The following resources comprised part of the module handbook for
NUR220 in the Competency Curriculum. They are reproduced here with
thanks for the work done by the developers of that module.
Please remember that the work was devised several years ago now, so
needs to be used with a certain amount of caution to take account of
recent changes in therapy and evidence.
NUR261 ‘Health Policy and Health Promotion’ will cover issues related
to health promotion and epidemiology, so reading here will be a good
preparation for that module.
Guided Study: The Patient with a Respiratory Problem
Today you will be researching information about the care of patients with chronic
respiratory problems. Below you will find a scenario about an individual with chronic
obstructive pulmonary disease; a term which describes several conditions in which
the end result is hypoxia. The second set of activities relate to a young woman who
is admitted to hospital with an acute attack of asthma and hypoxia.
Work through the list of activities and be prepared to discuss some of your
researched information to the class in the time-tabled session. You will have the
opportunity to demonstrate your understanding of both conditions by completing a
short quiz at the end of the activities.
Mr James, aged 58, retired from his job in the naval dockyard three years ago on
health grounds because of chronic obstructive pulmonary disease (COPD). He is a
heavy smoker and has tried a number of times to give up. He is admitted to the
medical ward with an acute exacerbation of his condition. On admission he is
pyrexial (T.38C), breathless with a productive cough, tired but agitated.
Explain the term chronic obstructive pulmonary disease and describe the possible
Using an A&P textbook, revise the normal physiology of respiration and explain the
abnormal physiology in COPD
On the assessment sheet provided, insert the subjective and objective assessment
data you would expect to gather about Mr James. Subjective data is what the
patient and others tell you and objective data are the physical signs that you detect
from your clinical observations.
Mr James is prescribed 28% oxygen via a Venturi mask. Explain how the respiratory
drive is altered in patients with COPD and why a higher level of oxygen
administration could be life threatening.
With reference to Mallett and Bailey (2000) list other hazards of oxygen therapy, and
the safety measures which should be taken by staff, patients or carers.
Using the attached assessment/care plan sheet, devise a plan of care for Mr James
and also state how you would evaluate whether the plan is meeting his needs.
What advice will you give him on his discharge home to help him avoid future
This morning Mary, aged 19, went for a session on the dry ski slopes with her
university friends. Following her third down hill run she became increasingly
breathless. Mary has had Asthma since the age of four, and for several years has
only used her salbutamol metered dose inhaler prior to strenuous exercise. She
uses her salbutamol inhaler now but this does not relieve her breathlessness. As
she is distressed and frightened her friends call an ambulance.
The ambulance takes Mary to the Accident & Emergency Department where a
diagnosis of an acute severe attack of asthma is made
Explain the possible causes of asthma.
Describe the abnormal physiology related to Mary’s acute asthma attack with
special reference to her current problems of expiratory laboured breathing,
production and retention of sputum and her distress.
Most Hospital Trusts have devised patient group directions for the emergency
treatment of asthma to enable speedy treatment as it can be exhausting and life
threatening. Emergency treatment with assisted ventilation and admission to an
Intensive Care Unit may be required.
However Mary’s reduced peak flow recordings, her tachycardia of 115, respiratory
rate of 28 and inability to complete a sentence in one breath indicated that her attack
is an acute severe attack, rather than life threatening at present.
She is prescribed high flow oxygen, Salbutamol via the nebuliser driven by oxygen
four hourly and oral Prednisolone 30 mg. daily. She also has an intravenous infusion
Explain the actions of Salbutamol and Prednisolone, stating their possible unwanted
Mary is transferred to the ward where her condition rapidly improves enabling her to
resume her metered aerosol of Salbutamol.
You are asked to assist Mary with her inhalation technique to ensure it is effective.
Describe the correct use of an inhaler.
Discuss appropriate approach and content of patient education for Mary prior to her
discharge from hospital. BTS Guidelines recommend that no patient should leave
hospital without a written asthma action plan.
BMA (1997)The New Guide to Medicines & Drugs Goldalming. The Colour Library
Dunn L.(1998) Oxygen therapy. Nursing Standard. Vol.13. No.7. 57-60, 63-64.
Edmund C (2000) The Respiratory System. in Alexander M. Fawcett J. & Runciman
P Nursing Practice Hospital & Home. The Adult 2nd Ed. Edinburgh. Churchill
Long, Phipps & Cassmeyer (1995) Adult Nursing: A Nursing Process Approach
Mallet. J. & Dougherty (Ed) (2000) Manual of Clinical Nursing 5th Ed. London:
Prosser,S. et al (2000) Applied Pharmacology London. Mosby
Roberts J.(2002) The management of poorly controlled asthma. Nursing Standard.
Vol.16. No.21. p45-53.
Quiz – Respiratory Disease Word Search
Crack the clues and find the words
This drug may kill life to save life
A disease characterised by inflammation
Acute or chronic. Is usually associated
with upper respiratory tract infection or
A plan of care
Cell which respond to chemicals, such as
O2 or CO2 bound to receptors on their
The medulla oblongata acts as a centre
for this reflex
Difficulty in breathing
When activated releases histamine and
An aid to converting liquid into an aerosol
21% of dry air, but only 16% of expired
A 2 adrenoreceptor stimulant often given
Increased in Inflammation, often colourful
Prepared by C Wheeler and M Gillard (1998), updated by C Wheeler (2001) and
D Kerslake (2002)
R O T P E C E R O M E H C
L L E C T S A M B O N A E
O C A R B O N T R I C E P
M Z R F R E T A N I B O R
A H G U O C I C T F N N I
T N X V N O M O E U E P M
U E L A C K I M N R B S I
B G A V H B N U S R U Y D
L Y M S I A Y T I U L D E
A X I T T C X U O L I D F
S O N N I H I P N E S I J
K A A I S O M S I S E O G
S N A L P E R A C U R V E
Assessment using Activities of Living Model (Roper, Logan and
Activity of living Assessment Data Plan of care
Maintaining a safe
Eating & drinking
Working & playing
Guided Study: Epidemiology Work Book
In Module 116 of the common foundation programme you received a brief
introduction to the science of epidemiology. The aims of this work book are to refresh
your knowledge and further develop your understanding of epidemiology within the
context of public health.
1. To define epidemiology
2. To identify methods of data collection
3. To critically review public health data in relation to local health
Epidemiology is the study of how often diseases occur in different groups of people
and why. It is used to plan and evaluate strategies to prevent illness and in addition
it can be a guide to managing patients currently with disease.
It is particularly beneficial in Public Health work for identifying disease patterns and
therefore subsequent management.
Epidemiology is a term derived from Greek language
EPI - upon
DEMOS - people
LOGOS - Science
It is the science of health events in Human Populations, the study of how health
states are distributed in the population and what environmental conditions, lifestyles
or other circumstances are associated with the presence or absence of disease. It is
concerned with the who, what where, when and how of disease causation
To understand epidemiology you must first refresh yourselves on the causal
relationships in the disease process.
a factor whose presence causes a disease or one whose absence causes disease.
refers to the external conditions and influences affecting the life of living things, i.e.
the physical, biological and socio-economic conditions where agents reside and
is the individual human in whom an agent produces disease. Disease can occur only
in a host who is susceptible.
In some conditions there are direct causal association. E.g. the tubercle bacillus will
cause tuberculosis, whereas an example of indirect causal association is when a
person smokes cigarettes causing damage to the respiratory epithelium which in turn
makes the individual more susceptible to infection which in turn may lead to the
condition of chronic bronchitis.
By identification of pathogenic agents and environmental influences, epidemiological
research into aetiology seeks to prevent their interaction with human agents (Barker,
rose, 1990). Aetiological studies represent a major use of epidemiological methods,
studies produce information on the natural history of the disease. Natural history
refers to the processes leading to disease occurrence, before any intervention and to
the course and outcome of the disease process.
Epidemiology is the measurement of disease outcomes in relation to a ‘population at
Population at risk = group of people whether they be healthy or sick who would be
counted as a case if they had the disease / condition being studied. E.g. If a Practice
Nurse was measuring the number of mothers who might seek information about
childhood vaccinations (they may not necessarily want their child to be vaccinated).
They could only be included in the population at risk if they are registered with the
Practice the nurse worked for.
Epidemiological conclusions (on risk) cannot be drawn purely from the number of
sick people seen. Implicit in any epidemiological investigation is the notion of a
target population about which conclusions are drawn.
Occasionally a study can be undertaken on the whole target population e.g. currently
any new case of Jacob Creutzfeldt disease is being closely monitored and studied.
However, it is more common to study a sample of the target population – study
Target population -> study population ->study sample
From the target population an accessible subset is determined which is known as the
study population and from this subset a study sample is subsequently often taken for
A study population begins with some characteristic, which all its members have in
common. This may be geographical, (e.g. all people living in a given area), or it may
be occupational (e.g. all coal miners), or possibly diagnostic (e.g. all people with a
given condition). Age, sex, or both may further break down this population.
Epidemiology primarily relates to groups rather than individuals. In other words it
provides nomothetic rather than idiographic information or data.
Conclusions from epidemiological studies are based on comparisons of data. Clues
to the causes of disease come from comparing disease rates in groups with differing
levels of exposure e.g. in Camelford epidemiologists studied the effect of the
pollutant in the water supply of those people exposed as compared to those people
who were not exposed. Epidemiology is dependent on heterogeneity. If all people
smoked 20 cigarettes a day it would be impossible to compare the effects of smoking
20 cigarettes a day on the incidence of lung cancer (i.e. no control group for
By comparing data it is possible to identify high risk and priority groups within a
community (population). Another task of epidemiology is to monitor disease and to
survey over time disease trends e.g. are they increasing, decreasing or changing in
their distribution and if so why? Epidemiological studies are required to identify any
emerging problems (e.g. from BSE) and are able to assess the effectiveness of
measures being taken to control the problem.
Measuring Disease Frequency in Populations
In order to do this, there needs to be some form of diagnostic criteria, however, it
must be remembered diseases in populations tend to exist as a continuum of
severity rather than an all or nothing phenomena.
Several measures of disease frequency are in common use.
Incidence – the rate at which new cases occur in a population during a specified
Incidence is measured as the number of New Cases over the Population at Risk X
Time during which Cases were ascertained. For example if 15 people developed
lung cancer in 1990 the incidence is 15 per 100,000 per year or per 100,000 person-
years. Incidence measures occurrence of disease as a rate, whereas prevalence
Changes in population at risk due to births /deaths / migration is overcome by
relating number of new cases to the person years at risk.
This is calculated by adding together the periods during which each individual
member of population at risk during measurement period. i.e. the Number of New
Cases over Total Person Years at Risk.
Episodes usually relate to first contact except for infectious diseases.
The proportion of a population that are cases (with the disease) at a point in time.
For example the number with lung cancer in a population of 100,000 in December
1990 is 30. Prevalence is therefore 30 over 100,000 or 0.0003.
Prevalence considers all sufferers regardless of when they were diagnosed.
This measure is only suitable for stable conditions and not suitable for acute
Proportion of a population that are cases at any time within a stated period.
Incidence of death from disease
Interrelation of incidence, prevalence, and mortality
Each new incident or case enters a prevalence pool and remains there either until
recovery or death. If recovery and death rates are low, then chronicity is high and
even a low incidence will produce a high prevalence: -
Prevalence = incidence x average duration
When studying aetiology, incidence is the most appropriate measure of disease
frequency. You need to be aware that patterns of mortality can be misleading if
survival is variable e.g. the recent decline in mortality from testicular cancer is a
result of improved treatments it does not reflect a fall in the incidence of the disease
In the study of rarer conditions e.g. Huntingdon’s Chorea where it is difficult to obtain
large numbers prevalence is often used as an alternative to incidence.
Crude and Specific Rates
A crude incidence, prevalence or mortality rate is one that relates to results for a
population taken as a whole, without subdivision or refinement.
Crude live birth - no. live births/total mid year population x 1000
Crude death rate - no. of death/total mid year population x1000
A specific rate is where the data has been broken down for specific age / sex.
Although incidence and prevalence have been discussed in relation to onset and
presence of disease these may be extended to include other factors e.g.
unemployment, smokers etc.
Other Rates that you may come across include:-
General fertility rate - Number of live birth/no of women aged 15-44 x 1000
Infant Mortality Rate - Number of deaths of children aged below 1 year/1000 live
births per annum.
Still birth rate - Number of intrauterine deaths after 28 weeks/ 1000 total births per
Perinatal mortality rate - Number of stillbirths and deaths in 1st week of life / 1000
total births per annum
Age specific death rate - Number of death of people of specified age/number of
people in population of that age.
Cause specific death rate - number of deaths from from specific cause/total mid year
population x 1000.
Comparing Disease Rates
As a practitioner in the community from time to time you will probably ask yourself
questions e.g. ‘Is this incidence of this disease on the increase?’ ‘Does it occur in the
community I work more frequently than other areas?’ ‘Is there a relation between the
incidence and a suspected cause?’
In order to answer these questions it is necessary to set two rates side by side and
make some sense of the comparison. However you need to be aware of some
problems that may arise.
The ICD system is the International Classification of Diseases, Injuries and Causes
of Death and is published by the World Health Organisation. This system is revised
periodically, on occasions the categories change and so disease rates may not be
Measures of Association
Relative Risk is the measure most often used by epidemiologists.
Relative risk is the ratio of the disease rate in exposed persons to that in people who
Odds Ratio is the odds of the disease in the exposed person divided by the odds of
the disease in unexposed person.
A problem with measuring statistics in health is that most epidemiological studies are
observational not experimental and will compare groups of people who vary in many
ways. Because there is more than one variable it may be difficult to know what is the
causes and effect of disease patterns. These differing variables are called
Two common confounding factors are age and sex e.g. if you look at the crude
mortality rates of two areas in east Devon you may find that Seaton has a much
higher mortality rate than Exeter. You cannot assume from this that Seaton is less
healthy it may be just that there are more elderly people living there.
In order to get over this problem epidemiologists use what is called Standardised or
Compares weighted averages of sex and age specific disease rates, the weights
being equal to the proportion of people in each age and sex group in a convenient
This method is used for large studies. As a community nurse you may visit a large
number of school aged children with a staphylococcus infection. You may wonder
whether or not this is increasing or comparable to what would be expected.
To establish this, you would take a sample of all the school aged children on your list
and identify how many had a staphylococcus infection, you would then take the total
number of the school age population in a given reference population e.g. all school
aged children in the county. You could then multiply the number of children in your
study with the symptom prevalence in your reference group this gives you the
expected number of cases in a group of that age and size based on the reference
So therefore if in your population you had seen 4 children with a infection and the
expected number was 2.5 this would give a standardised prevalence ration of 4/2.5 =
The Standardised Mortality Ratio (SMR) is widely used by the registrar general in
summarising time trends and regional and occupational differences. An SMR is an
index of mortality that enables the comparison to be made between populations,
allowing for age sex differences. For example the mortality in a local government
area can be compared with the region or with England and Wales. It is a ratio of the
number of deaths observed in an area, compared to the number of deaths expected
given national death rates. An SMR of 100 indicates a similar number of deaths as
expected; an SMR of 120 would indicate 20% more and an SMR of 80% would be
Rates in an area could be skewed by the fact that there are high numbers of a
susceptible population in the locality. SMR compensates for the effects of differing
age and sex distribution by:
1. Calculating age-specific death rate for whole population nationally.
2. Multiply this by age-specific population for the area, to give number of deaths to
be expected if the area follows national pattern.
3. Divide actual deaths in the area, according to cause by expected deaths and
express as a percentage.
4. A value significantly higher or lower than 100 indicates that mortality differs from
the national trend for reasons other than age/sex.
5. SMR greater than 100 indicates a significant health problem.
Two scores that you may be familiar with are the Townsend and Jarman scores.
These are derived from national census data and are used to assess relative
deprivation in any given area. The average national score is 0 for both indicators
with high values above 0 indicating relatively high deprivation.
Jarman scores are based on GP workload using the proportion of the prevalence of
the following:- children aged under five; ethnic minorities; single parent households;
unskilled manual workers; highly mobile people; overcrowding; poor housing and
Townsend examined and tried to explain trends in health inequalities. His score
uses the prevalence or proportion of the following:- economically active residents
who are unemployed; car ownership; owner occupied households and overcrowding
in private households.
More recently the Department of the Environment, Transport and the regions has
published the Indices of Deprivation (2000). The information is timelier than other
commonly used data which rely on the ten year census.
This work sheet has provided you with an introduction to epidemiology and some of
the common terminology used.
Demography and Epidemiology Quiz
1. What is the approximate resident population of the county in which you live?
2. Name the PCTs in the county.
3. Which PCT has the highest percentage of people over 75 years of age?
4. Why do you think this is the case?
5. What is the index of multiple deprivation (IMD 2000) made up of?
6. What are the problems with this score when measuring health?
7. What are the most common causes of death and premature mortality in the
8. Is the all age, all cause SMR for the county higher or lower than expected rates of
9. What is the SMR for Skin Cancer?
10. Is this higher or lower than expected?
11. What is the biggest single cause of death in the county?
12. Which areas have the highest SMR?
13. Consider the data for accidents. Comment on variations in death rate and
hospital admissions in different parts of the county and age groups.
14. Eighty percent of all admissions to hospital for fracture neck of femur are in
15. What factors may come into play when the numbers of babies born to teenage
mothers per 1000 falls?
16. Can you think of any condition for which incidence is low but prevalence is high?
REFERENCES AND INFORMATION SOURCES
Allen C (1993) ‘Water, water everywhere….’ Nursing Times June 23rd vol89, no 25
Barker D, Rose G (1991) Epidemiology in Medical Practice (4th ED.) London
Department of Health (1998) Saving Lives: Our Healthier Nation London HMSO
Harkness G (1995) Epidemiology in Nursing Practice USA Mosby
Helman C G (1990) Culture, Health and Illness Wright, London 2nd ed. (ch.12
Cultural factors in Epidemiology)
Vetter N. Matthew I. (2000) Epidemiology and Public Health London Churchill
Other sources of information and data
District / County Council web pages
Public Health Report available from local departments of public health or via the
Census information broken down by ward or post code available from local town
halls/ regional council offices.
GP practice age sex register. Some Practices have very detailed information
available on computer .
DETR web site: www.regeneration.detr.gov.uk
GUIDED STUDY: NURSING THE PATIENT WITH CARDIAC PROBLEMS
(i.e. hypertension, cardiac failure, ischaemic heart disease, including cardiac failure.)
In previous modules you have covered the anatomy and physiology of the cardio-
vascular system. The aim of this guided study is for you to relate this previous
learning to the common physiological problems that affect the heart and vascular
system. The study takes you through a typical scenario and helps you explore the
implications of the pathological changes. You will be expected to feed back your
answers during one of the module taught study days.
Mr John Huxtable, a 50 year old factory worker, is married and has two teenage
children who live at home. He goes to the pub three nights a week and smokes 20
cigarettes a day. He enjoys “everything with chips” and is 10 kilograms overweight
He visits his GP complaining of headaches and it is discovered that his blood
pressure is 160/105
What factors should his GP check to ensure he is recording Mr.Huxtable’s blood
1) Primary or essential hypertension
2) Secondary hypertension.
Which aspects of Mr. Huxtable’s life and life-style may be influencing his blood
As a practice nurse running a hypertension clinic, what health promotion advice
might you give Mr. Huxtable? What other interventions might you consider?
Over the next six months Mr. Huxtable is prescribed diuretics, and calcium
antagonists. a) What actions and side effects may each have.
b) What information should he be given about his medication?
Beta blocking drugs are frequently prescribed for hypertension
Explain the action of beta blocking drugs and suggest why they may be considered
unsuitable for Mr Huxtable
Six months later Mr. Huxtable started getting chest pain walking up the hill to the
pub, and is diagnosed as having angina pectoris.
What is the nature and cause of anginal type pain?
Mr. Huxtable is given glyceryl trinitrate tablets (GTN) to put under his tongue. As
his practice nurse, how would you reinforce the correct use of this medication?
Explain how trinitrates act, and the side effects that Mr. Huxtable should be warned
Mr Huxtable is informed by his Doctor that he now has “furred up arteries to his
heart”. He continues to cope with most of his daily activities, taking his GTN sub-
lingually only if episodes of chest pain occur. However, he has noticed he gets
breathless going up stairs and on activities that take effort. He woke up at three
o’clock one morning gasping for breath, wheezing and coughing frothy sputum.
Mrs Huxtable rang the duty Doctor who called, and made a diagnosis of Left
Ventricular Failure due to Mr Huxtable’s history of hypertensive heart disease.
Explain the patho-physiological changes that have caused Mr Huxtable’s current
The General Practitioner administers Frusemide 20mg intravenously that quickly
helps his breathing difficulties.
Explain the action of Frusemide
Mr Huxtable accompanied by his wife were transferred by ambulance to the District
General Hospital for further treatment..
Outline the main priorities of treatment and care for a patient with acute left
Mr Huxtable is discharged home after a week. He remains breathless on exertion but
is able to maintain his usual activities. He is put on the waiting list for cardiac
surgery, however over the next few months he has two further admissions for Left
Ventricular Failure. Since his last admission he has become increasingly tired and
breathless and has lost his appetite. He has also noticed that sitting around all
day his feet and ankles get too swollen for his shoes.
This morning, Mrs Huxtable called in her General Practioner because Mr Huxtable
felt too lethargic to get out of bed. The General Practioner finds that there has been
a considerable deterioration in Mr Huxtable’s condition. He now appears to have
ascites and an enlarged liver. His pulse is irregularly irregular. The GP arranges
for immediate transfer to Hospital where a diagnosis of Congestive Cardiac Failure
with atrial fibrillation is made.
Explain the pathophysiology of the clinical features highlighted above.
Mr Huxtable is prescribed Digoxin 0.25 mg, Frusemide 40mg, and potassium
Explain the actions of these drugs.
Using the a framework for care that you are familiar with, write down the expected
assessment data that you would obtain from a patient suffering from Congestive
Cardiac Failure and then devise a care plan which would meet Mr Huxtable’s
Alexander M. et al (2002) Nursing Practice Hospital & Home. The Adult Edinburgh.
BMA (1997)The New Guide to Medicines & Drugs Goldalming. The Colour Library
Collins T. (2000) Understanding shock august Nursing Standard 23/vol 14/no49
Hand H. (2001) Myocardial Infarction Part 1 Nursing Standard 15(36) p45-55
Hand H. (2001) Myocardial Infarction Part 2 Nursing Standard 15(37) p45-55
Long, Phipps & Cassmeyer (1995) Adult Nursing: A Nursing Process Approach
Prosser S. Et al (2000) Applied Pharmacology London Mosby
RCN Nursing Update Heart Health: Prevention Learning Unit 074 Nursing Standard
Oct 1 Vol12/Number 2/ 1997
RCN Nursing Update On the way up: Hypertension Unit 080 Nursing Standard
March 18/ Vol12/Number 26/ 1998
Tortora & Agnostikos Principles of Anatomy & Physiology New York Harper & Rowe
Underhill D. (1999) The uses of pulse oximetry Nursing Standard Nov 3 /14/7
Devised by Chris Wheeler & Marian Gillard (1998), updated September 2001 by
Guided Study: Health Promotion Work Book
In module NUR 118 you were introduced to the concepts of health and health
promotion. This study guide aims to build on these concepts and introduce you to
different ways of thinking about how you plan and carry out health promotion
The objectives are to:
1. Define Health Promotion
2. Describe the various approaches to health promotion
3. Explain two Models of Health Promotion which underpin practice.
4. Identify ways in which you might help people to change
Standards developed by the National Service Framework for Coronary Heart
Disease (DOH 2000) will be used as examples throughout this study guide
Defining Health Promotion
How Health Promotion is defined depends on an individual's concept of health. This
can be a positive concept that defines health as a state of wellbeing or a negative
concept, which defines health in terms of absence of illness and disease.
Even though there are differences in theories and concepts relating to health,
Seedhouse (2001) suggests that there is a common underlying factor:
'' All theories of health are designed to increase health by advising against,
preventing the creation of, or removing obstacles to the achievement of human
potential. These might be biological, environmental, societal, familial or personal.''
Health is a positive concept which means different things to different people. The
ability of people to reach their optimum level of health depends on a wide range of
factors which can be defined as the determinants of health (Ewles and Simnett 1999)
Activity: List the main determinants of health
The WHO's definition of Health Promotion encompasses the need to improve health
and for individuals to have more control over it.
'' Health Promotion is the process of enabling people to increase control over, and to
improve, their health'' (WHO 1984).
The development of health promotion has progressed with recognition that improving
health is not just about individuals changing their own behaviours but also involves
social, political and environmental change. The concept of empowerment is integral
to this definition which seeks to raise people's self-esteem by giving them the skills to
be able to control their own lives.
Current government strategy emphasises the importance of improving the health of
everyone. However it also recognises that inequalities in health exist between those
who are worse off and the need to address these (Our Healthier Nation, DOH 2000)
There is also recognition that health promotion activities encompass the combined
efforts of many agencies besides those in the health service and that collaborative
working is more effective.
Activity: State a number of different agencies and individuals that may be
involved in health promotion activities.
Differing concepts of health lead to different approaches to health promotion being
used. These approaches can be recognised by their differing aims and methods.
Often a person's approach to health promotion may be defined by their job role.
However it is useful to consider if an alternative approach may produce an improved
Our Healthier Nation (DOH 2000) identified Coronary Heart Disease (CHD) as a
health priority and a National Service Framework (DOH 2000) has been developed
for CHD to provide a quality service to prevent and treat CHD. For the purposes of
the following activities CHD will be used as an example to clarify health promotion
Five different approaches, as defined by Naidoo and Wills (2001) will be considered,
these being, the medical approach, the behaviour -change approach, the educational
approach, the empowerment approach, the societal change/ radical approach. Ewles
and Simnett (1999) also define five similar approaches to health promotion but they
replace the empowerment approach by the client-centred approach.
Activity: Give examples of health promotion activities related to Coronary
The Medical Approach
Aims to reduce morbidity and mortality of medically defined disease
Values expert led medical intervention
The behaviour change approach
Aims to encourage individuals to adopt healthier lifestyles by changing their attitudes
and behaviour to those defined by 'experts' as being healthy.
The educational approach
Aims to provide knowledge so that individuals can make well informed decisions and
choices about their health. Its prime aim is information giving not seeking to
motivate people to change their behaviour.
The empowerment approach
This approach aims to work with people to identify their own health concerns and
gain skills and confidence to address these concerns. It is a bottom up approach
where the health promoter acts as a facilitator and not an expert.
The societal- change approach
The aim is to change society rather than individuals through focusing on economic,
environmental and social policy changes. The emphasis is on making the healthier
choice an easier choice.
Models of Health Promotion
Theoretical models of health promotion have been developed to encourage a greater
understanding of the philosophical underpinning of health promotion work. They
provide an opportunity to critically examine practice and develop new ways of
Tannahill and Downie (1990)
Tannahill developed a model for defining, planning and doing health promotion. This
model is widely used amongst health professionals. Tannahill's model consists of
three overlapping spheres of activity: health education, health protection and
prevention. It shows how each activity relates to the other. The principle underlying
Tannahill's model is that of empowerment (Tannahill et al 1993)
Prevention Health Protection
Beattie bases his model on four paradigms (different views) for health promotion
which are developed from the mode of intervention and the focus of intervention.
(see diagram below). The spectrum of the mode of intervention ranges from
authoritative to negotiated and the focus of intervention from the individual to the
group. From these, four strategies of health promotion are developed which are
Health persuasion encouraging individuals to change behaviours
Legislative action campaigning for change in policy and legislation
Personal counselling the health promoter works with the client acting as a
facilitator to address the individuals needs as defined by themselves
Community Development. working with community groups to address their health
needs through empowerment and promotion of skills
Authoritative Mode of
HEALTH PERSUASION LEGISLATIVE ACTION
PERSONAL COUNSELLING COMMUNITY
Activity: Using one of the models described above apply it to promotion of
health and prevention of CHD as described by the National Service Framework
for CHD (2000), eg smoking, healthy eating, physical activity, obesity.
Helping People Change
Health behaviours are important in predicting mortality and longevity of individuals.
Much of a health professional's work in health promotion involves helping people to
take on new health behaviours to promote a healthier life-style. A major focus of
helping people change is recognising their right to freedom of choice to take on new
health behaviours. Barriers to change and how they can be overcome also need to
Many psychological theories may aid the practitioner in understanding how and why
people choose the health behaviours they exhibit eg Becker's Health Belief Model
(1970), Azjen and Fischbein's theory of Reasoned Action
A useful model which may clarify your thinking about health related behaviour
change is Prochashka and DiClemente's (1982) Stages of Change Model.
Stages of Change Model (Prochaska and DiClemente 1982)
This is a practical model which explains how change might take place rather than
what contributes to the change. It identifies a number of stages an individual may go
through when trying to change a behaviour (see diagram below). It may be used to
guide health professionals in working with clients who are carrying out health
damaging behaviours such as smoking or drug addiction.
Precontemplation: Thinking about
Not interested in change
Consider how this model might be used with a client who is a smoker or who
is obese which are risk factors related to CHD.
Planning Health Promotion
Health Promotion is a planned activity for which Ewles and Simnett(1999) have
devised a set of steps which need to be considered before carrying out any health
promotion work. These are illustrated in the flow chart below.
Planning and Evaluating Health Promotion
Identifying needs and priorities
Set aims and objectives
Decide the best way of achieving aims
Plan evaluation methods
Set action plan
(Ewles and Simnett 1999)
Regardless of whether your Health Promotion Activities are planned events or
opportunistic encounters it is important to ensure that you understand what you are
trying to achieve, how you intend to achieve it and how you will know whether you
have been successful.
Activity: Consider a Health Promotion topic related to Coronary Heart Disease
e.g. smoking behaviour and plan a health promotion activity using the above
References and Further Reading
Ewles I and Simnett (1999) Health Promotion: A Practical Guide Middlesex Scutari
Kerr J.(ed) (2000) Community Health Promotion London, Balliere Tindall
Naidoo J and Wills J (2000) Health Promotion Second Edition London, Balliere
Seedhouse (2001) Health: The Foundations for Achievement Second Edition
Although this workbook will mention both Type 1 and Type 2 Diabetes
Mellitus, the main focus will be Type 2
Mr Smith is a 50 year old office worker. He lives with his wife and two teenage
children in a semi-detached house in suburbia. He drives to work and spends most
of his day in front of a computer. In his leisure time he enjoys watching television and
playing in the darts team at the local pub.
Mr Smith is overweight. He has recently found that he is often thirsty and tired. He
also has to pass water more frequently than he used to do. He decided to consult his
On investigation his GP found his blood glucose reading to be 12mmols/l. His blood
pressure was 130/95 and his BMI 28. Mr Smith was asked to return the next day for
a fasting blood glucose, which was found to be 9mmols/l. His lipid profile was
What is the normal range for pre-meal blood glucose?
Explain how blood glucose is normally controlled in the body
Mr Smith was diagnosed as having Type two Diabetes Mellitus.
What are the two main types of Diabetes Mellitus?
Write a short paragraph about each type explaining the epidemiology and
causation of these types
Can you name any other types of diabetes?
After his GP's assessment and examination Mr Smith was referred to the practice
nurse who discussed the importance of a healthy diet with him.
He was also advised about sensible drinking and the benefits of moderate exercise.
What type of diet would have been recommended to Mr Smith?
Mr Smith's care would be shared between the Primary Care team at his surgery and
the diabetes team at the hospital.
Who might be the members of the diabetes team?
He was also taught to monitor his blood sugar on a regular basis using a blood
Name three important points to ensure accurate blood glucose monitoring
Mr Smith returned to see his GP after 3 months. Although he had lost some weight
and his blood pressure was now 120/85 his blood glucose remained outside of
normal limits despite a modified diet and increased exercise. The GP prescribed a
hypoglycaemic medication for Mr Smith to stabilise his blood sugar.
What are the two main categories of hypoglycaemic agents? What are their
properties, dosage and cautions?
It was also important that Mr Smith’s blood pressure was monitored and maintained
within normal limits. The UKPDS (United Kingdom Prospective Diabetes Study
1998), confirmed the importance of normo-glycaemia and normo-tension in
prevention of complications from Diabetes Mellitus.
Access the UKPDS Study and consider its recommendations.
Although Mr. Smith’s blood glucose was maintained within normal limits with
hypoglycaemic medication there is always the possibility that he may need insulin in
What are the main complications that can occur for a patient with Diabetes
Mr Smith’s blood glucose is now within normal limits. His blood pressure is now
120/85. He comes regularly at 6 monthly intervals to see the practice nurse/ GP for
monitoring and advice. The nurse discussed with him the importance of his diet,
medication and exercise.
What regular screening procedures would also be implemented to monitor and
prevent any diabetic complications?
Diabetes Mellitus has been recognised as a major health problem in the Western
World and the numbers of people diagnosed with diabetes is increasing.
The St. Vincent Declaration was produced in 1989 to lay down guidelines for
improving health and reducing complications attributed to diabetes.
More recently The National Service Framework for Diabetes has been developed
(DOH 2002) to ensure quality and equity of service both in the prevention and
treatment of diabetes mellitus. A major focus of this document is the Promotion of
Health in improving quality of life to prevent Diabetes Mellitus and also in the
prevention and reduction of complications caused by Diabetes Mellitus.
Which groups of people are particularly at risk of having diabetes? mellitus?
Access the National Service Framework for Diabetes Mellitus. What are the 12
key standards that this document covers?
Consider how these standards are being met in Primary Care from what you
have experienced in practice.
Department of Health (2002) National Service Framework for Diabetes
Krentz A. and Bailey C. (2001) Type Two Diabetes in Practice London, Royal
Society of Medicine Medical Press
St Vincent Declaration (1989) in Krentz A. and Bailey C. (2001) Type Two Diabetes
in Practice London, Royal Society of Medicine Medical Press.
United Kingdom Prospective Diabetes Study (1998) Several reports in Lancet, BMJ.
Williams G. and Pickup J. (1999) Handbook of Diabetes Second Edition Oxford,