PUBLIC HEALTHDEVELOPING HEALTHY

COMMUNITIES

PART ONEHEALTH NEEDS ASSESSMENT PROFILE

PART TWOHEALTH PROMOTION PROPOSAL

Theresa Lowry-LehnenSpecialist Nurse Practitioner

Surrey University 2005

PUBLIC HEALTHPART ONE: HEALTH NEEDS ASSESSMENT PROFILE

CONTENTSPage

1. Introduction

1. Context and Theoretical Framework

4. Identification and Boundary of the Community

5. Practice Population Statistics

5. Wards and Deprivation Scores

6. Ethnicity

6. The Community’s Locality

7. The Community’s Social Structure

7. Lone Parent Households

8. Teenage Pregnancy Rates

8. Elderly Patients Living Alone

9. Children – Health Visitors Case Files 2004

11. Key Health Determinants

13. The Community’s Social Activity and Sentiment

14. What Is Being Done?15. Sutton and Merton PCT (Targets and Aims – 2003-

2006)

16. The Community’s Health

16. Chronic Illness Patients

17. Chronic Illness Patients and Smoking

18. Key facts –Smoking - DoH 2004

18. Governments Targets – Smoking – DoH 2004

19. Summary of Identified Community Health Needs

Main Health Need Identified ( Requiring

Intervention)

(Smoking Among The High Risk - Chronic Disease

Group Patients)

20. Conclusion

22. References

PUBLIC HEALTH

Theresa Lowry-LehnenGeneral Practice Nurse

PART ONE: HEALTH NEEDS ASSESSMENT PROFILE

INTRODUCTION

Since the first Public Health Act in 1875 there has been

a continuing development towards our current

understanding of public health, which is influenced by

legislation and policy, theory and practice-based

research. This paper focuses on current public health

policies and how they can be translated into practice.

Part One considers the wider determinants of health and

the concept of health needs and analyses and evaluates

collated data with regard to a community selected from my

practice area within the Sutton and Merton Primary Care

Trust. Part Two introduces a plan devised to address an

identified health need, i.e. smoking among high-risk

groups, and critically appraises an appropriate

intervention and evaluation strategy, based on the health

promotion model by Tannahill (1985). The proposed action

plan also incorporates the ‘stages of change’ model

developed by Prochaska and DiClemente (1984 cited by

Naidoo & Wills 2000).

Context and Theoretical FrameworkPublic health is not a new concept, but since the public

health movement of the 19th century the concept has

changed significantly. Evolving from a somewhat

paternalistic movement, public health now stresses the

participatory aspect of health promotion, with special

emphasis on the empowerment of patients.

The World Health Organisation has been pointed out as a

leading international influence on health care policy and

practice, with its development of worldwide health

initiatives aimed at addressing inequalities (Tinson:

1995). In Britain, the Black Report, published in 1982,

confirmed the extent of inequalities in health and health

care (Naidoo & Wills 2000). According to Ewles and

Simnett (2003), this report highlighted inappropriate

health care and a requirement to focus more on the health

needs of different groups.

The current view is expressed in the definition of public

health given by the Acheson Report (1988) “as the science

and art of preventing disease, prolonging life and

promoting health through the organised efforts of

society”.

The new public health aims to use regulations, fiscal

measures, policies and voluntary codes of practice to

provide the population with the opportunities to make the

healthier choice the easier choice (Naidoo & Wills 2000).

According to the World Health Organisation (1998), the

new public health is characterised by a comprehensive

understanding of the ways in which lifestyle and living

conditions determine health status and aims to protect

health by supporting lifestyles and creating supportive

environments for health.

“Making healthy choices easier” is the subtitle of the

current Labour government’s white paper “Choosing

Health”, which identifies an approach which respects the

freedom of individual choice and which addresses the fact

that too many people or groups have been left behind or

ignored in the past (DoH 2004a). Furthermore, the current

government stresses that health promotion, with a focus

on prevention and tackling inequalities, is one of the

key roles of primary care nurses (DoH 2002) and the

health service as a whole (DoH 2000, DoH 2004b).

A Health Assessment Profile can help to fulfil such a

role in a meaningful way. It has been acknowledged as the

most suitable assessment tool for community-based care,

marking a shift from the traditional assessment of health

needs by nurses on a one-to-one basis to a more

collective view which considers the wider and more

complex health needs of the community (Tinson 1995).

Such a profile has been defined as the systematic

collection of data to identify the health needs of a

defined population, and the analysis of that data to

assess and prioritise strategies in health promotion

(Twinn, Dauncey, Carnell 1990).

In determining health needs, the profiler must be aware

of the various ways in which they can be defined:

normative needs, felt needs, expressed needs, and

comparative needs (Bradshaw 1972 cited by Tinson 1995;

Blackie 1998).

A health needs assessment must also take into account

wider determinants of health, such as deprivation and

poverty, cultural and social influences, education,

housing, transport, and environmental factors (Naidoo &

Wills 2000, Ewles & Simnett 2003).

Both the various needs and the wider determinants will be

addressed in detail in the course of the Health Needs

Assessment Profile, which is based on the framework

suggested by Tinson (1995).

Tinson (1995) asserts that the first and most essential

task in compiling a profile is to identify the community

under examination and define its boundaries. It is also

important to consider the various dimensions within a

community, i.e. its locality (where it is), its social

structure (who lives there), its social activity (what

happens there) and its sentiment (what is it like to live

there) (Orr 1992 cited by Tinson 1995). Finally, the

dynamic nature of a chosen community should be taken into

account: Tinson (1995) suggests an approach using systems

theory as a framework, in which the community as a system

can be divided into subsystems, i.e. key health

determinants such as employment, education, housing,

crime, health care and transport. For this profile, data

was collected from a variety of sources, including a GP

practice profile I compiled at the surgery where I am

based, the Sutton and Merton PCT, local and national

government statistics, the latest Northern Wards

Participatory Needs Assessment and the national census.

Identification and Boundary of the Community The community chosen for this profile is the St Helier

(Merton) and St Helier North and South (Sutton) practice

population of Faccini House Surgery, Middleton Road,

Morden, where I am based as a practice nurse. The surgery

is situated on the borders of Merton and Sutton and is

part of the Sutton and Merton PCT, with 53% of patients

living in the borough of Sutton and 47% in Merton

( Faccini House Surgery -GP Practice Profile 2005).

TABLE 1: PRACTICE POPULATION

Faccini House Surgery, Morden

Patients 5630

Male 2834 (50.3 %)Female 2796 (49.7 %)

Age ranges

0 -12 991

13 - 18 55419 - 30 88331 - 50 165651 - 65 614 65+ 922

Source: Faccini House Surgery GP Practice Profile (2005)

The practice is situated on the St. Helier estate, which

is one of the top ten most socially deprived areas in the

South Thames region (Office of National Statistics 2002).

Both Sutton and Merton are relatively affluent boroughs

but the northern wards of St. Helier South and North

(Sutton) and St. Helier (Merton) have high deprivation

scores and lower health status (Sutton and Merton PCT

2002). Almost 90 per cent of the practice population live

in those three wards.

TABLE 2: WARDS AND DEPRIVATION SCORES

WARDS PRACTICE POPULATION DEPRIVATION SCORE(ONS 2002)

St. Helier 47% 25.9St. Helier North 22% 37.9

St. Helier South 20% 36.6

Rosehill 7% 14.4Sutton Common 4% 11.2

Sources: ONS (2002), Faccini House Surgery GP Practice Profile (2005)

While Faccini House Surgery does not yet have a complete

record of patient ethnicity, Table 4 shows data on ward,

local and national data level, with white ethnicity in

St. Helier being significantly higher than the London

average.

TABLE 4: ETHNICITY

EthnicitySt.

Helier(Merton)

Merton London England

White 83.8 % 75 % 71.2 % 92.2 %Asian 7.7 % 11.1 % 12.1 % 4.6 %Black 3.8 % 7.8 % 10.9 % 2.1 %Chinese (other) 2.1 % 3.0 % 2.75 % 0.9 %

Mixed 2.5 % 3.1 % 3.2 % 1.3 %

EthnicitySt.

Helier(Sutton)

Sutton London England

White 90.6 % 89.2 % 71.2 % 92.2 %Asian 3.0 % 4.7 % 12.1 % 4.6 %Black 3.0 % 2.6 % 10.9 % 2.1 %Chinese (other) 1.1 % 1.4 % 2.75 % 0.9 %

Mixed 2.2 % 2.1 % 3.2 % 1.3 % Source: Office of

National Statistics 2002

The Community’s LocalityFaccini House Surgery is situated over two kilometres

from Morden town centre, three kilometres from Sutton

centre and one and a half kilometres from Rosehill. The

vast St Helier estate was built in the late 1930’s. The

houses are small redbrick council style terraced houses,

each row backing on to another row of similar type

houses. The centralisation of facilities and services has

resulted in a lack of local services to meet the

population needs. To access most services in the locality

travel by bus or car is required. The closest

supermarkets are in Rosehill and Morden, and without

transport they are difficult for the elderly or those

with small children to access (Windshield Survey 2005).

There are four primary schools and one high school in the

immediate area, with lower educational achievements

compared to other schools in more affluent areas of

Merton and Sutton (Ofsted 2004). There is a significant

lack of green areas and playground facilities for

children and the nearest social centres and cafés are in

Rosehill and Morden centre (Windshield Survey 2005).

The Community’s Social Structure

The Census 2001 shows that the geographical area of the

Faccini House practice population has a high proportion

of lone parent households (Table 5). Teenage pregnancy

rates are also much higher than average (Table 6).

TABLE 5: LONE PARENT HOUSEHOLDS

St.Helier

(Merton)Merton London

7.6 % 6.0 % 7.6 %

St.Helier

(Sutton)Sutton London

11.8 % 6.1 % 7.6 % Source: Office of National Statistics 2002

TABLE 6: TEENAGE PREGNANCY RATES 2002 (Ages 15-17)

St. Helier(Merton) Merton England

54.1 per1000

40.5 per1000

46.2 per1000

Source: Merton Teenage Pregnancy Unit, Office of National Statistics 2002

St. Helier(Sutton) Sutton England

63.4 per1000 35 per 1000 46.2 per

1000Source: Sutton Teenage Pregnancy Unit, Office of National Statistics 2002

The number of elderly patients aged over 65 registered at

Faccini House surgery is 922. The practice population

number of elderly patients living alone is 175. 19% of

the elderly practice population therefore lives in lone

households, a higher proportion than both local and

national averages (GP Practice Profile 2005).

TABLE 7: ELDERLY PATIENTS LIVING ALONESt. Helier (Sutton) 17.4 %

Sutton 13.8 %St. Helier (Merton) 19.1 %

Merton 12.8 %England/Wales 14.4 %Source: Office of National Statistics 2002

Table 8 gives an overview of needs in relation to

children and families, as identified by the practice

Health Visitors case files (2004).

TABLE 8 : CHILDREN – HEALTH VISITOR CASE FILES 2004

There are 78 families with children under the age

of 5 registered at Faccini House Surgery, who

belong to the Sure Start programme.

There are 22 families with children under 5 years

who are considered a low level of vulnerability

(Level 1).

There are six families at Level 2, whose needs are

complex enough to require more than one agency.

There are two families at Level 3, whose needs are

complex and require a co-ordinated multi-agency

assessment, service plan and review process.

There are three families at Levels 4 and 5, who

have the highest level of vulnerability.

Specialist assessment has confirmed the need for

specific, sustained and intensive support.

The number of practice population births recorded

for 2004 is 95.

The number of practice population low birth weight

babies for 2004 is 11. This means 11.6 % of the

practice population births for 2004 were low birth

weight. Low birth weight is associated with low

socio-economic status, smoking, maternal nutrition

pre pregnancy, and energy intake during pregnancy

(Sutton and Merton PCT 2003b).

Health Visitor Case Files 2004, Faccini House Surgery

From the above data and the key health determinants

listed in Table 9 a picture emerges of the geographical

area in which the majority of the Faccini House practice

population lives. It is an area with high deprivation

scores, a high proportion of elderly people, and a much

higher than average teenage pregnancy rate. While

unemployment rates are the same or only slightly higher

than the national average, they are higher than the local

average in Merton and Sutton. There is a high percentage

of people without qualifications, indicating a level of

education lower than both the local and national levels.

There is also a higher than local and national average of

lone parent households. Rented council accommodation, as

opposed to owner occupied housing, is considerably higher

than both the local and national average, with a high

percentage of accommodation without central heating.

There is also a relatively high number of people without

private transport.

TABLE 9: KEY HEALTH DETERMINANTS

Limiting long term illness

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

18.7 % 13.8 % 18.2 % 14.8 % 18.2 %

Unemployment

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

3.4 % 3.3 % 3.8 % 2.6 % 3.4 %

Providing unpaid care

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

8.8 % 8.0 % 8.5 % 9.0 % 10.0 %

No Qualifications

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

33.8 % 19.9 % 37.8 % 23.3 % 29.1 %

One person households

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

33.2 % 32.1 % 30.6 % 33.1 % 30.0 %

Households with dependent children

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

31.0 % 28.6 % 37.8 % 30.0 % 29.9 %

Lone parent households with dependent children

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

7.6 % 6.0 % 11.8 % 6.1 % 6.5 %

Owner occupied housing

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

59.7 % 68.8 % 51.8 % 74.3 % 68.9 %

Rented council accommodation

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

26.4 % 9.2 % 42.0 % 10.9 % 13.2 %

Without central heating

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

22.8 % 10.2 % 13.1 % 7.1 % 8.5 %

No car or van

St.Helier

(Merton)Merton

St.Helier(Sutton)

Sutton Eng/Wales

35.8% 30.1% 35.1% 23.3% 26.8%

Source: Office of National Statistics 2002

The Community’s Social Activity and Sentiment

To find out what the residents themselves think of the

St. Helier area (Table 10), data was obtained from the

most recent Northern Wards Participatory Needs Assessment

(Merton, Sutton and Wandsworth Health Authority 1998).

TABLE 10: RESIDENTS’ VIEW NORTHERN WARDS PARTICIPATORY NEEDS ASSESSMENT 1998 The St. Helier residents expressed concern about the

lack of facilities in the area for young people. This included poor provision of nurseries and after school clubs, with cost being a major issue, especially for single mothers.

With regard to older people, the need for day care, more nursing homes and social services was highlighted. Housing issues were raised, especially the poor provision for older people living alone, and the slow repairs to council houses.

With regard to health issues, the residents were concerned about long GP waiting times, and talk about the closure of St. Helier Hospital. Other concerns about St. Helier Hospital included long waiting lists and the early discharge of patients. Residents felt more resources were required for respite care, mental

health, out of hours services, health visitors and social workers visiting the housebound.

With regards to leisure, lack of facilities for young people was a major concern, and was blamed by many residents for an increase in drugs and crime in the area. For adults, facilities were also considered poor, with the need to travel out of the area by limited public transport or expensive taxis.

Environmental issues raised were traffic pollution, graffiti, and the vandalism and destruction of public phones and bus shelters. Regarding safety and crime, residents, both young and old, said they felt unsafe on the streets at night. Much of the crime in the area is thought to be related to alcohol, under age drinking and drugs.

However, long standing and older residents also felt the area had a strong sense of community, helped by having a happy and stable network of family and friends. There was some hostility towards new residents who were regarded as having a reputation of being “rough”. As a consequence there was some conflict between generations, and differences were also seen to be aggravated by unemployment levels experienced in the area.

( Merton, Sutton and

Wandsworth Health Authority 1998)

What is being done?Since the 1998 Northern Wards Participatory Needs

Assessment, there have been some improvements in the area

(Table 11).

TABLE 11

A new leisure centre has been built on Middleton Road and was opened to the public in 2002.

Connexions, the government’s support advice and personal development service for 13 to 19 year olds, has opened a local centre.

Traffic calming measures and some road and public transport improvements have been put in place.

For the elderly and needy, cook and eat clubs and exercise and falls prevention classes have been introduced in the local area .

(Sutton and Merton PCT 2003b)

The overriding aims of the Sutton and Merton PCT formed

in 2002, are to improve local health services, the health

of the local population and to address health

inequalities (Sutton and Merton PCT 2003a). Table 12

shows the 2003 - 2006 Sutton and Merton PCT targets and

aims.

TABLE 12 : SUTTON AND MERTON PCT, 2003-2006 TARGETS AND AIMS (Primary Care) To shift services nearer to people’s homes,

particularly for the management of chronic illness, but also to coordinate with other local agencies both statutory and voluntary to enable the management of health needs to become more local and less hospital focused.

To improve the coordination of services for older people so that they receive the best care in or as close as possible to their homes.

To develop primary care particularly in the more deprived areas where investment has been low.

To address health inequalities To improve mental health services. That services for children are directed by the needs

of the child. Develop the ability of communities to improve their

own health. The PCT envisages the provision of diagnosing and

treating people where possible in the community . The PCT plans to work across the interface between

hospital and primary care to achieve more support for older people and more outpatient and chronic illness services in primary care.

To ensure access for patients to see a primary care professional within 24 hours and a GP within 48 hours.

The PCT recognises that smoking is a major contributor to ill health, and responsible for the socio-economic gradient in ill health. The target for Sutton and Merton is that 5,441 smokers successfully stop smoking by March 2006.

The Sutton and Merton PCT is aware of and addressingthe socio-economic issues which influence the healthof many local people, such as, smoking, nutrition, alcohol and drugs, sexual health and teenage pregnancy.

Smoking is a key target and being addressed through smoking cessation services, however the PCT

recognises that more needs to be done and more robust efforts are required to ensure services reachthose most vulnerable and particularly at risk.

Sutton and Merton PCT 2003a Sutton and Merton PCT 2003b Sutton and Merton PCT 2003c

The Community’s Health

There are 220 patients registered at Faccini House

Surgery who are currently diagnosed with or who have been

treated for cancer. This is equal to 3.9% of the practice

population (GP Practice Profile 2005).

Computer records for certain categories of illnesses such

as mental health are presently being updated at Faccini

House, and I was unable to obtain accurate statistics.

Present records identify 15 patients as suffering with

severe mental health problems and 82 patients with other

mental health problems such as depression. The Practice

Manager and GP’s believe that the actual figures are much

higher (GP Practice Profile 2005).

St. Helier North and South wards have the highest level

of chronic illness in Sutton, the former 16% and the

latter 14%. The St. Helier ward at 17% has the highest

level of chronic disease in Merton (Sutton and Merton PCT

2003a). Table 13 shows the number of patients registered

at Faccini House Surgery with asthma, diabetes and

coronary heart disease.

TABLE 13: CHRONIC ILLNESS PATIENTS

ASTHMA DIABETES CORONARY HEARTDISEASE

AGE NUMBER AGE NUMBER TOTAL 183 0 – 12 82 0 – 12 1313 – 24 90

13 – 24 25

25 – 44

125

25 – 50 74

45 – 64 63 50+

104

65 – 74 25 TOTAL 18975+ 14

TOTAL 399

Source: Faccini House Surgery GP Practice Profile (2005)

The practice population also comprises a high number of

smokers. Of the 4,085 patients aged over 18, a total of

1307, or 32%, are registered as smokers (GP Practice

Profile 2005). This is a higher proportion than the

national average of 26%, but close to the national

proportion of those in routine or manual employment who

smoke (31%) (DoH 2004a). Of 554 young people aged between

13 and 18 registered at the surgery, 55 smoke (GP

Practice Profile 2005), that is 10%, slightly higher than

the national average (9%) of 11 to 15 year-olds who smoke

(DoH 2004a).

A comparison between smokers and those with chronic

illnesses shows that a high proportion of chronic disease

patients are smokers. Of the 399 asthmatic patients, 194

or 61% are registered as smokers. Of the 189 diabetic

patients, 62 or 35.2% are smokers, and of the 183

coronary heart disease patients, 115 or 63% are smokers

(GP Practice Profile 2005).

TABLE 14: CHRONIC ILLNESS AND SMOKINGDISEASE TOTAL SMOKERS PERCENTAGEAsthma 399 194 61.0 %Diabetes 189 62 35.2 %CHD 183 115 63.0 %Source: Faccini House Surgery GP Practice Profile (2005)

TABLE 15 : KEY FACTS – SMOKING (DoH 2004a) Smoking is the greatest cause of preventable

illness and early death in the UK Smoking is the single biggest cause of health

inequalities and is associated with poverty and social deprivation

Over 120,000 people die from smoking in the UK each year.

10,000,000 adults are smokers in England.

26% of adults smoke ( 25% of women, 27%of men)

9% of 11 – 15 year olds are smokers Smoking causes a wide range of illnesses,

including cancer, respiratory diseases and heartdisease

Smoking costs the NHS between 1.4 and 1.7 billion pounds per year in England

70 % of smokers say they would like to stop.

TABLE 16 : GOVERNMENT TARGETS ON SMOKING (DoH 2004a) To reduce adult smoking rates from 26% in 2002

to 21% or less by 2010 To reduce the prevalence of smoking among

routine and manual groups from 31% in 2002 to 26% or less by 2010

Smoking cessation to be embedded in all NHS social care pathways by 2006

The NHS to become a smoke free zone by 2006. Nurses to be targeted to quit smoking as part ofa joint DoH and RCN campaign from 2005

Boost smoking cessation campaigns. Provide information, support, NRT and access to NHS support and stop smoking services

Restrict tobacco advertising In 2005 – 2006, the Healthcare Commission will

examine what PCT’s are doing to reduce smoking in the local populations. Progress will be monitored against national standards and indicators

SUMMARY OF IDENTIFIED MAIN HEALTH NEEDSTable 17 summarises the main health needs identified

within the defined practice population and requiring

intervention. However, the high incidence of smoking

within our practice population, and especially among the

high risk chronic disease patients, has been identified

as a most serious health need requiring urgent

intervention.

TABLE 17: SUMMARY OF IDENTIFIED MAIN HEALTH NEEDS A high incidence of pensioners living alone = 19%(17.4%

for St Helier Sutton, and 19.1% for St Helier Merton, compared to the national average of 14.4%. The large number of lone pensioner households, reflects the need for rehabilitation and home help services

Lone parent households and teenage pregnancy rates, higher than both the local and national averages. (St Helier Merton 51.4 per 1000, St Helier Sutton 63.4 per 1000, compared to 46.2 per 1000across England, 40.5 in

Merton and 35 in Sutton. Lone parent households are associated with poverty and social deprivation (Blackburn 1991). This theory is also supported by Whitehead (1988), who also suggests that poverty and ill health are interrelated.

A high incidence of vulnerable children and low birth weight babies. Low birth weight is associated with low socio-economic status (highest in births registered by single mothers), smoking, maternal nutrition pre pregnancy and energy intake during pregnancy ( Sutton and Merton PCT 2003b).

A high number of practice population patients who smokecompared to the national average (32% vs 26%). Smoking is the single biggest cause of health inequalities and is associated with poverty and social deprivation (DoH 2004a).

St Helier North and South has the highest level of chronic illness in Sutton, the former 16% and the latter 14%. The St Helier ward at 17% has the highest level of chronic disease in Merton

(Sutton and Merton PCT 2003a) A high incidence of chronic disease patients (Asthma,

Diabetes and Coronary Heart Disease) registered at Faccini House Surgery who smoke (Asthma= 61%, Diabetes = 35.2% and CHD = 63%).

(GP Practice Profile 2005)

CONCLUSIONThis Health Needs Assessment Profile has described the

practice population of Faccini House Surgery in its

geographical locality and its social structure and

activity. It has also given some insight with regard to

the views of residents and what it feels like to live in

the area (Orr 1992 cited by Tinson 1995). The picture

emerging from the collated data is one of an area of

relatively high social deprivation. From the locally

relevant data a number of comparative needs can be

identified, e.g. with regard to some key health

determinants such as education, transport, housing and

amenities, i.e. the subsystems mentioned above (Tinson

1995). A Participatory Needs Assessment by Merton, Sutton

and Wandsworth Health Authority (1998) has described both

felt and expressed needs.

This profile has also identified normative needs with

regard to the health of the practice population. One of

those needs is the high number of chronic disease

patients who are also smokers, thus exacerbating their

condition. While Tinson (1995) cautions that normative,

or professional, assessments can be problematic because

they do not always involve the client or community, the

identified health need is clearly one to be addressed

under the current government’s health targets, which

describe smoking as the UK’s single greatest cause of

preventable illness and early death and point out that 70

per cent of smokers say they want to give up (DoH 2004a).

“Smoking Kills – A White Paper on Tobacco” (1998)

describes smoking as the most identifiable factor

contributing to the gap in healthy life expectancy

between those most in need and those most advantaged (DoH

1998). Smoking is the single biggest cause of health

inequalities and is associated with poverty and social

deprivation (DoH 2004a).

“Liberating the Talents” (DoH 2002) highlights three main

core functions for nurses in primary care. As well as

being a point of first contact for patients and taking a

lead role in chronic disease and minor illness

management, they also have a responsibility to deliver

health protection and promotion programmes and the

various National Service Frameworks. The identified

community health need, i.e. smoking among the high-risk

chronic disease patients at Faccini House Surgery,

relates to the core functions of chronic disease

management, health protection and promotion and

delivering NSF’s (DoH 2001, DoH 2003) and will be

addressed by a health promotion intervention in the

second part of this paper.

(2192 words excluding tables)

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PUBLIC HEALTHPART TWO: HEALTH PROMOTION PROPOSAL

CONTENTS Page

1. Introduction

1. Context and Theoretical Framework

2. Health Promotion Model – Tannahill (1985)

3. Intervention: Planning and Evaluation Framework

(Ewles & Simnett 2003)

4. The intervention

4. Needs and Priorities

4. Aims and Objectives

7. Best Way To Achieve Aims

8. Objectives and Methods

9. Ethical issues

9. Resources

10. Roles and Responsibilities

11. Evaluation Strategy

12. Action Plan

13. Conclusion

15. References

Appendix 1 TABLE 6: Action Plan (Intervention) Patient invitation letter Letter to PCT, requesting funding Proposed budget Poster Patient feedback / Evaluation questionnaire

Appendix 2 Determinants of health Jarman scores - Sutton Statistics St Helier Sutton and St Helier Merton Indices of Deprivation 2000 Sutton and Merton

PUBLIC HEALTH

Theresa Lowry-LehnenGeneral Practice Nurse

PART TWO: HEALTH PROMOTION PROPOSAL

INTRODUCTION

The Health Needs Assessment Profile in Part One has

identified smoking among the high risk groups (i.e.

patients with the chronic illnesses, asthma, coronary

heart disease and diabetes) within the GP practice

population of Faccini House Surgery as a major community

health need requiring intervention. Part Two of this

paper will devise and critically appraise a clinic-based

smoking cessation intervention, targeting chronic disease

patients within this GP practice population. It will use

the health promotion model suggested by Tannahill (1985)

and the planning and evaluation framework devised by

Ewles and Simnett (2003). The devised smoking cessation

action plan (Table 6, Appendix 1) also incorporates the

‘stages of change’ model developed by Prochaska and

DiClemente (1984 cited by Naidoo & Wills 2000).

CONTEXT AND THEORETICAL FRAMEWORK

Health Promotion – Definition

“Health Promotion” can mean a number of quite different

activities, and practitioners must be aware of the

available options (Naidoo & Wills 2000). The World Health

Organisation defines health promotion as the process of

enabling people to increase control over, and to improve,

their health (WHO 1984). The current government speaks of

delivering sustained improvement to the health of the

people by responding to people’s concerns about their

health with practical support on their own terms and by

providing the context and environment needed to make real

progress (DoH 2004a). Naidoo and Wills (2000) point out

that the phrase “making the healthier choice the easier

choice” has come to encapsulate the meaning of health

promotion. However, Tannahill (1985) claims that the term

“health promotion” has acquired so many meanings as to

become meaningless. A more detailed look at an

appropriate health promotion model will help to provide a

focus and a rationale for the proposed intervention.

Health Promotion Model – Tannahill (1985)

Tannahill (1985: 167) suggests reserving health promotion

“to define clearly a realm of health-enhancing activities”. He

proposes a model in which health promotion is seen as

comprising health education, prevention and protection as

three overlapping spheres of activity. Education is seen

as a communication activity aimed at enhancing well-being

and preventing or reducing ill health in individuals and

groups. Preventive action can take the form of prevention

of an illness or of avoidable complications of an already

established disease. Health protection is defined as

“legal or fiscal controls, other regulations or policies,

or voluntary codes of practice” (Tannahill 1985: 168).

While in an intervention such as the one proposed here

not all parts of Tannahill’s model may have equal weight,

it allows the practitioner to be aware of the possible

different activities and available options (Naidoo &

Wills 2000). It also enhances an awareness of current

policies and national service frameworks (DoH 2001, DoH

2003) and how the proposed intervention fits into

government policies and targets regarding smoking as the

“single greatest cause of preventable illness and early

death” (DoH 2004a).

Tannahill (1985) stresses that empowerment of individuals

and groups within the community is an important objective

for health promotion. He warns against a “top down”

approach and advocates a participatory process.

It should be pointed out that no health promotion model

can be seen in isolation. There is always a certain

overlap with other models, such as Caplan and Holland

(1990 cited by Naidoo & Wills 2000) and Beattie (1991

cited by Naidoo & Wills 2000). Similarly, the various

possible approaches to health promotion, such as medical,

behaviour change, educational, empowerment and social

change (Naidoo & Wills 2000), are not mutually exclusive

but should complement each other.

Intervention – Planning and Evaluation Framework

For the purpose of the proposed intervention the planning

and evaluation framework suggested by Ewles and Simnett

(2003) will be used. It sets out a seven-stage cycle. I

have adapted the planning process to include ethical

considerations, as shown in Table 1.

Table 1: Planning/Evaluation Cycle (adapted from Ewles &

Simnett 2003)

Identify needs and priorities Set aims and objectives Decide the best way of

achieving aims Consider ethical issues Identify resources Plan evaluation methods Set an action plan Implement plan, including

evaluation

THE INTERVENTION

Needs and priorities

The Health Needs Assessment Profile in Part One has

identified smoking cessation as a health need to be

addressed. In particular, the profile has identified a

high proportion of smokers among the chronic illness

patients at Faccini House Surgery. Smoking exacerbates

such illnesses as diabetes, respiratory and coronary

heart disease (DoH 2004a). The priority for this

intervention will therefore be smoking cessation targeted

at the chronic disease patients within the Faccini House

Surgery practice population.

While it may be pointed out that a cessation intervention

should be aimed at all smokers, not just those in high-

risk groups, the health belief model (Becker & Maiman

1975 cited by King 1984) may be used to support a more

targeted approach: As King (1984) states, most people do

not tend to think in terms of abstract statistics but

rather they think of concrete examples. It is hoped that

a cessation programme aimed at the identified high-risk

groups may allow a more targeted, and therefore, it is

hoped, more successful approach.

Aims and Objectives

According to Ewles and Simnett (2003) aims are broad

statements of the outcome one hopes to achieve while

objectives are much more specific, making the setting of

them a critical stage in the planning process.

The overall aim of this intervention is to address the

identified health need, i.e. to reduce the incidence of

smoking among chronic disease patients in line with

general government and local PCT targets (DoH 1998,

2004a, 2004b, Sutton and Merton PCT 2003a, 2003b, 2003c).

With regard to Tannahill’s (1985) model, this overall aim

should be approached in a comprehensive way. The aspect

of health protection can be seen in the context of

current government policies and targets with regard to

smoking cessation (DoH 2004a). Within this context, this

proposed intervention devises an educational approach in

the form of a communication activity aimed at enhancing

the well-being and preventing or reducing the ill health

in individuals and groups. The preventive aspect can be

seen in the attempt to avoid complications of an already

established disease.

It is possible to identify aspects of a number of health

promotion approaches (Naidoo & Wills 2002). There is a

medical component in that those at special risk have been

identified by the practitioner. Individuals may be

encouraged to take responsibility for their own health

and choose a healthier lifestyle in an approach aimed at

behaviour change. There is also the educational element

trying to increase knowledge and skills about healthier

lifestyles. The overall aim may be achieved by working

with clients within the community, thus strengthening

their empowerment (Naidoo & Wills 2002).

Objectives must be set in order to enable the

practitioner to work towards the overall aim. Ewles and

Simnett (2003) stress that objectives are the desired

outcome of an intervention and that, while challenging,

they should be attainable, relevant and as measurable as

possible. On the basis of Tannahill’s (1985) model, the

objectives should cover education, prevention and

protection, and Table 2 lists the objectives for this

proposed intervention.

TABLE 2: A clinic-based smoking cessation intervention

targeting chronic disease patients within a GP practice

population

Overall Aim To reduce the incidence of smoking in chronic

disease patients in line with national and local government targets

Objectives Ensure that every targeted patient on the GP

register receives information about the clinic based smoking cessation programme

Educate and empower clients to give up smoking

Impart clear messages about the risks associated with smoking and chronic illnesses

Encourage personal responsibility Equip patients with skills/knowledge and

appropriate nicotine replacement therapy (NRT) Promote self-esteem in a population already

disadvantaged in health terms Promote inclusion with a community outreach

service for those unable to attend clinics Establish self-help group networks within the

chronic disease population Promote participation and working in partnership Work within current PCT/Government guidelines on

smoking cessation

Best Way to Achieve Aims

In choosing methods for an intervention, one must

consider whether they are appropriate and effective,

acceptable to clients and others involved and financially

viable (Ewles & Simnett 2003).

Working with individuals and small groups has been

identified as effective for changing attitudes, feelings

and behaviour (Ewles & Simnett 2003).

The objectives identified in the previous section can be

listed under such headings as health awareness,

improvement of knowledge, empowerment, changing attitudes

and behaviour, and societal change, which also correspond

to the three spheres of activity identified in

Tannahill’s (1985) model. Adapting the aims and methods

identified by Ewles and Simnett (2003), the chosen

methods for the objectives in this intervention are group

work, group teaching and talks with the opportunity of

one-to-one counselling and the appropriate use of NRT,

audio visual and written materials. Table 3 groups the

objectives under overall goals as well as activities

corresponding to Tannahill’s (1985) model and shows the

chosen methods.

TABLE 3: Objectives and Methods (Adapted from Ewles & Simnett 2003 and Tannahill 1985)

GOALS / ACTIVITY Health Awareness/ Promotion Education Knowledge Empowerment Changing attitudes and behaviour Health protection and illness prevention Reducing inequalities Participation and partnership working Societal change/protection

METHODS

Specialist nurses: Talks, education, specialist knowledge

Expert patients: Motivate, support, encourage, role models

Counselling: Change behaviour/attitudes, support, motivate

Outreach nurse: Visit patients unable to attend in the community

Group-work : Patient networking and forming self help groups

Literature: Education, information

Nicotine replacement therapyOBJECTIVES

Ensure every targeted patient receives information about local smoking cessation programme, impart clear messages about the risks associated with smoking and chronic conditions

Equip and empower patients with skills/knowledge and appropriate nicotine replacement therapy (NRT)

Promote inclusion with a community outreach service forthose unable to attend clinics

Educate and empower clients to give up smoking Encourage personal responsibility Promote self-esteem Establish self-help group networks within the chronic

disease population Work within current PCT/Government guidelines on

smoking cessation

Ethical Issues

Having set aims and objectives and having decided on the

best way of achieving them, it is appropriate at this

point to adapt Ewles and Simnett’s (2003) planning and

evaluation framework by including a consideration of

ethical issues. As Jenkins and Emmett (1997) point out,

nurses may assume that their perceptions and assessments

of a patient’s health is accurate and corresponds with

those of the patient, but there is a danger of

manipulating a patient under the guise of health

promotion. Not only is it important to establish what

health promotion itself is but also what impact nurses’

own perceptions may have on the implementation of a

health intervention (Gott & O’Brien 1990). If the concept

of empowerment is to be taken seriously, then the

patient’s autonomy must be respected. Group work and

group teaching are appropriate methods to allow patients

a say in matters which concern them. Those methods also

allow the practitioner to take into account the fact that

health education cannot be effective without

consideration of patients’ beliefs and attitudes. The

“health belief model” can help to illustrate how a

patient’s beliefs can influence his health-related

behaviour (King 1984). In the context of this

intervention it means that it must be taken into account

how patients may perceive risks and benefits.

Resources

As has already been demonstrated, the proposed

intervention fits in with the priorities and targets set

by current government policy (DoH 2004a). In terms of

material resources, use will be made of nicotine

replacement therapy, written material /literature, audio

and visual aids and display materials. It is also

important to identify existing local self-help groups for

the targeted chronic illnesses as well as voluntary

organisations such as the British Heart Foundation,

Diabetes UK and Asthma UK. The people involved in the

intervention (clients and staff) and their commitment,

time, skills, knowledge and expertise are the most

important resources. Table 4 proposes roles and

responsibilities.

TABLE 4: Roles and Responsibilities

Practice Nurses Co-ordinate the cessation programme

Point of contact/support

Overall responsibility Budgets/ Timetable

Evaluate programme

Specialist Nurses Respiratory nurse specialist Education CHD nurse specialist Specialist

information Diabetes nurse specialist Empowerment

GP Prescriptions for NRT Point of contact and support

Expert patients(CHD, Asthma, Diabetes) Empowerment

Motivation/encouragementRole models

Smoking cessation counsellor NRT adviceOne-to-one and group

counsellingEducation /Support/

Encouragement

Outreach nurse Communityoutreach visits Support /Education/ Counselling

Patients Participation Share experiences

Provide ongoing supportForm own support networksPart of decision and evaluation

process

Practice manager HousekeepingHealth and safety

Administrative staff Letters/posters/information Phone calls Point of contact

Evaluation Strategy

In setting out an evaluation strategy, it is worthwhile

assessing both the outcome and the process of the health

intervention (Ewles & Simnett 2003). While it may be

difficult to measure the outcome for some of the stated

objectives, such as encouraging personal responsibility

and promoting self-esteem, there are ways in which the

overall objective can be measured to some degree. Given

the nature of the proposed intervention, two methods of

measuring the outcome are most appropriate. Firstly,

feedback will be sought from the participants, patients

as well as practitioners, both in a more informal way

such as a group feedback session and through a more

formal questionnaire (Appendix 1). Secondly, and most

importantly given the overall aim of the intervention,

participating patients will be monitored on a voluntary

basis in order to record whether they have given up

smoking. It is suggested that the patients will be

approached after one month, three months, six months and

twelve months to update the record of their progress. For

those patients who have given up smoking their health

indicators and their own perceptions about their health

may be recorded at future appointments.

With regard to evaluating the process, it is suggested

that all input in terms of time, money and materials will

be recorded, enabling the course facilitator to set the

costs against the benefits of the intervention. In

addition, the facilitator should keep a diary to allow

self-evaluation. Finally, feedback from clients and other

practitioners will be sought, both at the end of group

sessions and through a suggestion box (Ewles & Simnett

2003).

TABLE 5: Evaluation Strategy

Evaluating the outcome

How many patients give up smoking? How many patients do not smoke after one, three, six,

twelve months? Record health indicators at future appointments

Record patient’s perception of his or her own health Feedback from patients and practitioners: group

session and questionnaireEvaluating the process

Record all input (time, money, materials)

Keep diary for self-evaluation

Feedback from clients and practitioners

Suggestion box

Action plan

The action plan is the final stage in the planning

process before the actual implementation of a health

intervention. Such a plan draws together the aims,

objectives, methods and resources and sets a timeframe,

marking either “key events” or “milestones”, while also

taking account of the evaluation strategy (Ewles &

Simnett 2003). The action plan for this health

intervention is set out in terms of key events. The

intervention will take place over a twelve week period,

based on Tanahill’s 1984 health promotion model

(education, prevention and protection) and incorporating

the “Stages of Change” model developed by Prochaska and

DiClemente (1984, cited by Naidoo & Wills 2000). This

model describes how clients change their behaviour

through various stages ranging from pre-contemplation and

contemplating change to then making the change (action

stage) before a final stage of maintenance, at which the

new behaviour is sustained and the client moves into a

healthier lifestyle. Table 6 (Appendix 1) sets out the

action plan and key events within a set timeframe.

CONCLUSION

This paper has devised and critically appraised a clinic-

based smoking cessation intervention, targeting chronic

disease patients within a GP practice population. The

intervention concerns one of the main needs identified in

the Health Needs Assessment Profile undertaken in Part

One. Using Tannahill’s (1985) health promotion model, the

planning and evaluation framework suggested by Ewles and

Simnett (2003), and the ‘stages of change’ model

developed by Prochaska and DiClemente (1984 cited by

Naidoo & Wills 2000), the intervention has been designed

to enable people to increase control over, and to

improve, their health, thus reflecting the World Health

Organisation’s definitions of health promotion (WHO 1984)

and the “new public health” (WHO 1998). The intervention

also takes into account current government policies by

responding to people’s concerns about their health with

practical support on their own terms and by providing the

context and environment needed to make real progress (DoH

2004a). In a wider socio-political context, the current

government describes health promotion as one of the key

roles of primary care nurses (DoH 2002) and the health

service as a whole (DoH 2000, DoH 2004b). In that

respect, the Health Needs Assessment Profile and the

health promotion intervention can also be seen as a

contribution to delivering relevant National Service

Frameworks (DoH 2001, DoH 2003).

Above all, the intervention aims not only to improve the

health of patients but also to empower them to make the

right choices about their own health, providing them with

the appropriate knowledge and guidance. This is made

possible by taking into account the three overlapping

spheres of activity – education, prevention and

protection - identified by Tannahill (1985) with regard

to health promotion. That health promotion should be a

comprehensive concept is reflected in the fact that the

intervention in this paper includes elements of various

approaches, medical, behaviour change, educational and

empowerment, as described by Naidoo and Wills (2000).

Using theoretical models and frameworks to explore and

address practice-based health needs and interventions

allows practitioners to gain a deeper understanding of

the concepts of public health. These models and

frameworks are useful tools for translating the aims of

health promotion, protection and illness prevention into

practice. This in turn makes it possible to enhance

practice with the ultimate aims of reducing inequalities,

improving health and providing better outcomes for

individuals and society as a whole.

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