PUBLIC HEALTH

DEVELOPING HEALTHY
COMMUNITIES

PART ONE
HEALTH NEEDS ASSESSMENT PROFILE

PART TWO
HEALTH PROMOTION PROPOSAL

Theresa Lowry-Lehnen
Specialist Nurse Practitioner
Surrey University 2005

PUBLIC HEALTH
PART ONE: HEALTH NEEDS ASSESSMENT PROFILE
CONTENTS
Page
1.

Introduction

1.

Context and Theoretical Framework

4.

Identification and Boundary of the Community

5.

Practice Population Statistics

5.

Wards and Deprivation Scores

6.

Ethnicity

6.

The Communitys Locality

7.

The Communitys Social Structure

7.

Lone Parent Households

8.

Teenage Pregnancy Rates

8.

Elderly Patients Living Alone

9.

Children Health Visitors Case Files 2004

11.

Key Health Determinants

13.

The Communitys Social Activity and Sentiment

14.
15.

What Is Being Done?

Sutton and Merton PCT (Targets and Aims 2003-2006)

16.

The Communitys Health

16.

Chronic Illness Patients

17.

Chronic Illness Patients and Smoking

18.

Key facts Smoking - DoH 2004

18.

Governments Targets Smoking DoH 2004

19.

Summary of Identified Community Health Needs

Main Health Need Identified ( Requiring Intervention)
(Smoking Among The High Risk - Chronic Disease Group
Patients)

20.

Conclusion

22.

References

PUBLIC HEALTH
Theresa Lowry-Lehnen
General Practice Nurse

PART ONE: HEALTH NEEDS ASSESSMENT PROFILE

INTRODUCTION
Since the first Public Health Act in 1875 there has been a continuing
development towards our current understanding of public health, which is
influenced by legislation and policy, theory and practice-based research. This
paper focuses on current public health policies and how they can be
translated into practice. Part One considers the wider determinants of health
and the concept of health needs and analyses and evaluates collated data
with regard to a community selected from my practice area within the Sutton
and Merton Primary Care Trust. Part Two introduces a plan devised to
address an identified health need, i.e. smoking among high-risk groups, and
critically appraises an appropriate intervention and evaluation strategy, based
on the health promotion model by Tannahill (1985). The proposed action plan
also incorporates the stages of change model developed by Prochaska and
DiClemente (1984 cited by Naidoo & Wills 2000).

Context and Theoretical Framework

Public health is not a new concept, but since the public health movement of
the 19th century the concept has changed significantly. Evolving from a
somewhat

paternalistic

movement,

public

health

now

stresses

the

participatory aspect of health promotion, with special emphasis on the

empowerment of patients.
The World Health Organisation has been pointed out as a leading
international influence on health care policy and practice, with its development
of worldwide health initiatives aimed at addressing inequalities (Tinson: 1995).
In Britain, the Black Report, published in 1982, confirmed the extent of
inequalities in health and health care (Naidoo & Wills 2000). According to
Ewles and Simnett (2003), this report highlighted inappropriate health care
and a requirement to focus more on the health needs of different groups.
The current view is expressed in the definition of public health given by the
Acheson Report (1988) as the science and art of preventing disease,
prolonging life and promoting health through the organised efforts of society.
The new public health aims to use regulations, fiscal measures, policies and
voluntary codes of practice to provide the population with the opportunities to
make the healthier choice the easier choice (Naidoo & Wills 2000). According
to the World Health Organisation (1998), the new public health is
characterised by a comprehensive understanding of the ways in which
lifestyle and living conditions determine health status and aims to protect
health by supporting lifestyles and creating supportive environments for
health.
Making healthy choices easier is the subtitle of the current Labour
governments white paper Choosing Health, which identifies an approach
which respects the freedom of individual choice and which addresses the fact
that too many people or groups have been left behind or ignored in the past
(DoH 2004a). Furthermore, the current government stresses that health

promotion, with a focus on prevention and tackling inequalities, is one of the

key roles of primary care nurses (DoH 2002) and the health service as a
whole (DoH 2000, DoH 2004b).
A Health Assessment Profile can help to fulfil such a role in a meaningful way.
It has been acknowledged as the most suitable assessment tool for
community-based care, marking a shift from the traditional assessment of
health needs by nurses on a one-to-one basis to a more collective view which
considers the wider and more complex health needs of the community (Tinson
1995).
Such a profile has been defined as the systematic collection of data to identify
the health needs of a defined population, and the analysis of that data to
assess and prioritise strategies in health promotion (Twinn, Dauncey, Carnell
1990).
In determining health needs, the profiler must be aware of the various ways in
which they can be defined: normative needs, felt needs, expressed needs,
and comparative needs (Bradshaw 1972 cited by Tinson 1995; Blackie 1998).
A health needs assessment must also take into account wider determinants of
health, such as deprivation and poverty, cultural and social influences,
education, housing, transport, and environmental factors (Naidoo & Wills
2000, Ewles & Simnett 2003).
Both the various needs and the wider determinants will be addressed in detail
in the course of the Health Needs Assessment Profile, which is based on the
framework suggested by Tinson (1995).
Tinson (1995) asserts that the first and most essential task in compiling a
profile is to identify the community under examination and define its

boundaries. It is also important to consider the various dimensions within a

community, i.e. its locality (where it is), its social structure (who lives there), its
social activity (what happens there) and its sentiment (what is it like to live
there) (Orr 1992 cited by Tinson 1995). Finally, the dynamic nature of a
chosen community should be taken into account: Tinson (1995) suggests an
approach using systems theory as a framework, in which the community as a
system can be divided into subsystems, i.e. key health determinants such as
employment, education, housing, crime, health care and transport. For this
profile, data was collected from a variety of sources, including a GP practice
profile I compiled at the surgery where I am based, the Sutton and Merton
PCT, local and national government statistics, the latest Northern Wards
Participatory Needs Assessment and the national census.

Identification and Boundary of the Community

The community chosen for this profile is the St Helier (Merton) and St Helier
North and South (Sutton) practice population of Faccini House Surgery,
Middleton Road, Morden, where I am based as a practice nurse. The surgery
is situated on the borders of Merton and Sutton and is part of the Sutton and
Merton PCT, with 53% of patients living in the borough of Sutton and 47% in
Merton ( Faccini House Surgery -GP Practice Profile 2005).

TABLE 1: PRACTICE POPULATION

Faccini House Surgery, Morden
Patients
Male

5630
2834 (50.3 %)

Female

2796 (49.7 %)

Age ranges
0 - 12

991

13 - 18
19 - 30
31 - 50
51 - 65
65+

554
883
1656
614
922

Source: Faccini House Surgery GP Practice Profile (2005)

The practice is situated on the St. Helier estate, which is one of the top ten
most socially deprived areas in the South Thames region (Office of National
Statistics 2002). Both Sutton and Merton are relatively affluent boroughs but
the northern wards of St. Helier South and North (Sutton) and St. Helier
(Merton) have high deprivation scores and lower health status (Sutton and
Merton PCT 2002). Almost 90 per cent of the practice population live in those
three wards.

TABLE 2: WARDS AND DEPRIVATION SCORES

WARDS

PRACTICE POPULATION

DEPRIVATION SCORE
(ONS 2002)

St. Helier
St. Helier North
St. Helier South
Rosehill
Sutton Common

47%
22%
20%
7%
4%

25.9
37.9
36.6
14.4
11.2

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

While Faccini House Surgery does not yet have a complete record of patient
ethnicity, Table 4 shows data on ward, local and national data level, with white
ethnicity in St. Helier being significantly higher than the London average.
TABLE 4: ETHNICITY
St. Helier
(Merton)

Merton

White

83.8 %

75 %

71.2 %

92.2 %

Asian

7.7 %

11.1 %

12.1 %

4.6 %

Black

3.8 %

7.8 %

10.9 %

2.1 %

Chinese (other)

2.1 %

3.0 %

2.75 %

0.9 %

Mixed

2.5 %

3.1 %

3.2 %

1.3 %

St. Helier
(Sutton)

Sutton

London England

White

90.6 %

89.2 %

71.2 %

92.2 %

Asian

3.0 %

4.7 %

12.1 %

4.6 %

Black

3.0 %

2.6 %

10.9 %

2.1 %

Chinese (other)

1.1 %

1.4 %

2.75 %

0.9 %

Mixed

2.2 %

2.1 %

3.2 %

1.3 %

Ethnicity

Ethnicity

London England

Source: Office of National Statistics 2002

The Communitys Locality

Faccini House Surgery is situated over two kilometres from Morden town
centre, three kilometres from Sutton centre and one and a half kilometres
from Rosehill. The vast St Helier estate was built in the late 1930s. The
houses are small redbrick council style terraced houses, each row backing on
to another row of similar type houses. The centralisation of facilities and
services has resulted in a lack of local services to meet the population needs.
To access most services in the locality travel by bus or car is required. The
closest supermarkets are in Rosehill and Morden, and without transport they

are difficult for the elderly or those with small children to access (Windshield
Survey 2005). There are four primary schools and one high school in the
immediate area, with lower educational achievements compared to other
schools in more affluent areas of Merton and Sutton (Ofsted 2004). There is a
significant lack of green areas and playground facilities for children and the
nearest social centres and cafs are in Rosehill and Morden centre
(Windshield Survey 2005).

The Communitys Social Structure

The Census 2001 shows that the geographical area of the Faccini House
practice population has a high proportion of lone parent households (Table 5).
Teenage pregnancy rates are also much higher than average (Table 6).
TABLE 5: LONE PARENT HOUSEHOLDS
St. Helier
(Merton)

Merton

London

7.6 %

6.0 %

7.6 %

St. Helier
(Sutton)

Sutton

London

11.8 %

6.1 %

7.6 %

Source: Office of National Statistics 2002

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

St. Helier
(Merton)

Merton

England

54.1 per 1000

40.5 per 1000

46.2 per 1000

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

St. Helier
(Sutton)

Sutton

England

63.4 per 1000

35 per 1000

46.2 per 1000

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

The number of elderly patients aged over 65 registered at Faccini House

surgery is 922. The practice population number of elderly patients living alone
is 175. 19% of the elderly practice population therefore lives in lone
households, a higher proportion than both local and national averages (GP
Practice Profile 2005).

TABLE 7: ELDERLY PATIENTS LIVING ALONE

St. Helier (Sutton)

17.4 %

Sutton
St. Helier (Merton)
Merton
England/Wales

13.8 %
19.1 %
12.8 %
14.4 %

Source: Office of National Statistics 2002

Table 8 gives an overview of needs in relation to children and families, as

identified by the practice Health Visitors case files (2004).

TABLE 8 : CHILDREN HEALTH VISITOR CASE FILES 2004

There are 78 families with children under the age of 5 registered at

Faccini House Surgery, who belong to the Sure Start programme.

There are 22 families with children under 5 years who are
considered a low level of vulnerability (Level 1).
There are six families at Level 2, whose needs are complex enough
to require more than one agency.
There are two families at Level 3, whose needs are complex and
require a co-ordinated multi-agency assessment, service plan and
review process.
There are three families at Levels 4 and 5, who have the highest
level of vulnerability. Specialist assessment has confirmed the need
for specific, sustained and intensive support.

The number of practice population births recorded for 2004 is 95.

The number of practice population low birth weight babies for 2004
is 11. This means 11.6 % of the practice population births for 2004
were low birth weight. Low birth weight is associated with low socioeconomic status, smoking, maternal nutrition pre pregnancy, and
energy intake during pregnancy (Sutton and Merton PCT 2003b).
Health Visitor Case Files 2004, Faccini House Surgery

From the above data and the key health determinants listed in Table 9 a
picture emerges of the geographical area in which the majority of the Faccini
House practice population lives. It is an area with high deprivation scores, a
high proportion of elderly people, and a much higher than average teenage

pregnancy rate. While unemployment rates are the same or only slightly
higher than the national average, they are higher than the local average in
Merton and Sutton. There is a high percentage of people without
qualifications, indicating a level of education lower than both the local and
national levels. There is also a higher than local and national average of lone
parent households. Rented council accommodation, as opposed to owner
occupied housing, is considerably higher than both the local and national
average, with a high percentage of accommodation without central heating.
There is also a relatively high number of people without private transport.

TABLE 9: KEY HEALTH DETERMINANTS

Limiting long term illness
St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

18.7 %

13.8 %

18.2 %

14.8 %

18.2 %

Unemployment
St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

3.4 %

3.3 %

3.8 %

2.6 %

3.4 %

Providing unpaid care

St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

8.8 %

8.0 %

8.5 %

9.0 %

10.0 %

No Qualifications
St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

33.8 %

19.9 %

37.8 %

23.3 %

29.1 %

One person households

St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

33.2 %

32.1 %

30.6 %

33.1 %

30.0 %

Households with dependent children

St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

31.0 %

28.6 %

37.8 %

30.0 %

29.9 %

Lone parent households with dependent children

St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

7.6 %

6.0 %

11.8 %

6.1 %

6.5 %

Owner occupied housing

St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

59.7 %

68.8 %

51.8 %

74.3 %

68.9 %

Rented council accommodation

St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

26.4 %

9.2 %

42.0 %

10.9 %

13.2 %

Without central heating

St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

22.8 %

10.2 %

13.1 %

7.1 %

8.5 %

No car or van
St. Helier
(Merton)

Merton

St. Helier
(Sutton)

Sutton

Eng/Wales

35.8%

30.1%

35.1%

23.3%

26.8%

Source: Office of National Statistics 2002

The Communitys Social Activity and Sentiment

To find out what the residents themselves think of the St. Helier area (Table
10), data was obtained from the most recent Northern Wards Participatory
Needs Assessment (Merton, Sutton and Wandsworth Health Authority 1998).

TABLE 10: RESIDENTS VIEW

NORTHERN WARDS PARTICIPATORY NEEDS ASSESSMENT
1998

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

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

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

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

Environmental issues raised were traffic pollution, graffiti, and the

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

However, long standing and older residents also felt the area had a strong
sense of community, helped by having a happy and stable network of
family and friends. There was some hostility towards new residents who
were regarded as having a reputation of being rough. As a consequence
there was some conflict between generations, and differences were
also seen to be aggravated by unemployment levels experienced in the
area.
( Merton, Sutton and Wandsworth Health Authority 1998)

What is being done?

Since the 1998 Northern Wards Participatory Needs Assessment, there have
been some improvements in the area (Table 11).
TABLE 11

A new leisure centre has been built on Middleton Road and was opened
to the public in 2002.
Connexions, the governments support advice and personal development
service for 13 to 19 year olds, has opened a local centre.
Traffic calming measures and some road and public transport
improvements have been put in place.
For the elderly and needy, cook and eat clubs and exercise and falls
prevention classes have been introduced in the local area .
(Sutton and Merton PCT 2003b)

The overriding aims of the Sutton and Merton PCT formed in 2002, are to
improve local health services, the health of the local population and to
address health inequalities (Sutton and Merton PCT 2003a). Table 12 shows
the 2003 - 2006 Sutton and Merton PCT targets and aims.

TABLE 12 : SUTTON AND MERTON PCT, 2003-2006

TARGETS AND AIMS (Primary Care)

To shift services nearer to peoples homes, particularly for the

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

To improve the coordination of services for older people so that they

receive the best care in or as close as possible to their homes.

To develop primary care particularly in the more deprived areas where

investment has been low.
To address health inequalities

To improve mental health services.

That services for children are directed by the needs of the child.

Develop the ability of communities to improve their own health.

The PCT envisages the provision of diagnosing and treating people

where possible in the community .

The PCT plans to work across the interface between hospital and
primary care to achieve more support for older people and more
outpatient and chronic illness services in primary care.

To ensure access for patients to see a primary care professional within

24 hours and a GP within 48 hours.

The PCT recognises that smoking is a major contributor to ill health,

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

The Sutton and Merton PCT is aware of and addressing the socioeconomic issues which influence the health of many local people, such
as, smoking, nutrition, alcohol and drugs, sexual health and teenage
pregnancy.

Smoking is a key target and being addressed through smoking

cessation services, however the PCT recognises that more needs to
be done and more robust efforts are required to ensure services reach
those most vulnerable and particularly at risk.
Sutton and Merton PCT 2003a
Sutton and Merton PCT 2003b
Sutton and Merton PCT 2003c

The Communitys Health

There are 220 patients registered at Faccini House Surgery who are currently
diagnosed with or who have been treated for cancer. This is equal to 3.9% of
the practice population (GP Practice Profile 2005).
Computer records for certain categories of illnesses such as mental health
are presently being updated at Faccini House, and I was unable to obtain
accurate statistics. Present records identify 15 patients as suffering with
severe mental health problems and 82 patients with other mental health
problems such as depression. The Practice Manager and GPs believe that
the actual figures are much higher (GP Practice Profile 2005).
St. Helier North and South wards have the highest level of chronic illness in
Sutton, the former 16% and the latter 14%. The St. Helier ward at 17% has
the highest level of chronic disease in Merton (Sutton and Merton PCT
2003a). Table 13 shows the number of patients registered at Faccini House
Surgery with asthma, diabetes and coronary heart disease.

TABLE 13: CHRONIC ILLNESS PATIENTS

ASTHMA
AGE
0 12
13 24
25 44
45 64
65 74
75+
TOTAL

NUMBER
82
90
125
63
25
14
399

DIABETES
AGE
0 12
13 24
25 50
50+
TOTAL

NUMBER
13
25
74
104
189

CORONARY HEART
DISEASE
TOTAL
183

Source: Faccini House Surgery GP Practice Profile (2005)

The practice population also comprises a high number of smokers. Of the

4,085 patients aged over 18, a total of 1307, or 32%, are registered as

smokers (GP Practice Profile 2005). This is a higher proportion than the
national average of 26%, but close to the national proportion of those in
routine or manual employment who smoke (31%) (DoH 2004a). Of 554 young
people aged between 13 and 18 registered at the surgery, 55 smoke (GP
Practice Profile 2005), that is 10%, slightly higher than the national average
(9%) of 11 to 15 year-olds who smoke (DoH 2004a).
A comparison between smokers and those with chronic illnesses shows that a
high proportion of chronic disease patients are smokers. Of the 399 asthmatic
patients, 194 or 61% are registered as smokers. Of the 189 diabetic patients,
62 or 35.2% are smokers, and of the 183 coronary heart disease patients,
115 or 63% are smokers (GP Practice Profile 2005).

TABLE 14: CHRONIC ILLNESS AND SMOKING

DISEASE
Asthma
Diabetes
CHD

TOTAL
399
189
183

SMOKERS
194
62
115

PERCENTAGE
61.0 %
35.2 %
63.0 %

Source: Faccini House Surgery GP Practice Profile (2005)

TABLE 15 : KEY FACTS SMOKING (DoH 2004a)

Smoking is the greatest cause of preventable illness and early

death in the UK
Smoking is the single biggest cause of health inequalities and is
associated with poverty and social deprivation

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

10,000,000 adults are smokers in England.

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

9% of 11 15 year olds are smokers

Smoking causes a wide range of illnesses, including cancer,

respiratory diseases and heart disease

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

70 % of smokers say they would like to stop.

TABLE 16 : GOVERNMENT TARGETS ON SMOKING (DoH

2004a)

To reduce adult smoking rates from 26% in 2002 to 21% or less

by 2010

To reduce the prevalence of smoking among routine and manual

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

Smoking cessation to be embedded in all NHS social care

pathways by 2006

The NHS to become a smoke free zone by 2006. Nurses to be

targeted to quit smoking as part of a joint DoH and RCN
campaign from 2005

Boost smoking cessation campaigns. Provide information,

support, NRT and access to NHS support and stop smoking
services

Restrict tobacco advertising

In 2005 2006, the Healthcare Commission will examine what

PCTs are doing to reduce smoking in the local populations.
Progress will be monitored against national standards and
indicators

SUMMARY OF IDENTIFIED MAIN HEALTH NEEDS

Table 17 summarises the main health needs identified within the defined
practice population and requiring intervention. However, the high incidence of
smoking within our practice population, and especially among the high risk

chronic disease patients, has been identified as a most serious health need
requiring urgent intervention.

TABLE 17: SUMMARY OF IDENTIFIED MAIN HEALTH NEEDS

A high incidence of pensioners living alone = 19%(17.4% for St Helier

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

Lone parent households and teenage pregnancy rates, higher than

both the local and national averages. (St Helier Merton 51.4 per 1000,
St Helier Sutton 63.4 per 1000, compared to 46.2 per 1000across
England, 40.5 in Merton and 35 in Sutton. Lone parent households are
associated with poverty and social deprivation (Blackburn 1991). This
theory is also supported by Whitehead (1988), who also suggests that
poverty and ill health are interrelated.

A high incidence of vulnerable children and low birth weight babies.

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

A high number of practice population patients who smoke compared

to the national average (32% vs 26%). Smoking is the single biggest
cause of health inequalities and is associated with poverty and social
deprivation (DoH 2004a).

St Helier North and South has the highest level of chronic illness in
Sutton, the former 16% and the latter 14%. The St Helier ward at 17%
has the highest level of chronic disease in Merton
(Sutton and Merton PCT 2003a)

A high incidence of chronic disease patients (Asthma, Diabetes and

Coronary Heart Disease) registered at Faccini House Surgery who
smoke (Asthma= 61%, Diabetes = 35.2% and CHD = 63%).
(GP Practice Profile 2005)

CONCLUSION
This Health Needs Assessment Profile has described the practice population
of Faccini House Surgery in its geographical locality and its social structure
and activity. It has also given some insight with regard to the views of
residents and what it feels like to live in the area (Orr 1992 cited by Tinson

1995). The picture emerging from the collated data is one of an area of
relatively high social deprivation. From the locally relevant data a number of
comparative needs can be identified, e.g. with regard to some key health
determinants such as education, transport, housing and amenities, i.e. the
subsystems mentioned above (Tinson 1995). A Participatory Needs
Assessment by Merton, Sutton and Wandsworth Health Authority (1998) has
described both felt and expressed needs.
This profile has also identified normative needs with regard to the health of
the practice population. One of those needs is the high number of chronic
disease patients who are also smokers, thus exacerbating their condition.
While Tinson (1995) cautions that normative, or professional, assessments
can be problematic because they do not always involve the client or
community, the identified health need is clearly one to be addressed under the
current governments health targets, which describe smoking as the UKs
single greatest cause of preventable illness and early death and point out that
70 per cent of smokers say they want to give up (DoH 2004a). Smoking Kills
A White Paper on Tobacco (1998) describes smoking as the most
identifiable factor contributing to the gap in healthy life expectancy between
those most in need and those most advantaged (DoH 1998). Smoking is the
single biggest cause of health inequalities and is associated with poverty and
social deprivation (DoH 2004a).
Liberating the Talents (DoH 2002) highlights three main core functions for
nurses in primary care. As well as being a point of first contact for patients and
taking a lead role in chronic disease and minor illness management, they also
have a responsibility to deliver health protection and promotion programmes

and the various National Service Frameworks. The identified community

health need, i.e. smoking among the high-risk chronic disease patients at
Faccini House Surgery, relates to the core functions of chronic disease
management, health protection and promotion and delivering NSFs (DoH
2001, DoH 2003) and will be addressed by a health promotion intervention in
the second part of this paper.

(2192 words excluding tables)

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Disease HMSO, London

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London

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Executive summary HMSO, London

Department of Health 2004b Tackling Health Inequalities: A Programme for

Action HMSO, London

Ewles L, Simnett I 2003 Promoting Health: A Practical Guide 5th ed. Bailliere
Tindall, London

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in the London Borough of Merton Sutton and Merton Primary Care
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Sutton and Merton Primary Care Trust 2003a Public Health Annual Report
2002-2003 Sutton and Merton Primary Care Trust, London

Sutton and Merton Primary Care Trust 2003b Local Delivery Plan 2003-2006
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Sutton and Merton Primary Care Trust 2003c Business Plan 2004 2005
Sutton and Merton Primary Care Trust, London

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Sutton and Merton Primary Care Trust, London

Tannahill A 1985 What is Health Promotion? Health Education Journal 44 (4):

167-168

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PUBLIC HEALTH
PART TWO: HEALTH PROMOTION PROPOSAL
CONTENTS

Page
1.

Introduction

1.

Context and Theoretical Framework

2.

Health Promotion Model Tannahill (1985)

3.

Intervention: Planning and Evaluation Framework

(Ewles & Simnett 2003)

4.

The intervention

4.

Needs and Priorities

4.

Aims and Objectives

7.

Best Way To Achieve Aims

8.

Objectives and Methods

9.

Ethical issues

9.

Resources

10.

Roles and Responsibilities

11.

Evaluation Strategy

12.

Action Plan

13.

Conclusion

15.

References

Appendix 1

TABLE 6: Action Plan (Intervention)

Patient invitation letter
Letter to PCT, requesting funding
Proposed budget
Poster
Patient feedback / Evaluation questionnaire

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

Appendix 2

PUBLIC HEALTH
Theresa Lowry-Lehnen

General Practice Nurse

PART TWO: HEALTH PROMOTION PROPOSAL

INTRODUCTION
The Health Needs Assessment Profile in Part One has identified smoking
among the high risk groups (i.e. patients with the chronic illnesses, asthma,
coronary heart disease and diabetes) within the GP practice population of
Faccini House Surgery as a major community health need requiring
intervention. Part Two of this paper will devise and critically appraise a clinicbased smoking cessation intervention, targeting chronic disease patients
within this GP practice population. It will use the health promotion model
suggested by Tannahill (1985) and the planning and evaluation framework
devised by Ewles and Simnett (2003). The devised smoking cessation action
plan (Table 6, Appendix 1) also incorporates the stages of change model
developed by Prochaska and DiClemente (1984 cited by Naidoo & Wills
2000).

CONTEXT AND THEORETICAL FRAMEWORK

Health Promotion Definition
Health Promotion can mean a number of quite different activities, and
practitioners must be aware of the available options (Naidoo & Wills 2000).
The World Health Organisation defines health promotion as the process of
enabling people to increase control over, and to improve, their health (WHO
1984). The current government speaks of delivering sustained improvement
to the health of the people by responding to peoples concerns about their

health with practical support on their own terms and by providing the context
and environment needed to make real progress (DoH 2004a). Naidoo and
Wills (2000) point out that the phrase making the healthier choice the easier
choice has come to encapsulate the meaning of health promotion. However,
Tannahill (1985) claims that the term health promotion has acquired so many
meanings as to become meaningless. A more detailed look at an appropriate
health promotion model will help to provide a focus and a rationale for the
proposed intervention.

Health Promotion Model Tannahill (1985)

Tannahill (1985: 167) suggests reserving health promotion to define clearly a
realm of health-enhancing activities. He proposes a model in which health
promotion is seen as comprising health education, prevention and protection
as three overlapping spheres of activity. Education is seen as a
communication activity aimed at enhancing well-being and preventing or
reducing ill health in individuals and groups. Preventive action can take the
form of prevention of an illness or of avoidable complications of an already
established disease. Health protection is defined as legal or fiscal controls,
other regulations or policies, or voluntary codes of practice (Tannahill 1985:
168). While in an intervention such as the one proposed here not all parts of
Tannahills model may have equal weight, it allows the practitioner to be
aware of the possible different activities and available options (Naidoo & Wills
2000). It also enhances an awareness of current policies and national service
frameworks (DoH 2001, DoH 2003) and how the proposed intervention fits

into government policies and targets regarding smoking as the single

greatest cause of preventable illness and early death (DoH 2004a).
Tannahill (1985) stresses that empowerment of individuals and groups within
the community is an important objective for health promotion. He warns
against a top down approach and advocates a participatory process.
It should be pointed out that no health promotion model can be seen in
isolation. There is always a certain overlap with other models, such as Caplan
and Holland (1990 cited by Naidoo & Wills 2000) and Beattie (1991 cited by
Naidoo & Wills 2000). Similarly, the various possible approaches to health
promotion, such as medical, behaviour change, educational, empowerment
and social change (Naidoo & Wills 2000), are not mutually exclusive but
should complement each other.

Intervention Planning and Evaluation Framework

For the purpose of the proposed intervention the planning and evaluation
framework suggested by Ewles and Simnett (2003) will be used. It sets out a
seven-stage cycle. I have adapted the planning process to include ethical
considerations, as shown in Table 1.

Table 1: Planning/Evaluation Cycle (adapted from Ewles & Simnett 2003)

Identify needs and priorities

Set aims and objectives

Decide the best way of achieving aims

Consider ethical issues

Identify resources

Plan evaluation methods

Set an action plan

Implement plan, including evaluation

THE INTERVENTION
Needs and priorities
The Health Needs Assessment Profile in Part One has identified smoking
cessation as a health need to be addressed. In particular, the profile has
identified a high proportion of smokers among the chronic illness patients at
Faccini House Surgery. Smoking exacerbates such illnesses as diabetes,
respiratory and coronary heart disease (DoH 2004a). The priority for this
intervention will therefore be smoking cessation targeted at the chronic
disease patients within the Faccini House Surgery practice population.
While it may be pointed out that a cessation intervention should be aimed at
all smokers, not just those in high-risk groups, the health belief model (Becker
& Maiman 1975 cited by King 1984) may be used to support a more targeted
approach: As King (1984) states, most people do not tend to think in terms of
abstract statistics but rather they think of concrete examples. It is hoped that a
cessation programme aimed at the identified high-risk groups may allow a
more targeted, and therefore, it is hoped, more successful approach.

Aims and Objectives

According to Ewles and Simnett (2003) aims are broad statements of the
outcome one hopes to achieve while objectives are much more specific,
making the setting of them a critical stage in the planning process.
The overall aim of this intervention is to address the identified health need, i.e.
to reduce the incidence of smoking among chronic disease patients in line
with general government and local PCT targets (DoH 1998, 2004a, 2004b,
Sutton and Merton PCT 2003a, 2003b, 2003c). With regard to Tannahills
(1985) model, this overall aim should be approached in a comprehensive way.
The aspect of health protection can be seen in the context of current
government policies and targets with regard to smoking cessation (DoH
2004a). Within this context, this proposed intervention devises an educational
approach in the form of a communication activity aimed at enhancing the wellbeing and preventing or reducing the ill health in individuals and groups. The
preventive aspect can be seen in the attempt to avoid complications of an
already established disease.
It is possible to identify aspects of a number of health promotion approaches
(Naidoo & Wills 2002). There is a medical component in that those at special
risk have been identified by the practitioner. Individuals may be encouraged to
take responsibility for their own health and choose a healthier lifestyle in an
approach aimed at behaviour change. There is also the educational element
trying to increase knowledge and skills about healthier lifestyles. The overall
aim may be achieved by working with clients within the community, thus
strengthening their empowerment (Naidoo & Wills 2002).

Objectives must be set in order to enable the practitioner to work towards the
overall aim. Ewles and Simnett (2003) stress that objectives are the desired
outcome of an intervention and that, while challenging, they should be
attainable, relevant and as measurable as possible. On the basis of
Tannahills (1985) model, the objectives should cover education, prevention
and protection, and Table 2 lists the objectives for this proposed intervention.

TABLE 2: A clinic-based smoking cessation intervention targeting

chronic disease patients within a GP practice population
Overall Aim

To reduce the incidence of smoking in chronic disease patients in

line with national and local government targets
Objectives

Ensure that every targeted patient on the GP register receives

information about the clinic based smoking cessation programme

Educate and empower clients to give up smoking

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

Encourage personal responsibility

Equip patients with skills/knowledge and appropriate nicotine

replacement therapy (NRT)

Promote self-esteem in a population already disadvantaged in

health terms

Promote inclusion with a community outreach service for those

unable to attend clinics

Establish self-help group networks within the chronic disease

population
Promote participation and working in partnership

Work within current PCT/Government guidelines on smoking

cessation

Best Way to Achieve Aims

In choosing methods for an intervention, one must consider whether they are
appropriate and effective, acceptable to clients and others involved and
financially viable (Ewles & Simnett 2003).
Working with individuals and small groups has been identified as effective for
changing attitudes, feelings and behaviour (Ewles & Simnett 2003).
The objectives identified in the previous section can be listed under such
headings as health awareness, improvement of knowledge, empowerment,
changing attitudes and behaviour, and societal change, which also
correspond to the three spheres of activity identified in Tannahills (1985)
model. Adapting the aims and methods identified by Ewles and Simnett
(2003), the chosen methods for the objectives in this intervention are group
work, group teaching and talks with the opportunity of one-to-one counselling
and the appropriate use of NRT, audio visual and written materials. Table 3
groups the objectives under overall goals as well as activities corresponding
to Tannahills (1985) model and shows the chosen methods.

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

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

Specialist nurses:
Talks, education, specialist knowledge
Expert patients:
Motivate, support, encourage, role models
Counselling:
Change behaviour/attitudes, support, motivate
Outreach nurse:
Visit patients unable to attend in the community
Group-work :
Patient networking and forming self help groups
Literature:
Education, information
Nicotine replacement therapy
OBJECTIVES

Ensure every targeted patient receives information about local smoking

cessation programme, impart clear messages about the risks associated
with smoking and chronic conditions
Equip and empower patients with skills/knowledge and appropriate nicotine
replacement therapy (NRT)
Promote inclusion with a community outreach service for those unable to
attend clinics
Educate and empower clients to give up smoking
Encourage personal responsibility
Promote self-esteem
Establish self-help group networks within the chronic disease population
Work within current PCT/Government guidelines on smoking cessation

Ethical Issues
Having set aims and objectives and having decided on the best way of
achieving them, it is appropriate at this point to adapt Ewles and Simnetts
(2003) planning and evaluation framework by including a consideration of
ethical issues. As Jenkins and Emmett (1997) point out, nurses may assume
that their perceptions and assessments of a patients health is accurate and
corresponds with those of the patient, but there is a danger of manipulating a
patient under the guise of health promotion. Not only is it important to
establish what health promotion itself is but also what impact nurses own
perceptions may have on the implementation of a health intervention (Gott &
OBrien 1990). If the concept of empowerment is to be taken seriously, then
the patients autonomy must be respected. Group work and group teaching
are appropriate methods to allow patients a say in matters which concern
them. Those methods also allow the practitioner to take into account the fact
that health education cannot be effective without consideration of patients
beliefs and attitudes. The health belief model can help to illustrate how a
patients beliefs can influence his health-related behaviour (King 1984). In the
context of this intervention it means that it must be taken into account how
patients may perceive risks and benefits.

Resources
As has already been demonstrated, the proposed intervention fits in with the
priorities and targets set by current government policy (DoH 2004a). In terms
of material resources, use will be made of nicotine replacement therapy,

written material /literature, audio and visual aids and display materials. It is
also important to identify existing local self-help groups for the targeted
chronic illnesses as well as voluntary organisations such as the British Heart
Foundation, Diabetes UK and Asthma UK. The people involved in the
intervention (clients and staff) and their commitment, time, skills, knowledge
and expertise are the most important resources. Table 4 proposes roles and
responsibilities.

TABLE 4: Roles and Responsibilities

Practice Nurses

Specialist Nurses
Respiratory nurse specialist
CHD nurse specialist
Diabetes nurse specialist
GP
Expert patients
(CHD, Asthma, Diabetes)

Co-ordinate the cessation programme

Point of contact/support
Overall responsibility Budgets/ Timetable
Evaluate programme

Education
Specialist information
Empowerment
Prescriptions for NRT
Point of contact and support
Empowerment
Motivation/encouragement
Role models

Smoking cessation counsellor NRT advice

One-to-one and group counselling
Education /Support/ Encouragement
Outreach nurse

Community outreach visits

Support /Education/ Counselling

Patients

Participation
Share experiences
Provide ongoing support
Form own support networks
Part of decision and evaluation process

Practice manager

Housekeeping
Health and safety

Administrative staff

Letters/posters/information
Phone calls
Point of contact

Evaluation Strategy
In setting out an evaluation strategy, it is worthwhile assessing both the
outcome and the process of the health intervention (Ewles & Simnett 2003).
While it may be difficult to measure the outcome for some of the stated
objectives, such as encouraging personal responsibility and promoting selfesteem, there are ways in which the overall objective can be measured to
some degree. Given the nature of the proposed intervention, two methods of
measuring the outcome are most appropriate. Firstly, feedback will be sought
from the participants, patients as well as practitioners, both in a more informal
way such as a group feedback session and through a more formal
questionnaire (Appendix 1). Secondly, and most importantly given the overall
aim of the intervention, participating patients will be monitored on a voluntary
basis in order to record whether they have given up smoking. It is suggested
that the patients will be approached after one month, three months, six
months and twelve months to update the record of their progress. For those
patients who have given up smoking their health indicators and their own
perceptions about their health may be recorded at future appointments.
With regard to evaluating the process, it is suggested that all input in terms of
time, money and materials will be recorded, enabling the course facilitator to
set the costs against the benefits of the intervention. In addition, the facilitator
should keep a diary to allow self-evaluation. Finally, feedback from clients and
other practitioners will be sought, both at the end of group sessions and
through a suggestion box (Ewles & Simnett 2003).

TABLE 5: Evaluation Strategy

Evaluating the outcome

How many patients give up smoking?

How many patients do not smoke after one, three, six, twelve months?

Record health indicators at future appointments

Record patients perception of his or her own health

Feedback from patients and practitioners: group session and

questionnaire
Evaluating the process

Record all input (time, money, materials)

Keep diary for self-evaluation

Feedback from clients and practitioners

Suggestion box

Action plan
The action plan is the final stage in the planning process before the actual
implementation of a health intervention. Such a plan draws together the aims,
objectives, methods and resources and sets a timeframe, marking either key
events or milestones, while also taking account of the evaluation strategy
(Ewles & Simnett 2003). The action plan for this health intervention is set out
in terms of key events. The intervention will take place over a twelve week
period, based on Tanahills 1984 health promotion model (education,
prevention and protection) and incorporating the Stages of Change model
developed by Prochaska and DiClemente (1984, cited by Naidoo & Wills
2000). This model describes how clients change their behaviour through

various stages ranging from pre-contemplation and contemplating change to

then making the change (action stage) before a final stage of maintenance, at
which the new behaviour is sustained and the client moves into a healthier
lifestyle. Table 6 (Appendix 1) sets out the action plan and key events
within a set timeframe.

CONCLUSION
This paper has devised and critically appraised a clinic-based smoking
cessation intervention, targeting chronic disease patients within a GP practice
population. The intervention concerns one of the main needs identified in the
Health Needs Assessment Profile undertaken in Part One. Using Tannahills
(1985) health promotion model, the planning and evaluation framework
suggested by Ewles and Simnett (2003), and the stages of change model
developed by Prochaska and DiClemente (1984 cited by Naidoo & Wills
2000), the intervention has been designed to enable people to increase
control over, and to improve, their health, thus reflecting the World Health
Organisations definitions of health promotion (WHO 1984) and the new
public health (WHO 1998). The intervention also takes into account current
government policies by responding to peoples concerns about their health
with practical support on their own terms and by providing the context and
environment needed to make real progress (DoH 2004a). In a wider sociopolitical context, the current government describes health promotion as one of
the key roles of primary care nurses (DoH 2002) and the health service as a
whole (DoH 2000, DoH 2004b). In that respect, the Health Needs Assessment
Profile and the health promotion intervention can also be seen as a

contribution to delivering relevant National Service Frameworks (DoH 2001,

DoH 2003).
Above all, the intervention aims not only to improve the health of patients but
also to empower them to make the right choices about their own health,
providing them with the appropriate knowledge and guidance. This is made
possible by taking into account the three overlapping spheres of activity
education, prevention and protection - identified by Tannahill (1985) with
regard to health promotion. That health promotion should be a comprehensive
concept is reflected in the fact that the intervention in this paper includes
elements of various approaches, medical, behaviour change, educational and
empowerment, as described by Naidoo and Wills (2000).
Using theoretical models and frameworks to explore and address practicebased health needs and interventions allows practitioners to gain a deeper
understanding of the concepts of public health. These models and
frameworks are useful tools for translating the aims of health promotion,
protection and illness prevention into practice. This in turn makes it possible to
enhance practice with the ultimate aims of reducing inequalities, improving
health and providing better outcomes for individuals and society as a whole.

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Reform HMSO, London

Department of Health 2001 National Service Framework for Coronary Heart

Disease HMSO, London

Department of Health 2002 Liberating the Talents HMSO, London

Department of Health 2003 National Service Framework for Diabetes HMSO,

London

Department of Health 2004a Choosing health. Making healthy choices easier.

Executive summary HMSO, London

Department of Health 2004b Tackling Health Inequalities: A Programme for

Action HMSO, London

Ewles L, Simnett I 2003 Promoting Health: A Practical Guide 5th ed. Bailliere
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