Depression and Public Health 1 Subject: HAS911: Contemporary Issues in Public Health Assessment 4: Report Assessment Title: Puberty Blues: Interventions for addressing adolescent depression Report Due Date: 4th of June 2017 Tutor: Catherine MacPhail Tutorial group: Wednesday, 1:30pm Student Number: Word Count: 2,253 Depression and Public Health 2 Executive Summary: Depression is undoubtedly a public health issue and, globally, its effects are devastating. Adolescents are particularly burdened by depression, as this mental disorder is associated with significant functional impairment, a myriad of long-term problems and suicide. Thus, it is vital to public health that effective prevention interventions are available to address adolescent depression. The purpose of this report is to provide an examination of the impact of depression on adolescents. Furthermore, this report examines the interventions that have sought to produce change. This report reveals three prevention interventions that have demonstrated efficacy. These are family-based interventions, internet-based interventions and lifestyle interventions. Whilst these interventions present equally unique approaches to adolescent depression prevention, it was the family-based prevention intervention that emerged as the most successful. This was due to the intervention’s focus on the family system, adolescent specific risk factors and a longitudinal study design. This report concludes that the prevention of adolescent depression is possible. Prevention interventions that are well designed, and ensure the incorporation of specific risk and protective factors can produce immense change. However, as depression continues to persist amongst many adolescents globally, it is recommended that further research is needed. Once suitable and efficacious preventions interventions dissemination can occur. are identified, widespread implementation and Depression and Public Health 3 Table of Contents: Executive Summary………………………………………………………………p.2 Table of Contents…………………………………………………………………p.3 1. Introduction…………………………………………………………………….p.4 1.2 What is depression, and why is it a public health issue?......................p.5 1.3 Depression and adolescents…………………………………………..p.6 2. Interventions that have been implemented to produce change for adolescent depression……………………………………………………………………..p.7 2.1 Introduction………………………………………………………..p.7 2.2 Intervention one……………………………………………………….p.8 2.3 Intervention two……………………………………………………….p.9 2.4 Intervention three……………………………………………………...p.10 2.5 Comparison and contrast of interventions…………………………….p.11 3. Conclusion……………………………………………………………………...p.13 4. References……………………………………………………………………....p.14 5. Appendices……………………………………………………………………...p.18 5.1 Appendix A……………………………………………………………p.19 5.2 Appendix B……………………………………………………………p.20 Depression and Public Health 4 Puberty Blues: Interventions for addressing adolescent depression 1. Introduction: A significant contributor to the global burden of disease is the mental disorder depression (World Health Organisation 2012). Depression transcends geography, ethnicity, age and sex (Schuch et al. 2016, p.48). It is estimated that depression affects over three hundred and fifty million people worldwide (World Health Organisation 2012; Vilhelmsson 2014). It is the predominant cause of disability, and is associated with various unfavourable health, social and personal outcomes (World Health Organisation 2012; World Health Organisation 2017). Due to its high prevalence, cost to society and relationship with suicide, depression has become a significant public health issue (Merry et al. 2011). Depression is also a common problem for adolescents (Gladstone, Beardslee & O’Connor 2011; Merry et al. 2011, p.1414). Fifty percent of mental disorders emerge during adolescence, and by the age of eighteen, one in five adolescents will have experienced a diagnosable depressive episode (Cairns et al. 2014; Black Dog Institute 2016; Das et al. 2016). Adolescent depression is associated with the disruption of healthy development, long-term adverse outcomes and an increased risk for suicide (Gladstone, Beardslee & O’Connor 2011; Merry et al. 2011; Hetrick, Cox & Merry 2015). Given the prevailing impact and burden of depression on adolescents, it is imperative that effective interventions are identified and implemented (Das et al. 2016, p.50). This report will explore depression as a significant public health issue and its impact on adolescents. This report will also examine three prevention interventions that have produced change. The effectiveness and ethical practice of these interventions will be discussed. Depression and Public Health 5 1.2. What is depression, and why is it a public health issue? Remarkable advances have been made in the management and awareness of mental disorders over the last decade, but the prevalence of depression continues to be a challenge worldwide. It has been predicted that by 2030, depression will be associated with the highest level of disability attributed to any physical or mental disorder worldwide (Australian Psychological Society 2012). Depression, or major depressive disorder is commonly referred to as clinical depression (Purcell et al. 2013). Depression is characterised by sadness, low self-worth, lethargy, poor concentration, disturbed sleep, agitation, a loss of interest in daily activities and feelings of guilt (World Health Organisation 2012; World Health Organisation 2017). The aetiology of depression is complex, and occurs due to a combination of psychological, social and biological factors (Merry et al. 2011, p.1414; Beyond Blue 2016). There are different types of depressive disorders, with symptoms that range from relatively minor to severe (Purcell et al. 2013). Depression may also be chronic or recurrent. Nevertheless, individuals with depression can become severely impaired and may not be able to function effectively in their everyday lives (World Health Organisation 2012; Purcell et al. 2013). Depression has shown to reduce the health of an individual more than diseases such as arthritis, asthma, angina and diabetes (Jacob 2012; Kvam et al. 2016). There are significant personal and social costs that must also be considered, such as family stress and the comorbidity of other mental disorders. Depression is often highly correlated with anxiety, substance abuse and eating disorders. Perhaps most alarming, depression leads to a substantial risk for suicide (Australian Psychological Society 2012). It is estimated that worldwide, one million lives are lost each year due to pervasiveness of depression (World Health Organisation 2012). Depression and Public Health 6 1.3. Depression and adolescents: It is clear that that depression has a detrimental effect on all individuals worldwide (Kvam et al. 2016). However, it has been consistently identified in the literature that young people are increasingly burdened by depression (Purcell et al. 2013; Hetrick, Cox & Merry 2015). Adolescence is not only a period characterised by physical, emotional, social and educational development, it is a period that is marked by the emergence of mental disorders such as depression (Cairns et al. 2014). Depression can disrupt the healthy development of an adolescent, and result in adverse long-term outcomes such as impairment in school, difficulties in the workplace, dysfunctional interpersonal relationships, substance abuse and a risk for suicide (Gladstone, Beardslee & O’Connor 2011; Merry et al. 2011; Cairns et al. 2014; Hetrick, Cox & Merry 2015). Suicide is now the third leading cause of death for adolescents worldwide (Gladstone, Beardslee & O’Connor 2011). For Australia’s youth, suicide is now the leading cause of death (Australian Bureau of Statistics 2014). As such, intervening in adolescence presents an optimal opportunity for preventing depression (Hetrick, Cox & Merry 2015). Depression and Public Health 7 2. Interventions that have been implemented to produce change for adolescent depression: 2.1. Introduction: Adolescence is arguably the most promising period to intervene for depression, due to its peak in incidence, high prevalence and long-term negative outcomes (Gladstone, Beardslee & O’Connor 2011; Cairns et al. 2014). Adolescent depression is generally treated using medication and evidence based treatments such as cognitive behavioural therapy. Whilst these treatments can be beneficial, many adolescents who receive treatment continue to receive residual symptoms, experience relapse or do not respond at all. For these reasons, efforts for preventative interventions are warranted (Gladstone, Beardslee & O’Connor 2011, p. 2). It is imperative that prevention efforts for depressed adolescents involve a comprehensive understanding of specific risk factors and protective factors. Specific risk factors are those that are associated with increased risk for adolescent depression. These include a lack of social support, negative cognitive styles, low self-esteem and inadequate coping skills. Perhaps the strongest risk factor for adolescents is having a parent with a history of depression. Indeed, the offspring of depressed parents have a two-to-four fold increased risk in developing depressive disorders. Protective factors for adolescent depression are those that include having support from parents, strong family relationships, relationships with peers, and sufficient coping skills (Gladstone, Beardslee & O’Connor 2011, p. 3). Targeting risk and protective factors within prevention interventions may be the most efficient method of reducing the collective impact of adolescent issues (Cairns et al. 2014, p. 73). Depression and Public Health 8 2.2. Intervention one: The prevention of depression in the offspring of parents who have a history of depression is a public health priority (Compas et al. 2015, p.542). As such, the incorporation of the family system into prevention interventions for depressed adolescents is becoming increasingly well established (Gladstone, Beardslee & O’Connor 2011; Poole et al; 2017). Family-based interventions have the ability to enhance youth engagement, target interactions between family members, increase family cohesion, reduce family stressors and ensure adolescents have protective family environments (Lewis at al. 2013, p. 4). Building upon their previous study, Compas et al. (2015) sought to examine the efficacy and moderators of the family cognitive behavioural prevention intervention for adolescents who have parents with a history of depression. The design of the family cognitive behavioural prevention intervention provides education to families about depressive disorders, increases family awareness of depression and promotes adaptive coping strategies. It is a 12week program for families, which requires the inclusion of both parents and their adolescent children (Compas et al. 2009; Compas at al. 2011; Compas et al. 2015). The participants were assessed at 2, 6, 12, 18 and 24-months. Compas at al. (2015) revealed that at the two-year follow-up, participation in the intervention had successfully reduced depressive symptoms, depressive episodes, internalising symptoms and externalising symptoms for the adolescents and their parents. The results of the intervention provide support for the efficacy of the family cognitive behavioural prevention intervention. It is clear that is possible to prevent the onset of major depressive disorder. Whilst these achievements must be recognised, there were a few limitations of the study. These limitations included not utilising a diverse sample, not assessing the success of their blinding method and the inclusion Depression and Public Health 9 of more mothers than fathers. 2.3 Intervention two: A burgeoning approach to adolescent depression prevention is interventions that are internet-based (Brunwasser & Garber 2016, p.779). Interventions delivered through the Internet are cost-effective, and can increase participation, flexibility and sustainability (O’Kearney et al. 2009; Gladstone et al. 2015; Brunwasser & Garber 2016). Kruger et al. (2017) evaluated the protective and risk factors for depression in adolescents after they had undertaken the Internet intervention CATCH-IT (Competent Adulthood Transition with Cognitive-Behavioral, Humanistic, and Interpersonal Training). CATCH-IT is an internet-based depression prevention program that targets at risk adolescents in a primary care setting. It is based on the principles of cognitive behavioural therapy and provides resiliency skills to adolescents through internet-based modules (Gladstone et al. 2015, p.2). Kruger et al. (2017) examined factors that are known to protect against or increase the development of depression. These included automatic negative thoughts, educational impairment, social support from the family and social support from friends. The adolescents were assessed at baseline, 6 weeks, and at 2.5 years. Kruger et al. (2017) revealed that there was an enormous decrease in automatic negative thoughts and educational impairment for the duration of CATCHIT. The CATCH-IT Internet intervention could be useful for not only interrupting the vicious cycle of depression, but its prevention in adolescents. Nevertheless the researchers highlighted a number of limitations. Limitations included the failure to report any differences in perceived social support, not including a control group and a non-representative sample. In addition, adherence to the Internet intervention proved Depression and Public Health 10 difficult. At the final two and half year follow up, only half of the participants remained in the study. 2.4. Intervention three: The importance of lifestyle for adolescent mental health outcomes has also been highlighted in the literature (Cairns et al. 2014, p.73). There are modifiable, lifestyle related practices that can be promoted to young people. It appears that exercise may be a lifestyle practice that is associated with lowered levels of depression (Cairns et al. 2014, p.73). Indeed, there are an increasing number of reviews that demonstrate an association between reduced depressive symptoms and adolescent participation in exercise (Dopp et al. 2012, p. 2; Carter et al. 2016). Dopp et al. (2012) conducted a twelve-week intervention that was designed to examine the impact of aerobic exercises on depressive symptoms in adolescents. The exercises were a combination of independent and supervised exercise sessions, whilst performed on aerobic exercise equipment. Dopp et al. (2012) revealed that not only did all participants report reductions in their depression, these reductions were recognised in a clinician-administered measure. The participants also reported their ongoing participation in exercise at the three-month post intervention assessment. The results of the intervention suggest that exercise levels are related to a moderate decrease in depressive symptoms. Alternatively, exercise could be used as an adjunctive intervention for some adolescents. This study highlights that ongoing research should urgently focus on the relationship between exercise and depression (Dopp et al. 2012, p.7). However, the study had a number of limitations that must be considered. Limitations included the lack of blinding for the clinical staff administering the assessments, a lack of a control Depression and Public Health 11 group and having no objective measure of exercise for the vast majority of the independent exercise sessions. Some of the adolescents had also previously engaged with medication and/or psychological interventions. 2.5. Comparison and contrast of interventions: Upon comparing these prevention interventions, each displayed varying successes and degrees of efficacy. Whilst entirely different interventions, Compas et al. (2015) and Kruger et al. (2017) examined the specific risk and protective factors for adolescent depression over an extended period of time. Despite a few limitations, Compas at al. (2015, p.541) found that their study provided some of the strongest evidence to date for at risk adolescents of parents who had a history of depression. Kruger et al. (2017) concluded that the Internet interventions, such as CATCH-IT, provide a new form of intervention available to adolescents. They are high quality, cost effective, accessible and have proven some efficacy. In contrast, Dopp et al. (2012) found that exercise levels were related to a moderate decrease in depressive symptoms and emphasised that it could be used to influence the course of depression in adolescence (Dopp et al. 2012, p.8). However, the researchers did not focus on specific risk and protective factors for adolescent depression. Although exercise is important to promote during adolescence, its ability to act as a protective factor against depression is still largely unknown (Toseeb et al. 2014, p.1093). The family cognitive behavioural prevention intervention, as examined by Compas at al. (2015), proved to be perhaps the most effective intervention. The significant reductions in depressive symptoms and sustained effects of the intervention have important implications for depressed adolescents. As one of the most powerful risk factor for adolescents is having a parent with a history of depression, family-based interventions appear to be a promising and appropriate Depression and Public Health 12 approach to preventing adolescent depression (Compas at al. (2015). Utilising prevention interventions that focus upon the family can produce meaningful change and positive long-term outcomes (Gladstone, Beardslee & O’Connor, 2011, p. 11). Nevertheless, it should be noted that further, rigorous research and greater coordination efforts for prevention will be required to adequately prevent adolescent depression (Gladstone, Beardslee & O’Connor 2011; Brunwasser & Garber 2016) Depression and Public Health 13 3. Conclusion: Adolescent depression is undoubtedly a significant public health issue. Adolescent depression is devastating in nature. It erodes quality of life, impairs one’s sense of purpose and increases the risk for suicide. However, the period of adolescence presents a window of opportunity for prevention. Prevention interventions for adolescent depression have shown to prevent the onset of depression and are more beneficial than traditional forms of treatment, such as medication or cognitive behavioural therapy. In this report, three different prevention interventions that were shown to produce change were examined. Whilst these interventions obtained varying successes and degrees of efficacy, the family cognitive behavioural prevention intervention proved to be the most beneficial for adolescents with a high risk of developing depression. This was due to the intervention’s adaption of adolescent risk factors, longitudinal study design and focus upon the family as a whole. Depression and Public Health 14 4. 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Carter, T, Morres, I, Repper, J & Callaghan, P 2016, ‘Exercise for adolescents with depression: Valued aspects and perceived change, Journal of Psychiatric and Mental Health Nursing, vol. 23, no. 1, pp. 37-44. Compas, BE, Forehand, R, Keller, G., Champion, JE, Rakow, A, Reeslund, KL, Mckee L, Fear JM, Colletti, CJM, Hardcastle, E, Merchant, MJ, Roberts L, Potts, J, Depression and Public Health 15 Garai E, Coffelt, N, Roland E, Sterba, SK & Cole DA 2009, ‘Randomized controlled trial of a family cognitive–behavioral preventive intervention for children of depressed parents’, Journal of Consulting and Clinical Psychology, vol. 77, no. 6, pp. 1007-1020. Compas, BE, Forehand, R, Thigpen, JC, Keller, G, Hardcastle, EJ, Cole, DA, Potts, J, Watson, KH, Rakow, A, Colletti, C, Reeslund, K, Fear, J, Garai, E, Mckee, L, Merchant, MJ & Roberts, L 2011 ‘Family group cognitive–behavioral preventive intervention for families of depressed parents: 18- and 24- month outcomes’ Journal of Consulting and Clinical Psychology, vol. 79, no. 4, pp. 488-499. Compas, BE, Forehand, R, Thigpen, J, Hardcastle, E, Garai, E, Mckee, L, Keller, G, Dunbar, JP, Watson, JH, Rakow, A, Bettis, A. Reising, M, Cole, D & Sterba, S 2015, ‘Efficacy and moderators of a family group cognitive–behavioral preventive intervention for children of parents with depression’, Journal of Consulting and Clinical Psychology, vol. 83, no. 3, pp. 541-553. Das, JK Salam, RA, Lassi, ZS, Khan, MN, Mahmood, W, Patel, V & Bhutta, ZA 2016, ‘Interventions for adolescent mental health: An overview of systematic reviews’, Journal of Adolescent Health, vol. 59, no. 4, pp. 49-60. Dopp, RR, Mooney, AJ, Armitage, R & King, C 2012, ‘Exercise for adolescents with depressive disorders: A feasibility study’, Depression Research and Treatment, vol. 2012, no. 1, pp. 1-9. Gladstone, TRG, Beardslee WR & O’Connor EE 2011, ‘The prevention of adolescent depression, Psychiatric Clinics of North America, vol. 34, no. 1, pp. 35-52. Gladstone, TG, Marko-holguin, M, Rothberg, P, Nidetz, J, Diehl, A, Defrino, D. T., Harris, M, Ching, E, Eder, M, Canel, J, Bell, C, Beardslee, WR, Brown, CH, Griffiths, K & Van Voorhees, BW 2015, ‘An internet-based adolescent depression Depression and Public Health 16 preventive intervention: Study protocol for a randomized control trial’, Trials, vol. 16, no. 1, pp. 1-17. Hetrick, S, Cox, G & Merry S 2015, ‘Where to go from here? An exploratory metaanalysis of the most promising approaches to depression prevention programs for children and adolescents’, International Journal of Environmental Research and Public Health, vol. 12, no. 5, pp. 4758-4795. Jacob, KS 2012, ‘Depression: A major public health problem in need of a multisectoral response’, The Indian Journal Of Medical Research, vol. 136, no. 4, pp. 537539. Kruger, JR, Kim, p, Iyer, V, Marko-Holguin, M, Fogel, J, Defrino, D, Gladstone, T & Van Voorhees, BW 2017, ‘Evaluation of protective and vulnerability factors for depression following an internet-based intervention to prevent depression in at-risk adolescents’, International Journal of Mental Health Promotion, vol. 19, no. 2, pp. 69-84. Kvam, S, Kleppe, CL, Nordhus, IH & Hovland, A 2016, ‘Exercise as a treatment for depression: A meta-analysis’, Journal of Affective Disorders, vol. 202, no. 1, pp. 6786. Lewis, AJ, Bertino, MD, Skewes, J, Shand, L, Borojevic, N, Knight, T, Lubman, DI & Toumbourou, JW 2013, ‘Adolescent depressive disorders and family based interventions in the family options multicenter evaluation: Study protocol for a randomized controlled trial’, Trials, vol. 14, no. 384, pp. 1-21. Merry, SN, Hetrick, SE, Cox, GR, Brudevold-Iversen, T, Bir, JJ & Mcdowell, H 2012, ‘Psychological and educational interventions for preventing depression in children and adolescents’, Evidence-Based Child Health, vol. 7, no. 5, pp. 1409-1685. Depression and Public Health 17 O'Kearney, R, Kang, K, Christensen, H & Griffiths K 2009, ‘A controlled trial of a school-based internet program for reducing depressive symptoms in adolescent girls’, Depression and Anxiety, vol. 26 no. 1, pp. 65-72. Poole, LA, Knight, T, Toumbourou, JW, Lubman, DI, Bertino, MD & Lewis, AJ 2017, ‘A randomized controlled trial of the impact of a family-based adolescent depression intervention on both youth and parent mental health outcomes’, Journal of Abnormal Child Psychology, vol. 2017, no.1, pp. 1-13. Purcell R, Ryan S, Scanlan F, Morgan A, Callahan P, Allen NB, Jorm AF 2013, A guide to what works for depression in young people, Beyond Blue, Melbourne, Australia. Schuch, FB, Vancampfort D, Richards, J, Rosenbaum, S, Ward, PB & Stubbs, B 2016, ‘Exercise improves physical and psychological quality of life in people with depression: a meta-analysis including the evaluation of control group response’, Psychiatry Research, vol. 241, no. 1, pp. 47-54. Toseeb, U, Brage, S Corder, K, Dunn, VJ, Jones, PB, Owens, M, St Clair, MC, van Sluijs, EMF & Goodyer, IM 2014, ‘Exercise and depressive symptoms in adolescents: A longitudinal cohort study’, JAMA Pediatrics, vol. 168, no. 12, pp. 1093-1100. Vilhelmsson, A 2014, ‘The devil in the details: Public health and depression’, Frontiers in Public Health, vol. 2, no. 1, pp. 1-4 World Health Organisation 2012, Depression: A global public health concern, World Health Organisation, viewed May 1 2017, Depression and Public Health World Health Organisation 2017, Media centre: Depression, World Health Organisation, viewed May 1 2017, 18 Depression and Public Health 19 5.1. Appendix A: Search Strategy The literature search for this report was conducted within The University of Wollongong databases. This search was initially performed from the beginning of May, 2017. Electronic databases such as PsychINFO, PsycARTICLES, Scopus, Web of Science, Science Direct and Health Sciences were searched using a pre-defined search strategy. These databases were chosen based on their relevance to the theme of the report. The search was limited to articles written in the English language, retrieved from peer-reviewed journals and published from the year 2007 onwards. The following search terms were used: (Depression OR ‘‘Major Depression’’) AND (adolescen*, OR “young people” OR “youth”). As this report was also focused on examining prevention interventions for adolescent depression, two different search methods were utilised. First, the following search terms were used (adolescen* depression) AND (prevention). Second, articles were manually searched in the references lists of relevant meta-analyses and systematic reviews. Depression and Public Health 5.2. Appendix B: 20 Depression and Public Health Student name: Student number: 21 Amy Tapsell 4213993 Self- assessment criteria for report structure, format and presentation This guide will help you check your report assignment prior to submission. If you have difficulty with any of the points mentioned you should visit the UniLearning website (http://unilearning.uow.edu.au) Report Criteria Student Yes/No 1. Executive summary Does it provide a brief overview of the topic? Does it summarise the main findings and recommendations? Y Y 2. Introduction Does it explain the purpose and significance of the report? Does it define the main issues? Does it contain a content map (summary of the main sections in the reports in the order they will appear)? Y Y Y 3. Body Does it use numbered headings and subheadings? Does it present factual and objective information appropriately analysed? Does each paragraph start with a topic sentence (i.e. explain what the paragraph will discuss with a key sentence)? Do the paragraphs have a logical flow within each other and the report? Have you provided evidence for all your claims? Y Y Y Y Y 4. Conclusion Does it contain no new material? Does it summarise all the material? Does it provide recommendations/solutions? Y Y Y 5. Referencing Have you looked at the university’s plagiarism policy on the web? (http://www.uow.edu.au/about/policy/UOW058648.html) Have you used your own words to make your points or, when using the words of others, used quotation marks and acknowledged your sources, incl. page numbers? Does the referencing conform to the Harvard Standard? see https://webapps.library.uow.edu.au/refcite/style-guides/html/ Is the material in the reference list cited in the report and vice versa? 6. Presentation Y Y Y Y Depression and Public Health Did you check spelling and grammar? Are the font size, line spacing, margins appropriate (or as required by the subject)? Are any appendices attached? 22 Y Y Y Discuss the current status of maternal OR child health in a country of your choice with reference to both the Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs). Your report should focus on prevalence by key indicators of maternal/child health, significant recent achievements in the context of the MDGs and SDGs, and challenges to meeting the SGDs. Summarise your findings by creating your own original information leaflet/brochure/ infographic that could be understood by a lay person. Include this in an Appendix. Submission must use a report format including an executive summary (maximum 200 words on a separate page); a 12-point font, and double line spacing; and show your actual word count on the front page of the assignment Include a completed report checklist documenting how you have followed report writing guidelines. including an executive summary (maximum 200 words on a separate page); a 12-point font, and double line spacing; and show your actual word count on the front page of the assignment. Include a completed report checklist documenting how you have followed report writing guidelines. You are expected to read widely in the scholarly literature (i.e. peer-reviewed journals) for this assignment. Fifteen to 20 references would be considered adequate for this topic. Relevant online reports are acceptable but should not be the only sources used (no more than 25% of references) Executive summary - as per Self- assessment Checklist Item 1 Introduction - as per Self-assessment Checklist Item 2 Body - as per Self-assessment Checklist Item 3, including Discussion of the relevant MDGs and SDGs Supported by up-to-date data on key indicators National and international literature, as ap- propriate, is used to discuss achievement of MDGs and work towards SDGs Relevant, and comprehensive arguments are clearly stated Strengths of country response to issue and potential barriers to success are discussed Strengths of country response to issue and potential barriers to success are discussed Conclusion - as per Self-assessment Checklist Item 4 Referencing - as per Self-assessment Checklist Item 5 Information leaflet/brochure/infographic content - Clearly communicates up-to- date information about your chosen issue, including effective and ethical practice, expressed in easy to understand language and is visually engaging. You must complete and attach (1) the Report Self-assessment Checklist to your assignment - one mark will be deducted if not included
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