Implementation of the Solutions to the Healthcare Problems of Elderly and Schools

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Introduction

This report is the implementation of the solution to the problems highlighted in Assignment 2, which highlight; Elderly Home Support Service, Avoiding malnutrition by opening discounted outlets to provide food with essential nutrients, Schools in the community must have an experienced on-duty nurse to provide necessary treatments in case of any emergency, Accidents occur in the community due to bad weather, fewer signals and due to low traffic flux, there aren’t any signals everywhere.

A committee is set consisting of seven people who are responsible for performing research about specific prevalent diseases in specific months of the year. The committee is responsible for gathering the information from the local hospital using qualitative research. The key areas which are targeted in the qualitative research are; Type of disease with common reason, Specific months of disease, Percentage of each gender affected, Age group and Living standards, and eating habits.

Elderly Home Support Service

The major task of the committee program would be the overall objective of supporting older adults to stay in their own homes as long as possible, with a wide variety of services depending on the jurisdiction but which can include: home nursing, involving a range of clinical services such as dialysis, IV therapy, etc.; homemaker services; respite care for family caregivers and some kind of meals program. Furthermore supplements to public transportation; ‘friendly visiting’; handyman services; and other services depending on the community. These programs would be also available to young adults of the community with disabilities and families with children with disabilities or in distress (Richardson, 1990). Since the community consists of a rural area comprising a small town, therefore no big constraints with being there for home support service.

Based on their “ability to maintain independence” the community would take care of the elderly thereby marginalizing them in our society. They have not received the kind of adequate education, training, employment, and health care that many middle-class citizens take for granted. Therefore all these facilities would be provided by the community. Thus, they are very reluctant to admit any form of neediness. Many residents would be able to receive in-home supportive services (housekeeping, meals-on-wheels, etc.) and would remain in their houses.

An approach developed by most of the communities represents residential aged care services that are provided to their residents with the opportunity to express their views and any concerns they might have about the quality of their care. The same approach would be implemented in this community setting which would consider both, the extent to which the overall approach contributes to the increased empowerment of frail elderly people in residential care, as well as the extent to which specific impediments to empowerment, could be mitigated through its utilization.

Since the hospital is having only one gerontological nurse faculty member responsible for supervising the students, therefore home visits would be conducted and students would be interviewed by all participating residents (in the clinic or at home) to take health histories and fill out a lifestyle profile questionnaire about nutrition, stress, and exercise habits, medication use profiles and other basic health inventories. In this way, residents could gain a broader perspective on their health status, and students could provide residents with health information to which they might not otherwise have access. Students and the faculty members would also assist the residents in identifying questions to ask their doctors.

There are several other issues concerning the assessment of elders’ views. Given the increasing mental and physical frailty of residents in nursing homes, it is usually not possible to obtain feedback from them all. The extent to which family, caregivers, or health professionals can act as residents’ agents or proxies is thus an important question. Who is most appropriate to undertake an evaluation is also an important question. If it is to be conducted by service providers themselves, there are many sensitive issues, including possible bias in the selection of residents. The tendency of residents to give bland responses, and their reluctance to criticize services upon which they are dependent, further hinder the usefulness of consumer-derived information. This is exacerbated by the low expectations of many older people; residents’ views may reflect not only their present circumstances but also adverse previous life events and experiences (such as the war years, the Depression, and other hardships). Finally, it can be very time-consuming to administer consumer instruments, particularly interview schedules. (Boldy et al, 2001, p. 43) Therefore different research methods (Qualitative and Quantitative) would be deployed every year in the community to be aware of the needs of the people.

Providing Low-cost Quality Food

By opening discounted outlets throughout the rural community, many problems regarding poor quality food would be solved that has remained a part and parcel of the community for the last ten years. The issues regarding food quality include the various chemical, microbiological, and physical hazards to the food supply like chemical hazards, food additives, food allergens, naturally occurring toxins in food, and bacteria, and viruses on leftover food due to improper drainage system leading to unsanitary conditions.

Research suggests that up to 6 percent of children and 2 percent of adults suffer from food allergy due to unhygienic conditions of food preservation which result in the damage of the body’s immune system reacting to substances in food, usually a protein. The immune system misinterprets a chemical component of a food as harmful and releases histamines and other chemicals to combat it, which results in hives, swelling, itching, vomiting, diarrhea, cramps, or difficulty breathing. The Community is concerned about that too. Severe reactions may cause anaphylaxis, which results in death. (Roberts, 2001, p. 6) Therefore proper sanitary intake would be provided to the people and that even at a very low cost with a discount ranging from 40% – 60% depending upon the social condition of the people.

Sewerage System

Transmission of viruses comes from contact with sewage or water contaminated by fecal matter or direct contact with human fecal material. Uncooked raw or seafood in the form of shellfish or oysters are the food most often consumed and associated with foodborne viral diseases. Human viruses are often discharged into marine waters through treated and untreated sewage (Wittman, 1995). The other main source of transmission is from infected food workers who have poor personal hygiene. An infected worker can transfer viral particles to any food. Therefore, proper handwashing and using a clean water supply are vital to controlling the spread of foodborne viruses.

Even extremely poor households do not choose their food basket to maximize energy intake from the amount they spend on food; i.e., not only energy content but also the taste of food is important. This means that as incomes increase even poor households may shift to foods that simply have a better taste and total energy intake may not rise very much; i.e., the income elasticity of energy intakes is low. Thus, to increase energy intakes significantly, households’ incomes have to be raised substantially. Although this blunts the effectiveness of an income-based approach to undernutrition, given the problems associated with policies of direct nutrition intervention, not many cost-effective alternatives to improving the income-earning opportunities of the poor may exist for bringing about a long-term sustained improvement in the nutritional status of the poor.

Sanitation is the most vital factor which economically can harness resources to provide their citizens with an appropriate water supply and sewerage services. As the committee has visualized there is a need to invest heavily in the construction of community, including water supply, sewerage, and flood drainage services, this gradual growth rate would enable the community progressively and effectively to develop the necessary infrastructures and the capacities to manage their water supply and sewerage services. It would not be an easy task but somehow after collecting funds every year it would be manageable to some extent.

A regular food inspection would be started within the community with regulation standards concerning sanitation, labeling, good manufacturing practices, and food standards. Inspectors would collect and analyze food samples for physical, chemical, and microbial contamination. With 1000 food establishments to inspect and only 10 inspectors, FDA inspects plants under its jurisdiction on average once every two years. Some state agencies have cooperative agreements with FDA, bringing inspections of food processing plants.

Hospitals for Disease Control and Prevention (CDC)

The committee has decided to open up new Centres for Disease Control, as part of the Health and Human Services, and would be charged with protecting the community’s public health. Most of the food safety work is in the area of disease observation in such food rather than in the regulatory arena. Health inspectors would enforce sanitation regulations dealing with food, water, and sewage to protect the food supply and the public. Inspectors would be employed by states, counties, and cities which would be responsible for inspecting restaurants, grocery stores, convenience stores, institutions, fairs, festivals, and special events taking place throughout the community.

The correlation between the levels of dietary inadequacy prevailing in households and communities on the one hand and the degree of severity of undernutrition (as assessed by anthropometric criteria and clinical signs) obtaining among them on the other is not always strict. Three major reasons for this may be mentioned:

The severity of effects of primary dietary inadequacy in a population can be aggravated by superadded conditioning factors, such as infections and parasitic diseases, the extent of such aggravation being determined by the nature of such infections, their duration, frequency, and severity, and the promptness and efficiency with which they are prevented and treated in the community. Infections can increase the requirements of nutrients and inhibit their absorption and assimilation.
In communities subject to the same order of dietary deficiency right through the year, the clinical manifestation of undernutrition could be more pronounced in seasons characterized by a high prevalence of infections than at other times. For example, in India, poor communities are subjected to a monotonous dietary deficiency throughout the year, the peak incidence of ‘kwashiorkor’ (a disease caused by severe protein-calorie deficiency) in children in successive years was noticed in May-June, following the peak incidence of diarrhoeal diseases in the ‘fly season’ of April-May (Gopalan 1955). In parts of Kerala in India, nearly three decades ago, when health services were less adequate than at present, the peak prevalence of ‘kwashiorkor’ was noticed in the weeks following the monsoon when, again, diarrhoeal diseases attained their peak.

The most common issue among communities is the level of ‘dietary inadequacy’ which is the significant factor of undernutrition on which the level of primary health care in the community entirely depends and can modify the severity of its clinical manifestations. Where diets of entire households rather than of individuals within the family are being used as yardsticks in the assessment of community nutritional status, differences like interfamilial distribution of food, and in particular in infant feeding and child-rearing practices, between the families and between communities can result in important differences concerning nutritional status (especially of children) between households, and between communities with nearly similar overall levels of dietary inadequacy.

Differences for nutritional status of infants and young children between households with nearly similar dietary and socioeconomic status can arise from differences in duration and intensity of breastfeeding, the time of introduction of supplements, and the nature and amount of such supplements. Relatively small proportions of the overall family diet can make a significant difference to the level of adequacy or inadequacy of the diet of the preschool child. The level of female literacy in the household is often a major determinant of child-rearing practices and, therefore, of the level of child nutrition in poor households.

Furthermore, except in acute famine situations, the current nutritional status of a community is often a reflection of its erstwhile rather than (necessarily) its present dietary status. There is a variable time lag between dietary deprivation and the onset of clinical undernutrition. This consideration, however, may not matter in the case of communities wherein no significant or striking changes in dietaries have taken place, and where seasonal fluctuations in dietaries are not marked. Current dietaries may then well reflect the situation responsible for the prevailing nutritional state.

The time lag between the onset of nutrient deprivation and the appearance of clinical (or functional) manifestation can vary, depending on the nutrient and the clinical sign. Thus, for example, it could take much longer for eye lesions to appear following a vitamin A deprivation than for growth retardation to occur following calorie-protein undernutrition. In the case of growth retardation consequent on calorie-protein undernutrition itself, retardation in linear growth (stunting) is generally the outcome of a more longstanding dietary deprivation than retardation in body-weight increment (wasting).

These considerations will underscore the limitations concerning the measurement of nutritional status of communities based on the level of dietary inadequacy alone and will highlight the need for additional yardsticks. This is not to minimize the importance of diet surveys in the assessment of the nutritional status of population groups, but only to explain some of the seeming incongruities such as the lack of strict parallelism between dietary intakes and nutritional status. It will also explain the reasons why nutrition scientists rely not only on diet survey data but also on nutrition surveys (actual examination of human subjects both adults and children) for the assessment of the nutritional status of population groups.

Children subjected to Growth Retardation

In children of poor communities, habitually subsisting on inadequate diets, there is a continuous and insidious transition from the stage of normalcy usually obtaining up to about the fourth or sixth month (many infants being small-for-date may never start from normalcy) to that of fully-fledged, clinically manifest undernutrition which generally supervenes before the third year. The speed of this downward slide from normalcy to fully-fledged disease will depend on the extent of the dietary inadequacy, its duration, and the presence or absence of superadded aggravating factors such as infection. In poor communities, we may expect to see children in different stages of this transition. (Osmani, 1992, p. 20)

Not all will go through the entire transition: the downward slide may be arrested at different stages, or it may be so slow that the child may manage to cross the critical age period of four to five years before the ‘end-point is reached. It is necessary to emphasize that, unlike many infectious diseases, in the case of nutrition there is no point of striking or dramatic onset and no easily (visually) discernible dividing line between normalcy and the commencing of ‘disease’. In children whose growth is carefully monitored, a faltering in the growth rate and the point at which the growth curve begins to flatten and deviate away from the normal standard could provide the earliest indication of undernutrition; however, few children in poor communities of the developing world enjoy the benefit of such close and careful growth-monitoring. Biochemical tests could reveal sub-clinical undernutrition, but these are hardly feasible in large-scale community surveys.

Retardation of growth and the downward deviation from normalcy becomes progressively more pronounced with time, and children pass insidiously from the so-called ‘mild’ to the ‘severe’ grades of growth retardation. A considerable proportion of children presently in the ‘mild’ grades of growth retardation are potential candidates for the ‘moderate’ and ‘severe’ grades; those present in the ‘severe’ grades were probably in the ‘mild’ and ‘moderate’ categories a few weeks or months earlier. A fortunate small proportion may even reverse their direction.

To arrive at a given level of growth retardation, not all children need to follow the same route in the growth chart. The shape of the growth curve could vary. The speed and intensity of growth retardation and the consequent duration over which a given order of growth retardation results will differ depending on the nature and extent of dietary inadequacy and superadded infections.

Under these circumstances, as important as the child’s current position in the growth chart will be the route which that child took to arrive at the point whether the child is the victim of an acute fairly severe deficiency over a short duration, or of a chronic less severe deficiency spread out over a longer period. For the same low weight-for-age, the child in the latter category could be more ‘stunted’ (less height for age) than the one in the first and might require a much longer duration of more intensive nutritional rehabilitation for recovery. Quantification of undernutrition purely based on the degree of deficit of weight-for-age thus has its complexities and limitations.

A practical solution to under Nutrition Measurement

Despite these difficulties and limitations, a fairly reliable estimate of the quantum of undernutrition in a community may be made through two approaches which are practicable under the real-life conditions obtaining in the field, and which will largely serve the needs of the public health scientist and developmental economist:

A survey of the diets of representative households (supported by a survey of diets of individual members of the family in a sub-sample of households) in a community, to derive information on nutrient intake especially the calorie intake.
Anthropometric and clinical examination of children especially the under-fives (who constitute the ‘most sensitive’ segment of the population from the point of view of nutritional vulnerability).

Committee panel on analyzing various cost-effective programs in Health and Medicine notes that cost could be controlled not only by analysis but by serving a range of appropriate cost control measures, from a managed-care organization administrator who might wish to know the cost per year of life saved by a program for its enrolled population, to a state health official who might want to compare the cost treatment program to the cost that occurs of a program that would improve the nutrition of school-age children (Gold et al., 1996, p. 28).

Community Accidents

Vehicle speed is believed to be an important consideration in highway safety. It directly affects the likelihood of a crash through its impact on stopping distance and other considerations in accident avoidance. In the event of a crash, vehicle speed directly influences the energy released and, hence, the extent of property damage and injury. In community settings, accidents occur due to lack of weather conditions, inappropriate signals, lesser automobiles, and uneven damaged roads.

Truck accidents typically happen under normal weather conditions. If there are unfavorable conditions at the time of an accident, they usually involve some form of precipitation. Most truck accidents occur during the day because this is when trucks typically travel. For example, more than three-fourths of the travel by tractor-semi trailers are in the daytime. However, less than two-thirds of the fatal accidents involving tractor-semi trailers are at that time.

Data based on police reports indicate that vehicle defects primarily brake and tire problems are uncommon in accident-involved trucks. However, some researchers believe that the role of vehicle-related factors in truck accidents is unrecognized and underreported in communities. Cargo-related matters, such as overloading or load shifts, are contributing factors to a small number of accidents. Per vehicle mile traveled, combination trucks have more fatal crashes than single-unit (straight) trucks. Conflicting findings have been reported on the relative safety of two types of combination trucks: truck tractors pulling one trailer (singles) and tractors pulling two trailers (doubles). Some researchers have concluded that singles and doubles are equally safe, while others have reported findings that singles are safer. There is evidence that accident risk is significantly higher for tractors pulling no trailers (bobtails) than for singles and doubles.

Regarding environmental considerations, most truck accidents occur under normal weather conditions. According to recent evidence, such conditions exist in more than 80 percent of the fatal crashes involving medium/heavy trucks. Rain, the most frequent unfavorable weather condition when there is an accident, was found in one study to have a significant positive relationship with mileage-based injury and accident rates. Most medium/heavy truck accidents occur during the week between 6:00 A.M. and 6:00 P.M. There is evidence that greater highway congestion increases the likelihood of an accident in interstate trucking and that the risk of casualty accidents for truck tractors is greater at night than during the day. (Loeb et al, 1994, p. 119).

Monitoring Accidents

Statistics community collects data about accident mortality rates which include suicides and homicides. These rates vary enormously between the provinces and considerable variation can be found from one year to the next. Fluctuations are particularly evident in provinces with small populations. These data may be used to justify the introduction of preventive programs. Accidents (including suicides and homicides) are the primary cause of death among youngsters and teenagers above the perinatal age in the community and the reason that many are impaired, disabled and handicapped. Consequently, provincial governments are anxious to prevent accidents as much as they can.

New Perspective on the Health of community has identified health status risks as being related to lifestyle, environment, and biological risk, but the health departments themselves can do little in these areas except to provide educational programs. Most of the preventive work is done by others who have a special interest in a particular area. Quite often this interest is related to the question ‘who pays for the results of accidents?’ and that even in communities. Insurance companies providing income support to the injured would prefer to reduce demands upon their funds.

Hospitals

The offers of grants for hospital construction are taken up more enthusiastically than the governments had expected, for hospitals, then, were the symbol of collectivist caring. Rational planning of hospitals is conducted by consultants or committees in most provinces. But the plans were often swept aside by back-bench Members of provincial Legislative Assemblies (MLAs) anxious to see these symbols of caring set up in their constituencies. Most provinces found that they were pressured to build many small rural hospitals.

The committee is also concerned about damaged roads – the main cause of accidents. As the roads improved and modem technology has been introduced in communities and rural areas, the smaller hospitals are becoming relatively limited in what they could provide. The governments usually set up secondary referral hospitals in larger rural centers to provide services of specialists who were supported by laboratories and other diagnostic facilities. As well, they encouraged the development of traveling clinics staffed by tertiary care specialists who saw patient referrals and provided further training for local doctors to follow up on their cases.

Because travel to the secondary centers is much easier than it used to be, provincial governments have often tried to close rural hospitals, but there has been tremendous resistance (Houston, 1990). Hospitals are more than treatment centers they provide local employment and encourage local businesses.

Rural dwellers have always argued the necessity for maintaining emergency services and birthing centers closer to home and for many years provincial governments kept the small hospitals open because it was politically suicidal to close them. If the hospitals could not easily be closed, then perhaps they could be restructured. The committee has signed many proposals for redesigning some of their small acute care hospitals as extended or personal care homes. In this context, the committee is studying various researchers who have redesigned the buildings according to their usage. Texeira (1987) described how Saskatchewan turned some of these small rural hospitals into ‘community health centers’ (CHCs) from 1972 onwards. He said that, if the hospital board could arrange the services of a visiting physician, it could open a center staffed by a resident nurse on a twenty-four-hour call, and recruit part-time staff for laboratory, x-ray, and maintenance services. Social services could choose to use the facilities, too, if they so wished. By 1987 there were eleven rural so-called CHCs in the province, three in the pipeline and seven others which, Texeira said, might qualify for financial aid. given through a medical complex attached to an acute care setting. Extended care, elderly housing, and continuing care units are also available. All physicians in the area work through the center and are salaried. A health care team manages individual patient’s cases and the continuing care coordinator ensures linkage of services (Beaudin, 1989).

At a British Columbia Health Association Conference for Rural Hospitals in 1990, five hospitals’ outreach programs were described and help was offered to any other hospitals which wished to start up their programs in outreach for rehabilitation, treatment of chemical dependency, family support services, emergency response to family violence (Coleman, 1990) and mental health outreach (Riverview, 1990). It may well be asked whether the hospital is the most appropriate place to start these last four programs or whether there are other centers from which community development could be launched. In the British Columbia context, these new outreach programs were linked into the experimental Hospital/Community Partnership Program which sought to turn over some of the hospitals’ funds to prevention and promotion activities but they were still hospital-based. Now they will be taken over by the regions set up in 1993-94.

Mental Health Services

The committee has started working on the development of at least one mental hospital throughout the town. Mental health services in rural areas are usually provided by outpatient clinics of provincial mental health departments because rural hospitals seldom have psychiatric specialists on staff. Efforts are now being made to train family practitioners in psychotherapy (Trent, 1990) and some universities have developed traveling clinics. Richman (1989) has discussed the problems of general practitioners in deciding how to cope with psychiatric problems.

Kyle (1985) listed many alternative approaches to rural psychiatric care the psycho-educational approach, lay counseling programs, residential retraining programs in life skills, therapeutic caring for disturbed children, community-supported housing for disturbed individuals in a rural center of treatment. (Crichton et al, 1997) These British Columbia services have been well publicized by the federal government. A report on the conference of mental health workers from the western provinces addressed questions of personal, professional, and program survival in rural areas.

Conclusion

Ranging from the economic problems to the health care system, CBI seeks to carve out new territory and a new role for itself within the overall context of the provision of community-based services. History reveals that public health has always compromised those activities, which are undertaken with collective responsibility for the protection of the health of the public, primarily through primary prevention measures. There is a need to address public health activities that seem ‘alright’ but are ‘at at risk’ when it comes to health concerns and sanitation problems.

Generally, it has meant a shift, at least in the discussion within public health circles, away from the provision of traditional professionally determined public health services based on a scientific or clinical approach towards the provision of services based on a community-based planning and implementation approach.

References

Beaudin, Marquise. (1989). “Integrated Models for Health Service Delivery”. Vancouver: University of British Columbia Health Planning Project.

Boldy P. Duncan, Heumann F. Leonard & Mccall E. Mary, (2001) Empowering Frail Elderly People: Opportunities and Impediments in Housing, Health, and Support Service Delivery: Praeger: Westport, CT.

Coleman, Mike. (1990). “Emergency Response Team”. Penticton, BC: Penticton Regional Hospital Crichton Anne, Farrant Wendy, Gordon Christine & Robertson Ann, (1997) Health Care: A Community Concern?: University of Calgary Press: Calgary, Alta.

Gopalan C. (1955) “Clinical Aspects and Treatment”, in J. C. Waterlow (ed.), Protein Malnutrition. Rome: FAO.

Loeb D. Peter, Talley K. Wayne & Zlatoper J. Thomas, (1994) Causes and Deterrents of Transportation Accidents: An Analysis by Mode: Quorum Books: Westport, CT.

Osmani S. R., (1992) Nutrition and Poverty: Clarendon Press: Oxford.

Richardson, Blair G. (1990). “Overview of Provincial Home Care Programs in Canada.” Healthcare Management Forum 3, no. 3: 3-10.

Riverview Hospital and Fraser Valley Regional Mental Health Services. (1990). Outreach Initiatives. New Westminster, BC: Riverview Hospital.

Roberts A. Cynthia, (2001) The Food Safety Information Handbook: Oryx Press: Westport, CT.

Trent, Bill. (1990). “GP Psychotherapy: Its Popularity Is Growing Among MDs and Patients”. In: Canadian Medical Association Journal 143, no. 4: 320-23.

Wittman, R. J., and G. J. Glick. (1995). “Microbial Contamination of Shellfish: Prevalence, Risk to Human Health and Control Strategies” In: Annual Review of Public Health 16: 123–140.

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