of an aggregate within a selected community.
• discuss the use of models/frameworks in the program planning cycle.
• discuss the societal and political influences on the development of community health programs.
• apply the planning phase of a selected model to program development for an identified aggregate within a selected community.
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Focusing
Identify a community program in your area that you are familiar with. How did you become aware of the program? How would you describe the target population of the program? If you were to think about suggesting a nursing diagnosis for this program, how might it read? Answers to such questions in relation to an already existing program, although not a part of the planning process, perhaps provide evidence of what the program planners needed to think about prior to implementation of a program.
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Practicing
Activity 1: Developing a community diagnosis
Consult the course texts and the Neufeld and Harrison (2000) article, Nursing Diagnosis for Aggregates and Groups, in order to complete the following case study.
Consider the following situation and answer the questions that follow. You may want to write your ideas in your course notes.
You are working as a community health nurse in a rural area where there is high unemployment. One of your responsibilities is to promote the health of pregnant women. You have noticed that most of the women in the community are smokers and delay seeking prenatal care when it not their first pregnancy. A number of women developed complications during their pregnancy and had extended hospitalizations in a tertiary care hospital, located in a large urban centre some distance from your community. Some of their infants have also been ill or premature. When the women return to your community, they tell you that they were depressed and very isolated from their families and other sources of support during their hospitalization. They had no idea what to expect on admission to the hospital and had little time to prepare their families for the separation or to make arrangements for the care of their other children. On their return to the community, they were anxious and uncertain about where to find help with an infant whom they perceived as fragile and requiring extra care.
1. What are the strengths and limitations of using a community diagnosis with this aggregate?
2. Which level of diagnosis would you use?
o group diagnosis,
o individual diagnosis, or
o a combination of both levels?
o Provide rationale for your answer.
3. Develop both a wellness and a deficit diagnosis for this aggregate.
4. How would your priorities for program planning change depending on which community diagnosis you selected?
Adapted from 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.
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Activity 2: Develop a community diagnosis for your identified aggregate
Analyze the assessment data you collected related to your identified aggregate (Assignment 2) and develop an appropriate diagnosis. Consider posting your community diagnosis, including a brief rationale as to why you chose this diagnosis, to the Unit 6 Conference. Review the varied aggregates’ diagnoses that your peers are working with. Are the majority working with a “wellness” or “deficit” diagnosis? Feel free to engage in discussion.
Having completed an assessment and developed a community diagnosis for your identified aggregate represents an excellent time in the course for students to complete Assignment 2: Community Assessment and Diagnosis. Please review the Assignment Overview before you submit your work to your tutor so that you are aware of how your work will be evaluated.
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Activity 3: How do societal and political influences affect program planning?
If you are unclear as to what constitutes a societal or political influence, consult your course texts or websites of your choosing for clarification.
Identify a proposed change in your local community that is being instituted to improve the health of the population. It could be something large, such as enacting a city wide smoking bylaw inside all buildings, or something much smaller, such as initiating a scent free policy within the local school.
As you track the unfolding of the health promotion event in your community through information sources such as the local newspaper, letters sent home to parents, or memos within your work environment, keep a list of all the different influences that are represented.
Consider what your approach would be in communicating with the varied societal and political entities represented if you were the community health nurse working on this project.
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Activity 4: Planning the health promotion program
Once you have completed an assessment and developed a community diagnosis for your identified aggregate, it is time to design or modify a program to address the change that is sought and reflected in the community diagnosis.
Consult your course texts, course notes, the online Athabasca University library, and any applicable websites as you proceed to work the following case studies. If you find an exceptional resource related to this exercise, please share it with your fellow learners in the Unit 6 Conference.
Please spend some time working through this activity as it should provide you with a chance to utilize the theory in a practical way that you will take with you into your practice as a community health nurse.
Use the following case study to prepare a program outline.
Review the Application Exercise #1 Case Study
You, as the community health nurse working in this rural Alberta Health unit, were granted dedicated nursing time to work with this community beyond your day-to-day community health nursing practice routine of working with families in immunization clinics and home visits. You and your friend, the provincial nutritionist, as well as many community representatives, engaged in an assessment of this community and in collaboration with key participants developed the following community diagnosis.
Children of low income families in community ZZ have the potential for improved nutritional status related to parental interest in providing healthy meals on a fixed budget.
Prepare a program outline using one of the following models/frameworks:
• PRECEED-PROCEED Framework
• Program Logic Model
• Targeting Outcomes of Programs (TOP)
You may want to discuss your program outline with a friend or colleague at work, or with your fellow learners in the Unit 6 Conference.
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Use the following case study to determine how you as the community health nurse might respond.
Read the following short case study:
One of the elementary schools in the inner city is due to be closed and the children from that school will be integrated into the elementary school in the community in which you are the local community health nurse. Many of the children from the inner city school come from low income families and most do not have breakfast prior to coming to school in the morning. The principal has requested that you begin planning for a breakfast program for these children prior to their actual arrival in the school. In assessing the resources available to you within the school you discover that many of the children attending your school do not eat breakfast in the morning either.
You have been given a budget within which to work and you determine that it is sufficient to provide breakfast for only about one-half of the children who will be attending your school and would benefit from the program.
Respond to the following questions, providing clear, thoughtful, appropriately supported rationale for your answers.
1. Identify who among the students will be included in the client population for your breakfast program. On what basis will you make decisions as to who is or is not included in the program? What ethical dilemmas are you faced with in this situation?
2. Specifically, what need(s) will your program meet? What costs will be involved?
3. How will you determine that you have accurately determined the clients’ needs? How will you determine that you have actually met those needs?
Read the continuation of case study B.
In attempting to secure additional funding for your breakfast program you have approached two large grocery chains in the area for donations. One has agreed to give you a 20% discount on all purchases made by the program if their logo is prominently displayed in several locations within the school and on at least 10% of all the photocopied materials distributed by the school.
The other has offered to pay a flat rate of 25 cents each for proof of purchase labels for specific products (e.g., brand name milk and bread) sold exclusively by their chain. The children would collect these labels and bring them to school.
You have calculated that the returns from these two initiatives would be about the same and estimate that either would likely provide sufficient funds to make up for your budgetary shortfall. Both grocery stores have indicated that they are unwilling to participate in this project if the other is also involved.
Respond to the following questions, providing clear, thoughtful, appropriately supported rationale for your answers.
4. In making a case for subscribing to one or the other (or neither) of these two alternatives, what kinds of factors would you need to consider? Who would you need to involve in making such a decision?
5. What ethical issues are you faced with in this situation?
You may want discuss your ideas in relation to this case study with a friend or colleague at work or with your fellow learners in the Unit 6 Conference.
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Reflecting
Which principle of community health programming is also the most likely to address opposition to the program being planned?
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References
Neufeld, A., & Harrison, M. J. (2000). Nursing diagnosis for aggregates and groups. In M. J. Stewart, Community nursing: Promoting Canadians’ health (2 nd ed.; pp. 370-385). Toronto: Saunders.
Vollman , A. R., Anderson, E. T., & McFarlane, J. (2012).Canadian community as partner: Theory and multidisciplinary practice (3rd ed.). Philadelphia: Wolters Kluwer Health | Lippincott Williams & Wilkins.
Section 2: Health Promotion and the Community as Partner
Unit 7: Developing Health Promotion Programs – Implementation and Evaluation
“Evaluation is the “final” step of the community process, but it is linked to assessment, which is the first step. Professional practice is cyclic as well as dynamic, and for community-focused interventions to be timely and relevant, the community assessment database, community diagnoses, and program plans must be evaluated routinely. The effectiveness of community interventions depends on continuous reassessment of the community and on appropriate revisions of planned interventions”
(Vollman, Anderson, & McFarlane, 2012, p. 327).
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Learning Outcomes
By completing this unit, you will be able to
• discuss the process of implementing and evaluating change with a community.
• discuss the use of various evaluation models in the evaluation of community health programs.
• apply the implementation and evaluation phases of the nursing process with a group/aggregate or population within a selected community.
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Focusing
First, think of a community program that you have been involved with that you would rate as good-to-excellent. Second, think of a community program that you have been involved with that you would rate as poor-to-average. If asked to state the reasons for your ratings how would you respond? How much of your answer is related directly to the implementation of the program?
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Practicing
Activity 1: Implemention
It cannot be stressed enough how important it is to have the community involved in all phases of program development if the program is to be successful. Like the assessment and planning phases, implementation requires assessment of the community and planning to ensure a successful program.
Think of the aggregate/group you are working with in relation to the implementation of a health promotion program. Examples of some questions that must be asked and answered are: when would be the best place and time to offer the program, how will the target learn about the program, and what transportation issues exist? In essence, you are asking, “What are the potential barriers to the success of this program?” The best planned programs often do not succeed because of a relatively easily addressed issue that simply was not thought about in sufficient detail.
The Cho and Nadow (2004) article, Understanding barriers to implementing quality lunch and nutrtion education may offer some further ideas.
What specific questions would you want to have answered prior to implementing a health promotion program with your identified aggregate/group? You may want to write your ideas in your course notes.
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Activity 2: Evaluation
Perhaps one of the greatest oversights in community health promotion programming planning is the identification of measurable health indicators that will provide evidence of program outcomes. Health indicators were discussed previously in Section 2, Unit 5, Assessment-Practicing, Activity 1. Hence, as noted in the quote at the beginning of this unit, evaluation is clearly linked to assessment, and assessment should be ongoing.
Consult your course texts and websites of your choosing to complete the following questions. You may choose to write your responses in your course notes.
1. Explain in your own words the difference between formative and summative evaluation.
2. Explain what is meant by participatory monitoring and why it is perhaps the preferred method of community health promotion program evaluation.
3. You may find the Macaskill, et al., (2003) Eat smart! Ontario’s healthy restaurant program: A survey of participating restaurant operators article to be of interest.
Explain why it is so important that evaluation findings of community health promotion programs be reported.
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Reflecting
Often the role of the community health nurse is to implement and evaluate an already planned community health promotion program. Explain the differences, if any, that this makes to the planning-evaluation cycle. You may choose to discuss your ideas with fellow students in the Unit 7 Conference.
Congratulations on having completed Section 2: Health Promotion and the Community as Partner.
Having worked through Section II, it is an excellent time in the course for students to complete Assignment 5: Strategies for Health Promotion. Please review the Assignment Overview on the home page of this course before you submit your work to your tutor so that you are aware of how your work will be evaluated.
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References
Macaskill, L. A., Dwyer, J. J., Uetrecht, C. L., & Dombrow, C. (2003). Eat smart! Ontario’s healthy restaurant program: A survey of participating restaurant operators [Electronic version]. Canadian Journal of Dietetic Practice and Research, 64(4), 202- .
Cho, H., & Nadow, M.Z. (2004) Understanding Barriers to Implementing Quality Lunch and Nutrition Education, Journal of Community Health, 29(5), 421-435.
Vollman , A. R., Anderson, E. T., & McFarlane, J. (2012).Canadian community as partner: Theory and multidisciplinary practice (3rd ed.). Philadelphia: Wolters Kluwer Health | Lippincott Williams & Wilkins.