Health Promotion & Public Health
The aim of this essay is to discuss the public health issue of adverse childhood experiences and mental health in adults which affects individuals/communities in the author’s field of practice. The Mental Health Foundation (2016), states that around £600 million is invested in mental health services a year in Wales, which is more than any other service in the NHS. It is crucial to help minimise these figures by ensuring that proactive interventions are accessible to children to help prevent mental health issues from occurring before they develop during adulthood. It is important to remember, however, that preventive measures can be used to help encourage people to remain healthy with and without mental health concerns.
A survey conducted by Karen Hughes et al. (2016) comparing the relationship between adverse childhood experiences (ACEs) and mental health shows solid, increasing correlations between the number of ACE participants identified and mental disease, with the proportions reporting each result growing with ACE counts. A Welsh ACE study conducted by Mark Bellis et al. (2016), suggests that children who experience traumatic and low-quality childhoods are more likely to take up long-term health habits during puberty and adulthood, which can lead to mental health disorders.
According to Thornbory, G. (2013) “Public Health aims at preventing health problems before they occur and focuses on populations rather than individuals.” For example, an age group or social class. Furthermore, health promotion and public health are closely linked as health promotion is seen as giving people the information they need or tools to enhance their health. As well as developing the skills and capacities of the individuals, it can also include changing the social and environmental surroundings and health impact structures (National Institute for Health and Care Excellence NICE, (2020). The Royal College of Nursing ( RCN, 2020) believes that the emphasis should be on nursing to alleviate the impact of the illness, encourage well-being and help patients succeed at home, at work, and at leisure. There are resources for improving mental health and building resilience as clinicians care for patients and families at life-changing events or with chronic health problems (Steve Thomas et al. 2016).
This essay will address an overview of the public health issue chosen using supporting epidemiological data such as the identification of people at risk and the most effective intervention methods to help promote health and well-being. Furthermore, at least two identified environmental and socioeconomic factors will be discussed in detail followed by two supporting policies that are being used to help prevent the public health issue. Lastly, consider the particular role of the nurse both in the use of relevant public health / health promotion initiatives and in working relationships where relevant.
This topic was chosen because it is an important public health issue that needs to be challenged in order to diminish the number of people experiencing mental health issues during adulthood. This is due to the lack of support during childhood to deal with ACE events. The higher exposure someone has from ACE; the worse their health and well-being as an adult is affected. If children were provided with the resources through health promotion to help reduce the effects of toxic stress connected to ACE’s for example, sexual abuse or domestic violence within the family environment, they may be able to build resilience for later on in life (Karen Hughes et al. 2018). Actions to avoid and reduce ACEs and their long-term side effects are necessary to enhance population health for present and future generations (Bethell et al 2017). According to a Welsh ACE study from 2016, 47% of adults in Wales suffered at least one ACE during their childhood and 14% suffered 4 or more (Kathryn et al.2018). The most common ACE for maltreatment was verbal abuse at 23% and the most common childhood household was parental separation at 20%. The prevalence of individuals participating in health-harming behaviours and reporting low mental well-being as adults increased with the number of ACEs experienced. Additionally, individuals living in the most deprived areas of Wales were also more likely to encounter poor mental well-being relative to those residing in more prosperous areas after accounting for conflicting demographic and other variables, for example, ACE count.
A second study that shows the estimate of health and financial burden of ACEs in England and Wales calculated that the greatest ACE-attributable costs were for mental illness (anxiety, depression and other mental illness; England and Wales, £11.2 billion) and cancer (£7.9 billion) (Karen Hughes et al. (2020). In order to lower these statistics, there needs to be health promotion approaches put in place to promote protective factors and increase resilience. In addition, chronic ACE exposure can influence the development of the neurological, immunological, and hormonal systems. As a result, individuals who are subjected to such experiences during childhood can develop emotional control, cognitive reaction, attachment, memory, and learning difficulties that can persist throughout adult life (Hughes K et al. (2020).
Market al. 2015 believes that experiencing ACEs means that people are more likely to perform poorly at school, are more likely to participate in crime and consequently are less likely to be productive member of society. Such a cycle of childhood deprivation will force generations of successive family members into poor health and anti-social behaviour. However, avoiding ACEs in a single generation or that their impacts will help these children as well as future generations in Wales too.
Though there are a number of different factors underlying how ACEs affect mental health in adult life, the main causes are socioeconomic and environmental. According to Mark Bellis et al. 2015, children who experience stressful and poor quality childhoods are more likely to adopt health-harming behaviours during adolescence which can themselves lead to mental health illnesses and diseases such as cancer, heart disease, and diabetes later in life. This could involve a child being exposed to domestic violence within the household and as a result, engage in substance misuse as a coping mechanism. Poole, Dobson & Pusch (2017) describe ACEs useful from a public health perspective to explain the need to act on diverse social structures to avoid population-level health inequalities.
Evans and Schamberg 2011 (as cited in Braveman & Gottlieb 2014) it has been shown that the correlation between childhood poverty period and adult cognitive function tends to be explained not only by poverty-related material deficiencies but also by persistent childhood stress. Children growing up in socio-economic deprived communities face greater direct physical barriers to health status and health-promoting behaviours; they often encounter social and psychological stressors, such as family tension and uncertainty resulting from chronically insufficient services. Another public health problem is the so-called ‘lifestyle drift,’ i.e. the propensity for policy proposals to tackle health disparities to start with a wide awareness of the need to take action on the larger (upstream) social determinants of health, but then drift downstream to concentrate solely on individual lifestyle factors during their implementation (Hunter et al. 2009).
Children’s Commissioner for Wales (2018) discovered that many children who have experienced ACEs will feel particularly powerless. Children need to experience their rights (e.g. being cared for, listened to, kept safe) in order to be able to take them up. Therefore, empowerment means ensuring that children are equipped with the skills and experience to be able to confidently take up their rights.
The Well-being of Future Generations Act requires public bodies in Wales to think about the long-term impact of their decisions, to work better with people, communities, and each other, and to prevent persistent problems such as poverty, health inequalities, and climate change.
‘A Children’s Rights Approach’ can give coherence and strength to Wales’ approach to ACEs.
Action to tackle health inequalities is therefore embedded into policies and initiatives across the whole of Welsh Government through a ‘Health in All Policies approach. Tackling the link between poverty and poor health is a key feature of a range of commitments including employment programmes, fair work, quality housing, and access to childcare.
Role of the Nurse
Partnership working is well embedded in health policy and guidelines. The RCN (2020) believes that nursing skills are rightly valued as being able to provide meaningful public health interventions across all health and social care settings as part of holistic patient-centred care. From a professional perspective, the Code requires registered nurses to ‘prioritise people’ setting out that nurses must ‘listen to people and respond to their preferences and concerns and to achieve this you must: ‘work in partnership with people to make sure you deliver care effectively’ (Nursing and Midwifery Council [NMC] 2018). Overall, partnership working is a clear expectation for nurses but the meaning of partnership in the context of nursing practice is less explored.
The term ‘partnership’ is commonly used in healthcare, often in relation to interprofessional working or collaborations between different organisations. Health visitors in Wales collaborate with family members to achieve these targets, measure resilience, and offer resources to meet their needs. While no neighbourhoods should be considered free of ACEs, there is a greater likelihood that those living in areas of deprivation will experience multiple ACEs.
Health visitors in Wales work in partnership with families to meet these goals, assess resilience and provide support to meet their needs. While no communities should be considered free from ACEs, those living in areas of deprivation are at greater risk of experiencing multiple ACEs. In Wales, this is being addressed through Tackling Poverty Programmes such as Flying Start; Families First and Communities. These programmes are targeted at the most deprived communities in Wales. To be competent in delivering all aspects of the nursing process, nurses must have the core skill of effective communication in order to communicate directly and consistently with the service user and their families to meet their care needs.
According to the NMC (2015), a nurse must use a range of communication skills and technologies to support person-centred care and enhance quality and safety. A study to support this is one conducted by Vahdat, Hamzehgardeshi, Hessam, & Hamzehgardeshi, (2014) found that patient participation in health care decisions is a sign of valuing humanity and individuality of the patient. Therefore, planning and providing patient-oriented healthcare, based on the needs and preferences of patients are recommended.
The strong relationships between ACEs and mental illness indicate how important preventing ACEs and supporting those affected by them is in improving population mental health. Despite this, studies also suggest that most people who access mental health services are never asked about child abuse or neglect (Read et al, 2017). Using the ACEs may be prevented through enhanced public and professional awareness, evidence-informed universal service specifications, effective pathways into additional support, monitoring of intervention coverage and content and, routine audit of fidelity to intervention specifications. Although public health may have a leadership role in these innovations, collaborations and investment from healthcare providers, local authorities, and more broadly across the public sector are needed. The results from these ACE policies mentioned above will help inform and enhance developments in this area to increase the focus on preventing ACEs in the future.
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