Sexual Health Promotion among Young People - Assignment Example

Sexual Health Promotion - Young People In the UK problems associated with young people's sexual health include the high rates of teenage pregnancy (Social Exclusion Unit, 1999), an increasing rate of Sexually Transmitted Infections and unsatisfactory sexual relationships (Holland et al, 1998; Wright et al, 2000). It is usually believed that education in sexual matters will lead to reduction of risk taking and therefore reduction of these problems yet this assumption is not supported by randomised trials on any large enough scale to show this, and none in the UK (Buston et al, 2002). While some quasi-experimental studies have concluded that sex education is effective most randomised trials suggest that it is not (Wright et al, 2002). This team also demonstrates that teacher delivered sex education has some beneficial effect on the quality of young people's sexual relationships but do nothing to influence sexual behaviour. Last year the Minister of Health, Andy Kerr (2005), stated: "Improving Scotland's sexual health is central to our public health agenda. It is not something to be embarrassed about or to shrug of as someone else's problemby empowering young people with the values of respect and responsibility they will be able to make sensible choices about their own sexual health." This lays the foundation for the need to re-look at the path into the future of sexual health promotion among young people. The role of multi-professional and multi-disciplinary teams for providing primary health care thus comes to the fore. The teams form an essential element of health care and need to provide timely and evidence based inputs to health improvement, policy and planning. This will come once understanding is developed of the state of Scotland's sexual health and the measures required for improving it through increased competency and capacity to deliver health improvement programmes. Most importantly there is a need to address the barriers to provision of effective health care and issues of ethics that confront all primary heath care services in general. Health promotion is the combination of educational and environmental supports for actions and conditions of living conducive to health (Green & Kreuter, 1990) and is a science of helping people to change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health (O'Donnell, 1989). Health promotion follows two types of models (Whitelaw et al, 1997). With respect to modelling health 'determinants', models are characterized by the view that health status is a product of social, environmental, cultural, economic, political, behavioural, biological and health service 'fields' (Raeburn & Rootman, 1989; Hancock, 1993). The second type of model approaches health from an understanding of the practical consequences of global thoughts in terms of health promotion practice (Beattie, 1991). Common to both of these two types of models is their 'holistic' identity; Hancock (1993, p. 46) noting, 'a new understanding of the ''wholeness'' of health'. Individual clinical expertise implies the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice (Sackett et al., 1996). A similar definition of 'evidence-based health promotion' suggests the same pluralism: 'Evidence-based health promotion involves explicit application of quality research evidence when making decisions' (Wiggers & Sanson-Fisher, 1998). Wiggers and Sanson-Fisher, in writing about evidence-based health promotion, subscribe to the NHS Centre for Reviews and Dissemination (NHS Centre for Reviews and Dissemination, 1996) hierarchy of research evidence when information about effectiveness is needed. Different initiatives to implement the national sexual health strategy through participation in the National Sexual Health Advisory Committee and in the different sub-groups, namely, Education and Training, Needs of Rural Areas, Research, Data Collection, Clinical Indicators, HIV Health Promotion and Equality and Diversity have been taken up in Scotland. With the involvement of key stakeholders, NHS Boards, local authorities, volunteers, police and GP's various issues are being addressed to improve upon the state of sexual health in Scotland with specific focus on young people in the 13-15 years age bracket. The aim is to raise awareness of sexual 'ill health' and reach the health promotion initiatives to the 'harder to reach groups' (Sexual Health and Well Being Programme, 2006). Ethics have long been recognized as the keystone of health care. However, some aspects of primary health care, of which sexual health promotion is an integral part, raise the need for an ethical framework. Health care provider must liaise with patients, make treatment decisions and process patient information all of which have an ethics dimension. Little attempt has been made to formulate an ethics framework which is focused on sexual and reproductive health care, services and practices. The following discussion is restricted to sexual and reproductive health care at a primary level; that is, at the preventive, initial and basic care level. At this level the care providers may be from different disciplines and from different professions who in combination provide care in accordance with the basic principles of social justice. Care providers include GPs (family doctors), community nurses and other clinicians (Department of Health, 2001b), Primary care professionals (Reeves, 2001), Social care workers (Milburn, 2002), Representatives of patients and the community (Milburn, 2002) and require a 'rich mix' of differently skilled professionals (Department of Health, 2001c) operating across established organisational and professional boundaries (Department of Health, 1997). To be effective these multidisciplinary professionals need to operate in synchronisation to provide focussed service. Care provided must be personal and of a continuing nature (RCGP, 2003) in a joined and holistic approach (Department of Health, 2002c) and patient centred (Department of Health, 2002d). The care should be targeted towards improving and promoting health and healthy lifestyles (Department of Health, 2001b & 2002b). The provision of sexual and reproductive health care is specifically covered in these provisions of the guidelines established for the country (Department of Health, 2003a) and includes the physical, psychological and social aspects of diagnosis (RCGP, 2003). The very nature of the personal relationship between provider and patient is continuing, caring, personal and sustained (Leopold et al., 1996) and is of prime importance to the effectiveness of such care. Yet it may also take the form of a one-off, anonymous encounter in an open access environment (Martin, 2004). While the service is generally considered to be limited to persons on the patient list, giving providers some control over distribution of resources, it may also provide unfiltered services (Pringle, 1997). In addition to the provisions of the different government directives two other factors influence the practice of heath care. These are the Evidence Based Medicine and Practice (EBMP) and the human rights considerations. EBMP implies that clinical practice should be based on the 'conscientious, explicit and judicious use of current best evidence in making decisions about individual patients' (Sackett et al., 2000). The meaning of 'best evidence' is to be interpreted strictly in terms of scientific understanding that comes from 'RCTs (including systematic reviews) and meta-analyses of RCTs' (Sehon and Stanley, 2003). 'Evidence-based medicine, evidence-based nursing, evidence-based public health, evidence-based psychology - all the sciences that have come to rely on the research-literature nexus must be quite clear about the fallibility and uncertainty of their enterprises' (Goodman, 2003: 15). The constant tension between EBMP and the clinicians own experience and expertise leads to the first dilemma of ethics - what should take precedence EBMP or individualised treatment without waiting to make absolutely certain. This affects health promotion at primary levels the most. In tackling issues related to heath promotion at primary levels EBMP is not always a good tool for making diagnosis where personal experience and knowledge of patient history and patterns play a more important role (Grahame & Smith, 1995). In such situations Evidence based practices have 'proved inadequate' (Greenhalgh et al., 2003) and make 'false and dangerous promises' (Hammersley, 2001) for health education research and appears insufficient for effective health promotion (Tang et al., 2003). We see, therefore, that the concept of EBMP does not really apply at the level of sexual health promotion among young people where the issue is one more of education and guidance. The second dilemma of ethics is the need to follow the provisions of the Human Rights Act, 1998 which makes it mandatory for health care services to be contained within the ambit of the framework laid down in the law as also the European Convention for the Protection of Human Rights and Fundamental Freedoms. Not doing so can attract severe penalties and make the service provider open to litigation for recovery of damages through judicial review of a treatment decision or policy. Recent debate and broadcast of these laws and connected cases has made the public very aware of their rights - even 'experts'. They may demand treatments or medicines that the provider does not wish to offer or does not consider correct in the best of his/her judgement. Government policy also requires patient participation in the determination of treatment and medication. This necessitates the need for development of a set of ethical codes which will help achieve patient participation to avoid conflict (and later litigation) in interaction with them (Brooks, 2001). Changes in the structure and priorities have created an environment of uncertainty and have led to an 'attitudinal shift' (Brooks, 2001) among the service providers and patients as well as within the health services. New policy, human rights legislation and the ever increasing dominance of evidence-based practice magnify that uncertainty, and practitioners can find themselves pressed to make decisions where there is no obvious right answer. Some of the areas where health care ethics may need rethinking are discussed in the following passages. Patient autonomy: the provider-patient relationship has always been characterised as benevolent paternalism in the NHS. Autonomy implies respect for the dignity and worth of the patient and respect for different cultural, religious or ethnicity backgrounds. This automatically includes respect for privacy and confidentiality of patient information which is also a legal requirement (Human Rights Act 1998, Data Protection Act 1998). Now this respect has changed to include respect for the patient's right in the determination of care and the right to all information necessary to make an informed choice on treatment. Now this is where the problem begins, what about the EBMP considerations The providers of health care have to find a balance between what they consider the best line of treatment based on their knowledge, skills and experience, what the patient desires and all the time working within the constraints of ensuring Evidence Based Practice. Access: issues of ease and flexibility of access to health care have been attempted to be addressed by NHS Direct but these seem to have benefited only those who were already using services and have done little to improve access for those who are the most disadvantaged (Abbot, 2003). The human rights law requires equivocal access regardless of age, disability, social class or ethnicity and patient demands may not be refused on the grounds of economic considerations. This equal access will, however, have implications from the viewpoint of EBM which are based on medical efficacy rather than on socio-economic circumstances of the patient. Raising issues of ethics in determining the care to be provided to the patient and these will need to be resolved. Boundaries: The line differentiating social services and Health care at primary levels is thin and poorly defined (Flynn et al, 1996; Goodman et al., 2003). This raises issues of overlapping obligations. In addition to this another boundary that is vague is where the duties of the single practitioner end and where those of groups and multidisciplinary teams begin. Yet another problem arises in defining the responsibility of care between the home and the healthcare services. Similarly on the other side the definition between primary and secondary care is getting increasingly vague, with primary levels now providing drugs and care that were earlier in the domain of secondary care (Scott, 1996; Gray, 2003). In this atmosphere professionals find themselves operating in the context of shifting boundaries of professional identity, creating uncertainty (Price & Williams, 2003). Other concerns: Some of the other major concerns that face the provision of healthcare are mentioned here, and each of these can become cause for major problems if proper codes of ethics are not defined. The relationship between patient and care provider is an intimate one and there is need to define ethics that prevent abuse of intimacy. Issues of maintenance of confidentiality become even more intense when the treatment is being provided by teams instead of individuals (Troop, 1998). The Freedom of Information Act, 2003 requires the publication of details of practice, services and participants. Will this become an issue of advertising health care service - an unacceptable practice under existing ethical codes (Irvine, 1991) There have been suggestions made for setting up a code of ethics to support heath care providers at the primary level (Peile, 2001). This code is essential to be discussed and laid down without any further delay. References: Abbott, S. 2003: Equity of access to primary care in the UK: is it likely to increase Primary Health Care Research and Development: 4, 187_89. Buston, K. et al. (2002). 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