NUR026-2: Health for Communities Essay - Elderly Health Promotion

This essay, submitted by Florence Chidi from the University of Bedfordshire, analyzes health promotion strategies for elderly individuals, particularly focusing on a case study involving a 78-year-old woman named Deidre with osteoporosis. The essay delves into the global and local prevalence of osteoporosis, its impact on daily life, and the associated health burdens. It identifies key health promotion strategies, including pharmacological interventions (bisphosphonates, calcium, and Vitamin D supplementation), lifestyle modifications, and psychological support, all tailored to the patient's specific needs and circumstances. Furthermore, it examines the role of nurses, pharmacists, and community support staff in implementing these strategies, emphasizing patient education and medication adherence. The essay also explores the wider determinants of health, such as education, employment, social support, and access to healthcare services, and how these factors influence the patient's ability to manage their condition. It discusses behavioral health theories like the theory of planned behavior and the health belief model to understand and promote positive behavioral changes. The essay concludes by highlighting the importance of individualized and comprehensive health promotion plans to improve outcomes for elderly patients with osteoporosis, addressing both disease-related factors and individual health behaviors.

Health for Community
Name of the student: Florence Chidi
Name of the University: University of Bedfordshire
Student ID: 1706508
Cohort 17b

1COMMUNITY
Health promotion is the process undertaken to empower people to take control over their
health and take multi-sectoral action to improve health behaviors and enhance health outcomes
for the community (World Health Organization (2016). WHO (2016) also emphasizes the role
public health systems play in protecting and assuring the health of the community and
coordinating with direct or indirect services and taking steps to address health service needs for
vulnerable groups. The main purpose of this essay is to assess a case study to identify key health
issues in the scenario and discuss the factors affecting the promotion of health for the elderly
people. The essay will give an insight into the prevalence of their health conditions locally and
globally and discuss about public health promotion for the condition. With a focus on
determinants of health relevant to the chosen patient, the essay will analyze the potential of
nurses in health promotion and providing optimal support to such patients. Due to confidentiality
issue, a pseudonym will be used for the case study person instead of the actual name.
Considering confidentiality is important according to the NMC professional standard of practice
as it mentions the duty of respecting patient’s right to privacy and always protecting the
confidentiality of patient (Nursing and Midwifery Council 2015).
The case study about Deidre as mentioned in appendix 1 is a focus of this essay. The
essay focuses on Deidre’s health issues and discusses the strategies to engage in health
promotion for the elderly people with osteoporosis. Osteoporosis was the main health issue for
Deidre and it is a health condition associated with weakening of the bones and increased risk of
fractures in affected individuals. It is a chronic health condition associated with symptom of back
pain, increased risk of fracture, loss of height and stooped posture (Mu et al. 2018). Women are
at more risk of osteoporosis as bone loss accelerates after menopause (Royal College of Nursing

2COMMUNITY
2016). The disease is most commonly seen in elderly people and as Deidre is 78 years old, the
cause of fall and fracture is evidenced by her age and diagnosis of osteoporosis.
Osteoporosis is a health burden which is growing nationally and globally. As reported by
NHS England (2019), osteoporosis is a highly prevalent condition among elderly people in the
community. In 2015, 3.5 million people aged above 50 years were found to be suffering from
osteoporosis in UK and more than 500, 000 individuals received treatment for osteoporosis
related fractures every year (NHS 2019). Osteoporosis has become a serious global public health
concern as more than 200 million are suffering from the disease worldwide (WHO, 2019). The
UK National Osteoporosis Society (2015) mentions that osteoporosis has a profound impact on
quality of life and health care burden. However, there is lack of awareness of the condition
among the public and policy makers (Compston et al. 2017). The WHO emphasizes reducing the
burden of osteoporosis and its role in increasing the number of fractures (appendix 2) (WHO,
2019). The above statistics are indicative of the need to identify appropriate health promotion
strategies for elderly people affected by the condition.
To engage in health promotion for Deidre, identifying the impact of osteoporosis on daily
life is important. Deidre has currently fractured wrist because of fall. This has impaired her
ability to engage in daily life activities like cooking, dressing and hygiene related needs (Royal
Osteoporosis Society, 2019). As the couple is socially isolated and Deirdre’s husband Joseph has
early onset of dementia, she lacks access to a family member who can provide care related
support and get guidance on ways to access health services (NHS England 2019). Hence,
considering the patient’s context in the scenario, the key health promotion strategies that are
necessary for osteoporosis according to the NICE guidelines includes pharmacological
management, educational intervention, psychological support, physiotherapy, lifestyle

3COMMUNITY
intervention and preventative strategies (Compston et al., 2017). NICE recommends use of
fracture risk assessment tool to reduce risk for patients (National Institute for Health and Care
Excellence 2012).
As Deidre suffered a wrist fracture because of osteoporosis, implementation of
pharmacological strategies is most important as part of health promotion goals (NICE 2017). The
significance of a pharmaceutical strategy is that it can increase bone mass and strength by
promoting bone formation (National Osteoporosis Guideline Group 2017). Bisphosphonates are
the first line of treatment because of safety and beneficial effect on bone health according to the
NICE guidelines (NICE 2017). Combined supplementation of calcium and Vitamin D has
become one of the components of treatments to reduce future risk of fracture in elderly patients
(NICE 2017). The clinicians, pharmacist, community support staffs and nurses can play a role in
engaging in identifying appropriate drugs for patients. The pharmacist can play a role in
improving osteoporosis management by risk factor assessment and bone mineral density (BMD)
testing (Public Health England 2014). This may start with assessment of severity by the use of
BMD testing using central dual-energy x-ray absorptionmetry (DXA) (NICE 2012). It is the gold
standard to identify patients who are at high risk and this assessment can influence the decision
to identify appropriate drug therapy for patients (NOGG 2017). Nurse and pharmacist can play a
role in managing challenges related to medication adherence (National Institute for Health and
Care Excellence 2012).
However, the challenges that may arise in initiating pharmacological strategy for Deidre
includes age related issues such failing memory, difficulty in adhering to the regimen, lack of
social support because of isolation and other health issues (Kvarnström, Airaksinen and Liira
2018). Barnett (2014) explains that implementation of pharmacological intervention is

4COMMUNITY
particularly challenging for the elderly as they may struggle with adherence to the medication.
To overcome this issue, patient education and implementation of secondary prevention programs
such as liaison services and development of bone therapy groups can promote adherence
(Kvarnström, Airaksinen and Liira 2018). Nurses and community support staffs can play a role
in bone care and educating patients (National Osteoporosis Society 2019). Nurses interact with
Deidre to identify medication adherence related issues and develop tailored educational
intervention to improve medication adherence. Fracture liaison services can also get involved to
manage continuity of care and multi-professional pathways for patients with fractures (Royal
Osteoporosis Society 2019).
Apart from pharmacological intervention, health promotion for Deidre can be achieved
by non-pharmacological interventions such as smoking cessation, regular weight bearing activity
for 30 minutes, promoting active lifestyles, increasing intake of daily calcium and vitamin D
(Ong et al. 2014). These can play a role in the treatment of osteoporosis and preventing fractures.
In the context of Deidre, as she is 78 years old, loss of mobility and loss of physical fitness can
be one of the challenges in implementing lifestyle interventions. There is a possibility that as
both Deidre and her husband are above 10 years of age, the possibility of poor nutrition may also
be high. Living alone and poor nutrition may be the reason behind low body weight and body
mass index resulting in hip fractures (Ong et al. 2014). Therefore, considering varied challenges
and diverse health needs of elderly patient with osteoporosis, it is suggested that health
promotion strategies should be tailored to individual risks and needs which may enhance
treatment effects and promote long-term compliance (Menichetti and Graffigna 2016).
The common determinants of health that affects overall health and well-being of an
individual includes healthy housing, education, employment status, social support and access to

5COMMUNITY
health care services (Public Health England 2018). The level of education of an individual
determines behavioral modifications, knowledge and perception related to disease and illness and
self-efficacy to manage the disease (NICE 2015). Hence, as from the case scenario, no
information exists regarding education level of patient, there is a need for health care staffs to
first inquire about education level to plan appropriate educational intervention. This will affect
Deidre’s ability to follow advice and understand ways to prevent future risks of falls and
maintain bone health. Employment and financial condition might affect patient’s ability to
contact health services and seek timely care (Cecil et al., 2016). There is a need to inquire about
financial status of patient to improve accessibility to health services (Steven et al. 2016). Other
wider determinants for patients include physical activity and lifestyle. Information regarding this
determinant can be collected from patients regarding overall life course, type of occupation and
preferences for leisure (NHS 2017). This may help to predict whether any social inequalities
affect the occurrence of osteoporosis or not (Perry et al. 2016). One of the social inequities
inherent in the case of Deidre includes social isolation and lack of social support. This might be a
factor behind increase in psychological stress and poor quality of life. To eliminate these factors,
there is a need to counsel patient and also eliminate the fear of falling and sustaining future
fractures (NICE 2017). This form of psychological counseling may help to engage in physical
activity.
Accessibility to health care services is a critical factor that has overall impact of physical,
mental and social health (Montgomery et al. 2018). For different individuals, accessibility to
health services may be affected by various factors such personal factors, economic factors,
political factors and presence of inequity in the community (NHS England 2019). Generally,
people become aware of different types of health care services in community by contact with

6COMMUNITY
friends and relatives, going outside, interacting with health care professional groups and access
to social media (Yahia et al. 2016). Hence, accessibility to health service is a criterion for
identifying health care needs, early diagnosis, timely treatment and regular health care checkups
(Kelly et al. 2016). A study investigating challenges faced by older UK residents in accessing
health care services revealed that accessibility varies according to the geographical location in
which elderly people lives, their cultural background and level of multi-morbidity (Oliver, Foot
and Humphries 2014). For example, undersupply of health services in many areas create
perceptions of increased travel time and poor intention to access services because of long waiting
time. In the context of the patient in the case scenario, they are living in Peace Valley Lane and a
lack of adequate health care services in their area might be a reason for poor knowledge about
health care services.
Lack of social support and family members can also create barriers in accessing health
services for elderly (Memon et al., 2016). For example, if older people do not have transport and
have low income resources, they are dependent on other family members to access services.
Affordability factors such as financial burden and inability to manage costs associated with care
might also be a reason for many people to have limited access to health care services (Cecil et
al. 2016). Some of these challenges or factors are present in the life of Deidre. However, Deidre
does not have extended family members to support her in accessing appropriate health care
services. Financial or physical burden of travel might be a reason behind poor access (Memon et
al., 2016). Deidre’s access to health care service may be limited because of ageing, lack of social
contacts and social isolation. In addition, socio-demographic factors, type of health insurance
and socioeconomic status may significantly affect access to health care (Steven et al. 2016). For
these reasons, they are most likely to face challenges in accessing health services.

7COMMUNITY
Considering the determinants of health and factors contributing to diseases, it can be said
that apart from disease related factors, individual health behavior can play a major role in
determining health outcome for people (NHS, 2017). To correct negative health behavior and
promote positive behavioral change, health care professionals can utilize social and behavioral
health theories to promote health. (Public Health England 2018). Two useful behavioral health
theories include the theory of planned behavior (Cooke et al. 2016) and the health belief model
(HBM) (Sharma, 2015). The theory of planned behavior is a concept emerging from the theory
of reasoned action and this theory is based on the assumption that behavioral intentions are
influenced by the perception related to the behavior that will have expected outcomes and the
analysis of risks related to the outcomes (Ajzen, 2015). This theory is based on six constructs of
attitude, subjective norms, behavioral intention, social norms, perceived power and perceived
behavioral control (Cooke et al. 2016). The concepts of the theory of planned behavior can be
used for health promotion with Deidre and change her perception related to disease management
and control. Currently, Deidre might be unaware of positive health behavior and the benefits of
bone exercise in promoting health of patients (Eriksen et al. 2016). Therefore, health care staffs
can take steps to work with her and influence her attitude towards exercise. The perception
related to ease or challenges of performing exercise can be changed by increasing patient’s
knowledge regarding the ways to engage in appropriate exercise and reduce the risk of falling
(Eriksen et al. 2016). The utility of the theory of planned behavior has been utilized in research
to influence physical activity intention in elderly male residents working in a nursing home
(Peckham, Hann and Trenholm 2019).
Another behavioral health theory includes the HBM which has been utilized from the
concepts of the behavioral theory and which can be used to guide health promotion in an

8COMMUNITY
individual (Skinner, Tiro and Champion 2015). It is based on the assumption that health related
behavior of an individual is dependents on individual beliefs of the health conditions (Sharma,
2015).). This means that a person may develop interest in changing their behavior based on
factors of perceived susceptibility, perceived benefits, cues to action, self-efficacy and perceived
severity (Skinner, Tiro and Champion 2015.). As. Deidre has already sustained fractures because
of osteoporosis, there is a need for her to engage in some form of exercise to reduce future risk of
falls and fractures. However, before engaging the patient in exercise related intervention, the
HBM concept can be used to evaluate current perceptions of Deidre related to benefits and risks
of exercise (Sharma, 2015). NICE (2013) gives the evidence that addition of weight-bearing
exercise programs to medical treatments is critical to improve quality of life of patient with
osteoporosis.
From the review of the determinants of health influencing health outcomes and barriers to
health care access for Deidre, some of the issues identified for patients include social isolation,
lack of family members support, poor physical activity, low access to care and poor knowledge
regarding appropriate referral pathways (NHS England 2019). The role of nurses is critical in
health promotion of Deidre as they can guide patients to appropriate referral pathways and
engage in effective partnership with carers (National Osteoporosis Society 2019).Nurse’s
collaboration with Deidre is critical to improve access to health service and extend the patient’s
knowledge regarding appropriate multi-professional team that she can consult (National
Osteoporosis Society 2019). This includes physicians, physiotherapist, nurse and counsellors.
They can work to reduce care gap, identify risks and treat patients with adequate interventions.
Nurse’s role in educating patient will educate her about risk factors, causes of falls and fractures

9COMMUNITY
and process to promote bone health, also nurses can take her preference regarding any specific
challenges in adhering to health promotion advice to provide holistic care to patient (NHS 2017).
From the experience of analyzing the health promotion strategies for the case study, I
have learnt that various social and economic circumstances are a major cause behind the
deterioration of health. I feel that I need to develop my skills related to identifying needs of
patients treated at home and ensure that all their needs are met. The experience of analyzing the
case study helped me learn about the crucial role of nurses in effectively communicating with
patients, identifying their needs and planning appropriate health promotion interventions
accordingly. This knowledge will help me in my future practice to focus on analyzing
determinants of health during future patient interactions and planning appropriate care plan for
patients.
To conclude, the essay gave a discussion regarding the role of public health in identifying
health needs and promoting health through the review of disease condition of Deidre. As the
patient is an elderly patient with osteoporosis, the analysis of determinants of health relevant to
the patient’s life revealed that poor social support, ageing, low level of mobility and poor
perception about disease management as some issue for the patient. The essay gave ideas about
positive health promotion strategies that can reduce risk and promote health of elderly patients
with osteoporosis. Through the analysis of the concepts of behavioral health theories, the paper
gave the idea that physical exercise is vital in which nurse can play a role in influencing patients
to reduce further risk of fracture in patient.

10COMMUNITY
References:
Ajzen, I. 2015. Consumer attitudes and behavior: The theory of planned behavior applied to food
consumption decisions. Rivista di Economia Agraria, 70(2), 121-138.
Barnett, N.L., 2014. Medication adherence: where are we now? A UK perspective. European
Journal of Hospital Pharmacy: Science and Practice, 21(3), pp.181-184.
Cecil, E., Bottle, A., Cowling, T. E., Majeed, A., Wolfe, I., and Saxena, S. 2016. Primary care
access, emergency department visits, and unplanned short hospitalizations in the
UK. Pediatrics, 137(2), e20151492.
Compston, J., Cooper, A., Cooper, C., Gittoes, N., Gregson, C., Harvey, N., Hope, S., Kanis,
J.A., McCloskey, E.V., Poole, K.E. and Reid, D.M., 2017. UK clinical guideline for the
prevention and treatment of osteoporosis. Archives of osteoporosis, 12(1), p.43.
Cooke, R., Dahdah, M., Norman, P., and French, D. P. 2016. How well does the theory of
planned behaviour predict alcohol consumption? A systematic review and meta-analysis. Health
psychology review, 10(2), 148-167.
Eriksen, C.S., Garde, E., Reislev, N.L., Wimmelmann, C.L., Bieler, T., Ziegler, A.K., Gylling,
A.T., Dideriksen, K.J., Siebner, H.R., Mortensen, E.L. and Kjaer, M., 2016. Physical activity as
intervention for age-related loss of muscle mass and function: protocol for a randomised
controlled trial (the LISA study). BMJ open, 6(12), p.e012951.
Kvarnström, K., Airaksinen, M. and Liira, H., 2018. Barriers and facilitators to medication
adherence: a qualitative study with general practitioners. BMJ open, 8(1), p.e015332.

11COMMUNITY
Memon, A., Taylor, K., Mohebati, L. M., Sundin, J., Cooper, M., Scanlon, T., and de Visser, R.
2016. Perceived barriers to accessing mental health services among black and minority ethnic
(BME) communities: a qualitative study in Southeast England. BMJ open, 6(11), e012337.
Menichetti, J., & Graffigna, G. (2016). How older citizens engage in their health promotion: a
qualitative research-driven taxonomy of experiences and meanings. BMJ open, 6(7), e010402.
Montgomery, H. E., Haines, A., Marlow, N., Pearson, G., Mythen, M. G., Grocott, M. P. W., &
Swanton, C. (2017). The future of UK healthcare: problems and potential solutions to a system in
crisis. Annals of Oncology, 28(8), 1751-1755.
Mu, W.Q., Huang, X.Y., Zhang, J., Liu, X.C. and Huang, M.M., 2018. Effect of Tai Chi for the
prevention or treatment of osteoporosis in elderly adults: protocol for a systematic review and
meta-analysis. BMJ open, 8(4), p.e020123
National Institute for Health and Care Excellence 2012. NICE Clinical Guideline 146.
Osteoporosis: assessing the risk of fragility fracture. Retrieved from:
https://www.nice.org.uk/guidance/cg146
National Osteoporosis Guideline Group (NOGG) 2017. NOGG 2017: Clinical guideline for the
prevention and treatment of osteoporosis. Retrieved from:
https://www.sheffield.ac.uk/NOGG/NOGG%20Guideline%202017.pdf
NHS 2017. Health Survey for England 2016 Physical activity in adults. Retrieved from:
http://healthsurvey.hscic.gov.uk/media/63730/HSE16-Adult-phy-act.pdf
NHS 2019. Osteoporosis. Retrieved from: https://www.nhs.uk/conditions/osteoporosis/

12COMMUNITY
NHS England 2019. Reducing inequalities in access to general practice services. Retrieved
from: https://www.england.nhs.uk/gp/gpfv/redesign/improving-access/reducing-inequalities-in-
access-to-gp-services/
NICE 2013. Indicators for the NICE menu for the QOF. Retrieved from:
https://www.nice.org.uk/Media/Default/Standards-and-indicators/QOF%20Indicator%20Key
%20documents/NM31%20osteoporosis%20guidance.pdf
NICE 2015. Bone Health Programme: A Proactive Population Approach to Bone Health.
Retrieved from: https://www.nice.org.uk/sharedlearning/bone-health-programme-proactive-
population-approach-to-bone-health
NICE 2017. Osteoporosis. Retrieved from:
https://www.nice.org.uk/guidance/qs149/chapter/Quality-statement-2-Starting-drug-treatment
NICE 2017. Osteoporosis. Retrieved from:
https://www.nice.org.uk/guidance/qs149/resources/osteoporosis-pdf-75545487906757
Nursing and Midwifery Council 2015. The Code: Professional standards of practice and
behaviour for nurses, midwives and nursing associates. Retrieved from:
https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
Oliver, D., Foot, C. and Humphries, R., 2014. Making our health and care systems fit for an
ageing population. London: UK: King's Fund.
Ong, T., Sahota, O., Tan, W. and Marshall, L., 2014. A United Kingdom perspective on the
relationship between body mass index (BMI) and bone health: a cross sectional analysis of data
from the Nottingham Fracture Liaison Service. Bone, 59, pp.207-210.

13COMMUNITY
Peckham, S., Hann, A., & Trenholm, S. 2019. A pro-active approach. Health Promotion and Ill-
health prevention. Retrieved from:
https://www.kingsfund.org.uk/sites/default/files/field/field_document/health-promotion-ill-
health-prevention-gp-inquiry-research-paper-mar11.pdf
Perry, D. C., Metcalfe, D., Griffin, X. L., and Costa, M. L. 2016. Inequalities in use of total hip
arthroplasty for hip fracture: population based study. bmj, 353, i2021.
Public Health England 2018. Chapter 6: wider determinants of health. Retrieved from:
https://www.gov.uk/government/publications/health-profile-for-england-2018/chapter-6-wider-
determinants-of-health
Public Health England. 2014. Right Care Pathway: Falls and Fragility Fractures. Retrieved
from: https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/12/falls-fragility-
fractures-pathway-v18.pdf
Royal College of Nursing 2016. Osteoporosis. Retrieved from: https://www.rcn.org.uk/clinical-
topics/womens-health/osteoporosis
Royal Osteoporosis Society 2019. Everyday life with osteoporosis. Retrieved from:
https://theros.org.uk/information-and-support/living-with-osteoporosis/everyday-life/
Royal Osteoporosis Society. 2019. Fracture Liaison Services. Retrieved from:
https://theros.org.uk/healthcare-professionals/fracture-liaison-services/
Sharma, M., 2015. Multi-theory model (MTM) for health behavior change.
http://www.webmedcentral.co.uk/article_view/4982

14COMMUNITY
Skinner, C.S., Tiro, J. and Champion, V.L., 2015. Background on the health belief model. Health
behavior: Theory, research, and practice, 75.
Steven, K., Dowell, J., Jackson, C. and Guthrie, B., 2016. Fair access to medicine? Retrospective
analysis of UK medical schools application data 2009-2012 using three measures of
socioeconomic status. BMC medical education, 16(1), p.11.
The Osteoporosis Agenda England. 2015. Retrieved from:
https://theros.org.uk/media/1959/agenda-for-osteoporosis-england-final.pdf
World Health Organization 2016. What is health promotion? Retrieved from:
https://www.who.int/features/qa/health-promotion/en/
World Health Organization 2019. Nutrition. Retrieved from:
https://www.who.int/nutrition/topics/5_population_nutrient/en/index25.html
Yahia, S., Roji, A.M., Ledda, R., Chilaka, C., Chokkalingam, K., Prinsloo, P.J. and Divyateja,
H., 2016, May. Use of Denosumab for treatment of Osteoporosis at a Tertiary Referral Centre:
an evaluation according to the UK National Institute of Health and Care Excellence (NICE)
Guidelines. In 18th European Congress of Endocrinology (Vol. 41). Bioscientific.

15COMMUNITY
Appendix 1.
1. Case study:
Deidre is a 78 years old woman, who has been diagnosed with osteoporosis and recently
suffered a wrist fracture during a fall. She lives at her home with her husband, Joseph
(80) who is newly diagnosed with dementia. Deidre is struggling to manage her own
health issues and manage the behavioral changes of her husband due to dementia. As she
has no children and no relatives to visit her, her health issues have become even more
complex.
2. The estimated projection is that the worldwide incidence of hip fracture is likely to
increase by 240% in women and 310% in men by 2050