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Modification of the way health services are delivered, towards the prevention of illness and disease, rather than focusing on treatments will enable the National Health Service to use its resources better, healthier people equals fewer demands on an already stretched service. Better health is vital for quality of life, not just additional life years (DOH, 1999). Nurses have a major part to play in health promotion as they are the health care professionals most involved with individuals and communities at all levels of health promotion.

This assignment will define health promotion and discuss this in relation to sexual health it will consider how the nurse delivers health promotion at primary, secondary and tertiary level surrounding sexual health issues. The assignment will then go on to demonstrate how national policies influence the delivery of care, demonstrate some of the barriers to health promotion and explore ways of how these may be overcome.

Health promotion can be defined as ‘the art and science of helping people 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. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behaviour and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change. ’ (O’Donnell 2009).

The Department of Health (2001) suggest that the following statement defines health promotion in relation to sexual health, ‘sexual health promoting activities consist of any action which proactively and positively supports the sexual health and emotional well-being of individuals, groups and communities, reduces the rates of sexually transmitted infections and unplanned pregnancy, reduces psychosexual problems and facilitates fulfilling and pleasurable relationships’. The government has been attempting to improve the nation’s sexual health for many years as the rate of sexually transmitted diseases continues to grow.

The cost of treating sexually transmitted infections, not including HIV to the National Health Service is over ? 1 billion (IAG, 2004). The Department of Health released their publication ‘the national strategy for sexual health and HIV’ in 2001 with the main aims of the strategy being to reduce the transmission of HIV and sexually transmitted infections, reduce the incidence of undiagnosed HIV and sexually transmitted infection, and reduce the stigma associated with HIV and sexually transmitted infections (DOH, 2001).

Figures released by the Health Protection Agency in 2010 show that almost half a million people were diagnosed with a sexually transmitted disease in the United Kingdom during 2009, most of these being young adults aged between 16 and 24 (HPA, 2010). Chlamydia trachomatis is the most common sexually transmitted infection, it is easy to cure with antibiotics but if left untreated it can lead to problems with fertility and disease in later life (McLean & Keane 2000). However in most cases around 70% of women and up to 50% of men are found to be asymptomatic, many may go undiagnosed (Gleave 2002).

To successfully promote health and change behaviours the nurse will need to be aware of what stage the individual is at so they can decide which approach will work best. Prochaska and Diclemente (1984) suggest that individuals pass through four stages when attempting to change behaviours, these are; pre contemplation, the individual is unaware of any risks associated with their health behaviour, in relation to sexual health thinking that they have only had one sexual partner therefore are not at risk.

Contemplation, the individual may be looking at information and getting help to make a decision, a media message or poster surrounding sexually transmitted infection may trigger this, action, commitment to making the change, choosing to using condoms or minimising number of sexual partners, maintenance, sustaining the new behaviour so it becomes the norm.

Ewles and Simmnet’s (2003) model identifies five approaches to health promotion, medical, behavioural, educational, empowerment and social change, Sexual health promotion uses all of these approaches. In health promoting activity the nurse will have several roles; as an advocate who assists the individual or community to get what they need from the system, a care manager, who works collaboratively with the multidisciplinary team to ensure best practices are followed and that a seamless service is provided.

Nurses are consultants, providing individuals and communities with knowledge and skills, as service deliverer, hands on care and educator, structuring teaching according to needs and understanding, as healer, to ensure the individual is at optimum capability to heal, and as researcher, collecting evidence about what works and where and to improve patient care (Edelman & Mandle, 2006) The role of the nurse in sexual health promotion will now be discussed in more detail.

Primary health promotion is applied at generally healthy people before disease or dysfunction occurs, and in sexual health this will mainly focus around activities such as raising awareness of the increase in sexually transmitted infections the nurses role at this level can involve the production and distribution of information leaflets, posters, and media campaigns with the emphasis on practising safe sex and using condoms (DOH, 2003), this can provide triggers for action to susceptible individuals.

Nurses also have a role in conducting research to identify the people most ‘at risk’ and carrying out needs assessment of the local area in which they work. This information can then be used to develop specific services or developing outreach teams, for the most ‘at risk’ people have been found to be the least likely to access services.

A survey was carried out in Sussex during 2003 to find out what young people wanted from sexual health services, this showed differences of opinion in some areas between what professionals felt were important and what young people did (Sherman-Jones 2003). The nurse may use the educational approach to health promotion to improve the knowledge and skills of individuals and communities, in the hope that they will be able to make autonomous, informed and non-regrettable choices with regards to their sexual health.

Promoting confidence and building individual’s self-esteem will improve their mental, as well as physical well–being, and reduce the risk of conception and sexually transmitted infections. The nurse will educate through the giving of factual information with emphasis on the risks of having unprotected sex in an attempt to change the individuals attitude and help them to gain physical skills to implement this new learning (Naidoo & Wills 2000).

The nurse must use an effective communication style during all interactions with clients and should have a non-judgemental, respectful, sensitive and supportive attitude (French, 2006). This could apply to practical skills such as learning the correct way to use condoms, knowing why they are important, and applying the information to use them in the future. Availability of condoms without knowledge of how they should be used defeats the object, education can also be gained through demonstrations, leaflets and role-play (NICE, 2007).

However, once educated the individuals then have the right to make an informed choice of whether to change or not, (Naidoo & Wills, 2000) and within ethical issues this must be respected by the nurse (Beauchamp & Childress, 2001). The nurse can advise the individual of places where condoms can be obtained free of charge as cost can be a major deciding factor in whether individuals use them, this practice can therefore contribute to reducing inequalities in sexual health (DOH, 2003).

It is easier and more cost effective to prevent disease and dysfunction in the first place. Ewles and Simnett (1999) show the behaviour change approach as one which seeks to change the behaviour of individuals and communities to that of a healthier lifestyle. However it is determined by motivation and willingness to change. It can be viewed as a persuasive intervention, but if people are not ready to adapt to this approach it will be unsuccessful. It may be that they cannot change, or may not want to.

The focus of behaviour change can be educational or through a media style approach, however this initiative does seem to take a top down approach. The current government thinking is to have a bottom up focus to gain the thought and feelings of those who will be using the services provided (DOH 2001: 2010). A client centred or empowerment approach would cover the theory introduced by the WHO (1986), in this approach the nurse will act as a facilitator giving the individuals the power to make a decision about what they need to do in order to help themselves.

Screening for sexually transmitted infections is classed as secondary health promotion the nurse’s role at this level would involve taking a sexual history from the individual including physical, medical and psychological information and working with them to help them understand the implications of a positive test result and ways of minimising the risks of further infection and complications (RCN, 2001).

Partner notification must also be discussed and the nurse can encourage the individual to do this (RCN, 2004). Screening would fall into the medical approach category which is a top down approach, the aims of screening are to diagnose and treat infected individuals early reducing the risk of further transmission. However the medical approach is only useful if individuals agree to be screened and agree to be treated if infection is found (Naidoo & Wills, 2000).

Screening for sexually transmitted infections is usually aimed at young people however statistics show an increase in the older population who are rarely offered screening. This could be due to ‘taboos’ which surround sex in older adults and may be a barrier to promoting the sexual health of this age group, the nurse should include an assessment of sexual health during consultations for other health conditions this practice will follow the holistic approach to patients which is taught in nursing education.

The Royal college of Nursing stated that sexual health should be incorporated more into pre-registration nursing programmes (RCN, 2001) Tertiary level promotion is delivered when an individual has been diagnosed with a sexually transmitted infection, the role of the nurse at this level is to promote compliance with treatment in order to eradicate the infection and minimise further complications (Ewles & Simmnett, 2003).

If following infection fertility has been affected which can occur with chlamydia, the role of the nurse would be to offer emotional support, information and referral to other services, such as counselling and fertility treatments. National policy influences the delivery of health promotion by the nurse, this will now be demonstrated. Government policies have placed changing demands upon the nursing profession since 1992 with the release of The Health of the Nation, which put health promotion as a health service priority (Piper, 2009).

Changes have been made to the way nurses are trained; emphasis has shifted to a ‘health’ model rather than a disease model, as was the case before Project 2000 (UKCC, 1986). Health promotion is a standard of proficiency for pre-registration nursing students, the code of conduct states also that ‘the health of individuals and communities must be protected and supported’ (NMC, 2008). ‘Healthy Lives, Healthy People’ is the latest strategy by the government to show their long term vision for the future of public health.

This strategy proposes to give local authorities more responsibilities, freedom and resources to focus on improving health in their communities, tackling inequalities and developing the services they really need, instead of using a nationwide approach (DOH, 2010a). Public health policies suggest that to tackle the demands on overstretched genitourinary clinics, due to the increase in sexually transmitted infections, more sexual health services must be delivered at primary care level.

According to the Royal College of Nursing (2001) the implications for nurses are to ensure that they have the knowledge skills and attitudes to extend their roles, to meet these demands, practice nurses for example as argued by Evans (2006) have a duty of care to be pro-active and should use opportunistic health promotion during well- woman/man clinics, or contraceptive and travel vaccination consultations to discuss the issue of sexual health (Gilmour, 2005).

Policies relating to sexual health promotion outline strategies and guidelines which are recommendations for best practice and evidence based approaches for the nurse delivering sexual health promotion; these can range from structuring consultations, recognising individuals most at risk or strategies to assist in behaviour change (NICE, 2007).

Policies also set standards for sexual health services, this is a way of reducing inequalities in health care and ensuring everyone accessing sexual health services receives high quality care and identifies local and national targets (BASHH, 2010). The Essence of care benchmarks can have a significant effect on patient care as it incorporates a number of factors for promoting health along with targets for best practice which were identified and developed with collaboration from patients, carers and health professionals (DOH, 2010b).

Barriers to sexual health promotion are many, the social and cultural factors which view safe sexual practices as negative, an example of this being peer pressure not to use condoms, and an individual’s own health beliefs also have an impact on this, whether they feel susceptible to the threat of a sexually transmitted infection or not is according to their own norms and beliefs (Ewles & Simmnet, 2003). Campaigns to raise awareness of sexually transmitted infections also highlight the fact that if caught early enough they are fairly easy to treat with antibiotic therapy, this can also mean that individuals will still take a risk.

Language can be a barrier to sexual health promotion and is known to contribute towards health inequalities, the role of the nurse is to recognise the needs of the community in which they practice, and to use interpreters not a family member is considered best practice especially in sensitive areas such as sexual health. Information should also be available in all the spoken languages of that community, leaflets and posters should positively represent ethnic groups other than white British but these should also be culturally sensitive (Wright, 2010).

According to Horn (2007), access to services is a barrier to sexual health promotion, traditional Genitourinary clinics may be hard for some of the population to reach, especially individuals from rural areas who it has been found that would be reluctant to consult with their GP for sexual health services due to worries regarding confidentiality which is another major barrier, this is especially believed by young people and individuals from African communities (Horn, 2007: HPA, 2005, Mayisha).

Nurses are bound by the Nursing and Midwifery Council ‘Code of conduct’ (NMC, 2008) and the Data Protection Act 1998 and should reassure individuals that their consultation will be confidential and that if partner notification systems are used all identifying data is removed (Chippindale, 2002). The nurse should also be aware of professional boundaries and her own limitations.

Nurses can use a multidisciplinary approach to link with specific groups in the community such as young people, and black and ethnic minority groups to enable services to be developed in a variety of settings such as community centres, sports centres and health buses; this is another approach that aims to reduce health inequalities(DOH,2001). Embarrassment and fear are major barriers to promoting sexual health the individual may feel that the nurse will pre-judge or make false assumptions about their lifestyle labelling them as promiscuous and having the perceived stigmas attached to sexually transmitted infections (Schoular, 2001).

Nurses can alleviate these fears by having a warm approach, making eye contact and smiling when an individual enters the consulting room can make a big difference to whether they will feel comfortable in having an honest discussion regarding their sexual health and lifestyle (DOH, 2003). Many individuals have a false perception that testing for sexually transmitted infections still involves having swabs taken or internal examinations that may be degrading, tests for many infections are non-invasive.

Autonomy is a barrier to health promotion and nurses must recognise that to some individuals health is not a priority, if after gaining knowledge and understanding of the risks involved in continuing with their lifestyle choices they do not change then in this case the nurse must respect their decision and take steps to minimise harm (Beauchamp & Childress 2001). A new barrier is described by Atherton (2010), president of the Association of Directors of public health, who warns that the latest cuts in government spending could be extremely detrimental to health promoting activities.

He states that preventative programmes are the easiest places to make savings as they are not linked into contracts as are secondary and GP care. Atherton then argues that health promotion and disease prevention programmes need to have more money invested them as this process will make the most long term savings, currently the budget for health promotion is only 1% of the total National Health Service budget.

This is a statement supported by Maryon-Davies (2009) president of the United Kingdom Faculty of public health who proposes that savings could be made elsewhere such as inappropriate testing and treatments and the millions of pounds wasted on unnecessary accident and emergency visits, and that health promotion programmes are ‘soft targets’ and ‘short sighted’ in relation to sexual health the targets identified by government policies will not be met. This assignment has discussed health promotion and the nurse’s involvement within this process.

It has shown different approaches that can be used in health promotion by the nurse at primary, secondary and tertiary levels. It has demonstrated knowledge of government policies and the ways in which these influence nursing and the delivery of care in the field of sexual health and finally has demonstrated an awareness of some of the social, cultural, and personal barriers nurses may face when promoting sexual health and attempted to suggest ways in which these may be overcome.

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