NR 222 Unit 3 Notes

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NR 222: Unit 3 Notes Health Promotion Strategies and Interventions Lesson 1: The Healthy People Initiative Introduction to the Healthy People Initiative The Healthy People initiative identifies public health priorities to assist individuals, organizations, and communities across the United States to improve health and well-being. It provides 10-year, measurable objectives and tools to track progress toward achievement (Healthy People, n.d.). First developed in 1979, Healthy People 2030 is the fifth narration and builds upon the knowledge gained over the first four decades. The Healthy People initiative is a program to promote, strengthen, and evaluate the nation’s efforts to improve the health and well-being of all people. The program is to promote healthy development and behaviors for all ages, not just children. First developed in 1979, Healthy People 2030 is the fifth narration and builds upon the knowledge gained over the first four decades. It is not a new program. The program’s goal is to eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Type of Objective Description Core Measurable objectives that are associated with 10-year targets. Developmental Objectives that represent high-priority public health issues but do not yet have reliable baseline data. Research Objectives that represent public health issues with a high health or economic burden or significant disparities between population groups but are not yet associated with evidence-based interventions. The major difference between Healthy People 2020 and 2030 is an increased focus on health equity, social determinants of health , and health literacy . History of Healthy People Initiative

In 1979, Surgeon General Julius Richmond issued a landmark report titled “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention.” Then, in 1980, the Office of Disease Prevention and Health Promotion released Healthy People 1990, which was followed in later decades by new iterations of the Healthy People initiative, each building on the last (Healthy People, n.d.). Go through the timeline below using the arrows on either side or selecting a specific time period at the bottom. History of the Healthy People Initiative The first set of measurable 10-year objectives for improving health and well-being nationwide. It focused on decreasing deaths throughout the life span and on increasing independence among older adults. The second iteration was guided by three goals: increase the span of healthy life, reduce health disparities, and achieve access to preventive services for all. The third iteration had an increased focus on improving quality of life. Additionally, one of the main goals was to eliminate health disparities rather than simply reduce them. The fourth iteration had four goals:  Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death  Achieve health equity, eliminate disparities, and improve the health of all groups  Create social and physical environments that promote good health for all  Promote quality of life, healthy development, and healthy behaviors across all life stages The fifth iteration launched in August 2020 and has an increased focus on health equity, social determinants of health, and health literacy. Main Focus Decade of Focus Decrease overall deaths and increase independence of older adults 1990 Reduce health disparities and achieve preventive access for all 2000 Improve quality of life and eliminate health disparities 2010

Main Focus Decade of Focus Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death 2020 Focus on health equity, social determinants of health, and health literacy 2030 Mission, Vision, and Goals The Healthy People initiative emphasizes how the health of communities affects the overall health status of the nation. Healthy People 2030 is the fifth iteration of the initiative. It builds on the knowledge gained and lessons learned to address the latest public health priorities (Healthy People, n.d.). Mission and Vision: The mission is to promote, strengthen, and evaluate the nation’s efforts to improve the health and well-being of all people. Healthy People 2030’s vision is to have a society in which all people can achieve their full potential for health and well-being across the lifespan. Overarching Goals: Healthy People 2030’s overarching goals are to:  Attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death.  Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.  Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.  Promote healthy development, healthy behaviors, and well-being across all life stages.  Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all. Overall Health and Well-Being Measures Overall health and well-being measures (OHMs) are broad, global outcomes intended to assess the Healthy People 2030 vision. There are eight OHMs, organized into three tiers: well-being, healthy life expectancy, and mortality and health. The OHMs do not have targets and are not considered objectives. Each OHM is addressed by either core, developmental, or research objectives (Healthy People, n.d.). OHMs are monitored throughout the decade to illustrate the overall health and well-being of the population and to demonstrate improvements. Let’s learn more about OHMs.

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Well-Being: Overall well-being (OHM-1) is the only one in this category and is expressed as overall life satisfaction. Healthy Life Expectancy: There are three OHMs in this category, which combine a summary measure of mortality and health. These measures represent the expected number of years a person in good health will live, defined as free of activity limitation, disability, and in good health.  Life expectancy at birth – free of activity limitation (OHM-2)  Life expectancy at birth – free of disability (OHM-3)  Life expectancy at birth – in good or better health (OHM-4) Mortality and Health: There are four OHMs in this category, which are used individually and as components of the healthy life expectancy measures.  Life expectancy at birth (OHM-5)  Free of activity limitation (OHM-6)  Free of disability (OHM-7)  Respondent-assessed health status – in good or better health (OHM-8) Types of Objectives Healthy People 2030 includes a wide range of objectives in specific topics. Most objectives measure progress towards a target over time, but some are not measurable or have other limitations. There are three types of objectives: core, developmental, and research (Healthy People, n.d.). Additionally, 23 core objectives are termed leading health indicators (LHIs). Core Objectives: 355 measurable objectives that are associated with 10-year targets for the decade. They reflect high-priority public health issues and are associated with evidence-based interventions. Example : Reduce the syphilis rate in females (STI-03) Developmental Objectives: Objectives that represent high-priority public health issues that are associated with evidence-based interventions but do not yet have reliable baseline data. Example: Increase the proportion of older adults who get screened for osteoporosis (O-D01) Research Objectives: Objectives that represent public health issues with a high health or economic burden or significant disparities between population groups. They are not yet associated with evidence-based interventions. Example: Increase quality of life for cancer survivors (C-R01) Leading Health Indicators: A small subset of 23 high-priority Healthy People 2030 core objectives selected to drive action toward improving health and well-being. Example: Reduce the proportion of people aged 21 years and over who engaged in binge drinking in the past month (SU-10)

Objective Core Developmental Research Reduce the proportion of students in grades 9 through 12 who report sunburn (C-10) X Increase the proportion of females at increased risk who get genetic counseling for breast and/or ovarian cancer (C-D01) X Increase the proportion of people who discuss interventions to prevent cancer with their providers (C- R02) X Increase the proportion of people with colorectal cancer who get tested for Lynch syndrome (C-R03) X Increase the proportion of females who get screened for breast cancer (C-05) X The core objective CDK-04 is improving. The core objective D-07 has very little change. The core objective D-02 only has baseline data, so we cannot determine if progress has been made. The number of core objectives that are showing improvement is 0 . This category has 2 developmental objectives. Leading Health Indicators The Healthy People 2030 Leading Health Indicators (LHIs) place emphasis on important factors that impact major causes of death and disease in the United States. They help organizations, communities, and states across the nation prioritize resources and efforts to improve the health and well-being of all people (Healthy People, n.d.b). In 2030, LHIs are categorized by:  all ages (10 LHIs)

 infants (1 LHI)  children and adolescents (4 LHIs)  adults and older adults (8 LHIs) LHI Example 1 Step 1: Locate the Baseline Data First, notice at the top of the webpage, we have baseline data: “17.8% of children and adolescents aged 2 to 19 had obesity in 2013-2016” (Healthy People, n.d.c, Status: Baseline Only section). Step 2: Locate the Target Data Next, look at the target for 2030. It is to decrease the percentage of children and adolescents aged 2 to 19 with obesity from 17.8% to 15.5% (Healthy People, n.d.c, Status: Baseline Only section). Step 3: Locate the Evidence-Based Resources Now, find the evidence-based resources for this objective. Look on the right-hand side of the webpage under Objective Overview. If you click on Evidence-Based Resources, you will find four resources related to this objective. Step 4: Locate the Summary of the Objective Finally, if we keep moving down the webpage, we will find a summary of this objective. It states, Many children and adolescents in the United States have obesity. Obesity is linked to a higher risk for diseases and conditions like high blood pressure, high cholesterol, diabetes, asthma, anxiety, and depression. In addition, children with obesity are more likely to be bullied and to have obesity as adults. Evidence suggests that intensive behavioral programs that use more than 1 strategy are an effective way to reduce childhood obesity. Policy and school curriculum changes that make it easier for children and adolescents to eat healthy and get physical activity can also help reduce obesity. (Healthy People, n.d.c, Summary section). According to the leading health indicators, an increase in adults who exercise and get screened for colorectal cancer is the desired direction. A decrease in cigarette smoking in adults, maternal deaths, and children and adolescents with obesity is desired. Access to Healthcare Services Access to healthcare services was an important Leading Health Indicator (LHI) in 2020 and continues to be essential in 2030. The following Healthy People 2030 LHIs (Healthy People, n.d.) address access to healthcare:  Increase the use of the oral healthcare system (OH-08)  Increase the proportion of people with health insurance (AHS-01)  Increase the proportion of adults who get screened for colorectal cancer (C-07)

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 Increase the proportion of people who get the flu vaccine every year (IID-09)  Increase knowledge of HIV status (HIV-02)  Increase the proportion of adolescents with depression who get treatment (MHMD-06) The leading health indicator is to increase the proportion of people with health insurance. The target goal is to increase the percentage of persons under 65 years who have medical insurance from 89% to 92%. All other answer options are incorrect goals for this LHI. Adolescents are at higher risk of acquiring an STI. Therefore, the cue Jane should be concerned with is working in a high school with three STI cases in a week. STIs impact both males and females and infect all ethnicities. Jane’s level of experience working with teenagers is not relevant. The following goals will improve the health and well-being of Jane’s students:  Reduce the number of STIs diagnosed weekly.  Improve student knowledge of STIs.  Increase screening and testing for STIs.  Refer students for STI treatment.  Improve student knowledge of STI prevention. A review of the core objective target reveals that 52.9% of sexually active females aged 16 to 24 were screened for chlamydial infections in 2017. The Healthy People 2030 target goal is for 76.5% of young females to be screened. On the Healthy People 2030 webpage for this core objective, the evidence-based resource came from the U.S. Preventive Services Task Force. Chlamydia often does not cause clinical manifestations, so annual screening in sexually active females under 25 years is the most effective way to diagnose chlamydia and prevent complications. Healthy People 2030 objectives are categorized by topic to aid in easily locating information. The categories include population, health behavior, social determinants of health, health condition, and setting. Objectives are not categorized by gender or race. Increasing social and community support, increasing educational opportunities, and creating neighborhoods that promote health and safety are Healthy People 2030 goals under the social determinants of health category. Promoting safe and active transportation and helping healthcare providers and clients use health information technology are in the settings and systems category. Lesson 2: LHI: Drug Overdose Deaths Introduction to Leading Health Indicator: Drug Overdose Deaths

The use of illegal drugs or the use of prescription or over-the-counter drugs for purposes other than prescribed or in excessive amounts can lead to a substance use disorder. Excessive substance use can lead to social, physical, emotional, and job-related problems, as well as death. The Healthy People 2030 Leading Health Indicators (LHIs) place emphasis on important factors that impact major causes of death and disease in the United States. They help organizations, communities, and states across the nation prioritize resources and efforts to improve the health and well-being of all people (Healthy People, n.d.). This lesson will focus on the LHI, “Reduce drug overdose deaths – SU-03.” Substance Use Disorders and Drug Overdose Deaths Substance use disorders, which affect all socioeconomic groups, are linked to many health problems and can lead to overdose and death. Deaths from opioid use in particular have increased significantly in recent years. Healthy People 2030 focuses on preventing substance use disorders and helping people who suffer from these disorders get treatment. A leading health indicator (LHI) for 2030 is to reduce drug overdose deaths (SU-03). Select the tabs below to learn more about this LHI. Most Recent Data: 21.6 drug overdose deaths per 100,000 population Target & Baseline: 20.7 drug overdose deaths per 100,000 population Goal: Maintaining the baseline is the goal. Drug overdose deaths have been increasing significantly. While a reduction in deaths is ideal, halting the increase still benefits public health. Reduction Strategy: Currently, the data shows that this objective’s data is getting worse. Increasing access to naloxone can reverse opioid overdoses and prevent deaths. Most recent data : 21.6 drug overdose deaths per 100,000 population Target : 20.7 drug overdose deaths per 100,000 population Goal : Maintain the baseline Currently, the data shows that this objective’s data is getting worse . Increasing access to naloxone can reverse opioid overdoses and prevent deaths. Naloxone is the reversal agent for opioid overdose. Nalbuphine is an opioid pain medication that could cause opioid addiction and overdose. Related Objectives There are several related Healthy People 2030 objectives.  Reduce the proportion of adults who used drugs in the past month (SU-07).  Reduce the proportion of adults who use marijuana daily or almost daily (SU-08).  Reduce the proportion of people who misused prescription drugs in the past year (SU-11) .  Reduce the proportion of people who used heroin in the past year (SU-16).  Reduce the proportion of people who started using heroin in the past year (SU-02).

Objective Little or No Detectable change Improving Getting Worse Target Met Reduce the proportion of people who started using heroin in the past year (SU-17) X Reduce drug overdose deaths (SU-03) X Reduce the proportion of adults who used drugs in the past month (SU-07) X Reduce the proportion of adults who use marijuana daily or almost daily (SU-08) X Reduce the proportion of people who misused prescription drugs in the past year (SU-12) X Reduce the proportion of people who used heroin in the past year (SU-16) X Suspicious Behaviors For Substance Use Disorders Unusual or inconsistent behaviors may be an indicator of substance use disorder and should be investigated with a focused history and physical examination. Suspicious behaviors include:  agitation  problems thinking clearly, remembering, or paying attention  poor coordination  seizures or respiratory depression  self-inflicted trauma and suicidal ideation (thinking about or planning suicide) Other assessments include:

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 frequently missed appointments  frequently requests written excuses for missing school or work  frequently asks for prescription refills  frequently visits the Emergency Department  history of changing healthcare providers  frequent sexually transmitted infections, complicated pregnancies, multiple abortions, or sexual dysfunction  family history of substance use disorder  reported financial or marital problems  history of childhood sexual, physical, or emotional abuse  intimate partner violence RED FLAGS!  Attempted suicide, seizures, and violent behavior are high among individuals with substance use disorder. Substance use disorders are associated with child abuse, intimate partner violence, financial problems, and marital issues. These are social conditions. Although substance use disorders are associated with seizures and respiratory arrest, these are not social conditions. Client behaviors that are suspicious of substance use disorders include:  agitation  problems thinking clearly, remembering, or paying attention  poor coordination (frequent injuries)  seizures or respiratory depression  self-inflicted trauma and suicidal ideation The Healthy People 2030 Leading Health Indicators (LHIs) are objectives that place emphasis on important factors that impact major causes of death and disease in the United States. Developmental objectives represent high-priority public health issues that are associated with evidence-based interventions but do not yet have reliable baseline data. Research objectives represent public health issues with a high health or economic burden or significant disparities between population groups. They are not yet associated with evidence- based interventions. Core objectives are a set of 355 measurable objectives that are associated with 10-year targets for the decade. They reflect high-priority public health issues and are associated with evidence-based interventions. Documentation in the medical record that should alert the nurse to a possible opioid addiction includes:  missed three prenatal appointments last month  diagnosed with chlamydia at 10 weeks’ and 24 weeks’ gestation

 arm and back bruising suggestive of intimate partner violence  history of sexual abuse during high school  history of three previous abortions  admitted to the hospital last week after breathing stopped Requesting non-pharmacologic sleep strategies, previous history of child deliveries without complications, and requesting an epidural for pain control during delivery are not signs suggestive of an opioid addiction. Health Assessment Tools Several tools exist to evaluate a client’s risk for tobacco, alcohol, and illicit substance use. Select each item below to learn more about these assessment tools. TAPS Tool The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool may be self-administered directly by the client or as an interview by the healthcare professional (National Institute on Drug Abuse, n.d.). The questionnaire consists of four items.  In the past 12 months, how often have you used tobacco or any other nicotine delivery product?  In the past 12 months, how often have you had 5 or more drinks (men)/4 or more drinks (women) containing alcohol in one day?  In the past 12 months, how often have you used any prescription medications just for the feeling, more than prescribed, or that were not prescribed for you?  In the past 12 months, how often have you used any drugs, including marijuana, cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA? If any use is indicated in the past 12 months, a few additional questions are asked regarding use- related behaviors. Scores generate a risk level.  0 = No use in past three months  1 = Problem use  2+ = Higher risk CAGE Tool The CAGE Substance Abuse Screening Tool is used to screen for alcohol abuse. Four questions are asked. 1. Have you ever felt you should cut down on your drinking? (C) 2. Have people annoyed you by criticizing your drinking? (A) 3. Have you ever felt bad or guilty about your drinking? (G) 4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? (E)

A response of “no” equals 0 points. A response of “yes” equals 1 point. Higher scores indicate a substance abuse problem. The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool may be self-administered directly by the client or as an interview assessed by the healthcare professional. The questionnaire consists of four items. The CAGE Substance Abuse Screening Tool is used to screen for alcohol abuse. Four questions are asked. Question TAPS CAGE Have people annoyed you by criticizing your drinking? X In the past 12 months, how often have you used any drugs, including marijuana, cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA? X In the past 12 months, how often have you used tobacco or any other nicotine delivery product? X Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? X In the past 12 months, how often have you used any prescription medications just for the feeling, more than prescribed, or that were not prescribed for you? X Have you ever felt you should cut down on your drinking? X Have you ever felt bad or guilty about your drinking? X In the past 12 months, how often have you had 5 or more drinks (men)/4 or more drinks (women) containing alcohol in one day? X

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Several findings are suspicious for a substance use problem including:  requesting narcotic pain medication (this specific request is unusual)  agitated behavior  difficulty remembering how the injury occurred  three previous visits to the emergency department (ED)  listing two different primary care providers  cuts on the wrist that appear self-inflicted Crying and rating pain as 10/10 are not suggestive of a substance abuse problem. Expressing, not denying, suicidal ideation is suggestive of a substance use problem. Izaak’s symptoms (pupillary constriction, slow respiratory rate, and difficulty concentrating) as well as his specific request for narcotic medications despite being prescribed a narcotic (oxycodone) last week indicate he is likely suffering from an opioid use disorder. Methamphetamines produce a stimulant effect on the central nervous system, not a depressive effect. Izaak’s symptoms are most consistent with opioid overdose, not alcohol use. The healthcare professional should address Izaak’s physical symptoms, and then his addiction . His physical symptoms pose the greatest risk to his immediate health. Once recovered, his addiction can be managed. Goals that the clinic should incorporate into the plan for management of opioid overdose include:  quick identification of symptoms of overdose  administration of naloxone as a reversal agent  collaboration with a substance use treatment facility  compiling a list of community resources for substance use disorder Denying care to clients who are drug-seeking is not addressing the problem. On the Healthy People 2030 webpage for this leading health indicator, the majority of evidence- based resources came from the National Institute on Drug Abuse. The other answer options (resources) did not provide screening recommendations. After reviewing recommendations from Healthy People 2030, Jamal understands that it is important to administer naloxone to reverse opioid overdose. Increasing access to treatment can help reduce overdose deaths. Suicidal ideation is defined as thinking about or planning suicide. Attempting, whether successful or unsuccessful, is not suicidal ideation, it is self-harm and suggests a need for more advanced mental health care. A review of the leading health indicator for reducing drug overdose deaths reveals that 21.6 people per 100,000 died of a drug overdose in 2019. The Healthy People 2030 target goal is to reduce drug overdose deaths to 20.7 per 100,000.

Lesson 3: LHI – Tobacco Use Among Adolescents Introduction to Leading Health Indicator: Tobacco Use Among Adolescents Tobacco use continues to be a health problem, particularly among adolescents. Each day in the United States, approximately 1600 adolescents start smoking. Flavorings increase the appeal of tobacco products. In fact, 85% of high school students and 74% of middle school students who used tobacco products in the past 30 days reported using a flavored product (CDC, 2020). However, there is some good news! During the 2019-2020 data collection period, use of tobacco products in general by adolescents declined by approximately 1.7 million users (CDC, 2020). The Healthy People 2030 Leading Health Indicators (LHI) place emphasis on important factors that impact major causes of death and disease in the United States. They help organizations, communities, and states across the nation prioritize resources and efforts to improve the health and well-being of all people (USDHHS, n.d.). This lesson will focus on the LHI, “Reduce current tobacco use in adolescents – TU-04.” Education is the best strategy for the healthcare professional to take. Informing the parents will diminish the student’s trust in the professional. Telling the student that vaping is not appropriate and that they should stop will not likely work. Tobacco Product Description E-cigarettes Uses a nicotine-containing liquid to produce an aerosol Smokeless tobacco Tobacco product that is chewed or snuffed rather than smoked Hookah Water pipes used to smoke specifically made tobacco that comes in different flavors Heated tobacco Use of an electronic device to heat a stick or pod of compressed tobacco leaves Smoking causes cancer, stroke, heart disease, and lung disease. It increases the risk for tuberculosis, certain eye diseases, diabetes mellitus type 2, and autoimmune dysfunction, including rheumatoid arthritis. Smoking increases peristalsis, leads to weight loss, and favors wrinkling of the skin. Smoking does not cause osteoarthritis or weight gain. Current Tobacco Product Use Among High School Students

Adolescents who use tobacco products are more likely to develop dependence and continue tobacco use into adulthood. Let’s review the types of tobacco products available and used by type among high school students. Go through the presentation below using the arrows at the bottom. Electronic cigarettes have been the most commonly used product among adolescents since 2014 (CDC, 2020). They use a nicotine-containing liquid to produce an aerosol. Approximately one in every five high school students reported in 2020 using an electronic cigarette in the past 30 days (CDC, 2020). While e-cigarettes may be less harmful than cigarettes, they should not be considered safe. They can harm adolescent brain development and increase the presence of cancer-causing chemicals in the body. Additionally, vaping has been associated with serious lung problems related to allergic reactions to contaminants. Between 2011 and 2020, cigarette smoking decreased among adolescents. Approximately five of every 100 high school students reported in 2020 smoking cigarettes in the past 30 days. This represents a 15.8% decrease from 2011 (CDC, 2020). Between 2011 and 2020, the use of cigars decreased among adolescents. Approximately five of every 100 high school students reported in 2020 smoking cigars in the past 30 days. This represents an 11.6% decrease from 2011 (CDC, 2020). Smokeless tobacco is a tobacco product that is chewed or snuffed rather than smoked. Between 2011 and 2020, the use of smokeless tobacco decreased among adolescents. Approximately three of every 100 high school students reported in 2019 using smokeless tobacco products in the past 30 days. This represents a 7.9% decrease from 2011 (CDC, 2020). Hookahs are water pipes used to smoke specifically made tobacco that comes in different flavors. Though many think it is harmless, hookah smoking has many of the same health risks as cigarette smoking. Between 2011 and 2020, hookah use did not change significantly. Approximately three of every 100 high school students reported smoking hookah in the past 30 days (CDC, 2020). Heated tobacco products require the use of an electronic device to heat a stick or pod of compressed tobacco leaves. The stick or tobacco pod is heated to a temperature high enough to produce an inhalable nicotine-containing aerosol, but the temperature is below that required for full combustion (“Heated tobacco products,” 2021). In 2020, approximately one of every 100 high school students reported using heated tobacco products in the past 30 days (CDC, 2020). Reducing Tobacco Use in Adolescents Tobacco use is the leading cause of preventable death in the United States, causing almost 500,000 deaths annually. This number represents approximately 1300 deaths per day (CDC, 2021). In 2020, nearly 23 of every 100 high school students reported current use of a tobacco product (CDC, 2020). If smoking continues at this rate among adolescents, almost 6 million of today’s youth will die prematurely from a smoking-related illness (CDC, 2021).

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Most tobacco use begins in childhood and adolescence. Healthy People 2030 focuses on reducing tobacco use. A leading health indicator (LHI) for 2030 is to reduce tobacco use in adolescents (TU-04). Go through the below presentation to learn more about this LHI. Descriptor Data Most Recent Data 23 percent of students in grades 6 through 12 (2019) Target 11.3 percent of students in grades 6 through 12 Goal Decrease desired Currently, the data shows this objective’s data at baseline. Population-level interventions to reduce tobacco use include price increases, mass media campaigns, and smoke-free policies. Related Objectives There are several related Healthy People 2030 objectives.  Eliminate cigarette smoking initiation in adolescents and young adults (TU-10).  Reduce current cigar smoking in adolescents (TU-07).  Reduce current cigarette smoking in adolescents (TU-06).  Reduce current e-cigarette use in adolescents (TU-05).  Reduce current use of flavored tobacco products in adolescents who use tobacco (TU-09) . Reducing cigar smoking in adolescents is improving. Eliminating cigarette smoking initiation in adolescents and young adults is improving. Reducing current use of flavored tobacco is at baseline. Effects of Smoking Smoking has many ill-effects, both on the body and the economy. Read each tab to learn more. Health Effects: More than 16 million Americans are living with a smoking-related disease. Smoking causes cancer, stroke, heart disease, and lung disease. It increases the risk for tuberculosis, certain eye diseases, diabetes mellitus type 2, and autoimmune dysfunction, including rheumatoid arthritis. Smoking increases peristalsis, leads to weight loss, and favors wrinkling of the skin. In males, smoking may lead to erectile dysfunction (CDC, 2021). Effects of nicotine on the body

 Increased cancer risk in oral cavity, larynx and throat  Dependence by increased dopamine release, stroke risk increased  Increased respiratory rate, lung cancer, chronic respiratory diseases  Increased heart rate, higher blood pressure, atherosclerosis, myocardial infarction  Diabetes, pancreatic cancer  Increased gastric juice production and intestinal activity leads to faster metabolism, weight loss  Impotence, erection problems, infertility, pregnancy complications  Favors wrinkling, increased sensitivity to cold Economic Effects: The total economic cost of smoking is more than $300 billion dollars annually.  More than $225 billion in medical costs.  More than $150 billion in lost productivity due to premature death. The tobacco industry spends approximately $8 billion dollars every year advertising tobacco products. Retailers are offered significant price discounts from manufacturers in order to reduce the price of tobacco products for consumers. States receive billions of dollars annually from taxes and lawsuits to promote smoking cessation. However, currently, only a small amount of that money is used appropriately (CDC, 2021). Factors Associated with Adolescent Tobacco Use Social and Physical Environment Mass media portrays tobacco use as a normal activity which encourages the desire to try these products. Accessibility and price often make tobacco products easy for adolescents to acquire. Additionally, adolescents are more likely to use these products if their peer group or parents are using them. Belonging to a lower socioeconomic group and being uninsured also increases the risk for smoking (CDC, 2020). Parental involvement, higher academic achievement, and belonging to a religious group are related to lower smoking levels in adolescents (CDC, 2020). Genetic Factors Research suggests that adolescents are more sensitive to nicotine and develop dependence sooner than adults. Genetic factors may make quitting smoking harder for some young people. Smoking during pregnancy increases the chance that the child will smoke cigarettes regularly in the future (CDC, 2020). Mental Health There is a strong relationship between adolescent smoking and depression, anxiety, and stress (CDC, 2020). Personal Views

When adolescents expect positive changes from smoking, such as stress reduction and weight loss, they are more likely to smoke (CDC, 2020). Factors that increase adolescent risk of tobacco use include:  mother smoked during pregnancy  father has smoked for 25 years  struggles with peer pressure  suffers from depression  dieting to lose weight  father has been out of work for 2 years Factors that do not increase the risk of tobacco use include belonging to a religious group, high academic achievement, and decreased exposure to mass media campaigns. Strategies to Reduce Adolescent Tobacco Use National, state, and local programs have been proven to reduce and prevent adolescent tobacco use. According to the Centers for Disease Control and Prevention (CDC, 2020), some of these activities include:  higher costs for tobacco products  prohibiting smoking in indoor areas and public places  raising the minimum age of sale for tobacco products to 21 years  media campaigns aimed at teenagers to counter tobacco product ads  community and school programs that encourage a tobacco-free lifestyle All of the options listed are FDA enforcement action efforts to prevent e-cigarette use in adolescents. The majority of all tobacco use begins in childhood and adolescence. This cue is the alert that Li should be concerned about. Tobacco use is more common in males, minority races, and people with lower incomes. Electronic cigarettes have been the most commonly used product among adolescents. Adolescents need to be aware of modifiable and nonmodifiable risk factors to increase tobacco use and dependence, as well as the health effects of smoking. Li should discuss peer pressure and stress management strategies and provide resources for smoking cessation. A review of the LHI objective baseline reveals that 18.3% of students in grades 6 through 12 used a tobacco product in the past 30 days in 2018. The Healthy People 2030 target goal is to reduce the baseline to 11.3%. The organizations that made the screening recommendations for this LHI Included:  Centers for Disease Control and Prevention  Office of the Surgeon General  U.S. Preventive Services Task Force

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 National Institutes of Health While they may have been stakeholders in the process, the organizations that did not make the screening recommendations specifically for this LHI included:  American Academy of Pediatrics  National Institute of Drug Abuse  American Nurses Association The most positive action by school administration would be a poster media campaign highlighting dangers and treatment resources. Locking student bathrooms and instituting a smoke-free campus policy only deter tobacco use on campus, but not in general. Suspension for students caught using tobacco on campus is a reaction not a prevention strategy. Belonging to a minority racial group, highly stressful situations, and a mental health diagnosis (depression) increase the risk of tobacco use. Being uninsured or having Medicaid (low socioeconomic group) are risk factors. Medicare is a health plan for adults over the age of 65 years. Not graduating from high school is a risk factor. Nicotine replacement therapy (nicotine patches), psychotherapy (behavior modification and counseling), and medications (varenicline and buproprion) are all smoking cessation treatments. Lesson 4: LHI – Household Food Insecurity and Hunger Introduction to Leading Health Food Indicator: Food Insecurity and Hunger In 2020, approximately 38 million Americans, including 12 million children, were affected by food insecurity (Health + Hunger, n.d.). Food insecurity is defined as a lack of consistent access to enough food to maintain an active, healthy lifestyle due to a lack of available financial resources. Conversely, hunger refers to a personal, physical sensation of discomfort that may result from food insecurity (Health + Hunger, n.d.). The Healthy People Leading Health Indicators (LHIs) place emphasis on important factors that impact major causes of death and disease in the United States. They help organizations, communities, and states across the nation prioritize resources and efforts to improve the health and well-being of all people (Healthy People, n.d.). This lesson will focus on the LHI, “Reduce household food insecurity and hunger—NWS-01” (Healthy People, n.d.). Food insecurity is defined as a lack of consistent access to enough food to maintain an active, healthy lifestyle due to a lack of available financial resources . Conversely, hunger refers to a personal, physical sensation of discomfort that may result from food insecurity . An area where people live that has limited access to retailers that carry affordable and nutritious foods is called a food desert. A larger, affordable supermarket is not available, but smaller, more expensive grocery or convenience stores may exist.

Social determinants of health are social and economic conditions that affect the quality of life and health outcomes . Food insecurity Food insecurity is linked to negative health outcomes in both children and adults. However, this is a complex problem that is not easily solved. Though food insecurity is closely related to poverty, not all people living below the poverty line experience food insecurity. Additionally, some living above the poverty line experience food insecurity (Hunger + Health, n.d.). It is also important to remember that food insecurity does not occur in isolation. Low-income families are frequently affected by many overlapping issues, such as lack of affordable housing, high medical costs, acute and chronic health problems, and low wages (Hunger + Health, n.d.). When considered together, these problems are critical social determinants of health. Effective responses to food insecurity must address each of the overlapping challenges. Levels of Food Security There are four levels of food security used to describe a household’s experiences accessing food (Hunger + Health, n.d.). Learn about each level through the interactive below. Levels of Food Security High Food Security Household experiences no problems consistently accessing enough food. Marginal Food Security Household experiences problems at times accessing enough food but the quality, variety, and quantity of food is not significantly reduced. Low Food Security Household experiences reduced quality and variety in the diet, but the quantity of food intake and eating patterns are not significantly disrupted. Very Low Food Security Eating patterns are disrupted and food intake is reduced due to lack of household money or other resources for food. Reducing Household Food Insecurity and Hunger Food security means that all people at all times have enough food for an active, healthy life. In 2020, 9.4 million households experienced very low food security, which included approximately 584,000 children (USDA, 2021). Healthy People 2030 focuses on reducing food insecurity. A leading health indicator (LHI) for 2030 is to reduce household food insecurity and hunger (NWS-01). Let’s learn more about this LHI (Healthy People, n.d.). Most Recent Data 10.5 percent of households were food insecure in 2020. This has improved from 11.1 percent in 2018.

Target 6 percent of households (Healthy People, n.d.) Goal The goal is to reduce household food insecurity (i.e., desired direction is to decrease). In doing so, will help decrease hunger and improve overall health. (Healthy People, n.d.). Reduction Strategy Giving more people benefits through nutrition assistance programs, increasing benefit amounts, and addressing unemployment may help to reduce food insecurity and hunger (Healthy People, n.d.). Related Objectives There are several related Healthy People 2030 objectives (Healthy People, n.d.).  Eliminate very low food insecurity in children (NWS-02).  Increase the proportion of eligible students participating in the Summer Food Service Program (AH-R03).  Increase calcium consumption by people aged 2 years and over (NWS-13).  Increase consumption of dark green vegetables, red and orange vegetables, and beans and peas by people aged 2 years and over (NWS-08).  Increase fruit consumption by people aged 2 years and over (NWS-06). Effects of Unhealthy Eating Many Americans do not eat a healthy diet. This could be due to lack of information, lack of access to healthy foods, or lack of money to purchase healthy foods. People who do not eat healthy foods are at increased risk for obesity, heart disease, diabetes mellitus type 2, and many other chronic health problems (Healthy People, n.d.). Unfortunately, access to affordable, nutritious foods is limited for some people. Public health interventions that focus on helping everyone get healthy foods are essential to reducing food insecurity and hunger and improving health. Let’s learn more about food deserts! What is a food desert? An area where people live that has limited access to retailers that carry affordable and nutritious foods is called a food desert . Often, food deserts exist in low-income areas. To make matters worse, those who live in these areas may lack reliable transportation to travel to stores that may carry healthy foods. If the person can get to a larger retail store, healthy foods may be too expensive to afford (Ver Ploeg, 2010). What are the consequences? Living in a food desert can lead to a poor diet, which may cause diet-related conditions such as obesity or diabetes mellitus. Food deserts also contribute to food insecurity (Ver Ploeg, 2010).

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What makes matters worse? When a neighborhood lacks a supermarket, a smaller grocery store or convenience store may be available. Though these smaller retailers may offer some healthy food selections, prices are often much higher than a larger supermarket. This issue can lead to food insecurity (Ver Ploeg, 2010). What can be done? Public policies must encourage new store development in underserved areas. However, this alone will not solve the problems. We must work with residents to change their food-purchasing behaviors by providing nutritional guidance. Finally, even if a supermarket is available and people want to purchase healthy foods, if the food is too expensive, the problems remain. This is where food assistance programs can be beneficial (Ver Ploeg, 2010). Food Assistance Programs Child Nutrition Programs: Started in 1946, the National School Lunch Program (NSLP) provides nutritionally balanced, low-cost, or free lunches to eligible students each school day. Similarly, the School Breakfast Program (SBP) is a federally-assisted program started in 1966 to provide breakfast. Both programs are federally funded and operate in public schools, nonprofit private schools, and residential child care institutions. The NSLP assisted approximately 30 million children in 2016 and the SBP assisted more than 14 million children. Both programs grow annually. A division of the United States Department of Agriculture (USDA) called Food and Nutrition Services (FNS) administers the program at the federal level. At the state level, state agencies operate the program through agreements with school food authorities. Children are determined to be eligible for the NSLP and SBP through participation in certain federal assistance programs, such as the Supplemental Nutrition Assistance Program, or based on their status as homeless, migrant, or foster children. Children can also qualify based on household income and family size (USDA, 2017a; 2017b). The Healthy Hunger-Free Kids Act of 2010 is the legislation that authorized core child nutrition programs. It was the first time in many years that effective reform to the school lunch and breakfast programs was made to improve nutrition for children. Supplemental Nutrition Assistance Program: The Supplemental Nutrition Assistance Program (SNAP) provides nutrition benefits to supplement the food budgets of low-income families so they can purchase healthy food. Monthly benefits are provided in the form of an electronic benefits transfer (EBT) card, which can be used to purchase food at authorized retailers. SNAP is the largest federal nutrition assistance program. The USDA’s Food and Nutrition Services (FNS) division administers the program at the federal level. States operate the program at the local level and determine eligibility and issue benefits (USDA, 2018). More than 21 million households received benefits in 2021 (USDA, 2021). Senior Adult Nutrition Programs: The Child and Adult Care Food Program (CACFP) is a federal program that provides reimbursements for nutritious meals and snacks to eligible children and

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adults over the age of 60 who are enrolled in participating daycare centers. The program also provides meals for children participating in after-school activities and residing in emergency shelters (USDA, 2013). The Commodity Supplemental Food Program (CSEP) works to improve the health of low- income persons older than 60 years by supplementing their diets with healthy foods. Both foods and funds are distributed to participating states. An average of nearly 700,000 people participated each month in 2018 (USDA, 2019). Women, Infants, and Children: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was established in 1974 and is available to women who are pregnant, postpartum, and breastfeeding as well as their infants and children up to age 5 years. There are income eligibility requirements as well. As of October 2020, all WIC benefits are distributed via electronic benefits transfer (EBT) cards. Authorized foods include infant cereals, baby foods, iron-fortified adult cereals, fruits and vegetables, vitamin C-rich fruit/vegetable juices, eggs, milk, cheese, yogurt, soy-based beverages, tofu, peanut butter, dried and canned beans/peas, canned fish, whole wheat bread, and grain options. Iron-fortified infant formula is provided for mothers who do not breastfeed (USDA, n.d.). Food Distribution Programs: The Emergency Food Assistance Program (TEFAP) is a federal program that helps supplement the diets of low-income Americans by providing emergency food assistance at no cost. Foods are available through state distributing agencies. The amount of food each state receives is based on the unemployment rate and the number of households living below the poverty level. The state provides the food to food banks, which then distribute it to local organizations that directly serve the public (USDA, 2020). Lesson 5: Cost of Health and Wellness Introduction to Cost of Health and Wellness Many decisions affect the climate of healthcare. Those who provide client care are some of the most qualified to make suggestions for improvements. Therefore, it is essential for healthcare professionals to participate fully and effectively in all aspects of healthcare. Healthcare agencies are focused on improving the client experience while providing high-quality care and controlling costs. For many payors, client satisfaction and quality indicators are tied to healthcare payments. Competent and effective clinical practice, as well as multidisciplinary collaboration, are critical to maintaining healthcare quality while reducing costs. Although each of these objectives is aimed at improving healthcare access and quality, only AHS-01 is a leading health indicator for 2030. The other objectives are core objectives under the healthcare access and quality of care category. Healthcare costs in the United States are increasing annually. This is in opposition to similar peer countries. When compared to peer countries, the U.S. spends nearly twice as much on healthcare yet has the worst outcomes and lowest life expectancy.

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U.S. healthcare spending is much higher than our peer countries. Value is less than peer countries. Federal government spending for healthcare increased 36%, largely due to response to the COVID-19 pandemic. The Significant Cost of Healthcare in the United States Healthcare Costs Healthcare costs rise annually. In 2020, U.S. healthcare spending was $4.1 trillion or $12,530 per person, which was a 9.7% increase from 2019 (Centers of Medicare & Medicaid Services, 2021).  Medicare spending accounted for $829 billion (3.5% increase).  Medicaid spending accounted for $671 billion (9.2% increase).  Private health insurance spending accounted for $1,151 billion (1.2% decrease).  Out-of-pocket spending accounted for $388 billion (3.7% decrease). Overall, federal government spending for healthcare increased 36%, largely due to response to the COVID-19 pandemic. At this rate, by the year 2028, healthcare spending will reach $6.2 trillion annually (Centers of Medicare & Medicaid Services, 2021). Comparison to Peer Countries When compared to peer countries, the U.S. spends nearly twice as much on healthcare yet has the worst outcomes and lowest life expectancy (Tikkanen & Abrams, 2020). Despite increased spending, in comparison to peer countries, the U.S has:  more chronic disease burden  higher obesity rates  fewer healthcare provider visits  higher hospitalization rates from preventable causes  higher rates of avoidable deaths Greater use of medical technology and higher prices are the main drivers of increased spending. However, the U.S. outperforms peer countries in preventive services. For example, the U.S. has the highest rate of breast cancer screening among women ages 50 to 69 and the second-highest rate of flu vaccination in adults 65 years and older (Tikkanen & Abrams, 2020). Effect on the American Population As the United States spends money on technical healthcare advances, innovations in care, and new prescription drugs, it pays for these by raising the consumer costs associated with each (American Academy of Actuaries, 2018; Kaiser Family Foundation, 2007). Both the cost to the individual and society are factors in access to care. For example, insurance policy rates are typically paid by an employer and employee (i.e., copay). The employer raises employee insurance costs to cover its own increase, whereas the employee sees a decrease in take-home pay while paying more out-of-pocket expenses. In addition, preventative services may be expensive and limited. Well-baby checkups, preventive dental care, physical exams, and diagnostic screenings are costly and often limited by insurance

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plans. Although health promotion and illness prevention save money by preventing the more costly expense of treatment, they continue to become more expensive to fund. Also, living a healthy lifestyle is usually expensive to fund. The primary causes of increased healthcare spending in the U.S. are advanced technology, new prescription drug development, and innovations in care. Births in the U.S. are actually declining annually. Vaccination rates are increasing annually. Healthy People 2030 Healthy People 2030 places an emphasis on improving both healthcare access and quality of care. About 1 in 10 people in the United States don’t have health insurance. People without insurance are less likely to have a primary care provider, and they may not be able to afford the health care services and medications they need. Strategies to increase insurance coverage rates are critical for making sure more people get important health care services, like preventive care and treatment for chronic illnesses. (Healthy People, n.d., para. 2). Several key core objectives address these issues.  Increase the proportion of adults who get recommended evidence-based preventive health care (AHS-08).  Increase the number of community organizations that provide prevention services (ECBP-D07).  Reduce the proportion of people who can’t get medical care when they need it (AHS-04).  Reduce the proportion of people who can’t get prescription medicines when they need them (AHS-06).  Increase the proportion of people with a usual primary care provider (AHS-07).  Increase the proportion of people with health insurance (AHS-01) – leading health indicator.  Increase the proportion of people with prescription drug insurance (AHS-03).  Reduce the proportion of people under 65 years who are underinsured (AHS-R03). Increasing the Proportion of People with Health Insurance The Healthy People 2030 leading health indicators (LHIs) place emphasis on important factors that impact major causes of death and disease in the United States. They help organizations, communities, and states across the nation prioritize resources and efforts to improve the health and well-being of all people (Healthy People, n.d.). Without health insurance, people are less likely to have a regular healthcare provider and more likely to skip routine healthcare. This puts them at increased risk of serious health problems. Increasing the proportion of people with health insurance (AHS-01) is a Healthy People 2030 leading health indicator. Most Recent Data 89% of persons under 65 years had medical insurance in 2018

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Target 92.1% of persons under 65 years having health insurance Goal The goal is to increase from the baseline (most recent data) to the target by the end of the decade. Increasing access to healthcare through health insurance will improve health and reduce healthcare costs. Reduction Strategy Evidence has shown that strategies to reduce financial and other barriers to health insurance access can help increase coverage rates (Healthy People, n.d.). Reasons for Being Uninsured According to Cha and Cohen (2020), data from the National Health Interview Survey in 2019 identified people who are most likely to be uninsured and the most commonly reported reasons why.  In 2019, the largest population of uninsured clients were between the ages of 18 and 64.  Hispanic adults were more likely than non-Hispanic adults to be uninsured.  Men were more likely than women to be uninsured. Affordable Care Act The Patient Protection and Affordable Care Act (ACA) has three main objectives:  Reform the private insurance market.  Expand Medicaid to the working poor with income up to 138% of the federal poverty level.  Change the way medical decisions are made to lower the cost of healthcare (Silvers, 2013). Hospital value-based purchasing is a program that ties a portion of Medicare reimbursements for inpatient acute care to performance in quality measures, such as client perceptions and satisfaction. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is the standardized data collection tool for measuring the client experience. The Hospital Readmissions Reduction Program reduces Medicare reimbursement to hospitals with excessive client readmissions within 30 days of discharge. The specific conditions that are regulated by this program include heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, and knee/hip replacement. Healthcare professionals are essential in providing education that reduces the risk of readmission. Bundled payments for care improvements are when a single payment is received for all services to treat a client during a single episode of care. The goal is to encourage providers and hospitals to better coordinate care in an effort to improve quality while reducing cost.

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Hospital Acquired Conditions Reduction Program is designed to encourage hospitals to improve quality and safety. If a high incidence of healthcare acquired conditions (HAC) is noted, then the hospital receives reduced or no reimbursement from the federal government for treatment. Examples of HACs include pressure injuries, catheter-associated urinary infections, and central line-associated bloodstream infections. Lesson 6: Complementary and Alternative Therapies Introduction to Complementary and Alternative Therapies More than 30 percent of adults and about 12 percent of children use healthcare approaches that are not considered conventional and may have origins outside of Western medicine (NIH, 2021). Often, the words “complementary” and “alternative” are used interchangeably but they have very different meanings.  Complementary therapies are used in conjunction (together) with traditional medical approaches.  Alternative therapies are used instead of traditional medical approaches. Integrative healthcare brings conventional and complementary approaches together in a coordinated way. This type of healthcare aims for a multidisciplinary, coordinated approach between several different providers and institutions acting together to care for the whole person. Sometimes, you will see or hear the abbreviation CAM, which stands for complementary and alternative medicine. This general term is used to describe holistic approaches that are not part of conventional medical treatment. This lesson will further explore the concepts of both complementary and alternative therapies. Commonly Used Therapies Whether used as a complement to, or as an alternative for, conventional medical treatments, therapies are classified by their primary therapeutic benefit. Select each tab below for details. Nutritional Benefits Nutritional approaches include a variety of products, such as herbs, vitamins, minerals, and probiotics, which are often marketed to consumers as dietary supplements. These are the most popular types of complementary therapy. In 2012, almost 18 percent of American adults had used a dietary supplement in the past year (NIH, 2021). While there are indications that some supplements may be helpful, more research is needed to understand how these therapies affect the human body, their safety, and potential interactions with medications and other natural products (NIH, 2021). Physical and Psychological Benefits Physical and/or psychological approaches include tai chi, yoga, acupuncture, massage therapy, art therapy, music therapy, relaxation, breathing exercises, hypnotherapy, and mindfulness-based stress reduction. Some of these techniques are administered by a trained practitioner. Some popular approaches are yoga, chiropractic manipulation, and meditation.

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Research studies suggest that acupuncture, meditation, tai chi, and yoga, when used alone or in combination, are helpful for a variety of conditions. Other approaches have not been studied as closely (NIH, 2021). Complementary therapies (yoga) are used in conjunction (together) with traditional medical approaches (anti-hypertensive medication). Alternative therapies (meditation) are used instead of traditional medical approaches (anti- inflammatory medication). “According to practice guidelines from the American Academy of Sleep Medicine and the American College of Physicians, there is not enough strong evidence on the effectiveness or safety of melatonin supplementation for chronic insomnia to recommend its use. The American College of Physicians guidelines strongly recommend the use of cognitive behavioral therapy for insomnia as an initial treatment for insomnia” (NIH, 2021, para. 5). Relaxation Therapy One of the most effective therapies is relaxation therapy. Both progressive relaxation and passive relaxation are effective in managing the stress of illness and the daily challenges of life.  Progressive relaxation helps the client effectively rest and reduce tension in the body. While using slow, deep abdominal breathing, each muscle group in succession is tightened then relaxed. Usually, this follows a head-to-toe approach.  Passive relaxation calms the body and mind without intentionally tightening and relaxing muscle groups. Slow, abdominal breathing is used in conjunction with imagining that relaxation is flowing through specific body parts. This type of relaxation is used for clients who experience discomfort or exhaustion with active muscle contracting. Physically, the tension of stress and the state of relaxation are polar opposites—one cannot dominate while the other is in control. As such, relaxation is an effective management tool for countering stress, which is a primary harmful component for a majority of Americans. Meditation Meditation is any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus so that the person becomes more aware of self. It involves relaxing the body and calming the mind. For meditation to be effective, the person needs a quiet space, a comfortable position, a receptive attitude, and focus. This type of therapy does not require specialized training. Meditation is self-directed and differs from relaxation as the purpose is to become “mindful.” Slow, relaxed, deep abdominal breathing is used to evoke a restful state and lower oxygen consumption, reduce respiratory and heart rates, and reduce anxiety. Imagery Imagery or visualization is a therapy that uses the conscious mind to create mental images to stimulate physical changes in the body, improve perceived well-being, and enhance self- awareness. Imagery is often combined with relaxation techniques.

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Imagery can be self-directed, when the individual creates their own mental images, or guided, when a practitioner leads an individual through a particular scenario. This type of therapy does not require specialized training. The client begins with slow, abdominal breathing while focusing on the rhythm of breathing. Then the client visualizes a specific image while taking note of any sounds, smells, and temperature changes experienced. As the session continues, the client experiences warmth entering the body during inspiration and tension leaving the body during exhalation. Guided imagery scenarios should be individualized for the client to avoid evoking negative feelings or emotions. Herbal Therapies Herbal treatments are some of the oldest forms of medicine. Nonvitamin, nonmineral natural products were used to prevent disease or promote health by nearly 18% of the U.S. population in 2012 (NIH, 2021). A natural product is defined as a chemical compound or substance produced by a living organism. This includes dietary supplements, vitamins, minerals, myotherapies, essential oils, and probiotics. Many are sold over the counter. The most commonly used natural products are fish oil/omega-3 fatty acids, glucosamine, pro- and prebiotics, melatonin, echinacea, cranberry, garlic, ginseng, and ginkgo biloba (Clarke et al., 2015). Herbal supplements are not approved for use as drugs and are not regulated by the Food and Drug Administration. The Dietary Supplement Health and Education Act of 1994 allows companies to sell herbs as dietary supplements as long as no health claims are written on the labels. Select each tab below for details on clinical applications, common problems, and client education. Clinical Applications: Many herbs are safe and effective for a variety of conditions. For example, cranberry juice has been used to prevent urinary tract infections for many years. Curcumin has been found effective in clinical trials at lowering fasting blood sugars in prediabetic clients and those with metabolic syndrome. Common Problems: Just because a product is “natural” does not make it safe. These products are not regulated and concentrations of active ingredients, quality control, and manufacturing guidelines can vary greatly by manufacturer. Also, contamination with other herbs or chemicals, including pesticides, is problematic. Many herbal supplements interfere with prescribed medications, causing toxic reactions or reducing effectiveness. Client Teaching: Teach clients to purchase herbal supplements only from reputable manufacturers. Read the label before consuming. The label should contain the scientific name of the botanical, the name and address of the manufacturer, a batch or lot number, the date of manufacture, and the expiration date. Common Herbal Treatments

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Echinacea  Common use: Stimulate the immune system  Potential drug interaction: Interferes with anti-rejection medications used in organ transplants and antiretrovirals used to treat HIV/AIDS Garlic  Common use: Elevated blood cholesterol levels  Potential drug interaction: Anticoagulants (enhances effects) Ginseng  Common use: Increased physical endurance, improved immune function  Potential drug interaction: Anticoagulants, non-steroidal anti-inflammatories, and MAO inhibitors (enhances effects) Ginkgo biloba  Common use: Improved memory  Potential drug interaction: Anticoagulants and non-steroidal anti-inflammatories (enhances effects) Valerian root  Common use: Sleep disorders, anxiety (promotes CNS depression)  Potential drug interaction: Barbiturates, other sleep medications, and antihistamines (enhances effects) Aloe  Common use: Accelerated wound healing  Potential drug interaction: Interferes with furosemide and other loop diuretics Toxic Herbs Chaparral Used as an anticancer supplement and found in many weight-loss products. May cause severe liver toxicity and uterine contractions during pregnancy. Ephedra Used as a bronchodilator, cardiac stimulant, and in weight loss products. Unsafe for clients with hypertension, diabetes, or thyroid disease. Do not consume with caffeine.

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Liferoot Used as a menstrual flow stimulant. May cause hepatoxicity. Comfrey Used for wound healing and anti-inflammatory effects. Contains carcinogenic properties. May be hepatotoxic. Calamus Used as a fever reducer and digestive aid. Contains carcinogenic properties. May damage kidneys and cause seizures. Training-Specific Therapies Training-specific therapies are holistic treatments that healthcare professionals may perform only after completing the related training. These therapies often require post-graduate degrees, national certifications, and/or an additional license to practice or administer them. Examples of these types of training-specific therapies include biofeedback, acupuncture, therapeutic touch, and spinal manipulation. In certain situations, these therapies carry risk when used in conjunction with traditional medical treatments. Therefore, advanced knowledge is necessary to effectively discuss them with clients. Select each tab below for details. Biofeedback is a holistic technique that uses devices to teach self-regulation and voluntary self- control over specific physiologic responses. Electronic instruments measure and provide information to clients about muscle tension, cardiac activity, respiratory rate, brain-wave patterns, and autonomic nervous system activity. This information is provided by physical, auditory, and/or visual feedback to increase a client’s awareness of physiological processes that may be linked to illness or distress. Biofeedback is often used to change thinking, emotions, and behaviors, resulting in improved health. For example, an auditory alarm may sound if the pulse rate or blood pressure increases above acceptable limits. After receiving the cue, the client may use breathing, relaxation, or imagery exercises to gain voluntary control over the physical problem. Biofeedback is commonly used in the treatment of attention-deficit/hyperactivity disorder, smoking cessation, epilepsy, and migraines. Therapeutic touch affects energy fields that surround and penetrate the human body to aid with healing. Touch therapies include acupressure, healing touch, and Reiki. The energy of the therapist is used to positively influence the client’s energy field. The trained therapist places open palms either on or close to the body of the client to center themselves physically and psychologically, then scans the body with the palms 2-6 inches from the body from head to toe. While scanning, the therapist assesses the energetic biofield of the

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client, focusing on the quality of the qi and identifying areas of accumulated tension, sluggishness, and congestion. The therapist then redirects the negative energy using long, downward strokes. Finally, the therapist reassesses the energy fields to ensure energy is flowing freely. Therapeutic touch is commonly used to treat pain, dementia, and anxiety. Spinal manipulation, also known as chiropractic therapy, centers on the belief that when the spine is misaligned, energy flow is impeded and natural healing abilities are impaired. Chiropractic therapy aims to normalize body function through spinal manipulation. Therapists use their hands or devices to realign the spine with the application of controlled, sudden forceful movement to a joint. Manipulations are often combined with other modalities, such as heat, ice, electrical stimulation, and deep tissue massage. As opposed to many other forms of holistic therapy, chiropractic treatments are often covered by insurance. Chiropractic treatment is commonly used to treat acute back and joint pain caused by osteoarthritis and to enhance traditional medication treatment of asthma, migraines, dysmenorrhea, and vertigo.

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