The writer seeks to critically analyse the role of the public health practitioner in general, taking into consideration the current socio-political context, the knowledge and skills needed for the role, challenges that exists in fulfilling the public health role and the approaches. In the second part of this work, the writer has chosen an initiative and will critically appraise how well the identified initiative meets the criteria for good public health. Public health skills and competencies will be identified and discussed in this initiative including health promotion theories and approaches. See Appendix-1.
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The public Practitioner role, knowledge and skills
The writer has found it appropriate to start by defining public health though there are many definitions. The Public Health Resources Unit (2008) state that the purpose of public health is to: “Improve health and population wellbeing; disease prevention and minimise its consequences; prolong valued life and health inequalities reduction (PHRU, 2008).
PHRU states that all these can be achieved through: taking a population perspective; mobilising the organised efforts of society and acting as an public health advocate; enabling people and communities to increase their own health and wellbeing; acting on the social, economic, environmental and biological determinants of health and wellbeing; protecting from and minimising the impact of the health risks to the population and ensuring that preventive, treatment and care services are of high quality evidence-based and of best value” (PHRU, 2008).
Public health as defined by Webster and French in (Tones & Tilford, 2001) comprise of three aspects which are population-level health promotion; the epidemiological analysis and health professional trained in medicine. Naidoo and Willis (2000 p. 181) looks at public health being characterised by several factors and embraces three domains; the health promotion of the whole population, health protection-a concern for the prevention of illness and disease and health service improvement-a recognition of the many factors that contribute to health
The public health practitioners have autonomy on specified areas and continually own work area and support others to understand it and practitioners are likely to work in multi-agency and multi-disciplinary environment, whereas general practitioners work as a part of a larger team led by someone working at a higher level (PHRU, 2008). An approach to public health is described by the Faculty of Public (2000) with emphasis on the collective responsibility for improvement in health and prevention of disease; recognizes the key role of the state, linked to a concern for the underlying socio-economic and wider determinants of health as well as disease. This approach is multi-disciplinary, incorporating quantitative as well as qualitative methods; emphasizes partnerships with all those who contribute to the health of the population (FPH, 2000).
Sir Donald Acheson, (1988) defines public health as “the science and art of preventing disease, prolonging life and promoting, protecting and improving health through the organised efforts of society”. He also describes the role as planning and evaluation of services as well as undertaking the surveillance of disease and co-ordinating the control of communicable diseases and public practitioner provide epidemiological advice on priority setting. Naidoo and Willis (1998) states that this will include public health practitioner skills for example communication, planning, networking, management and the use of research based evidence.
A public health practitioner is identified by Naidoo and Willis (2001) and Donaldson and Donaldson (2006) as a trained person with a role to make people and the environment healthier, to carry out researches, to advocate and work collaboratively with the community on identified projects. The public practitioner is required to implement health initiative by the government that are aimed at improving health inequalities in society. Naidoo and Willis (2008) also points out that there are three principles that underpins the health practitioner for example empowerment, participation, equity and collaborative working which concurs with World Health Organisation (WHO, 1986). Reducing health inequalities is a priority and all health professionals have a role to play in the targeting of individuals whose health status is below average, or who may not access current health services for a variety of reasons.
The 10 year NHS Plan (DOH, 2000) set a new statutory objective for NHS to allocate resources to contribute to a reduction in health status. Public health practitioners work to increase individual knowledge concerning the body function and ways of preventing illness, raising competence using health care system and awareness about political and environmental factors that influence health. Community capacity can be built by increasing their abilities to participate in promoting their health.
The government White Paper, Saving Lives (DOH, 1999) on public health strategy for England first response to Acheson Report set a national agenda for action to reduce health inequalities for example it gave a commitment to action on living standards and tackling poverty, child poverty in particular, pre-school education, employment as a poverty way out, transport, urban regeneration, crime reduction and housing improvement for disadvantaged areas, as well as preventative activities through a strengthened public health workforce (Hogstedt et al, 2008).
The government’s strategy in “Our Healthier Nation” in Department of Health 1999a is to ensure that the public health labour force was knowledgeable and skilled, well staffed and resourcefully supplied to deal with major task of delivering health strategies. Health professionals with their knowledge and skills are expected to play a part in meeting the aims set in the “White Paper” (DOH, 1999). Public health practitioner skills includes acting as leaders knowledgeable and quipped to manage strategic change and working in partnership with other agencies, focus on health promotion for community development, familiarising with public concepts and use evidence in guiding work were appropriate.
Donaldson and Donaldson (2006) states that in the UK in 1980’s there were serious failures in the standards of care which was provided in public health. Communities before were seen as passive recipients of service and service users were not valued according to McKnight (1998) in (Gorin and Arnold, 1998). Naidoo and Willis (1998 p. 9) states that modern public health acknowledges the importance of living conditions to promote health, action on health inequalities, physical and social regeneration of neighbourhoods, development of healthy public policy on food, transport and the workplace.
Public health system lacked sufficient hospital beds, staff, buildings and equipment (Tones and Tilford, 2006). According to Naidoo and Willis (2001) the public health movement emerged with the noble idea of educating the public for good health. Under the Public Health Legislation of 1848 public health workers were appointed to regularly publicize health advice on safeguards against contamination. It was noted that there was a rise of the sanitary reform in which the local government focusing on environmental issues.
The National Health Service and Community Care Act (1990) was introduced which was a significant piece of public health legislation which brought changes in the way health services was delivered, which includes massive closure of health care institutions and people were cared for in the community (Donaldson and Donaldson, 2006). Naidoo and Willis (2006) notes the publication of “Health of the Nation” (1992) strategy which targeted five key areas which includes coronary heart disease, cancer, mental health, sexual health and accidents. However Donaldson and Donaldson (2006) pointed out that “Personal Hygiene” era noted that the main causes of death and disability shifted from infections to chronic illnesses, such as heart diseases, stroke, cancers, respiratory illness and accidents where lifestyles play a causative role.
Another role of the public health practitioner is to promote and protect individuals and the wider population’s health and wellbeing by preventing the spread of infectious diseases and protection against chemical radiation or other hazards. Lifestyle changes such as stop smoking, better nutrition and more physical activities can improve health and reduce the burden of diseases like obesity, coronary heart disease and cancer. Naidoo and Wills (2001), state that the intervention of the public health practitioner was health education with an emphasis on individual behaviour. The Public Health Act of 1994 focused on housing, sanitation, safe water and food.
Ewles and Simnet (2001) states that public health was introduced by the New Labour Party in 1997 matching with same principles as World Health Organisation adopting similar policies to the Jakarta (1997) declaration with emphasis on infrastructure and investment, with empowering the service user to make informed choices.
The Minister of Public Health was then introduced in 1997 (Donaldson and Donaldson, 2006) which led to the creation of Health Development Agency in (1998) with the aim of maintaining and publicizing evidence based for health improvement and advising on standards for public health and health promotion carrying out campaigns in addition to the formation of public health observatories which were linked with universities in order to monitor health and highlight areas of action and evaluating progress by local agencies with the aim to improve health and reduce inequality.
Naidoo and Willis (2000, p. 139) also states that the New Labour government created a Minister for Public Health in 1997 with a responsibility to co-ordinate health policy across different sectors and highlight the impact of different policies. New reforms were also introduced in ‘The New NHS-Modern, Dependable’ (DoH, 1997) with intention to replace the internal market with integrated care led by primary care groups of General Practitioners and community nurses whose responsibilities are commissioning and providing health care services for their local population. The New Public Health was introduced focusing on heath promotion and education using the “bottom-up” approach and focusing on public health rather than acute services.
Tones and Tilford (2001) cites the Acheson enquiry which raised concerns regarding critical inequalities in health that in society the worst off are more ill and die earlier resulting to Green Paper (2003) with aims to reduce health inequalities. Three areas were prioritised by the report in relation to health inequalities, assessment of all relevant policies, for example the health of families with children and further reduction of income inequalities and poverty.
The Department of Health (2003) Tackling Health Inequalities’ 3 year programme was set up to tackle health inequalities. It had four topics to support families to break the cycle of poverty, engaging communities and individuals to ensure relevance, responsiveness and sustainability as well as preventing illness and providing effective treatment and care culminating in addressing the underlying determinants of health.
Tones and Tilford (2001) furthermore notes the reformation of the NHS by the Labour government to create a health service fit for the needs of 21st century Britain which is better, faster, more convenient service for patients that is fair and free to everyone.
A variety of measures were introduced to improve quality of life in run down areas with a range of strategies to work towards quality homes for all. The New Labour implemented a policy of providing good housing in collaboration with the private sector in order to protect and meet the needs of the most vulnerable people (Naidoo and Willis (2001).
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Challenges that exists
Challenges that exist in the public health sector are the current economic situation faced by the government which can cause difficulty in securing funding. The other challenge is failure in understanding or valuing the work of public health professional which can undermine their effectiveness and generate a defensive culture and negatively affects their moral; a lack of defined standards for public health practice and; a lack of clear accountability for health improvement.
The shortage of some technical skills for example needs assessment, analysis and interpretation of information, critical appraisal and implementation skills; limited number of eligible applicants; sub-optimal working arrangements with local authorities manifesting in lack of consistency of local community plans and health plans. The other challenges are inadequacy of health as opposed to health service information systems and surveillance system for communicable and non-communicable disease. The other challenge is the difficulty in accessing public health evidence of promptly in a useable form; duplication of activity, in marshalling epidemiological information and evidence of effectiveness of health programmes.
Lastly limited partnership between academic and public health service departments; limited pooling of resources and expertise between Health Boards and the NHS and other agencies and a lack of milestones by which to measure success (Review of the Public Health Function in Scotland, 2000).
Part 2: Health initiative (Sure Start)
The writer has chosen to focus on Sure Start which is a government programme aimed at delivering the best start in life for every child by bringing together early education, childcare, health and family support. The following are responsible for delivering Sure Start within Department for Children, Schools and Families: The Early Years, Extended Schools and Special Needs Group.
Britain had the highest teenage pregnancy rate in Europe in the mid-1990s which led to the need of health promotion (UNICEF, 2001). In UK the Child Act, 2004 provides the legal underpinning children’s services set out by the government in the Green Paper in 2003, Every Child Matters as a Government’s approach to the well being of children and young people aimed at giving all children the support they need to be healthy, stay safe, enjoy and achieve, make a positive contribution and achieve economic well being which concurs with Ottawa Charter.
The Children’s Plan (2007) was then published with a ten year strategy with aims to improve educational outcomes for children, improve children’s health, reduce offending rates among young people and eradicate children poverty by 2020 (DCFS, 2007). Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health (Ottawa Charter, 1986). For that reason the government therefore planned to deliver the best start for every child in bringing together early education, childcare, health and family support through Sure Start (Asthana and Halliday, 2006).
Sure start is a public health approach that takes a population perspective, tackling causes of ill health and this is done by teaching mothers on breast feeding avoids “lifestyles” focus and its marginalisation of socio-economic and environmental influences on health which is in line with Saving Lives: Our Healthier Nation (1999).
The Department for Education and Skills (2000) set up Sure Start’s core aims, targets and initiatives in their guidance document at the beginning of the programme (DES, 2000, pp. 1-2) were to improve health by accessing appropriate healthcare; enable informed choices about continuing a pregnancy or not; support teenage parents in caring for their children.
Ewles (2006) support the idea that there is evidence to support the use of behaviour modification in conjunction with changes in caring for the vulnerable children and levels of activities involved in pre and post birth which concurs with the government’s programme responding to Acheson report (1998) in Tackling Health Inequalities. This is seen by Beattie (1991) as objective reality of empowerment based on actual situation on community level.
By promoting and protecting the health of pregnant and parenting teen mothers and their children Sure Start seem to be inline with Bradshaw’s taxonomy (1972) of health and social needs. Teenage parenthood is identified by Sure Start as both a cause and a consequence of social exclusion (Social Exclusion Unit, 1999) and this can be a normative need. Social Exclusion Unit (1999) also predicted the problems that involve a greater than average risk of being poor, unemployed and isolated. This is in accordance to the Acheson report (1998) which focuses on health inequalities and defines public health as the “art and science of the prevention of disease and the promotion of health through the organised efforts of society.
According to McLeod (2001) teenage mothers when compared to other mothers they have been seen as more likely to experience poverty and social deprivation and even in adult life, although these likelihoods might be a meaning of their deprived status relatively than of becoming a parent early per se (Ermisch and Pevalin, 2003). According to Bradshaw taxonomy this could be identified as a comparative need which concerns problems which emerge by comparison with others who are not in need. Furthermore he state that one of the most common uses of this approach is the comparison of social problems in different areas in order to determine which areas are most deprived.
According to Social Exclusion Unit (1999) the government policy objective is to promote continuous learning among young people through Sure Start focusing on prevention of conceptions and secondly focussing on supporting teenage mothers primarily by measures to strongly encourage them to complete their education and keep in touch with the jobs market. This concurs with Naidoo and Willis (2001) who views public health as working together with others on shared programmes on the other hand to ensure that health promotion activities were achieved. Sure Start use collaboration, education and participatory approaches.
Furthermore Dugan (1996) encourages public health practitioners to use participatory approach as a process that has rewarding effects and increases local talent and capacity, provides flexibility and systematic process for people.
Micklewright (2002) assets that seven out of thirteen indicators in the second annual statement on poverty and social exclusion connecting to children and young people are measures of education and gaining skills. Educational approach enables health promoters to work with the community as partners giving guidance and not taking control but listening and taking their perspective on board.
Educational approach expressed by Naidoo and Willis (2001) enriches the community with knowledge, information and developing skills that will enable them to make informed choices with regards to their health behaviour. Whereas community development aims at empowering people to work together to influence the social, economic, political and environmental issues that influence them (Naidoo and Willis, 2000). World Health Organization believed that people needed to hold some degree of control over their living and working conditions in order to develop lifestyles conducive to health (WHO, 1986). Ottawa Charter defines health promotion as the process of enabling people to increase control over, and improve their health (WHO, 1986).
In conclusion public health practitioners’ role is to influence and identify those factors that promote the health of the population and contributes to reducing health inequalities, and able to influence teams and organizations and valuing professional development. For health practitioners to work effectively, good and effective communication skills are required that enables them to use appropriate verbal and non verbal communication skills to deliver relevant information to various people. It is essential that studies are conducted that primarily focus on the whole range of public health roles within health practice with particular emphasis given to examine the effects of these roles on public health professionals, and the education and training that will be necessary for these roles.
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