This assignment aims to identify a public health need related to the authors’ current practice and a health promotion strategy to address the need. The health need chosen is Depression intervention in older Adults in the borough of Enfield. This health needs is derived from NICE, (2011) Depression in Adults Quality Standard, which highlights the identification, assessment and clinical management of depression symptoms. In addition, epidemiology data of the borough of Enfield highlighted the health need of this population group and the risk factors related to their ill health to increase awareness on preventive measures and to promote health.
The author is a district nurse and has chosen this health need due to her nature of work which includes dealing with a significant number of patients who live alone with persistent feeling of loneliness, sadness and loss of interest in her current practice. Due to increasingly ageing population worldwide, identification and treatment of depression in older adults becomes progressively more important, especially as older patients may have different presentations and needs than younger ones.
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Depression is a serious medical condition in which a person feels very sad, hopeless, and unimportant and often unable to live in a normal way. In other words, it is a mood disorder that causes a persistent feeling of sadness and loss of interest. (Craig and Mindell, 2007).Depression in older adults is an important public health problem. It is associated with increased risk of morbidity, increased risk of suicide, decreased physical, cognitive and social functioning, and greater self-neglect, all of which are in turn associated with increased mortality ( Blazer, 2003).
Depression is part of aging process but it becomes a problem when it has an impact on the older adults daily functioning (Godfrey et al, 2005).Due to increasingly ageing population worldwide, recognition and management of depression in older adults becomes progressively more important, due to the fact older patients may have diverse presentations and needs than younger ones (Hasin et al, 2005). 10 to15 per cent of older people have depression symptoms; however, major depression is relatively rare in older adults (Hasin et al, 2005).
In 2011/12, Enfield GPs had 17,508 people over the age of 18 – 65 on their registers recorded as suffering from depression, equating to 7.99% of adults on GP lists in Enfield. This was below both the England and London rates of 11.68% and 8.07% respectively, though Enfield still had the 12th highest rate of recorded depression amongst all London boroughs.
Depression can be mild, moderate or severe depending on the individual’s ill condition. Mild depression accounts for 70%, moderate depression 20% and severe depression 10% of all cases. It is estimated that depression is two to three times more common in people with a chronic physical health problem (such as cancer, heart disease, diabetes or a musculoskeletal, respiratory or neurological disorder), occurring in about 20% of this population.McCrone et al, (2008) estimated that the number of people identified with and requiring treatment for depression will increase by 17% to 1.45 million in 2026. The annual costs of depression as commonly quoted from two studies are being £9 billion in the UK (Office of National Statistics, 2009).
Health promotion strategy
District nurses can play a major role in health promotion. District nurses, more than any other sector, have the ability to prevent the development of many chronic diseases. Health promotion is defined in the Ottawa Charter (WHO, 1986) as the process of enabling people to increase control over, and to improve, their health as well as to reach a state of complete physical, mental and social well-being, an individual or group must be involves public policy change and community action to enable people to make changes in their lives.
Health promotion is aimed at improving the health of an individual, community or changing behavior that may have a negative influence on health. A Strategy in health promotion is a plan of action that anticipates barriers and resources in relation to achieving a specific objective (Green & Kreuter 1991) cited in Egger et al. (2005). Although everyone feels sad sometimes, later life can give you more reasons to feel down. You may have to deal with: Stopping work, arthritis and other health problems or the death of love ones (Craig and Mindell, 2007). Older people often posses inaccurate knowledge about ageing and may under report symptoms as they believe these symptoms are attributed to normal aging (Robert and Baldwin, 2014).
There are five different approaches in health promotion and these are: Medical or Preventive, Behaviour change, Educational, Empowerment, and Social Change. All of the approaches to tackle depression in the older adult in the day-to-day practice of district nursing will be discussed and comprehended in different ways of working. The Educational approach provides knowledge and information, and to develop the necessary skills so that people can make an informed choice about their health behaviour (Naidoo et al, 2009). (Ref) argues that, this may not result in behaviour change if the individual have not got the ability to use the information given.
The educational approach consists of three aspects of learning. The cognitive aspect is the provision of information such as leaflets, booklets or one-to-one advice to patients so they can make an informed choice about their health behavior. The affective aspect provides opportunities for patients to share and explore attitudes and feelings. The third aspect of the educational approach is the behavioral aspect, which entails developing decision-making skills required for healthy living.
The behavioural change approach aims to encourage individuals to adopt healthy behaviours in order to improve their health. Naidoo et al, (2009) agrees that this approach is popular since it views health as a property of individuals. However, the older adults may feel they are been told what to do.
Social change approach on the other hand relies on changing the environment to facilitate healthier life style. This approach has been indicated successful in previous health promotion, besides it can reduce the individuals’ freedom of choice and due to regulations and may discourage the individual from taking responsibility.
Empowering helps to identify any changes wished to be made to their lifestyles and enables priorities to be identified with support to help the older adult make changes tit her situations. Conversely, this might only be considered if the individual identifies them as concerns.
District nurses work in partnership with patients, families and carers to provide skilled nursing care at home, promote and maintain patient independence and provide education, advice and support to this targeted population group. All of the approaches encompass different ways of working. The most appropriate approaches identified to tackle depression in older adults in the day-to-day practice of district nursing which is the medical approach seeks to use treatment or screening to reduce ill health of the individual (preventive model). It aims to influence health through advice, instructions, persuasion, this requires relevant knowledge and expertise and helps to assess for the individual needs. However, preventive medical measures ignore the root causes of ill health. These will require exploring various top-down and bottom-up approaches to health promotion as stated by Beattie (1991).
There are various health promotion theories that will influence the authors’ health promotion strategy as mentioned above. Beattie (1991) believes that, one can successfully take a recommended health action if they have (self efficacy). Beattie’s model of health promotion is a complex systematic model that acknowledges that health promotion is surrounded in wider social and cultural practices Wills and Earle (2007). Governments and health care professionals typically work in a ‘top down’ approach, through legislative action and health persuasion techniques. Here, advice and recommendations are handed out, and policies and interventions designed to increase uptake of these recommendations are established. The aim of this is to protect individuals and communities.
However, both of these approaches on their own may disempower individuals through a ‘victim blaming’ culture and may therefore result in only limited change (Thomas and Stewart 2005).It showed the different ways in which education can put across different methods, which can help an individual’s health and wellbeing (Piper, 2007). The model identifies four paradigms: Health persuasion, Personal counselling, Community development and Legislative action. They contribute to achieving a whole picture when developing local action plans for partnership working (Piper, 2007).Besides District nurses should be cautious as it’s hard to identify the cause of a particular health problem as this model is generalised and not specific. Furthermore the model suggests that patient’s individual’s health related knowledge; behaviours and attitudes are the key determinants of their health status, as well as relationship between Health Care Professional (HCP) and patient Beattie, (1991). Beattie’s model supports this notion, by allowing us to analyse the complexities of health promotion approaches and by demonstrating that many agencies with many different approaches across all quadrants and axes are needed for well rounded health promotion policies and practice.
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When visiting a new patient, district nurses should carry a comprehensive holistic assessment to identify all the needs of the client. This involves getting to know the patient, family and their community while forming trusting, confident and mutual relationships (REF).Some adults with depression speak up and some remain silent however, there are things to look up to identify when people are depressed. Cognitive Behaviour Therapy (CBT) is a type of psychotherapy that looks at how you think about yourself, the world and other people around you affects your feelings and thoughts. It can also be helpful to look at the way our thoughts and feelings affect our bodies, and the physical sensations we can experience.
CBT aims to get you to a point where you can “do it yourself”, and work out your own ways of tackling problems (REF). NICE (2009) recommends that any patient who may have depression (especially those with a past history of depression or who suffer from a chronic physical illness associated with functional impairment) should be asked the following two questions: During the last month have you been feeling down, depressed or hopeless? During the last month have you often been bothered by having little interest or pleasure in doing things? Other assessments include Geriatric Depression Scale, the fifteen items (GDS-15) and 4 item (GDS-4).The systematic use of (GDS-4) helps identify depression among the elderly.
The original GDS was a 30 item questionnaire which was time consuming and challenging for some patients (and staff). Depression assessments such as the 4 item Geriatric Depression Scale are easy and quick to perform with a high sensitivity and specificity. Patients who screen positive for depression should be considered for antidepressants and be reassessed cognitively when their depression has lifted. Although screening tools are useful, they should not be a substitute for clinical judgement. The patient’s history, family history and the existence of co morbidities should be taken into account when diagnosing or assessing depression (ref). Referral can be made to the GP due to the fact that one in six older people with depression discuss their symptoms with their GP, Therefore based on the District nurse’s assessment, this targeted population group will receive adequate treatment.
How to consult the target population
The target population for district nurses will be the patients already on the caseload including their families, new referrals and residential care home patients and staffs.
The actual target for change will be identified with the individual for planning and setting of goals, (Lucas and Lloyd 2005). A qualitative study will be carried out in order to measure effectiveness before and after health promotion (Polit and Beck, 2012), as well as for confidentiality and anonymity. Thus looking at results to compare the before and after effect. A small size purposive sampling of patients from the caseload will be used. This will be achieved through face to face interviews with individuals. This step allows assessment for level of need and readiness to engage with the intervention. The nursing team will work together to implement the strategy through consultation, planning and delivery of person centered care. A team of six nurses will be involved to consult with 12 housebound patients who live alone, bereaved or have co-morbidity within the caseload. Each nurse will be allocated two patients to closely work with throughout the trial of the strategy. This will allow the nurse to build a rapport with the patient and have a good nurse patient relationship (ref).
According to the Nursing and Midwifery Council (NMC) (2008), nurses should actively engage in person centred care and empower people by involving them in assessments and care in planning. This is further affirmed by GB NICE (2011). Individual face to face interviews will be conducted to and the level of need and readiness to engage with the intervention. Eager et al (2005) posits that face to face communication has a potential to influence and to build trust. (GDS-4) will be used to assess depression level. This scale will later be used to evaluate the impact of intervention. Information on available services, treatments will be discussed for choice of care and informed decision. Health education will be delivered using evidence based practice (ref). Health risks related to awareness of symptoms or not seeking for an intervention will be discussed. This will help the person to be aware of the severity of depression to their health and may consider the help available.
Key stakeholders and resources
Stakeholder is a person or group with an interest, involvement or investment in something; Key stakeholders will be District Nurses, Carers and informal carers, GP, Local council Social workers, Mental Health services, Residential care homes, Families Clinical Commission Groups, Community leaders’ e.g. Religious leaders, Health and wellbeing board, Age concern, voluntary organizations, human recourses and commissioners. This will be a key for successful health promotion strategy which will be available due to the target group of people and good accessible resources (Linsley et al 2011) and is a useful comprehensive approach. Staff training will be required to implement this strategy. For example the recognition of the first three symptoms that are regarded as particularly important which include Depressed mood Loss of interest and enjoyment in the things the older adult enjoy doing most, (REF).
Even though the district nurses have a very busy caseload, time will be required to be allocated deliver support which might have an impact on recourses as nurses will still have to deliver care to patients and clinical duties. Nevertheless nurses are required to deliver health promotion on every patient contact, a more passionate person specific service such as the age concern will be more effective as it engages both the nurse and individual to work very close to achieve the set goal (Ref) Patients who need input from other agencies will be referred for example, community psychiatric nurse and GP for home visits. Although, this strategy is for housebound patients, carers, families and friends might benefit as well as nursing care is holistic and looks at a person as a whole including their family and environment.
Patients and local communities will be involved as stakeholders to ensure services are relevant to the local context (Naidoo and Willis, 2005) and to encourage people to feel empowered and to be able to measure satisfaction. The community Commissioning will be sought from the local health services provider who will be the key stakeholders. Communication and liaison will be made as required with the stakeholders for progress and update on the program.
The uptake of the service aims to increase awareness, improve quality of life and reduce stigma in depression within the local community and it is anticipated that at least three quarters of the participants will identify early onset depression in older adults. It will also reduce the annual cost of treatment depression. The outcome measurement can be biased due to possible exaggeration of costs. The long term outcomes will be to reduce prevalence of depression in older adult by 10% in 5 years. The evaluation of the strategy seeks to determine whether the program has had an impact on health knowledge, empowerment and behaviours and whether it has contributed to reduction in health risks and society. It is also for the commissioners to decide on the continuity of the programme and for the nursing team to determine if this is the best approach for the target population.
Linsley et al (2011) affirm that it is imperative to evaluate a program to determine its usefulness to service users or commissioners and deciding on whether to continue with the program or to highlight any need for improvement. Team members and the managers will work together in evaluating impact of care on quality of life of patients. This information will be needed after a year. However, the process evaluation will be performed every three months or as required to allow for improvements on effectiveness, safety and ensuring that the aims of the strategy are being met (Siriwardena, 2009). Also the commissioners might be interested in knowing the cost effectiveness of the programme and whether it’s sustainable. They may want to compare with other programmers running in local community centers.
Face to face in depth interviews and evaluation questionnaires will be used to collect data about the impact and outcome of the strategy. Mead et al, (2008) recommend qualitative research in gaining information about patient satisfaction for purposes of improving care. This is further supported by Holloway and Wheeler (2010) who appraise its holistic approach in individuals. However, this method is costly and data analysis can be difficult (Siu and Comerasamy, 2013). Validated questionnaires will be used and support will be given to participants who need help reading and understanding question due to visual impairment or language barrier. Information on program implementation, whether patients felt empowered and in more control over their health and if their relationship with the nurse contributed to their openness. As such, increased knowledge will be included in the questionnaire. Depression level will be assessed on those who were involved in various activities and programmes and compared with baseline assessment. Nurses will continue to monitor and observe patients during routine visits and offer support as needed. Information gained will be used to improve the strategy and in decisions regarding sustainability and continuity of the programme.
This assignment has highlighted the early identification of depression in the older adult. It has demonstrated that the use of health promotion theories and approaches can help nurses and individuals during the stages of education, social change and empowerment. The evaluation of the strategy will be used to develop services tailored to meet the needs of communities.
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