Health Promotion In Midwifery Essay

Phase 1

Of the sixty institutions identified, 55 were eligible as they currently offered pre registration midwifery education. A total of 29 institutions responded (53%) in relation to 37 programmes (3 year and 18mth programmes), of which 23 were in England, 3 in Scotland, 2 in Wales and 1 in NI. Participants responded in a variety of methods: 15 (52%) replied via survey monkey: 10 (35%) via post: 3 (10%) sent their curriculum documents for completion by the project team and 1 (3%) completed over the phone.

Explicit reference to public health in midwifery curricula

The pre registration survey asked respondents to state how explicit (direct reference) the inclusion of public health was in the curriculum philosophy or programme and module aims/objectives. The results are presented in Figure ​1.

Figure 1

Explicit Inclusion of public health/inequalities in pre registration programme documentation.

Public health topics included

Respondents were invited to select from a list of pre defined topics on public health and inequalities and indicate whether they were included in their provision of pre registration education for midwives (Table ​1). Participants were invited to indicate the approximate number of hours allocated to the list of topics. Table ​1 demonstrates the considerable variation across institutions both in relation to the topics provided and the hours allocated, for example, three institutions stated they did not cover the principles of public health, five reported they did not include epidemiology and the number of hours allocated to perinatal mental health ranged from 1.5 to 14. A number of respondents also reported that several subject areas were not offered, as illustrated in Figure ​2.

Table 1

Pre registration public health and inequalities subject areas

Figure 2

Specific public health and inequality subject areas not offered* pre registration programmes.

Curriculum gaps and limitations

Respondents were asked to identify any gaps or limitations in the current provision of public health education. Twenty five (68%) respondents reported there were no gaps, six (16%) reported they felt there were gaps; and six (16%) did not respond. There was recognition that public health was explicit in institutional programmes, however, it was also reported that more time was needed to explore theoretical models and often learning was solely focused on practical aspects. Some respondents who reported that they felt there were no gaps in the curriculum also commented that the public health elements of their undergraduate curricula depended on good links with practice for example the facilitation of clinical placements which provide exposure to public health roles. It was highlighted that the curriculum needed to be regularly revisited in order to ensure relevance. Specific topic areas where gaps were identified by respondents included perinatal mental health, asylum seekers and homelessness, obesity, nutrition and alcohol.

Public health as core to midwifery

Respondents were asked to rate on a scale of 1–5 (5=essential) how much they thought public health was part of the core role of the midwife. All participants denoted a score of 4 or 5 with the exception of one, indicating the majority considered public health as an essential element of core midwifery practice.

Phase 2

Nine focus groups with 59 participants (34 midwifery students and 25 registered midwives) were conducted. Four focus groups with students were conducted in three participating institutions (England, NI and Scotland) and five focus groups were held with registered midwives; participants included managers, midwives from practice, public health specialists and educationalists in England, NI, Scotland and Wales. Data from the focus groups are presented in relation to three key themes: understanding public health in midwifery; the reality of practice; knowledge and confidence about public health.

Understanding public health in midwifery

Throughout the group discussions it was evident that midwifery students did not have clear understanding of the public health role of midwives. In some groups, initially it was seen as a specialist area and not as core, given that midwives cannot be ‘experts’ in all areas. However, as the discussions continued within groups, there eventually (and usually) was consensus that public health was integral to midwifery practice and input from multidisciplinary teams or specialists could be utilised for additional support.

“I think the role of the midwife is really important but when I was doing my bit of research for my assignment one of the key things that was out there, a lot of midwives don’t accept that they have a role in public health” (Scotland Student Group)

In all of the focus groups with registered midwives the definition of public health relative to midwifery was difficult to pinpoint precisely and generally the question was met by initial silence. One group identified that it was important for midwives to have ‘their’ definition of public health and what it means in midwifery practice as other disciplines have a clearer understanding of what public health is.

“So I think what midwives need to do is (consider) what is our meaning, our understanding, our domain, what is our package of public health? What do we mean by it? What would be our targets? What would we want to see as perhaps, we can’t control the whole population but we can look at the whole of childbirth, say from maybe a little bit of preconception right up to is it midwives’ role up to 28 days after birth? What kind of targets, goals, public health things would fit in?” (England Midwifery Group)

Discussions with registered midwives were generally consensual about public health as an aspect of midwifery practice, although, there was often debate as to the extent of this role and boundaries regarding core or specialist practice. Terminology, such as ‘crucial’, ‘pivotal’, ‘the foundation of it’, ‘significant role’, was used to describe the public health role of the midwife in relation to the core aspect, although, within groups there was confusion relating to if and how midwives viewed themselves as public health practitioners.

‘It’s got to be the core function and then we build on top of that’ (Wales Midwifery Group)

One group discussed how difficult it was to marry the goals of public health and the aim of holistic midwifery care. It was proposed that the goals of public health are overarching and at population level, whereas in midwifery care the aim is more towards an individualised approach tailored to the specific needs of women and their families, and therefore, this may result in conflict (see quote below). This was not discussed voluntarily in subsequent groups, however, the moderator of the final focus group introduced the idea and the concept was generally agreed.

“.....public health tends to take a very global approach and they want everybody vaccinated and everybody to give up smoking and everybody to breast feed. And the reality is that midwives, we’re actually dealing with individuals who are giving us very good reason for why they’re going to continue smoking and why they’re not breastfeeding which may not fit with the public health agenda. I think that there’s a fundamental problem between imposing that perhaps, on a midwife who is actually working with an individual and understands that woman’s context. Yes, she knows it’s not good for her to smoke. Yes, she knows it’s going to give her cancer or whatever in the long term but right now she’s just trying to survive. And I think trying to superimpose this public health practitioner role on a midwife could actually lead to role confusion or completely role rejection”. (Scotland Midwifery Group)

The reality of practice

A general lack of confidence and some anxiety around discussing specific public health related topics with women was reported by midwifery students at various stages of their training e.g. smoking cessation.

“I’ve completely avoided that huge area of public health and midwifery and I feel terrified of it now, you know, if I were to get a woman who was saying, ‘I’m smoking, what can I do about it’... I wouldn’t know”. (England Student Group)

Students were also aware of the impact of busy clinical environments and the subsequent effect on the ability of midwives to address or discuss public health issues.

“I think time’s a big issue with all public health. I think midwives don’t have enough time to deal with all the public health issues that they need to deal with” (NI Student Group)

Although it was generally recognised that public health interventions and addressing inequalities are part of the midwives’ role, barriers in clinical practice were identified as influential on the effectiveness of that role. Barriers discussed included the shortage of time available clinically to care for women, the difficulty of providing copious health promotion messages at the booking interview, the ‘tick box’ approach to care, midwives’ reluctance to develop conversations with women due to a lack of time, continual ‘adding onto’ the midwives’ role, models of care and the lack of vision regarding long term outcomes of care. Additional barriers were identified that focused more generally around professional issues, such as, heavy administration and bureaucracy, work load volume and leadership. However, despite the recognised barriers, groups were unanimous that pregnancy was a time of opportunity for midwives to promote the overarching goals of public health. The recognition of pregnancy as a time of ‘opportunity’ was resonant through all the focus groups and there was unanimous agreement both within and between groups that pregnancy is a time in women’s lives which could be influenced with regard to a public health message.

“You know, I think what we do have as midwives is a captive audience. We have an opportunity. We engage with women, somewhere in and around six to twelve weeks in their pregnancy depending on how early they do their pregnancy test and who they contact first. And we have access to those women who are like sponges for information for at least six months and it is an opportunity” (NI Midwifery Group)

Knowledge and confidence about public health

The majority of students were able to discuss key public health topics relevant to midwifery practice and perceived their level of theoretical knowledge was good; however they reported that practical delivery was difficult. Several groups suggested some additional solutions, such as, motivational interviewing or training in communication skills through role play as highlighted below.

“Participant 1: But it’s hard, I think, for us I think to go out and start telling people this. I think you need more than a, confidence lessons or something...

Participant 2: Or, just different approaches to how you go about health promotion. You know, do you ask how, what the woman knows about it first and getting into like dialogue and conversation as opposed to telling the woman what to do.

Participant 1: Yeah...yeah, so like more of the ‘how to’.

Participant 2: Yeah, definitely. Role play....I think that would be really good” (NI Student Group)

Barriers to increasing knowledge were identified by the focus groups with registered midwives. These related to the availability of training, difficulty releasing staff for training and the type of training that is needed. The majority of groups acknowledged that training exists, however, the topic is often politically motivated or a current hot topic, for example, the focus on obesity and weight management during pregnancy. Another issue raised was the availability of funding for training; funding was prioritised for courses where the aim was to develop skills of direct benefit to practice i.e. medical prescribing or examination of the newborn skills over developing theoretical knowledge, as illustrated by a quote from a NHS midwifery manager, below:

“If a midwife came to me and said I want to go and do a module at (a HEI) or wherever on public health, unless she was doing it as part of a degree I can’t see her coming forward to do it, and I couldn’t support her unless I had a particular role for her” (NI Midwifery Group)

There was a recognition that public health was more prominent on pre registration education curricula and that newly qualified midwives were perceived to be ‘steeped in public health” (Scotland) and ‘more conscious of public health than midwives trained a few years back’ (Wales). However other groups felt that while this may be true, there were concerns around the general lack of midwives’ confidence to discuss many public health issues with women, for example obesity, weight management, and routine enquiry about domestic abuse.

Some of the discussion in the focus groups (registered midwives) outlined potential measures to address the barriers in order to maximise the public health role of the midwife. Recognition of the need for more training was identified and several examples of innovative practice were provided. For example, a NHS service manager gave an example of how funding had been obtained through the British Heart Foundation for a midwife to link into a community based obesity networking and motivational programme.

Several methods of training to address gaps in the effectiveness of a midwifery public health role were suggested. Online training in the form of a toolkit was suggested in one group. This would have the advantage that midwives could access it in their own time. However, another group felt that online learning was problematic in the area of public health, as there was a need for an interactive element and also monitoring compliance with online learning could be difficult if the training was not mandatory. Increased knowledge of interventions that midwives could conduct was discussed as something that would be helpful. Brief intervention training, which has been used effectively in other areas of practice, was also raised as a potential for midwives in the area of public health. Underlying the recognition of training, however, was the need for more emphasis on the application of public health to midwifery and for all midwives to understand better the relationship between public health and midwifery.

“.....so I think the longer term thing would be to change the culture of how midwives see their role in public health and accept that and maybe see that it’s not an add-on to our role” (NI Midwifery Group)

“I think a lot of it too is, [that] you do have to get underneath the midwife’s thought processes as well, in it all..if they’re going to deliver the positive message you’ve got to understand them, haven’t you, as a person and build their confidence” (Wales Midwifery Group)

The role of the nurse in health promotion

rodrigo | November 26, 2012

WritePass - Essay Writing - Dissertation Topics [TOC]

 

Introduction

This assignment proposes to discuss the role of the nurse in health promotion.  To facilitate the discussion in the delivery of primary, secondary and tertiary levels of health promotion, the health risk of tobacco smoking in relation to Lung Cancer has been chosen.  National policies will be explored in relation to smoking and how these influence the delivery of health promotion by the nurse.  The barriers to health promotion will be identified along with ways in which these may be overcome.

The intention of the World Health Organisation (WHO) to achieve “Health for All” by the year 2000 was published in their Ottawa Charter, the outcome of which was to build healthy public policy, create supportive environments, strengthen communities, develop personal skills and reorient health services.  They identified key factors which can hinder or be conducive to health; political, economic, social, cultural, environmental, behavioural, and biological (WHO 1986).

The current health agenda for the UK aims to improve the health of the population and reduce inequalities with particular emphasis on prevention and targeting the number of people who smoke (DH 2010).

Inequalities in health have been extensively researched and although attempts have been made to overcome these, there is evidence to support that the divide between the rich and the poor still exists in society.  Marmot (2010) highlighted the lower social classes had the poorest health and identified social factors such as low income and deprivation as the root causes which affect health and well being.   Increased smoking levels were found to be more prevalent in this cohort.  Bilton et al (2002) suggests the environment an individual lives in can have an adverse effect on health in that it can influence patterns of behaviour.  For example, families living in poor housing conditions, in poverty or in an environment away from a social support network can suffer psychological stress; which in turn can prompt coping behaviours such as tobacco smoking (Blackburn 1991, Denny & Earle 2005).

Smoking is a modifiable risk factor to chronic disease such as Cancer of the Lung, with 90% of these cases being the result of smoking (Cancer Research UK 2009) it   is the single biggest preventable cause of premature death and illness and is more detrimental to the poorer in society.  Responsible for 80,000 lives per year, the huge financial burden on the NHS to treat illness associated with smoking is estimated at £2.7 billion each year (DH 2010).  This illustrates the huge opportunity for public health to address the wider issues associated with inequalities and to target people who smoke.  Various White papers have demonstrated the Government’s commitment in reducing smoking figures and preventing uptake, both at individual and population levels, through health promotion activity, empowering individuals and enabling them to make healthier lifestyle choices (DH 2004, DH 2006, DH 2010).

Health promotion is a complex activity and is difficult to define.  Davies and Macdowall (2006) describe health promotion as “any strategy or intervention that is designed to improve the health of individuals and its population”.   However perhaps one of the most recognised definitions is that of the World Health Organisation’s who describes health promotion as “a process of enabling people to increase control over their health and its determinants, and thereby improve their health (WHO 1986).

If we look at this in relation to the nurse’s role in smoking cessation and giving advice to a patient, this can be seen as a positive concept in that with the availability of information together with support, the patient is then able to make an informed decision, thus creating empowerment and an element of self control.  Bright (1997) supports this notion suggesting that empowerment is created when accurate information and knowledgeable advice is given, thus aiding the development of personal skills and self esteem.

A vital component of health promotion is health education which aims to change behaviour by providing people with the knowledge and skills they require to make healthier decisions and enable them to fulfil their potential.   Healthy Lives Healthy People (2010) highlight the vital role nurses play in the delivery of health promotion with particular attention on prevention at primary and secondary levels.   Nurses have a wealth of skills and knowledge and use this knowledge to empower people to make lifestyle changes and choices.  This encourages people to take charge of their own health and to increase feelings of personal autonomy (Christensen 2006).   Smoking is one of the biggest threats to public health, therefore nurses are in a prime position to help people to quit by offering encouragement, provide information and refer to smoking cessation services.

There are various approaches to health promotion, each approach has a different aim but all share the same desired goal, to promote good health and prevent or avoid ill health (Peate 2006).  The medical approach contains three levels of prevention as highlighted by Naidoo and Wills (2000), primary, secondary and tertiary prevention.

Primary health promotion aims to reduce the exposure to the causes and risk factors of illness in order to prevent the onset of disease (Tones & Green 2004).  In this respect it is the abstinence of smoking and preventing the uptake through health education and preventative measures.  One such model of prevention is that of Tannahill’s (1990) which consists of three overlapping circles; health education for example a nurse may be involved in the distribution of leaflets educating individuals or a wider community regarding health risks of smoking, prevention, aimed at reducing the exposure to children, for example, in 2007 the legal age for tobacco sales increased from age 16 to 18 years in an attempt to reduce the availability to young people and prevent them from starting to smoke (DH 2008),  health protection such as lobbying for a ban on smoking in public places.

If we look at this in relation to the role of the school nurse, this is a positive step when implementing school policies such as no smoking on school premises for staff and visitors, as this legislation supports the nurse’s role when providing information regarding the legal aspects of smoking.   Research demonstrates that interventions are most effective when combined with strategies such as mass media and government legislation (Edwards 2010).   Having an awareness of such campaigns and legislation is essential to aid best practice and the nurse must ensure that knowledge and skills are regularly updated, a standard set by the Nursing and Midwifery Council (NMC 2008).

Croghan & Voogd (2009) identify the school nurse’s role as essential in the health and well-being of children in preventing smoking.    Many people begin to smoke as children, the earlier smoking is initiated, the harder the habit is to break (ASH) and this unhealthy behaviour can advance into adulthood.   Current statistics illustrate that in 2009 6% of children aged 11-15 years were regular smokers (Office for National Statistics 2009).  These figures demonstrate the importance of prevention and intervention at an early stage as identified by the National Service Framework (NSF) for Children, Young People and Maternity Services (DH 2004).  Smith (2009) highlights the school nurse as being in an advantageous position to address issues such as smoking and suggests that by empowering children by providing support and advice, this will enable them to adopt healthy lifestyles.

NICE (2010) suggest school based interventions to prevent children smoking aimed at improving self esteem and resisting peer pressure, with information on the legal, economic and social aspects of smoking and the harmful effects to health.   Walker et al (2006) argue self esteem is determined by childhood experiences and people with a low self esteem are more likely to conform to behaviours of other people.   This can be a potential barrier in the successful delivery of health promotion at this level, with young children exposed to pressure to conform; they are more likely to take up unhealthy behaviours such as smoking (Parrott 2004).   The nurse can overcome this by working in partnership with teachers and other staff members to promote self-esteem by ensuring an environment conducive to learning, free from disruptive behaviour which promotes autonomy, motivation, problem solving skills and encourages self-worth (NICE 2009).

Despite the well known health risks to tobacco smoking, unfortunately 1 in 5 individuals continue to smoke (DH 2010).  Whitehead (2001) cited in Davies (2006) argues the nurse must recognise and understand health related behaviour in order to promote health.  Therefore, when delivering health promotion the nurse needs to be aware of all the factors which can affect health, some of which can be beyond individual control.  Smoking cessation is one of the most important steps a person can make to improve their health and increase life expectancy, as smokers live on average 8 years less than non smokers (Roddy & Ross 2007).

Secondary prevention intends to shorten episodes of illness and prevent the progression of ill health through early diagnosis and treatment (Naidoo & Wills 2000).  This can be directed towards the role of the practice nurse in a Primary Care setting, where patients attend for treatment and advice that have symptoms of illness or disease as a result of smoking, such as Bronchitis.  Nice guidelines (2006) recommend that all individuals who come into contact with health professionals should be advised to cease smoking, unless there are exceptional circumstances where this would not be appropriate, and for those who do not wish to stop, smoking status should be recorded and reviewed once a year.  It is therefore essential the nurse maintains accurate and up to date record keeping.

Smoking cessation advice can be tailored to the specific individual and therefore it is important that the nurse has the knowledge and counselling skills for this to be effective.  The process of any nursing intervention is ultimately assessment, planning, implementing and evaluating (Yura & Walsh 1978), this applies to all nurses in any given situation including health promotion.  One such method of smoking cessation which can be used as an assessment tool is known as the 5 ‘A’s approach, ‘ask, assess, advise, assist, arrange’ (Britton 2004).  “Ask” about tobacco use, for example how many cigarettes are smoked each day, and “assess” willingness and motivation to quit, taking a detailed history to assess addiction.   Objective data can be obtained using a Smokerlyser which measures Carbon Monoxide levels in expired air (Wells & Lusignan 2003).  These simple devices can be used as a motivational tool to encourage cessation and abstinence.    Castledine (2007) suggests the principle of a good health promoter is to motivate people to enable them to make healthier choices; this is made possible by the ability to engage with individuals at all levels.  Individuals who are not motivated are unlikely to succeed (Naidoo & Wills 2000).   “Advise” patients to stop smoking and reinforce the health benefits to quitting, “assist” the patient to stop, setting a quit date and discussing ways in which nicotine withdrawal can be overcome.  Being unable to cope with the physical symptoms of withdrawal can cause relapse and be a barrier to success, therefore it is essential the nurse possesses a good knowledge base of the products available to assist in reducing these symptoms if she is to persuade people to comply with treatment, such as the use of nicotine replacement therapy (NRT).    NRT is useful in assisting people to stop smoking and has proved, in some instances to double the success rate (Upton & Thirlaway 2010).  NRT products are continually changed and updated; therefore the nurse must ensure she has the knowledge and skills to identify which products are available, the suitability, how it works and any potential side effects.  Identifying triggers and developing coping strategies is useful for maintenance of a new behaviour, measures such as substituting cigarettes for chewing gum and changing habits and routines are just some of the ways in which self control can be achieved (Ewles & Simnett 1999).  Finally “arrange” a follow up, providing continual support and engagement. For patients who do not wish to stop smoking, advice should be given with encouragement to seek early medical treatment on detection of any signs and symptoms of disease.  Good communication skills are essential to the therapeutic relationship between the nurse and a patient and these must be used effectively by providing clear, accurate and up to date information.  The nurse should be an active listener and encourage the patient to talk, using open-ended questions helps demonstrate a willingness to listen, listening and showing concern for a patient’s condition demonstrates respect (Peate 2006).  The use of medical jargon and unfamiliar words can be a barrier to communication and should be avoided as these can affect a patients understanding.  Leaflets can reinforce information provided by the nurse and increase patient knowledge, however the nurse must ensure these are in a format and language the patient can understand.  Lack of literacy skills can prevent a patient reading and understanding the content of a leaflet, the nurse can assist with this by reading and explaining to them.

To assist in the assessment process the nurse may utilise a model of behaviour such as Prochaska & DiClemente’s stages of change model (1984).  This works on the assumption that individuals go through a number of stages in order to change behaviour, from pre -contemplation where a person has not considered a behaviour change, to maintenance, when a healthier lifestyle has been adopted by the new behaviour.   The stage a person is at will determine the intervention given by the nurse; therefore it is essential that an effective assessment takes place.  Walsh (2002) highlights patient motivation as central to success using this model, in that a patient will have more motivation; the more involved they are in planning the change.

Despite the health promoting activities mentioned and the increasing public awareness of the health risks to smoking, there are people who continue to smoke and some further develop illness as a consequence.  Lung cancer has one of the lowest survival rates, and as little as 7% of men and 9% of women in England and Wales will live five years after diagnosis (Cancer Research UK 2011).  Acknowledging this, the governments “Cancer Plan” aimed to tackle and reform cancer care in England by raising awareness of the signs and symptoms of cancer by investing in staff and extending the nurses role (DH 2000).  This involves further training and education for nurses to develop their skills and knowledge to enable them to provide the treatment and/or advice required.  This was succeeded by “Improving outcomes: a strategy for cancer” the aim being to enable patients living with cancer a “healthy life as possible”.   The government pledged £10.75 million into advertising a “signs and symptoms” campaign to raise awareness of the three cancers accounting for the most deaths, breast, bowel and lung, to encourage the public to seek early help on detection of any symptoms (DH 2011).  Currently no results are available on the effectiveness of this intervention due to its recent publication, however, one national policy that has had a positive effect on the health of individuals and the population is that of the “smoke-free England” policy implemented in 2007 prohibiting smoking in workplaces and enclosed public places.  Primarily this policy was enforced to protect the public from second hand smoke; however, on introduction of the law smoking cessation services saw an increase in demand by 20%, as smokers felt the environment was conducive to them being able to quit (DH 2008).  This policy also extended to hospital grounds, and the nurse must ensure a patient who smokes is aware of this on admission and use every opportunity possible to promote health.

Tertiary prevention aims to halt the progression, or reduce the complications, of established disease by effective treatment or rehabilitation (Tones & Green 2004).  A diagnosis of cancer can cause great distress and a patient may go through a whole host of emotions.  Naidoo and Wills (2000) suggest the aim of tertiary prevention is to reduce suffering and concerns helping people to cope with their illness.   The community nurses role has been identified as pivotal in providing support for patients and families living with cancer (DH 2000).  The World Health Organisation describe Palliative care as treatment to relieve, rather than cure, the symptoms caused by cancer,  and suggest palliative care can provide relief from physical, psychosocial and spiritual problems in over 90% of cancer patients (WHO 2011).

Assessment and the provision of health education and information at this stage remains the same as that in secondary prevention, and it is not uncommon for the two to overlap.  Providing advice and education on symptom control may alleviate some of the symptoms the patient experiences,  for example breathlessness is a symptom of lung cancer (Lakasing & Tester 2006), and relaxation techniques may reduce this (Cancer Research UK 2011), therefore the nurse may be involved in teaching these techniques to the patient and family members.  Continual smoking despite a lung cancer diagnosis can exacerbate shortness of breath and reduce survival rate (Roddy & Ross 2007), therefore the nurse can use this opportunity to reinforce the risks of smoking.  However, the nurse must use her judgement effectively and be sensitive to the patient’s condition, as the willingness to learn and respond to teaching can be affected by emotional state (Walsh 2002).  Establishing effective pain control is essential in the care of a cancer patient and this may involve discussion with the patients GP if medication needs adjusting.  A referral to specialist help lines such as those provided by Macmillan cancer support may be useful in assisting a patient and/or family to cope with cancer, these services can be accessed in person or by telephone.  These are just two examples of collaborative working and demonstrate the importance of inter-professional working.

In conclusion, with the emphasis of health promotion concerning prevention of illness and disease, the role of the nurse is essential in raising awareness and providing education and advice to individuals to facilitate behaviour change. The complexities of health promotion indicate the extensive competences a nurse must possess to empower and motivate individuals.  However, governments also have a responsibility to promote and protect health and are pivotal in introducing national policy to build “healthy publics” and environments conducive to health.

 

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