26.4: Adult Health
By the end of this section, you should be able to:
- Recognize major diseases affecting adults.
- Compare health outcomes between adults.
- Create evidence-based educational interventions to promote self-care for health promotion, illness prevention, and illness management of adults.
- Examine major risk factors influencing the health of adults.
- Identify Healthy People 2030 goals established for adults.
- Describe health promotion and disease prevention actions applicable to adults.
- Discuss evidence-based strategies for integrating sociocultural and linguistically responsive health promotion and disease prevention interventions in the clinical practice of adults.
The prevention of chronic diseases has become a major public health concern. Cardiovascular disease, diabetes, and cancer are leading causes of death and disability in adults globally; in the United States, one in three deaths each year occurs due to heart disease, stroke, or other cardiovascular diseases (National Center for Chronic Disease Prevention and Health Promotion, 2022c). The good news is that many of these chronic diseases are preventable through efforts that target lifestyle modification and appropriate health behaviors. Therefore, promoting and maintaining good health practices among adults is critical for preventing chronic diseases and improving quality of life. While chronic diseases are a significant concern for adults, communicable diseases also substantially threaten public health. Influenza, tuberculosis, and STIs are only some illnesses caused by infectious agents that may spread from person to person. The COVID-19 pandemic demonstrated the importance of preventing the spread of infection (National Foundation for Infectious Diseases, 2023).
This section discusses various aspects of adult health promotion and disease prevention, including healthy lifestyle habits, recommended screenings and immunizations, the impact of communicable and noncommunicable diseases on vulnerable populations, and the importance of cultural competence in addressing these health issues. By understanding and implementing these activities into their lives, adults can protect themselves and their communities while also improving their overall health and well-being.
Major Diseases Affecting Adults
In the United States, several major diseases affect adults, leading to significant mortality (see Table 26.10). These diseases cause physical limitations, significantly impact quality of life, and increase health care costs. Nurses must understand the causes, risk factors, and preventive measures associated with these diseases to help reduce their burden on the population and promote healthy living. Of these 13 diseases, 11 are noncommunicable diseases.
| Mortality | |||
|---|---|---|---|
| Cause of Death Rank | Number of Deaths | Deaths per 100,000 Population | |
| Noncommunicable | |||
| Diseases of heart | 1 | 694,619 | 278.1 |
| Malignant neoplasms | 2 | 603,484 | 241.6 |
| Accidents | 4 | 215,485 | 86.3 |
| Cerebrovascular disease | 5 | 162,577 | 65.1 |
| Chronic lower respiratory diseases | 6 | 142,136 | 56.9 |
| Alzheimer’s disease | 7 | 119,398 | 47.8 |
| Diabetes | 8 | 103,135 | 41.3 |
| Chronic liver disease and cirrhosis | 9 | 56,576 | 22.7 |
| Nephritis, nephrotic syndrome, and nephrosis | 10 | 54,283 | 21.7 |
| Intentional self-harm (suicide) | 11 | 45,229 | 18.1 |
| Essential hypertension and hypertensive renal disease | 12 | 42,806 | 17.1 |
| Communicable | |||
| COVID-19 | 3 | 416,252 | 166.7 |
| Influenza and pneumonia | 13 | 41,653 | 16.7 |
Coronary Artery Disease
Coronary artery disease (CAD), also called coronary heart disease or ischemic heart disease (CDC, 2021j), occurs when plaque buildup in the wall of the coronary arteries (atherosclerosis) decreases blood supply to the heart. Risk factors for CAD include being overweight, eating poorly, and smoking tobacco. CAD also has genetic connections, particularly a family history of heart disease before age 50. For many, the first indicator of CAD is a heart attack.
Cancer
Cancer occurs when abnormal cells divide out of control and can invade other tissues (CDC, 2021f). Cancer cells can also spread to other body parts through the blood and lymph symptoms. There are more than 100 different types of cancer; some are preventable, and others are not. One of every five deaths in the United States is due to cancer (U.S. Cancer Statistics Working Group, 2022). One leading cause of cancer is smoking. In addition to lung cancer, smoking can cause cancer in the blood, bladder, cervix, colon and rectum, esophagus, kidney, larynx, liver, mouth and throat, pancreas, and stomach. Lowering one’s cancer risk can occur through making healthier choices such as maintaining a healthy weight, limiting alcohol intake, and protecting the skin from UV exposure.
 Regardless of the cause, parts of the brain become damaged or die, leading to problems with movements, memories, thoughts, emotions, language, or other body functions. Strokes can occur at any age, but some people are at greater risk. Those with a history of a previous stroke or transient ischemic attack (TIA), hypertension , high cholesterol , coronary artery disease, atrial fibrillation, diabetes, obesity, and sickle cell disease are at much higher risk of having a stroke. Some lifestyle choices that increase the risk of stroke include (CDC, 2023j):
- a diet high in saturated fats and cholesterol,
- a lack of enough physical activity,
- too much alcohol consumption, and
- tobacco use.
There are also genetic components to stroke risk and factors related to age, sex, race, and ethnicity. Individuals aged 55 and older are more likely to have a stroke, and strokes are more common in women than men. Those who are non-Hispanic Black or Pacific Islander are more likely to die from a stroke than non-Hispanic White people, Hispanic people, AIAN, and Asians. Black people have a higher risk of having a first stroke and are more likely to die from a stroke than White people (CDC, 2023j).
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is a group of diseases that block airflow and cause other breathing-related problems. COPD includes emphysema and chronic bronchitis. Tobacco smoking is the primary cause of COPD; other causes are related to exposure to air pollutants in the home and workplace, genetic factors, and a history of respiratory infections. The CDC (2021h) reports that women; people aged 65 and older; AIAN and multiracial non-Hispanic people; those who are unemployed, retired, or unable to work; those with less than a high school education; those who are divorced, widowed, or separated; current or former smokers; and those with a history of asthma are more likely to develop COPD.
Alzheimer’s Disease
Alzheimer’s disease is the most common type of dementia. It begins with mild memory loss and then progresses to the inability to hold a conversation or respond to the environment appropriately, causing severe difficulties in performing activities of daily living (CDC, 2020d). Alzheimer’s disease impacts the part of the brain that controls thoughts, memories, and language. Much remains to be learned about this disease. The best-known risk factor for developing Alzheimer’s disease is age. Genetics may also play a role in its development. Findings suggest that a healthy lifestyle could decrease the risk of developing Alzheimer’s disease (CDC, 2020d).
In the Aging and Health Matters podcast episode “Alzheimer’s Disease—Genes Do Not Equal Destiny,” host Montrece Ransom speaks with CDC’s Scott Bowen about research that found a healthy lifestyle can help reduce the risk for Alzheimer’s disease (CDC, 2022o).
Listen to the podcast or read the transcript, and then respond to the following questions.
- What were the new findings from the research?
- What were the four healthy lifestyles that helped to prevent dementias in the research?
Diabetes
Diabetes is a chronic health condition caused by the body either not making enough insulin or not using insulin effectively. When either of these occurs, too much blood sugar remains in the bloodstream (CDC, 2022e). Over time, the increased blood sugar can lead to serious health problems, including heart disease, vision difficulties, and kidney disease. More than one in three adults in the United States have prediabetes, with blood sugar levels higher than normal but not high enough to develop type 2 diabetes, and over 80 percent of adults do not know they have prediabetes (CDC, 2022j). Prediabetes can increase the risk of heart disease and stroke and can be viewed as an opportunity to prevent type 2 diabetes. See Figure 26.3 for more about prediabetes.
The three types of diabetes are type 1 diabetes, type 2 diabetes, and gestational diabetes. Gestational diabetes was discussed briefly earlier in this chapter. In type 1 diabetes, the body does not make enough insulin, perhaps due to an immune reaction. Risk factors for this type of diabetes are family history and age, as it usually develops in children, teens, or young adults. White people in the United States are more likely to develop type 1 diabetes than Black or Hispanic people (CDC, 2022j), and there is no known way to prevent it. In type 2 diabetes, the pancreas makes less insulin than previously, and the body becomes resistant to it. Type 2 diabetes can sometimes be prevented with healthy diet and activity. A variety of factors put a person at risk for type 2 diabetes, including:
- having prediabetes;
- being overweight;
- being age 45 or older;
- having a direct relative with type 2 diabetes;
- being physically active less than three times weekly;
- having gestational diabetes or giving birth to a baby weighing over 9 pounds; and
- being African American, Hispanic, or AIAN (CDC, 2022e).
Also, more than half of women with PCOS develop type 2 diabetes by age 40, likely related to insulin resistance that occurs with PCOS (CDC, 2022w). Diabetes is the primary cause of kidney failure, lower-limb amputations, and adult blindness. The number of adults diagnosed with diabetes has more than doubled over the last 20 years. Of the adult U.S. population, 38 percent have prediabetes (CDC, 2022j).
Chronic Liver Disease
Chronic liver disease is a progressive deterioration of liver function, which includes the production of clotting factors and other proteins, detoxification of harmful metabolism products, and bile excretion. Cirrhosis is the final stage of chronic liver disease. The most common causes of chronic liver disease are alcoholic liver disease, non-alcoholic fatty liver disease, chronic viral hepatitis, and certain genetic and autoimmune causes. Other causes include use of certain drugs (amiodarone, isoniazid, methotrexate, phenytoin, and nitrofurantoin) and the vascular Budd-Chiari syndrome (Sharma & Nagalli, 2022). Of the causes, it is possible to deter chronic liver disease by limiting the use of over-the-counter pain medications and consumption of high-fat foods and alcohol and reducing the risk of developing hepatitis through vaccination, safer sex practices, and good hygiene.
Chronic Kidney Disease
Chronic kidney disease involves the damage of kidneys such that they cannot filter blood to remove wastes, toxins, and excess fluid. This excess fluid and waste remain in the body, leading to heart disease and stroke. The kidneys also help control blood pressure, stimulate the production of red blood cells, keep the bones healthy, and regulate important chemicals such as sodium, potassium, and calcium (CDC, 2022c). Risk factors for chronic kidney disease include diabetes, high blood pressure, heart disease, a family history of chronic kidney disease, and obesity. Following a healthy lifestyle and addressing any of the conditions that are risk factors can help decrease the effects or prevent chronic kidney disease.
Communicable Diseases
Two of the 10 diseases in Table 26.10 are communicable diseases (influenza and COVID-19). Both are respiratory in nature, with similar symptoms, and are easily transmitted (CDC, 2022p). See Pandemics and Infectious Disease Outbreaks for more information.
Comparison of Health Outcomes Between Adults
When comparing health outcomes between adults, many factors must be considered. SDOH, discussed in Social Determinants Affecting Health Outcomes, including economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context, are only a few of these factors. Others include age, gender, race, and lifestyle behaviors.
The following key health outcomes are commonly compared in adults; see The Health of the Population for more information:
- Overall health status: An individual’s self-perceived health status ranges from excellent to poor. In the United States, in 2019, 11.2 percent of people reported fair or poor health status. Trends related to age group and economic stability can be viewed on the CDC Health Status page.
- Chronic disease prevalence: This refers to the proportion of a population with chronic disease at a point in time. Data from the 2018 National Health Interview Survey (NHIS) found that 51.8 percent of the U.S. adult population had been diagnosed with at least one of the 10 chronic conditions previously discussed, and 27.2 percent had more than one of them. Data broken down into categories of sex, race/ethnicity, age, health insurance coverage, and location of residence (urban versus rural) can be viewed at Prevalence of Multiple Chronic Conditions Among U.S. Adults, 2018 (Boersma et al., 2020).
- Mortality rates: These are the number of deaths in a population, typically measured as the number of deaths per 100,000 individuals. The provisional mortality data in the United States in 2022 indicated that overall death rates were highest among males, older adults, and Black persons. In 2022, the highest weekly numbers of overall deaths and COVID-19-associated deaths were in January and December. Overall death and COVID-19-associated death data by age group, sex, and race and ethnicity can be viewed at Provisional Mortality Data — United States, 2022 (Ahmad et al., 2023).
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Quality of life:
Health-related
quality of life
(HRQOL) is an individual’s or a group’s perceived physical and mental health over time. On the individual level, HRQOL involves perceptions of physical and mental health and their correlates, including health risks and conditions, functional status, social support, and socioeconomic status. On the community level, HRQOL includes community-level resources, conditions, policies, and practices that can influence a population’s functional status and perceptions of health (CDC, 2018). The
County Health Rankings
(University of Wisconsin Population Health Institute, 2023) model of health indicates measures that influence how well and how long people live. In this model, the following measures connect to quality of life:
- Poor or fair health
- Poor physical health days
- Poor mental health days
- LBW
- Frequent physical distress
- Frequent mental distress
- Diabetes prevalence
- HIV prevalence
In 2020, 12 percent of U.S. adults reported that they considered themselves in fair or poor health, that their physical health was not good on 3 of the previous 30 days, and that their mental health was not good on 4.4 of the previous 30 days. The percentage of live births with LBW (under 2,500 grams) was 8 percent. Also, 9 percent of adults were living with a diagnosis of diabetes, and 380 of every 100,000 residents aged 13 and over were living with a diagnosis of HIV (University of Wisconsin Population Health Institute, 2023).
Educational Interventions to Promote Self-Care in Adults
The WHO (2022d, para. 2) defines self-care as “the ability of individuals, families, and communities to promote their own health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a health professional.” The concept of self-care recognizes individuals as active participants in managing their health in various areas, including health promotion, disease prevention and control, self-medication, providing care to dependent persons, and rehabilitation, including palliative care. Self-care is not intended to replace the need for the formal health care system but allows a different option to receive health care.
Some examples of educational interventions that may be used to promote self-care in the adult population include:
- Health education classes: can provide individuals or groups with information on topics such as healthy eating, physical activity, stress management , and disease prevention. Classes can be offered in various settings, such as community centers, workplaces, or health care facilities.
- Self-help materials: brochures, pamphlets, and books can provide individuals with information to maintain good health and prevent illness and can be made available in waiting rooms, libraries, and other public spaces.
- Workshops: can focus on learning practical self-care skills, such yoga or healthy cooking; may be led by health care professionals, community leaders, or trained volunteers.
- Mobile health applications (apps): can provide individuals with personalized health information, reminders, and tracking tools to help them maintain healthy habits. Apps are downloaded on smartphones and are available at any time.
- Social support groups: can provide individuals with the emotional support and encouragement needed to maintain healthy habits; can be led by trained facilitators and can meet in-person or virtually.
The WHO’s Guideline on Self-Care Interventions for Health and Well-Being offers suggestions for many health situations for adults. These guidelines stress the importance of tailoring these interventions to the needs and preferences of the target population to ensure maximum effectiveness (WHO, 2022d). See Planning Community Health Education for more information.
Healthy People 2030 Goals for Adults
Several Healthy People 2030 goals specifically target the health of the adult population. Healthy People 2030 divides these into goals for males and females. The overarching goal is to “improve health and well-being" (ODPHP, n.d.-d, para. 1).
The difference in the wording of the Healthy People 2030 goals for each sex is likely because males die an average of 5 years earlier than females (ODPHP, n.d.-d). According to the NCHS (2022),
- Life expectancy at birth for females in the United States dropped 0.8 years from 79.9 years in 2020 to 79.1 in 2021, while life expectancy for males dropped one full year, from 74.2 years in 2020 to 73.2 in 2021. The report shows the disparity in life expectancy between males and females grew in 2021 from 5.7 years in 2020 to 5.9 years in 2021. From 2000 to 2010, this disparity had narrowed to 4.8 years, but gradually increased from 2010 to 2019 and is now the largest gap since 1996. (para. 4)
Males are also at higher risk for some serious health conditions, such as heart disease, lung cancer, and HIV (ODPHP, n.d.-d).
Females also have unique health issues, such as menopause , and some health issues that may affect both sexes can pose unique challenges for females (ODPHP, n.d.-i). Females are also at risk for breast cancer and cervical cancer. There are several specific Healthy People 2030 Objectives for females, including:
- Reduce iron deficiency in females aged 12 to 49 years
- Reduce the female breast cancer death rate
- Increase the proportion of females who get screened for breast cancer
- Increase the proportion of females who get screened for cervical cancer
- Increase the proportion of females at increased risk who get genetic counseling for breast and/or ovarian cancer
- Reduce infections cause by Listeria
- Reduce the proportion of adults with osteoporosis
- Reduce pelvic inflammatory disease in female adolescents and young females
- Increase the proportion of sexually active female adolescents and young females who get screened for chlamydia
- Reduce the syphilis rate in females
Other goals target adult health, even though Healthy People 2030 does not specifically group these into such a category. Table 26.11 provides some examples.
| Category | Example of Healthy People 2030 Objective |
|---|---|
| Physical activity | Increase the proportion of adults who meet the guidelines for aerobic physical activity and muscle-strengthening activity from 25.2% in 2020 to 29.7% in 2030. |
| Nutrition and healthy eating | Reduce the proportion of adults with obesity from 41.8% between 2017 and 2020 to 36% in 2030. |
| Tobacco use | Reduce current tobacco use in adults from 19.3% in 2021 to 17.4% in 2030. |
| Drug and alcohol use | Reduce the proportion of people who had alcohol use disorder in the past year from 5.3% in 2019 to 3.9% in 2030. |
| Mental health | Reduce the suicide rate from 14.2 suicides per 100,000 population in 2018 to 12.8 per 100,000 population in 2030. |
| Chronic diseases | Reduce the number of diabetes cases diagnosed yearly from 5.5 new cases of diabetes per 1,000 adults in 2019–2021 to 4.8 per 1,000 adults in 2030. |
These Healthy People 2030 goals and objectives reflect the importance of promoting healthy behaviors, preventing chronic diseases, and improving mental health in adults. This can be achieved by addressing some of the SDOH, mentioned previously in this chapter and in Social Determinants Affecting Health Outcomes. For instance, increasing access to healthy, safe, and affordable food can improve the nutrition and health of adults (Figure 26.4). There are a variety of factors contributing to access of such foods (ODPHP, n.d.-e):
- Availability: The location, number, variety, and quality of grocery stores, food services, and farmers markets affects the availability of healthy foods in the community.
- Cost: The cost of foods affects which items adults purchase. The availability of produce and other healthier items can be limited, and they are often more expensive at convenience stores or smaller markets.
- Transportation: Access to reliable transportation can make it easier to travel for food and gives adults more choice in where they obtain food. Less access to reliable transportation can be a challenge for those living in rural communities.
- Community Programs: Local participation in community food support programs, such as farmers markets that accept payment using Supplemental Nutrition Assistance Program (SNAP) benefits, can encourage healthier food choices.
Health Promotion and Disease Prevention Activities to Improve the Health of Adults
Many health promotion activities for adults focus on addressing the short list of risk behaviors that lead to chronic illness; these include tobacco use, poor nutrition, physical inactivity, and excessive alcohol use. By engaging in health promotion activities, adults can improve their health, reduce their risk of chronic diseases, and create supportive environments that make healthy choices easier and more accessible. Mitigation of 7 of the 10 diseases shown in Table 26.10 can occur by addressing these behaviors. The CDC’s National Center for Chronic Disease Prevention and Health Promotion (2022c) provides detailed approaches to address these behaviors, including:
- helping people who smoke quit,
- increasing access to healthy foods and physical activity,
- preventing excessive alcohol use,
- promoting lifestyle change and disease management,
- promoting community water fluoridation,
- promoting mental health and emotional well-being, and
- promoting better sleep.
Public health policies and programs can also play a critical role in promoting health and improving the overall well-being of adults. Many success stories have resulted from health promotion activities to address the risk behaviors connected to the United States’ common chronic illnesses:
- Healthy Foods in Alabama Corner Stores Help Fight Food Deserts
- Coeur d’Alene Tribe Gets More Native Americans Moving with Pow Wow Sweat
- Tiffany R.’s Story: Tips from Former Smokers ®
- Check Your Drinking. Make a Plan to Drink Less
- Beth’s Experience as a Breathe Well, Live Well Educator
- How Right Now
Adulthood comes with many responsibilities and increased productivity. From the ages of 18 through 65 years, significant biological, physiological, social, and psychological changes occur (Mayo Clinic, 2023). During this time, adults develop relationships with significant others, marriages or partnerships, families, and careers while making lifelong decisions. All of this impacts the health of adults.
Nurses are integral to fostering health promotion and disease prevention in U.S. adults. Along with individual, client-centered care , the nurse may need to provide family-centered and workplace health promotion and disease prevention to best address the health of this population. Nurses often conduct health assessments to identify risk factors and develop individualized, family, and population plans. This may include assessing lifestyle factors or screening for chronic diseases. Nurses provide education to individual and adult populations on healthy lifestyle behaviors, disease prevention, and self-care management. Nurses perform preventative measures to detect and prevent diseases, such as administering immunizations, performing screenings, and providing counseling. Nurses coordinate care for adults with complex health needs through referrals to appropriate health care providers, community resources, or social services to assist in meeting their needs. Finally, nurses advocate for the adult population by promoting policies and environments that support health and prevent disease, such as working to address SDOH that contribute to health disparities (Melariri et al., 2022).
Primary Prevention
Primary prevention involves taking measures to prevent health problems or injuries before they happen. A variety of primary prevention strategies can be used in the adult population. Some of these include:
- Immunization s: Immunizations are a highly effective mechanism of preventing infectious diseases such as influenza, pneumonia, COVID-19, and hepatitis B. The HPV vaccine can prevent several different types of cancer (CDC, 2023e). See the CDC’s 2023 Recommended Adult Immunization Schedule for specific recommendations for adults (CDC, 2023a).
- Health education : Education can alter behaviors that could lead to disease or injury and can increase resistance to disease or injury should exposure occur. Some examples of health education for the adult population include nutrition, regular exercise, avoidance of smoking, workplace safety, safe sex practices, and sun safety (Figure 26.5).
- Advocacy : Nurses can advocate for legislation and enforcement to ban or control the use of hazardous products, such as asbestos, or to mandate safe and healthy practices, such as the use of seat belts.
Averting musculoskeletal disorders such as lower back pain, neck and shoulder pain, wrist strain, and tendonitis is one example of primary prevention. These disorders are among the leading causes of work-related disability associated with prescription opioid use that can progress into substance use disorder (Le & Rosen, 2021). Primary prevention can address musculoskeletal disorders and implement proper ergonomics in the workplace. For example, nurses can educate workers to lift with their arm and leg muscles rather than their back. Implementing a work site stretch and flex program can prepare the employee’s body for the shift ahead (ResponsAble Safety Staffing, 2018). Personal protective equipment (PPE) designed to reduce the risk of injury, such as shoulder and knee pads, can prevent injury. These strategies can prevent the progression to a substance use disorder and reduce workers’ compensation, health care, social security, and other disability costs associated with work-related injuries (Le & Rosen, 2021). Caring Across Practice Settings discusses occupational health in more detail.
Secondary Prevention
Secondary prevention is critical for detecting and treating diseases, before they cause significant harm. Screening tests, diagnostic tests, and routine health exams are essential for early detection and treatment of diseases. The 2023 Adult Preventive Health Guidelines: Ages 19 through 64 Years provides specific information (Highmark, 2023a). Examples of secondary prevention strategies for adults include:
- Cancer screening: Screenings for cancer, such as mammograms, colonoscopies, and Pap tests, can detect cancers at its earliest stages, when treatment is most effective.
- Cardiovascular disease screenings: Regular blood pressure and cholesterol screenings can detect early signs of cardiovascular disease, allowing for early intervention and treatment.
- Diabetes screenings: Screening for diabetes with a simple blood test can detect the disease or prediabetes early, allowing for early intervention and treatment to prevent progression and complications.
- Routine health exams: Regular checkups with a health care provider can help identify health problems before they become serious.
- Skin cancer screenings: Routine skin cancer screenings can detect early signs of skin cancer.
- STI screenings: Regular STI screenings can detect early signs of infection, allowing for early treatment, prevention of spread, and prevention of complications
- Osteoporosis screenings: Regular bone density screenings can detect early signs of osteoporosis, allowing for early intervention and treatment to prevent fractures.
The HPV test, which looks for the virus that can cause cell changes on the cervix, and the Pap test, which looks for precancers or cell changes on the cervix that, if untreated, might become cervical cancer, are the two tests that can help either prevent cervical cancer or find it early in adult women. Jasmine’s Story: Preventing Cervical Cancer provides one person’s experience with this screening.
The CDC has also developed an interactive experience, called Talk to Nathan, that provides a conversation with an avatar to help clients determine if they should be screened for prostate cancer. Another interactive experience is provided to health care providers to allow them to practice helping clients make decisions about prostate cancer screening and treatment (CDC, 2022m).
Tertiary Prevention
Tertiary prevention focuses on preventing further complications and improving the quality of life for adults who are living with a chronic disease or condition. Some examples of tertiary prevention strategies for adults include:
- Disease management programs: Disease management or disease self-management programs are designed to help adults with chronic diseases manage their condition and prevent progression or complications. They may include education, lifestyle changes, medication management, and support groups.
- Rehabilitation programs: Rehabilitation programs, such as physical therapy and occupational therapy, can help adults regain strength and function following an illness or injury.
- Chronic pain management : Chronic pain management programs can help adults manage their pain and improve their quality of life. These may include medication management, therapies, and psychological support.
- Palliative care : Palliative care is specialized medical care for those living with a serious illness, such as cancer or heart failure. It is meant to provide symptom care to allow them to focus on their quality of life. Palliative care can be provided along with curative treatment (National Institute on Aging, 2021).
- End-of-life care : End-of-life care is often also known as hospice care. It focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life. Attempts to cure a person’s illness are no longer used (National Institute on Aging, 2021).
- Mental health support : Mental health support may include therapy and support groups to assist adults and their families in coping with emotional and psychological effects of diseases.
The CDC’s National Diabetes Prevention Program was created in 2010 to address the increasing burden of prediabetes and type 2 diabetes on adults in the United States. Partnerships between public and private organizations led to the development of evidence-based, cost-effective interventions to help prevent type 2 diabetes in communities. The Lifestyle Change Program is one result of this effort. It is designed for adults who are overweight, not yet diagnosed with type 1 or type 2 diabetes, and not currently pregnant but either are diagnosed with prediabetes, were previously diagnosed with gestational diabetes, or have high-risk results on the CDC’s prediabetes risk test. The program involves a CDC-approved curriculum, a lifestyle coach, and a support group of people with similar goals and challenges (CDC, 2022u).
Integration of Sociocultural and Linguistically Responsive Interventions for Adults
A “one size fits all” approach to health promotion and disease prevention may not be effective for all clients. Sociocultural and linguistic factors such as language barriers, cultural beliefs, and SDOH can significantly influence an individual’s health outcomes. Therefore, integrating sociocultural and linguistically responsive interventions into health care is crucial for promoting health equity and improving health outcomes for all individuals, including adults. This section explores the importance of integrating sociocultural and linguistically responsive interventions for adults and some examples of how nurses can effectively implement these interventions into practice.
Sociocultural Interventions
By incorporating socioculturally responsive components into the design of health promotion and disease prevention programs, nursing interventions can more effectively engage and promote healthy behaviors among the adult population. Immigrant adults are one specific population that may benefit from such integration. Immigrants face unique cultural barriers to participation in mainstream health promotion programs. These include a lack of access to health care for a variety of reasons, including ineligibility for certain programs, limited support for culturally appropriate health care services, lack of knowledge of the U.S. health care system, distrust of the U.S. health care system, and fears related to deportation with the use of public services (Ali et al., 2021). Other barriers may involve specific customs and unique cultural or religious understandings of health and disease. U.S. immigrants are more likely to be unaware of a chronic disease, such as hypertension, and have lower treatment rates. Ali et al. (2021) determined that while modifiable lifestyle behavioral risk factors must be the common target for hypertension reduction interventions, additional factors should be considered in immigrant communities. These factors include:
- gender roles,
- perceptions about physical activity,
- demanding work schedules,
- neighborhood barriers to healthy living, and
- limited physical and financial accessibility to appropriate spaces for healthy activities.
For example, Oshunluyi et al. (2020) described group-based culturally adapted educational sessions on hypertension for African immigrants that incorporated culturally appropriate storytelling. Ma et al. (2020) described using local libraries, churches, and homes to provide group-based culturally adapted education sessions to Filipino Americans at risk of hypertension. Family members have been shown to have a very strong role in impacting sociocultural and economic factors related to immigrant health and behavior change (Ali et al., 2021). Therefore, family members have been successful as change agents in this population.
Linguistically Responsive Interventions
While sociocultural responsiveness as a whole is imperative in the design of health promotion and disease prevention programs for adults, there is a specific need for linguistic responsive interventions. Kling et al. (2018) described using open, multipurpose rooms inside park recreation centers for group-based multilingual fitness classes. In the classes, five instructors were Hispanic, and four were non-Hispanic Black. Six instructors led the class in English, one led in Spanish, and one led in a mixture of English and Spanish.


14.5: Charlotte Perkins Gilman (1860 )
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- Berke, Bleil, & Cofer
- Middle Georgia State University, College of Coastal Georgia, & Abraham Baldwin Agricultural College via University of North Georgia Press
As she writes in her autobiography, Charlotte Perkins Gilman had one overriding goal in her life: “the improvement of the human race.” The niece of both the abolitionist Harriet Beecher Stowe and the suffragist Isabella Beecher Hooker, Gilman was one of the most important feminist writers, editors, and activists of the late nineteenth and early twentieth centuries. She led an unconventional life that directly inspired her poetry, fiction, and nonfiction alike. At the age of thirty-four, she divorced a husband who sought to “domesticate” her, leaving both him and her daughter to pursue an independent career authoring works of poetry, fiction, and social criticism; editing and publishing her own feminist magazine, Forerunner ; and lecturing for the American Woman Suffrage Association and other organizations on the need for social reform to ensure equality between men and women. In the 1890s, Gilman published three works that solidified her reputation as both a major American writer and a groundbreaking feminist theorist: a well-received collection of feminist poems, In This Our World (1893); the groundbreaking work of social theory, Women and Economics: A Study of the Economic Relation between Men and Women as a Factor in Social Evolution (1898), in which she criticized the economic dependency of women upon men; and the shocking short story included in this chapter, “The Yellow Wall Paper” (1892). Gilman remarried in 1900 and over the course of the first three decades of the twentieth century continued to edit, lecture, and publish works that advocated for the progressive reform of society. In her utopian novel Herland (1915), for example, she imagines a peaceful and ecologically sustainable society comprised solely of women who use technology and not men to reproduce.
While presented in the guise of a gothic tale of terror, “The Yellow Wall Paper” is a fine example of political realism. Through this terrifying story of a woman locked in an ancient manor and haunted by a shadowy figure, Gilman shows that the real relationship between married men and women in her time is not one of equality but of domination and dependency.  After giving birth to her daughter, Gilman fell into a state of depression and was sent to a clinic for treatment. Her doctor, a world famous neurologist, advised her to quit all creative and intellectual activity and instead dedicate herself wholly to a private domestic routine. However, this so called “ rest-cure ” only further deepened Gilman’s depression and so she sought and found a cure for herself in her true callings: the literary and political work to which she dedicated the rest of her life.
2.11.1 “The Yellow Wall-Paper”
It is very seldom that mere ordinary people like John and myself secure ancestral halls for the summer.
A colonial mansion, a hereditary estate, I would say a haunted house, and reach the height of romantic felicity but that would be asking too much of fate!
Still I will proudly declare that there is something queer about it.
Else, why should it be let so cheaply? And why have stood so long untenanted? John laughs at me, of course, but one expects that in marriage.
John is practical in the extreme. He has no patience with faith, an intense horror of superstition, and he scoffs openly at any talk of things not to be felt and seen and put down in figures.
John is a physician, and PERHAPS (I would not say it to a living soul, of course, but this is dead paper and a great relief to my mind) PERHAPS that is one reason I do not get well faster.
You see he does not believe I am sick!
And what can one do?
If a physician of high standing, and one’s own husband, assures friends and relatives that there is really nothing the matter with one but temporary nervous depression a slight hysterical tendency what is one to do?
My brother is also a physician, and also of high standing, and he says the same thing.
So I take phosphates or phosphites whichever it is, and tonics, and journeys, and air, and exercise, and am absolutely forbidden to “work” until I am well again.
Personally, I disagree with their ideas.
Personally, I believe that congenial work, with excitement and change, would do me good.
But what is one to do?
I did write for a while in spite of them; but it DOES exhaust me a good deal having to be so sly about it, or else meet with heavy opposition.
I sometimes fancy that in my condition if I had less opposition and more society and stimulus but John says the very worst thing I can do is to think about my condition, and I confess it always makes me feel bad.
So I will let it alone and talk about the house.
The most beautiful place! It is quite alone, standing well back from the road, quite three miles from the village. It makes me think of English places that you read about, for there are hedges and walls and gates that lock, and lots of separate little houses for the gardeners and people.
There is a DELICIOUS garden! I never saw such a garden large and shady, full of box-bordered paths, and lined with long grape covered arbors with seats under them.
There were greenhouses, too, but they are all broken now.
There was some legal trouble, I believe, something about the heirs and coheirs; anyhow, the place has been empty for years.
That spoils my ghostliness, I am afraid, but I don’t care there is something strange about the house I can feel it.
I even said so to John one moonlight evening, but he said what I felt was a DRAUGHT, and shut the window.
I get unreasonably angry with John sometimes. I’m sure I never used to be so sensitive. I think it is due to this nervous condition.
But John says if I feel so, I shall neglect proper self-control; so I take pains to control myself before him, at least, and that makes me very tired.
I don’t like our room a bit. I wanted one downstairs that opened on the piazza and had roses all over the window, and such pretty old-fashioned chintz hangings! but John would not hear of it.
He said there was only one window and not room for two beds, and no near room for him if he took another.
He is very careful and loving, and hardly lets me stir without special direction.
I have a schedule prescription for each hour in the day; he takes all care from me, and so I feel basely ungrateful not to value it more.
He said we came here solely on my account, that I was to have perfect rest and all the air I could get. “Your exercise depends on your strength, my dear,” said he, “and your food somewhat on your appetite; but air you can absorb all the time.” So we took the nursery at the top of the house.
It is a big, airy room, the whole floor nearly, with windows that look all ways, and air and sunshine galore. It was nursery first and then playroom and gymnasium, I should judge; for the windows are barred for little children, and there are rings and things in the walls.
The paint and paper look as if a boys’ school had used it. It is stripped off the paper in great patches all around the head of my bed, about as far as I can reach, and in a great place on the other side of the room low down. I never saw a worse paper in my life.
One of those sprawling flamboyant patterns committing every artistic sin.

The color is repellent, almost revolting; a smouldering unclean yellow, strangely faded by the slow-turning sunlight.
It is a dull yet lurid orange in some places, a sickly sulphur tint in others.
No wonder the children hated it! I should hate it myself if I had to live in this room long.
There comes John, and I must put this away, he hates to have me write a word.
We have been here two weeks, and I haven’t felt like writing before, since that first day.
I am sitting by the window now, up in this atrocious nursery, and there is nothing to hinder my writing as much as I please, save lack of strength.

I am glad my case is not serious!
But these nervous troubles are dreadfully depressing.
John does not know how much I really suffer. He knows there is no REASON to suffer, and that satisfies him.
Of course it is only nervousness. It does weigh on me so not to do my duty in any way!
I meant to be such a help to John, such a real rest and comfort, and here I am a comparative burden already!
Nobody would believe what an effort it is to do what little I am able, to dress and entertain, and order things.
It is fortunate Mary is so good with the baby. Such a dear baby!
And yet I CANNOT be with him, it makes me so nervous.
I suppose John never was nervous in his life. He laughs at me so about this wall-paper!
At first he meant to repaper the room, but afterwards he said that I was letting it get the better of me, and that nothing was worse for a nervous patient than to give way to such fancies.
He said that after the wall-paper was changed it would be the heavy bedstead, and then the barred windows, and then that gate at the head of the stairs, and so on.
Then he took me in his arms and called me a blessed little goose, and said he would go down to the cellar, if I wished, and have it whitewashed into the bargain.
But he is right enough about the beds and windows and things.
It is an airy and comfortable room as any one need wish, and, of course, I would not be so silly as to make him uncomfortable just for a whim.
I’m really getting quite fond of the big room, all but that horrid paper.
Out of one window I can see the garden, those mysterious deepshaded arbors, the riotous old-fashioned flowers, and bushes and gnarly trees.
Out of another I get a lovely view of the bay and a little private wharf belonging to the estate. There is a beautiful shaded lane that runs down there from the house. I always fancy I see people walking in these numerous paths and arbors, but John has cautioned me not to give way to fancy in the least. He says that with my imaginative power and habit of story making, a nervous weakness like mine is sure to lead to all manner of excited fancies, and that I ought to use my will and good sense to check the tendency. So I try.
I think sometimes that if I were only well enough to write a little it would relieve the press of ideas and rest me.
But I find I get pretty tired when I try.
It is so discouraging not to have any advice and companionship about my work. When I get really well, John says we will ask Cousin Henry and Julia down for a long visit; but he says he would as soon put fireworks in my pillow-case as to let me have those stimulating people about now.
I wish I could get well faster.
But I must not think about that. This paper looks to me as if it KNEW what a vicious influence it had!
There is a recurrent spot where the pattern lolls like a broken neck and two bulbous eyes stare at you upside down.
I get positively angry with the impertinence of it and the everlastingness. Up and down and sideways they crawl, and those absurd, unblinking eyes are everywhere. There is one place where two breadths didn’t match, and the eyes go all up and down the line, one a little higher than the other.
I never saw so much expression in an inanimate thing before, and we all know how much expression they have! I used to lie awake as a child and get more entertainment and terror out of blank walls and plain furniture than most children could find in a toy store.
I remember what a kindly wink the knobs of our big, old bureau used to have, and there was one chair that always seemed like a strong friend.
I used to feel that if any of the other things looked too fierce I could always hop into that chair and be safe.
The furniture in this room is no worse than inharmonious, however, for we had to bring it all from downstairs. I suppose when this was used as a playroom they had to take the nursery things out, and no wonder! I never saw such ravages as the children have made here.
The wall paper, as I said before, is torn off in spots, and it sticketh closer than a brother they must have had perseverance as well as hatred.
Then the floor is scratched and gouged and splintered, the plaster itself is dug out here and there, and this great heavy bed which is all we found in the room, looks as if it had been through the wars.
But I don’t mind it a bit only the paper.
There comes John’s sister. Such a dear girl as she is, and so careful of me! I must not let her find me writing.
She is a perfect and enthusiastic housekeeper, and hopes for no better profession. I verily believe she thinks it is the writing which made me sick!
But I can write when she is out, and see her a long way off from these windows.
There is one that commands the road, a lovely shaded winding road, and one that just looks off over the country. A lovely country, too, full of great elms and velvet meadows.
This wall-paper has a kind of sub-pattern in a different shade, a particularly irritating one, for you can only see it in certain lights, and not clearly then.
But in the places where it isn’t faded and where the sun is just so I can see a strange, provoking, formless sort of figure, that seems to skulk about behind that silly and conspicuous front design.
There’s sister on the stairs!
Well, the Fourth of July is over! The people are gone and I am tired out. John thought it might do me good to see a little company, so we just had mother and Nellie and the children down for a week.
Of course I didn’t do a thing. Jennie sees to everything now.
But it tired me all the same.
John says if I don’t pick up faster he shall send me to Weir Mitchell in the fall. But I don’t want to go there at all. I had a friend who was in his hands once, and she says he is just like John and my brother, only more so!
Besides, it is such an undertaking to go so far.
I don’t feel as if it was worth while to turn my hand over for anything, and I’m getting dreadfully fretful and querulous.

Of course I don’t when John is here, or anybody else, but when I am alone. And I am alone a good deal just now. John is kept in town very often by serious cases, and Jennie is good and lets me alone when I want her to.
So I walk a little in the garden or down that lovely lane, sit on the porch under the roses, and lie down up here a good deal.
I’m getting really fond of the room in spite of the wall-paper. Perhaps BECAUSE of the wall-paper.
It dwells in my mind so!
I lie here on this great immovable bed it is nailed down, I believe and follow that pattern about by the hour. It is as good as gymnastics, I assure you. I start, we’ll say, at the bottom, down in the corner over there where it has not been touched, and I determine for the thousandth time that I WILL follow that pointless pattern to some sort of a conclusion.
I know a little of the principle of design, and I know this thing was not arranged on any laws of radiation, or alternation, or repetition, or symmetry, or anything else that I ever heard of.
It is repeated, of course, by the breadths, but not otherwise.
Looked at in one way each breadth stands alone, the bloated curves and flourishes a kind of “debased Romanesque” with delirium tremens go waddling up and down in isolated columns of fatuity.
But, on the other hand, they connect diagonally, and the sprawling outlines run off in great slanting waves of optic horror, like a lot of wallowing seaweeds in full chase.
The whole thing goes horizontally, too, at least it seems so, and I exhaust myself in trying to distinguish the order of its going in that direction.
They have used a horizontal breadth for a frieze, and that adds wonderfully to the confusion.
There is one end of the room where it is almost intact, and there, when the crosslights fade and the low sun shines directly upon it, I can almost fancy radiation after all, the interminable grotesques seem to form around a common centre and rush off in headlong plunges of equal distraction.
It makes me tired to follow it. I will take a nap I guess. I don’t know why I should write this.
I don’t want to.
I don’t feel able.
And I know John would think it absurd. But I MUST say what I feel and think in some way it is such a relief!
But the effort is getting to be greater than the relief.
Half the time now I am awfully lazy, and lie down ever so much.
John says I musn’t lose my strength, and has me take cod liver oil and lots of tonics and things, to say nothing of ale and wine and rare meat.
Dear John! He loves me very dearly, and hates to have me sick. I tried to have a real earnest reasonable talk with him the other day, and tell him how I wish he would let me go and make a visit to Cousin Henry and Julia.
But he said I wasn’t able to go, nor able to stand it after I got there; and I did not make out a very good case for myself, for I was crying before I had finished.
It is getting to be a great effort for me to think straight. Just this nervous weakness I suppose.
And dear John gathered me up in his arms, and just carried me upstairs and laid me on the bed, and sat by me and read to me till it tired my head.
He said I was his darling and his comfort and all he had, and that I must take care of myself for his sake, and keep well.
He says no one but myself can help me out of it, that I must use my will and self-control and not let any silly fancies run away with me.
There’s one comfort, the baby is well and happy, and does not have to occupy this nursery with the horrid wallpaper.
If we had not used it, that blessed child would have! What a fortunate escape! Why, I wouldn’t have a child of mine, an impressionable little thing, live in such a room for worlds.
I never thought of it before, but it is lucky that John kept me here after all, I can stand it so much easier than a baby, you see.
Of course I never mention it to them any more I am too wise, but I keep watch of it all the same.
There are things in that paper that nobody knows but me, or ever will.
Behind that outside pattern the dim shapes get clearer every day.
It is always the same shape, only very numerous.
And it is like a woman stooping down and creeping about behind that pattern.
I don’t like it a bit. I wonder I begin to think I wish John would take me away from here!
It is so hard to talk with John about my case, because he is so wise, and because he loves me so.
But I tried it last night.
It was moonlight. The moon shines in all around just as the sun does.
I hate to see it sometimes, it creeps so slowly, and always comes in by one window or another.
John was asleep and I hated to waken him, so I kept still and watched the moonlight on that undulating wall-paper till I felt creepy.
The faint figure behind seemed to shake the pattern, just as if she wanted to get out.
I got up softly and went to feel and see if the paper DID move, and when
I came back John was awake.
“What is it, little girl?” he said. “Don’t go walking about like that you’ll get cold.”
I though it was a good time to talk, so I told him that I really was not gaining here, and that I wished he would take me away.
“Why darling!” said he, “our lease will be up in three weeks, and I can’t see how to leave before.
“The repairs are not done at home, and I cannot possibly leave town just now.
Of course if you were in any danger, I could and would, but you really are better, dear, whether you can see it or not. I am a doctor, dear, and I know. You are gaining flesh and color, your appetite is better, I feel really much easier about you.”
“I don’t weigh a bit more,” said I, “nor as much; and my appetite may be better in the evening when you are here, but it is worse in the morning when you are away!”
“Bless her little heart!” said he with a big hug, “she shall be as sick as she pleases! But now let’s improve the shining hours by going to sleep, and talk about it in the morning!”
“And you won’t go away?” I asked gloomily.
“Why, how can I, dear? It is only three weeks more and then we will take a nice little trip of a few days while Jennie is getting the house ready. Really dear you are better!”
“Better in body perhaps ” I began, and stopped short, for he sat up straight and looked at me with such a stern, reproachful look that I could not say another word.
“My darling,” said he, “I beg of you, for my sake and for our child’s sake, as well as for your own, that you will never for one instant let that idea enter your mind! There is nothing so dangerous, so fascinating, to a temperament like yours. It is a false and foolish fancy. Can you not trust me as a physician when I tell you so?”
So of course I said no more on that score, and we went to sleep before long. He thought I was asleep first, but I wasn’t, and lay there for hours trying to decide whether that front pattern and the back pattern really did move together or separately.
On a pattern like this, by daylight, there is a lack of sequence, a defiance of law, that is a constant irritant to a normal mind.
The color is hideous enough, and unreliable enough, and infuriating enough, but the pattern is torturing.
You think you have mastered it, but just as you get well underway in following, it turns a back-somersault and there you are.  It is like a bad dream.
The outside pattern is a florid arabesque, reminding one of a fungus. If you can imagine a toadstool in joints, an interminable string of toadstools, budding and sprouting in endless convolutions why, that is something like it.
That is, sometimes!
There is one marked peculiarity about this paper, a thing nobody seems to notice but myself, and that is that it changes as the light changes.
When the sun shoots in through the east window I always watch for that first long, straight ray it changes so quickly that I never can quite believe it.
That is why I watch it always.
By moonlight the moon shines in all night when there is a moon I wouldn’t know it was the same paper.
At night in any kind of light, in twilight, candle light, lamplight, and worst of all by moonlight, it becomes bars! The outside pattern I mean, and the woman behind it is as plain as can be.
I didn’t realize for a long time what the thing was that showed behind, that dim sub-pattern, but now I am quite sure it is a woman.
By daylight she is subdued, quiet. I fancy it is the pattern that keeps her so still. It is so puzzling. It keeps me quiet by the hour.
I lie down ever so much now. John says it is good for me, and to sleep all I can. Indeed he started the habit by making me lie down for an hour after each meal. It is a very bad habit I am convinced, for you see I don’t sleep.
And that cultivates deceit, for I don’t tell them I’m awake O no!
The fact is I am getting a little afraid of John.
He seems very queer sometimes, and even Jennie has an inexplicable look.
It strikes me occasionally, just as a scientific hypothesis, that perhaps it is the paper!
I have watched John when he did not know I was looking, and come into the room suddenly on the most innocent excuses, and I’ve caught him several times LOOKING AT THE PAPER! And Jennie too. I caught Jennie with her hand on it once.
She didn’t know I was in the room, and when I asked her in a quiet, a very quiet voice, with the most restrained manner possible, what she was doing with the paper she turned around as if she had been caught stealing, and looked quite angry asked me why I should frighten her so!
Then she said that the paper stained everything it touched, that she had found yellow smooches on all my clothes and John’s, and she wished we would be more careful!
Did not that sound innocent? But I know she was studying that pattern, and I am determined that nobody shall find it out but myself!
Life is very much more exciting now than it used to be. You see I have something more to expect, to look forward to, to watch. I really do eat better, and am more quiet than I was.
John is so pleased to see me improve! He laughed a little the other day, and said I seemed to be flourishing in spite of my wall-paper.
I turned it off with a laugh. I had no intention of telling him it was
BECAUSE of the wall-paper he would make fun of me. He might even want to take me away.
I don’t want to leave now until I have found it out. There is a week more, and I think that will be enough.
I’m feeling ever so much better! I don’t sleep much at night, for it is so interesting to watch developments; but I sleep a good deal in the daytime.
In the daytime it is tiresome and perplexing.
There are always new shoots on the fungus, and new shades of yellow all over it. I cannot keep count of them, though I have tried conscientiously.
It is the strangest yellow, that wall-paper! It makes me think of all the yellow things I ever saw not beautiful ones like buttercups, but old foul, bad yellow things. But there is something else about that paper the smell! I noticed it the moment we came into the room, but with so much air and sun it was not bad. Now we have had a week of fog and rain, and whether the windows are open or not, the smell is here. It creeps all over the house.
I find it hovering in the dining-room, skulking in the parlor, hiding in the hall, lying in wait for me on the stairs.
It gets into my hair.
Even when I go to ride, if I turn my head suddenly and surprise it there is that smell!
Such a peculiar odor, too! I have spent hours in trying to analyze it, to find what it smelled like.
It is not bad at first, and very gentle, but quite the subtlest, most enduring odor I ever met.
In this damp weather it is awful, I wake up in the night and find it hanging over me.
It used to disturb me at first. I thought seriously of burning the house to reach the smell.
But now I am used to it. The only thing I can think of that it is like is the COLOR of the paper! A yellow smell.
There is a very funny mark on this wall, low down, near the mopboard. A streak that runs round the room. It goes behind every piece of furniture, except the bed, a long, straight, even SMOOCH, as if it had been rubbed over and over.
I wonder how it was done and who did it, and what they did it for. Round and round and round round and round and round it makes me dizzy!
I really have discovered something at last.
Through watching so much at night, when it changes so, I have finally found out. The front pattern DOES move and no wonder! The woman behind shakes it! Sometimes I think there are a great many women behind, and sometimes only one, and she crawls around fast, and her crawling shakes it all over.
Then in the very bright spots she keeps still, and in the very shady spots she just takes hold of the bars and shakes them hard.
And she is all the time trying to climb through. But nobody could climb through that pattern it strangles so; I think that is why it has so many heads.

If those heads were covered or taken off it would not be half so bad.
I think that woman gets out in the daytime!
And I’ll tell you why privately I’ve seen her!
I can see her out of every one of my windows!
It is the same woman, I know, for she is always creeping, and most women do not creep by daylight.
I see her on that long road under the trees, creeping along, and when a carriage comes she hides under the blackberry vines.
I don’t blame her a bit. It must be very humiliating to be caught creeping by daylight!
I always lock the door when I creep by daylight. I can’t do it at night, for I know
John would suspect something at once.
And John is so queer now, that I don’t want to irritate him. I wish he would take another room! Besides, I don’t want anybody to get that woman out at night but myself.
I often wonder if I could see her out of all the windows at once.
But, turn as fast as I can, I can only see out of one at one time.
And though I always see her, she MAY be able to creep faster than I can turn! I have watched her sometimes away off in the open country, creeping as fast as a cloud shadow in a high wind.
If only that top pattern could be gotten off from the under one! I mean to try it, little by little.
I have found out another funny thing, but I shan’t tell it this time! It does not do to trust people too much.
There are only two more days to get this paper off, and I believe John is beginning to notice.
And I heard him ask Jennie a lot of professional questions about me. She had a very good report to give.
She said I slept a good deal in the daytime.
John knows I don’t sleep very well at night, for all I’m so quiet!
He asked me all sorts of questions, too, and pretended to be very loving and kind. As if I couldn’t see through him!
Still, I don’t wonder he acts so, sleeping under this paper for three months.
It only interests me, but I feel sure John and Jennie are secretly affected by it. Hurrah! This is the last day, but it is enough. John is to stay in town over night, and won’t be out until this evening.
Jennie wanted to sleep with me the sly thing! but I told her I should undoubtedly rest better for a night all alone.
That was clever, for really I wasn’t alone a bit! As soon as it was moonlight and that poor thing began to crawl and shake the pattern, I got up and ran to help her. I pulled and she shook, I shook and she pulled, and before morning we had peeled off yards of that paper.
A strip about as high as my head and half around the room.
And then when the sun came and that awful pattern began to laugh at me, I declared I would finish it to day!
We go away to-morrow, and they are moving all my furniture down again to leave things as they were before.
Jennie looked at the wall in amazement, but I told her merrily that I did it out of pure spite at the vicious thing.
She laughed and said she wouldn’t mind doing it herself, but I must not get tired. How she betrayed herself that time!
But I am here, and no person touches this paper but me not ALIVE!
She tried to get me out of the room it was too patent! But I said it was so quiet and empty and clean now that I believed I would lie down again and sleep all I could; and not to wake me even for dinner I would call when I woke.
So now she is gone, and the servants are gone, and the things are gone, and there is nothing left but that great bedstead nailed down, with the canvas mattress we found on it.
We shall sleep downstairs to-night, and take the boat home to-morrow. I quite enjoy the room, now it is bare again.
How those children did tear about here!
This bedstead is fairly gnawed!
But I must get to work.
I have locked the door and thrown the key down into the front path.
I don’t want to go out, and I don’t want to have anybody come in, till John comes. I want to astonish him.
I’ve got a rope up here that even Jennie did not find. If that woman does get out, and tries to get away, I can tie her!
But I forgot I could not reach far without anything to stand on!
This bed will NOT move!
I tried to lift and push it until I was lame, and then I got so angry I bit off a little piece at one corner but it hurt my teeth.
Then I peeled off all the paper I could reach standing on the floor. It sticks horribly and the pattern just enjoys it! All those strangled heads and bulbous eyes and waddling fungus growths just shriek with derision!
I am getting angry enough to do something desperate. To jump out of the window would be admirable exercise, but the bars are too strong even to try.
Besides I wouldn’t do it. Of course not. I know well enough that a step like that is improper and might be misconstrued.
I don’t like to LOOK out of the windows even there are so many of those creeping women, and they creep so fast.
I wonder if they all come out of that wall-paper as I did?
But I am securely fastened now by my well-hidden rope you don’t get ME out in the road there!
I suppose I shall have to get back behind the pattern when it comes night, and that is hard!
It is so pleasant to be out in this great room and creep around as I please!
I don’t want to go outside. I won’t, even if Jennie asks me to.
For outside you have to creep on the ground, and everything is green instead of yellow.
But here I can creep smoothly on the floor, and my shoulder just fits in that long smooch around the wall, so I cannot lose my way. Why there’s John at the door!
It is no use, young man, you can’t open it!
How he does call and pound!
Now he’s crying for an axe.
It would be a shame to break down that beautiful door!
“John dear!” said I in the gentlest voice, “the key is down by the front steps, under a plantain leaf!”
That silenced him for a few moments.
Then he said very quietly indeed, “Open the door, my darling!”
“I can’t,” said I. “The key is down by the front door under a plantain leaf!” And then I said it again, several times, very gently and slowly, and said it so often that he had to go and see, and he got it of course, and came in. He stopped short by the door.
“What is the matter?” he cried. “For God’s sake, what are you doing!”
I kept on creeping just the same, but I looked at him over my shoulder.
“I’ve got out at last,” said I, “in spite of you and Jane. And I’ve pulled off most of the paper, so you can’t put me back!”
Now why should that man have fainted? But he did, and right across my path by the wall, so that I had to creep over him every time!
2.11.2 Reading and Review Questions
- As you read “The Yellow Wall-Paper,” you will be tempted to diagnose the narrator as suffering from postpartum depression. However, does the source of the narrator’s lingering illness reside entirely in her body? Consider other causes for her on-going malaise. Why isn’t she getting better?
- Consider how the narrator’s loving doctor-husband John talks to and controls her. What does John allow and, more importantly, forbid his sick wife to think and do?
- The narrator of this story is unreliable as she is suffering from mental illness, which leads her to misinterpret the nature of her confinement. For instance, the narrator presumes that she is confined within a child’s former playroom. Close-read the details of the story’s setting, contrasting the narrator’s interpretation of the details of her room the bars on the windows, for instance with your own sense of what these things mean.


3.12: Diffusion and Osmosis Worksheet Answers
1. List 5 mechanisms by which molecules pass through the plasma membrane. State whether these mechanisms are passive or active (ie use energy or not).
|
Mechanism for crossing
plasma membrane |
Passive or Active? |
|---|---|
| 1. Diffusion | Passive |
| 2. Facilitated diffusion | Passive |
| 3. Osmosis | Passive |
| 4. Active transport | Active |
| 5. Pinocytosis/phagocytosis/exocytosis | Active |
2. Which mechanism:
- a.) uses no energy and results in an even distribution of molecules? Diffusion
- b) uses no energy, and occurs across a semi-permeable membrane? Osmosis
- c) occurs across the membrane of red blood cells causing them to swell and burst when placed in distilled water? Osmosis
- d) uses energy and allows the cell to take into itself particles and bacteria? Phagocytosis
- e) moves substances across the plasma membrane from a low to a high concentration? Active transport
- f) uses a carrier molecule to help substances across a membrane but does not require energy? Facilitated diffusion
3. Circle the correct statements below.
Diffusion is a process that:
- a) occurs in liquid and gases
- d) uses no energy
- e) occurs naturally
- g) occurs from a higher concentration of molecules to a lower one .
- h) results in an even distribution of molecules
- k) is more rapid at high tempera tures.
4. Circle the correct statements below.
Osmosis :
- a) is a special kind of diffusion .
- d) is the diffusion of water molecules only .
- e) is the diffusion of water molecules from a high concentration of water to a low concentration of water .
- f) requires a semi-permeable membrane .
- h) results in an even dispersal of water molecules .
5. A semi-permeable membrane is a membrane that:
- a) allows some molecules to go through but not others .
6. Active transport :
- a) uses energy .
- c) occurs from a lower concentration of molecules to a higher concentration .
7. Oxygen crosses the plasma membrane by:
- c) diffusion through the lipid bilayer .
8. Water crosses the plasma membrane by:
- e) osmosis .
9. Lipid soluble molecules cross the plasma membrane by:
- c) diffusion through the lipid bilayer .
10 Sodium ions move from a low to a high concentration across the plasma membrane by:
- b) active transport .
11 Glucose molecules cross the plasma membrane by:
d) facilitated diffusion .


4.1.6: Gender-Based Violence
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Rape
The definition of rape and its effects on victims have evolved historically alongside ideas about gender and sexuality.
Learning Objectives
Describe the influence of the feminist movement on public attitudes toward rape and the notion of consent
Key Points
- Rape has serious psychological and physical consequences for the victim.
 Recently, the definition or rape has been expanded to include any gender, and now contains stricter definitions of consent.
- Victim blaming and self-blame are rooted in public beliefs that a victim is at least partially responsible for rape. Rape shield laws prohibit legal testimony regarding a victim’s sexual behavior, in order to prevent victims from being placed on trial along with defendants.
- International law defines rape as a crime against humanity and a potentially genocidal act.
- Rape shield laws prohibit legal testimony regarding a victim’s sexual behavior in order to prevent the victim from being placed on trial along with the defendant.
Key Terms
- victim blaming : when the victim of a crime, an accident, or any type of abusive maltreatment is held entirely or partially responsible for the transgressions committed against him or her (regardless of whether the victim actually had any responsibility for the incident)
- date rape : non-consensual sexual activity between a victim and perpetrator that know one another
- self-blame : when one holds oneself responsible for a negative experience
Rape is a type of sexual assault in which one or more individuals forces sexual contact on another individual without consent. Rape can cause devastating physical and psychological trauma. In the aftermath of an attack, many victims develop post-traumatic stress disorder (PTSD), a severe anxiety disorder. Rape victims may also confront a number of emotions related to shame. Often, victims blame themselves for rape.
Although self-blame might seem like an unusual, intensely individual response to rape, it is rooted in social conceptions of rape and victimhood. In the case of rape, victim blaming generally refers to the belief that certain behaviors on the part of the victim, like flirting or wearing provocative clothing, encourage assault. Legal systems may perpetuate victim blaming. For example, in the United States, defendants are guaranteed an opportunity to explain their actions and motivations, which may allow them to instigate conversations about their victims’ sexual past or physical presentation. Lawyers and activists are aware of the negative consequences of this type of conversation in courtrooms, and many have encouraged state legislators to enact rape shield laws, which would prohibit testimony about a victim’s sexual behavior. Nevertheless, victims are often reluctant to report rape because of these social pressures.
Consent
The definition of rape rests on the notion of consent, which has changed over the course of history as sexual mores and understandings of gender have changed. For example, in medieval Europe, a woman could be legally married by her parents to a stranger without her consent and, once married, she could no longer refuse to consent to sex. The medieval concept of rape did not allow for the possibility of being raped by one’s husband. It was only in middle of the 16 th century that European courts began to recognize a minimum age of consent, though this figure was typically set around six or seven years. In modern legal understanding, consent may be explicit or implied by context, but the absence of objection never itself constitutes consent, and consent can be withdrawn at any time. Consent cannot be forced and it cannot be given by certain categories of people considered incapable of consent (e.g., minors and the cognitively disabled).
Rape and Gender
Rape is often thought of as a crime committed by a man against a woman, but increasingly, social and legal definitions of rape recognize that this does not have to be the case. In 2012, the Federal Bureau of Investigation updated its definition of rape, which had originally been instituted in 1972, and which previously limited rape to a crime against women. This definition, considered outdated and overly narrow, was replaced by a new definition, which recognizes that rape can be perpetrated by a person of any gender against a victim of any gender. The new definition also broadens the instances in which a victim is unable to give consent. These instances now include temporary or permanent mental or physical incapacity, and incapacity caused by the use of drugs or alcohol.
The FBI’s new definition continues a trend that gained traction with the feminist movement of the 1970s, when rape was publicly characterized as a crime of power and control rather than a sexual act. Leaders of the feminist movement started some of the first rape crisis centers, which not only provided basic services to victims, but also advanced the idea of rape as a criminal act with a victim who was not to be blamed. Feminist leaders also encouraged the codification of marital rape, or forced sexual contact between spouses. Currently, the struggle continues with efforts to bring attention to date rape, which is embedded in the gendered expectation that women engage in sexual activity following a date with a man. Conversations about date rape work to undo this social expectation and to reinforce the idea that consensual sex requires the explicit permission of both partners.
International Law
International law is changing to recognize rape as a weapon of war. The Rome Statute included rape in its definition of a crime against humanity, a definition first put into practice in the mid-1990s by the International Criminal Tribunal for the Former Yugoslavia. This judicial body recognized that Serbian soldiers and policemen had systematically raped Muslim women during the Balkan War. In 1998, the International Criminal Tribunal for Rwanda found that systematic rape was a crime against humanity.

Learning Objectives
Explain why sexual violence is difficult to track
Key Points
- An act is deemed sexually violent if the individual to whom the attention is directed does not consent to the sexual activity, if they are members of a class of persons who cannot consent (the severely cognitively impaired, etc.), or if consent is due to coercion or duress.

- Sexual violence is particularly difficult to track because it is severely under reported.

 The most commonly discussed form of sexual violence is rape.  Sexual violence is not limited to rape; it is a broad category that can include everything from verbal harassment to physical assault.

 Coercion can cover a whole spectrum of degrees of force. Apart from physical force, it may involve psychological intimidation, blackmail, or any other type of threat, like the threat of physical harm or of being dismissed from a job.
 Sexual violence can cause severe physical injuries, including an increased risk of sexual and reproductive health problems, with both immediate and long-term consequences. Additionally, sexual violence can impact mental health, which can be as serious as its physical impact, and may be even longer lasting.
Acts of Power
Sexually violent acts are acts of power, not of sex. This can be seen most clearly when considering war rape and prison rape.  Prison rape is the type of rape that is common (and seriously under reported) in prisons all over the world, including the United States, in which inmates will force sex upon one another as a demonstration of power.
Tracking Sexual Violence
Sexual violence is particularly difficult to track because it is severely under reported. Records from police and government agencies are often incomplete or limited. Most victims of sexual violence do not report it because they are ashamed, afraid of being blamed, concerned about not being believed, or are simply afraid to relive the event by reporting it. Most countries and many NGOs are undertaking efforts to try to increase the reporting of sexual violence as it so obviously has serious physical and psychological impacts on its victims.
 A good example of cultural variation with regards to sexual violence is the differing views associated with the practice of female circumcision/female genital mutilation (FGM). Female circumcision and FGM refer to the same practice, but the practice is called “female circumcision” by those who condone its usage. FGM has violent connotations and is used by individuals who conceive of the practice as a violation of human rights.
Female circumcision/FGM is a practice used in many parts of Africa in which parts of the female’s vagina, usually the clitoris, are removed in order to decrease sexual pleasure. The operation is performed most commonly on young females. The practice has been the target of many human rights campaigns as a serious affront to the fundamental human rights of the girls undergoing the operation. However, many individuals in Africa view the practice as an acceptable component of their cultures. Neither vantage point is simple; some women in Africa accept the practice, while others have been vocal in speaking out against the practice.

Learning Objectives
Explain when and how sexual harassment is prosecuted in the U.S.
Key Points
- Sexual harassment is common in the workplace.
- Sexual harassment happens any time intimidation, bullying, teasing, or coercion of a sexual nature occurs.
- Sexual harassment is rarely formally charged in a legal context and individuals who do make such charges official are frequently ridiculed.

 In most legal contexts this type of behavior is criminalized. The person intimidating a victim about his or her sexuality could be male or female; men and women can both be perpetrators of sexual harassment. Sexual harassment does not have to be only of a sexual nature; indeed, sexual harassment includes unwelcome and offensive comments about a person’s gender. Regardless of whether the content of the sexual harassment is about sex or gender, both victim and harasser can be either male or female and the victim and the harasser can be the same gender.
Though broad, the legal definition of sexual harassment does not include every injurious statement pertaining to sex or gender. The law does not prohibit simple teasing, offhand comments, or isolated incidents that are not very serious. Sexual harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in adverse employment, such as the victim being fired or demoted.  As one might guess, most of these cases turn on whether or not the offensive comment was “serious” or “offhand. ” It is the law’s job to decide if a comment that the victim clearly found serious and offhand is considered so legally.
 Victimhood for individuals subjected to sexual harassment can take a different and equally complicated form as victimhood for individuals who suffer from attacks for physical violence. Sexual violence that is expressed in terms of some sort of physical assault against a victim has become a condemnable act; victims of physical violence are more likely to find others who are sympathetic to their understandable distress. However, sexual harassment is more socially acceptable. Victims will often encounter opposition who claim that the harassment was mere teasing. As such, victimhood in response to sexual harassment has some unique properties. Nevertheless, sexual harassment may lead to temporary or prolonged anxiety, depending on the nature of the harassment and the type of support system in place. Given that harassment is a common problem in the workplace, anxiety on the victim’s part is usually tied into concerns about ramifications for one’s career if one reports the harassment.
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