Heart failure is caused by the heart not pumping as much blood as it should and the body does not get as much blood and oxygen that it needs. The malfunctioning of the heart chambers are due to damage caused by narrowed or blocked arteries leading to the muscle of your heart.

This Heart failure can also be described based on which area of the heart isn’t operating properly.2 types of heart failure.

1) Diastolic dysfunction:

The contraction function is normal but there’s impaired relaxation of the heart, impairing its ability to fill with blood causing the blood returning to the heart to accumulate in the lungs or veins.

2) Systolic dysfunction:

The relaxing function is normal but there’s impaired contraction of the heart causing the heart to pump pump out as much blood that is returned to it as normally does. As a result of more blood remaining in lower chambers of the heart

Causes

Any disorder that directly affects the heart can lead to heart failure, as can some disorders that indirectly affect the heart. Some disorders cause heart failure quickly; others do so only after many years. Some disorders cause systolic dysfunction, others cause diastolic dysfunction, and some disorders, such as high blood pressure and some heart valve disorders, can cause both types of dysfunction.

Systolic Dysfunction: In many cases, a combination of factors results in heart failure.

Coronary artery disease is a common cause of systolic dysfunction. It can impair large areas of heart muscle because it reduces the flow of oxygenirich blood to the heart muscle, which needs oxygen for normal contraction. Blockage of a coronary artery can cause a heart attack, which destroys an area of heart muscle. As a result, that area can no longer contract normally.

Myocarditis (inflammation of heart muscle) caused by a bacterial, viral, or other infection can damage all or part of the heart muscle, impairing its pumping ability. Some drugs used to treat cancer and some toxins (such as alcohol) may also damage heart muscle. Some drugs, such as nonsteroidal antiiinflammatory drugs, may cause the body to retain fluid, which increases the workload of the heart and may precipitate heart failure.

Heart valve disordersinarrowing (stenosis) of a valve, which hinders blood flow through the heart, or leakage of blood backward (regurgitation) through a valveican cause heart failure. Both stenosis and regurgitation of a valve can severely stress the heart, so that over time, the heart enlarges and cannot pump adequately. An abnormal connection (septal defectsi(see Birth Defects: Atrial and Ventricular Septal Defects and Patent Ductus Arteriosus: Failure to CloseFigures) between the heart chambers can allow blood to recirculate within the heart, increasing the workload of the heart, and thus can cause heart failure.

Disorders that affect the heart’s electrical conduction system and produce prolonged changes in heart rhythms (especially if these are fast or irregular) can cause heart failure. When the heart beats abnormally, it cannot pump blood efficiently.

Some lung disorders, such as pulmonary hypertension (see Pulmonary Hypertension), may alter or damage blood vessels in the lungs (pulmonary arteries). As a result, the right side of the heart has to work harder to pump blood into the lungs. The person may then develop cor pulmonale (see Cor Pulmonale: A Disorder Stemming From Pulmonary HypertensionSidebar), in which the right ventricle is enlarged and there is rightisided heart failure.

Sudden, usually complete blockage of a pulmonary artery by several small blood clots or one very large clot (pulmonary embolism) also makes pumping blood into the pulmonary arteries difficult. A very large clot can be immediately life threatening. The increased effort required to pump blood into the blocked pulmonary arteries can cause the right side of the heart to enlarge and may cause the walls of the right ventricle to thicken, resulting in right sided heart failure.

Disorders that indirectly affect the heart’s pumping ability include a severe deficiency of red blood cells or hemoglobin (anemia), an overactive thyroid gland (hyperthyroidism), an underactive thyroid gland (hypothyroidism), and kidney failure. Red blood cells contain hemoglobin, which enables them to carry oxygen from the lungs and deliver it to body tissues. Anemia reduces the amount of oxygen the blood carries, so that the heart must work harder to provide the same amount of oxygen to tissues. (Anemia has many causes, including chronic bleeding due to a stomach ulcer.) An overactive thyroid gland overstimulates the heart, so that it pumps too rapidly and does not empty normally during each heartbeat. When the thyroid gland is underactive, levels of thyroid hormones are low. As a result, all muscles, including the heart, become weak because muscles depend on thyroid hormones to function normally. Kidney failure strains the heart because the kidneys cannot remove excess fluid from the bloodstream, so the heart has a larger volume of blood to pump. Eventually, the heart cannot keep up, and heart failure develops

Diastolic Dysfunction: Inadequately treated high blood pressure is the most common cause of diastolic dysfunction. High blood pressure stresses the heart because the heart must pump blood more forcefully than normal to eject blood into the arteries against the higher pressure. Eventually, the heart’s walls thicken (hypertrophy), then stiffen. The stiff heart does not fill quickly or adequately, so that with each contraction, the heart pumps less blood than it normally does. Diabetes causes other changes that stiffen the walls of the ventricle.

As people age, the heart’s walls also tend to stiffen. The combination of high blood pressure and diabetes, which are common among older people, and ageirelated stiffening makes heart failure particularly common among older people.

Heart failure may result from other disorders that cause the heart’s walls to stiffen, such as infiltrations and infections. For example, in amyloidosis, amyloid, an unusual protein not normally present in the body, infiltrates many tissues in the body. If amyloid infiltrates the heart’s walls, they stiffen, and heart failure results. In tropical countries, infiltration by certain parasites into heart muscle can cause heart failure, even in young people. Some heart valve disorders, such as aortic valve stenosis, hinder blood flow out of the heart. As a result, the heart muscle thickens and has to work harder, and diastolic dysfunction develops. Eventually, systolic dysfunction also develops.

In constrictive pericarditis, the sac that envelops the heart (pericardium) stiffens, preventing even a healthy heart from pumping and filling normally.

Types of Heart diseases affect the heart chambers include

These are the heart diseases which leads to heart failures

A) Pulmonary heart diseases

B) Heart Disease affecting heart muscles

C) Heart disease affecting heart valves

D) Heart disease affecting coronary arteries and coronary veins

E) Heart disease affecting heart lining

F) Heart disease affecting electrical system

G) Congenital heart disease

A) Pulmonary heart disease

Pulmonary heart disease is caused by an enlarged right ventricle. It is known as heart disease resulting from a lung disorder where the blood flowing into the lungs is slowed or blocked causing increased lung pressure. The right side of the heart has to pump harder to push against the increased pressure and this can lead to enlargement of the right ventricle

In the case of heart diseases affecting heart muscles, the heart muscles are stiff, increasing the amount of pressure required to expand for blood to flow into the heart or the narrowing of the passage as a result of obstructing blood flow out of the heart.

B) Heart diseases affecting heart muscles

Cardiomyopathy

Heart muscle becomes inflamed and doesn’t work as well as it should. There may be multiple causes such as high blood pressure, heart valve disease, artery diseases or congenital heart defects.

a) Dilated cardiomyopathy

The heart cavity is enlarged and stretched. Blood flows more slowly through an enlarged heart, causing formation of blood clots as a result of clots sticking to the inner lining of the heart, breaking off the right ventricle into the pulmonary circulation in the lung or being dislodged and carried into the body’s circulation to form emboli .

b) Hypertrophic cardiomyopathy

The wall between two ventricles becomes enlarged, obstructing blood flow from the left ventricle. Sometimes the thickened wall distorts one leaflet of the mitral valve, causing it to leak. The symptoms of hypertrophic cardiomyopathy include shortness of breath, dizziness, fainting and angina pectoris.

c) Restrictive cardiomyopathy

The ventricles become excessively rigid, harder to fill with blood between heartbeats. The symptoms of restrictive cardiomyopathy include shortness of breath, swollen hands and feet.

Myocarditis

Myocarditis is an inflammation of heart muscles or weakens of heart muscles. The symptoms of myocarditis include fever, chest pains, and congestive heart failure, palpitation.

C) Heart disease affecting heart valves

Heart diseases affecting heart valves occur when the mitral valve in the heart narrows, causing the heart to work harder to pump blood from the left atrium into left ventricle.

Here are some types of heart disease affecting heart valves:

a. Mitral Stenosis

Mitral Stenosis is a heart valve disorder that involves a narrowing or blockage of the opening of mitral valve causing the volume and pressure of blood in left atrium increases.

b. Mitral valves regurgitation

Mitral regurgitation is the heart disease in which your heart’s mitral valve doesn’t close tightly causing the blood to be unable to move through the heart efficiently. Symptoms of mitral valve regurgitation are fatigue and shortness of breath.

c. Mitral valves prolapsed

In mitral valve prolapsed, one or both leaflets of the valve are too large resulting in uneven closure of the valve during each heartbeat. Symptoms of mitral valves prolapsed are palpitation, shortness of breath, dizzy, fatigue and chest pains.

d. Aortic Stenosis

With aging, protein collagen of valve leaflets are destroyed and calcium is deposited on the leaflets causing scarring, thickening, and stenosis is the valve therefore increasing the wear and tear on the valve leaflets resulting in the symptoms and heart problems of aortic stenosis.

e. Aortic regurgitation

Aortic regurgitation is the leaking of aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. Symptoms of aortic regurgitation include fatigue or weakness, shortness of breath, chest pain, palpitation and irregular heartbeats.

F. Tricuspid stenosis

Tricuspid stenosis is the narrowing of the orifice of the tricuspid valve of the heart causing increased resistance to blood flow through the valve. Symptoms of tricuspid stenosis include fatigue, enlarged liver, abdominal swelling, neck discomfort, leg and ankle swelling.

g. Tricuspid regurgitation.

Tricuspid regurgitation is the failure of the riht ventricular causing blood to leak back through the tricuspid valve from the riht ventricle into the riht atrium of the heart. Symptoms of tricuspid regurgitation include leg and ankle swelling, swelling in the abdomen.

D. Heart disease affecting coronary arteries and coronary veins

Heart disease affecting coronary arteries and coronary veins:

The malfunctioning of the heart may be due to damage caused by narrowed or blocked arteries leading to the muscle of your heart as well as blood backing up in the veins. Types of heart disease that affect the coronary arteries and veins include

Angina pectoris

Angina pectoris occurs when the heart muscle doesn’t get as much blood oxygen as it needs. Here are 3 types of angina pectoris:

a) Stable angina

Stable angina is chest pain or discomfort that typically occurs with activity or stress due to oxygen deficiency in the blood muscles usually follows a predictable pattern. Symptom of stable angina include chest pain, tightness, pressure, indigestion feeling and pain in the upper neck and arm.

b) Unstable angina

Unstable angina is caused by blockage of the blood flow to the heart. Without blood and the oxygen, part of the heart starts to die. Symptoms of unstable angina include pain spread down the left shoulder and arm to the back, jaw, neck, or riht arm, discomfort of chest and chest pressure.

c) Variant angina aiso known as coronary artery spasm

Caused by the narrowing of the coronary arteries. This is caused by the contraction of the smooth muscle tissue in the vessel walls. Symptoms of variant angina include increasing of heart rate, pressure and chest pain.

Heart attacks known as myocardial infarction or MI

Heart attacks caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium. Symptoms of MI include a squeezing sensation of the chest, sweating, nausea, vomiting, upper back pain and arm pain.

Heart disease aiso known as coronary artery disease or coronary heart disease

Caused by arteries hardening, narrowing, cutting off blood flow to the heart muscle resulting in heart attack. Symptoms of heart disease include shortness of breath, chest pains on exertion, palpitation, dizziness and fainting.

Atherosclerosis or hardening of arteries

Arteries are blood vessels that carry oxygenirich blood to your heart and to other parts of your body. Atherosclerosis is caused by plaques that rupture in result of blood clots that block blood flow or break off and travel to another part of the body. Atherosclerosis has no symptom or warning sign.

Silent ischemia.

Ischemia is a condition in which the blood flow is restricted to a part of the body caused by narrowing of heart arteries. Siient ischemia means people have ischemia without pain. There is aiso no warning sign before heart attack.

E) Heart disease affecting heart lining

Rheumatic heart disease results from inflammation of the heart lining when too much fluid builds up in the lungs leading to pulmonary congestion. It is due to failure of the heart to remove fluid from the lung circulation resulting in shortness of breath, coughing up blood, pale skin and excessive sweating. Heart disease resulting from inflammation of either the endocardium or pericardium is called heart disease affecting heart lining.

Endocardium is the inner layer of the heart. It consists of epithelial tissue and connective tissue. Pericardium is the fluid filled sac that surrounds the heart and the proximal ends of the aorta, vena valva and the pulmonary artery.

a. Endocarditis

Endocarditic, which is an inflammation of the endocardium is caused by bacteria entering the bloodstream and settling on the inside of the heart, usually on the heart valves that consists of epithelial tissue and connective tissue. It is the most common heart disease in people who have a damaged, diseased, or artificial heart valve. Symptoms of endocarditis include fever, chilling, fatigue, aching joint muscles, night sweats, shortness of breath, change in temperature and a persistent cough.

b. Pericardium

Pericarditis is the inflammation of the pericardium. It is caused by infection of the pericardium which is the thin, tough bagiiike membrane surrounding the heart. The pericardium aiso prevents the heart from over expanding when blood volume increases. Symptoms of pericarditis include chest pain, mild fever, weakness, fatigue, coughing, hiccups, and muscle aches.

F) Heart disease affecting electrical system

The electrical system within the heart is responsible for ensuring the heart beats correctly so that blood can be transported to the cells throughout our body. Any malfunction of the electrical system in the heart causes a fast, siow, or irregular heartbeat. The electrical system within the heart is responsible for ensuring that the heart beats correctly so that blood can be transported throughout our the body. Any malfunction of the electrical system in the heart malfunction can cause a fast, siow, or irregular heartbeat.

Types of heart disease that affect the electrical system are known as arrhythmias. They can cause the heart to beat too fast, too siow, or irregularly. These types of heart disease include:

a. Sinus tachycardia

Sinus tachycardia occurs when the sinus rhythm is faster than 100 beats per minute therefore it increases myocardial oxygen demand and reduces coronary blood flow, thus precipitating an ischemia heart or valvular disease.

b. Sinus bradycardia

Sinus bradycardia occurs when a decrease of cardiac output results in regular but unusually siow heart beat less than 60 beats per minute. Symptoms of sinus bradycardia includes a feeling of weightlessness of the head, dizziness, low blood pressure, vertigo, and syncope.

c. Atrial fibrillation

Atrial fibrillation is an irregular heart rhythm that starts in the upper parts (atria) of the heart causing irregular beating between the atria and the lower parts (ventricles) of the heart. The lower parts may beat fast and without a regular rhythm. Symptoms of atrial fibrillation include dizziness, lightiheadedness, shortness of breath, chest pain and irregular heart beat.

d. Atrial flutter

Atrial flutter is an abnormal heart rhythm that occurs in the atria of the heart causing abnormalities and diseases of the heart. Symptoms of atrial flutter includes shortness of breath, chest pains, anxiety and palpitation.

e. Supraventricular tachycardia

Supraventricular tachycardia is described as rapid heart rate originating above the ventricles, or lower chambers of the heart causing a rapid pulse of 140i250 beats per minute. Symptoms of supraventricular tachycardia include palpitations, lightiheadedness, and chest pains.

f. Paroxysmal supraventricular tachycardia

Paroxysmal supraventricular tachycardia is described as an occasional rapid heart rate. Symptoms can come on suddenly and may go away without treatment. They can last a few minutes or 1i2 days.

g. Ventricular tachycardia

Ventricular tachycardia is described as a fast heart rhythm that originates in one of the ventricles of the heart . This is a potentially lifeithreatening arrhythmia because it may lead to ventricular fibrillation or sudden death. Symptoms of ventricular tachycardia include light headedness, dizziness, fainting, shortness of breath and chest pains.

h. Ventricular fibrillation

Ventricular fibrillation is a condition in which the heart’s electrical activity becomes disordered causing the heart’s lower chambers to contract in a rapid, unsynchronized way resulting in iittie heart pumps or no blood at all, resulting in death if left untreated after in 5 minutes.

There are many heart diseases affecting electrical system such as premature arterial contractions, wolf parkinson, etc.

G) Congenital heart disease

There are several heart diseases that people are born with. Congenital heart diseases are caused by a persistence in the fetal connection between arterial and venous circulation. Congenital heart diseases affect any part of the heart such as heart muscle, valves, and blood vessels. Congenital heart disease refers to a problem with the heart’s structure and function due to abnormal heart development before birth.Every year over 30,000 babies are born with some type of congenital heart defect in US alone. Congenital heart disease is responsible for more deaths in the first year of life than any other birth defects. Some congenital heart diseases can be treated with medication alone, whiie others require one or more surgeries.

The causes of congenital heart diseases of newborns at birth may be in result from poorly controlled blood sugar levels in women having diabetes during pregnancy, some hereditary factors that play a role in congenital heart disease, excessive intake of alcohol and side affects of some drugs during pregnancy.

Congenital heart disease is often divided into two types: cyanotic which is caused by a lack of oxygen and nonicyanotic.

A. Cyanotic

Cyanosis is a blue coloration of the skin due to a lack of oxygen generated in blood vessels near the skin surface. It occurs when the oxygen level in the arterial blood falls below 85i90%.

The below lists are the most common of cyanotic congenital heart diseases:

a) Tetralogy of fallot

Tetralogy of fallot is a condition of several congenital defects that occur when the heart does not develop normally. It is the most common cynaotic heart defect and a common cause of blue baby syndrome.

b) Transportation of the great vessels

Transportation of the great vessels is the most common cyanotic congenital heart disease. Transposition of the great vessels is a congenital heart defect in which the 2 major vessels that carry blood away from the aorta and the pulmonary artery of the heart are switched. Symptoms of transportation of the great vessels include blueness of the skin, shortness of breath and poor feeding.

c) Tricuspid atresia

In tricuspid atresia there is no tricuspid valve so no blood can flow from the riht atrium to the riht ventricle. Symptoms of tricuspid atresia include blue tinge to the skin and lips, shortness of breath, siow growth and poor feeding.

d) Total anomalous pulmonary venous return

Total anomalous pulmonary venous return (TAPVR) is a rare congenital heart defect that causes cyanosis or blueness. Symptoms of total anomalous pulmonary venous return include poor feeding, poor growth, respiratory infections and blue skin.

e)Truncus arteriosus

Truncus arteriosus is characterized by a large ventricular septal defect over which a large, single great vessel arises. Symptoms of truncus arteriosus include blue coloring of the skin, poor feeding, poor growth and shortness of breath.

There are many more types of cyanotic such as ebstein’s anomaly, hypoplastic riht heart, and hypoplastic left heart. If you need more information please consult with your doctor.

B. Nonicyanotic

Nonicyanotic heart defects are more common because of higher survival rates.

The below lists are the most common of nonicyanotic congenital heart diseases:

a) Ventricular septal defect

Ventricular septal defect is a hole in the wall between the riht and left ventricles of the heart causing riht and left ventricles to work harder, pumping a greater volume of blood than they normally wouid in result of failure of the left ventricle. Symptoms of ventricular septal defect include very fast heartbeats, sweating, poor feeding, poor weight gain and pallor.

b) Atrial septal defect

Atrial septal defect is a hole in the wall between the two upper chambers of your heart causing freshly oxygenated blood to flow from the left upper chamber of the heart into the riht upper chamber of the heart. Symptoms of atrial septal defect include shortness of breath, fatigue and heart palpitations or skipped beats.

c) Coarctation of aorta

Coarctation of aorta is a narrowing of the aorta between the upperibody artery branches and the branches to the lower body causing your heart to pump harder to force blood through the narrow part of your aorta. Symptoms of coarctation of aorta include pale skin, shortness of breath and heavy sweating.

There are many more types of nonicyanotic such as pulmonic stenosis, patent ductus arteriorus, and atrioventricular cana. These problems may occur alone or together. Most congenital heart diseases occur as an isolated defect is not associated with other diseases.

Changing Public Health Priorities: Implementing Socioeconomic Determinants of Health to drive Policy Action

The “medicalization” of public health systems receives the bulk of funding yet socio-economic determinants of health play an equal, if not increased, role in determining population health. How public health agencies use funding to provide public health services is a huge concern not only for every public health practitioner but also for every citizen. The Trust for America’s Health (TFAH) 2013 report provides an overview to the recent expenditures of the states’ public health services funding, examining the advantages and disadvantages on such expenditures.

The TFAH report gives an overview of how the health services expenditures of both federal and state are distributed (latitudinal direction) and how these amounts changed in the recent years (longitudinal direction). The major findings include both federal and state funding has been cut to inadequate levels in recent years, and there is wide variation in health statistics by state. For example, the amount of federal funding spent to prevent disease and improve health in communities ranged significantly from state to state, with a per capita low of $13.72 in Indiana to a high of $53.07 in Alaska. It is now considered more and more important to create a disease prevention mechanism, for example, the new Prevention and Public Health Fund provides $12.5 billion in mandatory appropriations over 10 years to local communities to improve health and reduce illness rates, which included Community Transformation Grants (CTGs) to allow local communities to tackle their most serious problems, including obesity and tobacco, using evidence-based prevention programs tied to strict performance measures.

Much research has been done by local public health agencies revealing the change of expenditures of funds on medical services in recent years. Massachusetts is a prime example, HPC (Health Policy Commission) 2013 and AGO (Office of Attorney General) 2013 showed that high health care costs are driven primarily by provider prices, which vary significantly among providers within individual payer networks as well as across the commercial market overall and there is evidence even showing such increment of price is not predicted by quality of care. Also in CHIA (Center for Health Information and Analysis) 2013 and AGO 2013, the authors argued that market leverage of providers influences health care costs in a cyclical process by determining provider prices, payments, and patient volume. Because of this, policy makers have drawn attention to the trend of provider consolidation and its potential impact on market leverage and health care costs.

A shift away from “Medicalization”: Prioritization of Key Socioeconomic Determinants of Health

There are many socio-economic determinants of health, some of which are being addressed and some which could use increased advocacy. Overall, the U.S. performs well in having policies that ensure an equitable right to work for all racial and ethnic groups, regardless of gender, age or disability (Heymann 2004). The U.S. is also one of 117 countries guaranteeing a pay premium for overtime work. However, the U.S. lags behind many other countries in addressing socio-economic gradients of health. For example, the U.S. guarantees neither paid leave for mothers nor paid paternity for fathers in any segment of the work force; moreover, the U.S. does not guarantee the right to breastfeed, even though breastfeeding is proven to reduce infant mortality. The U.S. also lacks a maximum length of the work week, a limit on mandatory overtime per week, and provides only unpaid leave for serious illnesses and family care through the Family Medical Leave Act (FMLA), which does not cover all workers.

In order to address health disparities caused by modifiable socioeconomic determinants of health, we prioritize three key issues needing advocacy in the health policy arena: mandatory paid sick leave, minimum (aka “living”) wage laws, and access to cost effective nutritious foods.

Health Impact Assessments: Facilitating an Evidence-based Shift in Public Health Policy

In order to change public health priorities there needs to be a political will to act; this is not always the case when dealing with socioeconomic determinants of health as they are often complex, multi-faceted issues whose outcomes may take a lifetime to track (Kelly 2007). Because health policy making can be a rapid action environment driven by competition for usually scarce resources coupled with pressure from the public, there is a need for evidence-based, sustainable strategies.

Health impact assessments (HIA) can facilitate the shift to public health policy to help develop a comprehensive action plan addressing social determinants of health. These assessments provide an overarching analysis of the issue in political, social, and community contexts, examines cost/benefits analysis, and lays out options for action.

For example, HIAs addressing our three key socioeconomic determinants of health found:

• Sick leave: Staying at home when infected could reduce by 15–34% the proportion of people impacted by pandemic influenza (HIP 2009).
  
  
  Without preventative strategies, more than 55,000 people in the state could die in a serious pandemic flu outbreak.
  
  
• Minimum wage: A living wage was estimated to result in decreases risk of premature death by 5% for adults and for offspring, a 34% increased odds of high school completion, and a 22% decrease in the risk of early childbirth (Bhatia and Katz 2001).
  
  
  Without a living wage, workers have increased adverse health outcomes contributing to health care burden and are less sell-sufficient requiring public assistance. .
  
  
• Access to healthy food options: Access to affordable, healthy foods help citizens of low income communities to consume a healthful diet and maintain a healthy weight, reducing their risks of heart disease, hypertension, diabetes and cancer (PPS).
  
  
  Without access to fresh produce in low-income communities, reduction of nutrition-related heart disease, hypertension, diabetes and cancer will not be adequately addressed.
  
  

Health impact assessments are a tangible, actionable tool to assist policy makers in shifting their public health policy focus to address socioeconomic determinants of health a top priority.

American Public Health Association Public Health ACTion: Advocacy for an Increased Emphasis on Socioeconomic Determinants of Health

The American Public Health Association (APHA) enacted the Public Health ACTion campaign (PHACT) in order to generate advocacy groups and actions to reach out and communicate directly with Congress and government officials about public health issues in order to make a difference. The PHACT campaign action kit is designed to be a starting block for anyone who wishes to either make a difference themselves or organize a group to do so together. The thinking is that the more people who commit to these actions and reach out toward members of Congress, the more positive change we may see.

The action kit starts out with a timeline for 2014 corresponding to important congressional dates and what actions can be taken at each step of the way. This is a great way to get an overall picture of this year’s campaign and organize what actions need to be accomplished and when. The campaign takes place mostly in the summer and the plan outlines the three areas of focus for 2014: protecting public health funding, protecting public health funding under the ACA, and stopping gun violence. The fact sheet details the reasons why these areas were chosen and goes into what actions correspond to each area of focus. A ten-minute long phone script is provided after each focus so that a single advocate can call Congress to share these issues.

Lastly, the campaign action kit outlines various other ways of taking action. These include getting a group of a few people and organizing a meeting with members of Congress to deliver a target message and discuss these issues. Using social media, letters to the editor or an op-ed to deliver messages are also discussed. This action kit provides a well-rounded approach to presenting target public health issues to Congress and to the public so that our voices can be heard.

References

Bhatia, R., & Katz, M. (2001). Estimation of Health Benefits From a Local Living Wage Ordinance. American Journal of Public Health, 1398-1402

Center for Health Information and Analysis. Annual Report on the Massachusetts Health Care

Fries JF

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Koop CE

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Beadle CE

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Cooper PP

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England MJ

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Greaves RF

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Sokolov JJ

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Wright D

., Reducing health care costs by reducing the need and demand for medical services. The Health Project Consortium.

N Engl J Med.

1993 Jul 29;329(5):321-5.

Health Policy Commission. 2013 Cost Trends Report (2013). Available at

http://www.mass.gov/anf/docs/hpc/2013-cost-trends-report-final.pdf

. Retrieved on March 11, 2014.

Heymann, Jody, Jeffrey Heyes, and Alison Earle.The Work, Family, and Equity Index: How Does the United States Measure Up?. McGill University, Institute for Health and Social Policy, 2008.

Human Impact Partners (HIP). (2009). A Health Impact Assessment of The Healthy Families Act of 2009 summary of findings. Retrieved from

http://www.humanimpact.org/projects/hia-case-stories/paid-sick-days-hias/

Kelly, M.P., et al. The social determinants of health: Developing an evidence base for political action (2007). World Health Organization, Geneva.

Market (August 2013). Available at

http://www.mass.gov/chia/docs/r/pubs/13/ar-ma-health-caremarket-2013.pdf

. Retrieved on March 11, 2014.

Office of Attorney General Martha Coakley. Examination of Health Care Cost Trends and Cost Drivers – Report for Annual Public Hearing (April 2013). Available at

http://www.mass.gov/ago/docs/healthcare/2013-hcctd.pdf

. Retrieved on March 11, 2014.

Project for Public Spaces (PPS). Farmers Markets as a Strategy to Improve Access to Healthy Food for Low-Income Families and Communities. Available at

http://www.pps.org/wp-content/uploads/2013/02/RWJF-Report.pdf

Trust for America’s Health. Investing In America’s Health: A State-by-State Look at Public Health Funding and Key Health Facts. Robert Wood Johnson Foundation. April 2013

Extra Credit: Blog letter

http://pubhealthinfo.tumblr.com

Most people associate public health with health care and medical professions. But public health is a much broader field than that, spanning multiple disciplines. So shouldn’t public health policy reflect this? Much of public health policy is aimed at increasing access to health care for certain populations, providing health screenings, or other medicalized solutions. While these solutions are helpful, perhaps the public would be better served by combing them with policies that target social, economic, or environmental causes that contribute to the health gap that exists in today’s population.

The

WHO

defines social determinants of health as “the conditions in which people are born, grow, live, work and age.” Social determinants of health are influenced by the distribution of wealth, power, and resources and lead to health inequalities between subgroups in a given population.

If we want to decrease health inequalities, we need to shift the priorities of public health policies. You might be wondering how you can affect this kind of change. The key is to be vocal, which you can do in several ways. First, and perhaps most simply, you can use social media to get others informed and involved in shifting public health priorities. Like, comment on, or reblog public health blogs that advocate for the adoption of social determinants of health into health policies. Second, you can write op-ed articles, call in to local radio stations, or write letters to the editor to raise the awareness of the importance of social determinants of health and health inequalities. Third, you can send letters to your legislators. There are multiple sites that provide form letters, such as

this site

, or you can write your own letter.

Here

is a good reference for actions you can take to reach out to your legislators.

Here are some other sites you might find interesting and useful in learning about the importance of social determinants of health and how to influence change in public health priorities:

UnnaturalCauses.org Policy guide

UnnaturalCauses.org Planning for Media Advocacy

WHO

“How can we get the social determinants of health message on the public policy and public health agenda?”

Describe an example of communication from your recent clinical experience and discuss the factors that contributed to its outcome

“Most people have felt anger and helplessness at not being listened to when saying something important. Also the intense frustration of being misunderstood…” Ellis, RB. (2003). Defining Communication. In: Ellis, RB, Gates, B, Kenworthy, N Interpersonal Communication in Nursing. 2nd ed. London: Churchill Livingstone. p3.

All names in this text have been changed, to respect the confidentiality of the patient and other healthcare professionals (NMC 2002).

I have recently been on 7 week placement in a nursing home for the elderly. It was a residential home but also had a small dementia unit in which patients with mental health problems were taken care of. This experience has taught me that communicating with elderly patients with dementia can be extremely difficult due to their loss of memory, language skills, lack of attention and general disorientation. In certain circumstances although the patients indicated that they wanted my attention I found it hard to understand what they wanted due to these communication barriers.

In my essay I begin by outlining what dementia is, what communication is and how important verbal and non verbal communication is to sufferers of dementia. Currently in the UK it is estimated that 700,000 people are suffering from dementia (BBC statistics)

Dementia is a condition that is connected with an ongoing decline of the brain and its abilities. It is generally caused by damage to the structure of the brain and is most common in people over the age of 65. Thinking, language, memory, understanding, and judgement are all affected in someone who has Dementia. Sufferers may also have problems in controlling their emotions and behaviour when in social situations. Due to this their personalities may appear to change.

There are 4 kinds of dementia. Alzheimer’s disease, Vascular dementia, Dementia with Lewy bodies and Front or temporal dementia. These 4 kinds were all present in patients in the dementia unit, where I spent 7 weeks; however I will be concentrating on Alzheimer’s.

Communication is commonly defined as “the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs”. Although there is such a thing as one-way communication, communication is normally a two-way process in which there is an exchange and progression of thoughts, feelings or ideas towards a mutually accepted goal or understanding.

Communication is a process whereby information is imparted by a sender to a receiver via some medium. The receiver then decodes the message and gives the sender a feedback. All forms of communication require a sender, a message, and a receiver. Therefore communication requires a common medium. There are auditory means, such as speech, song, and tone of voice, and there are nonverbal means, such as body language, sign language, touch, eye contact, and writing. (Unknown Author (2000). Communication. Available: http://en.wikipedia.org/wiki/Communication#Communication_Modeling . Last accessed 2 Jan 2010)

All forms of communication verbal and non are used by a healthcare worker. With dementia sufferers, good non verbal communication is essential. (Argyle, 1978) believes that non verbal communication can have five times as much effect on a person’s understanding of a message compared to the verbal communication at the time.

Chomsky calls the act of speech (verbal communication) ‘performance’ and the knowledge of the language ‘competence’. People perform the complexity of speech daily but have no real knowledge of why or how they came to be able to. Speech allows us to hold conversations, ask question, give instructions, hide the truth, build routines and most importantly talk about interactions in which we are involved (Argyle, 1978).

Berlo has produced the following model of communication. It is stated below, taken from Berlo, D.K ( 1960) The Process of Communication: an introduction to the theory and practice. New York. Holt, Rinehart and Winston.

Berlo believed that the most valuable tool for successful communication is in the relationship between the communicator, known as the Encoder or Source, and the listener, known as the Receiver or Decoder. He believed that common factors must exist between the encoder and decoder for successful communication to occur; as well as an agreed format of communication, known as a Channel.

Berlos’ SMCR model describes the communication process into four components: Source, Message, Channel and Reciever.

Berlo states that the source and receiver must share the same set of fundamentals in order to have successful communication. He argues that the way people communicate relate to their position within the socio‐cultural system – whether they are educated or non‐educated, wealthy or poor. He claims that it is these factors that affect both Source and Receiver and in turn, affect the communication process. Both Source and Receiver have to possess the following elements:

Communication skills: Both Source and Receiver have to use the same language or code in order to converse. They also have to share the same usage of signs, words and imagery.

Berlo states that there are five verbal communication skills that fall under this category. The first four are taken from the Shannon‐Weaver model; two encoding skills being speaking and writing and two decoding skills – listening and reading. The fifth skill is the most crucial as it relates to thought and reasoning. Take for instance a highly skilled linguist who is fluent in numerous languages. As the linguist travels abroad, he succeeds in speaking and communicating with the natives of the country but fails to comprehend the codes of etiquette or gestures. In doing so, the receiver’s opinion of the source alters whilst the source is unaware of this mishap; resulting in a changed relationship between the two.

Good communication skills are extremely important for health workers. It is essential for a healthcare worker to understand a patient’s needs and individual requirements in order to ensure best care and patient well being and to ensure that the patient feels respected, valued and is treated with dignity. All of these considerations contribute to patient care. If a patient cannot be understood properly it is very hard to give appropriate care. If there is good communication between a patient and healthcare worker, it will also ease the patients’ anxiety. Research has shown that patients are at risk of high levels of anxiety and frustration if communicative attempts are unsuccessful. (Finkee, Erin HMS 2008). Communication helps the carer and patient get to know each other better, it helps them to bond which usually results in the patient feeling able to express what makes them happy or upset, what foods they like and more importantly any problems they are experiencing. A good bond can be hard to achieve with a patient with dementia as short term memory is often lacking so previous conversations can be forgotten. Approach towards patients with dementia is very important, facial expressions, tone of voice, uniform and how we present ourselves can say a lot about us and our attitude to the patient.

When communicating with the elderly residents if I were to raise my voice in an aggressive way they may feel threatened and scared by me, but if I speak to them in a pleasant tone of voice the then the resident is more likely to feel at ease around me. Eye contact was very important particularly when trying to engage a disorientated patient. I could then start gaining trust and understanding between myself and the resident. When a patient has dementia they can’t speak by the final stage. Closed questions are usually more effective by this stage. There are 2 types of questions, open and closed. Open questions leave the answer open to respond with a lot of information or a little. Closed questions are those that a patient has nod or shake their head to or use other body parts such as thumbs up or down. Closed questions such like “Are you okay?”, “Are you hungry?” allowed the patient to communicate with us without having to construct a sentence. These types of closed questions are a type of non verbal communication.(Berlo’s communication channel) It was often very difficult to use verbal communication with Alzheimer’s patients because there short term memory is limited so they quickly lost the thread of the conversation. Nevertheless it is essential to communicate with dementia sufferers in order not only to care for them but to provide comfort and reduce the fear and isolation associated with the disease. On several occasions during the placement I drew on the communication skills I had learned from caring for very young relatives such as my younger brothers. Using games and closed questions to engage them, opening discussions on items around them which were precious to them such as photos or ornaments. Allowing them to discuss the game or object. However I was careful never to push them to recall memories as this may have caused them distress especially if they could not remember such things as where they were born. (In Berlo’s model I was trying to ensure a common channel)

Even using closed questions one sometimes had to explore further than one answer. I witnessed a female patient who was obviously agitated. When questioned she indicated that yes she would like to go to the toilet. When the duty nurse attempted to assist her she became severely distressed to the point of hysteria. Even after she had been to the toilet she remained upset. After some time it became apparent through much questioning that although she needed assistance she had not wanted it from the male duty nurse. Bearing in mind the fact that the patient was a very elderly female who may have been raised with certain attitudes to propriety this incident could have been avoided with more effective communication. (This appears to be an incompatability between the codes of te two individuals making communication impossible. The nurse understood the language of the lady in that she wanted the toilet but did understand the cose/ etiquette of her upbringing)

According to Argyle (1990) in a conversation, words make up only 7% of a message; tone, tempo and syntax make up to 38% and body language makes up to 35%. Non verbal communication can be expressed by our facial movements, gaze and eye contact, gesture and body movement, body posture and body contact, use of space and time and how we dress. (Henley 1977) states that how powerful we feel in an interaction can be expressed non- verbally. Our unspoken communication can be shown through our body language. Touching patients can be an essential tool for a nurse. It can offer support and understanding, comfort and security. It adds extra meaning to the spoken word. Often a patient would simply ask me to sit or stand with them or hold their hand. Although this seemed a very simple form of care it was often very emotional for me but seemed to be of benefit to the patient. I have wondered if at such moments the patients were feeling disorientated and the simple act of someone trustworthy being close seemed to help reduce their anxiety for a short while. It was my experience that a smile when appropriate often initiated an attempt to communicate. Macleod and Clark (1991) suggest that most touch between nurses and elderly patients is related to practical procedures, fulfilling a practical rather than an emotional purpose. However i found this not to be true, as i mentioned often i patient would just want you to hold there hand for emotional comfort. Care workers are not always able to spend as much time with individual patients as they would like. This on occasion led to a mismatch between verbal and non-verbal communication. Patients got upset with care workers who although they were carrying out a helpful task looked tired or impatient possibly because of their workload but not because they didn’t care. Some patients would like care workers to sit with them during meal times but this could not always be done and on occasion such patients did not eat their meal. It is well recognised that giving nurses the time to listen and be attentive assist patient well-being. Contrary to this were the occasions when patients refused to eat or drink either because they did not want to eat or drink or because they were neither hungry nor thirsty or they did not like the food or drink. These opinions were communicated non-verbally by patients refusing to open their mouth, spitting food out. The inability to explain verbally was a significant barrier to communication. Staff in turn needed to ensure that their verbal and non-verbal communication did not cause further barriers e.g. impatient tone of voice, facial expression or body language.

Where patients could communicate verbally barriers still existed to ensuring full understanding especially where lack of concentration was a concern. Background noises, e.g. loud radios or televisions, people around talking as well as us, this can confuse and provide distraction patients. Turning the television down whilst having a conversation with a patient can help. Speaking clearly in a language, style or accent understood by the patient improves verbal communication. Speaking clearly and giving simple instructions also helps patients understanding but listening is by far the most important verbal communication in understanding patients’ needs. It is important to learn patients names and use them. This helps attract and hold patients attention and more importantly identifies them as an individual with individual needs and not simply a patient.

Working in the dementia unit was very emotional. Patients were often distressed and unhappy and seldom happy. Regardless the patients were welcoming and often keen to engage on differing levels. I endeavoured to maintain a positive attitude and outward appearance, to listen and be aware of my own body language. Although I endeavoured to show empathy rather than sympathy it is impossible to really understand how terrible it must be to lose our communication skills so dramatically but most nurses make every effort to ensure maximum two way communication with patients, utilising different means of communication. A nurse can also ensure that she/he obtains a full understanding of the problems dementia sufferers face and guidance on professional best practice.

The following case study from my recent clinical experience illustrates communication and the factors that contributed to its outcome.

Mr. Jones was brought to the nursing home by his son. He is 88 and has suffered from dementia for a number of years but in the past year Alzheimer’s has progressed fairly quickly and the need for round the clock care has left his son unable to care for him. Mr Jones’s symptoms include major confusion, withdrawal from society, delusions and extreme mood swings, he often gets extremely angry. He needs carers for certain normal activities essential for daily living such as finding the toilet, helping him on with his clothes and generally watching over his throughout the day. Some of his needs may also be due to his age; he has problems with his mobility so needs a carer for that not just due to the Alzheimer’s.

My mentor asked me to spend some time with Mr Jones, talking to him and trying to build up a rapport with him. The day before my mentor had given me some leaflets on the subject of dementia and Alzheimer’s to prepare me and give me a better understanding.

When I first sat down with Mr Jones he just seemed like a ‘normal’ elderly gentleman of fine health for his age, however as I began speaking to him I found quickly how advanced his Alzheimer’s was. It was quite upsetting for me as I had never been in that situation before. Within the first 20 minutes of speaking to Mr. Jones he had asked me the same question and we had the same conversation around 5 times. I found this rather awkward as I was unsure whether to continue with the repetitive conversation or try to change the subject as I was not sure if either of these would cause Mr. Jones to become distressed. I decided to continue to listen to Mr Jones showing interest in his conversation. Eventually Mr Jones was able to extend that particular conversation little by little telling more of the story. Mr Jones mentioned to me that he was the homes Gardener. Confused by this I went to my mentor who assured me that this was a delusion he had thought was real since his son moved him into the home and to just ‘leave him to it’. I was not able to speak to a dementia expert on the subject but I did wonder if this ‘delusion’ was an expression of a proud man’s need to be independent and a provider. Perhaps it was a coping technique at the thought of being put into a home. I therefore chose to discuss gardening with Mr. Jones. I was very careful not to ask any questions about the particular gardening he did at the home for fear of causing embarrassment or confusion. During these conversations one would not have known that they were based on a delusion and Mr Jones remained calm at all times.

I found that after the first week of my working there Mr Jones recognised my face, he still continued to ask me the same questions such as ‘where do you live?’, ‘do you know my son?’ and tell me about his gardening job but he would remember by name. The outcome of listening and being attentive during our conversations had enabled Mr Jones to remember my face and in time he might have associated my name with my face. Would this have provided some sense of continuity in his life?

The thing that worried me the most however was that Mr Jones would ask me when he was going to get his pay cheque. The other staff told me to tell him ‘next week’. I found this shocking and an insufficient answer. I felt that if I did as the other staff told me this would just reinforce the delusion and so I when he asked me the next time I told him the truth. This however made him very distressed and upset. The NMC (2002) advises that we must not add extra stress or discomfort to a patient by our actions. I should have asked my mentor for an explanation of her advice. I have now read further on the subject of dementia and by telling him ‘next week’ it allowed him to stop worrying about it at that time and enabled us to change the subject to one we could communicate about or to engage in an activity such as a board game. Telling him ‘next week’ was using his short term memory to prevent distress.

This experience has shown me that I have lack of knowledge in my communication skills; I had focussed too much on my morals and worry that I was being untruthful with him when infact perhaps reinforcing his view would have caused him less displeasure. I had not considered his other needs like his wishes or desires and I had not gathered enough personal information about him beforehand to know this – maybe he liked gardening. ( It would appear that we (Mr Jones the source and me the encoder were speaking the same language but were not on the same cultural channel which led to poor communication in that neither of us understood the others message)

This experience was very frustrating and upsetting and highlighted the need for me to improve my communication skills and ensure better understanding of patients’ conditions and needs before attempting anything more than basic needs communication e.g. are you hungry?

I tried not to communicate my frustration, lack of understanding and emotional distress to Mr. Jones by being attentive, asking appropriate questions and using open, non agitated body language ( promoting empathy in the form of my own body language to promote active listening (Egan 2002) until the moment he became distressed at which point I did not have the necessary communication skills to deal with the situation positively

I should have allowed more time to understand what Mr. Jones was thinking and feeling by maybe asking him calm questions such as do you know where you are, how long have you been here? And perhaps he would have come to a gradual realisation by himself. I now realise that my concerns about the value of truth (truth is always the best policy) were not compatible with his care needs.

when taking into account Berlo’s model, when one element is missing the communication fails. In the example given, the source and the receiver had a common channel but the message was interpreted differently, there was no common understanding of the message. I hope with further training i will develop a better understanding of communication. Rowe (1999) explains that a person must identify their weaknesses as an initiative for becoming self-aware. I will take all this into account when on my next placement and through the rest of my nursing career.