Helping women attain the best possible health means using initiatives which take into account the practicalities of women's lives. Health promotion activities to achieve this goal will need careful planning and appropriate preparation by nurses.
By reading this article and writing a Practice profile, you can gain ten Continuing Education Points (CEPs). Guidelines on how to write and submit a profile, along with examples that have been submitted by Nursing Standard readers, are featured immediately after the continuing professional development article every week.
This article will explore ways in which nurses can promote women's health in different areas of practice. After reading the article you should be able to:
It is important to acknowledge, when considering health promotion activities aimed specifically at one sector of society, that the needs in that sector are not more important than the needs of any other group in society. The NHS was set up with the specific aim of offering equal access to health for all on the basis of need, and this principle of equality remains. It is clear, however, that different groups in society have different needs. Hence, health care may need to be targeted and delivered in different ways so that all groups gain maximum benefit from the service. Age, sex, ethnic origin, socio-economic circumstances, geographical location and numerous other variables can all affect an individual's health, and every individual belongs to a large number of different subgroups of society as a whole (Fig. 1).
| [Help with image viewing] [Email Jumpstart To Image] | Fig. 1. Subgroups and multiple membership in society |
For nurses and other health workers, promoting women's health means working specifically to help women attain the best possible health, while maintaining a professional commitment to assist every individual to achieve maximum health.
Make a list of health issues which you might need to consider when planning a programme of health promotion activities aimed at women. Then compare your list with the text that follows.
Women's health issues can be divided into four categories:
[squf] Conditions and experiences which are exclusive to women, but are not diseases, such as pregnancy, childbirth, breastfeeding and the menopause.
[squf] Disorders which are directly related to the female anatomy, such as gynaecological cancers and breast disease.
[squf] Conditions which affect both sexes but are a significant health issue for women, such as coronary heart disease (CHD), lung cancer and breast cancer.
[squf] Issues that arise from women's lifestyles and experience in society, which may include mental health, sexual health and contraception.
The principle causes of death for women come from the second and third categories, and the biggest killer is CHD. One in five women die from CHD (BHF 1997). It is thought that before the menopause, endogenous oestrogens may confer protection against CHD.
After the menopause, there is some evidence that hormone replacement therapy can help to offset the rise in CHD mortality (Ettinger et al 1996, Hunt et al 1990). Other causes of death for women are:
Lung cancer For every 100,000 women, 24 died of lung cancer in 1990, compared with about 60 per 100,000 men. However, while the rate of lung cancer deaths in men has been falling since at least 1970, the rate of lung cancer deaths in women has been rising since 1970 (DoH 1992). In 1990, 28 per cent of women smoked cigarettes (DoH 1992), a potentially modifiable risk factor for lung cancer as well as heart disease.
Hypertension and cerebrovascular disease Stroke is the third most common cause of death in the UK. In many parts of the north of England, in particular, the standardised mortality ratio for deaths from stroke in women aged 35 to 64 is more than 124, where 100 is the average for England and Wales (IPH 1993). Hypertension is a major risk factor for stroke and is potentially modifiable if detected by screening, and if follow-up measurement and treatment is instituted.
Breast cancer In 1992, more than 13,600 women died from breast cancer, the commonest form of cancer in women (IPH 1993). With the national breast screening programme in place for women aged 50 to 64 who are registered with a GP, early detection of malignancies can maximise a woman's chances of survival. Younger women need teaching and reminding about breast awareness to ensure that they detect changes in the breast at the earliest stage.
Cervical cancer The incidence of invasive cervical cancer is 155 per million (IPH 1993) and rises with age. Premalignant changes can be detected by cervical screening, and treatment of such lesions can be curative. Education about the condition and the promotion of screening is essential to detect pre-symptomatic disease.
Hip fractures resulting from osteoporosis Women have a 12 per cent risk of developing a hip fracture before the age of 85, compared to 5 per cent for men (IPH 1993). Between 1987 and 1991, hip fractures caused more than 8,000 deaths. Osteoporosis is a modifiable risk factor for hip fracture as is the use of hormone replacement therapy. Regular physical exercise, stopping smoking and an adequate dietary intake of calcium are all factors which reduce the incidence of osteoporosis. Women can also be educated about these factors, and offered help to achieve them.
Where would you look for information on women's health and patterns of morbidity and mortality? Make notes on any specific sources you are aware of, then compare your notes with those in Box 1.
| [Help with image viewing] [Email Jumpstart To Image] | Box 1. Sources of information on women's health |
There are many different definitions of the term health promotion, and it is often used as an umbrella term for a range of activities which aim to enhance health and/or prevent disease.
Simnett (1995) describes five types of health promotion activities:
Nurses working in different settings will recognise opportunities to become involved in some or all of these activities. District nurses, practice nurses, school nurses and occupational health nurses will be called on to give information, and to participate in screening and immunisation programmes. Health visitors will be involved in community development activities, and may also lobby for health policies and environmental approaches. The principles of health visiting underline the commitment of this branch of the profession to the promotion and pursuit of public health (Box 2).
| [Help with image viewing] [Email Jumpstart To Image] | Box 2. Principles of health visiting |
Jones and Naidoo (1997) identify five approaches to health promotion. These are:
Try to apply the five approaches to health promotion above to a post-menopausal woman who has had a hip fracture due to osteoporosis (loss of bone mass, exacerbated by smoking, low calcium intake and little exercise). Then compare your notes with Box 3.
| [Help with image viewing] [Email Jumpstart To Image] | Box 3. Applying health promotion approaches |
Whichever approach is taken, there are some practical issues which need to be tackled for health promotion opportunities to be created. These practical topics can be considered under the headings of:
Infrastructure This refers to 'setting the scene' for health promotion activities. If, for example, an exercise group for postnatal women is to be set up, a suitable room needs to be identified, with a suitable floor surface, adequate heating, ventilation and privacy. Enough time needs to be available for people to arrive, change, exercise, cool down, perhaps wash, change and have a drink before leaving. Facilities need to be on hand for washing and changing and, if the mothers are going to bring their babies, even more facilities need to be available for the cr[egrave]che. Legal requirements regarding the amount of space, availability of facilities and the competence of people looking after children all need to be investigated.
For more opportunistic health promotion, carried out by an individual nurse with an individual client, there are still infrastructure issues. A practice nurse working with five-minute appointments, some double-booked, and 'extras' waiting at the end of surgery, will not have sufficient time to spend on health promotion with patients. If cervical smears or 'pill checks' are to be used as opportunities for health promotion, the nurse may need to negotiate for 15- or 20-minute appointments for these women.
Health visitors who regard health promotion as part of their daily work with families will also need to consider the infrastructure of their health promotion work. They may need to ensure that they have leaflets, videos or other relevant resources to hand out to clients who would benefit from them. They will need to update their list of voluntary and support groups regularly to ensure that they do not give people out-of-date information, and be aware of any local or national health promotion events which clients might be directed to, or which might prompt particular questions. Knowing, for example, if National Cot Death Week is approaching should prompt all nurses in contact with families to update their knowledge of sudden infant death syndrome to ensure they are able to answer questions, dispel myths and advise families appropriately.
Preparation In addition to 'setting the scene' by considering infrastructure issues, it is important to 'prepare the players'. This preparation will include specific training in promoting health. The Health Education Authority's 'Helping people change' course is one example, teaching the transtheoretical model of behaviour change (Prochaska and DiClemente 1983) is another.
Another useful preparation is the 'Look after yourself/look after your heart' training. Additional training or updating in the topic areas to be covered is also essential. Study days or longer courses on, for example, hormone replacement therapy and the meno-pause, primary and secondary prevention of CHD and sexual health issues are frequently available. The RCN Nursing Update series also has a number of titles relevant to women's health issues.
While funding and/or time for attending courses or study days may be difficult to find, such preparation is essential. The Code of Professional Conduct (UKCC 1992a) states that 'as a registered nurse... you are personally accountable for your practice, and, in the exercise of your professional accountability, must... maintain and improve your professional knowledge and competence; acknowledge any limitations in your knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe and skilled manner'.
This makes it clear that if a nurse is asked to take on the running of a menopause clinic, for example, and does not feel competent to do so, he or she must refuse to do so until adequate preparation has been undertaken.
Such preparation does not have to mean attending a course. Reading appropriate literature, visiting other clinics, working through distance learning packs and/or practising specific skills under supervision can all contribute to bringing a practitioner to the point where he or she feels competent to undertake a new area of work. The Scope of Professional Practice is the UKCC document governing the taking on of new roles by nurses, health visitors and midwives. It states: 'The registered nurse...must honestly acknowledge any limits of personal knowledge and skill and take steps to remedy any relevant deficits in order effectively and appropriately to meet the needs of patients and clients' (UKCC 1992b).
In addition to preparation through training and updating where necessary, it is useful to consider who is the most appropriate person in the primary healthcare team to undertake health promotion on a specific topic, or for a specific client group. If a need was identified for additional teaching on contraceptive choices for teenagers, for example, it might be more appropriate for the school nurse with specialist training in the needs and attitudes of this age group to undertake the work, than for the practice nurse to invite them to the surgery, with its 'medical' connotations.
Alternatively, the practice nurse and school nurse could work together, combining the school nurse's expertise with the practice nurse's information resources and access to the doctors for prescriptions. Similarly, if a series of talks about the menopause was planned, it might be appropriate for some of the sessions to be led by a health visitor, with an emphasis on health and choice, rather than by a medical colleague with the associated implications that the condition is a disease which requires treatment.
Evaluation Evaluation of health promotion is often difficult, as outcomes, particularly of prevention, can be hard to measure. Some conditions, such as CHD, are multifactoral and take many years to develop. It is impossible to measure the outcome of a smoking cessation group in terms of heart attacks prevented.
Other conditions, such as hip fractures in a practice population, are relatively small in number and therefore the impact of health promotion is hard to identify. But it is important to decide in advance what aspects of an initiative are to be evaluated so that appropriate data can be collected from the start. Some examples are shown in Box 4. Advice, assistance and samples of data collection sheets can usually be obtained from the local medical audit advisory group (MAAG), or primary care audit group (PCAG). Their contact details will be available either through a GP's surgery, or the health authority.
| [Help with image viewing] [Email Jumpstart To Image] | Box 4. Examples of evaluation of health promotion initiatives |
Setting up a health promotion initiative, whether a clinic, group session or opportunistic approach, is a beginning. However, if few women attend, or show an interest when the topic is broached during a visit, little can be achieved. There are a number of practical steps that need to be considered to encourage women to take up health promotion opportunities:
Timing It is impossible to generalise about women's lives, but it is worth considering whether a clinic or planned visit will coincide with a woman's working hours, interfere with her need to collect children from school, or mean she has to leave the surgery alone after dark. Late summer may be an appropriate time to promote flu vaccination which is given in October, but late for a campaign to immunise older women against tetanus before the gardening season. Promoting breast screening for the appropriate age group would be most effective in the months leading up to the area's 'call up' of eligible women, which only takes place once every three years.
Convenience This may make the difference between two people and 20 people attending a group or clinic. If children can be looked after, toilet and washing facilities are available, or a venue is used which is on a bus route, more women may be able to attend. One-stop visits - at which individual advice, group discussion, information and prescription, for example, can all be obtained in one visit - are helpful for people with busy lives.
Advertising Advertising of any health promotion activity should be clear and informative. A poster saying 'Women's group meets here weekly' does not convey much useful information. Details such as time, purpose and nature of the group would be more helpful. The look of a poster or leaflet is influential; those which have too much information, use vague terminology, or are nearly illegible from photocopying will not attract many people.
Other forms of advertising work best if given lots of time, and if undertaken as a whole team effort. Individual letters can be sent out to potential attendees using information from surgery computers or age/sex registers. This type of advertisement is most appropriate if a limited number of people are to be invited and they can be easily identified on the basis of information held on the computer.
Design a poster for a Women's smoking cessation group to be held at the clinic on Mondays for six weeks between 1 and 2pm. Show it to colleagues for comments.
Women's health encompasses conditions related to female anatomy, and other conditions which are a significant cause of mortality and morbidity for women. A number of approaches to health promotion can be taken, but all need careful planning and appropriate preparation of the practitioners who will be involved. Successfully attracting women to health promotion initiatives requires consideration of the practicalities of women's lives and appropriate targeting of information
Now that you have completed the article, you might like to think about writing a Practice profile. Guidelines to help you write and submit a profile are outlined on page 44.
British Heart Foundation (1997) Coronary Heart Disease Statistics. London, BHF. [Context Link]
Council for the Education and Training of Health Visitors (1997) An Investigation into the Principles and Practices of Health Visiting. London, CETHV.
Department of Health (1992) The Health of the Nation: A Strategy for Health in England. London, HMSO. [Context Link]
Ettinger B et al (1996) Reduced mortality associated with long-term postmenopausal estrogen therapy. Obstetrics and Gynaecology. 87, 6-12. [Context Link]
Hunt K et al (1990) Mortality in a cohort of long-term users of hormone replacement therapy: an updated analysis. British Journal of Obstetrics and Gynaecology. 97, 1080-1086. [Context Link]
Institute of Public Health (1993) Population Health Outcome Indicators for the NHS: England. Guildford, Institute of Public Health. [Context Link]
Jones L, Naidoo J (1977) In Katz J, Peberdy A (Eds) Promoting Health: Knowledge and Practice. Milton Keynes, The Open University.
Prochaska J, DiClemente C (1983) Stages and processes of self-change of smoking: towards an integrative model of change. Journal of Consulting and Clinical Psychology. 51, 390-395. [Context Link]
Simnett I (1995) Managing Health Promotion: Developing Health Organisations and Communities. Chichester, Wiley. [Context Link]
United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992a) Code of Professional Conduct. London, UKCC. [Context Link]
United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992b) The Scope of Professional Practice. London, UKCC. [Context Link]
This self-assessment questionnaire (SAQ) will help you to test your knowledge. Each week you will find ten multiple-choice questions broadly linked to the continuing professional development (CPD) article. The answers might not be found in the article itself and you may wish to use reference books to assist you. The key words listed at the beginning of the CPD article are used as a basis for the questions.
Note: There is only one correct answer for each question.
There are several ways that you can make use of this assessment.
[squf] You could test your subject knowledge by attempting the questions before reading the article, and then go back over them to see if you would answer any differently.
[squf] Alternatively, you might like to read the article to update yourself before attempting the questions.
[squf] The answers will be published in next week's Nursing Standard.
Each week there is a draw for correct entries. If you wish to enter, send your answers on a postcard to: Nursing Standard, Nursing Standard House, 17-19 Peterborough Road, Harrow, Middlesex HA1 2AX, or via e-mail to: joyce.harper@rcn.org.uk
Ensure you include your name and address and the SAQ number. This is SAQ No 002. Entries must be received by 10am on Tuesday February 15. This week's successful winner will receive [pound]50 in book tokens.
[squf] When you have completed your self-assessment, cut out this page and add it to your professional portfolio. You can record the amount of time that it has taken you, and don't forget to include any time spent consulting other sources to find answers. Space has also been provided for you to add any comments and additional reading that you might have undertaken.
[squf] If you wish to further your professional development, you might consider writing a practice profile, see page 45.
| [Help with image viewing] [Email Jumpstart To Image] | Figure. No caption available. |
Keywords: Women's health; Health promotion
Copyright (c) 2000-2007 Ovid Technologies, Inc.
No comments:
Post a Comment