Factors that influence health and health chances

Identify the major cultural and socio-economic factors that influence health and health chances of individuals and the implications for nursing practice.
The health chances of any individual are the accumulative factors which determine the overall morbidity profile of that person. They begin at the moment of conception with the determination of the genetic make-up of the individual and are then progressively influenced by a series of environmental exposures as life progresses. (WHO 2000). To a degree, the health chances of an individual are modified by their exposure to the healthcare services of their society and this essay will discuss some of the factors and barriers which influence that exposure.

The cultural and socio-economic factors are too numerous to mention in total but the essence of the relationship between such factors and overall health chances are summed up in a paragraph in the Wanless report:

Unemployment and economic inactivity affect self-esteem and mental health and increase stress, in addition to the effects of relative poverty on housing, diet and access to leisure activities. The social effect of unemployment through ill-health is substantial and the resulting poverty can aggravate such factors as crime and substance misuse which add to the cycle of poor conditions and ill-health. Wanless D K 2002)

In the specific case of James there are clearly a number of factors that are relevant. James’s genetic make-up is a fundamental factor for many of the problems and has determined many of his health chances throughout his life. The fact that he has communication and eating problems means that it is likely that he is unemployed and therefore may live in reduced circumstances which also reduce his health chances further. (Hindley D et al. 2002)

Analyse the differences in meaning of Health education and Health promotion.
Health education is the process whereby people can learn about health issues and is closely associated with patient empowerment. In a contextual analysis it refers to specific health issues that are related to a particular patient. (Howe P et al. 2003)

Health promotion, by contrast, has been defined as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health.” (BCHPCW 2005 Pg 6). Health education, along with mechanisms such as social marketing, are the prime means of health promotion. Health promotion is most commonly considered in the context of a population or society rather than at the level of an individual. The measures used to illustrate the next segment are prime examples of health promotion initiatives in the UK.

In the context of the case study, health education is a more important concept for James’s mother than perhaps it is for James. Although James is 28, and has been cared for largely by his mother throughout his life, there will still be elements of care for Down’s syndrome that his mother will need further information about. It is part of the caring and supporting role of the healthcare professional to ensure that she has as much information as she needs to adequately care for her son and that she should be actively empowered to act on that information. (Hogston, R et al. 2002)

James’s case will have been affected by issues of health promotion but the majority of health promotion messages are aimed at a general population level and, although many will be directly relevant to James, his specific needs are likely to be such that they will override many of the current health promotion initiatives. To give an illustrative example, the government is currently promoting “five a day” under the National Fruit and Vegetable Scheme (NFVS 2004). Because James has such specific dietary needs and bowel management requirements, the measures outlined in the scheme may not be totally relevant to his needs.

Demonstrate understanding of the legislation related to the provision of health and social care and debate why the nurse needs to be aware of inequalities if provision.
The legislative background to health and social provision should be seen as a continuum of government measures, guidelines and recommendations which have been progressively put in place over the last few decades. It can be argued that the seminal roots of modern day provision began with the Black enquiry in the late 1970s (Mulligan J et al. 2000) and were further shaped by the more recent Acheson report. (Acheson 1998). The thrust of both these reports was to highlight the health inequalities and the shortcomings of the provision of the various public health services. They have indirectly led to a whole raft of Public Health measures which have been introduced in the recent past.

To give some illustrative examples, one can cite Government White Papers in the area of dietary health, such as Healthy Eating & Choosing a Better Diet, which is a notable landmark step in the policy trajectory which has included other landmark Health promotion papers as The Healthy Start initiative, the Healthy Schools programme which promoted physical activity and healthy eating in schools, (Howell E H et al. 1998), The Obesity Care Pathway which was set out by NICE (OCP 2001), in addition to others such as the Choosing Health White Paper (CH 2002). All of these initiatives should all be seen in tandem with the Physical Activity and the Food and Action Plans, and are all examples of recent legislation in one health-related area, in terms of recommendations and guidelines by the policymakers and government legislators and therefore can be broadly seen as representing government policy. (Lloyd, C E et al. 2007)

James’s case illustrates some of the inequalities of health provision. It is not clear from the scenario why James did not have a care plan, why he had no bowel observations and why he did not have direct assistance and intervention with his eating, but one might assume that because he was probably a quiet uncomplaining individual that such measures may have been overlooked. It is also likely that a degree of cognitive impairment might also be relevant in James’s lack of complaint.

Clearly this is a sad fact that such events happen but the conscientious nurse should be aware of such difficulties and identify and address them at an early opportunity. James should have a holistic assessment of his situation and his needs and requirements should have been addressed early on in his hospitalisation. It is recognised that human nature might make certain cases appear to be more attractive to intervention than others at a nursing level, but it is part of the ethos of nursing that all patients should be treated equally and with appropriate respect and dignity. (NMC 2008). This appears to have been lacking in James’s case.

Explore what is meant by the term learning disability and explore what this means for health providers
The Council on Children with Disabilities help us further, who recently commented that every child with complex care needs should have local access to an “accessible, continuous, comprehensive, family-centred, coordinated, compassionate, and culturally effective health care provided by primary care physicians.” (CCD 2005).

Such ideals and goals are clearly admirable but the practical reality, as Ratcliffe observes, is that there are a huge number of barriers which may potentially reduce the possibility of attaining this optimum goal of provision. The nurse should obviously be aware of these barriers such as healthcare professionals having only a limited familiarity with unusual disorders together with their related currently accepted therapies, or having an incomplete or out of date knowledge of the available resources that are provided in their immediate community.

Patients who have complex needs and who are living at a substantial distance from secondary or tertiary care centres may experience the attendant travelling problems such as possible poor or non-existent reimbursement for travel. Other considerations such as insufficient time, due to factors such as pressure of work, can make it difficult for primary care healthcare professionals alone to provide an appropriate care package for medically complex and fragile children and youths with complex care needs.

The provision for learning disability has altered dramatically over the last two decades with the progressive deinstitutionalisation of services and the move towards mainstream educational inclusion. This has been accompanied by a change in emphasis from secondary care to primary health care services as being the prime gateway for individuals with learning disabilities. (Lindsey M 2002).

Explain the challenges inherent in meeting the needs of people with varying abilities and social backgrounds, when accessing health and social care
The essence of healthcare is communication (Mason T et al. 2003). It is part of the art of the healthcare professional to successfully communicate with the patient. This does not imply that they simply talk to them, but communicate fully so that they get a realistic impression of all of the problems that a particular patient has (or perceives). Part of the skill in communication is to achieve an empathy with the patient. This allows the healthcare professional to interpret what is being communicated in the context of the cultural and social background of the patient. (Veitch R M 2002)

At a deeper level there are also problems which some people may have in accessing healthcare. Language, cultural or educational difficulties may make getting appropriate healthcare difficult. Accessing primary health care may cause problems with transport or even language difficulties in arranging an appointment. Once there, the healthcare professional may not fully understand what the patient is trying to say and therefore make inappropriate decisions. (Nicol M et al. 2004)

In consideration of James’s case, communication appears to be the prime problem in terms of achieving therapeutic compliance. The fact that he had so many unaddressed problems and was unhappy in hospital appears to show that there has been a failure of effective communication between the healthcare professionals and James. One might hope that, had he been able to build up empathy with the staff, then the majority of the problems that he experienced might have been addressed and dealt with.

Reflect upon factors that trigger the accessing of multidisciplinary health and social services.
Multidisciplinary health care and the provision of a seamless primary/secondary healthcare interface is one of the major goals of the guidelines of the National Service Frameworks. In patients with complex care needs, such as James, these concepts are of vital importance. The advent of the modern multidisciplinary primary healthcare team is evidence of such an improvement in service that would have been quite unusual even 15 years ago. (Carter S P et al. 2003).

James’s needs for a physiotherapist, a dietician, and an occupational therapist and other healthcare professionals, together with community nursing should all be available from a contact with the primary healthcare team whereas before such innovations, they might only be available through secondary healthcare provision.

This essay has considered some of the barriers which may prevent James from accessing the healthcare services but the advent of primary care disease registers and chronic disability follow up clinics should mean that patients such as James are much less likely to “fall through the net” and contact with appropriate members of the multidisciplinary healthcare team should now be through the primary care gateway.

Patients like James, who have chronic complex needs, are always a challenge for the healthcare professionals who assist them. It is vital that, in order to sustain whatever autonomy and independence that may be possible for them, that a comprehensive and coordinated multidisciplinary approach should be adopted to try to optimise this and it should be remembered that it is the responsibility of the multidisciplinary primary healthcare team, not the patient, to try to ensure that this happens.

Appendix

CASE STUDY
The patient will be referred to as James throughout the essay in order to maintain confidentiality as recommended by the NMC (2008). James is currently in hospital receiving intravenous drugs for his Chest Infection.

James is 28 years old with Down Syndrome, non-verbal and swallowing difficulties since childhood. He lives with his Mother 72 years old who cares for him. James can only eat pureed foods and thickened fluids. As a result he suffers from recurrent chest infection due to aspirations and has a tendency to constipation. During his stay at the hospital, no care plan was put into place for him, no observations were made if he had emptied his bowels or not, James was very unhappy and declined any help from staff, refused to eat and lost weight. He was only able to eat when his mother came to visit him.

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