When Orleans Parish and the state of Louisiana exceeded the national average in number of citizens with many of the most common health problems, it was time to "Razoo Health." Statistics released by the Louisiana Department of Health and Hospitals (2000) and the Annie B. Casey Foundation (2000) depicted a health crisis of epic proportions that included high rates of obesity, heart disease, diabetes, teenage pregnancy, low birth weight babies, sexually transmitted diseases, drug addiction, and violent death. In response, Louisiana State University (LSU) Health Sciences Center School of Nursing faculty designed and instituted a neighborhood-based initiative that is integral to two community health nursing courses. This initiative facilitated a paradigm shift from exclusively illness management to include health promotion and disease prevention.
"Razoo," a local colloquialism used to claim an opponent's marble during game play, means to snatch or claim. In general use, razoo can be used when one wants to get something before someone else does. For example, "Let's get to the movies early so we can razoo the best seats." Appropriately, the motto Razoo Health describes the intent of Louisiana citizens to reclaim and take back the health of the cities' neighborhoods.
RESPONSE TO THE PROBLEM
To foster interest and awareness of the many possible locations and partners available for collaboration, a progressive game format was used to develop Razoo Health for teaching and programming purposes. This has engaged participants more readily than descriptions and checklists. Recognized principles of community-based nursing education (American Association of Colleges of Nursing, 1993, 2000; Matteson, 1995, 2000) were used to make the paradigm shift required by the Razoo Health model.
Acknowledging that health care occurs where people live, work, and play, a true partnership was formed between academia and the community. Through this partnership, clinical services emerged based on the capacities of all and in direct response to the voiced needs of the community. Based in four inner-city parochial schools and churches, nursing faculty and students mobilize neighborhood assets and talents to form partnerships for healthy change.
The Centers for Disease Control and Prevention (CDC) Coordinated School Health Model (Marx & Wooley, 1998) is used within each neighborhood school to provide access to health care services, decrease absenteeism, raise test scores, and deliver worksite health programming to faculty and staff, as well as to neighbors and parishioners. Nursing students work with citizens from all walks of Ufe, as well as students of other professions within the LSU Health Sciences Center (CVNeil & Pew Health Professions Commission, 1998) to learn community assessment skills and deliver primary, secondary, and tertiary services to individuals, families, and the community as a whole.
Faculty, students, citizens, and existing neighborhood health care providers come together as equals to develop, implement, and evaluate programs. Sharing power increases all participants' capacities. Nursing students learn to use the nursing process appropriately, think critically, and communicate honestly, and emerge prepared to make a difference. Faculty experience freedom to connect with new partners in education, develop innovative teaching strategies, and witness ongoing change. Citizens have the opportunity to express themselves, feel valued, and contribute to neighborhood change. As true citizens, they wear crowns of empowered sovereignty as they take back, or razoo, what is rightfully theirs - health.
The adoption of a community-based andragogy required nursing faculty to undergo cognitive restructuring. Consensual values were explored, and an optimistic vision for the future emerged. Terminology had to be clarified and defined. Dialogue ensued regarding the difference between community-focused versus communitybased approaches. Questione arose as to what constituted an authentic partnership and what comprised a neighborhood. Using critical thinking skills, the concepts of empowerment education (Freiré, 1993) and service learning (Seifer, 1998) were explored. Diverse viewpoints were invited; ambiguity was tackled; and creative conflict was welcomed to acknowledge existing biases and prejudices. In the end, consensus for change was achieved. Mutual trust and hope were restored. A model was devised in which each neighborhood could provide a unique context for education and a setting for respectful holistic care, focused on health promotion and disease prevention. It was time to link arms with partners in the neighborhood and Razoo Health.
DEVELOPMENT OF THE GAME
To make the learning experience fun and non-threatening for participants, the Razoo Health model was conceived as a game board. According to Kretzmann and McKnight (1993), the objective of the game is to promote community health by:
* Assessing and mapping the partners' strengths, assets, and talents.
* Identifying and mobilizing local citizens' capacities and skills.
* Combining citizens' talents to form neighborhoodbased, sovereign partnerships.
* Inviting "outsiders" in government, universities, and philanthropic organizations to join in these neighborhood efforts.
A player wins the game by reaching the round table within the school and selecting a sovereign crown. Rules of play (Figure) offer activities appropriate to both juniorlevel and senior-level community health nursing courses. Junior-level students focus on the assessment of one of the four partner communities and the formulation of statements of "possibilities for health." Their group findings are circulated both in term paper format and in creative group presentations at the end of the semester. Returning senior students review current findings and spearhead consensual program planning and evaluation within one of these four neighborhoods. Their findings are captured in written assignments and are featured in individual portfolios. Both groups document subjective learning in reflective journal entries. Citizens from the community conduct seminars to define neighborhood borders and describe each neighborhood's unique history and culture. Often, community members conduct all or parts of the "windshield" or walking tour of the neighborhood, introduce the students to other key neighborhood leaders, and attend students' presentations.
The CDC Coordinated School Health Model provides the structure that is applied to community assessment, partnership formation, the determination of "possibilities for health," and program planning. The CDC Model is used within the school hub, the parish church, and the neighborhood. The Razoo Health game board has eight signposts that depict the eight components of the Coordinated School Health Model and incorporate local culture, best practices, and pertinent publications.
The game begins at the "Kretzmann-McKnight Park": A Healthy Environment and the Integration with the Community (Kretzmann & McKnight, 1993) and "Caring in Action" (Hitchcock, Schubert, & Thomas, 1999) signposts. In an effort to set the stage for asset mapping, junior-level students are asked to select a partner within their clinical group and complete an Individual Capacity Inventory (Kretzmann & McKnight, 1996). Students introduce their partners to the group and highlight the talents, assets, and capacities they have discovered.
Figure. Razoo Health: Rules of play.
The community assessment paper written during the previous semester is distributed and read by the group. Students are guided by faculty and partners within the school and community to immerse themselves in the unique historical and cultural qualities of their partner neighborhoods. Assignments that contribute to the assessment process are created based on group members' assets and talents, and exploration of the neighborhood begins. A seat belt survey and school site assessment are conducted at the hub school. The neighborhood boundaries are defined, and the entire clinical group does a riding, walking, talking, and "use all your senses" tour. Interviews that focus on capacities are conducted with assigned individuals, institutions, and associations. Census data, health indicators, and other information sources then are analyzed. Students compile all of this information and work with key individuals in their partner community to develop "possibilities for health" that reflect the citizens' multifaceted talents, assets, capacities, and wishes. Senior nursing students review the latest edition of their neighborhood assessment paper and select a "possibility for health" that interests them and use it as a starting point for the development of a capacity-building paper that focuses on program planning and evaluation.
The next stop in the Razoo Health game is the "Cooper Institute Playground": Physical Education (Cooper, 1999). In this playground, the emphasis is on fitness as a component of health. Students not only assess their school and neighborhood for fitness opportunities, but they help plan and conduct programs with a fitness focus. These programs include the President's Youth Fitness Assessment, jump rope contests, creative dance, Kid Fit program (Cooper, 1999), and health education with a fitness component. Student nurses monitor playground activities to encourage safe and active play. Newsletter articles encourage parents to promote activities that require physical exertion at home. Students consult physical education teachers and provide feedback about the health risks associated with inactivity. An outcome of this work has been the partnering between nursing students and faculty and physical therapy faculty to conduct a study on backpack ergonomics. This study will add to the body of knowledge in physical therapy and help identify the best practice when asking students to carry heavy books for homework.
The "Gumbo Ya Ya Restaurant": Food Services is the next signpost in the game. The gumbo of culture, ethnicity, and diversity that constitute New Orleans neighborhoods is reflected in the number of restaurants and variety of foods available throughout the city. The problem of obesity among New Orleans citizens cannot be overstated. Understanding the magnitude of the problem, nursing students collect data on the body mass indexes of elementary and middle school children. These data are analyzed and reported to teachers, parents, community organizations, and interested partners (Kraus et al., 1999).
In an effort to address concerns about poor food choices, culturally acceptable nutrition programs have been developed. Children are rewarded for trying new fruits and vegetables on "Tasty Tuesday." In addition, healthy snacks and stickers are used as rewards for school activities instead of candy. School cafeteria workers have become involved in planning new ways of encouraging healthy food choices. Parents are provided with information about healthy snacks and recipes for heart-healthy foods. Progress has been slow but positive. As national reports confirm, finding strategies to increase healthy food choices and physical activity is a difficult challenge (Partnership for Prevention, 2000).
A visit to the "Elysian Fields Full Gospel Church": Counseling and Social Services signpost exposes students to the richness and depth of spirituality within New Orleans neighborhoods and the hearts and minds of the citizens. Partnerships have been formed and nurtured with nurses working in churches, synagogues, and mosques. Nursing students assess the availability of counseling and social services and help with programs that address social issues. Peer mediation on the playground, the Second Step violence prevention program, an adolescent growth and development workshop, and counseling services are some of the programs developed and offered in the neighborhood hub schools.
The "Best Practice Alley": Clinical Services (U.S. Department of Health and Human Services, 1998) component of the Coordinated School Health Model reflects the commitment to knowing and using the best practices available in the health care arena. Student nurses provide many school and neighborhood health services. Immunization records are updated; height, weight, and oral health assessment is conducted; vision, hearing, and blood pressure screening is provided; and case management services are offered to children with asthma. Appropriate referrals are made, and outcomes are tracked and reported (Kraus, Connick, & Morgan, 2002; Moore et al., 2001). Additional services such as health screenings, influenza vaccines, case management services, smoking cessation instruction, exercise programs, and oral health assessment are provided by nursing students to adults in senior centers, children in Head Start programs, and clients in neighborhood clinics. All services are planned and delivered in collaboration with neighborhood partners.
The seventh signpost is the "Passport to Wellness" Health Club: Worksite Health Program (LSU Health Science Center, 1999). Teachers, cafeteria staff, custodians, letter carriers, and any other staff member or citizen at the hub school and other community sites help plan and participate in a worksite health component of the Razoo Health model. Annual fitness assessments, health risk appraisals, various screenings, influenza vaccines, cardiopulmonary resuscitation classes, and educational programs are conducted by both junior-level and seniorlevel nursing students and faculty. Citizens are encouraged to razoo their own health by using a Passport to Wellness developed at LSU Health Sciences Center, which has sections to record demographic information and fitness, lifestyle, screening, and immunization results. Health care and service provider information also is available in the passport.
The eighth and final signpost is the Totally Awesome Health Education Theater": Health Education (MeeksHeit, 2000). Health education takes many forms in the capable hands of both the junior-level and senior-level nursing students. Junior-level students teach in the elementary school classrooms and discuss topics selected by the elementary school teachers and students. Senior-level students create their own classroom activities in partnership with the teachers and students. These have included the use of puppets, storytelling, parades, and the American Red Cross Scrubby Bear program. Children's books by local authors are used to deliver health-related messages to students.
Senior-level nursing students plan and engage kindergarten children in the Bodyworks program (Johnson, 1996), which teaches them about the beauty and mystery of their bodies. Young children learn that although their bodies are different on the outside, they are the same on the inside. The American Lung Association's Open Airways program is taught to children with asthma. Dental health is taught to children in neighborhood public and parochial schools and in Head Start programs. Nursing students create bulletin boards, health education centers, quarterly newsletters, and games. Health education is provided in schools, senior centers, Head Start programs, neighborhood libraries, the homes of citizens who are enrolled in the Health Link program developed by the Visiting Nurses Association and LSU Health Science Center School of Nursing, and United Cerebral Palsy clinics for citizens who are physically challenged. Health education is an integral part of the Razoo Health experience.
Working within the neighborhoods has been advantageous for everyone involved. Nursing faculty celebrate the neighborhood and its citizens as untapped educational resources. As citizens work together, the questions are, "Who is the teacher, and who is the learner?" Within these partnerships, every participant is a teacher and a learner. Faculty rely on citizens' lived experiences of neighborhood history, culture, geography, and people to teach nursing students health promotion, while confronting the realities of life across settings and the Ufe span. Within the comfort of the setting, new ideas germinate, and new roles emerge for all partners. Excitement is generated as new avenues for research and faculty practice are discovered and as new colleagues and additional resources are introduced. Reinforcement occurs and satisfaction results as practice causes real humanistic change.
For students, this community-based model demonstrates social justice. Razoo Health is inclusive. Health is defined as an achievable consumer good. To be attained, all must have a voice, access, and economic parity in obtaining health education and health care. Students quickly realize that although communities may differ, all communities are equal in their need for individual, family, and neighborhood health. When in dialogue with citizens, engaged listening quickly negates the use of terms such as "noncompliance" or "nonadherence" to describe citizen behavior. Students realize that, if asked, citizens offer creative, workable solutions of their own. In this and other ways, students' attitudes toward citizens change. Opportunistically, students truly participate in the full continuum of care and are exposed to real continuity over time. First-hand knowledge of the effectiveness of interventions yields a more optimistic picture of recovery. In addition, for the first time in nursing, students learn to value teamwork and collaboration and are rewarded for doing so. They see themselves as successful agents of social change who can practice in any setting and make a difference. This is empowerment education at its best.
Citizens of the community realize they are not alone in their struggle to Razoo Health. Their sense of connectedness and being valued increases as we eat, share stories, celebrate our Ufe events, and laugh together. We teach and learn together, and citizens share an active involvement in the educational process. Nurses are viewed as approachable partners, and recruitment of citizens into the nursing profession becomes a real possibility. Services formerly unavailable in the neighborhood now are delivered to citizens "right at their front doors." In addition, as new, relevant health information is obtained, it can be disseminated quickly and completely through neighborhood channels.
Change like this is not a passive, smooth, nor easy process. However, according to Gandhi (n.d.), "We must be the change we wish to see." Lessons learned in the process of developing community-based nursing education initiatives are discussed by Matteson (2000) and Edwards and Alley (2002). These authors agree that each individual involved in the change process must be patient and hold on to the vision, and they acknowledge the interconnecting relationships among ideology, power, and culture.
LOCAL LESSONS LEARNED
Participation in Razoo Health has provided the nursing students more than the opportunity to develop professional skills and provide care in a variety of settings. As with all community-based educational partnerships, students have gained the knowledge and perspectives of their partners, enabling them to not only be more appropriate but also more effective.
Understanding clients' needs starts with understanding their history. The culture of New Orleans is not that of the usual Southern city. Due to its geographical location as a port city and its peculiar ethnic composition, the unique and essential patterns of New Orleans culture took shape early. Gehman (1994) described New Orleans as the most Africanized city in the United States. The effects of slave culture in this area cannot be underestimated. Although "* originally colonized by the French and later falling under Spanish rule, the settlement of New Orleans was aided by the importation of 2,083 West African slaves between 1719 and 1723. Accustomed to the hot, humid climate and possessing natural immunity to indigenous fevers, the slaves were given the arduous task of building levees, draining 44 swamps, clearing land, and constructing rudimentary buildings. They also were skilled shipbuilders, iron workers, carpenters, and crop growers.
Conditions were trying for both the French immigrants and their slaves. Women in general were scarce, and single men of both races spent time with local native tribes. Although the French Code Noir prohibited interracial marriage, living conditions in the city were quite fluid. Many families had a few slaves who lived in extensions of the main house. Miscegenation resulted in children who "favored" the master, received an education, and were given freedom. From the start, some free Black individuals also came to New Orleans either from the Caribbean or France. In fact, New Orleans had by far the largest community of free people of color. Consequently, the faces of its citizens today reflect centuries of interracial mixing of French, Spanish, African, Latin, and Native American peoples - all of whom refer to themselves as Creoles (Gehman & Ries, 2000).
The cornerstones of Creole culture - family, food, faith, music, neighborhood, language, and celebration of life - have deep psychological roots in the descendants of these peoples. It is from them that the authors' local lessons emerged. These are expressed most easily by explaining six common expressions:
* "Who's ya mama, and where'd ya go to high school?" are questions that natives expect to answer to establish connectedness between and among families and neighbor- ^ hoods. Although paternal linkage is easily recognized by surname, the maternal "maiden name" completes the picture. Both sets of Creoles, descendants of White Europeans and of free people of color, cling to their history. Both also realize that it is a shared history, which has resulted in a loosely connected amalgam of neighborhoods, which share traditions that have been passed from generation to gener- * ation. To work and partner with people in the neighborhoods, acknowledgment of and respect for these traditions is essential. We must learn about and value what is important.
* "If you feed them, they will come" also is an important saying because in New Orleans food is not just nourishment, it is a religious experience. Natives live by this rule - if you've got a pot of red beans and rice, share it. Relationships cannot be formed and business cannot be conducted if food and drink are not offered and accepted. Sitting and having a cup of fresh, hot coffee, which locals ascribe as essential as the "benediction that follows prayer" is a way to demonstrate honor and regard for one another through the everyday ritual of taking refreshment together. It is here that conversation is savored and time is well spent.
* "Never do today what you can put off until tomorrow," which also is known as "Laissez le bon temps rouler." Perhaps because of the oppressive heat, it is the natives' tendency to embrace a slow, unhurried pace. The ambiance of the city and its people is impossible to appreciate at a fast clip, so time is required to explore its ambiguities. This mañana mentality is poorly understood by newcomers, but patience and tolerance are required to build partnerships.
* The expression, "Mamas don't play," is a reminder that since the city's earliest days, women have been the conscience and backbone of New Orleans. Under French law, single women of all races could own property and enter into contracts, thereby accumulating wealth and establishing a long history of women in business, politics, and social protest. Correspondingly, it was women who championed the city's humanistic issues of health, education, and welfare. The expression means that women, even today, do not or will not let anyone get away with doing anything wrong (Smith, 1996). As matriarchs, women maintain power over children, families, and neighborhoods, and as such, they are a force to be reckoned with as the gatekeepers of the community's health. Their assets, talents, capacities, and opinions are the first that must be identified and harnessed.
* Be aware that New Orleans natives strongly believe that "When God closes the door, he opens a window." It is this dependence and reliance on faith that has universally seen the citizens through many hard times. From the city's beginning, the Roman Catholic church dominated the spiritual lives of the citizens. The majority of slave owners were French Catholics, and therefore, their slaves came under the influence of the church. Church-sponsored schools, staffed by religious orders of priests and nuns, educated the city's children. As the "Yankees" arrived, the Protestant church made inroads. After emancipation, many freed slaves left Catholicism to join newly formed Negro Protestant churches (Owen & Murphy, 1987). Currently, regardless of denomination, race, or socioeconomic status, the faith component of culture in this area must be acknowledged and incorporated into any caring plan.
* Finally, when working in New Orleans neighborhoods, a certain "joie de vivre," or love of life, sets the tone. Citizens optimistically opine that "life is what you make it." Life itself is celebrated through music, parades, street festivals, and social clubs. Ordinary stoop sitting and visiting with neighbors who happen to pass by becomes an art form. Snowball stands* and corner grocery stores are still abundant in every neighborhood. New Orleans is a place where people from all walks of Ufe smile or nod when they pass strangers on the street. People using public transportation share family recipes even when they have just met. Opportunities to connect abound.
Teaching nursing students to partner with New Orleans citizens as they Razoo Health has been a meaningful endeavor for citizens, students, and faculty. Not only has the citizens' health improved, but the nursing students' ability to provide culturally sensitive care has increased and is carried into all practice arenas.
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