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Q1. Why is it the case that single men are prominently represented in the homeless? Is there a primary prevention program that could be a part of a public health initiative that would address this cohort specifically?

Q2. Pick a contemporary natural disaster with which everyone is familiar. The natural disaster selected for discussion should be one that affected a cross-section of society.

Discuss how the concept of distributive justice was applied in that situation. Look and review a variety of contrasting perspectives based upon differences in socioeconomic status, gender, race & ethnicity, disability, age, proximity of victims to important places in the vicinity, and other demographic factors.

Chapter 17:
Substance Use
Chapter Highlights
❖ Factors affecting prevalence rates of substance use: age,
gender, race, socioeconomic level, urban or rural settings
❖ Population‐based interventions to decrease substance use
❖ Evidence‐based treatment protocols for substance abuse
that should be incorporated by community health nurses
in all practice settings
❖ Self‐help groups: a highly effective community‐based
treatment with proven efficacy in sustaining recovery
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Question #1
Is the following statement true or false?
Addiction is a term, along with habituation, which the WHO
recommends be substituted with substance use.
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Answer to Question #1
False
Rationale: Addiction is a term, along with habituation,
which the WHO recommends be substituted with substance
dependence. However, clients and practitioners commonly
use addiction.
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International Aspects of Substance Abuse
❖ Scope of substance abuse
❖ Public health policies to minimize harms from substance
use
❖ National scope of substance use
o Alcohol
o Cannabis
o Tobacco
o Illicit drugs
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Substance Abuse
❖ A person is diagnosed as having substance abuse when
they exhibit the following behaviors associated with
substance use:
o Problems at work, home, and school
o Problems with family or friends
o Physical danger
o Trouble with the law
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Substance Use
❖ The use of alcohol, illicit drugs, and nonmedical use of
prescription medications
❖ Illicit drugs include cannabis, cocaine, heroin,
hallucinogens, inhalants, and methamphetamine.
❖ Nonmedical use of prescription medications includes pain
relievers, tranquilizers, stimulants, and sedatives.
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Question #2
Is the following statement true or false?
With no use of illicit substances or alcohol
in the preceding 9 months, a person is considered
“abstinent.”
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Answer to Question #2
False
Rationale: A person is considered “abstinent” with no use
of illicit substances or alcohol in the preceding 12 months.
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Addiction
❖ A term, along with habituation, which the WHO
recommends be substituted with substance dependence.
❖ Clients and practitioners commonly use addiction.
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Substance Dependence
❖ Health and emotional problems associated with
substance use
❖ Unsuccessful efforts to cut down on use
❖ Symptoms of tolerance or withdrawal
❖ Reducing other activities to use the substance
❖ Spending time in activities related to substance use
❖ Using the substance in greater quantities or for a longer
period of time than intended
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Abstinence
❖ If there is no use of illicit substances or alcohol in the
preceding 12 months, a person is considered “abstinent.”
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Question #3
Is the following statement true or false?
The United States leads the world in rates of substance
use.
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Answer to Question #3
True
Rationale: The United States leads the world in rates of
substance use. Patterns of substance dependence vary by
age, gender, race, ethnicity, and geographic location.
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Health Profiles and Interventions for
High‐Risk Populations
❖ Pregnant women
❖ Substance use at an early age
❖ College students and binge drinking
❖ Older adults
❖ Persons who inject drugs
❖ Methamphetamine users
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Public Health Models for Populations at
Risk
❖ Screening
❖ Maladaptive behaviors
❖ Social contexts
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Question #4
Is the following statement true or false?
Studies of disadvantaged adolescents in impoverished
areas or homeless youth have found that youth follow a
stepwise progression of substance use.
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Answer to Question #4
False
Rationale: There is debate in the literature about the
“gateway effect” theory of substance abuse, which
proposes that substance abuse is progressive and begins
with tobacco, then moves sequentially
to alcohol or cannabis, and ultimately to other illicit
substances. Studies of disadvantaged adolescents
in impoverished areas or homeless youth have not found
that these youth follow such a stepwise progression of
substance use.
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Environmental Factors
❖ Poverty
❖ Lack of access to health services
❖ Capacity of law enforcement to constrain supply
❖ Contribute to a disproportionate burden of harm among
o Native Americans
o Alaskan Natives
o African Americans
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Treatment Interventions #1
❖ Medication‐assisted treatments
o Naltrexone
o Acamprosate
o Disulfiram
o Methadone
o Buprenorphine
o Naloxone
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Treatment Interventions #2
❖ Evidence‐based psychosocial treatments
o Motivational interviewing
o Social skills training
o Cognitive‐behavioral strategies
o 12‐step programs
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Question #5
Is the following statement true or false?
Screening for substance use is the second step in assessing
if a person has substance use disorder.
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Answer to Question #5
False
Rationale: Screening for substance use is the first step in
assessing if a person has substance use disorder. The
efficacy of screening instruments is highly dependent
on the candor of client responses.
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Chapter 18: Underserved
Populations
Chapter Highlights #1
❖ Vulnerable versus underserved populations
❖ Social determinants of health/health disparities
❖ Genomics and underserved populations
❖ Health priorities in rural areas, particularly elders
❖ Health priorities in gay, lesbian, bisexual, and
transgender people; in people in correctional institutions;
and in people who are homeless
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Chapter Highlights #2
❖ Access to quality care
❖ Chronic disease management
❖ Veteran’s health
❖ Human trafficking
❖ Health personnel issues
❖ Risk, prevention, and health promotion in hard‐to‐reach
populations
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Context of Health Risks
❖ Vulnerability
❖ Social determinants of health and health disparities
❖ Genomics and underserved populations
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Question #1
Which of the following are included in the notion of
social injustice?
A. Belief of those in power that others are inferior
B. Denial of human rights to certain populations
C. Disparities in access to services, such as healthcare
D. All of the above
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Answer to Question #1
D. All of the above
Rationale: Social injustice involves the denial of economic,
sociocultural, political, civil, or human rights of certain
populations or groups based on the belief of those with
power that others are inferior. In healthcare, it manifests
as disparity in access.
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Vulnerability
❖ Underserved populations
o Subgroup of the population
o Higher risk of developing health problems
o Greater exposure to health risk because of
marginalization
â–ª Sociocultural status
â–ª Access to economic resources
â–ª Age
â–ª Gender
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Social Determinants of Health and Health
Disparities
❖ High‐risk mothers
❖ Chronically ill and disabled people
❖ People living with HIV/AIDS
❖ Mentally ill people
❖ Substance abusers
❖ Homeless people
❖ Immigrants and refugees
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Rural Populations
❖ Health personnel issues
❖ Morbidity and mortality issues
❖ Elderly people
❖ Occupational and environmental health problems
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Question #2
Is the following statement true or false?
Accessibility is insufficient number and diversity of formal
services and providers, or lack of acceptable services and
human service infrastructure to elders in rural areas.
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Answer to Question #2
False
Rationale: Availability—insufficient number and diversity of
formal services and providers; lack of acceptable services
and human service infrastructure.
Accessibility—shortages of adequate, appropriate, and
affordable transportation; cultural and geographic isolation.
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Correctional Health: Underserved
Populations in Jails and Prisons
❖ All levels of prevention need to be addressed for all
people who end up in correctional facilities.
❖ Most inmates are males who are African American or
Latino.
❖ The average age of inmates is 37 years.
❖ After release from incarceration, inmates often face
social injustices and economic problems.
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Gay, Lesbian, Bisexual, Transgender, and
Queer Community #1
❖ Four subgroups—gay, lesbian, bisexual, and transgender
people—have unique needs.
❖ Few population‐based studies have been conducted in
LGBT groups, with the exception of HIV‐related research,
particularly in men who have sex with men.
❖ Specific questions on surveys related to sexual
orientation are lacking.
❖ Recognition of same‐sex heads of households has not
always been included in survey data.
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Gay, Lesbian, Bisexual, Transgender, and
Queer Community #2
❖ More serious physical and mental health conditions,
including interpersonal violence and substance addiction
❖ Particular health concerns from a prevention perspective
include obesity, injury, violence, and access to healthcare
facilities
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Veterans and Health
❖ 2 million reintegrated veterans in the civilian sector
❖ 1 million veterans suffering from nonvisible or visible
trauma
❖ Need for civilian nurses to understand military culture
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Human Trafficking
❖ Recruitment and transportation of people for exploitation
❖ Nurse’s role of recognizing victims and responding based
on approved protocol
❖ Maintaining safety of victim and healthcare personnel
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Homeless Populations #1
❖ Deinstitutionalization efforts of the 1960s to mainstream
the mentally ill into society
❖ Unemployment and underemployment
❖ Domestic violence
❖ Abandonment
❖ Natural disasters and fires
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Homeless Populations #2
❖ Disability
❖ Substance abuse and addiction
❖ Immigration
❖ Political unrest and wars
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Nurses’ Approach to Homeless People
❖ Show respect and use a positive approach, which builds
trust.
❖ Support primary (advocacy), secondary (tuberculosis
screening), and tertiary (“detox” treatment) prevention
to make it easier to cope with difficult, challenging lives.
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Key Nursing Considerations
❖ Recognize the biases and prejudices that can be barriers
to understanding the needs of populations.
❖ Community and family assessments need to be grounded
in trusting approaches.
❖ Allow nurses to do what they do best: heal, and not
necessarily fix, healthcare situations
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ï‚ž Defining Rape
ï‚– Multiple definitions
ï‚– May be a discrepancy between the legal definition and
common definition
ï‚– Definition used by this textbook-an unwanted act of oral,
vaginal, or anal penetration committed though the use of
force, threat of force, or when incapacitated
ï‚ž Benchmark
Study: National Violence Against
Women Survey (National Institute of Justice
and Centers for Disease Control, 1998)
ï‚– 1 in 6 (17%) women and 1 in 33 (3%) men have
experienced an attempted or completed rape (in the United
States)
ï‚ž Underreporting
ï‚– Other studies report 15-33% of women and 10-15% of men
experienced an attempted or completed rape (in the United
States)
ï‚– 3 out of 5 sexual assault victims stated the offender was an
intimate, relative, friend, or acquaintance which leads to
underreporting
ï‚– Sexual abuse of children under the age of 12 is rarely
reported
ï‚ž The Unique Situation of Sexual Abuse/Rape
Survivors
ï‚– Crises resulting from sexual abuse and rape differ in nature,
intensity, and extent from other forms of crisis
ï‚ž Social/Cultural
Factors
ï‚– Four different factors:
ï‚–
ï‚–
ï‚–
ï‚–
Gender inequality
Pornography
Social disorganization
Legitimization of violence
ï‚– Historically, the crime of rape has been seen as:
 A crime against the woman’s father or her husband
ï‚– Psychosocial means by which the victors in wars reward
themselves and humiliate their opponents
ï‚ž
Personal and Psychological Factors of Rapists
ï‚–
ï‚–
ï‚–
ï‚–
ï‚–
ï‚–
ï‚–
Acts hostile but often feels weak
Lacks interpersonal skills
May need to exercise power
May show sadistic patters
Sees women as sexual objects
Holds stereotypical and rigid views of males and females
Harbors chronic feelings of anger toward women and seeks to control
them
Rape as an exercise in power and control
ï‚ž Four categories of rapists:
ï‚ž
ï‚–
ï‚–
ï‚–
ï‚–
Anger
Power exploitative
Power reassurance
Sadistic
ï‚ž Rape
is just rough sex.
ï‚– Equating rape and sex is perhaps the most
destructive myth of all.
ï‚ž Women
“cry rape” to gain revenge.
ï‚– People do not want to believe that rape really occurs
ï‚– Serves to focus the blame for sexual violence on
victims rather than perpetrators
ï‚– Easier to believe than knowing rape can happen to
anyone
ï‚ž Rape is motivated by lust.
ï‚ž Rapists are psychotic or weird.
ï‚ž Survivors of rape provoked the
ï‚ž Only bad women are raped.
rape.
Rape happens only in bad parts of town, at night, or by
strangers with weapons.
ï‚ž If the woman does not resist, she must have wanted it.
ï‚ž Males cannot be victims.
ï‚ž Homosexuals are usually the perpetrators of sexual
abuse of boys.
ï‚ž Boys are less traumatized than girls.
ï‚ž Boys abused by males will later become homosexual or
rapists.
ï‚ž If a person experiences sexual arousal, this means it is
not rape.
ï‚ž A female can not rape a male.
ï‚ž
ï‚ž Date
Rape Risk
ï‚– Child sexual abuse is a risk factor for both heightened sexual
activity and sexual victimization in dating.
ï‚– Alcohol and drug use (by both the survivor and the
perpetrator) is a risk factor for acquaintance rape.
ï‚ž Preventing
Date, Acquaintance, and Other
Forms of Rape
ï‚– Educational programs, especially at the secondary school
level, have been recommended as preventive measures in
reducing acquaintance rape.
ï‚– Results show changes are only short-term.
ï‚ž Empathy
ï‚ž Build
a Working Alliance
ï‚ž Use Support Systems
ï‚ž Stop Secondary Victimization
ï‚– Police, medical professionals, significant others
ï‚ž Responses
ï‚– May exhibit no emotions
ï‚– May feel humiliated
ï‚– May suffer immediate and long-term trauma
ï‚– May blame themselves
ï‚– May be reluctant to go to the police or rape crisis center
ï‚ž Critical Needs
ï‚– Continuing medical treatment
ï‚– Support system (family, friends, work, etc.)
ï‚– Understanding without pressure regarding further sexual
contact
ï‚ž Critical Supports
ï‚– Understanding mood swings
ï‚– Ensuring safety without overprotection
ï‚– Allowing the victim to make decisions regarding reporting
the rape
ï‚– Allowing the victim to talk about the trauma without
disclosing the information to others
ï‚– Recognize that loved ones also exhibit issues
ï‚– PTSD
• Rape ranks second in the potential for PTSD
• EMDR as a first option for treatment
• Cognitive-behavioral treatment
• Exposure treatment
• Affect regulation
• Cognitive therapy
ï‚ž Psychological
Trauma and Sequelae
ï‚– Effects on Adult Survivors
ï‚– Higher incidence of:
ï‚–
ï‚–
ï‚–
ï‚–
ï‚–
ï‚–
Depression and anxiety
Borderline personality disorder and Dissociative disorder
PTSD
Social stigmatization and alienation
Somatic complaints
Negative self-image
ï‚– Revictimization
ï‚– Early assault is additive
ï‚ž False
Memories
ï‚– Controversial topic
ï‚– False Memory Syndrome Foundation
 “Recovered memory” survey
ï‚ž
Assessment
ï‚– Can be difficult to assess and diagnose due to multiple ways it may
manifest
ï‚ž
Treatment of Adults
ï‚– Treat in a similar way to PTSD
ï‚ž
Grounding
ï‚–
ï‚–
ï‚–
ï‚–
ï‚ž
Have the client focus on the therapist and the “here and now”
Ask the client to describe current INTERNAL experiences
Orient the client to the current environment
Use relaxation techniques
Validation
 Validate that the trauma did occur even if it is denied by the client’s
family
ï‚– Advocate for the client
ï‚– Reinforce the resourcefulness of the client
ï‚– Be a role model to help the client with childhood developmental tasks
ï‚ž Extinguishing
Trauma
ï‚– The reduction or termination of a conditioned response as a result
of the absence of the reinforcement
ï‚ž Prolonged
Exposure/Cognitive Restructuring
ï‚– Reframing and relearning feelings
ï‚ž Grief
Resolution
ï‚– Confrontation
ï‚– Changing behavior through skill building and reconnecting
ï‚ž Support
Groups for Adult Survivors
ï‚ž Dynamics
of Sexual Abuse in Childhood
ï‚ž Dynamics of Sexual Abuse in Families
ï‚– Intergenerational transmission of sexual abuse
ï‚– Female abusers
ï‚ž Phases
of Child Sexual Abuse
ï‚– Engagement Phase
ï‚– Sexual Interaction Phase
ï‚– Secrecy Phase
ï‚– Disclosure Phase
ï‚– Suppression Phase
ï‚– Survival Phase
ï‚ž Assessment
ï‚ž Therapeutic
Options
ï‚– Play Therapy
ï‚– Cognitive-behavioral Therapy
ï‚– Trauma Systems approach
ï‚ž Affirmation
and Safety
ï‚ž Regaining a Sense of Control
ï‚ž Education
ï‚ž Assertiveness Training
ï‚ž Interviewing
the Child
ï‚– Ensure safety
ï‚– Collect appropriate evidence
ï‚– Carl Perkins model
ï‚ž Preparing
the Child for Testimony
ï‚– Education on the process
ï‚– Role play possible situations
ï‚– Orientation of the courtroom
ï‚ž Aftermath
ï‚– Counseling
ï‚– Placement of the child
ï‚ž Group
Counseling
ï‚ž Boundary Issues
ï‚ž Group Support Work With Non-offending
Parents
ï‚ž Preventing Re-victimization
ï‚ž Individual Counseling
ï‚– Session 1: Establishing safe ground
ï‚– Session 2: Introducing traumatic material
ï‚– Crisis session
ï‚– Last sessions: Transcending

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