This assignment will explore public health, wellbeing and health promotion within today’s society. For the purpose of this assignment I will select one health need within society and using appropriate data and policies, look to explore how the wider determinants of health impact upon local health inequalities and predisposition of this health need. I will analyse data to see how the health need impacts upon society on an individual and community level, as well as its influence on policy and health services. I will also explore how the socio-political role of the nurse and their ability to influence health promotion in practice to enhance the health and wellbeing of the population.
The health need I have chosen for this assignment is cervical cancer, exploring why women are unwilling to participate in the screening programme and how the lack of sex and relationship education (SRE) means adolescents and young adults continue risky sexual behaviours, thus increasing their chances of contracting the human papillomavirus (HPV).
Epidemiology uses quantitative data to examine associations and test hypotheses from with generalizable conclusions about aetiology are inferred (Shlomo et al, 2013). This data is then used to identify priorities which go on to inform the development of health promotion intervention, influencing policies and guidelines depending on the assessment of the health need (Evans etal, 2014). The most recent set of data shows that in 2013 3,207 new cases of cervical cancer were diagnosed and in 2014 there were 890 deaths of which 52% were under 45 (cancer research).
In England today cervical cancer is largely preventable, due to its national screening programme and the HPV vaccination programme. However, despite these, every day eight women are diagnosed with the disease and three women lose their lives to it (Cancer research UK). In the South West Cervical Cancer registration rates between 2011-2013 per 100,000 are greater at 10.5 compared to the England average of 9.6, with Cornwall alone being 10.3 (PHE, health profiles).
Update: Cervical Cancer Statistics (Cancer Research)
Epidemiological studies demonstrated a causality of HPV infections and the development of cervical cancer (Borruto & Ridder, 2012). Data has estimated that HPV infections are active within half of all sexually active women (CDC, 2004). A UK study was conducted between 2001-2003 and found 40% of cervical smears conducted on 20-24year olds were positive to HPV (Kitchener et al, 2006) and another detected HPV in 15% of samples from younger females who were being tested for chlamydia, showing a prevalence peak at 19 (Howell-Jones et al, 2012). Another study found that the proportion of females who had been infected with HPV increases rapidly from 14 years of age to the early twenties (Jit et al., 2007) and as women aged the infection rates decreased.
Epidemiology often highlights the social inequalities and the wider determinants of health, of which not only influence the individual’s health needs and their predisposition to disease but that of their community and the norms that develop within it. Warwick-Booth et al, 2012 identifies 5 determinants of cervical cancer; the first being genetics, however, this is something we do not have the ability to change, followed by; immunosuppression, smoking, sexual behaviour, all of these have the ability to be changed by addressing their causes and finally socio-economic status, although this again is an aspect of living that we have minimal control over.
When trying to understand the reasons behind behaviours the term looking upstream is often used this look to address the causes of the causes. For example; why do individuals engage in risky sexual behaviour and adopt unhealthy lifestyles by using alcohol, smoking and having a poor diet, as well as lacking education.
When looking to understand these wider determinants they are often applied to models such as Barton and Grants health map or Dahlgren and Whiteheads model as a framework. These models look to breakdown both the individual and social and community characteristics and their influences upon health (Warwick-booth etal, 2012.)
Studies looking at individual lifestyle factors have shown women who don’t smoke and adopt healthy behaviours, delay the age of participating in sexual relationship, who have fewer partners and practice safe sex reduce the risks of developing not only cervical cancer but contracting STI’s (Deacon et al, 2000). Health promotion can provide an effective toll to facilitate the healthy behaviours by providing education that females can use to adopt these lifestyle changes, as well as encourage the participation of women in screening and vaccination programmes. In 2009 Shepherd et al, conducted a review which demonstrated that socially and economically disadvantaged women changed their sexual practices by engaging in less risky behaviours when provided with education and armed with skills to develop their sexual negotiation skills. However, this was criticised due to the focus placed upon the individual to make lifestyle changes and health seeking behaviours and it argued they placed too much emphasis upon the individual’s choices and responsibilities creating a culture of victim blaming.
To date research that has been conducted addressing why women do not attend screening and one well documented and consistent attitudal factor for non-attendance has been embarrassment (Marlow et al, 2015) as well as lack of understanding. A study conducted by Cancer research UK in 2014 explored both the attitudinal and sociodemographic factors that influenced and explained non-attendance among white, black, asian and minority ethnics (BAME). It found older women, those with lower academic achievements and those that migrated to the UK and those from BAME cultures were less likely to attend screening. Ethnic disparities of knowledge, as well as the lack of knowledge in socioeconomically deprived groups need to be addressed and strategies looked into to address the emerging disparities (Robb et al, 2010).
In terms of the social and economic environment the socio-economic conditions in which we are born and raised have the ability to dictate and shape health behaviours. In 2010 the Marmot review released ‘Fair society, Healthy Lives’,it states health inequalities result from social inequalities. It highlighted that even within today’s society there is a social gradient and an individual’s position determined their health and by addressing and reducing health inequalities it will have a positive impact and benefit society not only on an individual level but economically due to the reduction in losses from illness. However, to facilitate change and reduce health inequalities will require both central and local government, as well as the NHS, and private sectors. The setting of national policies will only work with effective local delivery systems. These can only be delivered through effective participatory decision-making at local level which in turn requires the individual and local communities to be empowered.
Research has continued to demonstrate how those at the lower end of the social classes often partake in practices that are deemed unhealthy, and when looking at the causes for cervical cancer and the risks of contracting HPV they are no different, for example, those towards the bottom of the social gradient will have riskier sexual behaviours and the inability to negotiate safe sex (Deacon et al, 2000) as well as being more likely to smoke and consume higher quantities of alcohol ( ). Sexual behaviour is driven by biological factors however, it is shaped by gender identity and sociocultural classification ( ).
It involves two individuals and is the result of the interaction between two sets of beliefs, emotions and behaviours ( Ogden health psychology) so when addressing the issue of risky sexual behaviour it needs to be addressed by both individuals. All behaviours are rooted within their social context, sexual behaviour is one that illustrates this and therefor raises specific problems in terms of understanding and measuring what factors influence the decision to have sex and whether or not to engage in risky behaviours (Wellings, 2012).
Discussing sexual behaviour and health often generates embarrassment, which can cause problems when trying to gather research as it is considered a sensitive and personal aspect of life to discuss ( ) people often fear being stigmatised or embarrassed when addressing issues around this subject ( ). The education provided for children and adolescent about sex will play an important role in how they develop their sexual behaviours. The curriculum for sex education and its content is a matter of great debate on local and national levels ( ) However, compared to other countries it could be argued that the UKs current curriculum is inadequate () .
When identifying and planning strategies for health promotion programmes there are a number of theories and models used to understand and explain health behaviours ( ). In 2006 The National Institute for Health and Clinical Excellence (NICE) developed guidance on ‘the most appropriate means of generic and specific intervention to support attitude and behaviour change at population and community levels’. This review showed that the Theory of Planned Behaviour provides a better tool than that of the Health Belief Model or Theory of Reasoned Action when looking at health promotion.
However, none of these is specific enough to offer insight into how to best facilitate health behavioural change. So the use of a model that encompasses both stage of change and process of change may provide the best tool such as the Trans Theoretical Model.
Prochaska and DiClemente 1983, developed this model to approach behaviour change as a process in which a person passes through five different stages, at each of these stages a behavioural intervention can be designed to meet the individual’s needs. It is often referred to when focusing on addictive behaviours, however, a number of studies have based cancer screening promotion on this model (appendix 1).
Health promotion is defined as improving the health status of not only individuals but that of the population as a whole (Evans etal, 2014), one aspect of this is sexual health. Sex behaviours and health is a huge part of not only development but across the life span. Ensuring we are able to provide good sexual health implies not only the absence of disease, but the ability to understand all the risks, responsibilities, outcomes, and impacts of sexual actions (Evans et al 2014, Wellings et al 2012 & Ogden, 2012). By empowering individuals with education that enables them to be knowledgeable of and comfortable with their body, will not only create better health but minimise the risks of exploitation and coercion.
To address the embarrassment and lack of understanding surrounding not just screening programmes but the rate of HPV infections, it could be argued current education provided to young adults need to be addressed. As HPV is linked to a higher number of cervical cancers public health needs to tackle this primary source and address sexual health within adolescents.
To make public health successful you need to understand the psychology of the group (Benney, 2016), Adolescence is not only a time of physiological change but a time of change in behaviour, expectations and relationships (Goss, 2010). The passage to adulthood is multifactorial. Hall, 1904 argued an individual’s psychological development recaptures both their biological and cultural evolution, defining this time as a period of ‘storm and stress’.
During this time there is a disturbance of self-esteem, sexual urges become stronger and the pressures from peer groups become stronger. The majority of adolescents will have an external locus of control, with future discounting and shot-termism views of their actions ( ).Combined with the generation gap between adolescents and parents they withdraw into their peer groups with in turn create and define their own social norms and expectations. For these reasons it could be argued sex and relationship education (SRE) should be client lead.
As previously stated HPV is most prevalent in those in their early 20’s, so by ensuring good quality SRE not only could you reduce this STI infection rate and that of other STI’s you could provide education and understanding of vaccination and screening programmes as well as break down barriers and embarrassment around sexual health. In 2016 the sex education forum conducted a survey that highlighted the failings of SRE, 90% of those surveyed felt dissatisfied, as well as unequipped with the knowledge they would need to keep safe. Those that receive good SRE felt empowered by the knowledge and less likely to experience poor sexual health (Welling, 2013)
Sexualising and procreating are defined within Roper, Logan and Tierney’s activities of living, a nursing model still used within the NHS today, within the activities of daily living these activities increased quality of living. This nursing model was developed from Maslow’s (1954) Hierarchy of needs which ranked human needs from their most basic through to the most sophisticated and only by achieving each could an individual achieve self actualisation. These activities outside of the UK are positively embraced and taught through the education system for example; Germany sees sexual expression ‘ as a basic need and a normal and healthy of personality development, France has altered it education by giving students Wednesday afternoons off to access sexual health clinics and educational events (Berne and Huberman, 1999) and Sweden provides on site health slinics for students to access contraception, advice and testing (Rios, 2015).
In 2010 when comparing the UK to other countries 25% of year 8 pupils recognised the term chlamydia compared to 77% of their peers in Sweden (Westwwod and Mullan, 2010), the authors argued that school nurses in the UK were restricted by school policies when it came to SRE. Within the UK sex education is inconsistent and within secondary schools it is a postcode lottery when it comes to accessing sexual health and education (PHE, 2015) and their ability to access contraception.
However, in the South West general practices and school nurses are working to improve their services by engaging with other services such as Savvy Kernow and Brooke, these services works with other services to ensure they are young person (specifically aged 13-19) friendly. As well as providing an online service they help to educate services in contact with young people to respect their rights to talk in confidence and provide health interventions and services, providing up to date information about health and wellbeing and provide information and referrals to other services.
As well as providing individuals with good sexual health ensuring young people receive good SRE can help to keep them safe by educating them about healthy relationships as well as equipping them to deal with the increasing online world that is becoming an aspect of daily living (Ref), with Europe having the lowest prevalence of child sexual offences (Pereda et al, 2009) we could learn a lot from their education systems.
In 2010, the UK government published the white paper, The importance of teaching (Department of Education, 2010). Within this paper it acknowledged the need for high quality SRE to empower individuals to enabled them to make informed choices. However, legislation that relates to SRE and its curriculum is contained within the Education act (1996) and the Learning skills act (2000). To date the government has still not responded to this report and its calling for the prioritisation of SRE.
Nurses use a person centred approach to deliver care ensuring appropriate treatment, equal access to services, as well as autonomous patient lead care and facilitating collaborative care. By adhering to the Nursing and Midwifery Council Code of conduct, 2015 nurses provide equal opportunities and services not only to individuals but to communities.
To enable a nurse to effectively deliver health promotion and facilitate change they need to arm themselves with the knowledge, understanding and self-confidence to deliver the required education (Evans et al). In 2004 Skills for Health developed 10 areas of skills and competencies for registered nurses to help them understand and deliver health promotion.
Nurses often require an opportunist approach to tackle some subjects, this could also be true of screening and sexual health. They need to be able to adapt their planned clinics and tasks to seize opportunity and promote the uptake of services. Bradshaws taxonomy (Bradshaw, 1972) provides a classification of needs that can guide practice. With the identification of a need such as screening or SRE the nurse can identify the health need priority and encourage patient participation and patient centred health promotion (R ) adapting information and services to the individual need of patients.
Historically, medical advances and understanding of disease have facilitated changes in lifestyles. However, despite public health campaigns and reviews of health systems the general health of the population continues to deteriorate. PHE stated the cost of caring for the public was in excess of £11 billion and showed no signs of decreasing ( ). With a high proportion of disease being attributed to individual and community lifestyle choices that are forced upon them by government and the policies they create, it could be argued the cure lies with the public themselves and their desire to revolt against current government standards. The financial pressure and the ever increasing expectations placed on the NHS to undo the damage caused by poor life choices is causing the NHS to crumble. This could be reversed if attitudes and understanding of the public can be changes and individuals took responsibility for their own health and well-being.
Marmot 2010, states that the country’s economic growth in not the most important measure of its success and that ensuring the fair distribution of health, well-being and sustainability are far more important and valuable social goals. For this assignment it could be argued that Public Health England and the Department of Health should work together to deliver a curriculum that addresses sexual health and well-being as a whole and is delivered to the same standard regardless of socioeconomic status.
However, the collaboration of government departments to set basic learning standard that focuses on health and wellbeing as the most important need, that is reinforced by professionals rather than their current individualised concerns, should equipt the next generation to bring about the changes needed within society. Creating healthy lives and breaking down social inequalities will not only save the NHS but heal the current deteriorating health of society and reversing the damage on not only individual, community and organisational levels but the damage caused to the natural environment that currently sustains us and ultimately the global ecosystem that is abused to such an extreme it is being destroyed.
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