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Diversity among individuals, as well as cultures, provides a challenge for nurses when it comes to delivering meaningful health promotion and illness prevention-based education. How do teaching principles, varied learning styles (for both nurses and patients), and teaching methodologies impact the approach to education? How do health care providers overcome differing points of view regarding health promotion and disease prevention? Provide an example.

Minimun 250 words

Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013

or to seek care. Attention to this type of cross-cutting factor is not commonly employed in more theoretically shallow public health analyses of barriers and promoters of disease. This study highlights the importance of moving beyond uni-dimensional approaches to be able to capture the dynamics of social practices that operate across multiple dimensions of people’s lives in ways that may not immediately appear related to health. We demonstrate how structural forces simultaneously directly inhibit access to appropriate healthcare services and create fear among immigrants in Albuquerque, acting to further undermine health and nurture disparity. Although fear is not normally directly associated with diabetes health outcomes, in the community where we conducted this study participant narratives discussed fear and health as interconnected. People’s everyday lives are framed by fear. For residents of the ID, fear is both a psychological barrier for those seeking access to healthcare services and a further burden of stress that negatively affects their health. Institutional and social inequalities, poverty, discrimination, immigration status issues, and cultural bias, create an experiential landscape that generates fear. People are afraid because they recognize their inability to deal effectively with costs, language barriers, immigration documentation requirements, and the cultural incompetence of others that makes people feel inadequate. Fear is pervasive and multidimensional. Our study corroborates what Singer (2001) observed of social inequalities and health, namely, that structural forces create the social, emotional, and physical conditions that invite and sustain disease. Among Hispanic immigrants in the ID, fear is one of these conditions. Using a structural violence framework to conceptualize the multidimensionality of this fear, we can see how structural violence operates to further limit the personal agency of individuals already significantly constrained by structural inequality. Physician-anthropologist Arthur Kleinman (2006a) observes that a limit in personal agency causes an “enervating anxiety…[an] existential fear that wakes us at 3 a.m. with night sweats and a dreaded inner voice, that has us gnawing our lip, because of the threats to what matters most to us.” This type of existential fear is palpable in the ID, dramatically undermining the opportunity for immigrants at risk for diabetes to be healthy. Given the consequences of diabetes, the result is ultimately a matter of life and death. In this study, we aim to use our research to “ask questions about the assumptions built into public health studies…as a way to understand [the] embodied reality” (Coleman 2011, p. 13) of inequality. By expanding our theoretical repertoire to include frameworks from social theory, we are able to reveal dynamics underpinning health disparity in an immigrant community that are not commonly the focus of attention in public health research or interventions. As part of our analysis of structural violence in the landscape of diabetes in the ID, we identify the multidimensionality of fear. We give voice to what matters to individuals who have been made to seem invisible by a “regime of disappearance” (Goode and Maskovsky 2001, p. 17) created through a paradigm of research that tends to ignore and maintain a convenient ignorance of the structural forces that institutionalize inequality and produce and maintain health disparity. This “regime” makes health disparity appear as an unavoidable consequence of the natural order of things, reflecting risk factors internal to or specific to individuals, and allows the silo-ing of health from other dimensions of life. In this regard, the structural violence lens helps to reintegrate our understanding of health by illuminating and emphasizing the extent to which the dynamics of disparity are structured by broader political, economic and social forces. Deeper theorizing allows us to activate our conceptualization of how the social determinants of health operate rather than merely acknowledging that they exist. Like the IOM report (2002) on racial and ethnic disparities in health care, the data from our study demonstrate that effective diabetes prevention in communities like the ID requires that

43 Health Disparity and Structural Violence- Page-Reeves, et al.

Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013

we move beyond the focus on barriers and promoters that is common in public health research; if we are to reduce or eliminate diabetes health disparities, we must address factors previously assumed to be beyond the focus of public health, such as fear and its multiple root causes. Yet this means moving outside of the comfort zone created by the positioning of health research as separate from or above the need to address structural inequality. Those of us who attempt to approach the work of public health from a broader perspective are routinely instructed that such a focus is the purview of other disciplines, too far afield from health-related concerns, or too political. The perspective common in public health research is nicely summed-up in the experience of one of the authors who was told by a colleague leading a project that it was not possible or appropriate to think about or investigate poverty in relation to the public health issue that was the focus of the research, despite the fact that the community of study was characterized by significant levels of poverty and health disparity that had provided the central rationale for the research. Given the need to address the health disparities that are destroying lives in the ID and similar communities, public health as a discipline can no longer legitimately espouse an interest in addressing health disparity through environmental and policy change or “community empowerment” while generally being unwilling to think about non-health related factors and dynamics that generate disparity. Of course, this shift is extremely challenging given the epistemological tendency in public health to narrow the focus of research in order to improve the scientific quality of the variables, the concern that funders will find a broader focus distasteful, and the discomfort that many researchers (and Americans in general) feel about discussing structural inequality, its roots and our own potential complicity or participation in the creation and maintenance of privilege and disparity. Without this paradigm shift, however, we fear that hoped for improvements in health equity delineated clearly in the Final Report of the Commission on Social Determinants of Health from the World Health Organization (CSDH, 2008) will not be possible. Incorporating social theory (such as the structural violence framework utilized in the analysis presented here) into the way that we conceptualize public health contexts and the way that we view the purpose and focus of our own research helps to move us toward embracing a new research paradigm challenging the status quo. This shift improves the potential for our work to meaningfully reduce and eliminate disparities such as those experienced in relation to diabetes by immigrants in the ID.

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