Community Study Guide for the Hesi

Population Groups across the LifespanHealth Risks

InfantsNumber 1 cause of injury or death is suffocation followed by Motor Vehicle Accident then Homicide.Sudden Infant Death SyndromeInfection is the most significant cause of illness in infants and children.ChildrenObesity – Healthy people objectives have addressed youth fitness and obesity

Defined by using BMI which is a ratio of weight to height Risks for childhood obesity were related to obesity in the parents Obesity rates higher populations such as Native American, Hispanic, and

African Americans groups. Lower socioeconomic groups in urban settings have been associated with higher rates

Injuries and Accidents- Number one cause of death in ages 1 – 24 yrs.Motor vehicles accidents are the leading cause of death among children and teenagers. Toddlers experience a large number of falls, poisonings, and motor vehicle accidentsSchool age children has the lowest injury death rate; however, this group has difficulty judging speed and distance, placing them at risk for pedestrian and bicycle accidents.Adolescents injury accounts for 75% of all deaths and risk-taking becomes more conscious at this time especially among males.Suicide is the second leading cause of death among youths between the ages of 15 and 24. Suicide s the third leading cause of death among youth between the ages of 10 and 24 years.

Acute Illness- also a significant cause of illness in children.

Chronic Health Problems- improved medical technology has increased the number of children surviving with chronic health problems. Examples: Down Syndrome, spina bifida, cerebral palsy, asthma, diabetes, congenital heart disease, cancer, hemophilia, broncopulmonary dysplasia, and AIDS

Routine immunizations have been very successful in preventing selected diseases.

Good nutrition is essential for healthy growth and development and influences disease prevention in later life.

WomenThe women’s health movement was pivotal in bringing national recognition to women’s health issues. Women have a longer life expectancy than men

Women are more likely to have acute and chronic conditions that require them to use more services than men.Women of color are more statistically more likely to have poor health outcomes because of poor understanding of health, lack of access to health care, and lifestyle practices.Heart disease leading cause of death in womenLung Cancer leading cause of cancer in women and 2nd leading cause of death

MenMen are physiologically the more vulnerable gender, shorter life span and higher infant mortality rateLife expectancy of men in the US is one of the lowest in the developed countriesMen engage in more risk-taking behaviors than womenMen tend to avoid diagnosis and treatment of illnesses that may result in serious health problems

ElderlySteadily growing populationIncrease in chronic conditions, demand for services, and strained health care budgetsMore older adults live in the community Nurses address the chronic health concerns of elders with a focus on maintaining or improving self-care and preventing complications to maintain the highest possible quality of life.Assessing the elderly incorporates physical, psychological, social, and spiritual domains.Individual and community focused interventions involve all three levels of prevention through collaborative practice.

U.S. Healthcare problemsMore than 43 million people in the United States are uninsured, and many more simply lack access to adequate health care.

Health care reform measures seek to make changes in the cost, quality, and access of the present system.

The integration of primary care and public health is necessary for the future health of the nation

To achieve the specific health goals of programs such as healthy People 2010, primary care and public health must work within the community for community-based care.

The most sustainable individual and system changes come when people who live n the community have actively participated.

Nurses are more than able to fill the gap between personal care and public health because they have skills in assessment, health promotion, and disease and injury prevention; knowledge of community resources; and ability to develop relationships with community members and leaders.

Home Visits- give a more accurate assessment of the following than do clinical visits:- the family structure- the natural or home environment- behavior in that environment

Home visits provide opportunities to identify both barriers and supports for reaching family health promotion goals.

Home visits afford the opportunity to gain a more accurate assessment of the family structure and behavior in the natural environment. Home visits also provide opportunities to observe the home environment and to identify both barriers and supports to reducing health risks and reaching family health goals.

Parish nurses: nurses who respond to health and wellness needs within the faith context of population of faith communities and are partners with the church in fulfilling the mission of health ministry.

Parish nursing: a community-based and population-focused professional nursing practice with faith communities to promote whole person health to its parishioners usually focused on primary prevention.

Parish nurse coordinator: a parish nurse who has completed a certificate program designed to develop the nurse as a coordinator of a parish nursing service.

Parish nurse services respond to health, healing, and wholeness within the context of the church. Although the emphasis is on health promotion and disease prevention throughout the life span, the spiritual dimension of nursing is central to the practice.

The parish nurse partners with the wellness committee and volunteers to plan programs and consider health-related concerns within faith communities

To promote a caring faith community, usual functions of the parish nurse include personal health counseling, health teaching, facilitating linkages and referrals to congregation and community resources, advocating and encouraging support resources, and providing pastoral care.

Parish nurses collaborate to plan, implement, and evaluate health promotion activities considering the faith community’s beliefs, rituals, and polity. Healthy People 2010 guidelines are basic to the partnering for the programs.

Nurses working in the parish nursing specialty must seek to attain adequate educational and skill preparation for the accountability to those served and to those who have entrusted the nurse to serve

Nurses are encouraged to consider innovative approaches to creating caring communities. These may be in congregations as parish nurses, among several faith communities in a

single locale, or regionally; or in partnership with other community agencies or models such as block nursing.

To sustain oneself as a parish nurse healer, the nurse takes heed to heal and nurture self while supporting individuals, families, and congregation communities in their healing process.

Hospice: palliative system of health care for terminally ill people; takes place in the home with family involvement under the direction and supervision of health professionals, especially the visiting nurse. Hospice care takes place in the hospital when sever complications of terminal illness occur or when family becomes exhausted or does not fulfill commitments.

Professional Preparedness Requires nurses and other personnel to be aware of and understand the disaster plans at their workplace and community- participate in mock drills Adequately prepared nurses will function in leadership capacity and assist towards smoother recovery phase Fieldwork, shelter management requires creativeness and willingness American Red Cross provides training for health professionals to adapt existing skills to disaster setting

Role of Community Health Nurse Can initiate or update disaster plans at workplace and community and ensure education, drill participation Knowledge of vulnerable populations, available community resources Assessing and reporting of environmental hazards, unsafe equipment, faulty structures, disease outbreaks, e.g., measles, flu

Before anything happens: Prepare for Safety in a Disaster : Four steps1. Find out what could happen to you:

a. Determine what types of disasters are most likely to happenb. Learn about warning signals in communityc. Ask about care for petsd. Review the disaster plans at workplace, and other places where families

spend time togethere. Determine how to help the elderly or disabled

2. Create a disaster plana. Discuss types of disasters that are likely to happen and review what to dob. Pick 2 types of places to meetc. Choose an out-of-state friend to contactd. Review evac. Plans

3. Complete this checklista. Post emergency numbers next to phoneb. Teach how to call 911c. Determine when and how to turn of water, gas, and electricityd. Check adequacy of insurance coveragee. Locate and review use of fire extinguishersf. Install and maintain smoke detectorsg. Conduct a home hazard hunth. Stock emergency suppliesi. CPR certificationj. Locate all escape routesk. Find safe spots

4. Practice and maintain your plana. Review every 6 mos.b. Conduct drillsc. Replace stored water every 3 mos. and stored food every 6 mos.d. Test and recharge fire extinguishere. Test smoke detectors

Personal PreparednessNurses who are disaster victims themselves and provide care to others will experience considerable stress.

American Red Cross and Federal Emergency Management Agency (FEMA) are two well known authorities on disaster preparedness, response, and recovery

Three levels1st level – Personal Preparedness2nd level- Professional Preparedness3rd level- Community Preparedness

Most states and counties have an Office of Emergency Management (OEM) that is responsible for developing and coordinating emergency response plans within their defined area. The state office supports local OEMs and other state agencies that participate in disaster response. It provides planning and training services to local governments, including financial and technical assistance. During an actual emergency or disaster, the state OEM coordinates a state response and recovery program if necessary. County OEMs are in charge of creating a comprehensive, all-hazard plan that should address realistic dangers to the community and list available resources.

**Nurses need to review the disaster history of community, including how past disasters have affected the health care delivery system, how their particular organizations fit into the plan, and what role they and their organizations are expected to play in a disaster.

Stages: Preparedness, Response, and Recovery

Preparedness: Know who is at risk, Personal, Professional and Community Preparedness

Personal Preparedness Entails plan for keeping oneself ready for disaster, both mentally and physically Individuals not personally prepared will have less to give to family, community, job, and other disaster victims Nurses can be disaster victims- personal preparation needed to attend to patients Checklist helpful to prepare

Professional Preparedness Requires nurses and other personnel to be aware of and understand the disaster plans at their workplace and community- participate in mock drills Adequately prepared nurses will function in leadership capacity and assist towards smoother recovery phase Fieldwork, shelter management requires creativeness and willingness American Red Cross provides training for health professionals to adapt existing skills to disaster setting

Community Preparedness Level of preparedness only as high as people/ organizations in the community make it Well-prepared communities have written disaster plans, conduct drills, have adequate warning system, and backup evacuation plan Office of Emergency Management- state/ county office coordinating regional plans Understanding past disasters can influence planning for future, liabilities in resources

Response

The primary objective of disaster response is to minimize morbidity and mortality. The level of disaster determines FEMA’s response. Levels are not determined by the number of casualties but by the amount of resources needed.

FEMA Levels of Disaster Response Level III- a minor disaster, involves a minimal level of damage but could result in the president declaring an emergency. A minimal request for federal help Level II- moderate disaster- likely to result in major disaster being declared. Regional federal resources engaged, other outside area may be called on

Level I- massive disaster, severe damage or multistate scope. Full engagement of federal regional and national resources Citizens and health professionals must be attached to official agencies with disaster management responsibilities to avoid further risk

American Red Cross3 ways to classify a disaster : Type- agent that caused the event, such as hurricane, hazmat, transportation

Level- anticipated or actual Red Cross response and relief costsLevel I. costs less than $10,000Level II costs $10,000 or more, but less than $50,000Level II costs $50,000 or more, but less than $250,000Level IV costs $250,000 or more but less than $2.5 millionLevel V costs $2.5 million or more

Scope- magnitude of the event, units affected and responding ,e.g., single-family, local, state, major, federally declared

Single family – affects an individual or single family- occurs within the jurisdiction of a single Red Cross chapterLocal Disaster- Affects more than one family, occurs within the jurisdiction of a single Red Cross chapterState Disaster- Affects multiple families, occurs within the jurisdiction of one or More Red Cross chapters within a single stateMajor Disaster- has one or more of the following characteristics

-coordinated response of multiple Red Cross units- affects more than a single state- creates national news - result in emergency or disaster declaration by the President etc.

Presidentially Declared Disaster- requires full or partial implementation of the National Response Plan

The National Response PlanOnce a federal emergency has been declared, the National Response Plan may take effect, depending on specific needs arising from the disaster. The NRP is a concerted effort to prevent terrorist attacks within the US; reduce American’s vulnerability to terrorism, major disasters, and other emergencies; and minimize the damage and recover from attacks, major disasters, and other emergencies that occur.

Role of the Nurse Role in disaster response depends on nurse’s past experience, role in community disaster preparedness, specialized training, special interest

Community health nurses valued for skills in community assessment, case finding, prevention, education, surveillance, working with aggregates

Plans for triage must begin as soon as rescue workers arrive- highest priority given to life-threatening injuries with high probability of survival- nurse’s accurate assessment info will help match available resources to population’s emergency needs

RecoveryThe recovery stage of disaster occurs as all involved agencies pull together to restore the economic and civic life of the community. For example: the government takes the lead in rebuilding efforts whereas the business community tries to provide economic support.

Nurse’s Role in Recovery Multifaceted responsibilities- flexibility required to assist in successful recovery Teaching health promotion, disease prevention, assessment of physical, psychological problems incurred in cleanup efforts, as well as threat of communicable disease Case finding, referral for mental distress Assessment and reporting of environmental health hazards resulting from event

Get community back to normal, deal with emotional matters and after effectsAssess what might be going on in community using primary, secondary and tertiary care

TerrorismRole of the Nurse: Help people cope with the aftermath of terrorism Allay public concerns and fears of bioterrorism Identify the feelings that you and others may be experiencing Assist victims to think positively and move to the future Prepare nursing personnel to be effective in a crisis situation

Nurses are concerned with anthrax and small pox and should have awareness of these diseases

Need to have vaccine for small pox

Levels of prevention r/t Disaster Management

Primary Prevention- Participate in developing a disaster management plan for the community

Secondary Prevention- Assess disaster victims and triage for care

Tertiary Prevention- Participate in home visits to uncover dangers that may cause additional injury to victim or cause other problems (e.g. house fires from faulty wiring).

Population at Greatest Risk for Disruption After a DisasterPersons with disabilitiesPersons living on a low income, including the homelessNon-English speaking persons and refugeesPersons living aloneSingle-parent familiesPersons new to the areaInstitutionalized persons or those with chronic mental illness Previous disaster victims or victims of traumatic eventsPeople who are not citizens or legally documented immigrantsSubstance abusers

The five components to a comprehensive public health response to outbreaks of illness are the following

- Detecting the outbreak- Determining the cause- Identifying factors that place people at risk- Implementing measures to control the outbreak- Informing the medical and public communities about treatments, health

consequences, and preventative measures

Triage: the process of separating casualties and allocating treatment on the basis of the victims’ potentials for survival.

- Highest priority is always given to victims who have life threatening injuries but who have a high probability of survival once stabilized

- Second priority is given to victims with injures that have systemic complications that are not yet life threatening and could wait 45 – 60 minutes for treatment

- Last priority is given to those victims with local injuries without immediate complications and who can wait several hours for medical attention.

Rationale from SaundersIn an emergency department, triage is classifying clients according to their need for care and includes establishing priorities of care. The kind of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority.Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or the client with a renal stone have urgen needs and are classified as number 2 priorities.Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority.

Older adult health risks

Nutrition, safety, social isolation, and depression

Need to assess the health literacy of the client first

Program outcomes: smoking cessation, weight management, diabetic management- look at the evaluation of the specific outcome- Identifying changes in the client’s health status that result from nursing care

provides nursing data that demonstrate the contribution of nursing to the health care delivery system.

Research studies using the tracer or sentinel method to identify clients’ outcomes and client satisfaction surveys can be used to measure outcome standards.

From data, strengths and weaknesses in nursing care delivery can be determined.

The most common measurement methods are direct physical observations and interviews.

Primary Care- refers to organized community efforts designed to prevent disease and promote health (education).

Secondary Care- an intermediate level of health care that includes diagnosis and treatment. Screening.

Tertiary Care- rehabilitation and return of a patient to a status of maximum usefulness and a minimum risk of recurrence of a physical or mental disorder

Levels of Prevention

Primary Prevention- Counsel clients in health behaviors related to lifestyle

Secondary Prevention- Implement a family-planning program to prevent unintended pregnancies or young couples who attend the primary clinic

Tertiary Prevention- Provide a self-management asthma program for children with chronic asthma to reduce their need for hospitalization (prevent from getting worse)

Federal Agencies

Many federal agencies are involved in government health care functions. The agency most directly involved with the health and welfare of Americans is the U.S. Department of Health and Human Services

U.S. Department of Health and Human Services (USDHHS)Largest health program in the world, its mission is to enhance the health and well-being of the American people through the following:

- Alcohol, drug abuse, and mental health programs- Disease tracking and identification- Health care access for all and integrity of the nation’s health entitlement and

safety net programs- Identification and correction of health hazards - Medical assistance after disasters- Medical research- Promotion of exercise and healthy habits- Protection of the nation’s food and drug supply

The Health Resources and Services Administration of the USDHHS contains the Bureau of Health Professions, this bureau includes separate divisions for nursing, medicine, dentistry, public health, and allied health professionsThe Division of Nursing administers nurse education legislation, interprets trends and nursing needs of the nation’s health care delivery system, and serves as a liaison with the nursing community and with international, state, regional, and local health interests

Two other agencies with the DHHS:The National Institute for Nursing Research (NINR) and Healthcare Research and Quality (AHRQ)This institution is the focal point of the nation’s nursing research activities. It promotes the growth and quality of research in nursing and patient care, provides important leadership, expands the pool of experienced nurse researchers, and serves as a point of interaction with other bases of health care research

Nurses can apply for support for research, projects, or training from a variety of agencies within the federal government besides the NINR of the Division of Nursing.

Other federal agencies: Dept. of Commerce, Dept. of Defense, Dept. of Labor (includes OSHA), Dept. of Agriculture (includes WIC), Dept. of Justice, Food and Drug Administration.

Voluntary and Private Nonprofit AgenciesVoluntary and private agencies are grouped together as nonprofit home health agencies, voluntary agencies are supported by charities such as United Way, Medicare, Medicaid, other third-party payers, and client payment.

The amount of financial assistance the voluntary agency receives depends on the community it serves. With Medicare, the private nonprofit agency emerged as an alternative agency to the public-supported program. These agencies included rehabilitation agencies, based in either rehabilitation facilities or skilled facilities.

Nurses use assessment skills to detect potential and actual exposure pathways and outcomes for clients cared for in the acute, chronic, and healthy communities of practice.

Risk communication is an important skill and must acknowledge the outrage factor experienced by communities with environmental hazards.

Vulnerable populations- are those groups who have an increased risk to develop adverse health outcomes, vulnerable populations often experience multiple cumulative risks and they are particularly sensitive to the effects of those risks.

Vulnerable populations often are more likely than the general populations to suffer from health disparities.

Examples of areas that show health disparities across populations groups are infant mortality, childhood immunization rates, and disease-specific mortality rates.

Vulnerable Population Groups of Special Concern to Nurses- Poor and homeless people- Pregnant adolescents- Migrant workers and immigrants- Severely mentally ill individuals- Substance abusers- Abused individuals and victims of violence- Persons with communicable disease and those at risk- Persons who are human immunodeficiency virus (HIV positive) or have Hep B or

sexually transmitted disease.

Behavioral (Lifestyle) Health Risk AssessmentFamilies are the major source of factors that can promote or inhibit positive lifestyles. It is important to look at risks for the family as a unit.

Critical dimensions of lifestyle risks include the following:- Value placed on behavior- Knowledge of the behavior and its consequences- Effect of the behavior on the family- Effect of the behavior on the individual- Barriers to performing the behavior- Benefits of the behavior

It is important to assess the frequency, intensity, and regularity of specific behaviors. It also is important to evaluate the resources available to the family for implementing the behaviors.

Modifiable Risk and Unmodifiable RisksRisk factors that are "unmodifiable," are things that neither you nor your patients can do anything about. You need to know the "unmodifiable" risk factors, because they help you to define high-risk individuals and groups for whom treating or controlling the "modifiable" risk factors is a priority.

Mmodifiable risks can be changed such as smoking.

Epidemiology – how to calculate a rate The denominator includes the numerator

Example Crude birth rate Number of live births during 1 year X1000 Midyear population

Evaluating OutcomesOutcomes can be measured by looking at changes from before and after the intervention to solve the problems. Changes in the following can be used to see the outcomes of the interventions:

- Demographics- Socioeconomic factors- Environmental factors- Individual and community health status- Use of health services

In the example of infant malnutrition, one would look for the number of cases of infant malnutrition in the community before providing education to other health providers about assessment of infant development. A time period for evaluation would be chosen and perhaps 1 year later (the time frame). The number of cases of infant malnutrition would be measured to see if a change had occurred and there were fewer cases.

Incidence rate- the frequency or rate of new cases of an outcome in a populations; provides an estimate of the risk of disease in that population over the period of observation

Prevalence: number of existing cases in a population at a given time

Nursing Process- Always assess before starting an intervention

Community assessment

Most nurses are familiar with the nursing process as it applies to individually focused nursing care. Using it to promote community health makes this same nursing process community focused.

Community assessment- the process of critically thinking about the community and involves getting to know and understand the community as partner. The community assessment phase involves a logical, systematic approach to the initial phase of the nursing process. Community assessment helps as follows:

- To identify community needs- To clarify problems- To identify strengths and resources

Assessing the community health requires the following three steps:- Gathering relevant existing data and generating missing data- Developing a composite database- Interpreting the composite database to identify community problems and strengths

Data Collection and Interpretation The primary goal of data collection is to get usable information about the community and its health. The systematic collection of data about community health requires the following:

- Gathering or compiling existing data- Generating missing data- Interpretation of data- Identifying community health problems and community abilities

Data gathering is the process of obtaining existing, readily available data. The following data usually describe the demography of a community

- Age of residents- Gender distribution of residents- Socioeconomic characteristics- Racial distributions- Vital statistics, including selected mortality and morbidity data

Identify needs, problems, strengths, resources and apply what you know.

Windshield survey- are the motorized equivalent of simple observation. They involve the collection of data that “will help define the community, the trends, stability, and changes that will affect the health of the community”

School Nurse:- Primary -The school nurse monitors the children for all of their state-mandated

immunizations for school entry.- Secondary- School nurse is involved in screening children for illnesses and

providing direct nursing care

- Tertiary – The school nurse cares for children with long-term health needs, including asthma and disabling conditions

School nurses carry out catheterizations, suctioning, gastrostomy tube feedings, and other skills in school.

The concern for health promotion of adolescents is safety because of their propensity to take part in risky behavior.

To effectively reach a population group you must connect with someone in the community and establish trust.

Occupational ExposureJob categories Exposure Work-related diseases and conditionsFarm workers pesticides, infectious HTN, mood disorders, cardiovascular Agents, gases, sunlight disease

Chemical workers solvents, cleansers, etc. Cancer, etc.

Complete list on page 637 in textbook

MedicareProvides hospital insurance and medical insurance to persons ages 65 years and older, permanently disabled persons, and persons with end-stage renal failurePart A – covers: hospital care and home care (home care or hospice – can’t have both), skilled nursing carePart B- covers: (non-institutional care insurance) Medical care, diagnostic services and physiotherapy.

Medicaid- Financial assistance to states and counties to pay for medical services for poor older adults, the blind, the disabled, and families with dependent children.

WIC- a special supplemental food program administered by the Department of Agriculture through the state health departments; provides nutritious food that add to the diets of pregnant and nursing women, infants, and children younger than 5 years. Eligibility is based on income and nutritional risk as determined by a health professional

Outreach worker: a health worker who makes a special, focused effort to find people with specific health problems for the purpose of increasing their access to health services

- evaluate effectiveness find out if successful and use ways to measure success

Epidemiologic triangle – agent, host, and environment – changes in one of the elements of the triangle can influence the occurrence of disease by increasing or decreasing a person’s risk for disease. Risk is the probability that an individual will experience an event.

Agent: an animate or inanimate factor that must be present or lacking for a disease or condition to developHost: a living species (human or animal) capable of being infected or affected by an agentEnvironment- all that is internal or external to a given host or agent and that is influenced and influences the host and/or agent

Agent- an animate or inanimate factor that must be present or lacking for a disease or condition to develop

- causive – example: E. coli- Infectious agents (bacteria, viruses, fungi, parasites)- Chemical agents (heavy metal, toxic chemicals, pesticides)- Physical agents (radiation, heat, cold, machinery)

Host- a living species (human or animal) capable of being infected or affected by an agent

- anything capable of being infected- Genetic susceptibility- Immutable characteristics (age, sex)- Acquired characteristics (immunologic status)- Lifestyle factors (diet, exercise)

Environment- all that is internal or external to a given host or agent and that is influences the host and or agent

- anything external- climate (temperature, rainfall)- Plant and animal life (agents or reservoirs or habitats for agents)- Human population distribution (crowding, social support)- Socioeconomic factors (education, resources, access to care)- Working conditions (levels of stress, noise, satisfaction)

Relationship between the above 3 cause disease, try to break the connection, if a break then there will be no disease.

Web of Causality- complex interrelations of factors interacting with each other to influence the risk for or distribution outcomes.

- recognizes the complex interrelationships of many factors interacting, sometimes in subtle ways, to increase (or decrease) the risk of disease.

- Associations are sometimes mutual, with lines of causality going in both directions

Family assessment

Ecomap- represents the family’s interactions with other groups and organizations, accomplished by using a series of circles and lines.

- It is represented by a circle in the middle of the page

- Other groups and organizations are then indicated by circles- Lines representing the flow of energy are drawn between the family circle and the

circles representing other groups and organizations- An arrowhead at the end of each line indicates the direction of the flow of energy

(into or out of the family)- The weight of the line indicates the intensity of the energy

Genogram- is a pictorial display of a person's family relationships and medical history. It goes beyond a traditional family tree by allowing the user to visualize hereditary patterns and psychological factors that punctuate relationships. It can be used to identify repetitive patterns of behavior and to recognize hereditary tendencies.

Prevention Strategies for Violence

Individual and Family levels- Assess during routine examination (secondary)- Assess for marital discord (secondary)- Educate on developmental stages and needs of children (primary)- Counsel for at-risk parents (secondary)- Teach parenting techniques (primary)- Assist with controlling anger (secondary)- Treat for substance abuse (tertiary)- Teach stress-reduction techniques (primary)

Community Level- Develop policy- Conduct community resource mapping- Collaborate with community to develop systematic response to violence- Develop media campaign- Develop resources such as transition housing and shelters

High school students and middle school students- steer away from violence and teach to work on their own skills and build their self-esteem.