It is recommended that elderly persons, and persons of any age who are considered at “high risk” for influenza-related complications due to underlying health conditions, should be vaccinated. Among the elderly, vaccination is thought to reduce influenza-related morbidity by 60% and influenza-related mortality by 70-80%. Among healthy adults the vaccine is very effective (70-90%) in terms of reducing influenza morbidity, and vaccination has been shown to have substantial health-related and economic benefits in this age group. The effectiveness of influenza vaccine depends primarily on the age and the ability of the body to develop an immunity response in the vaccine recipient and the degree of similarity between the viruses in the vaccine and those in circulation. Influenza vaccination can reduce both health-care costs and productivity losses associated with influenza illness.
The WHO's Global Influenza Surveillance Network writes the annual vaccine recipe. The network, a partnership of 112 National Influenza Centres in 83 countries, is responsible for monitoring the influenza viruses circulating in humans and rapidly identifying new strains. Based on information collected by the Network, the WHO recommends annually a vaccine that targets the 3 most virulent strains in circulation.
Individuals can increase their knowledge of certain diseases through information booklets available from local medical practises; this local strategy will make people more aware and able to prevent disease earlier. Well-women and well-men clinics are also available for regular/general check ups meaning that early identification of lung cancer may occur. Also by the promotion of a healthy lifestyle the number of people with influenza may be reduced. Also awareness of the vaccination will increase its uptake and lower the morbility rate.
Choices individuals make about how they live has effect on their health. National and local strategies educate and persuade individuals into making healthy choices. These choices include personal hygiene; influenza viruses are spread by coughing and sneezing. Washing and changing clothes will help to reduce the number. Another individual choice is to smoke. Smoking can give a temporary feeling of well-being but can damage health, a reduction in smoking will result in a reduction in the number of related diseases such as lung cancer.
National strategies are being used to prevent both influenza and lung cancer. The National Health Service (NHS) plays a role in preventative strategies.
Cancer patients in the UK face long delays before treatment and their survival rates compare badly to the US and many European countries. To combat this well known fact, the highly ambitious NHS Cancer Plan was launched by the Government in September 2000, and has four main aims:
- To save more lives
- To ensure people with cancer get the right professional support and care as well as the best treatments
- To tackle the inequalities in health that mean unskilled workers are twice as likely to die from cancer as professionals
- To build for the future through investment in the cancer workforce, through strong research and through preparation for the genetics revolution, so that the NHS never falls behind in cancer care again. (NHS Cancer Plan, 2000)
The plan sets out clear guidelines as to what this government expects to achieve, and how it will go about achieving their goal. It is through these health promotion methods that the main areas of tackling health inequalities and preventing the increasing incidence of cancer, that this work will focus on, highlighting areas that could be expanded or reconsidered, by referral to relevant information.
More than one in three people in England will develop cancer at some stage in their lives. One in four will die of cancer. Every year, over 200,000 people are diagnosed (600 people a day), and around 120,000 people die from the disease (NHS Cancer Plan, 2000). Lung cancer is a leading contributor to this number, with the disease taking around 20,000 lives each year. Sixty five percent of cancer diagnoses in the UK will be in people over 65 years of age (Cancer Research UK, 2003). It is estimated that one third of all cancer cases will have been caused directly by smoking and a further third are attributed to poor dietary habits (Cancer Research UK, 2003). Health inequalities have increased over the last 20 years.
People from deprived and less affluent backgrounds are more likely to get some types of cancer and overall are more likely to die from it once they have been diagnosed (Cancer Research UK, 2003). In the early 1990s 17 professional men out of 100,000 would die of lung cancer, while the rate was 82 per 100,000 for unskilled workers (NHS Cancer Plan, 2000). There are a number of reasons for these inequalities in cancer. While genetic factors may have some part in explaining ethnic variations in incidence of cancers, different levels of exposure to key risk factors for cancer notably smoking and diet are very important. The affluent are less likely to smoke and tend to have more fruit and vegetables in their diet. Lower awareness of the symptoms of cancer in some social groups, later presentation to GPs, lower uptake of screening services and unequal access to high quality services (known as the “postcode lottery) also play a role (NHS Cancer Plan, 2003).
A key part of the NHS Cancer Plan is to prevent the development and decrease the percentage of incidence in cancer. The health promotion interventions that will be the main focus in the reduction in incidence of cancer will be primary and secondary preventative methods. Primary prevention seeks to avoid the onset of ill health by the detection of high risk groups (such as unskilled workers who smoke) and the provision of advice and counselling. Examples of primary prevention for cancer would be smoking cessation campaigns, and information on how a healthy diet and taking part in regular exercise can prevent the formation of cancerous tumours. Secondary prevention seeks to shorten episodes of illness and prevent the progression of ill health through early diagnosis and treatment. Examples of secondary prevention would be the national breast screening campaign that the NHS is currently conducting, as well as the identification and symptoms of cancer. Secondary prevention allows for early and correct diagnosis, therefore leading on to much earlier treatment, thus increasing the likelihood of survival for victims.
Within the primary and secondary prevention (health promotion) elements of the NHS Cancer Plan (2000) there are areas of immediate concern. The need to address cancer prevention is high on the agenda, as the saying goes; “prevention is better than cure”. The primary prevention (health promotion) aspect of the cancer plan addresses certain key issues that cause/are linked to the causes of cancer in the UK, including: tobacco/smoking, diet, reducing weight/obesity, increasing physical activity, alcohol, and skin cancer prevention. As mentioned before, what causes cancer is different for every individual, therefore a wide range of potential causes were identified, and have been set milestones within the 10 year plan. “Health education can be targeted at the whole population, or at different groups of the population” it is obvious in the plan that the government have taken this into account and are very clear in what they want to do.
In primary prevention the NHS plan aims to tackle the two main attributable areas of the causes of cancer: smoking and poor diet. Within these two areas, there have been inequalities recognised that give significant different incidence rates in different population groups as well as different socio-economic groups. The prevalence of smoking is higher among people in manual than non-manual social classes (31% compared with 23% in England in 2000). The widening of this gap over the past 20 years reflects a steeper decline in smoking prevalence among non-manual classes compared with manual classes (HDA Cancer Prevention, 2002). The social class differentials in smoking are reflected in the social gradients of deaths caused by smoking. Among men, smoking accounts for over half of the difference in risk of premature death between social classes.
Cigarette smoking among minority ethnic groups is generally less than among the UK population as a whole (27%), but a more detailed examination reveals important differences between and within groups. The smoking rate among Bangladeshi men is particularly high (44%). Smoking rates are even higher among middle-aged and older Bangladeshi men (50% and 54% for men aged between 35-54 and 55+ years respectively). This same group of men also has high rates of chewing tobacco products. Tobacco chewing is particularly high among older Bangladeshi women: 43% of women aged 35-54 years and 56% of women aged over 55 years chew tobacco (HDA Cancer Prevention, 2002).
Traditional measures of social class tend to underplay the extent to which high smoking rates have not decreased in the poorest sections of society (HDA Cancer Prevention, 2002). Recent studies have shown that smoking levels have remained virtually unchanged among those in the poorest groups, and among lone mothers smoking levels have risen. In a detailed study, lone parents living in rented accommodation and relying on social security benefits were found to have smoking levels in excess of 75%.
The cancer plan has outlines that people have a right to smoke, and the Government reinforces the fact that they have no intention to outlaw smoking outright. However, they do say that if introduced today, smoking would never be made legal due to the addictiveness and harmful effects it has. The Government has therefore made it integral to the cancer plan that it will advertise the harmful effects smoking has, not only to smokers, but also to those who can be affected by other peoples smoke. The NHS Cancer Plan, in conjunction with the white paper Smoking Kills has set out a tobacco control strategy which pledges to:
- Ban tobacco advertising
- Increase new specialist NHS smoking cessation services
- Make Nicotine Replacement Therapy (NRT) available through prescription from GP’s
- Ask Committee on Safety of Medicines to consider whether NRT can be made available for general sale rather than only through pharmacies or on prescription
- Make Zyban, a new treatment to help smokers give up, available on prescription from primary care
- Update guidance on smoking cessation for health care professionals and commissioners from the Health Development Agency (HDA)
- Enforce the best practice code, preventing the sale of tobacco products to under 16’s
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Launch a new media campaign and an NHS smoker’s helpline (NHS Cancer Plan, 2000).
In these main aims the plan does not directly identify the need to tackle inequalities in smoking, however it does go on to mention the need to do this. The plan identifies the introduction of Zyban and NRT on prescription for those who want to quit smoking. The available evidence indicates that a comprehensive tobacco control programme as set out in Smoking Kills, if efficiently and fully implemented, would bring down smoking in both manual and non-manual social classes (HDA Cancer Prevention, 2002).
After smoking, what people eat is the next biggest contributor to cancer deaths, and as mentioned before, may be responsible for up to a third of all cancer deaths. A healthy diet is one that is high in fruit and vegetables and cereals, and low in fat, salt and sugar (NHS Cancer Plan, 2000). Diet is therefore a risk factor for the development of some of the most commonly occurring cancers in England. Improving people’s diets is an important public health measure, not only to reduce the rates of cancer but other diet-related chronic conditions such as coronary heart disease (CHD), stroke, type 2 diabetes and obesity (HDA Cancer Prevention, 2002).
Behind reducing smoking, increasing the intake of fresh fruit and vegetables is seen as the second most effective way to prevent the development of cancer (NHS Cancer Plan, 2002). Dietary recommendations to reduce the risk of cancer in the UK were first made by the Committee on Medical Aspects COMA) working group on diet and cancer in 1998. The report recommends, on a population basis:
- Increasing the consumption of a wide variety of fruits and vegetables
- Increasing intakes of dietary fibre from bread and other cereals (particularly wholegrain varieties), potatoes, fruit and vegetables
- Maintaining a healthy body weight (within the BMI range 20-25) and avoiding an increase during adult life
- Avoiding an increase in the average consumption of red and processed meat, current intakes of which are about 90g/day
- Avoiding the use of beta-carotene supplements to protect against cancer and being cautious in using high doses of purified supplements of other nutrients. (HDA Cancer Prevention, 2002).
The intake of a healthy balanced diet can prevent the development of certain cancers, such as lung cancer. An inverse relationship between vegetable consumption and lung cancer has been reported in a number of case control and cohort studies. While the aim is ultimately to increase the population average daily intake of fruit and vegetables to at least five portions of around 80g each, a recent trial has shown that increasing intakes by the equivalent of around one portion per day may be beneficial in reducing the rates of chronic disease.
As it is generally accepted that having a healthy balanced diet can prevent such cancers as lung cancer, part of the NHS Cancer Plan (2000) is to introduce a national 5-a-day intake of fruit and vegetables. This scheme is currently in its pilot stage across 5 locations: Sandwell, Somerset, Airedale and Craven, County Durham and Hastings. The scheme aims to reach all areas of the community, particularly the economically deprived to make fresh fruit and vegetables readily available at reasonable prices. This strategy will hopefully reduce the inequalities in health regarding diet. Also the publication of how a healthy lifestyle will add to the primary prevention methods for cancer development. The most striking difference is the variation in amounts of vegetables and, particularly, in the amount of fruit eaten by people in lower socio-economic groups. In the UK, average consumption is about three to four portions a day, though there are marked differences between social groups with unskilled groups tending to eat around 50% less than professional groups (HDA Cancer Prevention, 2002). Improving knowledge alone is ineffective in improving people’s diets. Affordability and physical accessibility to foods such as fruit and vegetables have been identified as key barriers to eating a healthier diet. Interventions such as detailing what exactly is one portion of either vegetables or fruits have begun through supermarkets. For example; Tesco have started to label their fruit and vegetables with “stay healthy” messages, and give examples of what a portion of fruit/vegetables is, as observed on a packet of Clementine’s:
5-a-day:
- Eat 5 portions of different fruit & veg to help prevent cancer
- 2 Clementine’s = 1 portion (Cancer Research UK)
However, the effectiveness of this intervention is yet to be published. The “carefully monitored” intervention has provided the start of the national “5-a-day” programme (2002) to assist the nation in improving their diet. The scheme’s main areas to target are hard to reach areas such as schools, prisons and hospitals.
The national School Fruit Scheme has been launched in conjunction with the 5-a-day campaign. There are clear links between childhood diet and risk of disease later in life, and eating patterns are established early in life. The aim of this strategy is to therefore reduce the likelihood of today’s children establishing bad eating habits later in life. Children’s consumption of fruit and vegetables is particularly low; one in five do not eat any fruit in a week, and three in five eat no leafy green vegetables. Children growing up in disadvantaged families are about 50% less likely to eat fruit and vegetables than those in high income families. The National School Fruit Scheme, announced in the NHS Plan, has made a free piece of fruit available to school children aged four to six each school day (NHS Cancer Plan, 2000).
The secondary prevention (health promotion) aspect of the cancer plan looks to catch cancer in or even before the early stages of development, increasing the rate of survival, thus decreasing mortality, and possibly reducing incidence by finding precancerous growths. This prevention is mainly done through screening; testing large groups of healthy people for early signs of disease (Cancer Research UK, 2003). Those who have a positive test can then be treated. Self identification of symptoms through distribution of publications can also contribute to the early detection of cancer, and the wider the knowledge base for this, the more likely cancers can be caught at an earlier stage.
There are ethical issues surrounding screening for cancer. Although screening can pick up cancers long before a person develops symptoms, it also has the potential to cause anxiety in people who are entirely healthy (Cancer Research UK, 2003). People invited to participate in screening programmes need to understand the potential benefit and harm in doing so to be able to make an informed choice about whether or not they wish to proceed. Screening needs to be accessible and sensitive to peoples needs (NHS Cancer Plan, 2000). Screening can also be seen as an invasive process. The fact that screening results are never 100% accurate can lead to misdiagnosis and anxiety in patients, however, information provided to those invited must be honest, comprehensive and understandable to its audience.
The current screening facilities available in this country are for breast and cervical cancers, with a pilot screening service for colorectal cancer. The services look to mainly screen the over 50’s, or those most at risk to the disease. The NHS Cancer plan aims to vastly expand the screening service to a wider population group in all areas, as well as looking at the possibility to screen for prostate, ovarian and lung cancer. There are randomised clinical trials currently taking place, and if the Medical Research Council (MRC) see them as viable, and cost-effective the Department of Health will allocate the required funding needed for the service.
However, many factors can affect the prevention of disease including the public perception of the risks that they take for example people continue to smoke because they have the wrong perception of the risks. Another reason maybe because the individual has an unrealistic optimism when it comes to their chances of developing a disease; many people think it will not happen to them, therefore they continue to smoke. This could be due to the lack of personal experience of the disease. The media plays a huge role in affecting an individual’s perception of risk, through the news, documentaries and TV dramas such as casualty. The media helps individuals to be more aware resulting in behavioural changes but if the risks are over dramatised people may become too scared to find out if they have a problem.
Although leaflets, posters and media are a very effective national strategy in educating people on the disease and on various prevention methods, posters and media are a very effective national strategy in educating people on the disease and on various prevention methods.
Antibiotic resistance remains a major obstacle to the treatment of some diseases caused by fast-evolving pathogens that undergo genetic mutations. Combinations of drugs against, for example, influenza have to be used because of this problem. Antibiotics are only effective against bacterial infections and are ineffective against viruses.
A barrier which comes along with campaigns may involve the lack of funding, since a lot of money needs to be put into a campaign in order to make it effective. If there is an inadequate budget, then the campaign may not be as effective and can possibly fail if the proper job is not carried out.
Compliance in medicine is the need for the patient to play an active part in his or her own recovery from an illness. Patients that do not follow a specified treatment plan are considered non-compliant. In order for a patient to achieve good health, it is important for the patient to follow the guidelines set down by medical practitioners. Non compliance can come in many forms from refusing to take medicine to the lack of understanding of the patient’s condition and the long lasting effects this may have on their health.
Compliance can be seen as one of the most important factors regarding a patient’s recovery from an illness. In many cases non compliance is what affects the inability to prevent the disease. Most people customise their treatment to fit around their own lifestyles. If the patients conforming to the treatment could have a negative change on the person’s lifestyle they are more likely not to conform. People only adhere to 78% of short-term treatments and 54% for chronic conditions. A reason for this is that patients may feel that the illness in which they are suffering from really is not that bad or maybe the medical practitioner has a lack of knowledge regarding the illness or may have got the diagnosis wrong. In some cases it is possible for the person to become comfortable with the level of their illness or even to have conditioned themselves to cope with the pain in which they may be suffering from. Patients may feel that the medical treatment which they are receiving is having little or no effect on their long term health, this can be put down to the treatment not working as fast as the patient had expected. Although some people may be worried about the more simple unpleasant side effects of drugs and even the needles that in some cases are used to administer the drugs, this can be a massive hurdle for patients to over come. The Doctors and nurses being confident in their knowledge can rectify this, also, being friendly and approachable will have a positive effect by making the patient feeling more comfortable to be spoken to and allowed to administer the treatment with out complications. By making surgery’s a less threatening environment, and removing visual barriers, for example a desk in-between the professional and the patient, would make the service user feel more at ease. With the use of softer decoration and a not so sterile look would make the surgery a more comfortable, pleasant and welcoming place to receive treatment in. The Patient may feel more willing to listen and understand what is being discussed with them because it is less threatening. There are also the more practical problems of treatments such as the cost of prescriptions or getting to the hospital or surgery, some families or older people may find this difficult to afford. Or just find it hard to fit appointments into their busy lifestyles.
While other people don’t like to take anymore then 3 drugs at a time without a better understanding of the drug. These issues can cause major problems for health care workers. If people do not take medical treatment as required this can cause implications on the health service itself. For instance if a person refused to have a flu jab, and three months down the line contracted flu which later turned in to phenomena. This could result in a lengthy stay in hospital to recover, this also can be a drain on the health service resources and with risks to the persons long-term health.
To make treatments more successful simple rules can be followed. Keeping information to a low intellectual format that makes it easier for the patient to follow and adhere to. The medical practitioner should increase the communication regarding medication and the benefits this will have on their health, and by emphasising the importance of completing the treatment. Ensuring that the patient understands what the side effects of the drugs are, and the level to which the drugs will work, so that the patients understanding of the drug does not exceed expectations. Alongside with enhanced bedside manner this will inset confidence within the patient resulting in a better relationship between them and the health care worker. Once the patient has a better knowledge of what is expected of them, they will have a better understanding of the treatment and will feel happier implicating this into their lifestyle, therefore being compliant.
Concordance is fundamentally different from compliance in two important areas: it focuses on the consultation process rather than on a specific patient behaviour, and it has an underlying ethos of a shared approach to decision-making rather than telling people what is best.
Concordance refers to a consultation process between a health care professional and a patient. Compliance refers to a specific patient behaviour: whether the patient takes the medicine in accordance with the wishes of the health care professional. For this reason it is possible to have a non-compliant patient. It is not possible to have a non-concordant patient. Only a consultation or a discussion between the two parties concerned can be non-concordant.
Crucially, concordance advocates a sharing of power in the doctor-patient interaction. Concordance values the patient’s perspective, acknowledging that the patient has expertise in his or her body’s experience of illness and response to treatment. This expertise is different from the professional’s scientific expertise in drug treatment selection but is of equal relevance and value in terms of deciding on best management. A concordant consultation is one that includes both these views in the decision-making process regarding management. This is contrasted with the approach to personal relationships, in which the desire to help, advise, and protect may neglect individual choice underlying compliance: the patient is assumed to take an essentially passive role in the consultation and to be obedient to the health care professional’s advice. Paternalism is still possible in concordance provided it reflects the patient’s preference for involvement in the decision-making process and that this preference has been actively disclosed in the consultation.
However, it is possible for patients to reject what may be considered (by the professional) to be best clinical practice even when they have been fully informed as to the nature and consequences of this decision. This can be understood as being very ignorant as there are many people who do not want to perceive themselves as in need of services. One of the emotional barriers to accessing services is that people do not like to see themselves as needy or dependent, seeking care only when their conditions become more serious. These can create barriers to achieving good health.
There is little point in the consultancy taking up precious resources, including time, if the patient then proceeds to ignore the results the consultancy and fails to improve health.
