Introduction
The purpose of this assignment is to critically analyse a health promotion activity related to a public health issue. The chosen health issue is about the increasing use of Cannabis, an illegal drug among young people in the United Kingdom, Philippines and other countries. The epidemiology and demography will be cited as well as the policies.
The World Health Organization (WHO) described health promotion as a process of allowing people to have more power or control to improve their health by enabling them to make inform choices (WHO, 1986). It was also determined by Ewles and Simnet (2003), which the fundamental elements of health promotion are to improve health and empowerment.
This assessment will systematically analyse a public health issue and the strategy use in promoting health in relation to one of Ewles and Simnett's (2003) Five Approaches to Health Promotion model. Furthermore, it will evaluate the nurse's role in health promotion.
Introduction to the health issue
Cannabis is derived from a bushy plant which is scientifically called Cannabis sativa also known as hemp. It has three different types: cannabis resin or locally called (hash); traditional herbal cannabis also called (marijuana) in the Philippines; and sinsemilla which include the skunk (McLaren & Mattick, 2007).
Cannabis resin is made from the flowering and other parts of Cannabis plant that contain many glandular trichomes. The material is processed and compressed into blocks known as hash or hasish. The traditional herbal cannabis, also known as marijuana, is the weaker preparation of dried plant material. The other type is sensimillia which "is produce of the flowering tops of unfertilised female cannabis plants produced by intensive indoor cultivation methods" (ACMD, p. 2). Usually these substances are used with tobacco and smoked in a cigarette or pipe, or brewed in a drink or mixed it with food. Smoking allows the user to regulate the dose since the effects is very rapid when used as a cigarette (Advisory Council on the Misuse of Drugs, 2008). Cannabis will increase heart rate, red eye and dry mouth occurs regularly. Compared with other drugs controlled under the Misuse of Drug Act, cannabis has the greatest non medical usage. It is commonly used to enhance leisure activity, as a relaxant or mild intoxication by a large section of the population. (ACMD, 2008) The delta-9-tetrahydrocannabinol is the component in cannabis that affects the mind. (Philippine Drug Enforcement Agency, 2004-2008) Cannabis is addictive and impairs learning, concentration and educational performance. There is also wealth of evidence linking cannabis with mental health problems including Schizophrenia, psychosis and depression. (House of Commons, 2005)
EPIDEMIOLOGY AND DEMOGRAPHY
United Kingdom
Because it is illegal to possess, cultivate and supply cannabis, it is difficult to gather the exact data about the extent of it use not only here in the United Kingdom but all over the world. Cannabis was the most widely taken illicit drug in the United Kingdom according to the Advisory Council on the Misuse of Drugs (2008). The data obtained are of self-reported use. The most recent report by British Crime Survey (BCS) is that 2.6 million people that age from 16 and 59 years in England and Wales documented using cannabis in 2006/2007. Furthermore, 1.5 million of these admitted use in the month before the survey. These represent 8.2% and 4.8% of the total population of England and Wales (ACMD, 2008). The most recent (2006) Scottish Crime and Victimisation Survey data states that 11.0% of people in Scotland aged 16 to 59 years admitted using cannabis in the past year and 6.8% in the past month. (Brown & Bolling, 2007) Cannabis use is predominantly among younger people. Males have the higher number of users than females. The estimates of the prevalence of cannabis use among those below 16 years of age are inadequate, and the data available are based on small numbers. Schafer et. al. (2008) interviewed 182 young people, aged 11 to 19 years who had use cannabis and /or been involved currently with cannabis activities. In 2005, the widespread of cannabis use among teenagers aged 11 to 12 years old was around 1% to 2%, rising to 13% in those aged 13 to 14 years. (Advisory Council on the Misuse of Drugs, 2008)
PHILIPPINES
Cannabis is locally known as "marijuana", it is one of the most prevalent drugs in the Philippines second to methamphetamine hydrochloride, which is locally known as "shabu". In 2009, 73% of the total persons were arrested due to methamphetamine hydrochloride and 26.5% are related to cannabis. On the operation conducted by the Philippine Drug Enforcement Agency (2009), 35% of the drug users arrested is due to cannabis. Philippines is facing major drug-related activities such as cultivation, manufacturing and trafficking of cannabis. Cannabis is a perennial plant that naturally grows in high altitude areas in the Philippines. A considerable of cannabis produced is used locally and rest are exported to other countries like Australia, Japan, Malaysia, Taiwan, United States and Europe. (PDEA, 2009) Moreover, seizures cause by cannabis plants significantly increased in the Philippines (from 2.5 million in 2007 to about 4 million in 2008) so with seizures of cannabis from 1.2 tons in 2007 to 3.7 tons in 2008. (International Narcotics Drug Board, 2010)
WORLDWIDE
According to World Health Organization, about 147 million people, 2.5% of the world population, taking up cannabis compared with 0.2% cocaine and 0.2% taking up opiates. Now a day, cannabis abuse has grown rapidly than other illicit drugs. Developed countries such a North America, Western Europe and Australia have the most rapid growth in cannabis abuse since 1960s. Furthermore, Youth culture has become more linked to cannabis and started to use at an early age. It is highly abuse since it is cheap and young people can easily access and afford it. (WHO, 2010) In 2008, the cannabis herb seizures increased in Bolivia with 1,113 tons the seizures were more than two and a half times higher when compared to 2007. (International Narcotics Control Board, 2010)
Cannabis is considered one of the first substances that young people could take advantage of since they are considered cheap and easy to use. Young people, aged 12-15 are the target group in this initiative. Health promotion is needed in ages between 12-15 to help minimise the number of young people involve in misusing cannabis and it reduces the chances to indulge later on when they get older. This is the age group whom they started to get curious and peer pressured. Cannabis use and misuse is a health issue because of the dangers that the substance could result to one's health, both physically and mentally. They can pose dangers to others too because of the delusional effects that might lead to physical harm to others (Home Office, 2010).
POLICIES
United Kingdom
In the United Kingdom, Home Office (2009) recorded that Cannabis was reclassified from Class C to Class B in January 2009. Fourteen years of imprisonment will be sanctioned for supplying, dealing, production, and trafficking of Cannabis and a five years imprisonment will be the penalty of possession of Cannabis. Furthermore, young people, ages between 10 and 17 caught in possession of cannabis will be arrested and taken to the police station; there they can receive a verbal warning, final warning or charge that depends on the seriousness of the violation. After the final warning, the young offender will be referred to Youth Offending Team for a rehabilitation programme. (Home Office, 2009)
An adult caught in possession of cannabis could be arrested or sometimes a warning will be issued by the police for the first-time offenders or issue a penalty notice for disorder with an on-the-spot fine of ₤80. The offender can have a maximum of three months imprisonment and a fine from 1,000 to 2500 pounds. The maximum penalty for accusation is two to five years imprisonment. For the production and supply of cannabis, the maximum penalty is 6 months imprisonment and or a 5,000 pounds fine. The maximum penalty on accusation for supplying or producing cannabis is 14 years imprisonment or an unlimited fine. (Home Office, 2009)
Philippines
The penalty of life imprisonment to death and a ranging from Five hundred thousand pesos (P500,000.00) to Ten million pesos (P10,0000,000.00) will charge any person, who, unless authorised by law shall possess 10 grams or more of cannabis resin or cannabis resin oil and 500 grams or more of cannabis. On the other hand, if the quantity is less than 500 grams penalty is 20 years imprisonment and a fine ranging from Four hundred thousand pesos to Five thousand pesos. A penalty of twelve years and one day to twenty years and a fine ranging from three hundred thousand pesos to four hundred thousand pesos. A person arrested, found to be positive for use of any dangerous drug, after a confirmatory test shall be imposed a penalty of a minimum of six months rehabilitation in a government centre for the first offense. Second offense is 6 years imprisonment and one day to twelve years and a fine ranging from Fifty thousand pesos to Two hundred thousand pesos. (Supreme Court, 2006)
WORLDWIDE
In Finland, they have Narcotics Act. 373/2008, a drug control legislation that corresponds to European regulations which aim is to enhance drug control. It prohibits the cultivation of plants that can be use as raw material for drugs. Cannabis is considered by soft drugs by authorities, it produce less harm to both individual physically and mentally and the society, these being used mainly for medical benefits and recreational purposes. It can also be bought legally at the coffee shops. On the other hand, the National Strategic Response to Drugs (2008-2012) in Montenegro has comprehensive measures to reduce illicit drug supply and demand in the country which reduces the spread of drug abuse, especially the young people. This also increases the possibilities for the rehabilitation and social reintegration of drug addicts. Furthermore, Dutch government has a national drug policy which objective is to reduce the damage to the health of drug users, to diminish public nuisance by drug users and to combat the production and trafficking of recreational drugs. However, they believe that if a problem has shown clearly that has no solution, it is better to try different strategy such as controlling it and reducing harm instead of continuing to enforce laws such as the policy used by the Netherlands. (International Narcotics Control Board, 2009)
Strategies
United Kingdom
Talk to Frank is an anti-drug campaign of the government in the United Kingdom. The campaign's target groups are family/parents, adults, and young people age 11-18. It is advertised and promoted in the television, broadcast over the radio, in the internet, paper and any other campaign materials were used to raise awareness about drugs. Frank supports the United Kingdom Drug Strategy's objective of preventing young people to become problem drug users (European Monitoring Centre for Drugs and Drug Addiction, 2003). FRANK caters different services for people who seek information and advice about drugs. There is a confidential phoneline that is available 24 hours a day, an email, and a confidential automated chatterbot, the Talk to Frank boot, and a service to locate counselling and treatment (NHS leaflets, 2003). The government has also a Young People Partnership Grant. The Local Education Authorities and schools are anticipated to support drug education from within the total fund provided to them. The Home Office will manage the YPPG, which will be paid as a single grant to the authorities responsible to convey the drug strategy such as the Drug Action Team (DOH, 2004).
Philippines Strategy
"Batang Iwas Druga (BIDA)" or Children Avoid Drugs programme is a drug campaign project represents the government's renewed campaign for cause against illegal drug abuse by educating children from ages six to twelve years old. The chief of the programme challenges the schoolchildren to live up to their role as the "Hope of the nation" by being active in the campaign against illegal substance. Schoolchildren signed up taking up the role to be observant of their environment and let the authorities know if they notice people offering or using illegal drugs in their areas and should never accept drugs from strangers and even from friends, neighbours or family members. The BIDA Kids Club has visited 18 primary schools in central Manila and has recruited 250,000 students and they're aiming to recruit one million students (Genuino, 2008).
Worldwide Strategy
The Office of National Drug Control Policy developed a National Drug Control Strategy (2010) to combat and restore the drug problems in the United States. The strategy is designed to cater the local level such as giving information to parents, provide treatment resources to community members, help officials who search for new approaches to drug-related crime, and provide information about the policy of drug administration. In addition, US government launched recently a campaign called "Above the Influence" that highly focus on those substances most often abused by young people, including prescription drugs, cannabis, and alcohol (ONDCP, 2010). The WHO (2002) has played an outstanding role in supporting countries to prevent and minimise the problems of drug abuse. It also seeks new and integrated approaches to all psychoactive substance use problems.
The misuse of cannabis is a health issue because of its potential health effects to the user especially using the stronger strains of the drug and to the society. It has a significant threat to health, social and economic status of families and nations (WHO, 2010). Cannabis is addictive and it impairs learning, concentration, and educational performance. It is also associated with lung damage including severe emphysema, head and neck cancers in young people. Moreover, it increases the risk of accident especially combined with alcohol. It is estimated that, in London, about 80% of all new cases of Schizoprenia are due to cannabis misuse, therefore causing major problems to an overstretch psychiatric services (House of Commons, 2005).
It's been identified that cannabis misuse is based on the normative needs concept. It is influenced by expert's opinion and government policies (Ewles & Simnett, 2003).
Health Promotion Activity
According to Ewles and Simnett's (2003) educational approach to health promotion, it is giving individuals information to have an inform choices, helping explore their attitudes towards health and discover the health benefits or harmful to them.
Educational approach has perceived strengths and weaknesses. One of its strengths is that the target group can convey large amounts of information through group lectures; they can develop decision making skills in a one to one advice, and they have options to explore (Ewles & Simnett, 2003). In addition, it can also disseminate information to a large group at one time if it's a group lecture. However, it also has some drawbacks. The information alone given cannot guarantee any changes and information also can be forgotten very quickly. This approach may ignore also wider culture, social and economic factors or complexities in health related decision making. (Learning resources, 2010) Naidoo and Wills (2000) explained that educational approach cannot persuade the young people who are using cannabis to change, however, there is an assumption that having more knowledge will influence one's attitude that could lead to changed behaviour (Ewles & Simnett, 2003). The National Drug Policy (2003) emphasise the need for the young people ages 12-15 to be informed of the effects and risk of using cannabis to their health, which can make purely educational approach.
Research Evidence
The chosen research is titled "Swiss adolescents' and adults' perceptions of cannabis use a qualitative study" by Menghrajani et al. (2004). The main objective of the study is to explore the perception of adolescent and adults of use and misuse of cannabis and know their opinions and beliefs about the legal context and the strategies use for prevention. The researchers had focus group discussion with the four groups of people: younger adolescents aged 12-15 year old, older adolescents aged 16-19 years old, parents of teenagers and professionals working with young people. Four different sessions were run, one for each target group, with duration of about 90 min. A topic guide has 5 main questions: 1. How is cannabis defined and perceived? 2. Why do adolescents begin to use cannabis and why do some of them use it on a regular basis? 3. What is considered as cannabis misuse and what are the risks linked with misuse? 4. What are the points of view regarding the present legal context and how should it evolve? 5. How can prevention be set up and improved. The main hypothesis of the researchers is that there would be differences in the way adolescents, and parents or professionals perceive what cannabis use and misuse is. They also have a different idea on how they would propose to address cannabis issue both in terms of policymaking and preventive interventions. The result of the group discussions implies that many adults do not know about the physiological, medical and psychological properties of cannabis. There is certainly an urgent need for thorough information regarding the definition and risks of misuse of cannabis, and its application in different ages and background (Menghrajani, Klaue, Dubois-Arber & Michaud, 2004). It was also suggested that the content of the law itself does not play an essential role in the development of drug use (Reuband, 2001; Reinarman et al., 2004); it may be the type and content of messages which are delivered in the society in general, by parents, teachers and journalists, which mold the adolescent's behaviour. (Menghrajani et al., 2004) Based on the opinions expressed by the adolescents they suggest that prevention intervention should which should begin earlier, if possible before the age of 13-14 years. (Menghrajani et al., 2004)
Aims and Objectives
The aim of this health promotion programme is to raise awareness about the misuse of cannabis and its negative effects to young adults ages 12-15 in the United Kingdom. At the end of the teaching session, participants will be able to explain what cannabis is, list at least 2 adverse effects of cannabis misuse, and identify the penalties imposed by authorities if age 17 below caught using or in possession of cannabis.
The short term goal of this initiative is to be able to give information about Cannabis and its effect to young individuals ages 12-15 in 6 to 10 Secondary schools in the United Kingdom. The long term goal of this initiative is to reduce the number of young people using drugs in the area where the programme was conducted. Although, educational approach cannot persuade the individual to change but by giving young people enough knowledge about the effects of cannabis in one's health, some young people will might think that they will not use cannabis and that later on changed their behaviour (Ewles and Simnett, 2003).
One of the methods that can be use to achieve the health promotion initiative objectives is educating young people about cannabis through lecture discussion. According to Goodwin (2003), it is one of the most frequently use method of instruction. Lecture is an educational tool that can be use to share knowledge by telling the young people about the facts of Cannabis.
Another method is a comic book distribution discouraging cannabis use among very young people. Comic books can attract and motivate young people to read (Wright, 2001). According to Nagata (1999) using narrative form such as a comic can stimulate young people's interest in the certain subject and help them remember what they have learnt. Comic books are very appealing to those readers who do not like long text passages and less attention span like young people (Viadero, 2009).
In addition, information leaflets are another innovative educational tool that can be used to spread information to young people. National Health Services (NHS) use leaflets to provide specific comprehensive information to people about diseases, illnesses, and health programmes they provide. This tool help improves the communication between health care professionals and patients (NHS Choices, 2010). Leaflets containing a picture of cannabis, a brief definition, and side effects with comical drawing of its risk would catch the attention of teenagers.
Evaluation
Randomized experiment may be done to young people ages 12-15 that are exposed to health promoting to the programme compared to those not exposed to the programme. Same questions are asked to both groups to determine the effectiveness of each programme. The difference between the two is analysed to determine the change resulting from implementation of the programme. Sourtzi, Nolan and Andrews (1996), use cross-sectional survey such as questionnaire and interviews to determine the effectiveness of the activities.
Focus groups and in-depth interviews can be use to gather information about the young people's experience about the programme if they learn something, if the methods use are effective and the health promoter or the nurses has expertise and has enough knowledge. A before-and-after questionnaire is used to collect information before and after the implementation of the intervention programmes. This can be used to determine the knowledge of young people about Cannabis before the programme. This will also measure the extent of learning the attendees acquire during the programme. These changes can be measured from time to time and therefore determine the long term impacts of the programme. Panel studies can also be used to collect information from all ages 12-15 that was exposed to the programme. This would help evaluate the impacts of different aspects or levels of the programme and in turn understand the most critical level of the programme. Time series analysis which involves pre- and post-intervention evaluation done many times may also be carried out on learners. This data collected is used to project what might have happened if the intervention measures could not have been in place and use this to compare it to what happened using the post-intervention information.
The lecture discussion will be evaluated by the following. According to Hawe, Degeling and Hall (1990)'s guide in evaluating health promotion, the number of young people ages 12-15 from secondary schools who attend to the lecture discussion will be recorded. Before the lecture, questionnaires will be given to find out their experiences or knowledge about cannabis and its misuse. The effects of cannabis in the body will be shown and the government's policy will be introduced. During the lecture, what young people think about the topics discuss will be observed and their responses will be collected after the lecture is finished. An impact evaluation will follow, a post questionnaire will be given to the attendees to identify what they know and believe after the lecture. The difference in knowledge and beliefs will then be compared with before the education session. Lecture is not an expensive strategy, powerpoints and projectors use which can be borrowed or lend (The Office of Educational Development, 2004). The skills and resourcefulness of the lecturer is very important on how to catch the attention of young people according to Freud has less attention span. A Lecture can be boring if it's lengthy. The 60 minutes lecture discussion is not to lengthy and too short. Topics will be covered well.
Moreover, another method use is the information leaflet about the effects of Cannabis for the target group. A specific number of leaflets will be distributed to the target group as an educational tool. Hawe et al. (1990) evaluate leaflet based on attraction if the leaflet create interest and catch young people's attention. Its comprehension will be evaluated too if it's easy to understand and will not confuse the young target group. In addition, the leaflet will be evaluated also if its culturally sensitive, it does not conflict with cultural norms, not contain offensive and irritating words (Hawe et al., 1990). Survey will be conducted for the impact evaluation of the strategy used. An interview will take place to the young people who received the leaflets. The following will be recorded if how many young people read the leaflets after they received it, if how many leaflets will be taken home, and if what is their plan or action after reading the leaflets. This strategy is expensive; it needs enough budgets for the preparation of the leaflet. Multiple drafts will be made for comment and editing. A series of test will be conducted also for validity and reliability. It will also undergo through ethics committee for approval (CUREC, n.d.)
Humphris, Duncalf, Holt and Field (1999) at University of Liverpool Oral oncology conducted a study on the experimental evaluation of an oral cancer information leaflet. The result of the study shows that the participants who had access to the leaflet showed a significant increase in knowledge at post-test in comparison to pre-test. Therefore, distribution of information leaflets is an effective education tool and the objective of the programme which is to give education is likely meet.
Other strategy use is the comic book which is also use to disseminate information to young people about cannabis use and its effect to the individual. A combination of education and entertainment is an effective way of transmitting social norms and culture (Bartholomew, Guy, Parcel & Kok, 2006). Bartholomew et al. (2006) also stated that popular characters are used as a model or characters on the comic book to attract attention. The comic book characters are those who are perceived as attractive and similar to members of the target group. The comic book is directed at the reader personally. Same with the leaflets it will be evaluated for its impact based on its attraction, comprehension, acceptability personal involvement and persuasion (Hawe et al., 1990). This strategy can use comic-strip theme to engage youth and their families in discussions about drug-related issues. This strategy is costly, trainings are needed. A review of literature conducted by Morris and Elwood (1996) sun exposure modification programme, a comic book titled "Are you dying to get a suntan?" is one of the method used to gave awareness of a causal link between excessive sun exposure and skin cancer.
It is therefore important to evaluate the effectiveness of each strategy so as to understand their economic and ethical relevance. As stated by Farzanfar (2005) evaluation is also important to determine the usability, acceptability and effectiveness of the strategy being used. This information is very important to policy makers, nurse health educators, donors, medical health practitioners and even researchers (Doyle, Jackson, Oakley and Waters, 2006).
It is important to note that evaluating the effectiveness of provision of health promotion activities require individual level evaluation. This involves assessing the positive health practices adopted by the individual. This kind of evaluation is informal and since the target group is ages 12-15 it normally involves a school monitoring the individual learners in the school and also ensures that it reinforces its commitment to health promotion activities or even to change the way it handles its health promotion activities (World Health Organization, 1992).
Assessing this program also involves impact evaluation. This involves evaluating the individual knowledge and attitude and the resultant impact on the society as a whole as result of these programmes. This is important in determining future health promotion activities planning. In order to determine the functionality and progress of any health promotion programme, it is important to carry out an outcome evaluation of the program. Panel studies and time series analysis may be used for long term analysis of the effectiveness of health promotion activities in helping learners overcome the drug abuse. This will help show whether the programme is achieving the set objectives or not. It enables the health educators to provide evidence of the success of the programme and thus justify it or even to prove the need for providing additional resources. In carrying out an outcome evaluation, the health promoters has to consider the appropriate means to be used to measure the changes that have occurred and how to identify indicators of change in individuals and then decide on the best evaluation method to measure the outcome (Hawe et al., 1990).
According to the US National Institute of Health, (2010), a survey carried out at Maryland School, Prince George's County on the impacts of drug education on learners showed that the learners who received drug education scored higher on all the tested measures except in self-efficacy than those who did not receive the education. The measures included the knowledge of the substance abuse, the impacts of advertisements about the drug, conflict resolution among many other questions. The results showed that the use of video-based drug education which includes use of print materials plus the guidance of the nurse is more effective for drug education. Thus such programme enables young people to understand better and work towards achieving the set objectives and goals of the programmes.
Nurses have diversified roles; they could be decision makers, client advocates, case managers, comforters and counsellors, teachers and educators. As educators, the nurse explains to their clients the concepts and facts about health. This type of activity is found in the primary level of health care wherein the emphasis is on the community's health in terms of delivering personal health care services to them. In this type of setting, preventive and primary care is given and the health promotion is a major theme.
The nurse has the social responsibility to educate people since the nurse is the person knowledgeable of what is good for the health or not. Educating others in the community forms part of health promotion. Drug addiction adversely affects the health of people especially the youth who are the most susceptible to this menace. The young people attempt to establish a sense of identity and curiosity with people of his age and those older than him are doing. They seek to establish peer affiliations and always find ways to please them so that they could be "in" with the culture of the group.
As an educator, the nurse should place importance on teaching the young adolescents the serious dangers that the substance could result to. They need guidance since the physical and psychological changes maybe too much for them to handle and instead of asking advice from their parents they might turn to their peers who might lead them to the wrong way of life.
Conclusion
Evaluation of health promotion activities is important in analysing the effectiveness of planning and implementing health promotion programme. Individuals need to be educated about making appropriate choices on health patterns at an early age since these health patterns that are adopted during childhood are more often than not maintained throughout one's life (Cameron, McBride and Midford, 2010). The health patterns that are adopted by children have greater impacts on their adult health and in turn also affect the society's health trends and the related treatment costs. Nurses play an important role in promoting the health and wellbeing of individuals and their families and delivery of health education. The methods used to achieve the objectives of this health promotion activity emerge favourably and effective.
