The Human Side of Healthcare: Exploring Psychosocial Factors in Diabetes Management

Introduction

Mr X is a 48-year-old widower from the minority Black community who is a type II insulin-dependent diabetic patient. He had been admitted to the medical ward due to unstable blood glucose levels as a result of his non-compliant with his medications and diet. He has daily visits from the district nurse to check and re-dress his leg ulcers and to monitor his blood glucose levels but has not complied with his medications and hence his condition was deteriorating. As a nurse practitioner, I suspected that Mr X’s non-compliance could be as a result of various psychosocial factors that might of interest for me to discover. Therefore, the purpose of this assignment is to look at psychosocial factors which have influenced Mr X’s perception and behavior towards his health and illness. The focus will be on why Mr. X is reluctant to change his ways and improve his health and diabetes. This essay will take the form of a personal reflection, whereby I use the DIEP strategy to illustrate my reflections. In doing so, I will objectively describe what I learned from Mr X, interpret and evaluate the situation, and plan on how it will improve my approach to similar patients.

I realized that Mr X’s non-adherence to type 2 diabetes (T2D) medications was partly contributed by the fact that he was from the black community from a lower socio-economic background. This insight is connected to the evidence-based conclusion made by Karter et al (2000) that individuals from lower SES background, those from ethnic minority communities and those with communication difficulties are more likely to have poor medication adherence. Similar results were found by Trinacty et al (2009) whose study concluded that whereas T2D patients from minority ethnic groups (especially black adults) are just as likely to adhere to their medication prescription as their white counterparts, they are almost twice more likely to discontinue their medication 10-years. Thus, I have realized that Mr X’s non-adherence to medication might have been as a result of an overlap between his minority ethnic status and his low SES background.

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Secondly, cultural norms and beliefs may have also played a significant role in Mr X’s non-adherence behavior. I suspect that Mr X’s cultural beliefs and orientation might have triggered worry on him about the medication side effect, thus affecting his perception of medication dependency. My speculation on this might have been true, especially considering previous research that has had similar results. For instance, studies by Lynch et al (2012) found that low-income blacks with T2D are more likely to doubt the necessity of medication and thus may take lesser drugs than subscribed, to avoid the perceived side effects.

Nonetheless, I also suspect that the non-adherence to medication displayed by Mr X might have been as a result of the cultural difference between him and his hospital carers. My assumptions are based on the evidence by Weller et al (2012) revealing that patients tend to endorse explanatory diabetes treatment models that differ from those endorsed by their physicians’ approach to care especially when they are from a different socio-cultural background. Therefore, Mr X’s non-adherence might have been caused by the fact that he had a different socio-cultural background from that of his carers who were predominantly whites.

Inadequate knowledge

Successful adherence to diabetes medication and self-management requires adequate knowledge on the part of the patient and their families, including awareness on how diabetes affects the body, treatment objectives and how personal behavior affects glucose regulation in the body. Furthermore, according to Gottfredson & Deary (2004), a generally intelligent patient, regardless of their SES status, has better health outcomes through healthy behavior and disease self-management. However, if I use the social class as a measure of intelligence (Taylor et al, 2003), Mr X’s intelligence seemed to have been quite low to facilitate his effective medication adherence. While I find it difficult to separate intelligence from crudely measured indicators such as socioeconomic status, I find it admissible that one’s general ability to solve problems, learn and reason contributes to their medication adherence and self-management. A possible implication of this argument is that the lack of intelligence and knowledge could have contributed to Mr X’s non-adherence to medication.

A significant lesson I have learned from this experience is that programs for improving medication adherence, especially among minority ethnic communities must address the issue of patient literacy and knowledge because regardless of their SES as a mediating factor to non-adherence, improved knowledge on diabetes can improve medication adherence.

To this end, I take note of the fact that health literacy is an important element of medication adherence, and that the better the patients’ ability to read, write, communicate and make decisions about their health, the more likely they are likely to adhere to diabetes medication. Thus, as a nurse practitioner, my job is to enlighten the patient as much as possible on their health status to improve the adherence to medication and ultimately improvement of quality of life.

Emotional Distress

One thing I realized with Mr X was his emotionally distressed state following the recent death of his wife. Each time I interacted with him, he displayed depressive symptoms, some of which I could link to his non-adherence to medication. For instance, he had a generally hopeless outlook and I could tell he had a feeling of helplessness towards life, revealed by specific words that he keeps pronouncing such as ‘what’s the point.’ A possible implication of this realization is that Mr X could have had a negative attitude towards medication and developed a behavior of non-adherence. This insight is connected with the findings of Gonzlez et al (2008), which link depression to medication non-adherence and poor self-management. In their attempt to link depressive symptoms to medication non-adherence and poor self-management, Gonzales et al (2008) observed that whereas the association may not be as a result of comorbid psychopathology, emotional distress which seems to correlate with depressive symptoms tend to mediate this relationship.

A Similar finding was made by Fisher et al (2014), who concluded that the burden of living with diabetes causes distress that seems to be associated with poor self-management; even though the researchers found that diabetes-related depression has a closer relationship with glycemic control than depression. These pieces of evidence are also confirmed by the findings of Nicolucci et al (2010) that emotional distress is one of the most significant negative effects of diabetes after poor physical health. Therefore, I speculate that Mr X’s non-adherence to T2D medication could have been as a result of emotional distress associate with the burden of living with diabetes. This implies that strategies for addressing Mr X’s non-adherence must address his emotional distress issues.

This realization may have important relevance for a variety of reasons. For instance, Mr X might have been under emotional distress, especially based on the findings by Naranjo et al (2012) that diabetes patients from minority ethnic groups tend to have the worse diabetes treatment outcomes, report lower quality of life and have more emotional distress than their white counterparts.

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In conclusion, my personal reflection on Mr. X’s non-adherence to diabetes medication reveals that he must have been experiencing various psychosocial factors that led to his non-adherence. First, I realised that he his cultural norms and beliefs as a black person might have influenced his opinion against medication and his ability to acquire knowledge about the importance of medication. Lastly, Mr X seemed to be emotionally distressed, and this developed a sense of hopelessness towards medication.

References

Fisher L, Mullan JT, Arean P, Glasgow RE, Hessler D, Masharani U. Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care. 2010;33(1):23–28.

Gonzalez JS, Schneider HE. Methodological issues in the assessment of diabetes treatment adherence. Current Diabetes Reports. 2011;11(6):472–479.

Gottfredson LS, Deary IJ. Intelligence Predicts Health and Longevity, but Why? Current Directions in Psychological Science. 2004;13(1):1–4.

Karter AJ, Ferrara A, Darbinian JA, Ackerson LM, Selby JV. Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes. Diabetes Care. 2000;23(4):477–483.

Lynch EB, Fernandez A, Lighthouse N, Mendenhall E, Jacobs E. Concepts of diabetes self-management in Mexican American and African American low-income patients with diabetes. Health Education Research. 2012;27(5):814–824.

Nicolucci A, Burns KK, Holt RIG, Comaschi M, Hermanns N, Ishii H, Peyrot M. Diabetes attitudes, wishes and needs second study (DAWN2™): Cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabetic Medicine. 2013;30(7):767–777.

Naranjo D, Hessler DM, Deol R, Chesla CA. Health and psychosocial outcomes in US adult patients with diabetes from diverse ethnicities. Current Diabetes Reports. 2012;12(6):729.

Trinacty CM, Adams AS, Soumerai SB, Zhang F, Meigs JB, Piette JD, Ross-Degnan D. Racial differences in long-term adherence to oral antidiabetic drug therapy: A longitudinal cohort study. BMC Health Services Research. 2009;9(1):24.

Taylor MD, Frier BM, Gold AE, Deary IJ. Psychosocial factors and diabetes-related outcomes following diagnosis of type 1 diabetes in adults: The Edinburgh prospective diabetes study. Diabetic Medicine. 2003;20(2):135–146.

Weller SC, Baer RD, Garcia de Alba Garcia J, Salcedo Rocha AL. Explanatory models of diabetes in the US and Mexico: The patient–provider gap and cultural competence. Social Science & Medicine. 2012;75(6):1088–1096.


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