INFANTS AND YOUNG CHILDREN
The plummeting rates of infant mortality in the past cen- tury allowed health care professionals to move forward beyond infant survival and focus on prevention and early intervention with children’s health. Ideally, health pre- vention strategies targeting children’s health would begin as early as preconception. It has been learned, for exam- ple, that folic acid supplementation helps to prevent cer- tain birth defects. A fetus’ exposure to harm could poten- tially be prevented if a woman were counseled before pregnancy about the harmful effects of alcohol, tobacco, toxoplasma, and other teratogens (substances that adversely affect normal cellular development in the embryo/fetus). The fetal neurological system, especially the brain, is extremely vulnerable to even small amounts of potentially toxic substances.
Early intervention is especially important when it comes to growth and developmental delays. There is a well established link between developmental delays and learning diffi culties (Shonkoff & Phillips, 2000). Once
children reach school age, interventions are less likely to be effective if they have already begun to fail academically or socially. Today, a number of infant and child develop- ment screening tools have been developed and refi ned.
Unfortunately, however, close to one-third of develop- mental or behavioral disorders are not detected until children begin to attend school (Glascoe, 2000; Tebruegge, Nandini, & Ritchie, 2004).
The leading causes of death by age groups are revealing and offer clues about how to prioritize nursing interven- tions. SIDS is the leading cause of death among infants between the ages of 1 and 12 months. Accidents, or unin- tentional injuries, constitute the leading cause of death in children older than 1 year of age, which suggests that more community education and effort are needed to address child safety hazards. Although the incidence var- ies by age group, congenital malformations and malignant neoplasms shift between the second and fourth place for the leading cause of death in children.
Violence also takes a harsh toll on America’s children.
Homicidal assaults are the third leading cause of death of children in the 1- to 4-year-old age group, and also in the 15- to 19-year-old age group. Suicide is the third leading cause of death in teenagers and young adults, ages 15 to 24;
it is the sixth leading cause of death among children ages 5 to 14. Family violence, child maltreatment, and violence in schools such as bullying are also issues of great concern.
Anthropologists such as Sanday (1994) note that in American culture, “inter-personal violence has become a national pastime” (p. 2). The most watched television shows of 2005, Law and Order and CSI, were routinely based on violent acts. It is estimated that the average child will witness 9000 media murders by the time he or she fi nishes elementary school (Kunkel, 2001).
Violent video games are a more recent trend and research is still sparse regarding their effects on children.
A study by Anderson and Dill (2000) suggests that they may be even more harmful because they are interactive and the aggressor is the one glorifi ed and with whom the player identifi es.
There are other potentially preventable children’s health issues. Lead exposure provides another example where early intervention and teaching can have a posi- tive impact on children’s health. Exposure to lead can occur from contact with lead-based paint in older homes;
contaminated soil; a parent’s occupation; certain vinyl mini-blinds; various folk remedies; living close to major highways; and from contact with imported pottery, jew- elry or cosmetics. The American Academy of Pediatrics (AAP) recommends that all children between the ages of 1 and 2 years receive testing for lead exposure, since 25%
of homes presently occupied by children younger than the age of 6 have known lead contamination. Lead expo- sure has been linked to a number of medical and devel- opmental problems, including anemia, seizures, and mental retardation.
A trend not well understood is the alarming increase in childhood asthma, a condition that constitutes the most common cause of time missed from school. Asthma and allergies account for the loss of an estimated 2 million school days per year. In fact, the number one reason for pediatric emergency room visits due to chronic illness is for asthma-related problems.
Ch02_025-045-14864.indd 31
Ch02_025-045-14864.indd 31 12/12/08 2:24:21 PM12/12/08 2:24:21 PM
32 unit one Foundations in Maternal, Family, and Child Care
Other trends in children’s health status include a signifi cant rise in the diagnoses of attention-defi cit/
hyperactivity disorder (ADHD) and developmental delays due to autism. Children with ADHD are typically fi dgety, act without thinking, and have diffi culty focus- ing. ADHD now affects 4% to 8% of all school-age chil- dren (Glascoe, 2000). Autism is the third most common type of developmental delay in the United States. An autistic child presents as a solitary child and notably lacks social responsiveness to others. Autism affects lan- guage, which is absent, abnormal, or delayed. Autistic children may demonstrate a strong resistance to change and show an abnormal attachment to objects. The preva- lence of this disorder is diffi cult to gauge, since autism is not an easily accepted diagnosis, but it is estimated that it affects approximately 6 out of every 1000 children (Charles, 2006).
One way to visualize children’s health is to view it as an obstacle course. The fortunate child is one who was desired and planned for before conception and who has parents with a good genetic profi le, adequate resources, and who harbor no chronic illnesses. The fortunate child’s mother would have healthy eating habits; main- tain her ideal body weight; access early and regular pre- natal care; and abstain from the use of alcohol, tobacco, and other harmful substances. The child who does well through fetal life must then encounter birth and avoid major complications such as prematurity or aspiration pneumonia.
Following birth, the child must encounter the hurdles of the fi rst year of life to avoid becoming an infant mortal- ity statistic. She has to dodge SIDS and shaken baby syn- drome, and needs to be taken to health care providers for the hectic schedule of immunizations needed to prevent major childhood diseases. She must be fed and stimulated enough to grow physically, psychologically, socially, and emotionally. The child whose mother breastfeeds her gains an added bonus of immunities.
As the child matures, there are more obstacles to con- front. The child who attends day care faces a signifi cantly higher risk of infections. The tendency toward obesity and all the tempting fast food commercials on television offer additional stumbling blocks. She has to dodge all kinds of accidents that cause unintentional injury, tackle each developmental milestone, and land solidly in the “nor- mal” grid of childhood growth charts. Ideally, she will not develop asthma, autism, or ADHD. She will hope to avoid the stumbling blocks of sexual abuse, or coping with poverty, and poor housing in unsafe neighborhoods.
While parents work, the child’s day care environment may be laden with communicable childhood illnesses to be avoided. School-age children need to dodge being one of the 16% who are bullied (Volk, Craig, Boyce, & King, 2006). The obstacle course continues to pose challenges throughout childhood, and when adolescence arrives, the child again faces new foothills and crags.
Adolescents
Adolescents represent a population group with a set of issues uniquely their own. With regard to health care, adolescents are most often at risk for falling through the cracks. The adolescent must confront issues of self-esteem
along with demands to meet a cultural ideal, while at the same time deal with pressure to conform to gain peer acceptance. The adolescent may have to cope with changes in appearance such as acne and awkwardness. Reproduc- tive issues also arise. Girls must bridge the experience of menses, while boys encounter embarrassing erections and emissions. Issues such as sexuality, teen pregnancy, and sexually transmitted infections may pose further stum- bling blocks. Alcohol, tobacco, and drug use as well as bullies, gangs, and school violence may force more hur- dles in the envisioned obstacle course for the child to seek a full and healthy life.
One way nurses can make a difference is by learning and teaching others how to listen to children respectfully and value their experiences. Nursing can be called a “narrative profession” since patients present fi rst and foremost with their narratives of symptoms and illness. Children do so as well but it takes patience to really listen.
Nursing Insight—
Listening to our youngest patientsChildren tell us that we do not respect their expertise. The child who lives with an illness day by day holds the greatest insight into what it is to experience that illness. They come to know what the illness feels like, what treatments are neces- sary, what works, and what doesn’t. They often develop quite sophisticated knowledge about their medications and treat- ment. The diffi culty is that we do not give this knowledge and experience the same value as that held by the adults around them. Children also tell us that we do not give them uninter- rupted time to tell their story their way. Children, with their varying cognitive and communication abilities, need time to explain their illness experience and time to respond to our questioning. Sometimes, through adult eyes, their way of tell- ing us seems long and convoluted, and we therefore cannot resist the temptation of jumping in or interpreting what we think they are trying to say. Long story-telling does not fi t well in the busy world of practice (Dickinson, 2006).
Two of the priority goals for children in Healthy People 2010 address childhood vaccinations. One goal is to achieve and maintain effective vaccination coverage levels for universally recommended vaccines to 90% of children from 19 to 35 months of age and increase routine vaccina- tion coverage for adolescents. The second goal is to reduce vaccine preventable diseases as follows: (1) measles, mumps, and rubella to zero cases and (2) pertussis in children younger than 7 years to no more than 2000 cases per year (CDC, 2005).
Now Can You— Describe nursing actions that can serve to improve the current status of children’s health in the United States?
1. Describe two benefi ts of preconceptual health guidance and early intervention?
2. Discuss major causes of child mortality and describe nursing interventions that can make a difference?
3. Compare and contrast communication strategies for children with those of adults?
Ch02_025-045-14864.indd 32
Ch02_025-045-14864.indd 32 12/12/08 2:24:22 PM12/12/08 2:24:22 PM
chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 33
FAMILIES
Today’s world is full of complex, overlapping conditions and trends that infl uence the health of American families.
Families are often the core unit where health habits are fi rst formed. One of nursing’s most important roles is to foster the health capacity of families, whether those fami- lies are blood-related or are families of choice.
Families do not exist in a vacuum, but are situated within communities and regions that often have unique social and physical characteristics. Surrounding environ- mental hazards affect family health. Natural disasters such as earthquakes, hurricanes, tornadoes, fl oods, and fi res have favorite regional targets. Such disasters cause more damage when they strike high-population areas. Commu- nities with high poverty rates are more likely to have older, run-down homes with more asthma-producing sources, such as mold, lead, and pests. Poorer neighbor- hoods are more likely to be closer to highways and regional waste sites.
Access to health insurance is an enormous factor that affects the health status of families in what is considered the richest country in the world. There is an ever increas- ing number of uninsured and underinsured citizens in the United States. More than 45 million Americans were unin- sured at last count in 2004 (U.S. Department of Health and Human Services [DHHS], 2005b). One concerning trend is the erosion of employer-provided insurance.
Today’s employees are no longer guaranteed health insur- ance coverage through their jobs. According to the National Coalition on Health Care (2007), employer- sponsored health insurance fell 5 percentage points between 2000 and 2004, from 66% to 61%.
A recent study conducted by investigators at Harvard University found that illness and medical bills constitute the leading cause of personal bankruptcy and affect approximately 2 million Americans each year (Warren, 2005). Those with health insurance coverage frequently have gaps in coverage that can lead to missed appoint- ments or the inability to fi ll a needed prescription. Health care problems among children extend beyond the millions who are uninsured, because for each of those children is another who misses a doctor’s appointment or fi lled pre- scription due to coverage gaps in their parents’ plans.
Researchers suggest there are many more children in the nation receiving inadequate health care than are refl ected in the uninsured fi gures. Persons without health insur- ance have limited access to health care and are left vulner- able to the effects of illness, both physical and fi nancial.
One of the more ambitious goals of Healthy People 2010 is to increase to 100% the proportion of persons with health insurance.
WOMEN
The leading cause of death for women in the United States in 2005 was heart disease, which accounted for 28.6% of all female deaths. Cancer represented the second leading cause at 21.6%, followed by cerebral vascular disease (stroke) as third, which accounted for 8.0%.
There is plenty of room for improvement in health behaviors that are precursors to heart disease. According to the 2002 CDC’s Behavior Risk Factor Surveillance System
(BRFSS),two-thirds of women in the 25- to 65-year-old age group do not get the recommended 30 minutes of daily physical activity. One in fi ve adult women smoke tobacco.
With regard to nutrition, 72% of women do not get the rec- ommended fi ve or more servings of vegetables and fruits per day. There are also defi ciencies in calcium and folic acid intake, nutrients important to women’s health. Folic acid is a B vitamin that is linked to prevention of certain birth defects. Calcium is important to bone health. Lack of cal- cium contributes to osteoporosis, which makes a person susceptible to fractures, which can lead to disability and death (U.S. DHHS, 2005a).
Perinatal Health
In the area of perinatal health, national statistics reveal that over the past 20 years, there has been no decline in the number of pregnancy-associated deaths. According to the CDC (2005), two to three women in the United States die from pregnancy complications each day. Studies show that at least one-half of pregnancy-related deaths could be prevented. One reason for the recent escalation in high- risk pregnancies is related to pregnancies that occur in women with preexisting chronic conditions. Complica- tions before childbirth account for more than 2 million hospital days of care and more than $1 billion spent each year in this country. In actuality, this number would be even higher if it also included complications that occur during and after childbirth.
Several years ago, health care professionals in Florida developed a program to address these issues at the state- wide level. Florida’s Pregnancy Associated Mortality Reviews (PAMR) is a best practices example of how nurses initiated a plan to mobilize an entire state to work on improving pregnancy outcomes and reducing maternal mortality. PAMR started in 1996 in response to a cluster of maternal deaths noted in one particular county. Nurses organized an interdisciplinary team with wide representa- tion, consisting of nurses, nurse-midwives, obstetricians, fetal-medicine specialists, family physicians, emergency medical services personnel, medical examiners, pediatri- cians, social workers, researchers from colleges of public health, and insurance payers. Using all available sources of data (i.e., physician offi ce and hospital records, EMS records, autopsy reports), a nurse abstractor compiles the cases and sends them to each team member for review. The interdisciplinary team then meets, reviews each case, and collectively develops solutions for the identifi ed problems.
Confi dentiality is key to the entire process. No providers’
names are ever used and if team members recognize case details, they do not reveal that information. Contracts of confi dentiality are signed at each quarterly session. To date, several important gaps in care have been discovered and recommendations and changes were made based on team fi ndings. In addition, trends in pregnancy-associated deaths have been identifi ed, leading to enhanced services and innovative approaches in caring for pregnant women.
Four million women give birth each year in the United States. Interestingly, in this day where there are more con- traceptive methods than ever before, at least one-half of all pregnancies are unintended or mistimed. Another Healthy People 2010 goal is to reduce unintended pregnancies to 30% or lower by 2010. Currently, there are some positive
Ch02_025-045-14864.indd 33
Ch02_025-045-14864.indd 33 12/12/08 2:24:22 PM12/12/08 2:24:22 PM
34 unit one Foundations in Maternal, Family, and Child Care
trends in perinatal health. For example, women are start- ing their prenatal care earlier. In the latest CDC Behav- ioral Risk data (2004), 83.9% of women initiated prenatal care during the fi rst trimester. Smoking during pregnancy decreased from 20% in 1989 to less than 11% in 2003.
Also, today, there is more published information about proper nutrition, folic acid, and healthy lifestyles than ever before.
There is evidence that contemporary health care systems are more cognizant of women’s needs. Children maneuver- ing giant balloons as they eagerly bounce down the post- partum hall en route to visit their mothers and newborn siblings is a welcome and familiar sight. There is more understanding in research circles about the differences in the health care needs of women and men. Women are being empowered more in health care settings, enabling them, in turn, to make better health care decisions for their families.
Now Can You— Discuss elements of the current health status of American families and women?
1. Discuss how recent national trends have affected families’
access to health insurance?
2. Identify the three leading causes of death in women in the United States?
3. Describe a state-wide model developed by nurses to improve pregnancy outcomes and reduce maternal mortality?