Consider the case study in order to demonstrate your understanding of key principals of Public Health
Case Study 4
Tom is a 68 year old Chinese male and lives alone in a large property. He took early retirement several years ago from the local council and he is feeling increasingly isolated and lonely, since his wife died last year. He has a son and daughter but they are both very busy with their families and don’t get to see him much. He smokes and finds it difficult to cook for himself; he has takeaway meals most days.
Health is a “state of complete physical, mental and social well-being, not merely the absence of disease or infirmity” World Health Organisation (1946).
As the world’s population as a whole is living longer, the health and well-being of the aging population becomes increasingly important. Although age is not a reliable indicator of an individual’s health or mental capacity, the probability of death or of suffering limitations of function and a wide range of health problems, increase with increasing age (Public Health England, 2000). Therefore, there is a significantly higher demand for the provision of services to meet the needs of this aging population. This has resulted in a governmental agenda, attempting to reduce the risks and behaviours that negatively affect our health. There is a growing frequency of public health issues that dominate the media, for example; smoking, alcohol consumption, illicit drug use, and diet; the public are inundated with information about how such issues affect our physical and mental health. Public health aims to prevent ill health through mass education, through providing information, and promoting good health practice (Naidoo & Wills, 2005). Prolonged life expectancy combined with poor health choices has culminated in increased effort from the government and public health policy to improve outcomes and reduce the burden on the health service.
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With regards to the above case study, there are many identifiably public health concerns for Tom. An elderly individual living alone is a risk factor in itself, but when combined with feelings of loneliness, social isolation, bereavement, lack of support networks, smoking, and poor diet it is clear that Tom is experiencing a wide range of health risks. This assignment will address the health risks of Tom’s lifestyle choices such as smoking and poor dietary choices. As well as public health issues regarding his social isolation, and the associated impacts such factors can have on Tom’s health. The assignment will also look at governmental policy and initiatives put in place to encourage health promoting behaviour, as well as relevant sociological theories.
Cigarette smoking is known as the primary avoidable cause of premature death in the UK, and is a risk factor for many physical and mental disorders (Ebrahimi, Sahebihagh, Ghofranipour, & Tabrizi, 2014). It is associated with a range of negative health effects, irrespective of the age of the user; such as coronary artery diseases, renal failure, cancers, and pulmonary diseases (Ebrahimi, et al., 2014). Despite worldwide anti-smoking campaigns, some smokers remain in denial or ignorant to the associated health risks. Cigarette smoking in the elderly in particular, is more likely to lead to a poor quality of life in later years, increase the chances of serious disease and decrease one’s lifespan (Senior Health 365, 2011). Research suggests that older smokers are less likely than younger smokers to attempt quitting; however, they are more likely to be successful when attempts are made. Rates of developing smoking related diseases and mortality due to smoking increase with increasing age and duration of smoking (Burns, 2000). Although, lung cancer is the largest cause of excess smoking-related mortality over the age of 60 years, there are many other health risks associated with cigarette smoking in the elderly; for example bone mineral density, chronic obstructive pulmonary disease (COPD), circulatory disorders which increase the risk of heart attack or stroke, vision impairment and reversible blindness, the effects of smoking are also detrimental to mental health; even in the absence of disease, the age-related changes in cognition can be further aggravated by cigarette smoking (Burns, 2000; Yanbeava et al., 2007; Higgins et al., 1993).
In 2011 the Government published ‘Healthy Lives, Healthy People: a tobacco control plan for England’, outlining plans to promote smoking cessation throughout England. The document discusses using plain cigarette packaging and legislation to end tobacco displays in shops, higher taxes on tobacco in order to make cigarettes more expensive and therefore discourage consumers, and encouraging people to quit with support through local and NHS stop smoking services (Department of health, 2011). People, on average, are 4 times more likely to stop smoking with the help of an NHS stop smoking service, which offer a free telephone support service, one to one sessions, and online community for individuals to swap tips and stories about their experiences of quitting smoking; clinics are readily accessible through most GP’s. There are alternatives ways of accessing support, for example if Tom does not have access to a computer or the internet. Yorkshire Smokefree Sheffield, in 2016, opened a ‘shop’ which offers clients a confidential and expert service to help them to quit smoking for good (Yorkshire SmokeFree, 2016). The service provides advice and support-including nicotine replacement therapy for anyone who wants to stop smoking. Every smoker’s experience of trying to stop is different and what works for one successful quitter will not necessarily work for another. Tom may prefer to use nicotine replacement therapies (NRT) which reduce withdrawal symptoms by replacing nicotine in the blood and come in many forms, for example; tablets (Varenicline or Bupropion Hydrochloride), lozenges, inhalators, patches or gum; which are all offered through the NHS. Research shows that when using NRT people’s attempts to quit smoking are more successful, however, no NRT seems to be more successful than the other (Silagy, Lancaster, Mant, & Fowler, 2007).
The benefits of cessation are proportionately somewhat less among the elderly and may manifest more slowly than among younger smokers, but cessation remains the most effective way of decreasing the risk of smoking-induced diseases at all ages, including those over the age of 60 years (Senior Health 365, 2011). However, Tom could find it more difficult to stop smoking, particularly if he has been doing so for many years; smoking may be such a large part of his life that it would be difficult to break that routine. Other discouraging factors would be if Tom has attempted to quit smoking before and failed, this could make Tom feel that he would not be successful in future attempts.
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Loneliness, social isolation, and a lack of adequate support are also public health issues that exact a significant toll on physical health and psychological well-being, the costs of these conditions are particularly high among the retired and elderly population (Cohen, 2000; Sorkin, Rook, & Lu, 2002). Research shows that social isolation and loneliness are related to negative health outcomes and that social support of various types and sources is associated with positive health outcomes (Ernst & Cacioppo, 1999; Uchino, Uno, & Holt-Lunstad, 1999). Research also suggests that being from an ethic minority community for example; China, African, the Caribbean, Pakistan and Bangladesh, increases ones risk of experiencing social isolation, particularly in old age (Victor, Burholt & Martin, 2012). Yu (2016) found that members of the Chinese community within the UK report to suffer from social isolation due to language barriers, lack of knowledge of social and public services; and older people’s rights to these, and difficulties in expressing health concepts from their own cultural perspective. Further information about Tom’s circumstances is required in order to determine whether such factors would further influence his feelings of isolation.
The importance of tackling social isolation and loneliness to improve older people’s well-being and quality of life is increasingly recognised in international policy and in some national health strategies (Wheeler, 2001). In the United Kingdom, the National Health Service National Service Frameworks for Mental Health and for Older People have provided local incentives to address loneliness and isolation (Wheeler, 2001). Health promotion services and activities intended to alleviate social isolation and loneliness among older people have long been considered important in providing support to develop, improve and maintain social contacts and mental wellbeing (Walters, Cattan, Speller, & Stuckleberger, 1999).
Research has suggested that retirement from an important role can lead to feelings of loss of purpose and identity (Curtis & Barnes, 1994). The Public Health and Active Lifestyles Working Group aims to promote an active lifestyle among the elderly, involving keeping physically and mentally active, eating a healthy diet, not smoking, drinking in moderation, pursuing one or a number of interests and leading a sociable life. Maintaining an active lifestyle is the single most effective way Tom can encourage physical and mental wellbeing and reduce his feelings of loneliness and social isolation (Age Action Alliance, 2014). Likewise, National policy initiatives, such as ‘Improving Opportunities for Older People’ (Department of Work and Pensions, 2016) focuses on building purpose into individuals elderly years by enabling older people to remain active, or remain in employment or voluntary positions. Similarly, Age UK strive to inspire older people to get healthier and become active, as well as offering a telephone befriending service “Call in Time” to tackle feelings of loneliness and isolation (Age UK, 2015). Such initiatives would be beneficial to Tom in order to instil a sense of purpose and improve his self-esteem, alongside providing opportunities for Tom to meet new people and become involved with his community and help diminish feelings of isolation and loneliness.
There are many issues that Tom is currently faced with that could potentially affect his mental health, and the reality is that it may not be as easy as simply offering a befriending service or engagement in activity, there may be many barriers to break down first. Someone who is lonely probably also finds it hard to reach out. There is a stigma surrounding loneliness, and older people tend not to ask for help because they have too much pride (NHS Choices, 2016). Loneliness is found to be a precursor to psychological disorders, mental health problems, depression, and even suicide (Koropeckyj, 1998; Vanderweele, Hawkley, & Cacioppo, 2012). Apart from their spouse, adult children provide the most important support and social contact in old age. Adult children’s more frequent contact, care and affection may lessen the feelings of loneliness among older persons (Long, & Martin, 2000). This again, highlights an issue for Tom as he does not see his children frequently due to their busy lives.
Ramnic, Panjic, Batic-Mujanovic, & Alibasic (2011), found that elderly people who live alone are more likely to suffer from malnutrition due to a reduction in daily meals, significantly lower protein intake, fruits and vegetables in their diet. As Tom is eating takeaways every day he will be missing out on vital vitamins and nutrients that the body requires; which could lead to a variety of physical health problems, and put Tom at risk of developing a chronic disease (Ramnic, Panjic, Batic-Mujanovic, & Alibasic, 2011). Tom’s current poor diet could be due to the recent lose of his wife and his subsequent change in circumstances, Rosenbloom & Whittington, (1993) found that widowhood changed the participants social environment and therefore, changed the social meaning that eating held for them; this resulted in negative effects on eating behaviours and nutrient intakes.
Changing behaviours in elderly individuals poses a challenge in itself, older people often become resistant and decline interventions due to being “set in their ways”, and therefore unwilling to change (Naidoo & Wills, 2009). There are a wide range of approaches and models used when attempting to modify and improve behaviours. One approach that could be beneficial with regards to Tom is the educational approach. This approach aims to help people make an informed choice about their health behaviour through providing knowledge and understanding, and developing the necessary kills (i.e. cooking); with the aim to modify Toms attitudes towards his health; hopefully resulting in a change in his behaviour. Although this approach is expert lead, it may be beneficial as it does not try to influence the individual in one way or another, Tom’s choices about his health would be his own voluntary decision (Ewles & Simnett, 2003); this in itself can be empowering as it puts the individual in control, and could subsequently help raise Toms self-esteem.
However, this approach is limited, as health related decisions can be very complex; and the approach does not consider the effects that social and economic factors can have on behaviour change. Also, educating Tom on his life choices may not address the factors that are leading to Tom’s isolation, smoking, and poor diet in the first place. Tom’s recent stressors can also impact and cause difficulties when making health related decisions (Naidoo & Wills, 2009). This approach may therefore not be enough on its own, and further support may be necessary to encourage behaviour change. Motivational interviewing may also be useful with Tom; this technique aims to help patients explore their uncertainty about changing and about their readiness of change (Naidoo &Wills, 2009). However, further exploration of Tom’s situation and his other health risks would be required.
Tom is faced with several factors that could affect his mental and physical health; however, he does not need to suffer alone. There are countless government incentives available for Tom, in order to help with his loneliness, social isolation, and bereavement, as well as his smoking habits and aid to develop healthier eating habits. However, as discussed it may be difficult to break down barriers in order to encourage Tom to engage in changing his behaviours. In order to enable Tom to make positive changes within his life his situation needs to be assessed holistically. Advertisements and the mere availability of services may not be enough; there is a need for early intervention and for staff to be able to identify such issues and refer individuals to the appropriate service.
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