NRSE 4540: MODULE 1 ASSESSMENT 2: WRITTEN ASSIGNMENT – COMMUNITY HEALTH DIAGNOSES TEMPLATE Community Statistics Name: ELIZABETH RESENDIZ Student ID: P100968703 Date: 08/28/2021 Emal Selected County, State: lr202419@ohio.edu San Diego County, California Number of population 3,347,270 Public Services and Access to Care Provider County State Nation Source/Reference of Data Hospitals 1.4 1.9 2.9 AHA Annual Survey Physicians (both 1.3 1.7 2.6 World Health Organization’s Global Health Workforce Statistics 0.0 0.2 8.9 Centers for Disease Control and Prevention 5% 8% 21% primary care and specialty) Overdoses - heroin Public transportation Bureau of Transportation Statistics Demographic and Ethnic Data (Example: search Google for “Ohio, County Name, and Population”) Data MUST be presented in a comparable manner (i.e. percentage by population) Demographic Variable County State Nation Source/Reference of Data 6.1% 6.0% 6.0% Quick Facts – U.S. Census Bureau 18 and younger 21.4% 22.5% 22.3% Quick Facts – U.S. Census Bureau 65 and older 14.5% 14.8% 16.5% Quick Facts – U.S. Census Bureau Male 50.3% 49.7% 49.2% Quick Facts – U.S. Census Bureau Female 49.7% 50.3% 50.8% Quick Facts – U.S. Census Bureau White 75.4% 71.9% 76.3% Quick Facts – U.S. Census Bureau Black 5.5% 6.5% 13.4% Quick Facts – U.S. Census Bureau American Indian 1.3% 1.6% 1.3% Quick Facts – U.S. Census Bureau < 5 y.o. Last updated 09/04/2021 © 2021 School of Nursing - Ohio University Page 1 of 5 NRSE 4540: MODULE 1 ASSESSMENT 2: WRITTEN ASSIGNMENT – COMMUNITY HEALTH DIAGNOSES TEMPLATE Asian 12.6% 15.5% 5.9% Quick Facts – U.S. Census Bureau Hispanic 34.1% 39.4% 18.5% Quick Facts – U.S. Census Bureau Single 35.5% 36.5% 33.0% Statistical Atlas Married 47.0% 46.5% 48.0% Statistical Atlas Health Statistics (Example: search Google for terms such as “Infant Mortality Ohio,” etc.) Data MUST be presented in a comparable manner (%, per 1000, per 100000, etc.) Rate County State Nation Data Source Infant Mortality (Infants < 1 Y.O. Reported as per 1000 Live Births) White 2.8 3.2 4.7 Health & Human Services Agency; National Center for Health Statistics Black 21.0 8.3 10.9 Health & Human Services Agency; National Center for Health Statistics Hispanic 65.0 4.7 5.2 Health & Human Services Agency; National Center for Health Statistics Death Rates: (Usually reported as per 100000) Motor Vehicle Accidents 30.1 43.2 72.0 National Center for Health Statistics Lung Cancer 33.8 40.1 450.5 National Center for Health Statistics Breast Cancer 25.2 30.8 439.8 National Center for Health Statistics Cardiovascular Disease 228.1 199.8 1000.4 National Center for Health Statistics AIDS 12.8 15.8 49.7 National Center for Health Statistics Diabetes 25.4 22.1 100.6 National Center for Health Statistics Prenatal Care (% of Mothers delivering live infants who did NOT receive prenatal care in the 1st trimester) 43.6 75.1 145.4 National Center for Health Statistics Obesity 26.5 30.4 100.6 National Center for Health Statistics Risk Indicators: Last updated 09/04/2021 © 2021 School of Nursing - Ohio University Page 2 of 5 NRSE 4540: MODULE 1 ASSESSMENT 2: WRITTEN ASSIGNMENT – COMMUNITY HEALTH DIAGNOSES TEMPLATE Insufficient Physical Activity 30.1 33.6 89.4 National Center for Health Statistics Economic Statistical Data: (Example: search Google for “Ohio Income Range”) Variable County State Nation Data Source $78,980 $75,235 $62,843 Quick Facts – U.S. Census Bureau 10.3% 11.8% 10.5% Quick Facts – U.S. Census Bureau 6.5% 7.7% 5.6% U.S. Bureau of Labor Statistics Income Mean Poverty rate Unemployment Rate Educational Levels: (Example: search Google for “Ohio Income Range”) Data MUST be presented in a comparable manner- i.e. % City or County State Nation Data Source < High school 23.5% 20.8% 22.1% Statistical Atlas High school 87.4% 83.3% 88.0% Quick Facts – U.S. Census Bureau College degree 38.8% 33.9% 32.1% Quick Facts – U.S. Census Bureau Variable Analysis: San Diego County in California has a very small population of about 3.3 million. This population is just 8.3% of the total population in California while 0.99% of the total population in the United Sates. Although the county’s population is very small, the data obtained in this activity revealed that the county experiences key risks and concerns with regards to population health. To note, the identification of these risks is based on the correlated values that the variables have in this information, together with the data provided by reputable publications. Based on these correlation, it shows that San Diego County has two major leading causes of death. These include cardiovascular-related diseases and cancer. Also, the county’s risk indicator for prenatal care is relatively high as compared to other risk indicators which are obesity and insufficient physical activity. To be specific, the death rate for cardiovascular-related diseases is 228.1 per 100,000 persons. This rate is twice that of the indicated death rates of the other leading causes in Last updated 09/04/2021 © 2021 School of Nursing - Ohio University Page 3 of 5 NRSE 4540: MODULE 1 ASSESSMENT 2: WRITTEN ASSIGNMENT – COMMUNITY HEALTH DIAGNOSES TEMPLATE the list. Acknowledging that 14.1% of the county’s population is 65 years and older, it could be deduced that the rate at which the disease has caused death in the population of the county has reached that of the demographics of the younger individuals. This information is alarming as it is known that cardiac diseases are common among the elderly. According to Andersson & Vasan (2018), lifestyle habits account for the increasing prevalence of cardiovascular disease among young adults. The persistence of these lifestyle habits had led to the increase of the risk factors that influence cardiovascular-related diseases to even increase among the young adult population (Lopez et al., 2021). Moreover, since obesity and insufficient physical activity are persistent in the county, the expectancy of deaths related to cardiovascular disease could potentially even increase as obesity and insufficient physical activity are direct risk indicators of cardiac diseases. The next leading cause of death in the county is cancer. Based on the information provided in the death rate table, it shows that death rates (per 100,000 persons) for lung cancer and breast cancer are 33.8 and 25.2, respectively. Although the factors that contribute to breast cancer is diverse, early symptoms are manageable. Thus, early hospitalization could trim down the death rate caused by breast cancer. Referring to the information about public services and access to care, San Diego County is able to provide the necessary healthcare that the population needs to assess its health. Information about the importance of submitting to healthcare services is one of the main factors that limits individuals to apply to these services (Nies & McEwen, 2019a). On the other hand, the correlation of smoking to lung cancer attributes the death rate as caused by the cancer of the lung. The young population of the county makes it more reasonable for the prevalence of smoking to surge as one of the risk indicators that needs attention. According to Freedman et al. (2016), smoking at early age makes a person more vulnerable to severity of respiratory illnesses. Data shows that about 200 youth start smoking every day in the US. To further note, prenatal care is the highest risk indicator in the county at 43.6 per 100,000 persons. This information is also one of the biggest threats in the population of the county as this risk indicator is attributable to the increased risk of infant mortality. Basically, it shows that the Hispanic race has the highest infant mortality rate at 65.0 per 1000 live births. This occurrence is highly related to lack of knowledge about the importance of prenatal care among mothers (Partridge et al., 2017). Although healthcare access is not limited in San Diego County, the lack of dissemination of information about the importance of health checkups makes mothers at risk of healthcare problems and infant mortality. The lack of this knowledge creates the biggest barrier towards achieving a healthy population (Nies & McEwen, 2019b). Thus, it is significant that the dissemination of health information becomes one of the priorities to achieve the national objective of making people healthier and live longer. Last updated 09/04/2021 © 2021 School of Nursing - Ohio University Page 4 of 5 NRSE 4540: MODULE 1 ASSESSMENT 2: WRITTEN ASSIGNMENT – COMMUNITY HEALTH DIAGNOSES TEMPLATE Andersson, C., & Vasan, R.S. (2018). Epidemiology of cardiovascular disease in young individuals. Nat Rev Cardiol, 15(4), 230-240. Freedman, N.D., Abnet, C.C., Caporaso, N.E., Fraumehi Jr., J.F., Murphy, G., Hartge, P., Hollenbeck, A.R., Park, Y., Shiels, M.S., & Silverman, D.T. (2016). Impact of changing US cigarette smoking patterns on incident cancer: risks of 20 smoking-related cancers among the women and men of the NIH-AARP cohort. Int J Epidemiol, 45, 846-856. Lopez, E.O., Ballard, B.D., & Jan, A. (2021). Cardiovascular Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Nies, M.A. & McEwen, M. (2019a). Health: a community view. Community/public health nursing: promoting the health populations (7th ed.). St. Louis, MO: Saunders/Elsevier. Nies, M.A. & McEwen, M. (2019b). Historical factors: community health nursing in context. Community/public health nursing: promoting the health populations (7th ed.). St. Louis, MO: Saunders/Elsevier. Partridge, S., Balayla, J., Holcroft, C.A., & Abenhaim, H.A. (2017). Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: a retrospective analysis of 28,729,765 U.S. deliveries. Am J Perinatol, 15, 931-942. Priority Community Health Nursing Diagnoses #1 Risks of cardiovascular-related diseases among young adults in San Diego County related to obesity, insufficient physical activity, poor health management, and lack of knowledge regarding proper healthcare as evidenced by cardiovascular disease as the major leading cause of death in the county. Priority Community Health Nursing Diagnoses #2 Risks of poor healthcare management among infants in San Diego County related to the high percentage of non-prenatal care, lack of awareness to healthcare options, and incomplete education as evidenced by the high infant mortality rate among different races in county. Last updated 09/04/2021 © 2021 School of Nursing - Ohio University Page 5 of 5 Community Assessments and Epidemiology Discussion In my recent forages on social media, I came across the TikTok of a retired ER Tech who goes by the handle “Steveioe”. In some of his short “stories” he tackles the various scenarios that he encounters, and one that particularly struck me as both funny and sad (and happening in real life, too) was the girl (played by him) asking for refills of her birth control pills. She exclaims that the pharmacists never give “them” enough, later on saying that she and her boyfriend both take the pills. It is funny because we, in the healthcare field, know that birth control pills are taken by women, but it is also sad because it reflects the lack of information that many consumers have regarding their medications and healthcare in general. In the previous assignment, one of the glaring realities that I have seen is the term “lack of knowledge/awareness” or “incomplete education”. My first priority community health nursing diagnosis was the risks of cardiovascular-related diseases among young adults in San Diego County related to obesity, insufficient physical activity, poor health management, and lack of knowledge regarding proper healthcare as evidenced by cardiovascular disease as the major leading cause of death in the county. It is said that Americans are suffering fewer heart attacks as a whole, but heart attack rates for people below the age of 40 years old are going up. With the pandemic and restrictions in place, many young adults rely on too much takeout and fast food. Screen time has also increased a lot, and many jobs also lean towards the sedentary, especially with the workfrom-home scheme in place (Cleveland Clinic, 2019). Certain populations are at a higher risk of developing heart disease, which includes those who have existing heart defects or heartbeats, high body mass indexes, and diabetes. Poor management of these can increase the risk of cardiovascular-related diseases, and they can be further exacerbated by negative lifestyle choices, such as smoking, excessive drinking, and poor diet (LiveStories, n.d.). I personally believe that better implementation of health promotion and disease prevention activities, especially with the use of social media and other digital outlets, can help boost knowledge of young adults. History already showed that primary prevention strategies such as teaching about smoking cessation, reduction of dietary saturated fat intake, and hypertension control were successful in educating the public (Nies & McEwen, 2019). References Cleveland Clinic. (2019, April 26). Why Are Heart Attacks on the Rise in Young People? https://health.clevelandclinic.org/why-are-heart-attacks-on-the-rise-in-youngpeople/ LiveStories. (n.d.). San Diego County Heart Disease Statistics. https://www.livestories.com/statistics/california/san-diego-county-heart-diseasedeaths-mortality Nies, M. A. & McEwen, M. (2018). Community/Public Health Nursing: Promoting the Health of Populations (7th ed.). Elsevier. Chapter 8 Community Health Education Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. Health Education … … is any combination of learning experiences designed to predispose, enable, and reinforce voluntary behavior conducive to health in individuals, groups or communities. – Green and Kreuter, 2004 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Health Education’s Goals   To understand health behavior and to translate knowledge into relevant interventions and strategies for health enhancement, disease prevention, and chronic illness management To enhance wellness and decrease disability Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3 Health Education’s Goals (Cont.)   Attempts to actualize the health potential of individuals, families, communities, and society Includes a broad and varied set of strategies aimed at influencing individuals within their social environment for improved health and well-being Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 Learning Theories    Humanistic theory helps individuals develop their potential in a self-directing and holistic manner. Cognitive theory recognizes the brain’s ability to think, feel, learn, and solve problems; theorists in this area train the brain to maximize these functions. Social learning is based on behavior that explains and enhances learning through the concepts of efficacy, outcome expectation, and incentives. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5 Adult Learners       Need to know Concept of self Experience Readiness to learn Orientation to learning Motivation – Knowles (1980, 1989) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Health Education Models Health Belief Model (HBM)        Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Self-efficacy Demographics Cues to action Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Health Education Models (Cont.) Health Promotion Model (HPM)  Individual characteristics and behaviors   Behavior—specific cognitions and affect   Prior behaviors, personal factors Activity-related affect, interpersonal influences, situational factors, commitment to plan of action, perceived self-efficacy, immediate competing demands and preferences, perceived benefits of health-promoting behaviors, perceived barriers to health-promoting behaviors Behavioral outcome  Health-promoting behavior Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8 Model of Health Education Empowerment … nurses cannot assign power and control to the individual within the community but rather … the “power” must be taken on by the individual and community with the nurse guiding this dynamic process. – Van Wyk, 1999 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Model of Health Education Empowerment (Cont.)  Process includes examining       Education Health literacy Gender Racism Class Recognizes the structural and foundational changes that are needed to elicit change for socially and politically disenfranchised groups Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 Problem-Solving Education …  …centers on empowerment (Freire, 2005)      Allows active participation and ongoing dialogue Encourages learners to be critical and reflective about health issues Involves individuals as subjects, not objects Increases health knowledge through a participatory group process Involves activism on the part of the educator   Facilitator-educator is a resource person and is an equal partner with the other group members Leads to sustainable lateral relationships Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11 Participatory Action Research (PAR)   Goal of PAR is social change Embraces the use of community-based participatory methods  Participation and action from stakeholders and knowledge about conditions and issues helps to facilitate strategies reached collectively Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12 Community Empowerment    Community members take on greater power to create change Based on community cultural strengths and assets Attention must be given to collective rather than individual efforts to ensure that outcomes reflect voices of the community and truly make a difference in people’s lives Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 The Nurse’s Role in Health Education       Become a partner with individuals and communities Serve as catalyst for change Activate ideas Offer appropriate interventions Identify resources Facilitate group empowerment Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14 Framework for Developing Health Communications Figure 8-1 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15 Health Education Model Stage I: Planning and strategy selection  Questions to Ask       Who is the intended audience? What is known about the audience and from what sources? What are the communication and education objectives and goals? What evaluation strategies will the nurse use? What are the issues of most concern? What is the health issue of interest? Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 Health Education Model Stage I: Planning and strategy selection (Cont.)  Collaborative Actions to Take         Review the available data. Get community partners involved. Obtain new data. Determine perceptions of health problems. Determine the community’s assets and strengths. Identify underlying issues and knowledge gaps. Establish goals and objectives. Assess resources. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17 Health Education Model Stage II: Developing and pretesting concepts, messages, and materials  Questions to Ask        What channels are best? What formats should be used? Are there existing resources? How can the nurse present the message? How will the intended audience react to the message? Will the audience understand, accept, and use the message? What changes may improve the message? Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Health Education Model Stage II: Developing and pretesting concepts, messages, and materials (Cont.)  Collaborative Actions to Take      Identify the messages and materials. Decide whether to use existing materials or produce new ones. Select channels and formats. Develop relevant materials with the target audience. Pretest the message and materials and obtain audience feedback. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 Health Education Model Stage III: Implementing the program  Questions to Ask         How should we launch the health education program? How do we maintain interest and sustainability? How can we use process evaluation? What are the strengths of the health program? How can we keep on track within timeline and budget? How do we know if we have reached our intended audience? How well did each step work (process evaluation)? Are we maintaining good relationships with partners? Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Health Education Model Stage III: Implementing the program (Cont.)  Collaborative Actions to Take    Work with community organizations to enhance effectiveness. Monitor and track progress. Establish process evaluation measures. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21 Health Education Model Stage IV: Assessing effectiveness and making refinements  Questions to Ask       What was learned? How can outcome evaluation be used to assess effectiveness? What worked well, and what did not work well? Has anything changed about the intended audience? How can we refine methods, channels, and formats? What lessons were learned? What modifications could strengthen the health education activity? Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22 Health Education Model Stage IV: Assessing effectiveness and making refinements (Cont.)  Collaborative Actions to Take       Conduct outcome evaluations. Reassess and revise goals and objectives. Modify unsuccessful strategies or activities. Generate continual support from community groups. Provide justification for continuing/ending the program. Summarize in an evaluation report. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23 Health Literacy Definitions Evolved Over Time  National Literacy Act (1991)   Literacy is operationally defined as the ability to read and write at the fifth-grade reading level in any language and can be measured according to a continuum. IOM Report (2004)  The capacity to obtain, interpret, and understand basic health information and services and the competence to use such information and services to enhance health Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24 Health Literacy In 1999, the AMA’s Report of the Council on Scientific Affairs reported that patients with the most health care needs are often the least able to read and understand information that would enable them to function successfully within the health care system. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 25 Health Literacy (Cont.)  Health literacy is about empowerment …    Having access to information, knowledge, and innovations Increasingly important for social, economic, and health development A key public health issue in the delivery of safe, effective care Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 26 Low Literacy        Increases the use of health care services Decreases self-esteem; increases shame and stigma Adversely affects outcomes and treatment of some medical conditions Poses barriers to obtaining informed consent Impacts participation in research Leads to health care and linguistic isolation Impedes patient-provider communication Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 27 Literacy Concerns    Serious mismatch exists between the reading levels of materials and patient’s reading skills. Materials often fail to incorporate the intended audience’s cultural beliefs, values, languages, and attitudes. Low literacy prevents many from gaining the full benefits of health care. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 28 Literacy Concerns (Cont.)   Inability to read and understand instructions influences self-care abilities and health and wellness. Individuals with very low literacy skills are at an increased risk for poor health, which contributes to health disparities. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 29 Levels for Interventions  Functional/basic literacy   Communicative/interactive literacy   Increasing basic reading/writing skills Understanding and using information with providers Critical literacy*  Analyzing and using information in life situations *Most important because it increases empowerment and success in everyday situations Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 30 Helpful Tips for Effective Teaching       Assess reading skills Determine what client needs to know Identify motivating factors Stick with essentials Set realistic goals and objectives Use clear and concise language      Develop a glossary of common words Space teaching over time Personalize health messages Incorporate methods of illustration, demonstration, and real-life examples Give and get Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 31 Helpful Tips for Effective Teaching (Cont.)         Summarize often Be creative Use appropriate resources and materials Put patients at ease Praise patients Be encouraging Allow time for questions Employ teach-back methods    Remember that comprehension and understanding take time and practice Conduct learner verification Evaluate the teaching plan Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32 Assess Materials  Become a Wise Consumer and User    Evaluate health materials, including websites, before disseminating them Materials should strengthen previous teaching Materials should be used as an adjunct to health instruction Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 33 Assessing the Relevancy of Health Materials      Do materials match the intended audience? Are materials appealing and culturally and linguistically relevant? Do they convey accurate and up-to-date information? Are messages clear and understandable? Do messages promote self-efficacy and motivation? Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 34 Assessment of Reading Level  Assess reading levels of intended audience     Assess readability of educational resources    Rapid estimate of adult literacy in medicine (REALM) Single Item Literacy Screener (SILS) Short Assessment of Health Literacy for SpanishSpeaking Adults (SAHLSA) SMOG readability formula Flesch-Kincaid formula (on most computers) Verify understanding of learner Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 35 Role of Social Media    Numerous platforms now available May reach diverse community constituents with important public health messages Potential to…     Facilitate interactive communication Increase sharing of health information Personalize and reinforce health messages Can empower community members to make informed health decisions Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 36 
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