Evidence Based Practice | Evaluating the program or policy

Southwark is a home to around 306,745 310,000, according to the sources. This   is equally divided into male and female residents of the borough. The division of this    into different age groups is as follows, along with the comparison of population demographics of London and England.Figure 3: Population age and gender structure of Southwark Vs London & England (GLA, 2014).

It can be seen that the nearly 42% of the people in this community are aged between 20-39, which is greater than the 35% of the London and 27% of England and have a smaller older population than London and England. Its population comprises people from diverse ethnic and cultural backgrounds, with 55% belonging to white and 46% to black, Asian and others. Life expectancy rate of Southwark is 83.9 years for women compared to 82.2 and 83.2of London and England respectively. For men its 78.9 years, compared to 77.9 & 79.5 of London and England (NHS, 2016). Newington ward is the most densely populated and deprived electoral wards of Southwark as compared to other wards. Newington ward shows that the population density is 18,204 persons/Sq.Km compared to other wards.

The deprivation rank of wards in Southwark can be seen in the following graph, which shows that South Bermondsey is comparatively less deprived than other wards, while Peckham is comparatively more deprived.

According to the Social Model of Health determinants by Dahlgren and Whitehead, the socioeconomic, cultural and environment factors of a community are most essential factors associated with poor health, pursued by the living and working condition.

Figure 6: Dahlgren and Whitehead model of factors affecting health (Maylahn, 2013.)

Housing rents are rather expensive and have increased over approximately 19% over the last three years, which although is lesser than other boroughs but is higher from inner London. This lead to the surge in homelessness and in 2015, 875 households owned no place to live statutorily (Chartered Institute of Environmental Health, 2016). 45% live in rented houses, which less than the 1991 of statistics of the borough. However, according to the 2011 census approximately 18,545 households were overcrowded. The poor air quality of the borough caused an increase in deaths because of the respiratory, lung and cardiovascular diseases.

Healthcare services in Southwark are relatively poor, which is even worse for minorities and people belonging to low earning families. The risk factors are particularly elevated for individuals from the less affluent backgrounds, as the children from more deprived wards are reported to have lesser healthy life expectancy, more inclination for drug abuse and smoking prevalence rates. According to OHSEL, findings, the healthy life expectancy of a person belonging to affluent class is 65 years, which is 55 years for a person from a deprived area, having less access to educational and health facilities (2016.)

Water and sanitation system of Southwark employs crossness sewage treatment works, located in the southern east of London. It upgrades its services gradually and serves the community very effectively. The water quality requirements of the community are well met and also ensure the reduction of storm sewages.

Smoking rate in adults is reported to be 21%, which is higher than 16% of England. Shisha and cigarettes are getting popular among young adults of the community, with 46,000 people smoking in 2016 (Southwark council, 2016). Alcohol and drug abuse mortality rate of Southwark is higher than 16% of England and is 19%.

The literacy rate of Southwark is quite high and according to the Southwark council statistics 29% people work in professional jobs, 14% in technical jobs and 8% in administrative jobs. But despite this high literacy rate, unemployment rate of Southwark is quite high as compared to other boroughs of London  and has increased significantly from the last 2 years, as shown in the given below graph. The work related illnesses, including stress, depression and other health problems are also increasing in this area and were recorded 1.2 million in 2016. The nature of work is also getting more sedentary becoming a cause of obesity and other predicaments.

Stage 2: Quantifying the issue

Strengths and weaknesses

On the basis of the above community assessment, some of the strengths and weakness recognized for Southwark are briefly discussed below

Strengths

The recent reports of the Southwark council depict that the overall percentage of inhabitants of the community enjoying a reasonably good health and having an approximate healthy life expectancy of 6 years is roughly around 72%. While the percentage of people with quite good health state is 16.3% and those with not good health state are 11.7%. The life expectancy is also improved and is in accordance to the average life expectancy rate of the boroughs with more affluent residents. The infant mortality rate is also controlled over the last ten years and is noted to be only 3.9%, which is even lesser that 4.1% of London. It also offers free swimming pools, gyms, playgrounds and sports activities centres, which stay open from morning to night from Monday to Friday. More than 64,000 residents registered for these facilities to improve their physical health. In addition, it has upgraded waterworks and sewerage systems (Southwark Council. 2016).

Weaknesses

The major weaknesses of Southwark include the intensification of unhealthy weight, particularly among teenagers, high unemployment rate, widening inequality between rich and poor, increasing rents of houses and poor quality of air. Risky behaviours of substance misuse, smoking, alcohol drinking etc, which negatively affect the physical and psychological health of young population of the community is another noteworthy issue. The rate of sexually transmitted diseases and infections is enlarging with each passing year.

Moreover, high homelessness rate of the community weakens the healthy development of a child with full mental and physical growth potentials. Mental health issues of inhabitants are relatively higher than London with 3800 s suffering with some sort of mental problem grown-up. Physical inactivity is getting higher for young adults and teenagers, causing obesity, which is referred to the mother of other diseases.

Existing resources

The current resources owned by Southwark that contribute to maintain and improve the health of the individuals include

• Southwark library
• Hospitals
• Social and healthcare institutions
• Train station
• Shopping centres
• Local parks
• Fair waterworks system

In Southwark, the most prominent health concerns and diseases among young adults aged between – according to the assessment data collected are

Obesity, smoking and unemployment are observed to be the most prominent health concerns of Southwark, which are the major reasons of the health issues faced by the community. The ranking of these key health issues faced by the Southwark community is done in the graph below

Stage 3: Developing a concise statement of the issue

As mentioned in the previous section, obesity is the foremost and most unchecked health concern of Southwark community. Although, it itself is not a disease, yet it leads to many serious diseases which are prevalent in this community, like diabetes, chronic heart diseases and many types of cancer. It also boosts the mortality rate of the population by following many other physical disorders. It is also found to be linked with mental illnesses by causing depression and lack of confidence in one’s capabilities. In Southwark the obesity rate for children below 13 years is 42.1%, which is the highest rate in London and for adults it is 55.3%, according to the report of the public health England. In addition, 15.3% of the children in the community below 7 years are overweight and 26.7% children of this age are clinically declared to be obese (Southwark Council, 2016). This state is quite alarming and needs immediate attention to be paid.

Stage 4: Determining what is known about this health concern through the scientific literature

Obesity is a worldwide phenomenon, with ever rising numerical figures observed around the world, especially in developed countries. A person is referred to as obese in case the measurement of his or her body mass index is above the range of 30 kg/m² (Haslam, Sattar and  Lean, 2011). In some cases this issues is related to the genetic makeup and hereditary facets. Or it could be the result of some medical problem like endocrine disorders.  Yet, in most of the cases, an individual’s food habits are also a huge factor in determining this health issue. Low physical activity, eating unhealthy junk food, and having an imbalanced diet also lead to obesity.

It is a multifaceted and very complex challenge faced by individuals around the globe. WHO statistics show that obesity has increased from 15% in 1993 to 25.6% in 2016. On one hand, obesity in adults generates numerous serious health issues and on the other hand in children it can cause feelings of low self esteem and low confidence levels, which is because of the bullying faced by such pupils. They are more likely to become obese adults. National Childhood Measurement program reports indicate a direct correlation between the social status of a child and his weight dynamics at all the ages. It is also more frequent in women to a certain extent than men. It was previously found in elite class who had more access to food and had people serving them, so they had low physical activity but the increasing sedentary life styles of people in all sectors has now complemented it. It is more severe in U.S, Canada and Australia; however, it is slightest in Africa (Doak et al., 2011).

Interventions used in Southwark to address obesity

Some of the interventions employed by the borough of Southwark to effectively cope up with this matter of grave concerns are

• It encourages the people to be active physically not only at home but also at their workplaces and try to walk as much as possible through its SilverFit and Ourparks schemes. It develops plans to induce people to reduce weight. It also organizes sports weeks and programs at school levels to control the obesity of school going children.
• It has devised plans and strategies to generate awareness among the people about the healthy weight benefits and alarming long term drawback of being overweight. Healthy eating habits are promoted. Even teachers are advised to guide young students about the advantages of healthy fresh food eating habits.
• Many campaigns and advertisements with the intent of spreading public service messages about this ever rising health concern are broadcasted on TV, Radio and other mediums.
• Local policies and strategies are also being devised and implemented vigilantly to deal with issue in an effectual way by allocating 40% of the greener and safer funds in the development of the infrastructure and green space.
• The health practitioners working in different health and social care setting also provide free guidance and advice to their patients about it. They also arrange seminars, campaigns and community awareness programs in this context.
• Active transport initiatives including bicycles, skate boards and walking are instigated so as to promote active life styles in the children and youth of the borough. The cycle to work scheme is another remarkable initiative implemented by the Southwark council.
• As it is obvious from the community assessments conducted regularly that obesity and being overweight is more common among the population of deprived and less affluent areas, who are inclined to spend more on unhealthy food, a review of Cap is issued to narrow the gap between the rich and poor. Endeavours are also being made to enhance the access of the less affluent people to the required health services and to ensure the availability of adequate and affordable food to them
• Campaigns are also launched to lessen the sodium quantity, which is observed to be a factor of causing obesity, in processed food.
• In addition, strives are also made for creating a more engaged community through interacting with them appropriately.

After conducting a health needs assessment of a community, it becomes essential to take the steps in accordance to the identified health needs, while keeping into consideration the strengths and challenges  of the community, which otherwise prove this CHNA process futile if no action is taken on the basis of the information collected through it. It helps in devising policies, plans and programs while concentrating the available resources optimally to address the needs of the community ease the health disparities among different residents of the community and improve their overall quality of life by increasing the accessibility to quality health and preventive services. In this section of the paper, the focus will be on developing a community based project by assessing and prioritizing interventions to overcome the chief health concern faced by the community of Southwark.

Stage 5:  Developing and prioritizing programs and policy option

Obesity as discussed in the previous section of this research paper is the most serious health concern affecting the population of the Southwark detrimentally and is one of the most obvious element of the several diseases prevalent in that community. It is the fourth leading reason of the premature deaths in this community with figures recorded to be 308 persons per year, according to the active people and health fact sheet of the Southwark council, published in the year of 2015. This report states that 59.7% of people in affluent wards are physically active, which is only 42.3% for individuals from deprived wards. This ratio is observed to even higher in women and children of low income earning families. The inactivity rate is reported to be lower than that of London and England. The black ethnic groups are also more prone to this health impediment.

A strategy devised by the different strategy partners f the Southwark council collectively, named as healthy weight strategy, aims to reduce this problem considerably in both adults and children over a period of the next five years. It was published in mid of 2016 and primarily focused on the children under the age of 11. It has four underpinning objectives, which are

• Evidence based
• Family oriented
• Across the life course
• Across the whole system

Southwark council makes sure that all the strategy partners work in collaboration with each other for an integrated endeavour to tackle this momentous issue. It is believed that working in partnership with education, sports, leisure and other departments of the community, along with the partners from the national health services department can make this process not only more successful but will also reduce the time taken to achieve the desired results. The council continues to prioritize the different actions and sets of actions recommended by its healthy weight strategy, according to their urgency, based on the data collected through regular assessments. It also investigates the most recent and useful evidences used and other innovative advancements in this field.

The Food safety team of the council ensures that all the fast food chains follow the requisites of the Food Safety Act. This act delineates the various standards and requirements that need to be met for the production of food items that are free of hazardous chemicals and are healthier to eat with low contents of sugar, salt and fats, so as to make it less fattening. It is also restricting the fast food takeaways edifice to encourage the habit of eating homemade healthy food in the inhabitants of the community.

It has invested in the expansion of the green spaces and parks to promote physical activities in the leisure time of the individuals and also to create opportunities for the social interaction among them. This also increases the air quality of the borough. Better travel options are encouraged by improving the infrastructure of the borough, especially by creating such streets that facilitate the residents to walk or do cycling. These activities help in burning fats.

Get moving is another such program implemented in Southwark to promote physical activities in the older men and women of the community and funding on this program is augmented with the intent of growing their bodily strength and boosting of their immune systems to combat with diseases. The leisure management contract is also recomissioned for this purpose. Free Swim scheme enables people above the age of 60 years and those having some sort of physical and mental disability to avail this facility free of any cost at any time or day.

The free NHS health checks offered by the NHS hospital trusts of the community have the capability to add years to a person’s life by checking his or her health condition and suggesting steps and measures to be taken in relevance to diet and medications. These checks also measure the BMI of the individuals and advices them how to maintain healthy weight. The disparities in the access to the healthcare services are also tried to minimize by enacting the provisions of relevant laws in the policies of these healthcare institutions. They are mandated to respect the individuals coming from diverse ethnic, social, economic and racial backgrounds.

Analysis of the strengths and barriers of the above interventions

In order to analyze the strengths and obstructions to the above stated intervention of Southwark council, the framework of pest analysis will be used. pest is an acronym of political, economic, social and technological factors and it assess the impact of these external factors on the interventions.

The role of local government and parliament is inevitable in improving the health and living conditions of the individuals of the locality. It can devise and implement policies and schemes nationwide having the potential to affect the wellbeing of people on the whole. Through its legal policies and regulations, the government can organize and direct the food practices of a community, its food businesses and the way food is grown and processed. It serves to regulate the physical environment of an area and the working conditions. It also influences the attitudes and lifestyles of the inhabitants through directing the social media and other sources of media to spread awareness about this issue. The Change for life program commenced by the government guides and advice people across the country to adopt health diet and everyday life. Actions taken the government for convalescing the labelling on the eatables sold by companies, assist buyers to make more informed decisions while keeping into consideration their nutrition values whilst buying these items.

In order to implement the policies, schemes and programs devised by the government, economic analysis of the finances and funding required for them is essential. This analysis provides insights into the monetary value of these strategies and how useful they would prove in the long run by cutting costs on other services. In case of obesity, spending by the government to resolve this issue can lead to a decrease in expenses required for the healthcare services provisions of the diseases caused by it.

The social status of the individuals, as discussed in the task 1 of this report serves as a determining element in influencing their body weights. The age is a socio demographic attribute which is observed to have relevance with the obesity. The children aged 7 in Southwark has the highest obesity ratio in comparison to other boroughs of London and the basic reason for this is examined to be the setup of their schools, which concentrate on academic activities mainly. Nevertheless there is no obvious substantiation of the correlation between the other social demographic features of a population and obesity or being overweight. The religion, culture and values or norms of a person doesn’t seem to affect their healthy eating habits or physical activities.

Technology serves to accelerate the interventions adopted by the Southwark council to control obesity by spreading awareness among people through the various apps and internet. Information can be communicated easily and cost effectively to the individuals with the use of these technological advancements. However, these advancements in technology have also made people to use machines and other gadgets to get their work done with no physical activity. The advent of mobile phones, computers, games and TV cause children to spend more time indoors watching and playing games digitally rather than playing sports.

The principles of community development will be employed in this stage, in an attempt to develop a community based project for Southwark. Community development is a combination of two words, community and development; therefore, it refers to the development of a community as a whole by their joint endeavours of its members. It boosts the knack of community members to make better decisions collectively rather than individually. O’Neil et al., define it as a communal effort to the creation of a social, economic, political and cultural environment where the members can utilize their skills, aptitudes and capabilities to their full potentials, to improve their quality of life (2012, p.412) Community development is usually associated with the principles of empowerment of the members in decision making process, their active participation, inclusion of all the members without any bias, self determination and partnership with the agencies and institutes for the successful accomplishment of the targets.

This project is focused on the school going children under the age of 15 years, who are observed to be the most vulnerable group to the most prevalent identified health concern of Southwark, which is obesity. This project will be designed for one term of all the classes from play group to high school level, in a school. The three basic objectives of this project are:

1. Changing the attitudes of the children by augmenting the awareness among them about the severity of this issue, the problems caused by this issue in the long run and informing them about the benefits of maintaining a healthy weight.
2. Promoting the habits of an active life and advising them to indulge themselves into physical activities. Scheduling and organizing sports weeks including games of football, cricket, volleyball, swimming, running races and other feasible games, with the incentives of prizes to the winners of the games and regular daily exercise sessions in the schools. Promoting the active transport and walking to school habits.
3. Planning and devising healthy diet programs and advising the students about the impact of eating habits on their overall body weight. Students will be guided about the nutritional value of the food items they eat and how much calories, fats and proteins they can intake to maintain a healthy physique. BMI checks will also be conducted on regular basis to identify any divergence along with the change in eating habits. In addition, there will be cooking classes to teach students how to cook healthy food within reasonable budget restraints.

Students in all the different classes of the school campus will be empowered to give their personal suggestions or viewpoints by meeting me in personal and by encouraging them to take part in the sessions that be organized twice a week on Tuesday and Friday for an hour after the school time. This method will not only increase the interest of the students but also help me in making amendments in the interventions according to the feedback, to make the project more effective.

All the students will be encouraged to take active part in the sessions, cooking classes and physical activity programs. This participation will assist them in building their confidence levels, which is usually observed to be low in obese or overweight pupils. They will also be encouraged to share their stories, if they have been successful in losing their weight to attain normal body weight, in accordance to the clinically accepted statistics.

Self determination of the participants will be enhanced by including real life stories of the boys or girls of their age who lost weight by adopting healthy lifestyle and eating habits and by taking involving themselves in regular physical activities to burn the body fats. In addition, a team and collaborative working atmosphere will be created, where all the participants will support each other rather than making fun of others.

All the participants will be involved in this project as equal partners, playing their individual roles to contribute to the attainment of the overall goals, for which this project is designed and implemented. They will be asked to give ideas about different sports that must be included in the sports week, recipes of dishes to be cooked in cooking classes and buying ingredients for cooking different dishes, with each member of the program cooking a dish in a group or playing a game as a part of a team.

All the students will be treated equally with no biasness on the basis of having a different ethnic, racial or cultural background or because of the social status of the family he or she comes from. The students belonging to less affluent or low earning family who cannot afford to buy ingredients for cooking classes or sports wears and instruments will be provided with these things.

The three types of barriers that can be faced in the effective implementation of the project interventions are cultural, social and technological barriers. In order to overcome these impediments all the pupils from different cultural and socioeconomic families will be given equal opportunities and no one will be given unnecessary preference over others. The interventions will be such that won’t offend any cultural or ethnic group. All the instructors will be given training beforehand to tackle these difficulties and those who will not be able to pay for different interventions will be supported either financially or allowing he willing members to help them by sharing their boosts, shirts, instruments and other things. Technical hurdles will be solved by giving leaflets to all the members, clearly stating the details of the project like its timing, venue and interventions. These details will also be posted on the school notice boards and website.

This is the last phase of the model and it comprises the appraisal of the project or interventions devised on the basis of CHNA, prioritized according to community needs urgency and implemented while considering the strengths, barriers and current resources of the community. Evaluation of an intervention or project is to spot out any discrepancy in their outcome and set standards or goals. Through the evaluation process, gaps are figured out to make improvements in the programs or their execution techniques. To evaluate the project designed to tackle with the issue of obesity in children under the age of 15, RE-AIM model will be used.

Reach refers to the target population for which the obesity interventions are intended. It comprises the exact number of the participants. It is also assessed whether they are actively taking part in these programs under this obesity control project and making their best efforts to accommodate the organizers in doing well at their plans.

It is the extent to which the obesity control programs have been effective in the attainment of the required outcomes. The changes in the population are noted to appraise whether they are losing weight or making changes in their physical activity and eating habits. One important tool that can be used for this evaluation is body mass index measurements.

It relates to the number of the pupils at the school campus who have adopted themselves according to the advice and training of the organizers and instructors of project. The organizers and those who are conducting these cooking, sports and exercise programs can affect this adoption of the children significantly. If they are well trained, competent and committed to it, the likelihood of the success increases. The organizer or representatives of the program, conducting should have the potential to motivate the participants.

Implementation means the way in which this project will be executed. Its timings, costs and its usefulness are all observed. Any recommendations from the participants are thought about and are used to make improvements in the interventions or their methods of conductance.

Maintenance means all the necessary arrangements done to carry out the projects. Any sort of damage to the tangible assets or harm to the individuals taking part in the programs is avoided. It is mandatory to make sure that the interventions are well maintained and no one is hurt during their execution.

In order to structure my report coherently and lucidly several logical frameworks and methodologies are employed with the core guiding framework of EBPH model presented by Brownson et al. This model comprises 7 distinct stages which are interlinked and each phase supporting the subsequent phase. It is a very practicable framework which has made it easier for me to organize my report in a very well organized and systematic way. Using this model and the Dahlgren and Whitehead model of factors affecting health and RE-AIM model has enhanced by knowledge of public health significantly.

Through the completion of this comprehensive report, I am enabled to have a better understanding of numerous public health concepts and principles. It has facilitated it for me to understand how to conduct the assessment of a community, in order to identify the particular health needs of the individuals in that community effectively, by looking at the different features of the community.  It also supported me to design interventions in accordance to those needs to improve the overall health status and well being of the members as a public health practitioner. I also learned how to develop a project by assessing the barriers and strengths to it and how to implement it effectively. These learning will help me remarkably in my future to pursue my career in this field.

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