Case Study: Factors of Health and Healthcare

This essay will focus on the factors to healthcare and health promotion based on Fiona, a character derived from a scenario in the university close. The author will examine how social, political, equality and diversity influence public health. An analysis of statistical and theoretical framework will be carried out. A comparison of the behaviour models Health Belief Model (HBM) and Trans theoretical Model (TTM) will be analysed to find which model is suitable for Fiona. The author will discuss the role of a nurse working in partnership with the multi-disciplinary team to provide Fiona’s well-being and as well reflect on what they have learnt from Fiona’s condition.

Fiona, a 54 years old lives alone due to recent sudden death of her husband (from a road traffic accident). She has one son who is 30 years and lives in Australia. She has had to return to work due to financial difficulties. Fiona has been a type two diabetic for three years and was recently seen by the GP because of uncontrolled blood sugars and symptoms of depression. Names have been changed for confidentiality according to Nursing and Midwifery Council (NMC), (2018).

There are two type of diabetes type 1 and type 2 which are both lifelong condition with different causes, this essay focuses on TD2 (Mohamed et al.,2018).Type two diabetes (T2D) is a  progressive condition which occurs when enough insulin for the body is not produced causing the blood sugars to become high (National Health Services (NHS), 2017a). The two major causes of T2D are overweight and obesity, and also a combination of genetic and environmental factors apply ( Public Health England (PHE), 2018; Sung et al.2012). Fiona’s pancreas is not producing enough insulin to maintain normal blood sugar levels. In the long term, T2D has risk factors which includes blindness, renal failure and amputation (NHS, 2017b).

Sources form PHE (2016) indicated that T2D has cost national health services (NHS) 10% of its budget amounting to 10 billion each year. According to World Health Organisation (WHO), (2018) an estimated figure of 108 million adults are living with diabetes globally and that figure has risen to 422 million within four years in 2014 because of the rise in T2D which has accounted for 90% of all diabetes cases in the UK. Currently there are 3.8 million people diagnosed with diabetes in the UK and 90% of those have T2D ( WHO, 2019 ; PHE, 2018).  The prevalence of diabetes in Luton is 7.6% in which Fiona lives and it is significantly higher than the average of England 6.3% (Luton Borough Council, 2016). T2D is a major cause of premature death claiming around 22 000 people each year in UK (PHE, 2018).

There are many public health promotions available for T2D and there is need to support  individuals to change their lifestyle and  eating habits (WHO, 2018). Ottawa Charter 1986 mentioned in WHO (2014), explained health promotion as “the process of enabling people to increase control over, and to improve their health, so that they have full capacity of physical, mental and social well-being”.

Educational programmes like Diabetes Education and Self-Management for Ongoing and Newly Diagnosed course (DESMOND) is a health promotion that provides Fiona with self-management education modules and care pathways for people withT2D (Diabetes UK, 2019). A research done by Torjesen, 2016 indicated that people who attend DESMOND programme benefit more on how to self-manage their diabetes.

Another programme which might help Fiona is Health Living for People with diabetes (HELP- Diabetes) which has shown improvement for glycaemic control. It is an online programme  offered during NHS routine appointments put in place of face to face programmes like DESMOND (Khunti et al, 2012). A research done by Arafat et al, (2016) shows that people feel that awareness of diabetes brings fear and hysterical while missing the point on how serious is type two diabetes and the risk factors associated with it. The campaign resulted in more people having their risk assessed at pharmacies and GP surgeries.

Public Health for England launched a national ‘Change for Life’ which encourages people to do more physical activities and eating healthy. This campaign might be useful for Fiona to stabilise her blood sugar levels when eating healthy. According to Ley, et al, (2014) found that eating wholegrain food, fruits, nuts, vegetables, white meat helps glycaemic control. PHE (2016) have the opportunity of supporting behaviour change of individuals’ well-being through NHS programmes and in collaboration with NHS England and NHS improvement. The challenges Fiona might get is financial difficulties to fund this life style however she can get personal independence payment (PIP) since she is over 16 and has not reached pensionable age (GOV.UK, 2019).

World Health Organization (WHO, 2019) defined health inequalities as the contrast of health determinants among a group of population because of geographical, social, psychological, physical  and other aspects. According to WHO, (2019) social determinants of health are “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness”. These circumstances are made by social, cultural, economic, environmental and political determinants (Marmot, 2010). These are daily activity and lifestyle of an individual  see Dalgren Whitehead model in appendix 1 in line with health inequalities.

The wider determinants of health which determine the health quality of Fiona are age, gender, individual life style behaviours, social and community networks.  Fiona’s age and gender puts her at high risk for T2D and depression. Higher risk of depression is found in women than men ( Mocan et al, 2016). Effective diabetes management help address Fiona’s depression symptoms as her mood is enhanced and able to comply with treatment routines ( Petrak et al, 2015). Yin, et al, 2016 suggested that T2D is more common in middle-aged woman and this implies to Fiona who is 56 years old. Fiona lives alone since she lost her husband and feels isolated with no support from family as her son lives in Australia. There is no evidence to suggest that she has other friends and relatives. This has an impact on her mental and physical wellbeing ( Utz, Caserta and Lund , 2011).

Important factor to consider is Fiona’s awareness of services available to her and how she can gain access. Dalstra et al, 2012 states that less than one in five patients know the services available in their community. Advertisement of the services through  posters or leaflets can be helpful as many service users tend to read posters and leaflets while waiting health care waiting areas ( Maskell, McDonald and Paudyal, 2018). Health care professions such as the GP or other specialists, can provide awareness of health services, such as support groups to Fiona.

There are barriers to health services which includes psychological, geographical, educational , employment, cultural and language issues (Dezetter et al, 2015). Financial difficulties act as a barrier for Fiona as she will need to have money to  attend appointments or travel to support groups. Distance and cost of transport to the GP is a barrier to access  health services. Fiona does not have the financial support of her husband  and travelling costs can affect her. Education is another barrier as health literacy is important to break the barrier. Fiona needs to know where and when to seek support when having a health issue. She also needs the confidence and skills to talk about her illness and treatment with health professionals. Employment is one of the social determinants of health, it can hinder your personal life and social life. Fiona could not afford to buy healthy food because of  income Fiona’s social life is affected as she will be having anxiety of not having  enough money hence not able to go out with friends  and the only family she has is her son who is in Australia, this affect her mental wellbeing. Fiona’s health may also be affected because of long waiting list, and the budget allocated to the hospital. Since Fiona has just returned to work, the fear of not getting time off is another barrier of her health service (Ross, et al, 2018).

Statistically, 70% of individuals with diabetes are from low and middle income countries and poor education, unemployment and low income contributes to the risk of diabetes which leads people to live in deprived areas (Sundmacher, et al, 2011). People who have poor education or not educated may get  a low paid job or unemployed  which results for them to live in deprived areas and being homeless (Dalstra et al, 2012). Therefore, they might have limited access to health services and  less chances of living longer compared to those who are educated and earning more money as they have more access to private health services, engage to healthier lifestyles and can live longer (Ford et al, 2016). Although Fiona has not been going to work in the past it was no longer the case as she has just returned to work and this may help her to bring back her old routine.

Treatment is based on lifestyle changes for Fiona such as weight loss, physical activities and diet. Fiona needs to attend regular medical examinations and screening such as eye checking which needs to be done yearly to reduce developing physical health problems. Therefore, getting an appointment maybe a challenge since there are long waiting list at NHS and getting time off can be difficult because she has just started a new job.

There are many types of behavioural theories and the author will analyse Health belief model (HBM) and trans-theoretical model (TTM). HBM focuses on identifying aspects influencing people in preventing health action in their condition. It is made up of four stages namely perceived susceptibility and severity, perceived benefits and barriers, cues to action and self-efficacy (Rosenstock, Strekher and becker, 1988). Perceived susceptibility is suitable for Fiona as she needs to change her diet to tackle blood sugars level from rising.

However, TTM or stages of change, which was developed by Prochaska and Diclemente in 1980  is the most applicable theory in promoting healthy behaviour on weight management as it comprises of six stages which are precontemplation, contemplation, preparation, action, maintenance and relapse (RCN, 2016 : Prochaska and Diclemente , 1984).  Research by Jalilian et al (2019) found that 48.1 of the patients were on the pre-contemplation stage. This means the patients have lack of knowledge regarding how weight loss have a benefit in controlling blood glucose, hence educational awareness can be the primary prevention. In addition, astudy by Holmen et al (2016) identified half of the patient on pre-action for physical change and 79% for dietary change. The barriers were cultural and lack of proper spaces for exercising. Fiona was on the maintenance stage of change  because she  was maintaining her blood glucose levels very well  but, she is now not coping maybe because there is no one to motivate her and hence the symptoms of depression. She is now on relapse stage which is the stage when a person has gone back into old or unhealthier lifestyle  and the best plan for the nurse is to begin the process again. In supporting Fiona to begin the process again the nurse has to make sure Fiona gets the information clearly and ask for her opinions as well.

If Fiona controls her blood glucose, the chances of developing further diseases and complications like renal failure and damaged eyes will be prevented and even the chances of  lower amputation  due to damaged nerves resulting in no sensation and foot ulcers will be reduced (NICE,2015). Fiona has symptoms of depression maybe because of loneliness since she lost her husband and does not have family near her. She is in a phase of grieving her husband and responding to the  loss of herhusband (Hamilton (2016). Fiona was more attached to her husband and seems he was the only family member she could rely on and losing him is painful and it is more challenging to accept as she cannot see the purpose of living.

The nurse can refer Fiona to the psychologist for counselling, support and also involve her family which means the nurse has to contact her son who is in Australia for support. According to (Schrempt, et al 2019) the link between loneliness and isolation contributes to depression, additionally Diabetes UK  states that people with T2D are prone to depression and anxiety because managing diabetes regularly can be  stressful. Roy and Lloyd, (2012) states that there is a link between T2D and depression. This is a challenge for Fiona and she needs someone to motivate and remind her to attend the appointments.

Person-centred approach with the help of interprofessional team  is needed to help Fiona to overcome these conditions. Person-centred evolving a plan with a person who is prepared to take action and eager to change. Fiona should give consent before any treatment or procedure (NHS, 2019). General Practitioner (G.P) and nurses are the first professions to see a patient.  Nurses play a vital role  and  responsibility when looking after patients with diabetes and prescribing medication (RCN, 2019).  Additionally, Matzious et al (2014) emphasised that one profession cannot treat a patient on their own nonetheless needs interprofessional to work together with and have a better care of the patient.

Community diabetes nurse’s role is helping Fiona to monitor blood sugars, help her to have a better understanding of the risk factors of not controlling blood sugars and any referrals needed.  A referral to the dietitian is essential to advise Fiona on the  healthy food choices  for a healthier balanced diet. Taplin, Anderson and Meller, (2018)  stated that patients seen by dietitian can manage to control their blood sugar well and they are taught about reducing carbohydrates in their meals.

This is upon the individual to make their own decision and the nurse should accept the individual’s decision in accordance to NMC (2015) code of conduct which states that nurses have to respect individual’s right for decision making to refuse or accept treatment. As Fiona has mental capacity the nurse must respect the decisions she makes however, if it was determined that she lacks capacity an assessment will be carried out under Mental Capacity Act, (2005) in order to treat Fiona in her best interest.

Reflecting on the above I have learnt that type two diabetes is an ongoing condition which needs commitment of self-management. Further I know the prevalence of diabetes globally and internationally and it is the main cause of premature death. To prevent it  there are social behavioural theories which can be introduced to the patient. In future I will consider all these when I qualify to support patients with type two diabetes.

In conclusion type two diabetes can lead to other risk factors such as amputation and kidney failure, and is the most cause of death in the United Kingdom. There are several health promotion campaigns for awareness and prevention  of T2D which patient should be engaged. Despite all the health intervention the numbers of people with diabetes are growing.  Health services can have impact on patients access to health like long waiting lists and hospital budget. Employment, low income and education hinders the patients access to health. It is important to include the patient in decision making of their health and respect their opinion.

REFERENCES

• Arafat, Y., et al (2016) ‘Diabetes UK defends its type two diabetes awareness campaign’, Royal Pharmaceutical Health Service Research, 7(3), pp. 149-156
• Dalstra J. et al. (2012).’Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries’. International Journal of Epidemiology, 34 (3), pp316–326; doi:10.1093/ije/dyh386
• Dezetter, A. et al. (2015) ‘Reasons and determinants for perceiving unmet needs for mental health in primary care in Quebec’, The Canadian Journal of Psychiatry, 60, pp. 284-293. https://doi.org/10.1177/070674371506000607
• Diabetes UK, (n.d), Depression and Diabetes. Available at: https://www.diabetes.org.uk/guide-to-diabetes/emotions/depression [Accessed 11 August 2019]
• Ford, J.A., et al (2016) ‘Access to primary care for socioeconomically disadvantaged older people in rural areas: a realist review’, BMJ Open 6(5) pp. 1-14  doi: 10.1136/bjmopen-2015-010652
• GOV. UK, (2019) Personal Independence Payment. Available at: https://www.gov.uk/pip [Accessed 12 September 2019]
• Hamilton, J.(2016). ‘Understanding grief and bereavement’ . British Journal of General Practice, 66(651) pp523.
• Holmen,H. et al. (2016) ‘Stages of Change for physical activity and dietary habits in persons with type two diabetes included in a mobile health intervention’, BMJ Open Diabetes Res Care 4(1)
• Jalilian, H. et al. (2019) ‘Readiness for weight change and its association with diet knowledge and skills, diet decision making and diet and exercise barriers in patients with type 2 diabetes’, Diabetes & Metabolic Syndrome: Clinical Research & Reviews. doi: 10.1016/j.dsx.2019.07.052.
• Khunti, K., et al (2012) ‘Effectiveness of a diabetes education and self-management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care’, BMJ.
• Ley, S. et al (2014) ‘Prevention and management of type 2 diabetes and nutritional strategies’. Physician and nursing perceptions concerning interprofessional communication and collaboration’. 383(9933)
• Luton Public Health Intelligence Team(2016) Diabetes Health Needs Assessment  Luton Borough Council. Available at: https://www.luton.gov.uk/Community_and_living/Lists/LutonDocuments/PDF/JSNA/Diabetes%20Needs%20Assessment%202016.pdf [Accessed 12 September 2019]
• Marmot, M. (2010) Fair Society, Healthy Lives: The Marmot Review. Available at: http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf [Accessed 1 August 2019]
• Maskell, K., McDonald, P. & Paudyal, P. (2018) ‘The usefulness of health education materials in GP waiting rooms: a cross-sectional study’, The British Journal of General Practice: The Journal of the Royal College of General Practitioners, 68(1), pp. 343.
• Matziou, V., et al (2014) ‘Physician and nursing perceptions concerning interprofessional communication and collaboration’, J Interprof. Care, 28(6), pp. 526-533, http://dx.doi.org/10.3109/13561820.2014.934338
• Mental Capacity Act, (2005) The code of Practice. Available at: http://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpga_20050009_en.pdf [Accessed 10 August 2019]
• Mocan, A.S. et al. (2016) ‘Depression in Romanian patients with type 2 diabetes: prevalence and risk factors’, Clujul Med, 89, pp. 371-377.
• Mohamed, S.F. et al. (2018) ‘Prevalence and factors associated with pre-diabetes and diabetes mellitus in Kenya: results from a national survey’, BMC Public Health, 18(3): 1215. https://doi.org/10.1186/s12889-018-6053-x.
• National Health Service, (2017a) Health problems: Type two diabetes. Available at: https://www.nhs.uk/conditions/type-2-diabetes/health-problems/ [Accessed 30 July 2019]
• National Health Service, (2017b) What is type two diabetes. Available at: https://www.nhs.uk/conditions/type-2-diabetes/ [Accessed 30 July 2019]
• National Health Services  (2019) Consent for treatment. Available at: https://www.nhs.uk/conditions/consent-to-treatment/ [Accessed 17 August 2019]
• National Institute for Health and Care Excellence, (2016) Quality statement: Structured education programmes for adults with type two diabetes. Available at: https://www.nice.org.uk/guidance/qs6/chapter/Quality-statement-2-Structured-education-programmes-for-adults-with-type-2-diabetes [Accessed 1 August 2019]
• Nice . (2015). Diabetic foot problems: prevention and management. Available at: https://www.nice.org.uk/guidance/ng19
• Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
• Nursing and Midwifery Council, (2018) The Code, Professional Standards of Practice and behaviour for Nurses, Midwifery and Nursing Associates. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf [Accessed 25 July 2019]
• Petrak, F. et al. (2015) ‘Depression and diabetes: treatment and healthcare delivery’, Lancet Diabetes Endocrinol, 3, pp. 472-485.
• Prochoska, J. O. and DiClemente, C. C. (1984) The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood IL., Dow Jones Irwin.
• Public Health England (2016) Strategic plan for the next four years: better outcomes by 2020. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/516985/PHE_Strategic_plan_2016.pdf [Accessed 1 August 2019]
• Public Health England (2018)  Wider Determinants of Health. Available at: https://www.gov.uk/government/publications/health-profile-for-england-2018/chapter-6-wider-determinants-of-health [Accessed 31 July 2019]
• Public Health England (2018) Health matters: Preventing Type 2 Diabetes. Available at: https://www.gov.uk/government/publications/health-matters-preventing-type-2-diabetes/health-matters-preventing-type-2-diabetes [Accessed 18 July 2019]
• Public Health England, (2017) Competencies for staff undertaking administrative roles within the NHS diabetic eye screening programme. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/774676/Diabetic_eye_screening_aministrative_staff_competencies.pdf [Accessed 17 August]
• Rosenstock, I., Stretcher, V. and Becker, M. (1988)  Social Learning Theory and the Health Belief Model, United States, North America: Sage Publications.
• Ross, J. et al. (2018) ‘Developing an implementation strategy for a digital health intervention: an example in routine healthcare’, BMC Health Services Research, (1), pp. 1-13 doi: 10.1186/s12913-018-3615-7.
• Roy, T. and Lloyd, C.E. (2012) ‘Epidemiology of depression and diabetes: A systematic review’, Journal of Affective Disorders, 142, Suppl. S8- S21.
• Royal College of Nursing, (2016) Stages of change. Available at: https://rcni.com/hosted-content/rcn/first-steps/stages-of-change-model [Accessed 15 August 2019]
• Royal College of Nursing, (2019) Education, prevention and the role of a nursing team. Available at: https://www.rcn.org.uk/clinical-topics/diabetes/education-prevention-and-the-role-of-the-nurse [Accessed 2 August 2019]
• Schrempt,S., et al.(2019) ‘Associations between social isolation, loniliness, and objective physical activity in older men and women’, BMC Public.19(74), pp.1-10
• Sundmacher, L., Scheller-Kreisen, D. and Busse, R. (2011) ‘The wider determinants of inequality in health: decomposition analysis’, International Journal for equity in health. 10(30), pp. 1-13
• Sung, K. C., et al. (2012) ‘Combined influence of insulin resistance, overweight or obesity, and fatty liver as risk factors for type two diabetes’, Diabetes Care,35, pp. 717-722
• Taplin J., Anderson M. and Mellor P., (2018) Diabetes Type 2 Available at: https://www.bda.uk.com/foodfacts/diabetes_type_2
• The King’s Fund (2010) Managing people with long term conditions. Available at: https://www.kingsfund.org.uk/sites/default/files/field/field_document/managing-people-long-term-conditions-gp-inquiry-research-paper-mar11.pdf [Accessed: 5 August 2019]
• The Kings Fund, (2019) The broader determinants of health: Future trends (picture for Dahlgren and Whitehead) Available at: https://www.kingsfund.org.uk/projects/time-think-differently/trends-broader-determinants-health [Accessed 10 August 2019]
• Torjesen, I. (2016) NHS England rolls out world’s first national diabetes prevention programme. BMJ, p. i1669.
• World Health Organisation. (2014). The Ottawa Charter for Health Promotion. Available at: https://www.who.int/healthpromotion/conferences/previous/ottawa/en/ [Accessed 31 August 2019]
• World Health Organization, (2018) Diabetes key fact Available at: https://www.who.int/news-room/fact-sheets/detail/diabetes [Accessed 31 July 2019]
• World Health Organization, (2019) Social determinants of health. Available at: https://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/ [Accessed 11 August 2019]
• Yin, J. (2016) ‘Gender, diabetes education, and psychosocial factors are associated with persistent poor glycaemic control in patients with type 2 diabetes in the Joint Asia Diabetes Evaluation (JADE) program’, Journal of Diabetes, 8, pp.109–119, doi:10.1111/1753-0407.12262