Case Study
Sexual Health (Chlamydia)
I. Knox Action Plan for Chlamydia
Case
Chlamydia, one of the fastest growing sexually transmitted infections (STIs) in the UK, will be the center case for this action plan. What is alarming is that Chlamydia is the most common STI in young people and the symptoms always go unnoticeable. On a national scale, about 1 in 10 sexually active young people who are tested Chlamydia but will show no signs or symptoms that they actually have. Most of the cases also would not know that they actually have it. It only takes having an unprotected sex once or a condom failing with an infected person for such to be passed on. Others could be also contaminated by Chlamydia through hands and into the eyes. Newborn babies could be also infected through their mothers who have Chlamydia. This might have been recently or many months and even years earlier. Chlamydia affects both genders and can have distressing and expensive complications. Nevertheless, Chlamydia can be easily and effectively treated with antibiotics once diagnosed. When not treated, the infection could possibly spread to other parts of the body, causing more damages and more serious complications. It can be also prevented through the proper and consistent use of condoms.
Ordinance/Legislation
Devolved decision-making in the health service implicates an increasingly important role for local authorities and strategic leaders. More personalized health services with more information and choice to service users and the public and provision for primary and community health services are central to current policies. Elements of sexual health have remained prominent in the national priority frameworks and this has driven local policymaking. Vital Signs framework, for instance, put emphasis on developing locally defined strategic priorities in line with local need. Chlamydia screening has been a key national target and a cross-governmental priority. Local Area Agreements (LAAs) are prioritized which should be aligned with Local Delivery Plans (LDPs).Joint Strategic Needs Assessments (JSNA) will inform the future strategic priorities for LAAs and the selection of local targets from the New Indicator Set (NIS). Chlamydia prevalence in under 25s is one amongst the two new indicators that directly relates to sexual health.
Further, National Health Service (NHS) recognizes the necessity to maximize the voice of service users and the public, which is a key contemporary vision and an integral part of JSNA and LAAs. Local Government and Public Involvement in Health Act made it a statutory duty for providers to demonstrate response to patient feedback. As part of the Quality and Outcomes Framework (QOF), new mechanisms of delivery through a diverse range of providers across new settings are part of NHS reform channeled to local authorities. Such action has created an increased capacity related to sexual health services to include the rollout of the National Chlamydia Screening Programme (NCSP). Greater self-management that considers diagnostic testing has formed part of the NHS’s approach to managing long-term conditions. Self-taken Chlamydia samples have been the main mode of delivery of the NSCP in many areas including Coventry.
Primary Administering Agency
There are at least four agencies chosen for this action plan: Contraception and Sexual Health Services (CASH), Coventry Chlamydia Screening Programme, British Pregnancy Advisory Service (Bpas) and Terrence Higgins Trust. One thing common among these agencies is that they provide Chlamydia screening to under 25s in Coventry. These agencies also provide information, advice and support on sexual health issues confronting the younger generation in Coventry. CASH also provides condom distribution for young people aged 14-25. CASH is available at Coventry and Warwickshire Hospital. Clinic in a Box and One Stop Shops also provides testing and advice though One Stop Shops are consist of youth practitioners across Coventry whom are trained in Chlamydia screening. ASP Pharmacies, general practitioners and genitourinary medicine (GUM) clinics will be also considered as key agencies.
Communities
There are two communities which will be considered for this action plan: Coventry and Wolverhampton. A city and a metropolitan borough in the county of West Midlands, Coventry has a total of 303, 475 population according to the 2001 Census. It is the 9th largest city and the 11th largest in the UK. In the English Midlands, Coventry is the second largest city. Wolverhampton is also a city and metropolitan in West Midlands. The 2004 population estimate by the local government district is 239, 100 but the wider urban area had a population of 252, 462, making it the 13th most populous city in England. STIs are currently on the rise in Coventry while Wolverhampton has the highest number of people diagnosed with HIV, Chlamydia and gonorrhea. Sexual health is advocated basically through using contraception and avoiding STIs hence protecting oneself toward safer sex thinking and doing something about them. Making positive choices about sexual health is important not just for the physical health but also on general wellbeing of an individual.
Lead Community
Coventry will be treated as the lead community for this action plan. As already noted, Chlamydia rates in below 25 in Coventry is on the rise, at 14% of the total population 42, 367. Therefore, there are about 5, 932 who are potentially infected and there are also cases that are still unknown to the individual especially when symptoms do not manifest at all. Nonetheless, only 3, 500 are expected to undergo screening. The more pressing issue here is that Chlamydia is linked with other infections, illnesses and diseases. If untreated, for example, it could lead to infertility aside from being linked to recurrent urinary tract infection. Chlamydia is also discovered to be a precursor of chronic lower abdominal pain.
Target Area Rationale
With this, it would be therefore necessary to reduce the rate of Chlamydia among young people under the age of 25 in Coventry. The target percentage of reduction is from 14% to 10% by March 2012 by means of participating in Chlamydia screening. Invites should be sent to 16 to 25 year olds to partake in screening and be treated if there is the necessity to do so. Considering the unknown rate of infected individuals, the rationale behind this is to produce a Chlamydia sexual health profile of under 25s to determine a longer-term intervention. Raising awareness of the risks of Chlamydia in young people would be also a requirement to prevent future incidences of Chlamydia in Coventry as much as possible.
Intervention
One intervention in mind is that ran by Terrence Higgins Trust and locally in NDC where there is approximately 250 individuals screened in the period of 3 months. This campaign is known as the Wee for a Wii, planned to provide an incentive for 16 to 25 to participate in screening. The prize for participants on the draw date is a Wii. Not only the screening will be free will also motivate them because of the prize they could get just by signing up and joining in the campaign. The target participants are at least 12, 115 young people since the target requires treatment of 1, 696 infected people.
Proposed Activities
For this campaign, a requirement is to build strategic partnerships and/or clinician network so that a multidisciplinary team could work on this. Clinicians therefore need to be up to date and need professional support to make sure they deliver high quality services. This can be achieved through clinical partnerships, collaborative working and agreed service standards.
First, it is important to develop joint planning and partnership mechanisms and ensure sexual health issues that impact on sexual health. Development of more systematic partnership would be needed to support the development of sexual health improvement strategies. Next, partnership with third sector organizations should be likewise developed to recognize the value that can contribute to further needs assessment, service use empowerment and delivery of services. The main reason for this is to build a strong public health base for sexual health wherein public health intelligence will be used to improve the understanding of young people about Chlamydia and how it will affect their wellbeing.
Furthermore, ensuring that there is a strong link between health and education sector would be a significant step. Dialogues between school administrations and students with the aim of the campaign should be considered. This is the main reason why schools will be consulted. Since this Chlamydia eradication campaign will include the role of schools, shared responsiveness could be achieved especially when it comes to prevention and linked service provision. A comprehensive sexual health service needs to incorporate the areas of contraception and what to do when an individual learned that she is infected with Chlamydia.
The necessary next step would be to market the campaign. Because the campaign is intervention-focused, social marketing will be used. Social marketing aimed at individual level approach wherein media advocacy as the most cost-effective way to bring about important social changes. Social marketing was primarily associated with health problems and thus having continuous dominations of health applications. Communication tools will be used although majority of these are visual. Leaflets and posters that will be put on visual portals like freedom wall in schools, display portion in clinics, grocery stores, leisure parks, gyms, train stations and buses’ sides among others. Online collaborations could be also achieved especially in social network sites that enable the campaign to be noticed. After the campaign was marketed, the actual Chlamydia screening will take place in various participating agencies. Info cards will serve as the identification of whether screening took place. Evaluation will happen when the period of screening is over.
Impact/Implications
The campaign could require increase staff availability and time as well as increase in administration time. Since the campaign also requires equipments for screening and treatment, costs would escalate. Promotional items are deemed necessary such as wee for a Wii entry/information cards, posters, leaflets, Nintendo Wiis and other communication materials intended for a city-wide campaign. Staff of participating agencies should be also informed of the campaign and its mechanics. Current campaigns and activities had requires the reorganization due to poor access of young people. Outreach clinics also have poor attendance and costly. There are too many independent sexual health services as well available in Coventry. As such, this new campaign will aim at specific sexual health issue aimed to a specific population. Provision of incentive to participate and accessibility will be generally considered in the campaign.
Citizen Participation
Consultation will be conducted. Primary care trust (PCT) is currently funding Consultation on Public and Patient Engagement. With this, online questionnaires will be designed; if there are questionnaires that could be used, it will be adopted to reflect Coventry setting. Online questionnaires are wide-reaching hence it would be plausible to make use of such to tap a wider audience. Various media tools are used to include websites and social networking sites like Facebook and bebo. Youth councils and young advisor groups will be also consulted aside from sexual health professionals from CCC, PCT and private and voluntary organizations. Other consulting parties could be sexual health staff that is based in general practitioner clinics as well as the clinicians themselves. Professional and stakeholder consultation will be conducted, moreover, on NHS Coventry, Coventry City Council, Terrence Higgins Trust, Family Planning Association, CASH and CiB, GPs and medical center staff and GUM, youth practitioners and SHADOW and in schools.
Budget
The quality-adjusted life year of infertility in Coventry is 0.83 while reduction is 0.17. The maximum expense is £5, 100 per person hence intervention is not more than £5, 100 per person, making it a cost-effective campaign. The actual cost per test is £25 per person plus a single dose of azithromycin at £14, which equals to £39. The relative effective cost is £193 per finding and treatment. This is intended for 12, 115 people which needs to be screened. Age cost per person is £8 in target criteria or will only cost £30 per person for those responding.
Evaluation
Evaluation will be three-tier: formative, process and outcome. In formative evaluation, the campaign will be evaluated by means of determining whether participants understood the messages of the campaign and if it is culturally appropriate. It is imperative to design a semi-structured questionnaire to assess the level of understanding of the participants. Examples of questions to be asked should include: Are you aware that you might be at risk of acquiring Chlamydia? What does Chlamydia screening means to your future? How does the campaign change you? Further, process evaluation will be conducted during the intervention. These will be both qualitative and quantitative since numbers of young people screened and barriers to implementation will be identified. Education and awareness amongst young people could be also evaluated in terms of question and answer portions during the screening process. Outcome evaluation will be quantitative as this will seek to determine the total number of people screened and reduction rate of Chlamydia infection in the next years.
Outcomes to be Evaluated
1) Did the participants understand the causes, risks and threats of Chlamydia
2) How the campaign better equipped them with knowledge to be used to combat the spread at individual level
3) How many under 25 are screened; did the campaign achieve the target reduction rate
4) If not, what are the reasons of non-participation
5) Determine the degree of shared responsiveness between the campaign and schools
Final Recommendations
What is currently happening is that there are Chlamydia-reduction national campaigns that could be adapted and used in Coventry. Thereby, costs could be significantly reduced and there will be a tested intervention with easier evaluation. Additional recommendations are implementation of Chlamydia screening that should be of highest priority not only because it can save money through reduced infections and fertility problems later but also because outcomes could inform the reorganization of provisions, regulations and policies. While development of increased access to young people should prevail, targeted provision should also include gay and bisexual men as another at-risk group. Coventry PCT should also commission a dedicated GU practitioner or consultant to provide sexual health services for young people with Chlamydia. Specifically, the use of in-house communication teams would be critical. Evaluation would not be difficult and complicated if there will be a single entity that will conduct such.
Action Plan
Case: Chlamydia
Ordinance/ Legislation: LAAs, LDPs, JSNA and QOF
Primary Administering Agency: CASH, Coventry Chlamydia Screening Programme, Bpas and THT.
Lead Community: Coventry
Intervention: Wee for a Wii
Budget: £5, 100 per person
ACTIVITIES
KEY PERSONS
TARGET DATE
Development of an actual working plan
Campaign coordinators
Month 1 – ½
Build strategic relationships and/or clinician network
-Interface with the local clinicians
-Systematize partnerships with local clinics and clinicians or the primary administering agencies
-Systematize partnership with local health agencies like health-related NGOs
Campaign coordinators and primary administering agencies
Month ½ to 2
Build link with the education sector (Schools consultation)
-Interface with local school administrations and students
Campaign coordinators and the local academic actors, students
Month 2
Marketing the campaign
-Social marketing activities
Campaign coordinators
Month 3
IMPLEMENTATION
Campaign coordinators and participants
Month 4-10
Evaluation
-Formative evaluation
-Process evaluation
-Outcome evaluation
Campaign coordinators and participants
Month 11
Announcement of Winner
Campaign coordinators and participants
Month 12
II. Needs Assessment
Various forms of healthcare needs assessment has always been necessary in health service planning. Concept of needs in the UK context had move along with the changes in society. For instance, needs are identified as social concerns identifying gaps in health service provision relating to deprivation and patchy facilities prior to becoming a rational plan attempting to design services systematically but with no formal needs focus. During the period before 1980s to 1990s, needs were recognized and measured by surrogate means, notably demographic. The most important change after this is when needs assessment became established as a critical process in health care. Health care needs assessment has two primary roles, the first of which is the need for healthcare must be distinguished from the need for health. While the second characteristic is needs assessment for practical purchasing that requires a usable level of detail (Stevens, 2004, p. 3).
As such, needs assessment centers the necessity to define people’s ability to benefit from healthcare through interventions. Baldwin (1998, p. 36) asserts that individuals share universal human needs by virtue of their existence but there are those who have special needs as well. Not all existing needs assessment have been designed to reflect this complex template of needs. It has been said that the approach to needs assessment based on the triangulation of incidence and prevalence, effectiveness and cost-effectiveness and existing services (Spasoff, 1999, p. 108). Notably, needs assessment will usually aim to making relevant changes to existing services. Three approaches relevant to healthcare that will be explored herein are corporate, comparative and epidemiological.
Corporate Needs Assessment
Corporate approach to needs assessment is based on the demands, wishes and alternative perspectives of interested parties which include professional, political and public views (Stevens, 2004, p. 10). The weakness of blurring the difference between need and demand and between science and vested interest is compensated by the strength of allowing scope for managing supply and demand at the same time as assessing need as affected by local circumstances hence giving a specified measure of the demand. In the NHS context, the corporate approach has been widely used as it puts emphasis on ‘local voices’ and on partnership and collaboration (Stevens, 2004, p. 10). According to Percy-Smith (1996, p. 72), another advantage of the corporate approach is it can make use of comparative and epidemiological approaches while also exploring the views of key stakeholders.
Sines (2009, p. 63) relate that there are arguments that this approach does not go far enough than seeking the views of local people. The rationale behind this is that in order for any intervention to be successful the community should be involved in identifying and prioritizing their own needs as well as going on to identify the appropriate actions to address those needs. These could be taken from the perspectives of all relevant stakeholders such as service users, service providers and service commissioners among others (Cohen and Eastman, 2000, p. 69). As such, another strong point of the corporate is it aims to represent national, regional and local priorities that are mainly based on consultations. However, this approach does not always give the appropriate indication of the extent of the problem.
Comparative Needs Assessment
Stevens (2004) also made mention that the comparative approach to needs assessment contrasts the services received by the population in one area with those received elsewhere. Comparisons can be powerful tool in investigating health services, particularly in the context of capitation-based funding. Variations in costs and service use may be appropriate depending on local circumstances, a weakness because this approach tends to be context-dependent. As Pardeck (2002, p. 120) puts it, despite this weakness, the strength is that it considers a specialized technique because it takes account of local population characteristics. Outcome data generated from the assessment accurately mirrors the current status of the locality being considered.
Talbot and Verrinder (2005, p. 151) also note that another weakness, however, is that the use of data relies on assumption that healthcare is a major determinant of mortality and morbidity, that could not be easily reconciled. The choice of comparators is also critical so that the needs assessment would not focus on the ideal and hence may not be feasible. Comparative approach has yet another strong point that is considering the local variation in risk exposure, level of morbidity and mortality and availability of resources. Such an approach, therefore, will be relevant in identifying gaps in service utilization and delivery of such service to reach the population that needs it (Rawaf and Bahl, 1998, p. 25).
Epidemiological Needs Assessment
Lugon and Secker-Walker (1999, p. 211) relate that epidemiological approach, which is based on the interaction between the agent, the host and the environment, published and local information on the evidence and prevalence of a disease, together with evidence of interventions effectiveness. As it is used to define the needs of a local population through evidences, a strength of the approach would be that interventions will be of highest quality as well as the outcomes. Gullota and Bloom (2003, p. 39) maintain that the main drawback, though, is informations needed to complete an epidemiological needs assessment are not always readily available. The main outcome of epidemiological approach is to distinguish mismatch between needs and service provision. With this, the approach attempts at arriving at objective assessment of health care needs. Reviews effectiveness and cost effectiveness of services and assesses existing services is the main goal (Sargeant, 2008).
Twinn et al (1996, p, 395) maintain that the traditional approach to needs assessment has been to use morbidity and mortality data to measure the total amount of ill-health in the community. The information derived from needs assessment is then used to set priorities for allocating resources between different diseases. As such, another critical theme that is covered by the epidemiological approach is that needs has been taken into a new context. Ahrens and Pigeot (2005, p. 1492) contend that needs is thus defined in terms of lives lost, life years lost, morbidity and loss of social functioning. Thereby, through epidemiological approach, means of scoring and ranking areas according to their degree of relative disadvantage or affluence is achieved.
In sum, needs that vary individually and collectively could be assessed on the basis of the requirements of the people of both the intervention and the ways to deliver such intervention, the comparisons of mortality and morbidity rates and the evidences that needs assessment are deemed necessary. One central theme that is common to all is the interface of needs, users and the environment.
III. Health Promotion Models
Beattie’s Model
Beattie (1991), basically, developed the model to deal with information, education, legislation, psychological and social factors as strategies in achieving health. The model presents four quadrants namely health persuasion, legislative action, personal counseling and community development. Tones and Green (2004, p. 165) describe the former as which ranges from authoritative to negotiated and the latter as which is either on the individual or collective. What is good about Beattie’s model is that it incorporates two fundamental dimensions: the mode of intervention and focus of intervention. Earle et al (2007, pp. 155-156) said that the strength of this model lies in acknowledging the tensions exist those who claim to provide objective definitions of health and those who would want to provide more subjective and relativist accounts. Nonetheless, to better understand the weaknesses, the interventions should be broken down to pieces.
The primary objective of the first health promotion activity is to convince an individual to change their behavior and adopt a healthier lifestyle. Wills et al (2007, p. 58) stress that the approach is based on the premise that the expert knows best and epidemiological evidence is likely to be used to target high risk patients and health issues. It would be easy to understand that such approach could be delivered effectively because it can be delivered as a part of consultation as it also appears to address high risk factors and individuals. Aside from this, health persuasion intervention is a relatively cheap form of intervention that does not require or rely on any shift in organizational commitment to become a health promotion setting (Whitehead, 2005).
On the other hand, when health persuasion is used in isolation this not always give effective health results or outcomes. The attempt to persuade patients to change their behaviors should be expert driven and medically approved although the approach tends to overlook the necessity of exploring whether an individual is capable or ready to undergo changes in their lifestyle (Whitehead, 2005). I am one with Lavarack (2005) when he mentioned that the focus on the responsibility of individual does not recognize the relative powerlessness of some and the lack of choice that the situation may impose them.
Legislative action also concerns changing behaviors but the channel is through the benevolent actions of the state or an organization. One commendable strength of the approach is that it highlights actions to bring changes to national legislation with the development of national, local or organisational policies and supportive environments for health in mind (Wills et al, 2007, p. 59). While the intervention aims at encouraging change and making healthier choices easier per se, universal measures are often unable to meet the specific needs of vulnerable groups or individuals within a population. The implementation of such may be met with resistance from specific sections of the group. An unlikely result of this is the danger of prohibitive legislation which may take effect on driving certain behaviors underground and so making it harder to access vulnerable groups and potentially increasing inequalities in health.
The third activity, community development, is committed to bottom-up, community-led, participatory approaches. Beneficially, this intervention often leads to the empowerment of communities in identifying and prioritizing their own needs. Therefore, people are encouraged to work together to seek solutions to those needs and implement changes as part of an ongoing process. Interventions, evidently, are more relevant while also creating a sense of ownership which could lead to being more effective and sustainable (Ledwith, 2005). A challenge that Latter (2001) relates, on the other hand, is that it requires professionals to be led by communities the work with, becoming potentially radical in the process. A complex process that requires long-term commitment, specific resources and skills are not easily pooled. Critical consciousness-raising is also a requirement.
Personal counseling interventions are led by and negotiated with individuals with specific needs, and is conducted on a one-to-one basis. The strong point of this is its flexibility as either to promote positive health and well-being or to prevent ill-health through health management. Basically, as the intervention is dependent on social and economic issues, this may create barriers to change. Wills et al (2007, p. 62) argue that the limitation is the ability of individuals to sustain such changes when faced with issues that are beyond an individual’s control.
Ottawa Charter
The Ottawa Charter for Health Promotion, according to World Health Organization (WHO), is a very important milestone in the development of the health promotion ideology that underlies health promotion via community development. A political document, the charter defines health promotion as the process of enabling people to take control over and to improve their health (cited from Bracht, 1999, p. 6). Ottawa charter can guide practice within socio-ecological, behavioral and medical approaches to health promotion. An essential strength of the charter is that it views health as “a positive concept, emphasizing social and personal resources as well as physical capabilities” (cited from Weare, 2000, p. 17).
Weare (2000) claims that the charter is highly influential in moving forward people’s understanding of how to shift the focus of health promotion away from health attitudes and practices of individuals alone to include holistic concern with developing ‘supportive social and natural environments’ often summarized as the healthy settings approach. True enough, Ottawa charter is regarded as a revolutionary initiative in social concept wherein the document sets out five areas for action to promote health, three of which were social and structural. These are healthy public policy, create supportive environment, strengthen community action (community participation, develop personal skills and reorient health services. In our enthusiasm to promote the social, one should bear in mind that the changes within a social context should be complemented by the changes at individual levels. Ottawa charter does not neglect the requirement to build the capacities of the individuals whereby it purports on “the enhancement of the individual with the knowledge, skills and motivation to make competent decisions about their health” (Weare, 2000, p. 23). Weare (2000) argues that this is entirely an individual change and the reorientation initiative is also partly about individual change in the behavior, attitudes and values of those who attempt to deliver health.
Minkler (2004, pp. 83-84) offers an argument that Ottawa charter had provided conceptualization of the term community in both beneficial and detrimental ways. Conspicuously, there is a little agreement on what community means, and even the recognition of the active and organisational nature of community like what the charter is trying to achieve does not clarify them. Community as implied in WHO papers like that of Ottawa charter can do no wrong especially since the building of stronger communities is often regarded as an elemental strategy for strengthening community health. However, though it is important to accept community self-determination in principle, it is also vital to recognize that what communities do for their own health may be inimical to a broader public health. Indeed, practitioners certainly need to be more critical in their use of the concept.
Social Capital
A social science concept used in public health referring to the connections within and between social networks, social capital is simply the investment in social relations with expected returns in the marketplace. The chosen market for analysis could be economic, political, labor or community whereby individuals engage in interactions and networking in order to produce profits. This is a capital captured through social relations, and capital is seen as a social asset by virtue of actors’ connections and access to resources in the network or group of which they are members.
Lin (2002, p. 19) explains that there are four premises on how social capital works. First is through the facilitation of flow of information. Individuals could be provided with useful information about opportunities and choices otherwise unavailable. Social ties, secondly, may exert influence on the agents who play a critical role in decisions. With these social ties are acknowledged relationships to the individuals which may be conceived as certifications of individual’s social credentials. These credentials reflect the individual’s accessibility to resources through social networks and relations. Social relations are expected to reinforce identity and recognition. Reinforcements are essential to the maintenance of health and the entitlements to resources.
One strong point of social capital is also its flexibility to promote health both at individual and collective levels. In one perspective, the focus is on the use of social capital by individuals – how individuals access and use resources embedded in social networks to gain returns in instrumental actions. There are two focal points of analysis: how individuals invest in social relations and how individuals capture the embedded resources in the relations to generate a return. An individual could also access personal and social resources which are defined as resources possessed by an individual and may include ownership of material as well as symbolic goods and resources access through individual’s social connections, respectively. One limitation therefore is that the individuals could have differential social resources depending on the intensity and diversity of social connections. On another perspective, social capital at the group level focuses on how certain groups develop more or less maintain social capital as a collective asset and how such a collective asset enhances group members’ life chances (Lin, 2002, p. 22).
Kawachi and Subramanian (2007, p. 216) explain the health-related explanations of social capital. Social support and social networks either enables or constrains the adoption of health-promoting behaviors while also providing access to resources and coping responses for individuals and communities. Such networking also buffers negative health outcomes. Social cohesion and social capital also enable to enforce or reinforce group or social norms for positive health behaviors while also tapping the provision of tangible support.
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