This essay is to critically analyse the health policy on Tuberculosis (TB) published by Public Health England (PHE) in 2015. The policy derived from the 2010 Department of health’s white paper” Healthy lives, Healthy People: Our strategy for public health England. Secondary to tuberculosis being mentioned in the white paper, the framework produced is part of the Housing for Health and Tuberculosis and other Mycobacterial Diseases: diagnosis, screening and management of data (2014). The Collaborative Tuberculosis Strategy for England 2015 – 2020 then followed this, which stands precedent on the future of TB in the UK (2015). It sets out the evidence base for the eradication of TB. This essay will analyse the strength and weaknesses of the TB policy and strategy but also analyse how it influences healthcare and the changing role of the nurse and workforce development. I will discuss the prevalence of issues surrounding TB, its effect on health and psychosocial impact on people and society; discuss legal and ethical aspects of policy, the role of the nurse in TB and brief interventions.
An approach to health promotion appropriate for the purpose of this assignment is the Tannahill model (1989). It was created as a health promotion model that encompasses three overlapping spheres on health education, prevention and health protection. It is has been widely critiqued for the reductionist medical model in that it pays insufficient attention to community based factors, however is advantageous in use of training and teaching. Due to this a collaborative approach using the health belief model as well as the behavioural change model allows all aspects of what is needed from a public perspective to assess.
The aim of the TB strategy is to promote better living conditions, remove the damaging stigma surrounding and eradicate TB globally. The strategy also aims to Enrich and empower people to seek advice and prevent further infections. Disease prevention aspires to decrease risk factors and minimise the consequences of the disease. Health protection focuses on fiscal and legal controls, which consists of public policies.
A health policy is a written policy document intended to improve the people’s health through medical treatment and the health services. The WHO definition of a health policy relates to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term. It outlines priorities and the expected roles of different groups; and it builds consensus and informs people (WHO, 2016). Health has always been subject to wide individual, social and cultural interpretation. Individuals experience health and illness, but it is through influences such as culture and gender that the experiences are shaped. Images of TB and healthcare in general are also built on health rights, access, and awareness. There is large stigma and social expectations about what it means to be healthy.
Tuberculosis is an infection caused by the rod-shaped, non–spore-forming, aerobic bacterium Mycobacterium tuberculosis. The bacterium is slow growing and is spread by small airborne droplets, generated by the coughing, sneezing, talking, or singing of a person with pulmonary or laryngeal tuberculosis. These minuscule droplets can remain airborne for minutes to hours after expectoration and its prevalence is known to increase with poorer social conditions, inadequate nutrition and overcrowding. In developing countries it is most commonly acquired in childhood. Due to widespread misuse of antibiotics (WHY?) combined with breakdown of healthcare systems in parts of Africa and parts of Europe led to the resistance to antibiotics and host defense mechanisms. Introduction of M tuberculosis into the lungs leads to infection of the respiratory system; however, the organisms can spread to other organs, such as the lymphatic, pleura, bones/joints, or meninges. Once inhaled, the infectious droplets settle throughout the airways. The mucus produced by the body detects foreign substances, and the cilia help remove this from the body as part of its initial defense mechanism. TB present differently depending on a person’s immune system and not all those who are infected develop the active disease. Stages of the disease include latent TB infection, primary active TB and reactivation TB. Each stage has different clinical manifestations people with latent tuberculosis have no signs or symptoms of the disease, do not feel sick, and are not infectious. However, the immune system can later becomes compromised, which may cause the disease to be reactivated. There are factors that affect the prevalence and risk of developing TB, those who originate from a high incidence country and frequent travel to those areas, along with immune deficiencies such as diabetes mellitus, chronic kidney disease, immunosuppressant therapy, chemotherapeutic drugs and vitamin D. Along with lifestyle factors such as drug or alcohol misuse, homelessness and prison.
Tuberculosis globally and in England has been identified as a priority. The World Health Organisation (WHO) created an End TB strategy which states that they would like to eliminate TB as a public health problem by 2050(<1 case per million population). Public Health Outcomes Framework (PHOF) provides indicators and outcomes of TB incidence and treatment outcomes, by taking action on the results found damage caused by the disease can be reduced which could then facilitate reaching the WHO goal of reduction.
England has a higher prevalence of TB than most European countries. There is a distinct contrast in similar countries that have managed to attain stable reductions by introducing collaborative approaches to TB prevention, treatment and control (Abubakar et al., 2015). Even though there is substantial evidence of TB control working well in certain areas, there has been no sustained decrease. England require a tough approach to TB control in order to be advantageous of what both PHE and the National Health Service (NHS) do to diminish the damage that TB causes to communities and individuals. There is collaborative working with PHE and NHS England in initiating the strategy across England at a national level, there is then a partnership within the NHS, clinical commissioning groups (CCGs) and then further to local authorities, which is critical in ensuring the strategy and vision can be a success.
England shows distinct areas where there are inequalities linked to geographical and socioeconomic distribution. TB is concentrated in large urban centres, with rates in London amongst other major cities, and other areas with high caseloads including Leeds and Slough show that almost 75% of the cases of TB originated from a person who was born abroad in a high prevalence TB area and are not new entrants. There is a strong association between TB and social deprivation, with 70% of cases occurring among residents of areas in the two most deprived quintiles in the country and 9% of all TB cases having at least one social risk factor a history of alcohol or drug misuse, homelessness or imprisonment. The preponderance of cases seen are due to reactivation of latent infection acquired years before, this then continues the transmission of TB from person to person, which eventually leads to a spread of infection and outbreaks.
TB has major health and social impacts for those affected. Known to be infected contributes to increasing health inequalities in already deprived populations. Each case that is deemed infected signifies a risk of onward transmission fails to protect communities from TB. There is a direct correlation with statistics from the Kings fund 2016 between those who are infected with TB and the outcome of care. The Chief Medical Officer has identified the inequalities associated with TB, and rising levels of antimicrobial resistance, as an important priority for England. The Health and Social Care Act 2012 has placed a duty on local government, CCGs, PHE and NHS England to reduce inequalities. TB cases are curable. However as mentioned earlier, there is now an increasing number of drugs that are resistant especially in those that are co-infected with HIV (WHY). Due to the resistant drugs, the treatments then become longer, complex and treatment costs increase, and poor outcomes.
TB eradication would result in major savings across public health, the NHS and Clinical Care Commissioning groups, specific interventions estimated by the LMC (London Model of Care) would save a substantial amount of money. The UK is currently in a position where the risk of TB infection is increasing, if there is failure to diagnose and treat TB in a short period of time as this could cause onward transmission, drug resistance and outbreaks. There are many examples of successful TB control programmes internationally. In comparison to other areas in Europe, they have managed to sustain reductions in TB rates. Features of strong TB control programmes in these countries include clear lines of governance and accountability, adequate resourcing, local implementation of actions and close monitoring of individual and programme outcomes. An effective strategy to improve TB control in England will need to learn from these international examples, be tailored to our particular epidemiology and health system, and build on current examples of good practice.
The framework stated that there should be clear liability at both local and national levels, develop appropriate commissioning frameworks, and address gaps in public health and clinical services, such as specific interventions by the nurses and other healthcare professionals to address the large reservoir of latent TB infection, and outreach services to address the needs of under-served populations.
TB can be problematic to diagnose promptly, which results in delayed isolation of patients and potential spread of the disease. All nurses play an important role in recognising the clinical signs and symptoms of TB in the community and hospital. By being able to identify the changes it allows the nurse to promote early recognition of the disease, diagnosis, treatment and reduces transmission. Nurses are also in a position to optimise nutrition, educate, provide emotional support, and prepare patients and patients’ families for discharge from the hospital.
Nearly every type of health care setting has been linked in the transmission of TB. The accident and emergency department has a vital role in play a vital role in monitoring TB as it the main entry into the hospital. However, the disadvantage is that there is nonspecific signs and symptoms and screening protocols are very dated, the early detection of TB is still missed in emergency department triage (WHERE/how why). Therefore, patients can be discharged into the community or admitted into the hospital with no intervention. Another critical point that needs to be addressed is that patients who are admitted due to major trauma may also escape screening for TB as the main focus will entirely be solely be on their injuries. Often trauma patients are admitted to an intensive care unit, where it is common for patients to be susceptible to any infection. Intubated patients are compromised directly from the pulmonary standpoint and lack normal upper airway defenses that protect the lungs from bacteria. Many nosocomial tuberculosis outbreaks have been reported emphasising that nurses and all other health care professionals should remember that even in-patients may have tuberculosis. Due to the fact that nurses play a key role in detecting tuberculosis, they should advocate for prompt isolation of patients with suspected or confirmed TB infection. Nurses should be familiar with the isolation procedures and protocols in the hospital or community that must be implemented. Patients with suspected tuberculosis should be placed in a negative-pressure room, and appropriate particulate respiratory masks should be readily available outside the door for anyone entering the room. Patients should be instructed to cover their nose and mouth with a tissue when sneezing or coughing. In addition to the direct responsibilities of nursing, many nurses are also a key source of emotional support for patients and patients’ families during times of illness. Many patients with tuberculosis experience feelings of guilt and face stigma, and patients’ family members often fear associating with the patients. Nurses can provide education to patients and patients’ families about transmission and treatment to help reduce misconceptions and can elicit conversations to communicate concerns. Encouragement combined with education can affect a patient’s adherence to therapy, as well as improve the patient’s mood and perception of the illness. Compliance from nurses and other healthcare professionals in terms of following protocols and the patients to the treatment prescribed is vital. Adherence is the degree to which a person’s behaviour follows the agreed healthcare recommendations (World Health Organisation, 2009a). The nurse must understand and overcome the barriers for adherence to treatment regimens and reduce or eliminate these barriers. Nurses can use incentives to motivate the TB patient to comply with treatment, which can improve patient and nurse relationships. Incentives include reimbursement for travel, food, visits and phone calls. Some patients may have financial difficulties therefore malnutrition is a serious problem and food is considered essential for treatment success – rather than an incentive.
Adequate nutrition is an important feature though all stages of infection. Malnutrition appears to increase the risk for tuberculosis; persons with low body mass index are greatly more at risk for tuberculosis than are those with a high index(WHY). Nurses should take particular note of underweight tuberculosis patients, recognising that being underweight is a risk factor for relapse and encouraging aggressive nutritional support. Also, because functional recovery often lags behind microbiological cure, the aim of nutritional intervention should be to restore lean tissue. Nurses should also encourage patients to engage in physical activity to counter the loss of muscle mass and subsequent fatigue. Advocating for a nutritionist and physical therapist to evaluate a patient with tuberculosis to make patient-specific recommendations would be an appropriate action for nurses. There are now brief interventions, using these can facilitate the patients’ focus and their thinking at a critical moment. Within TB there is smoking cessation and alcohol as an intervention strategy. Unfortunately as health professionals smoking cessation and TB may not be seen as an obvious link and therefore the importance of intervention may not be fully understood. Patients will not necessarily readily appeal for information concerning their smoking habits, and health professionals will generally respond to patients questions rather than bring them up themselves (slama, 2007), which then leads to missed opportunities for health training to the patient which is a major barrier within brief interventions. In relation to alcohol, the nurse could talk to the patient whilst during a consultation or on the ward to identify if there are any alcohol-related problems, by using a standardised alcohol questionnaire, introduce referral service if necessary and make the patient aware of the risks of alcohol and TB. The nurse has to be prepared and willing to use cessation intervention within TB management. TB patients who are commencing treatment are much more likely to be emotionally enthusiastic and attentive to information regarding activities and actions they can adhere to improve their health. This is therefore considered an essential teachable moment for change.
According to the ICN Code of Ethics, “Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal.” (International Council of Nurses, 2012) In relation to TB, nurses promote health primarily to prevent people becoming susceptible to the disease; this is done by reducing transmission of TB in the community and treating active cases; the nurse re-establishes health by ensuring patients receive the treatment needed; and relieve any stress by coordinating support for patients according to their individual needs.
The reaction of people being informed of having TB largely differs depending on elements such as cultural beliefs and values, previous experience, and knowledge of the disease. TB sometimes has a high profile in the media where there can be a major stigma attached. Nurses are positioned well within the community, and closely with patients and their families, which is critical as part of the treatment for TB. Patient-centred in the End TB Strategy is defined as one of the main priorities that the WHO acknowledge as being fundamental in the success to the eradication of TB. Nurses working in primary healthcare people who present with symptoms and are crucial to the early identification and management of presumed TB.
Screening for TB can be expensive therefore it is cost effective to target the
highest risk groups based on epidemiological trends within a local population. Often screening is targeted at hard-to-reach groups, which means identified cases are a challenge to treat (Williams et al., 2007).
To ensure a high level of case detection, a cornerstone of TB control, nurses working with individuals, families, communities and other services need to understand their role in controlling this preventable disease. The nursing process is a systematic approach to providing individualised, patient-centred care through a cycle of assessment, planning, implementation and evaluation. To ensure all stages are met the nurse requires a range of skills such as identifying and handling adverse effects; counselling; as well as organisational skills for co-ordinating care, communication to ensure clear teaching is given (Williams et al., 2007). There are two main types of finding cases; passive finding is when a person presents with symptoms. Detection of symptoms relies on the nurses and healthcare professionals. However, it is fundamental that people have relevant and accessible public information of services for people to recognise TB symptoms and know where to get help.
If diagnosed with active TB, a TB specialist nurse is responsible for ensuring that the patients are entered into the London TB Register (LTBR) and that this is kept updated along with alerting the Health Protection England (HPE) of new cases. Along with visiting the patients home, school and place of work, for anyone that has come into contact in order for them to be tested.
Diagnosis usually leads to an investigation of the patient’s contacts to see if any of them have active TB (active case finding). Once diagnosed the nurse ensures that the patient can adhere to the drug treatment as easily and as soon possible. The nurse must assess and implement the treatment plan, as patient’s needs may be subject to change during treatment, therefore the nurse must monitor the patient’s progress at regular intervals. This may start weekly followed by fortnightly and monthly, during these follow ups the nurse can and re evaluate to ensure there is suitable care at each stage that the patient’s continues and follows the TB treatment.
There are many organisational aspects of ensuring there is success to TB eradication. Human resources are critical in ensuring there is sufficient staffing and protection for workers. Training and quality assurance is vital to eliminate any practice development issues. Constant feedback from the patients and further research into TB is necessary to guarantee the protocols and procedures are up to date (ANY CURRENT RESEARCH?).
Nurses need protection themselves from TB infections and to maintain a continued high level of patient care, it is important for nurses to understand the risks of contracting TB and to know the recommended methods of protection. Yet, protection and safety of nurses and other health professionals is often a neglected area.(WHY).It has been reported that entire nursing classes had been infected with TB within the first year of nursing training (Israel et al., 1941). It is estimated that more than 50% of healthcare workers globally have LTBI placing them at a greater risk of developing active TB. Moreover, healthcare workers are two to three times more likely to develop active TB than the general population (Joshi et al., 2006, Menzies et al., 2007). To reduce these statistics amongst workers, there are pre- employment routines for TB screening, TB skin tests are also done when new staff are first employed, every six months or annually thereafter (based on the level of TB found in the community and in the health facility), and whenever an employee has signs and symptoms of active TB (World Health Organisation, 2009c). such as checking BCG status and giving the vaccination if necessary and heaf skin testing. TB control involves all levels of the health system – international and national policy makers, regional and district TB coordinators and TB specialty nurses, as well as primary care nurses working in a variety of settings. The general practice nurse is the first line of defence in TB control worldwide, and this important role must be recognised and strengthened.