This essay critically examines the effectiveness of policy frameworks and assessment tools in public health disease management of tuberculosis. The essay discusses the role of the community nurse and multidisciplinary teams in empowering individuals and populations in reducing health inequalities. The essay also explores the nursing and public health frameworks that assist in holistic assessment, planning implementation and the evaluation of care in the community, primary and public health sector. The essay also discusses how environmental, epidemiological and demographic data can influence policies and tackle the underlying social determinants of the health of populations. The essay also discusses strategies that enable the empowerment of individuals and groups, to make them responsible for their own health. The essay also identifies key issues emerging from the health and well-being of communities and discusses the impact that these will have on the role of the nurse and the multidisciplinary team.
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The main policy framework that has been put forward to combat tuberculosis is contained within the 2004 Department of Health document entitled Stopping tuberculosis in England: An Action Plan from the Chief Medical Officer, which outlines the goals of the programme, namely the long-term reduction and ultimately elimination of tuberculosis from England, with the immediate aims of reducing the risk of people being newly affected by tuberculosis, providing high quality treatment for all people living with tuberculosis and maintaining low levels of drug resistance to tuberculosis, through careful usage of antibiotics (DoH, 2004). This framework has dictated how health professionals treat cases of tuberculosis but has, in practical terms not stopped the drastic rise in tuberculosis in England: in 2002, for example, 6638 people were diagnosed with tuberculosis (DoH, 2004), whereas in 2005, the number of people infected by tuberculosis rose by 10.8% to 8113 (HPA, 2005; BBC, 2006), with the largest increases being in inner cities, particularly London (HPA, 2005; BBC, 2006).
The public health management of tuberculosis includes: vaccinating uninfected at-risk groups; minimizing the chances of spreading the infection through minimizing contact of humans with cattle, for example; actively seeking infected individuals from within those groups most at risk; thoroughly investigating outbreaks of the disease when they occur; having appropriate measures in place to ensure that those with the disease do not infect health professionals; developing more rapid diagnostic techniques and creating an effective and easy-to-use national monitoring and surveillance system which functions within a legal framework (NICE, 2006).
The spread of tuberculosis is not, seemingly, therefore being effectively managed as per the outlines in the policy framework in the 2004 Department of Health document entitled Stopping tuberculosis in England: An Action Plan from the Chief Medical Officer nor by the public health management schemes that are currently in place. Increases in tuberculosis are consistently most notable in the poorest sectors of the population (Bhatti et al., 1995), and for this reason, tuberculosis has been described, as it was historically, as a disease of the poor. There is, therefore, a massive socioeconomic influence over the spread of tuberculosis (Bhatti et al., 1995). Given this, then, it is important that the community nurses working in the ‘poorer’ sections of inner city areas are fully trained in how to diagnose, and how to best treat, tuberculosis, within the general framework as specified by the Department of Health (2004) policy document.
In terms of the role of the community nurse and multidisciplinary teams in empowering individuals and populations in reducing health inequalities, as identified by Palacios et al. (2003), nurses play a key role in the management of tuberculosis cases in the community, with nurses being responsible for, amongst other things, identifying patients, evaluating patients prior to treatment starting, managing emergencies, educating patients and other health professionals, and providing coordination, for example overseeing other health workers and communicating between the members of a multidisciplinary team. Not only do the community nurse and the multidisciplinary teams they are involved with have a duty to identify and treat tuberculosis cases, but there is also an implicit obligation (built in to the framework for controlling tuberculosis as outlined by DoH (2004)) that health professionals should also educate individuals at risk as to how to minimize the risk that they would contract tuberculosis. Health inequalities, such as the greater likelihood of contracting tuberculosis if one comes from a poor background, need to be first recognized by health professionals and then treated, through treating the diseases as they manifest themselves, and through education programmes, which would aim to minimize the risks of contracting such diseases. Obviously this is approach does not treat the root causes of the inequalities, which is a political matter.
In terms of exploring the nursing and public health frameworks that assist in holistic assessment, planning implementation and the evaluation of care in the community, primary and public health sector, there is a national framework for dealing with tuberculosis which offers guidelines as to how tuberculosis should be managed on the ground as it were (Singh et al., 2002). Tuberculosis care is generally undertaken on an out-patient basis with only emergency (usually previously undiagnosed) cases being dealt with on an in-patient basis (White et al., 2002). There is a system in place that ensures that any patients with suspected tuberculosis are seen by a tuberculosis team as soon as possible, following their first presentation to a health care professional, and that the presence of tuberculosis is noted on the national database and then managed according to national guidelines (i.e., those from the British Thoracic Society) (DoH, 2004). This national database of tuberculosis cases is part of the Health Protection Agency’s surveillance scheme for tuberculosis, through the Statutory Notification of Infectious Diseases (NOIDs) scheme. The current best practice in terms of managing tuberculosis is the allocation of the patient with tuberculosis to a named case manager, who provides routinely supervised care to ensure that the medication is taken correctly and that the disease is being managed properly (DoH, 2004).
In terms of how environmental, epidemiological and demographic data can influence policies and tackle the underlying social determinants of the health of populations. There are many organizations that collect data on various diseases that are present in the UK, and who then relate this data to socioeconomic factors. The Rowntree Foundation is one such organization, for example. Tuberculosis is a pertinent example of how environmental, epidemiological and demographic data can be used to effect changes to the political structures in place. As has been seen, it is known that socioeconomic variables can predict the presence of tuberculosis in the population, with those individuals from poorer areas more likely to suffer from a higher incidence of tuberculosis than those individuals from more affluent areas (Bhatti et al., 1995).
The fact that there are still such diseases, with a strong socioeconomic aspect, present in the UK is cause for concern, and as many reports from the Joseph Rowntree Foundation have pointed out (for example, North et al., 2007; Dorling et al., 2007), the UK is facing higher levels of inequality than for four decades, which has major health implications for those living in the poorer sectors of society. These studies have been listened to, as the Government embarks on their social justice programme that aims to provide social equality for all members of society, in terms of health and education, for example. Thus, the use of environmental, epidemiological and demographic data can be responsible for directly influencing policies and tackling the underlying social determinants of the health of populations. If, for example, the poorer sectors of society were lifted out of this poverty, it is likely that ‘diseases of the poor’ such as tuberculosis would decline in frequency in the UK.
In terms of strategies that enable the empowerment of individuals and groups, to make them responsible for their own health, such strategies take many and varied forms, according to the disease under consideration. For tuberculosis, this entails, amongst other things, educating the patients as to why it is important to continue to take their medication even when they ‘feel’ better, to ensure that the disease does not recur and, more importantly, that antibiotic resistance is not developed. Most strategies for patient empowerment are based around patient education, in terms of bringing about changes in their immediate environment, or in their patterns of thinking, that will effect changes to their lifestyle and the ways in which they view their lives and, through this, will effect direct positive changes to their health; patient empowerment is generally a necessity for preventative medicine to be fully effective (Wensing, 2000). Empowering patients through education and through better communication – in the media, for example – can lead to much higher levels of conformity with healthcare plans and to greater adherence to preventative medicine schedules (Wensing, 2000) which, in a disease like tuberculosis, which is notoriously difficult to treat if medicine schedules are not followed, is crucial to gaining control of the disease.
In terms of the key issues emerging from the health and well-being of communities and the impact that these will have on the role of the nurse and the multidisciplinary team, it has been seen that tuberculosis is a disease of the poor, occurring most commonly in poorer areas in inner cities. Firstly, these health professionals have to recognize the socioeconomic aspect of such diseases, and to work within this context. For health professionals working in such situations, it is imperative that these health professionals are aware of all the current guidelines and policy frameworks with regards to such diseases, to ensure that they are aware of the necessity of conforming to these guidelines and frameworks. The impact that this has on the role of the nurse and the multidisciplinary team is to focus the health professionals attention to the diseases that are associated with poverty, and to focus their attention on treating these diseases in the optimum manner, and to empower their patients, in an attempt to manage, as effectively as possible, the incidence of such diseases.
In conclusion, this essay has looked at the issue of tuberculosis in the UK, finding that whilst there is a policy framework in place aimed at reducing the incidence of tuberculosis, this is not wholly effective. The socioeconomic aspect of tuberculosis was discussed, as were the treatment options, the need for patient empowerment and the ways in which treating tuberculosis impacts health professionals. It is recognized that dealing with the root cause of diseases such as tuberculosis, which are generally known as ‘diseases of the poor’ is a political and not a health, matter, in terms of smoothing the inequalities that lead to the conditions where such diseases develop.
BBC (2006). Sharp rise in tuberculosis cases. 2nd November 2006. Available from http://news.bbc.co.uk/2/hi/health/6109228.stm [Accessed on 27th January 2008].
Bhatti, N. et al. (1995). Increasing incidence of tuberculosis in England and Wales: a study of the likely causes. BMJ 310, pp.967-969.
DoH (2004). Stopping tuberculosis in England: An Action Plan from the Chief Medical Officer. Department of Health.
Dorling, D. et al. (2007). Poverty, wealth and place in Britain, 1968 to 2005. Joseph Rowntree Foundation. Available from http://www.jrf.org.uk/bookshop/eBooks/2019-poverty-wealth-place.pdf [Accessed on 26th January 2008].
HPA (2005). Annual report on tuberculosis cases reported in England, Wales and Northern Ireland. Available from http://www.hpa.org.uk/infections/topics_az/tb/pdf/2003_Annual_Report.pdf [Accessed on 26th January 2008].
NICE (2006). Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. Available from http://www.nice.org.uk/nicemedia/pdf/CG033niceguideline.pdf [Accessed on 26th January 2008].
North, D. et al. (2007). Interventions to tackle the economic needs of deprived areas: analysis of six policy case studies. Joseph Rowntree Foundation. Available from http://www.jrf.org.uk/bookshop/ebooks/2137-devolution-governance-deprivation.pdf [Accessed on 27th January 2008].
Palacios, E. et al. (2003). The role of the nurse in community-based treatment of multidrug-resistant tuberculosis. The International Journal of Tuberculosis and Lung Disease 7(4), pp.343-346.
Singh, S. et al. (2002). Tuberculosis in primary care. British Journal of General Practice 52, pp.357-358.
Wensing, M. (2000). Evidence-based patient empowerment. Quality in Healthcare 9, pp.200-201.
White, V. et al. (2002). Management of tuberculosis in a British inner-city population. Journal of Public Health Medicine 24(1), pp.49-52.
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