Anti Smoking Promotion Policies Difference Health And Social Care Essay

According to the Oxford Medical Companion (1994) cited in the WHO report on the global tobacco epidemic 2008, “tobacco is the only legally available consumer product which kills people when it is used entirely as intended”. Tobacco is the leading preventable cause of death in the World which causes one in ten deaths among adults worldwide and in 2005, tobacco caused about 5.4million deaths, an average of one death every six seconds. At the current rate, the death toll was projected to reach more than eight million annually by 2030 (over 175 million deaths by then as shown in figure 1) and a total of up to one billion deaths in the 21st century (WHO 2007).Certain behaviours have been labelled as risky behaviours associated with negative health outcomes among which smoking is and which has been the subject of UK national health strategies (Naidoo & Wills 2005). Smoking causes about one fifth of all deaths in the UK, most of which are premature and has hugely significant impacts on the wider environment and community through causing air pollution, fires, litter and environmental damage (Ewles 2005). This essay will look into why smoking is an important public health issue in England by defining it from various perspectives and will analyse why people smoke. Also, it will examine various demographical and epidemiological data related to smoking and in addition, it will examine how smoking is addressed in International, National and Local policy. It will also analyse various measures adopted at various geographical levels to address inequalities in health on promoting anti-smoking. In addition, it will look into various values, norms and ethical principles that influence anti-smoking policy development. From the gaps identified, recommendations and conclusions will be made.

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According to Ewles (2005), smoking in the UK can be defined from three different perspectives in terms of; the activity, the product and the market. In terms of the activity, it is the largely use of tobacco in manufactured and hand-rolled cigarettes which is the most common form of tobacco use since the early twentieth century. In terms of the product, the manufactured cigarette consists of
chopped tobacco that has been cured and mixed with a variety of additives to add flavour, increase nicotine availability from smoke and improve shelf life all rolled up in a paper tube with a filter at one end. In terms of the market, UK is home to several Worlds’ major tobacco companies such as the Imperial Tobacco, British American Tobacco, Gallagher and Rothmans UK who all together employ 9000 people in the UK and have more than 90% of UK cigarette market. The principal constituents of cigarette smoke are tar, carbon monoxide and nicotine and the paper used for manufacturing cigarettes is treated with chemicals to prevent self-extinguishing whenever the cigarette is lit. The filter usually consists of cellulose acetate which traps some solid particles in smoke and cools it (Ewles 2005). The principal constituents of cigarette smoke are carbon monoxide, tar and nicotine which is highly addictive (Cancer Research UK 2009).
FIGURE 1: Cumulative tobacco- related deaths, 2005- 2030.
The impact of tobacco smoking on public health extends beyond the direct effects on the individual smoker and personal health being to economic, environmental and social effects (Ewles 2005). Tobacco smoking is an important public health issue because the smoke is very toxic to every human tissue it touches on its way into, through and out of the smoker’s body (Ewles 2005). Smoking harms nearly every organ of the body thereby causing many diseases, reducing quality of life and life expectancy. Also it has been estimated that in England, 364,000 patients are admitted to NHS hospitals each year due to smoking related diseases which translates into about 7,000 hospital admission per week and 1,000 admissions per day (ASH 2006). In the UK, smoking causes about a fifth of all deaths, approximately 114,000 each year, most of which are premature with an average of 21 years early (Ewles 2005). According to Peto et. al. (2003) cited in Ewles (2005), most premature deaths caused by smoking are Lung and coronary cancer, chronic obstructive heart diseases and coronary heart diseases with 42800, 29100 and 30600 deaths respectively every year. In addition, smoking is known to also bring increased risk of many debilitating conditions like impotence, infertility, gum disease, asthma and psoriasis (Ewles 2005). Research has also shown that non-smokers are put at risk by exposure to other people’s smoke which is known as passive or involuntary smoking and is also referred to as second-hand smoke (SHS) or environmental tobacco smoke (ETS) (Cancer Research 2009).
Tobacco was first introduced to Britain way back in the sixteenth century when it was commonly smoked in pipes by men. Later snuff and cigar smoking became popular among men but as a result of the invention of the cigarette making machines in the latter part of the nineteenth century, mass consumption of tobacco was made possible and in 1919, more tobacco was sold as cigarettes than in any other form (Wald & Nicolaides- Bouman 1991). According to Wald& Nicolaides- Bouman (1991) cited in Cancer Research UK (2009), smoking was firstly common among men and the consumption rose steadily until 1945 when it peaked at 12 manufactured cigarettes per adult male per day. After the Second World War, there was a slight dip in consumption but thereafter it remained at around 10 manufactured cigarettes per day until 1974 which marked the beginning of a steady and continuous decrease to about 4.6 manufactured cigarettes per adult male per day in 1992. On the other hand, women began to smoke cigarettes in the 1920s but not in large numbers until after the Second World War when they were smoking 2.4 cigarettes per adult female per day. Later, consumption among women continued to increase until it reached 7.0 cigarettes per day in 1974 after which it declined to 3.9 cigarettes per day in 1992 (Cancer Research UK 2009).
The link between smoking and life threatening diseases began in the early 1950’s when Dr Richard Doll and Prof Austin Bradford conducted the first ever large scale study between smoking and lung cancer which was later published in 1954. In 1957, the British Medical research Council announced that, there is a direct causal connection between smoking and lung cancer. Later in 1962, the Royal College of Physicians concluded that smoking causes lung cancer, bronchitis and coronary heart diseases and recommended tougher laws on cigarette sales, advertising including smoking in the public places. In 1965, the British Government banned cigarette advertising on television and in 1971, there was an agreement between the Government and the tobacco industry that, Government health warnings must be carried out on all cigarettes packet sold in the UK. In 1973, the first tar/nicotine tables was published in UK which was later upgraded and divided cigarettes into five categories of tar content in 1974. In 1975, the Imperial Tobacco agreed to drop brand names and logos from racing cars in UK races as control of tobacco advertising switched from the Industry to the Independent advertising Standards Authority. In 1976, Prof Sir Richard Doll and Richard Peto published the results of 20 years study of smokers and concluded that, one out of three people died from the habit. In 1983, the Latest Royal College of Physicians report featured passive smoking for the first time and asserted that more than 100,000 people died every year in the UK from smoking -related illness which later resulted in the banning of smoking on London Underground trains in 1984. In 1985, the smoking ban was extended to stations that were wholly or partly underground and in 1986, new advertising and promotion guidelines agreed on including banning tobacco advertising in cinemas. In 1987, the London Underground smoking ban was extended to entire network following the King’s Cross station fire outbreak in which 31 people died. The Independent Scientific Committee on Smoking and Health report in 1988 concluded that, non-smokers have a 10-30% higher risk of developing lung cancer if exposed to other people’s smoke and in June 1988, a UK court ruled that injury caused by passive smoking can be an industrial accident. The first nicotine skin patch became available for prescription in the UK in 1992 and in 1993, Sir Richard Doll’s study results suggested that smokers were three times more likely to die in middle-age than non-smokers and up to half of all smokers may eventually die from the habit. In May 1997, the New Labour Government pledges to ban tobacco advertising and in the same year, the Government called for Formula One to be exempted from proposed EU directive on tobacco advertising and sponsorship but later backed down in the face of widespread criticism that was threatening the entire directive. In 1998, a White Paper named Smoking Kills was published after the Government -appointed Scientific Committee on Tobacco and Health announced that, passive smoking was responsible for causing lung cancer and heart disease in adults. In 2001, their was a new EU directive requiring larger and more prominent health warnings on tobacco packaging and in 2002, the British parliament passed legislation that began as a Private Member’s Bill, banning tobacco advertising named the Tobacco advertising and promotion Act. In December 2002, the British Medical Association called for the banning of smoking in the public places because of threat to non-smokers and young children. The Cancer Research UK launched an advertising campaign in 2003 and was funded by the Department of Health which target smokers of mild brand of cigarette, warning on the risk associated with the habit. In January 2004, the British Heart Foundation used graphic images to reinforce the Government -sponsored anti-smoking campaign. In March 2004, the Irish Republic introduced the toughest anti-smoking laws in Europe described as the landmark legislation with a complete ban on smoking at workplaces. In November 2004, a Public Health White Paper proposed to introduce smoking ban in workplaces in 2008 with the exemption of private members club and pubs that do not serve food. In, March 2005, the British Medical journal report produced data showing that smoking killed 11,000 a year in the UK and in April 2005, MSPs voted by 83 to 15 to introduce a ban on smoking in public places from April 2006 and any smoker who defy is liable to pay a £1,000 fine. In October 2005, the discussions over the England smoking ban broke down at the cabinet level causing severe delays. In December 2006, the Government announced the smoking ban in public spaces in England known as Smoke free England, which began on the 1st of July 2007 (BBC NEWS 2007). On the 1st of October 2007, the law for selling tobacco changed and became illegal to sell tobacco products to anyone under the age of 18 (an increase from 16) (Smoke free England 2007). In May 2008, the Health Bill then called the National Health Service Reform Bill was contained in the Draft Legislative Programme published and it was announced in the Queen’s speech during the state opening of Parliament on 3rd December 2008. The Bill was later introduced into the House of Lords on 15th January 2009 and was published on the 16th January 2009 which proposes measures to improve the quality of NHS care, the performance of NHS services and to improve public health (DOH 2009).
The United Kingdom of Great Britain and Northern Ireland (UK) is located in Northern and or Western Europe and it comprises the Island of Great Britain (England, Scotland and Wales) and the Island of Ireland (Northern Ireland) (Wikipedia 2009). According to the 2001 census, the population of the United Kingdom was 58,789,194 and has increased to 60,587,300 according to mid -2006 estimates by the Office for National Statistics.
The prevalence of smoking varies widely around the World and has been observed to be on the increase in many developing countries thereby creating huge health problems for the future. Approximately 1.3 billion people smoke cigarettes or other tobacco products Worldwide (WHO 2003) and Figure 2 shows the worldwide tobacco epidemic model which describes the rise and decline of smoking prevalence followed by similar trends for smoking. The first stage is characterized by a low smoking prevalence of less than 20%, which is commonly observed among the males with no increase in lung cancer and other chronic diseases caused by smoking. Countries in this stage includes those in the Sub-Saharan Africa that have not yet been drawn into the global economy but are vulnerable to growth and changing strategic initiatives of transnational tobacco companies (WHO 2003). Stage two of the model is characterized by increase in smoking prevalence to above 50% in men with early increase in cigarettes smoking among women and a shift towards smoking initiation at younger age with an increasing burden of lung cancer and other tobacco-attributable diseases. These are characteristics of countries in the Asia, Latin America and North Africa continents. In these regions, tobacco control activities have been observed to be poorly developed and the health risks associated with tobacco smoking are not well understood. There are very low public and political supports for the effective implementation of tobacco control policies (WHO 2003). The third stage is characterized by a decline in smoking prevalence in men and gradual decline among women. Here, there is a convergence of male and female smoking prevalence at 45% and the burden of smoking attributable diseases is on the increase. Also, smoking-attributable deaths comprises of 10%to 30% of all deaths within the region which is about three quarters of men. Countries within this stage are those in the Eastern and Southern Europe where health education about the diseases caused by smoking decreases with the public acceptance of smoking, most especially among the educated ones (WHO 2003). The fourth stage is characterized by a decline in smoking prevalence among men and women with deaths attributable to smoking peaked at 30% to 35% of all deaths most of which are middle aged men. Among the women, smoking attributable deaths rose to about 20% to 25%. Examples of countries within this stage are the United States and United Kingdom where England falls.
FIGURE 2: Four stages of the Worldwide Tobacco Epidemic. (Source: WHO 2003).
According to the Cancer Research UK (2009), the survey of smoking in Britain began in 1948. Then, smoking was extremely prevalent among men and the survey showed that 82% smoked some form of tobacco while 65% smoked cigarette. Later on, smoking prevalence fell rapidly through the 1980s until the mid 1990s when the overall smoking rates stabilizes just below 30% among the population as shown in figure 3. The sharp fall in smoking prevalence during this period is as a result of several interventions put in place by the Government then such as banning of tobacco advertisement on TV in the 1960s and others. Since the mid 1990s, the rate of fall has been very slow and in 2007 it was observed that 22% of men aged 16years and over smoke cigarette. The percentage of female smokers on the other hand has remained constant between 1948 and 1970 as shown in Figure 2. Between 1970 and 2007, the % of women who smoked dropped from around 43% to 20 % still due to certain measures developed in the late 1960s.
FIGURE 3. % of person aged 16+ who smoke cigarettes in Great Britain from 1948 to 2007.
Source: General household survey, ONS.
Available from:
FIGURE 4: Prevalence of Cigarette smoking by sex, England and Govt. Office Regions 2005.
Source: Cancer Research UK.
Figure 4 shows the cigarette distribution of cigarette smoking prevalence in England and it can be observed that, the overall smoking prevalence in England is about 25% among men and around 22% among the women. Within the various regions in England, smoking prevalence is higher among men and women in the North East because the region is economically active and home to 588 overseas companies from 32 different countries employing over 27,000 people (UK Trade& Investment 2009). There has been a link between socio economic class and high prevalence of smoking as demonstrated in Figure 5 which buttresses the reason why the prevalence is high in Northeast England. Regions with high manual employee, occupation and high numbers of Industrial factories are characterised by high smoking prevalence.
FIGURE 5: Prevalence of cigarette smoking by sex and socio-economic groups in England in 1992, 1998 and 2002.
Source: Cancer Research UK.
As shown in figure 5, smoking prevalence is observed to be higher among manual workers than non-manual workers. From 1992 to 2002, smoking prevalence reduced as a result of some interventions introduced within these years especially the White Paper on Smoking Kills introduced in 1998 making the prevalence to reduce from 33% in 1998 among the manual workers to 28% in 2002.
FIGURE 6: Prevalence of cigarette smoking by age, persons aged 16+ in Great Britain, 1974-2005.
Source: Cancer Research UK.
FIGURE 7: Self reported cigarette smoking percentages by sex and minority ethnic group persons aged 16+ in England 2004.
Source: Cancer Research UK.
Smoking is more prevalent among the younger age groups of 16-19, 20-24 and 25-34 as shown in figure 6, where highest rate was observed among the 20-24 age group. Between 1974 and 2005, smoking prevalence among the 20-24 age groups fell from 48% to 32 %. On the other hand, among the 60+ age group, smoking prevalence halved between the same year intervals from 32% to 14%. Therefore, smoking prevalence has been observed to reduce with age as smokers tend to give up in middle age or die of smoking-related illnesses. (ONS 2002).
Smoking prevalence has been observed to vary among different ethnic minority groups in England as shown in figure 7. Smoking prevalence is higher among the Bangladeshi men of about 41% but rare among the women with about 3%. Although this rate is alarming but there has been a decrease as to what was observed in 2001, when cigarette smoking and tobacco use was around 44% among the men with a relatively small percentage among the women (ONS 2001).
FIGURE 8: Prevalence of cigarette smoking and use of tobacco products among ethnic minorities in England 2001.
Source: DOH 2001.
Smoking in the UK has been observed to be closely associated with social class and deprivation. The prevalence of smoking among the low paid groups has been observed to be twice those of the affluent groups because of the great difficulty people in the less affluent groups experience in stopping smoking (Ewles 2005). Tobacco smoking is also widely recognised as a cause of health inequality in the UK because it is common among the deprived groups and also compromises the already poorer health of deprived population such as those that fall within the marginalized groups. Examples are people with mental problems and prisoners, who are more likely to smoke and less likely to have access to mainstream smoking cessation services (Ewles 2005). The Index of multiple deprivation ranks areas from the most deprived to the least deprived and the odds of smoking increases as deprivation in the area increases (The NHS Information centre 2008).
Children smoke for all sorts of reasons. Some smoke to show their independence, others because their friends do while some smoke because adults tell them not to and others do smoke to follow the example of role models. There is no single cause. Parents, brothers and sisters who smoke are a powerful influence. Also is the way it is been advertised and the tobacco companies sponsor sport which makes children want to try it (DOH 1998). The problems of smoking during pregnancy are closely related to health inequalities between those in need and the most advantaged. Women with partners in manual groups are more likely to smoke during pregnancy than those with partners in non-manual groups: 26 per cent of women with partners in manual groups smoke during pregnancy, compared with 12 per cent with partners doing non-manual work (DOH 1998).
Education is also another social determinant of health for smoking. Education empowers individuals to make healthy choices and provides practical, social and emotional knowledge needed to achieve a full and healthy life (The Annual Report of the Director of Public Health for Newham 2007). The relationship between education and smoking has been extensively examined in developed countries and in the1989 US Surgeon General report analyzed by Bao-ping et al.(1996), it was stated after reviewing the literature of smoking that, education is the best socio demographic predictor for cigarette smoking pattern. The general agreement was that, the fewer the year of education one has, the more likely the person smokes and this again accounts for why there is high smoking prevalence among the ethnic minority groups in England.
Another factor is the social norms whereby, in environments where smoking is freely permitted, it becomes a normal thing and becomes more difficult for individuals to opt out from (Ewles 2005).Other factors that prompt people to start smoking includes, the price and availability of cigarette, colourful advertisement and accessibility to treatment facilities for those that want to stop, the more available the facilities, the more people will be willing to use the facilities and stop smoking (Ewles 2005).
In response to the global tobacco epidemic, May 31st of every year was declared as the World No Tobacco day, so as to globally address the danger associated with smoking tobacco. Also, the World Health Organization developed a WHO Framework Convention on Tobacco Control in May 2003 (WHO 2003), which later came into force on the 27th o February 2005 (WHO 2009). This was the first global treaty for public health negotiated under the auspices of the WHO and requires participating countries to implement a range of legislative and other measures to control smoking by taking appropriate action on passive smoking, banning tobacco promotion, providing services to smokers , monitoring smoking prevalence and international cooperation to control smuggling (Ewles 2005).In order to expand the fight against tobacco epidemic, the WHO introduced the MPOWER package of six proven policies namely:
Monitor tobacco use and prevention policies,
Protect people from tobacco smoke,
Offer help to quit tobacco use,
Warn about the dangers of tobacco use,
Enforce bans on tobacco advertising promotion and sponsorship, and
Raise taxes on tobacco. (WHO 2008)
Smoking has been addressed at Government level in the UK since the publication of the White Paper Smoking Kills in 1998 which takes a comprehensive approach and prioritises people who want to give up, pregnant women, children and young people (DOH 1998). Between 1998 and 2009, various policies have been developed as stated earlier in this essay under the historical perspective of smoking in England which includes;
1998: Smoking Kills
2002: Tobacco Advertising and Promotion Act
2006: Health Act
2007: Smoke Free England.
2008: National Health Service Reform Bill
2009: Health Bill.
In line with the WHO directive to address tobacco epidemic, the UK signed into the International WHO framework Convention on Tobacco Control in 2003 and has implemented a range of legislative measures to control smoking at different geographical levels and between various population groups. The overall measures were broadly classified into three sets of overlapping effects namely;
Changing social norms,
Influencing attitudes, and
Supporting individual behavioural change (Ewles 2005).
Measures classified under the changing social norms and influencing attitudes includes; educational programmes such as the Government-funded mass media education campaigns aimed to educate the public on the danger associated with smoking, bans on tobacco promotion with health warnings covering 30% of the front and 40% of the back of tobacco packaging while terms such as ‘low-tar’ and ‘light’ have been prohibited on cigarette packet (DOH 2003). Also education on the benefit of quitting smoking was also part of the measure and explaining why people get fat after quitting as a result of increased eating unbalanced by increase activity because smoking has slight appetite suppressant effect (Ewles 2005).
In addition, picture warnings started appearing on tobacco products in autumn 2008 and by October 1st 2009, all cigarette packs will have to carry picture warnings including other tobacco products by 1st October 2010 (DOH 2003). Also, another measure employed was prohibiting sales of tobacco products to people under the age of 18 by directing tobacco retailers to ask for form of identification from buyers who are teenagers. Taxation has also been used frequently to increase the price of smoking with rises in duty imposed in each year’s budget by the Government (Ewles 2005). On average, a price increase of 10% on a packet of cigarette reduced consumption by about 4% in developed countries, however, price control is undermined by tobacco smuggling which currently accounts for 16% of the UK market (Cancer Research 2009). Another measure is ensuring a smoke free environment which has been introduced in 2007 as smoke free England whereby smoking in enclosed public places is illegal.
Under the supporting individual behavioural change is the cessation treatment programme, examples of which includes; a national telephone help lines and NHS specialist services for smokers who want to stop (Ewles 2005). To help smokers quit, the NHS Stop Smoking Services was set up between 1999 and 2000 following the recommendations of the White Paper Smoking Kills in 1998(DOH 1998). It was later observed that between April and September 2006, approximately a quarter of a million people (246,254) in England set a quit date through this NHS Stop Smoking Services and majority of these people receiving Nicotine replacement therapy (The Information Centre 2007).
The formulation of anti-smoking policy in England has always been big issue in most developed countries. In the UK, the Government needs people to smoke because the economy largely depends on it. The Government obtains £8billion per year from excise duty on tobacco products which is approximately 2% of its annual revenue (Ewles 2005).
Both in the policy formulation and in the implementation phase conflicts of commercial and health interests have been strongest on three issues: the ban on advertisement and sales promotion, the setting of upper limits for harmful substances in tobacco products, and proposals for an efprice policy. In the political process Parliament has been much more sensitive to the public health interest and to public opinion than to the lobbying power of the tobacco industry and trade, which has been more clearly visible in many Government decisions
After thorough review of the various policies aimed towards reducing cigarette smoking at the International, National and Local level, various gaps have been identified. Firstly, banning of smoking in public places is not enough to reduce the effect of smoking on health because be it passive or active smoking, it still endangers the life of the smoker. Therefore, abstinence should be the only message since smoking is a major cause of litter. In the UK, 200million cigarette ends are discarded each day and each takes 18months or more to biodegrade (Ewles 2005). Also, smoking in bus stops tends to serve as passive smoking to others waiting to join buses and therefore smoking in areas like this also needs to be banned. Another lapse in the smoking in the public places law is that, when people are not allowed to smoke in public places, they tend to do so when they get into their private cars and homes and these could be dangerous to young children living in the same house.
Another area worth reviewing is the use of taxation to increase the price of tobacco products. High price has helped dissuade people especially young children from smoking and prompted many smokers to stop; however, smoking is concentrated among the lowest paid sector of the society and common among the addicted population who continue smoking despite prices, therefore such measures by the Government is not fair because the poor people pay disproportionately more as a consequences of their acquired addiction caused by the Government originally (Ewles 2005).
Another misconception of tackling smoking is the youth smoking prevention programme which has always assumed to be the best way to tackle smoking among children and youths. The Youth-oriented media campaigns has a poor record of credibility among the target group (youths) and is often difficult to differentiate between those created by the health organizations and those created by the tobacco manufacturing companies. Therefore, discrediting smoking among the adult population will lessen the attraction for the youths because they tend to smoke in aspiration to be more adult (Ewles 2005). In addition, the law prohibiting sales to under -18s tend to add to the allure of smoking as an adult activity and thus creating challenges to children on finding a way around it buy getting the cigarette through adult friends, older siblings or black market routes(Ewles 2005).
Also people who stop smoking through the nicotine replacement therapy gets addicted to the cessation programme and use the product beyond the recommended period. Since the nicotine delivery rate in the content is slow, it mostly prompts a relapse making people return to smoking (Ewles 2005).
Reducing inequality in smoking has always been an issue the UK Government have been addressing and in response to this, a specific inequality target on smoking was set up in The NHS Cancer plan and the Public Service Agreement (PSA) 2004 aimed to reduce smoking rates among manual groups from 32% in 1998 to 26% by 2010 in order to reduce the health gap between the two groups. (DOH 2000).
Evaluation of smoking patterns indicates that there has been an historic reversal of trends in total consumption, but distributional data show a widening social gradient in smoking. Two developments are needed for further improvement: a price policy that would support health policy and not contradict it, and better understanding of the socio-cultural dynamics of smoking which would be required for new innovative approaches in health education.
Action on Smoking and Health (2006). Smoking Statistics; Illness and death. [Online]. Available from: (Accessed 25/04/2009).
Bao-ping, Z., Giovino, G., Mowery, P. & Eriksen, M. (1996). The Relationship between Cigarette Smoking and Education Revisited: Implications for Categorising persons educational status. American Journal of Public Health.1996. Vol.86, No 11.
British Broadcasting Corporation (2007). Timeline: Smoking and Disease. [Online] Available from (Accessed 28/09/2009).

Climate Change and its Impacts on Health


The increase in the average temperature and the consequent climate change caused by the accumulation of anthropogenic greenhouse gases in the Earth’s atmosphere has begun to affect and will affect more in the coming decades, the health of the environment and the world population. In recent years, the World Health Organization (WHO) has warned that the health risks posed by climate change are considerable and irreversible and affects the entire planet (Crowley 61). Its impact on health will differ depending on the geographical region and, mainly, on the capacity and knowledge to mitigate or respond to its effects; In short, its impact will depend on the degree of development of the countries. This article describes the foreseeable impacts that climate change can have on the health of the population and various measures and policies are suggested to reduce their impact. It should be noted that in our region these changes are not expected to be drastic; higher annual oscillations are expected; however, due to the availability of more energy in the climate system. It is a change in the trend in the medium and long term, with short-term evidence that corroborates these expectations.

Climate Change and its Impacts on Health

WHO defines the term “health” as “a state of complete physical, mental and social well-being, and not only as of the absence of disease or diseases” (Watts et al. 1872). Considering this broad definition of health status, climate change impacts will affect human health in various ways. These effects have already begun to cause essential changes in ecosystems, in agricultural production, in aquifers, in marine ecosystems, in biodiversity, in the socioeconomic field, in the migration of people and animals, in the distribution of vectors of diseases, in seasonal patterns, in an increase in the frequency of natural disasters, etc. These effects will increase in the coming years and will directly or indirectly affect the health of the populations.

Changes in Morbidity and Mortality Related to Temperature

Increased emission of greenhouse gases will increase average temperatures (Patz 1568). Although this increase will be more significant in summer than in winter, softer winters are expected and with lower daily thermal oscillation. This situation will favor the appearance of a higher number of forest fires in summer, whose fumes represent a severe risk to health. Also, a higher frequency of heat waves is expected, which will lead to an increase in mortality and the heat shock incidences.  The rise in the temperature in summer will produce an increase in energy demand due to the use of air conditioners. This increase in energy demand may, in turn, lead to a rise in greenhouse gas emissions (and therefore pollution), since there is also a need to reduce the hydroelectric potential due to the foreseeable reduction in precipitation. This increase in pollution will have direct effects on health.

Effects Caused by Extreme Weather Conditions

The days of extreme heat will present increases in the maximum temperature of between 2 and 6 degrees and will increase their frequency from 6 days a year (average 1961-1990) to more than 36 days per year in the last third of the century (Gosling 374). Another meteorological situation that may pose a risk to health is extreme precipitation. Studies indicate a reduction in the number of days with excessive rainfall, although of higher intensity, in spring and summer. These extreme situations, if they occur, could pose a higher risk to the population that can suffer injuries due to drowning or trauma, isolation of people, or cause shortages of drinking water and the appearance of epidemics and allergic diseases (asthma, dermatitis, etc.). It is also necessary to consider the increase in the risk of extreme droughts, which can negatively impact on agriculture and livestock and, therefore, on the feeding of the poorest sectors of the population. Likewise, these episodes will affect the supply of drinking water and increase the risk of rain or foodborne disease transmission.

Diseases Related to the Consumption of Food and Water

The different predicted impacts of climate change foresee a reduction in rainfall and, therefore, an increase in the stress of water resources, a pressure that is already present due to population growth, economic change and land use, and, in particular, to urbanization (Springmann 1943). There is also the possibility of extreme droughts that will negatively affect sectors such as water supply, agriculture, livestock, energy production and, once again, health.

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The increase in temperatures would also affect the physical, chemical and biological properties of freshwater lakes and rivers, which, together with the reduction of rainfall, will cause a worsening of water quality. Another factor to be taken into account, related to the increase in temperature, is the possible increase in nephrolithiasis (kidney stones) whose incidence is directly related to the average temperature of the latitude where it is inhabited, being most prevalent in temperate latitudes (Singh et al. 115). The average increase in temperature will harm this health problem, which could be further aggravated by the foreseeable deterioration in the quality of drinking water.

The primary digestive infections are those caused directly by microorganisms, such as amoebiasis or salmonellosis, or also by the ingestion of toxins produced by organisms, such as botulism or staphylococcal poisoning. The scarcity of water, its low quality and high temperatures may favor the impact of these infections on the population.

Mitigation and Adaptation Measures

Climate change should not be treated as a single problem, detached from others that also affect the environment in which we live. For this reason, it is necessary to consider global measures that mitigate the impact of human activities on the environment as a whole. Measures to reduce the effects of climate change produce a clear and direct benefit on health. For example, decreasing dependence on fossil fuels would reduce air pollution and, therefore, the incidence of respiratory and cardiovascular diseases.

One of the mitigation measures that should be carried out is the exhaustive control of air quality and the development of a warning system for the population in situations of risk, due to extreme weather values (temperatures, precipitations, etc.), by the declaration of uncontrolled fires, by the increase of pollution (ozone, nitrous oxides, etc.) or by increases in the concentrations of aeroallergens (pollen, spores, etc.) (Watts, Patz). The monitoring of these factors is carried out at present, but precise and effective policies are still necessary to achieve a system that integrates all the sectors involved, which includes such measures as restrictions on emissions to protect health. Likewise, complementary measures aimed at promoting education for health, promoting citizen awareness for the solution of these problems and the promotion of healthy habits are necessary.

Given that climate change seems ultimately inevitable and irreversible, adaptation measures are necessary, because even if the emission of all greenhouse gases were interrupted in a short space of time, the climate change would continue to occur. Failure to make efforts to adapt to this change will have a price in terms of diseases, health spending and loss of productivity always higher than the cost necessary to carry out mitigation or adaptation efforts. These adaptation efforts include placing health security concerns at the center of climate change mitigation, applying local, national and international adaptation strategies, avoiding new severe and potentially disastrous health effects, as well as promote the adoption of measures to mitigate the causes of climate change derived from human activity.

Nations and communities should study the extent to which current health systems can cope with the impact of climate change, and if necessary, strengthen them, and increase health investments to formulate and better apply the strategies of adaptation in front of these risks (Kjellstrom et al. 102). In particular, it would be advisable to improve the response to public health emergencies associated with climate variability, especially given the health repercussions of natural disasters and the possibility of increasingly frequent, severe and far-reaching epidemics. Likewise, it is necessary to promote applied research on the protection of health in the face of climate change.

In summary, the solutions must come from all sectors, politicians (legislative changes, in particular in matters of air quality control and infectious vectors), technicians’ actions (monitoring, contamination reduction techniques), urban planning, transport, energy supply, food production, land use, water resources, education and information, all of which measures, together with those of emission reduction, could prevent more than 700,000 deaths per year between 2009 and 2020 around the world.


Climate change will seriously endanger health security in our region. The effects of climate change, such as worsening of air quality, extreme weather situations (heat waves, torrential rains or droughts), episodes of severe pollution, for example, ozone, fires, problems of drinking water supply and Food, changes in the distribution of infectious diseases, increased energy demand, etc., will have a negative impact on the health of the population.

It is urgent to carry out a process of evaluation by qualified experts of the capacity of the health services of our society to face extreme situations and their impact on health caused by climate change, to take the most effective management measures to respond to new emergencies and those potentially affected. In this regard, it is advisable to pay special attention to the needs of the most vulnerable populations, children and the elderly, and especially to areas that suffer from a precarious infrastructure, lower income levels and poor education.

The problem of climate change is not limited to the increase in temperatures. We are facing a global shift in the environment that will require solutions in which all sectors of the planetary society are actively involved and willing to give in, at times, to economic interests, and to prioritize sustainability over and above developing.

Works Cited

Crowley, Ryan A. “Climate change and health: a position paper of the American College of Physicians.” Annals of internal medicine 164.9 (2016): 608-610.

Gosling, Simon N., and Nigel W. Arnell. “A global assessment of the impact of climate change on water scarcity.” Climatic Change 134.3 (2016): 371-385. Retrieved from

Kjellstrom, Tord, et al. “Heat, human performance, and occupational health: a key issue for the assessment of global climate change impacts.” Annual review of public health 37 (2016): 97-112.

Patz, Jonathan A., et al. “Climate change: challenges and opportunities for global health.” Jama 312.15 (2014): 1565-1580. Retrieved from

Singh, Abhinav, and Bharathi M. Purohit. “Public health impacts of global warming and climate change.” Peace Review 26.1 (2014): 112-120.

Springmann, Marco, et al. “Global and regional health effects of future food production under climate change: a modelling study.” The Lancet 387.10031 (2016): 1937-1946.

Watts, Nick, et al. “Health and climate change: policy responses to protect public health.” The Lancet 386.10006 (2015): 1861-1914.


Acute Kidney Injury Aki Health And Social Care Essay

The first description of ARF, then termed ischuria renalis, was by William Heberden in 1802.25 At the beginning of the twentieth century, ARF, then named Acute Bright’s disease, was well described in William Osler’s Textbook for Medicine (1909), as a consequence of toxic agents, pregnancy, burns, trauma, or operations on the kidneys. During the First World War the syndrome was named”war nephritis”26, and was reported in several publications. The syndrome was forgotten until the Second World War, when Bywaters and Beall published their classical paper on crush syndrome.27 However, it is Homer W. Smith who is credited for the introduction of the term ”acute renal failure”, in a chapter on ”Acute renal failure related to traumatic injuries” in his textbook The kidney-structure and function in health and disease (1951). Unfortunately, a precise biochemical definition of ARF was never proposed and, until recently, there was no consensus on the diagnostic criteria or clinical definition of ARF, resulting in multiple different definitions.

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Acute kidney injury (AKI) is a protean syndrome of varied severity. It is characterized by a rapid (hours to weeks) decline in the glomerular filtration rate (GFR) and retention of nitrogenous waste products such as blood urea nitrogen (BUN) and creatinine.2,3 In recent years, it has been recognized that the time-honored term acute renal failure (ARF) fails to adequately describe what is a dynamic process extending across initiation, maintenance, and recovery phases, each of which may be of variable duration and severity. The term acute renal failure suggests that the syndrome is dichotomous and places an undue emphasis on whether or not renal function has overtly failed. This belies the now well-established fact that even mild decrements in glomerular filtration may be associated with adverse clinical outcomes.28-32 The alternative proposed term acute kidney injury has much to recommend it, perhaps better captures the diverse nature of this syndrome, and has entered into widespread clinical use.
Historically, patients with AKI have been classified as being nonoliguric (urine output >400 mL/day), oliguric (urinary out-put For purposes of diagnosis and management, AKI has been divided into three categories34
1. Diseases characterized by renal hypoperfusion in which the integrity of renal parenchymal tissue is preserved (prerenal states),
2. Diseases involving renal parenchymal tissue (intrarenal AKI or intrinsic AKI), and
3. Diseases associated with acute obstruction of the urinary tract (postrenal or obstructive AKI).
Most acute intrinsic AKI is caused by ischemia or nephrotoxins and is classically associated with ATN.
AKI may occur in someone either with previously normal renal function or as an acute and unanticipated deterioration in function in the setting of previously established chronic kidney disease.
The etiology and outcome of AKI is heavily influenced by the circumstances in which it occurs, such as whether it develops in the community or in the hospital. It is similarly important to distinguish whether the kidney injury occurs as an isolated process, which is more common in community-acquired AKI, or if it occurs as part as a more extensive multiorgan syndrome. In the former context, management is often, at least initially, conservative and follows an expectant approach-deferring renal replacement therapy when possible while awaiting the spontaneous recovery of renal function. In the case of a critically ill patient with multiorgan failure, dialysis may be commenced much earlier, because the goal is not simply control of azotemia but rather one of renal support in an attempt to optimize the subject’s physiologic parameters.35
More than 35 different definitions of AKI have been used in the recent literature.36 In 2004, the Acute Dialysis Quality Initiative (ADQI)1,19-23 group, comprising experts in the fields of nephrology and critical care medicine, published the RIFLE classification, a new consensus and evidence-based definition for AKI.1 The RIFLE classification defines three grades of severity of AKI (Risk, Injury and Failure) based on changes to serum creatinine and urine output and two clinical outcomes (Loss, End-stage).
The classification system includes separate criteria for creatinine and urine output (UO). A patient can fulfill the criteria through changes in serum creatinine (SCreat) or changes in UO, or both. The criteria that lead to the worst possible classification should be used.
The acronym RIFLE stands for the increasing severity classes Risk, Injury, and Failure; and the two outcome classes, Loss and End-Stage Renal Disease (ESRD). The three severity grades are defined on the basis of the changes in SCr or urine output where the worst of each criterion is used. The two outcome criteria, Loss and ESRD, are defined by the duration of loss of kidney function.As of early 2010, over half a million patients have been studied to evaluate the RIFLE criteria as a means of classifying patients with AKI.37-39
In 2007, the Acute Kidney Injury Network (AKIN), an international network of AKI researchers, organized a summit of nephrology and critical care societies from around the world. The group endorsed the RIFLE criteria with a small modification to include small changes in SCr (> 0.3 mg/dl or > 26.5 mmol/l) when they occur within a 48-hour period.24 Two recent studies examining large databases in the USA40 and Europe41 validated these modified criteria. Thakar et al. found that increased severity of AKI was associated with an increased risk of death independent of comorbidity.40
Diagnostic criteria for acute kidney injury24
An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to 0.3 mg/dl (≥ 26.4 μmol/l), a percentage increase in serum creatinine of more than or equal to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours).
A major challenge in the investigation and management of AKI is the timely recognition of the syndrome. It remains difficult to easily and reliably measure rapid changes in the GFR. Although the severity in decline in GFR correlates with the onset of oliguria, the latter is insensitive marker of the syndrome because many subjects with severe renal failure remain nonoliguric. In AKI, there is poor agreement between serum creatinine and GFR, at least until a serum creatinine steady state is reached, and even then, the absolute rise in serum creatinine must take into account differences in creatinine generation rates.42 As a result, definitions of AKI that are based on a fixed increment in serum creatinine would be expected to be biased toward making an early diagnosis in well-muscled as compared with malnourished subjects or in men as compared with women. Creatinine clearances, especially when measured over a short time frame such as 2 to 4 hours, has some utility but may substantially overestimate GFR at low levels of renal function owing to a relatively high proportion of tubular secretion. Even the use of markers such as iothalamate to estimate GFR may be less precise in the acute as compared with the chronic setting owing to alterations in their volume of distribution as well as issues relating to tubular obstruction and backleak.
Acute kidney injury is a common and important diagnostic and therapeutic challenge for clinicians.43The incidence of AKI is difficult to estimate because no registry of its occurrence exists and because up until recently there was no standardized definition. From a variety of predominantly single center studies it is estimated that 5% to 7% of hospitalized patients develop AKI.44-47 More detailed information is available regarding its development in the intensive care unit (ICU) environment, where approximately 25% to 30% of unselected patients develop some degree of AKI, although again estimates vary considerable depending on the definition used and the population casemix. Renal replacement therapy is typically required in 5% to 6% of the general ICU population or 8.8 to 13.4 cases per 100,000 population/year.30,43,48-53 AKI is also a major medical complication in the developing world, particularly in the setting of diarrheal illnesses, infectious diseases like malaria and leptospirosis, and natural disasters such as earthquakes. The incidence of AKI has grown by more than fourfold in the United States since 1988 and is estimated to have a yearly incidence of 500 per 100,000 population, higher than the yearly incidence of stroke. AKI is associated with a markedly increased risk of death in hospitalized individuals, particularly in those admitted to the ICU where in-hospital mortality rates may exceed 50%.44
The epidemiology of AKI differs tremendously between developed and developing countries, owing to differences in demographics, economics, geography, and comorbid disease burden. While certain features of AKI are common to both-particularly since urban centers of some developing countries increasingly resemble those in the developed world-many etiologies for AKI are region-specific such as envenomations from snakes, spiders, caterpillars, and bees; infectious causes such as malaria and leptospirosis; and crush injuries and resultant rhabdomyolysis from earthquakes.44Factors responsible for this higher incidence of AKI in the tropics include hot climate in conjunction with excessive sweating, increased predisposition to hypovolemic insults, poor nutritional status and increased susceptibility to infections.

Evidence Based Mental Health Nursing

This report will focus on the assessment and care planning for an individual using the mental health services. Evidence based approach will be deploy in order to be able to record, review and monitor the progress of the service user. Evidence-based practice is a structured and systematic approach to using research based knowledge of effectiveness to inform practice (Olfson, 2009). Knowledge includes formal information derived from research, for example from published trials and reviews. It also encompasses the informal knowledge and wisdom of practitioners, sometimes called tacit knowledge. This informal knowledge can include, in addition, the expertise of those who receive an intervention, whether that is medication, talking therapies or attending a parenting skills group.

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Care Programme Approach(CPA)provides the framework for assessing and care planning for a person with mental illness. CPA was introduced in 1991 by Department of Health as a systematic arrangement for assessing the health and social needs of people accepted into specialist mental health services (Kingdon, 1998). The formation of the plan will detail the health and social care required from a variety of provider as well as the appointment of a key worker to keep in close touch with the service user and to monitor and co-ordinate care. In addition, regular reviews will be conducted where necessary, agreed changes to the care plan. Hence, in this report, I will outline the main principles of CPA and deploy the use of Tidal Model and principles throughout the report by Tidal model’s principles to clinical practice and assessment and care planning.
A detailed background and information about the individual receiving care in the clinical section of where I work will be provided. And to make it clearer for the audience of this report, I will highlight the purpose of conducting this assessment as well as the process of the assessment. The discussion will centre on care planning and the strategies or issues that may impact the process. In order to keep the identity of the person under care anonymous in in accordance with confidentiality and the NMC code, only the initial of the individual will be used through the discussion in this report. As a nurse, I owe a duty of confidentiality to all those who are receiving care under me and that includes making sure that they are informed about their care and that information about them is shared appropriately (Maloney, 2016).
Care Programme Approach Framework and The Tidal Model
The Care Programme Approach (CPA) is a way that services are assessed, planned, co-ordinated and reviewed for someone with mental health problems or a range of related complex needs (, 2017). CPA are generally offered to individual that have been diagnosed for having a severe mental disorder, someone who is at risk of suicide, self-harm, or harm to others and people with history of violence or self-harm. In addition, the service is available for people that vulnerable, this could be for different reasons such as physical or emotional abuse, financial difficulties because of mental illness or cognitive impairment.
The three main core principles of CPA according to Rowland (2013) are the assessments of the needs of the individual, allocation of a care coordinator and plan how to meet the needs of the person. The coordinator will ensure that the plan include the fully assess of the service user needs, it will also show how the NHS and other organisations will meet the needs of the person, including the family in some cases. It has to be regularly reviewed by the coordinator to monitor progress. In addition, the coordinator will have to think about all the mental health needs of the service user, medication and side effects, employment, training or education and personal circumstances including family and carers. The assessment will include the risk of the service user to themselves or other, either there is a problem with drugs or alcohol. The CPA is a model for good practice which remains applicable today.
However, the CPA is a care for those of working age in contact with specialist mental health and social care services (Donohue, 2014). It is crucial to work have an integrated approach across health and social care to minimise the distress and confusion sometimes experienced by people referred to the mental health system and their carers. In addition, professionals have found some aspects of the CPA over-bureaucratic, managers and service users alike have found the lack of consistency confusing (Donohue, 2014). It is they who have been working and living with the CPA for some years now and it is important to take account of their views. In the nutrshell, Bree-Aslan and Hampton (2009) indicated that CPA is not a model of care but a tool and process to guide nurses on how to provide effective service for people with mental illness. By embracing an integrated approach where by a seamless service can be achieved through an integrated approach to care co-ordination which provides for a single point of referral and a unified health and social care assessment process (Koopmans, 2013).
Tidal model will be deployed through the care planning and assessment in this report. This principles and philosophies of this model will help to give an in depth understanding to the process of assessment and care-planning. Tidal model is a mental health recovery model which may be used as the basis for interdisciplinary mental health care. It was developed by Dr Phil Barker and Poppy Buchanan-Barker as a philosophical approach to the discovery of mental health (Barker and Buchanan-Barker, 2010). The Tidal Model accentuates helping people reclaim the personal story of mental distress, by recovering their voice. With service user, own language, metaphors and personal stories, people can begin to reclaim the meaning of their personal experiences. Helping someone to a problem in living is rarely easy because everyone is unique and each person’s reaction to any problem in living also is unique. Hence, what works one person may not always ‘work’ for another.
In Tidal model. The first step towards someone with mental illness recovering control over their lives. The model enable mental health nursing to be used as the basis for interdisciplinary mental health care and the focus begin with begin with the recovery journey when the person is at their lowest ebb experiencing the most serious problems in living (Barker and Buchanan-Barker, 2010). The Tidal Model provides a practice framework for the exploration of the patient’s need for nursing and the provision of individually tailored care. (Barker P, 2001) and it is considered as a mid-range theory of nursing, hence the main focus of the model is on helping individual people, make their own voyage of discovery. From the research, already been conducted by different scholars, the combination of CPA framework and Tidal model with the collaboration with the service user will enable them to recognise areas and needs that will be most suitable for their recovery as well as promoting a culture of person-centred care that is not associated with CPA framework.
Janet Bonet is a 58-year-old female living with her daughter who is one of her three children. Janet has never been married and also has no partner at the moment, although she said to have been in different relationships in the past but which seem to lead nowhere. My mentor and I have been asked to assess Janet during her inpatient appointment at the centre. Janet has been known to mental health services over the years and has a history of disengagement. She has had a diagnosis of severe depression in the past and also suffers from back problem which impacts on her mental health.
Janet has never been able to keep a job due to her physical health and so she has been in benefits most of her life. Due to financial stress in the past, she has self-neglected and now depend on her carer who is also her daughter for support in daily activities. Also, she was asked by the council to downsize her four-bedroom house to a two-bedroom house which she has done but still waiting on the housing list to be moved closer to her family and she finds this waiting period stressful as she has been waiting for over a year so housing is also her concern.
Recently, she has been experiencing a lot of fluctuations in her mood as she reports that she lost her Dad, Mum,Nan,and Grandad within two weeks of each other and found this extremely distressing and also has been having thoughts of harming herself. Her daughter is her carer and she also claims that her other children along with her grandchildren do visit sometimes which makes her think less about self-harming herself. She says “My children and grandchildren are my protective factors”. She went further to say that she has been experiencing feelings of emptiness and anger due to the fact that she does not feel safe in her neighbourhood as she feels some people are out to get her.
Janet admits that in the past she has not been compliant with her medication due to side effects but is willing to be compliant with treatment now that she feels she is in crisis in order to promote her recovery. Janet has also reported suicidal thoughts in the past and has had two attempts at committing suicide.
The assessment of service user with mental illness include collections of different range of information. The information may include mental health symptoms and experiences of the service user, feelings, thoughts and actions physical health and wellbeing, culture and ethnic background, use of drugs or alcohol, social and family relationships and past experiences, especially of similar problems. The whole essence of conducting assessment is for the coordinator to be familiar with the life history of the service user. However, I prefer deploy Barker (2008, p.66) procedures of assessment by trying to answer the question who the service user is. The procedure will enable the coordinator to focus on the individual as a whole by considering their needs instead on focusing on diagnosis. The second question like “what is wrong”? will prompt the service user to give information about their state of mind and wellbeing. For a nurse, the concept is to show empathy for the service user to be at ease and feel unthreatened to give more information about the state of the health and their experience. The correlate with Tidal model of Barker and Buchanan-Barker (2010) that indicated that coordinator can deploy a “holistic assessment whereby the service user is allowed to tell their story and world of experience. Through holistic assessment, therapeutic communication, and the ongoing collection of objective and subjective data, nurses are able to provide improved person-centred care to patients. A holistic assessment approach acknowledges and addresses the physiological, psychological, sociological, developmental, spiritual and cultural needs of the patient (Kreys, 2014).

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However, finding out who the person is and what is wrong with them, is just one part of the assessment. It is essential to form a collaborative and empowering relationship with the service user in order for them to be comfortable around the coordinator. Hence, service user should be treated with respect and dignity no matter the state of their health.
Barker, P. (2008). What are psychiatrists for?. Mental Health Practice, 12(1), pp.11-11.
Barker, P. and Buchanan-Barker, P. (2010). The Tidal Model of Mental Health Recovery and Reclamation: Application in Acute Care Settings. Issues in Mental Health Nursing, 31(3), pp.171-180.
Bree-Aslan, C. and Hampton, S. (2009). Pressure care, part two: the importance of assessment. Nursing and Residential Care, 11(1), pp.12-17.
Donohue, P. (2014). Involving families in planning and assessment of community services. Nursing and Residential Care, 16(3), pp.175-176.
Kingdon, D. (1998). Reclaiming the care programme approach. Psychiatric Bulletin, 22(6), pp.341-341.
Koopmans, R. (2013). Mental health in long-term care settings: The Dutch approach. Geriatric Mental Health Care, 1(1), pp.3-6.
Kreys, T. (2014). A holistic approach to patient care in psychiatry. Mental Health Clinician, 4(3), pp.98-99.
Maloney, P. (2016). Nursing Professional Development. Journal for Nurses in Professional Development, 32(6), pp.327-330. (2017). Mental health services: Care Programme Approach – NHS Choices. [online] Available at: [Accessed 28 Feb. 2017].
Olfson, M. (2009). Review: limited evidence to support specialist mental health services as alternatives to inpatient care for young people with severe mental health disorders. Evidence-Based Mental Health, 12(4), pp.117-117.
Rowland, P. (2013). Core principles and values of effective team-based health care. Journal of Interprofessional Care, 28(1), pp.79-80.

Epidemiological Data Of Stroke Health And Social Care Essay

This piece of assignment will discuss about a stroke patient that I have provided care for, it will describe the significance of epidemiological data of stroke, It will demonstrate knowledge and understanding on a nursing frame work that has been used to assess patient physical, psychological and social state it will also going to looking at the care that has been required to the patient based on the nursing assessment. I am going to use the Roper Logan Tierney model for assessing, planning, implementing and evaluating the patient need I am also going to be using Kaiser Model to manage and deliver a quality care for patient. In accordance with the Nursing and Midwifery Council Code of Conduct and Performance (NMC), (2008) to maintain confidentiality the patient’s name and hospital will be disclosed, he will be referred to as Mr P. Patient information must be treated as confidential and should only be used for the purpose intended for (NMC 2008).

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Mr P is a 72years old black Caribbean origin admitted to the ward from accident and emergency with ischemic stroke. On arrival in accident and emergency Mr P had been assessed by using Glasgow coma scale (GCS) to find out his level of consciousness Robert (2008) the scale comprises of three tests eye, verbal and motor responses Mr P was unable to response to verbal sounds makes no movement and only opens his eyes to painful stimuli, checking his blood pressure which was high and he also had a CT scan to examine the various structures of the brain to look for stroke, area of bleeding or blood clotting in the brain and what type of stroke if it is hemorrhagic or ischemic Sophie Cottrell and Alex Davies (2006) the result showed that there was a blood clot in his brain which is called ischemic stroke. Mr P has a past medical history of diabetes and high blood pressure; he was initially found unconscious by his wife in his home and was taken to accident and emergency by ambulance. Mr p was used to work for a company as an accountant before he become retired, he lives with his wife and youngest daughter and does some voluntary job at his local elderly day centre he smokes five to eight packet of cigarette per day he is very friendly and quite popular in his local pub.
The rational of choosing stroke patient is because it is a huge public health concern According to stroke association (2008) stroke is the third largest cause of death in the UK it also mention that at least 450,000 people are severely disabled as a result of stroke in England with high morbidity and disability that raised my interest to know more about stroke and its management. It is also a life changing long term condition and a number one reason why people admit to nursing homes, as an adult student nurse I will definitely face a stroke patient in my future placement and career therefore I am required to have knowledge and skills on how to deliver a quality of care to chronically ill patients.
Ischemic stroke occurs when an artery to the brain is blocked.  The brain depends on its arteries to bring fresh blood from the heart and lungs. The blood carries oxygen and nutrients to the brain, and takes away carbon dioxide and cellular waste. If an artery is blocked, the brain cells cannot make enough energy and will eventually stop working. If the artery remains blocked for more than a few minutes, the brain cells may die Kathryn et al (2006). The CT scan Mr P had in accident and emergency department also confirmed that the effect of the stroke is a left sides hemisphere stroke, the effect of a left hemisphere stroke include right-sided weakness or paralysis, sensory impairment, problems with speech and understanding language(aphasia), visual problems including the ability to do math or to organize, reason, and analyze items, behavioural changes such as depression, cautiousness and hesitancy, impaired ability to read, write and learn new information, and memory problems.
Stroke is the leading cause of disability; it is the third biggest killer in the UK and its one of the most expensive conditions to treat. Each year more than 110,000 people in England will suffer from a stroke which costs the NHS over £2.8 billion department of health (DOH) (2005). almost one in four men and one in five women aged 45 can expect to have a stroke if they live to 85 which Mr P are, the incidence of first ever stroke is expected to rise by 30% over the next decades from 1983-2023 due to ageing demographic, there are at least 300,000 people in England living with moderate to severe disabilities as a result of stroke. According to National Health Service (NHS) (2009) about 72-86%of strokes are ischemic. Each year in England over 130,000 people have a stroke, Mr p age is one of the factor that put him to have stroke, the estimated annual stroke incidence in England and Wales male aged 75+ is 26,269, people aged 75 years or older have nine-fold higher risk of suffering from a first ever stroke, and a 14- fold higher risk of suffering a recurrent stroke when compared to people to aged 45 to 64 years. Stroke causes over 60,000 deaths each year in the UK, in 2004 male who are aged 75 years or older the number of deaths caused by stroke was 16,596. Factors such as his ethnicity, hypertension and diabetics have contributed to Mr P stroke incidence. According to Graeme et al(2003) African-Caribbean people are twice as likely to have a stroke compared with Caucasian (white) people possibly because of a high prevalence of hypertension and diabetes which Mr p suffers from. According to NICE (2008) More than 900,000 people in England are living with the effects of stroke, with half of these being dependent on other people for help with everyday activities. One of the risk factor which leads Mr p to have a stroke is his smoking according to Warlow et al (2001) cigarette smoking is associated with approximately double the risk of ischemic stroke in males and females. Warlow et al (2001) also mention that increasing age is associated with both increasing blood pressure and risk of stroke.
For the purpose of this assignment under the supervision of my mentor I used the Roper, Logan and Tierney model (1996) is widely used in nursing practice in UK. The advantage of using Roper, Logan and Tierney’s activities of living model of nursing it indicates 12 activities daily of living which are related to basic human needs, they are maintaining a safe environment, communication, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying,( roper et al.) by using this model I am able to produce a care plan for Mr p and able to carryout a nursing assessment on him. Royal college of nursing (2004) explains assessment is considered to be the first step in the process of individualised nursing care. It provides information that is critical to the development of a plan of action that enhances personal health status.
Because of the word limits I am only going to looking at eating and drinking, mobilising and personal cleansing and dressing the reason I choose those is because they are essential for life if a person is not mobilising that means he is not able to do his personal care and eating and drinking which can affect him from socialising, give him depress and isolated from others.
About half of patients admitted to hospital following a stroke cannot swallow safely. Mortality in this group is high (rowan al.2005). Mr P swallowing function evaluated before he was given any food, fluid, or medication by mouth. If he cannot adequately swallow he is at risk of choking. Patients who cannot swallow on their own may require nutrition and fluids delivered intravenously or through a tube placed in the nose. According to NICE (2008) on admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral foods, fluid or medication. Immediately after admission bed side swallowing test was done by the trained nurse he has been given a small spoon of water and different thickening drinks to listen his chest if he is able to swallow it with out any problem however Mr P was coughing and straggle to swallow, so the nurses referred him to the speech and language therapists they are responsible for assessing and treating swallowing and communication difficulties the salt suggested that Mr P require his drinks to be thickened up with thickening powder to a syrup or yoghurt consistency so it goes down slower.
Swallowing problems affect over a third of people after stroke when a person cannot swallow properly, there is a risk that food and drink may get into the windpipe and into the lungs called aspiration which can lead to chest infections and pneumonia.
Ischemic stroke affect Mr Ps ability to swallow, problems of swallowing were in the past thought to occur only where both hemisphere were involved over the years by stroke damage. In the early weeks after stroke about one-third of patients with single hemiplegia suffer from swallowing problem (Gordon et al., 1987).
The plan was to feed Mr P, reemphasize proper positioning and thinking about swallowing. Allow him to see and smell the food in order to stimulate salivation, and place the food on the most sensitive mouth areas. When spoon feeding, pass the utensil below his chin to encourage neck flexion, give him only small portions, using verbal coaching to emphasize chewing, holding the food, and swallowing hard. Pause between feeding allow him to rest, and make sure all of the food was swallowed.
He also referred to dietitian for further ongoing assessment, to allow monitoring, the risk of malnutrition, to ensure his identified needs are referred for specialist advise, In meal time to assist Mr. P to seat up on his bed in a good position, Keep the surrounding area clean and free of unpleasant smells, remove bedpans, urinals and other such objects from Mr P’s sight. It is important that the patient’s room and table offer a pleasant environment for eating. As Mr P is unable to use his right side of his body when he is feed, put the tray on his right hand side just to remind him he can use his right hand to eat this will encourage Mr P’s ability to use his weaken side of his body, to provide a special tray and cutlery to help him not to spelt the food, and monitor quantitatively all food and drink consumed as accurately as possible on the food chart. Food record charts can provide the essential information that forms the basis of a nutritional assessment and help to determine subsequent treatment plans. They are therefore a valuable resource for dietitians, nurses and ultimately the patient. (Nursing times 2002).
Swallowing difficulty cause psychological effect on Mr P such as considerable distress for him and family and contribute to him loss of self esteem and self worth, loose his appetite and discomfort, less enjoyment of eating; embarrassment in social situations involving eating. As well as making difficult for family members to understand or communicate with him. According to Ebrahim, (1985) and Collin et al (1987) more severe psychological effects such as anxiety, agitation or clinical depression, requires more specific intervention. A patient who is severely depressed will lack motivation to perform even the simplest task such as maintaining posture, attempting communication etc. Physically he loses weight and start developing malnutrition include weakness, bedsores and urinary tract infection. Emotionally he become distress and become very angry in mealtime especially when he spelt food.
Washing is important not only for the reason of hygiene, but also for self esteem, the hemiplegic hand particularly can smell offensive if not washed regularly Robert Fawcus (2008) Mr p was unable to wash himself and dress due to his left hemisphere stroke the right side of his body is become paralyse.
The plan was as he requires full assistance from another individual for personal care. Personal hygiene is an important aspect of his daily living routine. To keep him remain fresh through the day, every morning to assist him brush his teeth, shower and deodorize him, to keep his skin, nails hair clean and to provide him clean cloth.
A break in this routine will give him a feeling of being dirty and cause depression and frustration. Unfortunately, personal hygiene may become an issue for Mr P, due to stroke.
Maintaining personal hygiene enhances an individual’s physical and emotional wellbeing. Mr P becomes dependent because of his long term condition; he can experience a deep loss of independence and self-esteem. On the other hand helping him to smell fresh and look his best can be a great booster to Mr P.
After brain damage by stroke, normal muscle tone is missing. First and foremost normal movement depends on normal muscle tone and without normal muscle tone the patient will never again normal movement Margaret (1987) after assessed by the manual handling advisor to evaluate his ability of moving and to determine how much assistance he needs in terms of movement due to weakness of right side of his body he is at high risk of developing pressure sore so he has been put on waterlow risk assessment chart The primary aim of this tool is to assist nurses to assess risk of patient developing a pressure ulcer.
The plan was to be given good skin care and light powder areas were skin touch skin to avoid friction, with two assistant using sliding sheet to turn him frequently to change position provides exercise for muscles stimulates circulation, helps prevent ulcers and comfort him and he has been provided pressure relief mattress to avoid any pressure sore also to give him dignity while doing personal care when he need bedpan.
According to NICE (2008) early mobilisation may have beneficial effects on oxygenation and lead to a reduction in complications such as venous thrombo-embolism and hypostatic pneumonia. There could be benefits in terms of motor and sensory recovery, and patient motivation.
Mr p is referred to physiotherapist to be assessed to his mobility to help promote his health and wellbeing and to assist the rehabilitation process by developing and restoring body systems, he also being referred to occupational therapist (OT) to assess his physical, mental and social challenges and devises, treatments, programs such as rehabilitation to increase the ability to tackle his difficulties independently.
At the result of lying on bed all the time due to his mobility and unexpected disability made Mr P depressed. This also affected his social life as he cannot go out and socialise with friends like he used to without assistance. This might make him isolated and frustrated and have a feeling of worthlessness.
At the centre of the health and social care long term conditions model is the Kaiser Permanente Health Care Model. This model builds a personalised vertical care continuum for patients with long term conditions. It also identifies the percentage of patients who will require delivery of care at different levels of the continuum through a risk assessment system. The Model provides a structured and consistent approach to help local health and social care partner’s shape the way they deliver integrated long term care locally. It details the infrastructure available to support better care for those with long term conditions as well as a delivery system designed to match support with patient need (department of health.,2007) according to Kaiser model Mr P is on level two This involves providing people who have a complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams Because of his vulnerability, simple problems can make his condition deteriorate rapidly, putting them at high risk of unplanned hospital admissions or long term institutionalization.
According to National Service Framework (NSF) (2005) anyone with a long term neurological condition who would benefit from rehabilitation is to receive timely, high quality rehabilitation service in hospital or other specialist settings when they need them, also People with long-term neurological conditions living at home are to receive a full range of rehabilitation, advice and support to meet their continuing and changing needs. This is to increase their independence and help them to live as they wish.
On the discharge date of Mr. P the multi disciplinary teams got involve because of his contentious care needs the social worker to provide career and to keep supporting him and his wife financially and for social net working such as a day centre, physiotherapist working with Mr. p to identify the physical problem, developing and reviewing treatment programs, to educate and advise Mr. P and his family how to prevent and improve his condition. He has been referred to occupational therapy which is important for him improves daily living activities and social participation, and to a district nurse to make regular home visits for example to arrange equipment such as wheelchair commode or hoist to be provided through social services and to take blood pressure measurements.
Mr. P and his family understood what foods he can and cannot eat. He has been told to eat slowly, and chew food thoroughly liquids or pureed foods than solids in order to swallow easily.
He has been advised for safety measures around the home to compensate for difficulties in mobility that are inherent with this problem. For example, avoid clutter, leave wide walkways, and avoid throw rugs or other objects that might cause slipping or falling.
Family members have been given advice to encourage Mr P to participate in normal activities and to have extreme patience because he suffers from poor coordination. Take time to demonstrate ways of performing tasks more simply. He has been advice to continue taking antiplatelet medication due to blood clot according to national clinical guidelines for stroke (2008) all patient with ischemic stroke who are not on anticoagulation should be taking an antiplatelet agent such as aspirin .Antiplatelet medication reduces the ‘stickiness’ of platelets. This helps to prevent blood clots forming inside arteries. He has been given advice to stop smoking and to have a regular check up for his blood pressure, to eat a healthy diet and to keep his blood sugar as near normal as possible to avoid further stroke, teaching him to perform specific tasks using repetitive drills in response to certain stimuli. For example, he was told to press a buzzer each time he hear a specific number. A variant of this approach trains him to relearn real-life skills, such as driving, carrying on a conversation, or other daily skills.
In conclusion the Roper, Logan and Tierney model of nursing I found it very useful in terms of assessing patient, to provide proper holistic care from admission to discharge, it allow multidisciplinary team to get involve in order to deliver quality of care for patients. The Kaiser model also helps me to identify in what stage my patient is and give me an idea of what kind of care he/she require. Overall doing this assignment I learnt so much about stroke the cause, symptoms and its management and it allow me to know the patient, how he felt and react about his illness and how it affect him psychologically, socially or emotionally.

Challenges Faced Rural Healthcare Facilities Health And Social Care Essay

Twenty-five percent of the total population in the United States are living in rural areas and compared with urban Americans and healthcare facilities in rural areas generally serve low-income, the elderly, and individuals who are less informed and armed with less knowledge concerning health care prevention measures. Moreover, rural individuals accessing healthcare in rural facilities face barriers to healthcare such as fewer doctors, hospitals and health resources in generation and face difficulty in accessing health services.
Statement of the problem
 Hospital closures and other market changes have adversely affected rural areas, leaving State and Federal policymakers, and others concerned about access to health care in rural America. Considerable changes in the health care delivery system over the past decade have intensified the need for new approaches to health care in rural areas. Managed care organizations, for example, may not be developed easily in rural areas, partly because of low population density.
Research Questions
      The primary research question in this study is the question of whether rural health care facilities overcome the ongoing challenges to provide quality medical care to their communities.
Rationale of the Research
The rationale of this research is based upon the following facts:
1.) Rural Healthcare and Barriers to Accessing Care: Many small rural hospitals have closed, while other health care supply of primary care physicians and other health care provider facilities are in financial straits. Unavailability of resources and transportation problems are barriers to access for rural populations.
2.). The supply of primary care practitioners and other health care providers in rural areas is decreasing. Some are leaving rural areas to join managed care organizations elsewhere.
3.) Barriers to Health Promotion and Disease Prevention. Goals for improving the Nation’s health over the next decade can be achieved only if rural populations are included in efforts to remove barriers to access and use of clinical preventive services.
4.) Barriers Related to Lack in Health Care Technology. Technologies including telemedicine offer promise of improved access to health care, but their most efficient and effective applications need further evaluation.
5.) Organizational Barriers of Service Provision to Vulnerable Rural Populations: Low population density in rural areas makes it inherently difficult to deliver services that target persons with special health needs. Groups at particular risk include: the elderly; the poor; people with HIV or AIDS; the homeless; mothers, children, and adolescents; racial or ethnic minorities; and persons with disabilities.
6.) Consumer choice and the rural hospital. Factors that drive changes in rural hospitals have a critical effect on consumer choice and access.
Significance of the Study
This study is significant in that individuals in rural areas are likely to continue to receive less healthcare as well as less effective healthcare if rural healthcare does not gain necessary knowledge, informed by research study as to what should be done to better deliver health care services to those in rural areas. This study is of significance to several groups including patients depending on rural healthcare services, the families of these patients, the rural communities at large and the insurance companies who provide insurance coverage for individuals in rural areas.
The methodology of the proposed research is one of a qualitative nature in which data will be gathered through survey/questionnaires of individuals, physicians and business in the rural community at focus in the research in order to asses whether the needs of the community in terms of healthcare provision are being met. Data analysis will be both qualitative and quantitative in nature. After having administered and compiled data from the survey/questionnaires focus groups will be scheduled to gain further insight into the unmet needs of the community in health care services in needs assessment focus group discussions.
Literature Review
The California Healthcare Foundation, in its “Rural Health Care Delivery: Connecting Communities through Technology” report of December 2002 states : Challenges facing rural health care include scarcity of local medical resources and distance between patients, physicians and facilities.” (Turisco and Metzger, 2002) Furthermore, it is related in this report that there are insufficient numbers of primary care practitioners in rural areas. (Turisco and Metzger, 2002; paraphrased) In the instance where a patient is forced to travel from home to another area for accessing health care services resulting is a “range of difficulties” including: (1) time away from work; (2) additional expenses; and (3) the complications of coordinating care in different locales.” (Turisco and Metzger, 2002) This increases the chance the patient information will come up missing or incomplete and as well may result in care that is “delayed or fragmented.” (Turisco and Metzger, 2002) The physicians in rural areas as well as other health care providers experience negative impacts due to the low number of health care practitioners in rural areas as well as in the distance factor, which results in “limitations on productivity, communication and ongoing education.” (Turisco and Metzger, 2002) Research notes that there is more difficulty for the rural providers in communication with other providers of health care. There is much less in the way of opportunities to attend conferences and training due to the requirements of travel, which limits access to medical knowledge and research work. Lower efficiency results due to travel time involved in visiting patients in hospitals and nursing homes as well as in “…fewer face-to-face visits, and more time on the telephone with other providers and with patients.” (Turisco and Metzger, 2002)

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In a recent report relating to healthcare in rural India stated is that: “The number of patients is increasing exponentially each year, putting enormous pressure on healthcare delivery systems worldwide. Hospitals and specialists are concentrated in cities and are inaccessible to the rural poor.” (Tata Consultancy Services and Microsoft Corporation, nd) This report relates that several physicians in India along with Tata Consultancy Services (TCS) and the largest IT company in India collaborated in the creation of which is stated to be: “…a comprehensive healthcare portal like no other.” (Tata Consultancy Services and Microsoft Corporation, nd) Offered are “abundant health-related reference material, online medical consultation, online appointment scheduling, and online lab results for physicians.” (Tata Consultancy Services and Microsoft Corporation, nd) The website was stated to have been created with the Microsoft.NET Framework, Microsoft Windows 2000 Advanced Server, Web services and Microsoft SQL Server 2000. The requirements set out by the physicians in rural areas included:
Ease of use by a wide cross section of people;
Cutting-edge yet cost-effective technologies;
Simple log on by many different users and easy assignment of user rights;
Tight security to keep medical records confidential;
Structured data capture for future data mining;
Scalable to handle millions of users; and
Extensible to accommodate audio and video interface. (Tata Consultancy Services and Microsoft Corporation, nd)
Benefits resulting from implementation of this healthcare service delivery Network include:
Improved access to healthcare;
Better use of doctors’ time;
Rapid development, usability;
Scalable to millions of patients; and
Extensible to new technologies. (Tata Consultancy Services and Microsoft Corporation, nd)
Key features of are stated to include the following:
Online, real-time medical consultation with remote healthcare professionals.
PC or mobile-phone access to regional directories for hospitals, specialists, blood banks, medical appliance suppliers, and welfare agencies.
An online appointment scheduler that enables patients to make appointments with participating physicians.
An online lab report tool that helps diagnostic centers automate the process of uploading lab reports to the Web.
Access to test results through mobile devices.
Online access to electronic health records.
Medical image upload services.
Online sonogram viewing.
A medical student resource center.
Healthcare job listings.
Online shopping for healthcare supplies. (Tata Consultancy Services and Microsoft Corporation, nd)
The Agency for Healthcare Research and Quality (AHRQ) held an expert panel meeting to provide guidance on its new health information technology on July 23-24 2003. The focus of AHRQ is the implementation and evaluation of technologies, which have been shown to be effective in small and rural communities. Secondly, the AHRQ has set its’ focus upon supporting advancement in the HIT field through implementation and evaluation support for innovation in technologies for use in diverse health care settings.” (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) The Meeting Summary reports that “two general themes emerged from the discussion” which are those of: (1) Bringing people together; and (2) Providing technical assistance. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Activities recommended for achieving their goals are those as follows:
Support demonstration projects that involve HIT implementation and will lead to the creation of learning networks comprised of providers from various types of rural health care organizations.
Create learning communities that span geography; collect and analyze the outcomes associated with participation.
Once factors that facilitate learning communities and HIT implementation have been identified, engage CMS and other purchasers to define an appropriate reimbursement strategy.
Incorporate evidence-based primary care guidelines with rural relevance into technological templates. Clinicians are likely to accept clinical guidelines offered by the Federal Government at no cost.
Support local capacity development for HIT, including barrier analysis, education and other activities.
Provide sustained technical assistance (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003)
Evaluation of the process in rural and small communities includes: (1) scope of the project; (2) goals; (3) critical success factors; and (4) technical assistance.” (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Community grants have been focused on the provision of ‘personal digital assistant (PDA) systems in assisting with the decision support role. The initiative is stated to include: (1) development of toolkits; (2) leveraging known tools; (3) developing capacity; and (4) disseminating best practices. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003)
Ormond, Wallin, and Goldenson report in the work entitled: “Supporting the Rural Health Care Safety Net” (2000) state: “The policy – and market-driven changes in the health care sector taking place across country are not confined to metropolitan areas. Rural communities are experiencing changes impelled by many of the same forces that are affecting urban areas.” However, due to the demographical differences and other facts existent only in rural life the health care system can be differentiated from those in urban areas in various ways. According to Ormond, Wallin, and Goldenson, it is that difference that highlights the importance of giving consideration “explicitly” to the “impact of competitive forces and public policy developments on rural health care systems and the patients and communities they serve.” (2000) The changes that are occurring in the health care sectors are resulting in many providers being threatened in both rural and urban areas however, health care provider failures in a rural area is likely to a much greater impact as compared to health care provider failure in urban areas. “Because alternative sources of care in the community or within reasonable proximity are scarce, each provider likely plays a critical part in maintaining access to health care in the community. For this reason, in most rural communities all providers should be considered part of the health care safety net – if not directly through their care for vulnerable populations, then indirectly through their contribution to the stability of the community’s health care infrastructure.” (Ormond, Wallin, and Goldenson, 2000) The study reported by Ormond, Wallin and Goldenson is based on case studies in rural communities in the states of Alabama, Minnesota, Mississippi, Texas, and Washington selected in representation of “…a broad range of pressures facing rural providers.” (2000) A debate is stated to exist in terms of ‘limited services’ models for hospitals who fear that more insured patients or those who are wealthier will be reluctant to use this facilities. Challenges to full-service facilities in rural areas include “recruitment and retention of health care professionals and of ensuring the financial viability of local hospitals.” (Ormond, Wallin, and Goldenson, 2000) Also related is the fact that health care providers are very reluctant “to locate in communities without a hospital…” while simultaneously when there is not a strong physician practice in an area, hospitals “find it difficult to attract patients.” (Ormond, Wallin, and Goldenson, 2000) Constraints upon a rural hospital of either a full or limited service hospital include its rural location. “The population required to support given service, such as a hospital or particular physician practice is spread over a much greater area. Low volume can mean high average costs, a factor that rural health officials feel is not always taken into account in reimbursement.” (Ormond, Wallin, and Goldenson, 2000) Demographical and socioeconomic differences in rural areas places demands upon health care system providers in terms of the need for treatment for more elderly people which are those “more likely to have chronic health care needs.” (Ormond, Wallin, and Goldenson, 2000) Furthermore, due to the lack of access to mass and major media in rural areas, the individuals residing in these areas are much less likely than those in urban areas to be aware of the availability of health care and public programs. Insurance coverage in rural areas is also a factor because rural areas have higher self-employment than urban areas, and specifically relating to farming operations making it very likely the employer-sponsored insurance in minimal. Of those who are insured in rural areas, it is likely that many of these are under insured with high premiums and low benefits as compared to those insured in urban areas. “The social structure of rural communities may make the stigma attached to participation in public programs greater, particularly in the case of Medicaid.” (Ormond, Wallin, and Goldenson, 2000)
The range of services offered in rural hospitals is limited by the size of the area it serves as compared to the population within that area. Many of the hospitals in the study reported by Ormond, Wallin and Goldenson “relied on a local primary care physician for core services…but augmented his or her capabilities by making arrangements with other, nonlocal providers. The core services each hospital offers depend primarily on the capabilities of their physicians.” (2000) In order that a hospital be able to support a visiting specialist program it is a requirement that the hospital have the staff that is appropriate and qualified to assist “in the various specialties and physicians be able to monitor recovery, as well as the necessary space and equipment for procedures.” (Ormond, Wallin, and Goldenson, 2000) The rural hospital is not in the position to provision all the services needed within the community it serves and this makes a requirement of having a referral system of a reliable nature. Stated to be a “mainstay of the safety net in rural areas” just as is the case in urban areas is the community health center.” (Ormond, Wallin, and Goldenson, 2000) Another important provider of care in rural areas is the local health department. Another problem in rural areas is transportation for patients in that in rural areas there is oftentimes no public transportation. Internal strategies reported to be used by rural health care providers are inclusive of: “…increasing the stock of physicians and other health professionals, tailoring facilities and services to the needs of the community, and expanding, downsizing, or diversifying as needed.” (Ormond, Wallin, and Goldenson, 2000) Other stated strategies are inclusive of “cooperation among rural providers and developing links with urban providers through mergers, management contracts, and joint projects.” (Ormond, Wallin, and Goldenson, 2000) Initiatives have been developed for recruitment of physicians and other health professionals who are “familiar with life and medical practice in rural areas”. (Ormond, Wallin, and Goldenson, 2000) Those who are recruited for practice in rural areas are likely to remain after recruitment. All five states in this study report that they provide support: “…for the development of rural health professionals by requiring, facilitating, or funding training opportunities in rural areas so that students become familiar with the particular demands and satisfactions of rural medical practice, or by funding education either through scholarships for aspiring providers from rural areas or through loan forgiveness for providers agreeing to locate in rural areas.” (Ormond, Wallin, and Goldenson, 2000) Only the state of Washing is stated by this report to have a formal residency program. Service expansion is reported to be utilized by rural hospitals and clinics for enabling them in meeting a “broader range of health care needs in their communities.” (Ormond, Wallin, and Goldenson, 2000) Areas of expansion included: (1) the construction or renovation of a physician plant; (2) the addition of new medical services; and (3) diversification beyond traditional acute services.” (Ormond, Wallin, and Goldenson, 2000) In fact, “growth and expansion” as compared to downsizing “appeared to be the more common, and seemingly more successful, route.” (Ormond, Wallin, and Goldenson, 2000) Expansion is also noted in outpatient services offered by hospitals and clinics. Cooperative efforts among rural providers as these health care providers collaborate in order to ensure the capability of serving their communities will continue is noted in this report stating that “cooperation with other rural providers is also a mainstay of rural hospitals’ strategy to ward off encroachment by urban health care systems.” (Ormond, Wallin, and Goldenson, 2000)
The work of Rygh and Hjortdahl entitled: “Continuous and Integrated Health Care Services in Rural Areas: A Literature Study” makes a review of literature that examines possible methods of improving healthcare services in rural areas. Stated by these authors is the fact that: “Healthcare providers in rural areas face challenges in providing coherent and integrated services.” (Rygh and Hjortdahl, 2007) This study proposes a need for “greatly flexibility in traditional professional roles and responsibilities, such as nurse practitioners of community pharmacists managing common conditions.” (Rygh and Hjortdahl, 2007) Further stated is that the “substitution of health personnel with lay health workers or paraprofessionals often in combination with interdisciplinary teams, is among measures proposed to alleviate staff shortage and overcome cultural barriers.” (Rygh and Hjortdahl, 2007) Other findings of this study include that for those working in rural areas called for is “flexibility of roles and responsibilities, delegation of tasks, and cultural adjustments by the healthcare practitioners.” (Rygh and Hjortdahl, 2007) This study states that rural case management is greatly dependent upon a locally based case manager and that the highest ranked skills for rural case managers are: “the ability to be creative in the coordination of resources, multidimensional nursing skills, excellent communication skills, high-caliber computer skills and excellent driving skills.” (Rygh and Hjortdahl, 2007) Stated is that: “Case management in a rural environment requires a much broader and generalist knowledge base, it covers all levels of prevention and transverses all age groups. Rural case management is a distinct specialty area of practice, with a distinct knowledge base and skills level, and nurses should be prepared at the advanced practice level.” (Rygh and Hjortdahl, 2007) This study further relates that evidence exists of the success of: “…collaboration at the interface between primary and secondary sectors may improve access, continuity of care and the quality of service delivery in rural areas.” (Rygh and Hjortdahl, 2007) This study defines telemedicine as “Medicine practiced at a distance” therefore encompassing “diagnosis, treatment and medical education.” (Rygh and Hjortdahl, 2007) The state of Maine is stated to have a “well-functioning telemedicine” services system using telemedicine in a “broad array of interactive videoconferencing applications, including mental health and psychiatry, diabetes management, primary care, pediatrics, genetics and dermatology.” (Rygh and Hjortdahl, 2007) According to this review telemedicine has the potential to be a tool of a valuable nature in achievement of healthcare access in rural areas although the cost-effectiveness of telemedicine has yet to be documented. (Rygh and Hjortdahl, 2007; paraphrased)
The work entitled: “Providing Hospice and Palliative Care in Rural Frontier Areas” states that the National Rural Health Association (NRHA) “…believes that all Americans are entitled to an equitable level of health and well-being established through health care services, regardless of where they live. An important but often overlooked aspect of health and well-being is assurance of appropriate care and support when people are experiencing chronic, progressive illness and/or approaching the end of their lives.” (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005) In order to study this area of service provision the method for defining and assessing needs is stated to be through a needs assessment to include recruitment of a group of members of the community for participation in identifying the needs and creating a method of assessing results. Data is gained from various sources an may include the following:
Demographics of the community;
disease statistics (county health department and state vital statistics division);
List of health care organizations/agencies that provide related services;
A definition of unmet or under-met service needs;
Identification of the unique characteristics that differentiate palliative care and/or hospice services from other services in the community;
Vital statistics, including cause of death, age at death and location of death;
Loss data;
Community residents’ satisfaction with current hospice and/or palliative care services, obtained through interviews; and
Community members preferences about hospice and palliative care. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005)
Recruitment of individuals in this type study are stated to include:
Community residents;
Representatives from other community service providers such as a librarian, store owners, chiropractor or dentist;
The president of a fraternal organization, the Rotary Club, another service club or the Chamber of Commerce;
Pastors or leaders of local faith communities;
Someone involved with the local food pantry or other emergency relief organization;
An influential local business person such as the feed store owner;
A county extension staff person active in community events and volunteer work;
Someone who organizes the town’s annual parade, festival or other special events;
Someone who works on civic clean-up and beautification; and
Representatives from other small organizations and entities in each of the countries the provider serves. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005)
This study speaks of the creation of “capacity building” in expansion of the service provision and in meeting unmet or undermet needs in rural areas. Capacity building strategies include education and training of staff for skills development needed in broadening the services provided. Community education in establishing a broader understanding of what services and opportunities are available for care is also stated to be a strategy for capacity building as service utilization will be increased as well. Capacity building strategies as well are stated to include outreach strategies for development and sustaining partnerships and collaborations as well as in sustaining and supporting growth of expectations related to hospice and palliative care services. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005; paraphrased) Stated as practical examples of the training and education of staff and the philosophy used by rural providers in the creation and sustaining of program capacity are those as follows:
Development and adoption of service performance parameters;
Education of the board and/or local leaders in national trends such as palliative care, open access, managed care, chronic care management and the nursing shortage;
Establishment of an ethics committee comprised of community members, hospital representatives, palliative care and hospice program staff, and church members to review specific ethical considerations/cases and to address projects such as advance care planning and advance directives;
Importing best practices in enhancing service definition and outreach;
Offering support for local and offsite continuing staff education an subsidies for staff to pursue relevant credentials;
Offering support for local and offsite continuing staff education and subsidies for staff to pursue relevant credentials;
Appointing full-time or substantially part-time physicians and advanced practice nurses as soon as feasible and involving these individuals in professional and community outreach;
Establishment of bridge programs and/or extended palliative home care;
Improved/extended utilization of volunteers in meeting caregiving requirements. For hospices, this may include volunteer participation in providing continuous care as allowed by regulations; and
As needed, referrals to other organizations. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005)
The work entitled: “Planting the Seeds for Improving Rural Health Care” relates the ‘Chronic Care Model’ which portrays the “essential involvement of the community, the design and function of the health care system and effective interaction between patients/families and their team of caregivers, producing optimal clinical outcomes.” (2005) The following figure labeled figure 1 shows the ‘Chronic Care Model’:
Figure 1
Chronic Care Model
Source: Planting the Seeds for Improving Rural Health Care (2005)
Components of this program include the following:
Use of a rapid-cycle method for implementing quality improvements;
Use of a standard set of changes for teams to implement;
Sharing a vision of the ideal system of care developed by clinical experts;
Monthly reporting of process and outcome measurements;
Three ‘learning sessions’;
A final ‘national forum’ during which teams attend sessions with expert faculty to share progress, best practices, and lessons learned. (Planting the Seeds for Improving Rural Health Care, 2005)
The work entitled: “Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals” asks the question of “Why Collaborate?” and answers this question by stating that collaboration strengthens community health infrastructure; improves efficiency levels; and provides joint economic advantage. Collaboration is stated to be a process “through which parties who see different aspects of a problem can explore constructively their differences and search for (and implement) solutions that go beyond their limited vision of what is possible.” (Taylor-Powell, et al., 1998) There are five levels of relationships in building collaborative interorgnaizational relationships around health issues in a rural community which are: (1) networking; (2) cooperating; (3) coordination; (4) coalitions; and (5) collaboration. These five levels of relationships according to purpose, structure and process are shown in the following ‘Community Linkages- Choices and Decisions’ matrix.
Figure 2
Community Linkages – Choices and Decisions
Source: Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005)
The following are examples of the ways that CHCs and hospital partnerships are able to collaborate. These initiatives may also be used by any rural hospital, CHC or primary care provider:
Joint training, recruitment, human resources, and clinical direction;
Shared case managers;
Working together on ‘disease collaboratives’;
Shared medical laboratory;
Partnership establishment enables organizations in qualifying for funding through grants for which they would not otherwise have been eligible to receive; and
Shared electronic patient medical records systems; (Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005)
This study states findings that a number of activities specific to an individual site have the potential for wider replication. Those activities are stated to be as follows:
Local foundations can support rural health-related activities; namely physician recruitment and retention.
Collaboration of CHCs, hospitals, nursing homes, and assisted care facilities in the same location can serve a large rural area and make efficient use of scarce resources; namely physicians.
Affiliation with a large regional hospital can be a positive experience that is supportive of community-based services.
Collaboration may be a vehicle for expanding benefits to CHC patients; namely as a result of the collaborative, a hospital utilizes the CHC’s sliding fee scale for laboratory services provided to CHC patients.
Case management for discharge planning and care coordination between the CHC, home health care agency, and the hospital can improve patient care.
Electronic patient medical records systems that integrated the CHC and the hospital medical records are the key to future collaboration and the development of a comprehensive model of a health care system for the rural community. (Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005)
There are important factors identified for organizing a successful collaboration which include: (1)

Health Promotion Proposal Reducing Obesity Health And Social Care Essay

The increase in obesity has been identified as a major public health threat. It has been predicated by the Government Office for Science Foresight that without taking action nearly 60% of the UK population will be obese by 2050, which would have serious financial consequences for the NHS and the economy.1
The causes are complex and related to behavioural, social and environmental factors therefore to tackle obesity a range of agencies and communities need to work together to:
Change the obesogenic nature of the local environment.
Develop opportunities to make healthy choices easier.
Help those already obese or at high risk of becoming obese.
This strategy provides a framework for local action and seeks to:
Provide an understanding of the extent of the problem in the local population and sets goals.
Provide leadership by bringing together a multi agency group.
Choose interventions that evidence has shown to be effective.
Enable monitoring and evaluation.
Build up local capacity via training.
There is a focus on childhood overweight and obesity in line with government recommendations. This two year evidence based strategy will require funding, the costs and resources required are provided in the action plan.
2.0 The organisation
2.1 The geographical area and population
To make up the target population for this strategy, 90% of Preston’s population and 15% of South Ribble were chosen, this is a population of approximately 150,000.
Preston’s health profile3 shows there are inequalities with nearly 40% of the residents living in the most deprived quintile. The percentage of children classified as obese is similar to the England average. South Ribble’s health profile4 shows less than 5% of residents living in the most deprived quintile, child poverty and deprivation rates are low, the percentage of children classified as obese is better than the England average. Preston has a Black Minority Ethnic (BME) population of 15.5% which is greater than the England average, the largest majority being Asian (Indian the majority) or Asian British.3 South Ribble has a BME population of less than 5%.4

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To ensure the population had a range of social classes, age groups and ethnic groups, two of the most deprived wards of Preston (Ribbleton [GL] and Fishwick [GB]) – total population 12,720 were replaced with 3 less deprived wards of South Ribble (Broad Oak [GC], Kingsfold [GL] and Middleforth [GU]) – total population 12,430, see Figure 1. This ensured the target population for the purpose of this strategy was approx 150000 with mixed class, age and ethnicity. The geographical area for the purposes of this strategy is called Preston Ribble Council.
Figure 1: Wards of Preston (A) and South Ribble (B) 5
2.2 Health Improvement
As part of Preston Ribble Council, the Health Improvement Team delivers a range of services and health campaigns designed to improve the health and wellbeing of the population of Preston Ribble.
The health improvement team includes public health consultants and practitioners who work with the NHS, other organisations, the voluntary sector and local business to provide education and training services to empower residents of Preston Ribble to make healthy lifestyle choices.
Health improvement and tackling inequalities is an integral part of Preston Ribble Council’s Culture. All policies that support health improvement are evidence based. Partnership working is a necessity to deliver the health improvement agenda.
3.0 Obesity strategy development
Obesity is a multi-faceted problem and therefore requires a multi-agency solution. A multi-agency Obesity Strategy Group was set up with key partners from the Local Authority, NHS and the voluntary sector to develop this strategy. The group was lead by the Health Improvement team’s consultant in public health. It sets out how partners and communities will work together to reduce obesity by taking into account the specific needs of the local population. This strategy will link in with other strategic plans to ensure tackling obesity is high on the political agenda of Preston Ribble Council.
4.0 Background
4.1 Defining overweight and obesity
Overweight and obesity are terms used to describe excess body fatness which can lead to adverse effects on health and wellbeing.2 Overweight and obesity occurs when energy intake from food and drink is greater than energy expenditure i.e. what is used by the body. The causes however are more complex and related to behavioural, social and environmental factors.2
The calculation of BMI body mass index (BMI=weight/(height)2) > 30 kg/ a widely accepted definition obesity. The World Health Organisation produced a classification of overweight adults based on BMI, see Table 1.
Table 1 Classification of overweight adults.6
Classification BMI (Kg/m2) Risk of co-morbidities
Underweight Clinical problems increased)
Normal weight 18.5 – 24.9 Average
Overweight > 25
Pre-obese 25 – 29.9 Increased
Obese class I 30.0 – 34.9 Moderate
Obese class II 35.0 – 39.9 Severe
Obese class II > 40.0 Very severe
Source: Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. Geneva. World Health Organisation, 2000 (WHO Technical Report Series, No 894)
Guidance published by the National Institute for Health and Clinical Excellence now recommends the use of waist circumference in conjunction with BMI as the method of measuring overweight and obesity and determining health risks.7
Because a child’s BMI varies with age and sex, the BMI score for children is related to the UK 1990 BMI growth reference charts.8
4.2 Obesity and Health
Life expectancy is reduced in obesity cases by an average of three years, and in severe obesity cases (BMI >40) life expectancy is reduced by eight to ten years.9 It has been estimated that the cost to the UK economy from overweight and obesity was £15.8 billion per year in 2007, £4.2 billion of which were costs to the NHS.9
Childhood obesity
Short term risks mostly include emotional and psychological affects associated with being overweight through being teased by peers, resulting in low self esteem and depression. There are longer term consequences as obese children are more likely to become obese adults, there are however some obesity related conditions such as type 2 diabetes which have increased in overweight children.9
Adult obesity
Evidence has shown that adult obesity is associated with a range of health problems including those related to; the musculoskeletal system because of the extra strain on joints; circulatory system e.g. coronary heart disease and stroke; metabolic and endocrine system e.g. type 2 diabetes; cancers such as breast and colon; reproductive problems; gastrointestinal and liver disease and psychological and social problems.9
5.0 The scale of the problem in the UK
Within the last 25 years, the prevalence of obesity in the UK has more than doubled.1 The latest Health Survey for England (HSE) in 2009 showed that the proportion of obese men increased from 13% in 1993 to 22% in 2009 and from 16% of women in 1993 to 24% in 2009 i.e. more women are obese than men, there were however more overweight men (44%) than women (33%).10 The 2007 Foresight Report predicted that if no action were taken, by 2025 47% of men and 36% of women will be obese and Britain could be a mainly obese society by 2050, adding £5.5 billion annual cost to the NHS.1
The rise in obesity among 2-10 year olds from 1 in 10 in 1995 to 1 in 7 in 2008 appears to be flattening out.10 There are however, still 1 in 5 children that are overweight or obese by the age of 3 years.11
Rates of obesity are higher among some Black and Minority Ethnic (BME) communities and also in lower socioeconomic groups.12 The latest Health Survey for England in 2009 also showed the link between obesity and deprivation, women in the lower income quintiles had a higher BMI and greater prevalence of obesity than those women in higher income quintiles, there was no apparent pattern in men,10 see Figure 2.
Figure 2 Age-standardised prevalence of overweight and obesity by equivalised household income and sex.10
6.0 The scale of the problem in Preston Ribble Council.
Using the NICE costing tool13 the selected population obesity and overweight prevalence and numbers were calculated, see Appendix 1. The extent of the problem is summarised in Figure 3. There are an estimated 4511 children and young people who are classified as obese (BMI over 30), and a further 4580 who are classified as overweight (BMI between 25 and 30). There are an estimated 31993 adults who are classified as obese and a further 51821 who are classified as overweight. 22.9% of adult females and 26.8% adult males are obese.
Figure 3 the extent of the problem in Preston Ribble
Normal weight
BMI > 40 n=2105*
BMI 30-39 n=29888*
BMI 25-30 n=51821*
Children & Young people
BMI >40 n=69*
BMI 30-39 n=4442*
BMI 25-30 n=4580*
*NICE costing tool
The National Child Measurement Programme (NCMP) introduced in 2005 aims to monitor the prevalence of overweight and obesity in children in Reception Year and Year 6. The table below presents the results for the local authorities of Preston and South Ribble compared to the North West and national averages.
Table 2 Local prevalence of overweight and obesity among children for the Local Authorities of Preston and S.Ribble and for England 2009/10 and 2008/09 14
Year 6
The table above shows an increase from 2008/09 to 2009/10 in Reception Year in the numbers of overweight and obese children in both Preston and S.Ribble. In Year 6 there was just an increase in obese children in S.Ribble. The targeted population for this strategy is ‘Preston Ribble’, as the population is 90% Preston and 15% South Ribble these increases are clearly a concern.
A report by Intelligence for Healthy Lancashire (Joint Strategic Needs Assessment) on childhood obesity in Lancashire showed that measurements of year 6 pupils from the 08/09 NCMP dataset highlighted that across Lancashire there could be found extremes of weight (underweight and obese) in the most deprived areas and there was a link between higher levels of overweight and lower levels of deprivation.15
6.1 The local cost of obesity
Using the NICE costing tool for the target population of Preston Ribble, the estimated savings from implementing NICE guidance is approximately £43,000 savings on prescriptions and £127,000 in GP contacts, see appendix 1. That is the current local cost to the NHS of not implementing NICE guidance for tackling obesity is approximately £170,000. There would be however additional costs with disease associated with overweight and obesity plus costs on the economy from days off work due to obesity and associated diseases and conditions.
7.0 National Drivers and Guidance
Reducing obesity is a national priority for government as highlighted in the recently published white paper ‘Healthy Lives, Healthy People: Our Strategy for public health in England’.16 In January 2008, the government published the national obesity strategy ‘Healthy Weight Healthy Lives’.17 It highlighted the need for a long term approach and set out a new Public Service Agreement target for England:
‘Our ambition is to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to achieve and maintain a healthy weight. Our initial focus will be on children: by 2020, we aim to reduce the proportion of overweight and obese children to 2000 levels’.17
In 2006 Nice Guidance on Obesity was issued, this set out guidance on ‘prevention, identification, assessment and management of overweight and obesity in adults and children in England and Wales’.7 In addition to the NHS the guidance was also aimed at non-NHS settings for example, local authorities, schools early years and workplaces and sets out recommendations aimed at these various settings. It was also highlighted that obesity cannot ‘simply be addressed through behavioural change at individual level; population based interventions are needed to change the “obesogenic environment” of modern industrialised nations’.7
The Foresight Report, ‘Tackling Obesity: Future Choices’ (2007) highlighted that obesity is determined by ‘a complex multifaceted system of determinants’ and that in the 20th century ‘the pace if technological revolution outstrips human evolution’ which has left an ‘obesogenic environment’.1 To tackle the complexities of obesity the report advocated using a multi agency or whole system approach. The report concluded that ‘Preventing obesity requires changes in the environment and organisational behaviour, as well as changes in group, family and individual behaviour’.1
8.0 Effective interventions
Research highlighted in the Foresight report1 found that the top five policy responses which they assessed as having the greatest average impact on obesity levels were:
€ ‘increasing walkability/cyclability of the built environment
targeting health interventions for those at increased risk
controlling the availability of/exposure to obesogenic foods and drinks
increasing the responsibility of organisations for the health of their
€ early life interventions at birth or in infancy.’ 1
9.0 The Local Approach
‘Healthy weight, healthy lives: a cross government strategy for England’17 and the accompanying ‘Healthy weight, healthy lives: a toolkit for developing local strategies’2 have been utilized to develop this strategy for Preston Ribble. It supports the government’s recommended approach of focusing on five key themes:
Children: Healthy growth and healthy weight. The stages of pre-conception, breast feeding, infant nutrition through to early years can shape outcomes and choices made in adulthood.18
Promoting healthier food choices. Supporting the government’s recommendation for promotion of a healthy, balanced diet.
Building physical activity into our lives. Supporting the government’s recommendation of promoting active living throughout the life course.
Creating incentives for better health. Promoting action for maintaining a healthy weight in the workplace through promotion of healthy eating choices and more opportunities for physical activity within the workplace.
Personalised support for overweight and obese individuals. Providing clinical care pathways to assess and manage overweight and obesity through effective weight management services.
A life course approach has been used to assess the various stages of peoples’ lives where evidence has shown targeting interventions can be successful in preventing or treating overweight and obesity. This strategy uses ‘universal’ population preventative approaches in addition to ‘targeted’ interventions for those already obese or at high risk of developing. As evidence suggests peoples lives are shaped from very early years11,18 this strategy focuses on children’s health.
To help people overcome barriers to maintaining a healthier lifestyle and changing their behaviour, this strategy takes a combined approach as recommended in the Foresight Report1 that is using types of interventions that focus on the determinants of behaviour such as the environment and education, the second type of intervention focuses on the behaviour itself in those at risk.1 The strategy uses all 5 different approaches to health promotion, i.e. medical, behaviour change, education, empowerment and social change to tackle both the determinants and the behaviour itself.
10.0 The Obesity Strategy Aim and Objectives
The overall aim of the strategy is to reduce obesity levels in the local population of Preston Ribble. The strategy has three strategic themes with objectives:
Change the obesogenic nature of the local environment.
Develop opportunities to make healthy choices easier.
Help those already obese or at high risk of becoming obese.
10.1 Change the obesogenic nature of the local environment
Influence public policy
Influence businesses to become healthy workplaces
Work with communities to make active lifestyles easier
As planning and transportation policy development can have huge effects on opportunities for activity within the local built environment, it is important that health issues such as obesity are considered in policy decisions, Health Impact Assessment (HIA) should form part of policy development. As part of this strategy’s action plan HIA training will be rolled out to planning and transportation teams within the council.
Foresight report1 found that one of the five policy responses which they assessed as having the greatest average impact on obesity was increasing the walkability/cyclability of the built environment. The report highlighted that ‘residents of highly walkable neighbourhoods are more active and have slightly lower body weights than their counterparts in less walkable neighbourhoods’, it was also highlighted how perceptions of social nuisances may increase the risks of obesity.1 Therefore key actions of this plan include interaction between Environmental Health, Housing, Police and communities to tackle social nuisances, set up community action teams and working with communities to empower and reassure residents.
Community food growing initiatives have been recognised as providing benefits to help tackle obesity, they can offer physical activity, increase food knowledge and give a better appreciation of food that helps them make healthier food choices, in addition they help create cohesive communities and social inclusion thereby reducing health inequality.19 Because of the potential health gain this strategy aims to set up several community horticultural projects targeting the most deprived areas likely to have high risk individuals.
The influence of the workplace on health of employees is well recognised and the Foresight report1 found increasing the responsibility of organisations for the health of their employees was one of the five policy responses which had the greatest impact on obesity. As part of this strategy the importance of this has been recognised and therefore a newly created ‘health & wellbeing workplace officer’ will be recruited to promote and facilitate the development of healthy active workplaces promoting the national ‘Workwell campaign’20 a health and wellbeing workplace award scheme will be launched.
10.2 Develop opportunities to make healthy choices easier.
Enable young children to eat a healthy diet
Enable adults and families to eat a healthy varied diet
The stages of pre-conception, breast feeding, infant nutrition through to early years can shape outcomes and choices made in adulthood.18 In ‘Tackling obesity through the healthy child programme, a framework for action’ evidence is presented which strengthens the argument for focusing interventions in the very early years, it is highlighted that epidemiological studies have shown once obesity is established in a child it can continue into adulthood.11 The Foresight report1 found that one of the five policy responses which they assessed as having the greatest average impact on obesity was early life interventions at birth or in infancy. Therefore this strategy focuses on early years as they have been identified as critical opportunities for interventions in the life course, see figure 4.
Figure 4 Critical opportunities for intervention in the life course of an individual 1
Source: Government Office for Science (2007) Tackling Obesity: Future Choices, Foresight Report.
Breastfeeding can provide protection against obesity and related health problems in later life22 and that by breastfeeding mothers are more likely to return to their pre-pregnancy weight.23 It has been recommended by the WHO and the Department of Health that breastfeeding should be encouraged for the first 6 months of life.24 This strategy includes actions to increase uptake of breastfeeding.
Both parents and childcare providers have a role in ensuring children have healthy balanced diets. This strategy includes actions to help ensure healthy eating at childcare premises. A healthy eating award scheme for childcare will be launched to encourage and provide recognition to childcare providers.
NICE guidance recommends a whole school approach to tackling overweight and obesity.7 Healthy weight healthy lives highlights the importance of schools in ensuring opportunities are provided for children to develop healthy eating habits. This strategy therefore supports ‘Healthy Schools’25 and also increasing the take-up of school meals.
National qualitative research commissioned by the Department of Health for the change 4 life campaign included segmentation of the population into 6 clusters, it was identified that 3 cluster types that were more at risk of obesity, Clusters 1 and 2 also had low income, these clusters each require specific key messages.26 See Figure 5. People on low incomes (Cluster 1 and 2 ) will be targeted as the Food Standards Agency low income and diet survey highlighted they had poorer diets due to several factors including a lack of cooking skills and knowledge.27
Figure 5 Department of Health Segmentation analysis 26
Taking an educational approach to promote healthy food choices in the home this strategy will implement a package of workshops designed for these high risk clusters to provide knowledge, practical skills and confidence to prepare healthy affordable food.
As BME communities have also been identified as high risk of obesity, they will also be targeted for healthy eating workshops. As suggested in ‘Healthy Weight Healthy Lives a toolkit for developing local strategies’ 2 to effectively engage BME communities, interventions will be culturally appropriate and group workshops will include sharing ideas how to make traditional meals healthy.
The availability of affordable fresh food in deprived areas will also be address by this strategy, by introducing initiatives such as fruit and vegetable box schemes and food co-operatives which will promote local sustainable suppliers.
10.3 Help those already obese or at high risk of becoming obese
Identify early those at high risk of overweight or obesity and direct towards appropriate intervention
Ensure provision of and equal access to weight management services for those who want to loose weight.
As the numbers of obese individuals is forecast to rise1 it is paramount that services are in place to meet their needs and help individuals reduce and maintain a healthy weight. For those individuals already burdened with obesity or are at high risk of becoming, comprehensive care pathways for both adults and children will be developed using NICE guidance7,28 to ensure they are evidenced based.
It was recommended in ‘Healthy Weight Healthy Lives a toolkit for developing local strategies’ that more weight management services should be commissioned.2 Counterweight is an evidence based weight management programme that has been shown to be highly cost effective.29 This strategy will therefore utilize this cost effective service to ensure weight management services are available for those who want to loose weight. Weight management schemes designed specifically for children will also be assed and introduced on securing funding e.g. MEND (Mind, Exercise, Nutrition, Do it).30
The full Obesity Strategy Action Plan is shown in Table 4.
11.0 Monitoring and evaluation
The implementation and monitoring of this strategy will be overseen by the Obesity Strategy Group for Preston Ribble. To measure success of the overall aim of reducing obesity levels in the population, overarching strategy indicators are shown in Table 3.
Table 3 Overarching strategy indicators.
% children in Reception who are obese
Annually Feb
% children in Reception who are overweight or obese
Annually Feb
% children in Yr 6 who are obese
Annually Feb
% children in Yr 6 who are overweight or obese
Annually Feb
Prevalence of BMI > or equal to 30 in adults over age of 16 in previous 15 months in GP registers
The Obesity Strategy Action Plan shown in Table 4 includes an evaluation framework. For each action, the outcome and performance measure is indicated. The highlighted lead will be responsible for ensuring the specified outcomes and performance indicators are measured and reported back to the Strategic Obesity Group at the specified time.
Table 4 Obesity Strategy Action Plan
Strategic Theme 1: Change the obesogenic nature of the local environment
Objectives and key actions
Approach to health promotion indicated:
(medical / behaviour change / educational / empowerment / social change)
Lead responsibility and partners
Performance Measure / Outcome
(Social Change)
Objective: Influence public policy
Ensure HIA part of policy development
Roll out HIA training to planning and transportation teams within the council.
Within 6 months
IMPACT 5 day HIA training course for team leaders (£700 pp)
In house HIA awareness 1 day course delivered by trained HIA champions.
Training providers
All team leaders completed 5 day HIA course
1 day in house HIA awareness training attended by 90% of officers
Increase availability of active transport –
Planning and transportation to map existing cycling and walking routes around the district and undertake a gap analysis of opportunities for more routes.
Within 6 months
Planning Officer time
Parks and Leisure
Existing cycling & walking routes mapped.
Results of gap analysis reported.
Restrict access to unhealthy food.
Work with planning to restrict permission of fast food outlets within 500 metres of schools
Planning Officer time
PCT Health Promotion
No applications granted after 1 year.
Improve walkability of neighbourhoods.
Improve timely interaction between Environmental Health, Housing, Police to tackle social nuisances.
Monitor community satisfaction via questionnaires / community meetings every year.
Procedural development time by all partners.
Environmental Health
Housing Department
Housing Associations
Community Groups
Community group and resident feedback of significant improvement.
Establish new food growing sites to improve the health and well being of residents.
Identify land available for food growing projects.
Within 6 months
Planning Officer time
Land Owners
4 new growing sites to be established.
Objective: Influence businesses to become healthy workplaces
Organise an area forum and develop website for representatives of local businesses to raise awareness in employers of production benefits in promoting healthy lifestyles. Promote business in the community workwell campaign, case studies of good practice.
Within 6 months
Health and wellbeing workplace officer (in Environmental Health) £30K
Environmental Health,
PCT Health Promotion,
Occupational Health,
Existing Area Business and Commerce Forums
Forum website developed.
Influence roll-out of workplace policies to
tackle obesity via newly appointed health and wellbeing workplace officer – employed to promote and facilitate the development of healthy active workplaces.
1 – 2 years
Health and wellbeing workplace officer
Environmental Health,
PCT Health Promotion,
Occupational Health,
Existing Area Business and Commerce Forums
Feedback from forum of increase in healthy policies. (website survey monkey at 1 and 2 years)
Critically assess workplace practices in NHS and the Local Authority and introduce policies that encourage physical activity and healthy eating. Promote implementation of NICE Guidance 43.
1 – 2 years
Health and wellbeing workplace officer
Environmental Health
PCT Health Promotion, Human Resources teams, Occupational Health,
Catering services
All NHS and LA workplaces assessed after 2 years.
Launch a workplace health and wellbeing award scheme to encourage employers to recognise the influence that they can have on their employee’s health.
6 – 12 months
Health and wellbeing workplace officer time, LA communications team
Environmental Health,
Council Comms,
PCT Health Promotion,
Occupational Health,
Existing Area Business and Commerce Forums
Award scheme launched after 12 months.
Objective: Work with communities to make active lifestyles easier
Work with communities to identify perceived needs for cycling and walking routes.
6 – 12 months
Planning Officer time
Parks & Leisure
Community Groups
Health walk Leaders

Health Promotion in Adult Nursing: Adult Asthma Case Study

This essay will address how to help a 20 year old asthma sufferer bring to an end his recurrent admissions to hospital because of acute exacerbations in his asthma. Asthma is a common and chronic inflammatory disorder of the airways, associated with marked health and economic consequences. It is estimated that approximately 5.2 million people in the United Kingdom (UK) suffer from asthma, making the condition the most common long term illness in this country. Asthma accounts for 1,400 deaths per annum, with a third of these being among individuals under 65 years of age. Similarly, asthma also accounts for about 69,000 hospital admissions a year. It is estimated that more than half of the 5.2 million people with asthma in the UK do not have adequate symptom control. While 500,000 of these have asthma that is difficult to control with available medication, and are thought to be resistant to corticosteroids, asthma is not well controlled in approximately 2.1 million people for reasons such as non-concordance with medication (Asthma UK, 2004, pp3-7).

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As already mentioned asthma is a long-term chronic condition (LTC) and although chronic illness is not a newly-recognised phenomenon, the incidence and prevalence has significantly increased over the second half of the 20th century and continues to rise in the 21st century (Howie, 2005, p318). This is not least because of the aging population and advances in medical science diminishing the impact of infectious diseases. In addition, the emergence of unhealthy lifestyles is arguably the trigger for many non-communicable diseases such as chronic heart disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease to which asthma has similar pathophysiology. (Nissinen et al, 2001, p963). It is estimated that in the UK over 17.5 million people are affected by a LTC and 8.8 million have long term illness that severely limits their day to day ability to cope. It is proposed that those aged over 65 affected by a LTC are more likely to have multiple long term conditions, which makes care particularly complex. Debatably, unhealthy lifestyles and an aging population are the reasons for the high prevalence of LTCs contributing towards the large financial costs in caring for these patients who occupy up to 42 percent of all acute hospital bed days (Department of Health (DH), 2005b, p10). Arguably, these issues indicate that these patients are not receiving the care in ways that meet their needs or the needs of the health system. It is proposed that this is why management of LTCs is of specific importance to current Government health strategies. To this effect, numerous policy documents have been published that define the present philosophies for the management of LTCs.
One particular policy; The National Service Framework (NSF) for Long Term Conditions was published by the DH in March 2005 (DH, 2005b, p24). The NSF predominantly concentrates on individuals’ with long-term neurological conditions. However, it is anticipated that to a great extent the guidance presented could be relevant to all long-term conditions. The document has outlined 11 “quality requirements” and among others there are various ones that are particularly pertinent to Steven Williams’s case. These include the provision of person-centred care and choice, the offering of information and support for the safe and effective use of medicines, the supporting of self care and the consideration of health promotion needs.
It is suggested that in order to meet Steven’s needs he will require support and education so that he can make informed choices. Metcalf (2005, p60) suggests that informed choice for those with LTCs is the key to success and a means of examining issues pertaining to non-concordance, risk taking behaviours and patient choice. As already mentioned, Steven began to smoke when he started attending university. Cigarette smoking is implicated as a health-risk behaviour and there is evidence to suggest that active smoking in adults with asthma increases asthma severity. A study by Siroux et al, (2000, p470) on the relationships of active smoking to asthma and asthma severity, found that current smokers with asthma had more asthma symptoms, more frequent asthma attacks (≥ 1 attack per day) and scored higher on the asthma severity scores, compared to those asthma sufferers who had never smoked and ex-smokers. Other trigger factors that can exacerbate asthma symptoms include house dust mites, pet allergens, pollen, moulds and fungal spores, certain drugs such as asprin and beta blockers, occupational triggers and viral respiratory tract infections (Roberts, 2002, p46).
Arguably, in Steven’s case, alongside his lack of concordance with his asthma medication, it is suggested that his smoking habit is a key factor in his acute asthma exacerbations. Therefore, it is proposed that Steven needs help with smoking cessation and education on the side effects and concordance of his medication.
Numerous approaches are presently being utilised for smoking cessation. These approaches incorporate pharmacological methods, such as nicotine replacement therapy or antidepressants, hypnotherapy, and exercise supported interventions. Behavioural approaches include stage based interventions, which mainly use the transtheoretical model (Prochaska, DiClemente & Norcross, 1992, p1102-14) and this model divides people into five different stages. These are the precontemplation, contemplation, preparation, action, and maintenance stages. The justification behind “staging” people, as such, is to fit the therapy to a person’s need at his or her particular point in the change process. Succession through the stages is in order, although relapses to previous stages can happen. The model also recognises 10 processes of change, the theory being that the effectiveness of the different processes of change will vary according to the patient’s stage. Arguably, however, this has not repeatedly been defended in empirical research (Sutton, 2000, p31).
It is proposed that it would be necessary for health professionals to recognise precisely an individual’s stage of change, or readiness to change. This is so that an intervention based on “stage specific processes” of change can be employed. It is important that the stage of change is re-evaluated regularly, and that the intervention should reflect changes in the individual’s willingness to change. These elements of the intervention can be continual until the person accomplishes and sustains the change in behaviour. In this way, stage based interventions develop and adjust in answer to the individual’s progression through the stages of change. Therefore it is debated that stage based models recommend that interventions that take into account the existing stage of the individual will be much more successful and efficient than “one size fits all” interventions (Prochaska, DiClemente & Norcross, 1992, p1103). Having said this however, the stages of change theory does not take into account any outside influences that might have an impact on a person’s ability to change.
It is proposed that Steven recognises that he has a problem and has asked for help. Therefore, it is suggested that this places him in the contemplation stage. It is suggested therefore, that Steven needs to be given help and advice that will lead him to the preparation for action stage. In doing this, debatably, it will be necessary for Steven to assess his feelings regarding his smoking behaviour. It is important therefore that health professionals who are using behavioural change models for smoking cessation are thoroughly trained in the procedure or at least are aware of the availability of a smoking cessation nurse. Ethically, it is argued that health professionals have a duty of care to help patients like Steven live healthier lifestyles. However, ethically Steven has the right to autonomy in his lifestyle choices (Tschudin, 2003, p151).
It is proposed that inhaled corticosteroids are still the most effective preventer drug for attaining treatment objectives (British Thoracic Society, Scottish Intercollegiate Guidelines Network (BTS, SIGN, 2004, Chapter 4, p2). Steven has voiced concerns about the effects of steroids and this has stopped him taking his preventative inhaler. Similarly, he only uses his reliever inhaler when he becomes extremely wheezy. This is in accordance with Bender’s (2002, p554) suggestion that one of the reasons people do not take their medication is because they are worried about side effects. It is argued that this could be because their initial concerns might have not been fully addressed by health professionals (Carter et al, 2003, p27). It is proposed that nurses are ideally placed to educate patients on the benefits of medication concordance. It is important that a nurse thoroughly explains the necessity of the treatment and any subsequent side effects. Inhaled corticosteroids are the main preventative treatment for asthma sufferers. When taken twice daily at a low dose, corticosteroids are highly effective in reducing asthmatic symptoms, improving lung function, and reducing cellular inflammation. Systemic effects are rare on a low dose and most asthma patients are extremely well controlled on a low dose inhaler. Adverse local effects can include dysphonia and oral candidiasis. These symptoms can be relieved by either gargling or rinsing the mouth with water after inhalation (Roberts, 2002, p48). It is proposed that if Steven regularly takes his preventative inhaler then his asthma will be better controlled and he is much less likely to need systemic corticosteroids that can have adverse side effects such as weight gain and thinning of the skin when taken long-term.
The NSF quality requirements of person-centred care and choice, and the offering of advice on the use of medication are relevant to the case mentioned, as is the consideration of health promotion needs. The patient will require help in giving up smoking as this is a major factor contributing to his repeat admissions to hospital. Help in the correct use of his medication is also required if he is to remain free from episodes of acute asthma. Nurses caring for patients like Steven will need to know what help is available with smoking cessation and the various options that can be offered to individuals who want to cease smoking. The Prochaska and DiClemente model of behaviour change is commonly used in smoking cessation; however, its effectiveness is questionable.
Asthma UK (2004) Where do we stand, (last accessed: June 25th 2007)
Bender BG (2002) Overcoming barriers to nonadherence in asthma treatment, Journal of Allergy and Clinical Immunology, 109 Supplement 6, S554-559
British Thoracic Society, Scottish Intercollegiate Guidelines Network (BTS, SIGN) (2004) British Guideline on the Management of Asthma: A National Clinical Guideline, revised edition, Edinburgh,, chapter4, (last accessed: June 26th 2007)
Carter S, Taylor D & Levenson R (2003) A Question of Choice: Compliance in Medicine Taking, Medicines Partnership, London
Department of Health (2005b) The National Service Framework for Long-term Conditions, (last accessed: June 25th 2007)
Howie K (2005) Long-term conditions, Practice Nursing, 16, 7, 318
Metcalf J (2005) The management of patients with long-term conditions, Nursing Standard, 19, 45, 53-60
Nissinen A, Berrios X & Puska P (2001) Community-based noncommunicable disease intervention: lessons from developed countries for developing ones, Bulletin of the World Health Organisation, 79, 963-970, (last accessed: June 25th 2007)
Prochaska JO, DiClemente CC & Norcross JC (1992) In search of how people change: Applications to addictive behaviors, American Psychologist, 47, 1102-14
Roberts J (2002) The management of poorly controlled asthma, Nursing Standard, 16, 21, 45-51
Tschudin V (2003) Ethics in Nursing: The Caring Relationship, Third edition, Butterworth Heinemann, London
Siroux V, Pin I, Oryszczyn MP, Le Moual N, & Kauffmann F (2000) Relationships of active smoking to asthma and asthma severity in the EGEA study, European Respiratory Journal, 15, 3, 470–477
Sutton S (2000) A critical review of the transtheoretical model applied to smoking cessation. In: Norman P, Abraham C, Conner M, eds. Understanding and changing health behaviour: from health beliefs to self-regulation. Amsterdam: Harwood Academic Press

Diabetes Management In Older People Health And Social Care Essay

This research proposal comprises two parts. Part 1 introduces the topic of diabetes management in older people with type II diabetes, posing the problem statement to be investigated. The aims and objectives are presented, along with the significance of the proposed research and some of the background literature pertaining to the problem statement. This is followed by Part 2, which identifies the theoretical and philosophical underpinnings of research method chosen to explore the problem statement. Justification for the chosen methodological approach will be provided, followed by an outline of methods of sampling, data collection and analysis, and ethical considerations. Throughout the proposal rigour will be demonstrated with supporting evidence from the literature.

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There are more than 220 million individuals in the world living with diabetes (World Health Organisation, WHO, 2011). Type II diabetes, which results from the body’s ineffective use of insulin, comprises 90% of individuals with diabetes worldwide (WHO, 2011). It is primarily caused by preventable lifestyle factors such as excess body weight and lack of physical activity (Steyn et al., 2004). The world is facing an epidemic of unhealthy lifestyles and obesity, and subsequently type II diabetes is on the increase (Farag & Gaballa, 2010). Diabetes is especially prevalent among the older population and such prevalence is growing along with an ageing population (Mooradian, McLaughlin, Boyer, & Winter, 1999). This is of great concern given the serious complications associated with the condition, which include increased risk of heart disease and stroke, loss of vision, kidney failure, and neuropathy (nerve damage) (Madani, 2008). In addition, mortality risk is doubled among individuals with diabetes compared to individuals without the condition. The World Health Organisation has predicted that mortality rates from diabetes will double between 2005 and 2030 (WHO, 2011).
These figures highlight the need for urgent action in terms of preventing the overall burden of the disease. One way that this can be achieved is by helping individuals with diabetes to take control of their condition through self-management and improved adherence to treatments. Treatment generally involves lowering blood glucose through changes in lifestyle (i.e. diet, physical activity, smoking cessation, etc.), oral medication, insulin injections, blood pressure control, and foot care. The evidence suggests that adherence to such treatments is not always forthcoming (Moreau et al., 2009). Older people have been found to have greater problems with health care adherence due to cognitive problems such as failing memory (Feil et al., 2009). Therefore, it is argued that there is even more reason to explore the reasons for lack of adherence among this vulnerable population so that interventions can improve adherence and health outcomes.
A key component of how individuals adjust to diabetes, thus minimising any associated complications, is their perceptions of the risks and benefits of their treatment. These perceptions are implicated in decisions regarding treatment, adherence to treatment, adjustment to treatment, and efficacy and outcome of treatment (Nair, Levine, Lohfeld, & Gernstein, 2007). Qualitative researchers are making efforts to examine the perceived risks and benefits of diabetes treatment (Nair et al., 2007), but there remains a paucity of phenomenological insight into how older people with type II diabetes perceive the risks and benefits of their treatment (Hope, 1999). There is also a lack of qualitative research into the impact these perceived risks and benefits have on the lived experiences of older people with diabetes and their treatment management.
Problem Statement and Research Question
Older people living with type II diabetes are vulnerable to serious complications that can be further influenced by their expectations, knowledge and understanding of the risks and benefits of treatment. This study will explore the question: What are diabetic elder patients’ perceptions of the risks and benefits of their treatment?
Aims and Objectives
The aim of this study is to gain phenomenological insight into diabetic elder patients’ perceptions of the risks and benefits of their treatment. This will be achieved by conducting semi-structured interviews with a heterogeneous, purposive sample of older people with type II diabetes, which will be analysed via interpretive phenomenological analysis.
The significance of this study is that it will provide new insight into the unique experiences of older people with type II diabetes and the personal meanings they attach to the risks and benefits of treatment. By illuminating how older people attempt to balance the risks and benefits of treatment according to their experiences and expectations, this study will facilitate a better understanding of how these individuals can be helped to adhere to treatment and thus experience longer, healthier lives. This study will add to the qualitative research evidence for the effective treatment of diabetes through an analysis of qualitative factors such as psychological profiles, perceptions, attitudes, and behaviours in relation to the disease and its treatment.
Background and Literature Review
The literature indicates that individuals with diabetes want to know both the benefits and risks of treatment in order to help them make treatment-related decisions (Astrom et al., 2000; Berry, Knapp, & Raynor, 2002; Ziegler, Mosier, Buenaver, & Okuyemi, 2001). Nair, Levine, Lohfeld, and Gerstein (2007) sought to build on this knowledge by examining the experience of benefits and risks assessment in people with type II diabetes when making treatment decisions. Using a grounded theory approach, they conducted semi-structured interviews (n=18) with participants following various treatment regimens (i.e. nutritional treatment, oral medications, and insulin). It was concluded that individuals with diabetes engage in a cycle of complex decision-making, balancing potential and actual risks of treatment with their benefits to gain a sense of control and mastery in their lives. However, they also found that participants did not tend to consciously assess treatment benefits and risks, indicating that in the proposed study prompts might be needed to make this a conscious process during the interviews.
The study by Nair et al. (2007) did have a number of theoretical limitations, one being that the sample was fairly homogenous in terms of treatment regimen, thus limiting the interpretation and generalisation of findings. Furthermore, the grounded theory approach is questionable in terms of seeking to gain insight into the meanings individuals attach to their lived experiences. Since grounded theory starts with a hypothesis, this is likely to raise implications for data authenticity. It could be argued that an inductive approach would be more appropriate when exploring subjective experiences. This is supported by research conducted by Bogatean and Hancu (2004), which took such an approach and subsequently produced richer data than that which was produced by Nair et al. (2007).
Bogatean and Hancu (2004) used a phenomenological approach to explore the lived experiences of people with type II diabetes (n=18) starting insulin therapy in order to establish factors involved in psychological insulin resistance. By using an inductive approach, they were able to illuminate new insight into the subjective experiences of individuals with diabetes by identifying salient themes within semi-structured interviews. This study highlighted the potential benefits of further phenomenological research into the perceived risks and benefits of treatment for type II diabetes.
In terms of qualitative research comprising older people with diabetes, there is a paucity of high quality studies in this area. Tjia, Givens, Karlawish, Okoli-Umeweni, and Barg (2007) explored the concerns of older people (age 65-years and older) with diabetes about the complexity of their medication regimens (n=22). It was found that despite perceived risks of medication, participants were reluctant to discuss these concerns with their health care team, which affected treatment decision-making.
Another qualitative study, using a grounded theory approach, explored self-reported goals of older people (age 65-years and older) with type II diabetes (n=28) (Huang, Gorawara, & Chin, 2005). It was found that goals were highly influenced by perceived risks, supporting the rationale for examining this issue further in the proposed research. Indeed, this was supported in a quantitative studies examining age related comorbidity and its affect on patterns and goals of diabetes treatment (Glynn, Monane, Gurwitz, Choodnovskiy, & Avorn, 1999) and the impact that such risks can have on feelings of independence and control (Howorka, Pumpria, Wagner-Nosiska, Schlusche, & Schabmann, 2000).
The proposed study will expand on the findings presented by Nair et al. (2007) that individuals with diabetes balance potential and actual risks of treatment with their benefits, by utilising the methodological strengths inherent within the phenomenological study conducted by Bogatean and Hancu (2004). Rather than take a theory-driven approach, as Nair et al. (2007) did, an inductive, interpretive approach will be taken in order to gain insight into the lived experiences and shared meanings that shape diabetic elder patients’ perceptions of the risks and benefits of their treatment.
Part 2: Methodology
Theoretical Underpinnings
The proposed study will be underpinned by an interpretive perspective, using the phenomenological approach to explore the lived experiences of older people with diabetes. A naturalistic approach to the science of this human phenomenon will be utilised (Husserl, 1962; Heidegger, 1962). By focusing on the essence and structure of the lived experiences of older people with type II diabetes, and showing how complex meanings are built from these direct experiences, attempts will be made to understand treatment related perceptions and behaviours within this population (Patton, 1990). Knowledge and understanding will be gained through the social constructions of language, consciousness, and shared meanings implicit within participant narratives (Klein & Myers, 1999, 2001). Thus, focus will be on the unique processes involved in conceptualising the risks and benefits of diabetes treatment and in participants very ‘being’ within the world – focus will be on the ‘how’ of the experience as opposed to what the experience is, supporting Heidegger’s (1962) philosophy. No hypotheses will be developed prior to data collection as the aim will be to seek subjective insight into the experiences of older people with diabetes. Thus, understanding and insight will be inductive and data-driven, guided by participants’ individual and shared experiences (Woods & Catanzaro, 1988; Morse, 1989).
The problem statement posed for this study aims to explore personal perceptions as opposed to attempting to produce objective accounts, providing the rationale for the interpretive phenomenological approach. In order to gain a holistic picture of the phenomena under investigation, individual characteristics and mannerisms of participants will form an important aspect of gaining insight into their production of meaning. Reflexivity will underpin the methodology and any personal beliefs and presumptions about the phenomena under investigation will be acknowledged and placed to one side during data collection and analysis.
Semi-structured interviews will be utilised in support of the underlying philosophy of phenomenological inquiry, offering a flexible method of gaining rich data on individual and shared experiences. The flexibility of semi-structured as opposed to structured interviews will facilitate the generation of new and unexpected ideas during the study so that lived experiences can be explored with less bias than when the interview agenda is guided purely by the researcher. Such interviews allow ‘inquiry from the inside,’ so that interviewer and interviewee jointly guide the direction in which the interview goes (Everet & Louis, 1981). In this sense, phenomenological research is not only data-driven but also participant-driven.
In order to maintain the subjective, phenomenological approach of the research, interpretative phenomenological analysis (IPA) will be utilised to interpret the meanings that participants attach to their perceived risks and benefits of diabetes treatment. IPA will be used to explore in detail the processes through which people make sense of their own experiences (Chapman and Smith, 2002; Smith et al., 1997). IPA is believed to have particular relevance to exploring personal experiences of living with chronic illness (Smith et al., 1999). It is an approach that has been recommended for use in research concerned with “complexity, process or novelty,” (Smith and Osborn, 2003, p. 53), the rationale for its use within the proposed research being that people’s cognitions, perceptions and attitudes regarding the risks and benefits of treatment are complex processes (Nair et al., 2007). The appropriateness of IPA to this study is further supported by a systematic review describing studies that have adopted this technique (Brocki and Wearden, 2006). A number of the identified studies explore similar concepts to those included in the proposed study, such as subjective health (Chapman, 2002) and the psychosocial impact of illness (Duncan et al., 2001; Green et al., 2004).
Interpretation of data will be idiographic in nature, with the aim being to go beyond the surface issues shared by participants to develop a deeper, more intricate understanding of their experiences and the meanings they attach to them. This will be achieved by exploring participants’ interpretations of their own thoughts, feelings, and experiences (Heidegger, 1962). Thus, interpretation will not be a methodological procedure as such, but will be an inevitable and natural process within the lived experience. Taking a hermeneutic philosophy, prior knowledge on the phenomenon, in this case on the perceived risks and benefits of diabetes treatment will not be ‘bracketed,’ but will be acknowledged, with reflexivity being exerted throughout the study (Giorgi, 1994; Halling, Leifer, & Rowe, 2006).
In adopting a phenomenological approach, the proposed study will follow a process starting from the development of the problem statement or research question to the collection of rich, subjective, participant-driven data. This data will then be understood through the generation of themes, as guided by IPA, which can then be related back to addressing the problem statement. The final understanding provided into the perceived risks and benefits of treatment experienced by older people with type II diabetes will thus be one that is the subjective interpretation of participants and their social reality. Through the use of quotes to illustrate interpretations of the lived experiences of older people with type II diabetes, the authenticity of individual mental representations and meanings can be maintained, as can the essence of pure experiences (Husserl, 1962; Merleau-Ponty, 1962). This authenticity will be enhanced further through methodological triangulation and the confirming of interpretations with participants. In other words, the essence of phenomenology, which is “to return to things themselves” will underpin the proposed study (Merleau-Ponty, 1962, p.viii). Such methods of triangulation are purported to add rigour to qualitative research (Jordan, Buchbinder, and Osborne, 2010).
Sampling and Recruitment Strategy
Participants will be recruited through advertisements sent out in mailing lists of diabetes organisations. Diabetes Australia, a national federated body comprising state and territory organisations supporting people with diabetes, will be approached for assistance with this.
In accordance with the data analysis method of IPA, participants will be purposively selected in order to clarify the problem statement and to develop a full interpretation of the data that addresses the problem statement (Touroni and Coyle, 2002). Thus, a small sample size of no more than ten participants will provide sufficient perspective (Smith and Osborn, 2003) as a ‘maximum variety sampling’ technique (MacLeod, Craufurd and Booth, 2002) will be used. This will ensure that despite a small sample size, the group will be heterogeneous and thus rich data can still be generated. In the proposed study, participants will be selected with the aim of acquiring insight into the lived experiences of individuals following different treatment regimens and thus experiencing varying levels of treatment invasiveness. This approach will be taken to gather comparative information on perceived risks and benefits in relation to different treatments. It is anticipated that this will result in the generation of diverse data from the target population, as well as provide opportunity for including examples of all potential outcomes (i.e. perceived risks and benefits, positive and negative experiences) (Trochim and Donnelly, 2007).
Pre-defined inclusion and exclusion criteria will facilitate sampling and recruitment. The inclusion criteria are as follows:
Adults formerly diagnosed with type II diabetes no less than 1-year previously
Aged 65-years or older
Following a diabetes treatment regimen such as nutritional or lifestyle advice, oral medication, or insulin
Despite comorbidities, diabetes is the primary chronic condition
The exclusion criteria are as follows:
Non-English speaking
Cognitive deficit rendering individuals unable to provide informed consent
Data Collection
Semi-structured interviews, which are the ‘gold standard’ data collection tool in IPA (Smith and Osborn, 2003), will be used to collect data in a systematic way. Semi-structured interviews are more flexible than standardised methods of research such as structured interviews or surveys (Economic and Social Data Service, 2009). Although some established general topics will form the basis of the interview schedule (i.e. problems with treatment), the use of semi-structured interviews will allow for the exploration of emergent themes and ideas rather than relying solely on concepts and questions defined in advance of the interview. Whilst a general format and order of questions will be devised in order to allow comparisons between participants, there will be scope for pursuing and probing for novel information through additional questions and prompts.
The researcher will immerse themselves in the interview, increasing their engagement in the process and thus making the interview process more comfortable for the interviewee as the dynamic will be conversational rather than formal (Legard, Keegan, and Ward, 2003). The value of this is that participants are less likely to place limitations on the information they feel comfortable enough to share when in a more relaxed and less artificial environment
An interview schedule will be developed and prompts used to maintain the ‘flow’ of the interview. Interviews will last no longer than 45-minutes and will be conducted with participants in a mutually agreed upon location. Interviews will be tape recorded for later analysis and to ensure accuracy of quotes used.
Questions to be included in the interview schedule will be informed by the literature. In particular, the study conducted by Nair et al. (2007) highlights that individuals do not tend to consciously assess treatment benefits and risks, indicating that in the proposed study prompts might be needed to make this a conscious process during the interviews. In order to reduce bias, the questions will not directly ask about risks and benefits but will broadly explore these issues through an examination of lived experiences of diabetes treatment. Potential interview questions and prompts are presented in Figure 1.
Figure 1: Interview Schedule
What treatment are you currently taking to control your diabetes?
Prompts: For example, diet, exercise, oral medication.
Is there any information would you like to know about this treatment?
What are you hoping this treatment will do for you?
Are there any barriers that you see with this treatment?
Prompts: For example, costs, side-effects, interference with daily life.
Do you have any concerns about your treatment?
How does managing your diabetes fit into your life?
Data collection will be data-driven, with additional questions outside of the interview schedule being generated from participant responses to previous questions. In particular, participants will be asked to expand upon certain experiences in order to provide richer data for subsequent analysis.
Data Management and Analysis
Each interview will be transcribed verbatim before being analysed via IPA (Smith and Osborn, 2003; Willig, 2001). IPA is a data-driven approach, involving a systematic analysis of interview data, whereby a number of steps are followed (Figure 2). Thus, a cyclical process will adopted, whereby new themes from each transcript will be checked against previous transcripts (Biggerstaff and Thompson, 2008). Transcripts will be read with the aim of providing deeper insight into the perceived risks and benefits of treatment experienced by older people with type II diabetes.
Figure 2: IPA Process
On identifying the super-ordinate (i.e. prominent) and subordinate (i.e. less prominent) themes emerging from each interview transcript, narrative accounts will be used to form individual case studies. This will be followed by a shared experience narrative, where super-ordinate and subordinate themes between interviewees will be merged and examined together. The identification of recurrent themes across transcripts will facilitate some generalisations to be made.
One transcript will be independently themed by another researcher for cross-validation purposes. Furthermore, narratives will be presented to participants to validate the interpretation of their interview data. This method of verifying researcher interpretation has been supported for research aimed at providing insight into the subjective experiences of participants (Patton, 1999).
Data will be analysed until saturation is reached and no new themes emerge.
Ethical considerations
Participant information sheets outlining the research and details pertaining to participant involvement will be provided to individuals interested in taking part in the study so that they can make an informed decision regarding their participation. Two consent forms will also be provided for participants to confirm that they read and understood the participant information sheets and would like to take part in the study. Interested individuals will be advised to take at least 24-hours to consider their participation and to raise any questions they might have. One signed consent form will be retained by the participant and the other returned to the researcher.
The participant information sheets will outline issues around confidentiality, explaining that all data will remain anonymous and that pseudonyms will be used in any documents that present the data. Participants will also be informed of their right to withdraw from the study at any point, without this in anyway affecting their treatment or the support they receive from Diabetes Australia. Furthermore, the older age of participants will be considered in terms of the length of interviews, with a short break being offered half way through.
Information on local support groups will be provided at the end of interviews in case any of the questions provoke any distress. Since perceived risks of treatment will be discussed during the interview, it is possible that participants will require information or support to address these perceived risks, which can be sought via the list of support groups provided.
These ethical considerations will be highlighted within an application for ethical approval from the University.

Health and Social Care Provider

In this assignment, I am going to explain how one health or social care provider has contributed in national provision and describe three roles within the NHS and explain their responsibilities and possible career pathways.
West Cumberland Hospital is one of two acute hospitals in Cumbria, serving around 140,000 residents of West Cumbria. The hospital is located on the outskirts of Whitehaven, in Hensingham, and also provides Diagnosis/screening, care for long-term conditions, Rehabilitation for illness/injury, 24 hour Accident and Emergency, CHOC, a consultant-led maternity unit, special care baby unit, an outpatient’s service and a range of specialist clinical services. In 2015, a £90 million new building was added to West Cumberland Hospital, the building contains advanced surgical theatres and the new buildings’ interior and services are all modernised. The new modern build makes the hospital look more pleasing and attractive. However, issues and complaints have occurred regarding centralising consultant-led maternity services in Carlisle and women in labour may have to travel to Cumberland Infirmary, this is due to a shortage of children’s doctors, states the North Cumbria University Hospitals NHS Trust, and some kind of change is essential. The Hospital offers free National Health Service Treatment. Local GPs refer patients to outpatient clinics for specialist treatment and advice.
Care Quality Commission (CQC) are independent regulators who make sure health and social care services provide people with safe, effective, compassionate, high-quality care and encourage them to improve. Their inspection in 2015 on Whitehaven hospital concluded that the hospital required improvement and so was placed in special measures (CQC 2016).
West Cumberland Hospital is manged by North Cumbria University Hospital Trust which is an acute hospital trust committed to providing a high standard of care to a population of around 320,000 from Carlisle, Allerdale, Eden, Copeland and parts of the Dumfries and Galloway and Northumberland. Services, such as paediatrics and A&E, are provided from West Cumberland Hospital in Whitehaven and the Cumberland Infirmary in Carlisle. The trust also supports a wide range of diagnostic and clinical services which are located in nine community hospitals across North Cumbria. The trust became a university Hospital in September 2008.
Within the NHS, there are large variety of positions which all require different specialist skills and training. Each job in health and social care settings is important in contributing to providing the best quality care for service users.
Roles, responsibilities and career pathways of a Doctor.
Medical doctors examine, diagnose and treat patients who have been referred to the hospital by GPs or other healthcare professionals. Doctors apply their specialist medical knowledge and skills to the contribution of prevention and management of disease.
After five years of medical school, a junior doctor will do a minimum of four years further training to qualify as a general practitioner (GP), or a further eight years to qualify as a hospital consultant. Once a registrar, after one year they can become a GP, or a specialist consultant in five to six years.
There are numerous responsibilities of a doctor. Doctors must undertake patient’s physical examinations and consultations, perform surgical operations, monitor and regulate medication of patients, plan and assess required treatments of service users, communicate daily with nurses, doctors, GP’s and other healthcare professionals and they also maintain records of patients. These responsibilities require a doctor to have an ability to solve problems, work effectively under pressure and have leadership and management skills.
Roles, responsibilities and career pathways of a Radiographer.
The role of a Radiographer is to undertake clinical imagining diagnostic examinations using different kinds of radiation to treat injured or ill patients. They must ensure that every service user is fully aware of the procedure and remain as comfortable and relaxed as possible. You can study to become either diagnostic radiographer or therapeutic radiography at university. A diagnostic radiographer uses radiation to diagnose an injury or illness of a patient and a therapeutic radiographer uses different kinds of radiation to treat illnesses or injuries. It is important for a radiographer to have good communication skills and strong analytical skills.

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There are several responsibilities of a radiographer. They need to be able to assess patients and their clinical requirements to ensure they know which radiographic techniques to use. Radiographers also need to provide support and reassurance to patients, taking into account their psychological and physical needs. Taking responsibility for radiation safety is also important. A radiographer will also work alongside radiologists and surgeons by taking part in more complex radiological examinations.
A diagnostic radiographer can become an advanced practitioner where they can undertake a high level of clinical responsibilities. Diagnostic radiographers also can go on to work at consultant level, where you will be able to contribute to strategic development of services.
Role, responsibilities and career pathways of a paramedic.
The role of a paramedic is to provide immediate response to emergency 999 and 111 calls. Paramedics are usually the first senior healthcare professionals on the scene and the level of care they provide can range from dealing with minor illnesses and injuries to life threatening conditions.
There are many responsibilities of a paramedic. They must be capable of monitoring the patient’s condition and be able to use technical equipment, including ventilators and defibrillators to help stabilise and resuscitate patients, they must also perform surgical procedures if necessary, such as intubation (inserting a breathing tube). Paramedics will also communicate with other emergency services to ensure a suitable level of response is provided.
EMT’s and Paramedics are both well trained healthcare professionals. EMT’s are trained to provide a basic level life support to patients such as CPR, spinal immobilization, basic airway management and bandages and splinting, an EMT is considered the entry level for emergency medical services. An EMT can become a paramedic by undertaking a foundation degree in Paramedic Science which will take around two or three years to complete. A paramedic can undertake extra training to become a specialist paramedic or take a further qualification depending on which qualifications they already hold, a specialist paramedic are advanced practitioners in dealing with emergency situations and they need to be able to understand situations quickly and stay calm in stressful situations. A specialist paramedic can take further training of three to five years to become an advanced paramedic and once an advanced practitioner, a further six years to become a consultant paramedic.