Module Title:
Promoting the Public Health of Populations in Specialist Community Public Health Nursing
Module Code: SHN3048
Critical evaluation of the current public health agenda in relation to a health need identified within a community profile.
 
The purpose of this assignment is to critically analyse the current public health agenda in relation to a health need identified through use of community profiling. This paper will aim to provide recommendations as to how a Specialist Community Public Health Nurse (SCPHN) can proactively address high levels of obesity identified within the Cwmbwrla ward (Appendix 1). For the benefit of the reader Cwmbwrla is a suburban area of Swansea, with good transport links to the city centre. In considering the level of deprivation Cwmbwrla is ranked 181 0f 1,909 (LSOA) in Wales (Welsh Government, 2014a).
Public health in the 21st century is defined by Riegelman (2010 p4) as “the totality of all evidence-based public and private efforts that preserve and prolong health and prevent disease, disability and death” thus, recognising public health as a varied approach which should be viewed holistically.
Health visitors are a group of specialist community public health nurses (SCPHN), skilled in delivering a proactive Public health service which relies on evidence base research to enhance health and reduce inequalities for all families with children 0-5 (Royal College of Nursing, 2011; The National Institute for Health and Care Excellence (NICE) 2014). The current Public Health strategy in Wales aims to achieve a healthier, happier and fairer Wales, through improving health, reducing inequalities and supporting a good start in life (Public Health Wales (PHW), 2015; Welsh Assembly Government (WAG), 2010; WAG, 2011a; Welsh Government (WG), 2016). There is consistent evidence which suggests investment in the early years significantly improves the health of the child and has a positive impact on long term outcomes (Acheson,1998; Black,1980; Marmot, 2010). As a result of the reaffirmation of the public health role of the SCPHN in recent policy, it is believed that the health visitor is strategically placed to empower individuals and positively influence the health outcomes of young children and their families (Department of Health (DoH), 2011; WG, 2012a).

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The four domains of SCPHN practice begin with Search for health needs (Cowley & Frost, 2006), thus requiring health visitors to undertake an assessment of the population’s health and well-being. A key part of this process is health needs assessment (HNA) (Nursing and midwifery Council, 2010).  In defining HNA, Stewart et al, (2009) suggests the purpose is to identify the health assets and need of a population in order to inform decisions regarding service delivery to improve health and reduce inequalities. Through use of HNA policies are developed and needs are prioritized across services, with the aim of targeting those in greatest need (Williams, 2013).
Statistics from the profiled area of the Cwmbwrla ward (Appendix 1), identify high levels of obesity in adulthood as being a significant problem. Despite there being no local data to highlight the levels of childhood obesity specifically within the ward, research suggests a strong link between childhood obesity and obesity in later life (NHS, 2015). Findings from the child measurement program 2014-2015, recorded that 11.8% of 4-5 year olds in Swansea were obese (Public Health Wales Observatory, 2016), a trend mirrored throughout Wales, with findings from the Welsh health Survey (2011) identifying that 35% of children living in Wales were classed as overweight or obese.

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Obesity has fast become a global epidemic (World Health Organisation (WHO), 2003; 2016), with research suggesting that obesity is the world’s most common nutritional disorder (NICE, 2014). The 2007 Foresight report emphasized the need to tackle the problem of obesity in the United Kingdom, particularly in childhood. The prevalence of obesity in infants, children and adolescents is increasing rapidly both nationally, and internationally, which has a significant impact on both short and long term health (Hall et al, 2009; WHO, 2016 ). Exploration of the literature suggests that there are many risk factors associated with becoming overweight, with the key principles leading to obesity being laid down in childhood (WAG, 2010). Wanless (2004) and Jones et al (2005) identified that during the period of 1986-2002 weight gain in children translated to a doubling in the proportion of those classified obese.  Childhood obesity is becoming evident in younger ages, with studies documenting a sizable increase in the percentage of overweight children between the ages of two and three years (Hall et al, 2009; Nelson, 2004). Studies linking overweight to psychological consequences show that obese children tend to have low self-esteem, increased rates of sadness, loneliness and are often bullied and socially excluded outside the home (Strauss,2000).
Promoting healthy weight and preventing and managing obesity have become pressing public health priorities over recent years (Phillips et al 2011). The effects of addressing obesity in early childhood are not solely limited to its health benefits; improvements in the rates of obesity could potentially save the NHS millions. In Wales alone it is estimated that between 1.65 million a week is spent treating conditions linked to Obesity (PHW, 2016). Despite obesity being at the forefront of the Public health agenda within the UK, progress in tackling childhood obesity has been slow and inconsistent, with a clear lack of provision identified as a problem within Wales (WAG, 2010; WHO, 2016).
It has long been recognized that socioeconomic class has a significant impact on health inequalities, with those living in the most deprived areas more at risk of becoming overweight or obese (Acheson, 1998; Black, 1980). This is of particular relevance to the Cwmbwrla ward (APPENDIX 1), which falls within the 20% most deprived areas within Wales (WG, 2014). NICE (2014) supports this, with statistics indicating that 29% of children living in the most deprived areas of Wales being overweight or obese compared to 21% in the least deprived areas. More recent findings have suggested that, despite improvements in the overall health of the general population, there continues to be significant gaps between the social classes (Dahlgren and Whitehead, 1991; Marmot, 2010). These differences have been tackled within Welsh Government policy, which aimed to target the most deprived areas of Wales, through the delivery of the Flying Start program, which promotes health and delivers intensive services in areas of greatest need (WAG, 2005, 2011a; WG, 2016). While such services must be applauded for their proactive approach, it must also be considered that as a consequence of this, the availability services relies heavily on postcode (WG, 2013), resulting in many families in ‘need’ being unable to access necessary support. However, more recent WG policy has identified the need to tackle inequality, and improve health outcomes for all children, delivering support in key areas to all families with children under 7, underpinned by the principle of progressive universalism (HCWP, 2016).
As previously identified, the determinants of obesity are complex and varied, it is important to recognise than no single intervention is likely to prevent or improve childhood obesity alone (WHO, 2012). Availability of data is important in planning services at a local level. Collaboration, leadership and quality improvement play a leading role within WG policy (PHW, 2013; WG, 2011, 2016). These policies emphasize the importance of adopting a muti-agency approach in addressing health needs, thus, identifying the need for SCPHN to support existing programs when planning health interventions to address obesity, with the aim of strengthening current initiatives and reducing the need for later more expensive treatments (NICE, 2013). The all wales obesity pathway supports this, and sets out a multi-agency approach in targeting obesity, allowing the identification of gaps in provision and the determination of where to best focus efforts (WAG, 2010). Over recent years, the WG have invested millions on strategies targeting obesity; for example, ‘Free swimming programme (2003)’, ‘Health Challenge Wales’ (2005), ‘Creating an active Wales (2009)’, ‘Mend (2009)’, and ‘Our healthy future (2009)’, despite this the number of overweight children and adults continues to rise (Mc Pherson & Marsh, 2007).
Research suggests it Is highly likely that obese children will have obese parents, thus indicating the possible detrimental effects of learnt behaviours in childhood such as poor eating habits (NICE,2015). The literature emphasises the need for family involvement in interventions to ensure improvements in outcomes (Public Health England, 2014). There is emerging evidence that programmes that aim to enhance parenting skills can have a positive impact on childhood obesity (Berge & Everts, 2011). Therefore, within the Cwmbwrla area, a recommendation would be to build community capacity for healthy eating by setting up a 4 week weaning programme. The programme would be available to families between the 16 week clinic contact and 24 week health review as per the HCWP (2016), and will deliver education and advice within a group setting. The programme will cover topics such as, delayed weaning, healthy eating in childhood, controlling portion size and how to quickly create cheap but nutritious meals, with the aim of encouraging behaviour change using an educational approach (Naidoo & Wills, 2016). The programme would aim to build upon existing initiatives such as ‘Change 4 Life’, which has previously been judged for not fulfilling its full potential (WAG, 2014). However,  it is important to consider that in the past, group programmes have been criticised for failing to involve individuals and communities who are “hard to reach” resulting in poor engagement (PHW, 2013).
A further recommendation for the Cwmbwrla ward would be the provision of Increased/intensive home visits to specific families identified during the antenatal or birth visit as being at risk of overweight or obesity. Research has indicated a correlation between parenting lifestyle and that of their children in terms of diet and physical activity (Rhee, 2008). Arguably, the most effective strategy we can employ in tackling obesity in childhood is to work with parents (Golan, Kaufman & Shahar, 2006).The aim is to focus on parents and support them to making positive choices that facilitate a healthy start in life. The additional visits will enable SCPHN to facilitate behaviour change by addressing key influences such as; positive parenting, feeding behaviour and food and activities accessible within the home, while also allowing the SCPHN the flexibility to  tailor the program specifically to the needs of the individual family. It is imperative that SCPHN are mindful that there is no one correct parenting style, it is therefore important when delivering the program not to stereotype, but to encourage a generally more authoritative approach. Delivering the program within the home will aim to address the possible barriers families experience in accessing services (PHW, 2013).
To conclude, this paper has evaluated the current public health agenda in relation to high levels of obesity identified within the Cwmbwla ward, a trend mirrored throughout the UK. Findings suggest that effort needs to be invested in preventing obesity, particularly in children; targeting early intervention and encouraging and educating families to adopt a healthy varied diet and active lifestyle (NICE, 2006, 2014).
Through raising awareness, and by influencing local and national policies, SCPHN can facilitate ways to combat the problem of childhood obesity and seek to change the patterns which lead to obesity and poor health in later life (Cowley & Frost, 2006; WG, 2014). As a result, recommendations for practice were identified for implementation within the profiled area of Cwmbwrla. The overall aim is for SCPHN to identify, address and facilitating families to overcome the current obesity epidemic, which could potentially result in a huge gain in terms of both cost to the NHS and more importantly the health of children and the adults they become (WG, 2015).