The logic of public health

Imagine shopping at the mall or supermarket and someone wearing a bright-colored vest approaches to talk to you about your being fat and wants to measure your waist. Would you be happy to discuss your weight with a stranger and welcome the unsolicited diet and exercise advice?

Thought not...

Fat-buster street nurses are being sent out into the community as part of the latest initiative of public health officials at the NHS Ayrshire and Arran. According to the news coverage, people are happy to discuss their weight with a nurse off the street; answer questions about their private lifestyles, smoking and drinking habits; be referred to weight loss meetings; and even have the street nurse contact their doctor.

Convincing the public that “everyone else thinks this is okay, so you should to” is a common marketing approach, employing the bandwagon effect. But is it evidence of sound public health policy?

Since this program is not unlike the national health corps envisioned as part of the office of the National Nurse to promote the U.S. Surgeon General’s preventive health initiatives, you might be interested in how it’s showing to be a valuable use of public healthcare resources in Scotland. As Scotsman reports on the new program:

Fat-buster nurses won't give an inch

A TEAM of NHS nurses is patrolling Scotland's streets to target pot-bellied members of the public and tell them how to lose weight. Armed with measuring tapes to check waists and equipment to test blood pressure, the "Street Nurses" are policing busy shopping centres, supermarkets and community centres... The move is part of a scheme by NHS Ayrshire and Arran to target members of the public in its most deprived areas... If they spot someone who looks overweight they will approach them and strike up a conversation about their health, inviting them to have a "rapid nursing assessment"...

Any man with a paunch, or woman with an "apple-shaped" body whose waist measurement is higher than recommended limits is given diet and lifestyle advice or referred to local slimming classes. For women this would be a waist measurement of more than 32 inches and for men over 37 inches because middle regions larger than these are linked with an increased risk of heart disease, type 2 diabetes, bowel and liver cancer, and strokes... Overweight women can be referred to local Weight Watchers meetings, and men are sent to the NHS Ayrshire and Arran men-only weight loss club 'Slimmin Withoot Wimmin'...

Shoppers are also asked about other aspects of their lifestyle and given advice on how to quit smoking or cut down on alcohol if they admit drinking more than the recommended weekly limits.

The news story went on to quote a Street Nurse who said that people “were usually happy to discuss their weight if it meant getting some good diet and exercise advice... People honestly aren't that shy. It's a bit of light-heartedness, but getting a serious message across. People are generally OK about us talking about their weight...” The article also repeated three times the importance of waist circumference, as a risk factor for “obesity-related” chronic diseases like heart disease. There was no critical look at the medical evidence of waistline measurements.

But the media didn’t follow-up on an even more critical concern raised by Margaret Watt, Scotland’s Patients Association chairperson. NHS Ayrshire and Arran is the first health board to begin a street nurse program for deprived areas, an initiative supported National Obesity Forum. Watt, however, said this program wouldn’t make sense unless there were enough nurses and doctors where they were needed.

While the national health service is diverting nurses from medical facilities and sending them out in waistcoats to hunt down fat people and give them weight loss advice — advice that’s known to be ineffective — who is caring for the sick patients? There’s no evidence that the severe nursing shortage has suddenly disappeared, yet just months ago the NHS baby care units were reported as being at the breaking point because there weren’t enough nurses, which was putting babies’ lives in danger. Just days ago, hospitals in Ayrshire and Arran reported a severe shortage of junior doctors, especially needed in acute medicine. NHS officials are scrambling to fill the gaps in care and extending the use of nurse practitioners and developing contingency plans to care for patients.

Is sending out nurses to go after fat people really the best use of strapped medical personnel or limited healthcare resources?

Just two weeks ago, on August 1^st, the NHS Ayrshire and Arran released its 60-age executive summary draft strategy, “Promoting health and reducing health inequalities strategy 2007-2012,” outlining the most pressing public health needs facing Ayrshire and Arran. The report’s key points were that health in Ayrshire and Arran is improving and premature deaths from cancer, heart disease and stroke are down and improving, although Scotland lags behind the rest of the UK.

“Efforts have become more focused on reducing health inequalities and inequalities in access to services, with an increased focus on evidence based practice leading to more effective methods being employed,” it states. According to this report:

Evidence clearly shows that the major causes of health inequalities are poverty, unemployment, poor housing and homelessness. Other factors include people living in rural locations and the difficulty accessing services. Inequalities can be a result of race, gender and poor health literacy.

The authors outlined the complex issues surrounding poverty that need to be addressed, defining poverty as:

Poverty is a condition in which a person or community is deprived of, or lacks the essentials for a minimum standard of well being and life. Since poverty is understood in many senses, these essentials may be material resources such as food, safe drinking water and shelter or they may be social resources such as access to information, education and health care, social status, political power, or the opportunity to develop meaningful connections with other people in society..

There are many other issues which impact more on some groups than others, for example,suicide through drug use, mortality through violence and road traffic accidents (a leading cause of death in young people and where there is huge inequity) which similarly are not currently the focus of national targets. It is important to establish appropriate local targets which will inform the targeting of efforts to achieve the aims of this strategy for all groups in society.

“Well care, not sick care”

If you’re a poor mother with a sick baby, it appears you may find a nurse at the mall, although she’ll want to pull out a tape measure and talk to you about your figure. The focus of public health officials on both sides of the pond increasingly appears to be caring for well people, rather than sick people.