Essay: Critically discuss health education and challenges in managing Type 2 diabetes in a diverse community

Introduction
Diabetes is a lifelong illness that affects children, young people and adults of all ages impacting on all aspects of their life often with debilitating effects (DOH, 2001). This essay sets out to critically discuss health education and challenges in managing Type 2 diabetes in a diverse community, as one aspect of diabetes management that requires improvement in my practice area. The discussion will be through analysis of current evidence and policy contexts and will further explore how nursing intervention can successfully meet the needs of patients to address quality and evidence-based practice.
The rationale for choosing this area for discussion is the recognition of multiple comorbidities relating to diabetes observed in practice. The inner-borough, in which I practice, has high percentage of the population having poor health according to available statistics (towerhamlets.gov.uk, 2010). This costly for Trust and the NHS as a whole. I will relate practice to recognised competencies, integrated multidisciplinary pathways and local as well as national guidelines.
In line with the NMC (2015) code of conduct, confidentiality will be maintained.
Main Body
As a global health problem diabetes affects a projected 425 million people currently and an estimated 693 million by the year 2045 (International Diabetes Foundation, 2017). “Diabetes is among the top 10 causes of death globally” (IDF, 2017). The NHS already has a budget of £9.8million for treatment of diabetes and according to the Diabetes UK (2012) in 25 years to come the budget will drastically increase to 16.8 billion and the International Diabetes Foundation (2017) suggested that the money will be spent on diabetes complications. Figures released by Diabetes UK (2019) specify that the total number of people living with diabetes in the UK has now reached 4.7 million for the first time, and this consists of 3.8 million adults, who have been diagnosed (Diabetes UK, 2019). Diabetes UK (2010) research showed that in the UK, even though a projected 90% of individuals generally above the age of 40 years are identified to have Type 2 diabetes, there is an estimated 500,000 people who are still uninformed of having diabetes in the community.
According to Mary et al (2014) diabetes is a metabolic disorder in which the production of insulin is not enough to normalise blood glucose levels or where the insulin made is incapable to function efficiently. Jerreat (2004) states that the definition of diabetes refers to 2 classifications described as Type 1 which is Beta cell damage often prominent to total insulin absence and Type 2 occurring from insulin resistance with absolute insulin deficit to a predominately secretory defect with or without insulin resistance. Home (2014) defines it as when the pancreas can no longer make enough insulin.
There are other forms of diabetes such as gestational diabetes, maturity-onset diabetes of the young (MODY) and diabetes related to Cushing’s syndrome as a group of metabolic disorders (Barbot et el, 2018). Mary, et al (2014) mentioned that type 2 makes up 90% of all circumstances; this transpires when the body either seize to make insulin for its essentials or becomes resistance to the effect of insulin made. The illness is progressive and needs lifestyle monitoring (diet and exercise) at all times.
Age, obesity, hypertension, genetics, medication and gestational diabetes are risk factors related with the growth of type 2 diabetes. Research indicates that age links to the progression of type 2 diabetes as when people grow older they tend to adopt a more sedentary lifestyle which leads to weight gain. Darryl (2011) suggested that type 2 diabetes is recognised to progress at middle age, even though it is becoming more prevalent in children and young adults. Obesity and the length of it also predispose an individual to increased risk of having type 2 diabetes. Mary et, al. (2014) in their studies elaborated that obesity may stimulate fat cells to discharge pro-inflammatory chemicals. “These chemicals can make the body less sensitive to the insulin it creates by disrupting the purpose of insulin responsive cells and their capacity to respond to insulin” (Diabetes.co.uk, n.d.)
Dunning (2013) stated there is microvascular disease, macrovascular disease, and neuropathy which damages nerve. Kumar et al (2015) in studies suggested that vascular complications block the blood vessels and causes heart problems.
Census carried out in 2011 in my practice area showed that it has one of the most diverse populations in the country (towerhamlets.gov.uk, 2011). Basran (2015) supported this in her report that found London inner-boroughs to be among the most deprived across England. Mary et, al. (2014) in a study concluded that deprivation is diligently associated to the risk of obesity which relates to type 2 diabetes. On the nursing case-load which had 208 patients, 40% had Type 2 diabetes and district nursing team focuses on health education as a priority to minimise the risk of diabetes. A vital aspect of the clinical management of people with diabetes ever since the 1930s is stared to self-manage and educating individuals on diabetes. Donnell Etzwiler (1994) 40years ago, organised an outpatient education centre for the first time to deliver simple information on diabetes and self-care education to patients with diabetes. The constructed group set up by Etzwiler (1994) consisted of three health professionals, a dietitian, nurse and physician. The aim was to expand the ability to improve glycaemic control, give information, promote awareness about lifestyle changes and to develop skills to prevent and identify late complication of diabetes such as diabetes foot (Mishra et al., 2017). He further emphasised that, often majority of people with diabetic condition are diagnosed either when they become apparent with the medical symptoms or accidentally identified when the patient come for admission with different illness. When diagnosed with the condition the treatment and management of the illness becomes often costly.
The DOH (2001) national service framework for diabetes confirmed that type 2 diabetes is costly and people with diabetes incur direct cost, including costs associated with managing their diabetes. Chronic diabetes management can be managed by non-clinical interventions like nutritional modifications and physical activities (Gillett et al., 2012). Health education at this point plays a vital role in order to strengthen the non-clinical interventions. Tones et al (2013) defines health education as understanding the need to “change the ways and conditions of living to promote health” which forms an important part of health promotion. They further explained that as an individual’s genetic makeup cannot be changed, it is “possible to influence individual behaviour and lifestyle [which] has been the main goal of traditional health education”. Health education is linked with self-management and DOH (2009) states that self-care training is the route of educating individuals to take control of their condition, increase their quality of life and to avoid acute and chronic complications, while keeping cost acceptable. To attain effective care in diabetes, there is the need to establish individual education and cost effective community.
Challenges
Although the role of the community health service is to promote education through non-clinical interventions, Snow et al (2013) found that patients who graduated from “intensive education course such as DANFE emerged” with specific knowledge and understanding of their diabetes that exceeds community and hospitals healthcare professionals. This health education posed an obstacle when healthcare professionals were not comfortable with patients’ high level of expertise. The study found that “healthcare professionals cannot become experts in the detailed management of every complex condition” (Snow et al., 2013). Doctors and nurses’ attitude to self-management can act as a hindrance and this need to be addressed. Maybin et al (2016) emphasised that good care from district nurses is encouraging self-management and involving patients’ in the decisions about their care.
District nurses play a vital role within the multidisciplinary team often acting as change agents to promote self-care management in diabetes care. Research conducted by Olry de Labry Lima et al (2017) on glycated haemoglobin concluded that HbA1c levels improved following “intervention implemented in a primary care setting to improve diabetes self-management in patients with low educational levels”. This is important because the Department for Children, Schools and Family (2009), now known as the Department for Education pointed out that “deprivation has a negative impact on educational attainment” which has short and long term consequences, one being it direct effects on health. My practice area has been recognised as being the 10th most deprived area in England (towerhamlets.gov.uk, 2015). So, adopting Olry de Labry Lima et al (2017)’s research in my practice area and ensuring district nurses as well as all in the community promote adequate self-management by working with patients ensuring education is “simple, face to face, and individually delivered”.
A part of the district nursing team’s role is to promote diabetic education and self-management by addressing the needs of the diabetic patients through daily visits. There are challenges faced by the community health professional. Shrivastava et al (2013) mentioned in their studies that addressing the continuous needs and demands of people with chronic conditions like diabetes has been one of the major challenges for health care professionals today. A part of the district nursing team care to the diabetic patient is daily blood glucose monitoring and advice given based on the needs. This is important as it rules out health needs and prevents difficulties. Research has conveyed that strict metabolic control can interrupt or avoid the development of complications related with diabetes (Shrivastava et al., 2013). Therefore, it is essential for health care providers to adhere to regular follow up of diabetic patients, as it helps in preventing any long-term complications (UKPDS 1998a). In my practice area staff shortages, has posed a challenged, and visits from regular follow-up can be delayed due to increasing workloads. This tends to affect the accuracy of blood glucose levels as patient would have eaten before the nurse arrives. Titrations of medication become affected due to the inaccurate readings which can lead to unsafe treatment. Staff shortage has a significant effect on diabetes management as mentioned by Merrifield (2016); that patients’ safety will be compromised without immediate action to secure the shortage of nurses. The majority of the patients in this diverse community with poor glycaemic control has been highlighted to be the middle aged from 50years and under. The district nursing team faces a huge challenge in managing the blood glucose levels as visits are often missed and patients manage their own blood glucose and is not accurate. An audit carried out in a diverse London PCT by Mold et, al (2008) indicated that people aged 50years or under presented with large proportion of poor glycaemic control and this group of patients had less frequent contact with community health professionals.
As part of managing diabetes, the district nursing team educate patients on their condition through empowering. Empowering patients according to Tol et al (2015) helps patients to discover and develop the inherent capacity to be responsible for their condition. They added that the purpose of patient education within the empowering philosophy is to help patients make decision about their goals, values and motivation. District nurses in providing interactive teaching to patients face challenges. Diverse community like the inner-London borough has language barrier to be one of the challenges. Communication is a vital tool between patients and health professionals and Lussier and Richard (2005) emphasised that poor communication also poses risks to health care providers, increasing likelihood of malpractice claims and complaints. Language barrier is a form of communication that affect patients’ safety; it demonstrates health literacy which hinders care provided. This issue can delay treatment and more interventions are sometimes needed. District nurses in dealing with this challenge use various communication skills to commune with patients and family such as taking time to speak, paying attention to body language, using non-verbal skills and an interpreter that is health professional or a trusted translator. Freeman and Hughes (2010) suggested that eliminating of language barriers would not only create way to safe and effective care as mentioned, but it would also help to steer clear of any liability risk (Quan and Lynch, 2010).
Cultural awareness is the primary step towards providing delicate and competent diabetes education. To deliver diabetes education, district nurses need cultural competence which is defined as the knowledge and skill to work with an ethnically diverse population irrespective of language, customs, beliefs, values, communications and actions of people according to race and ethnicity (American Association of Diabetes Education, 2011). District nurses need to be mindful of the cultural traditions and customs among all cultural and ethnic groups and to recognize socio-economic challenges that may exist. They further explained that culture and traditions is a cluster of learned behaviours, customs, preferences, beliefs, and ways of knowing. When diabetes education is delivered using culturally appropriate methods in diverse population by nurses it can improve patients’ health behaviour, knowledge, health status and self-efficacy. Akiyode (2015) emphasised that understanding the “motivational stimuli of people from diverse backgrounds will enable diabetes educators to develop effective programs, teaching strategies and individualised care plans to mitigate the impact of diabetes”. District nurses in facing this challenge overcome the barrier by interacting with patients using effective communication. The American Association of Diabetes Education (2011) stated that “when teaching patients with low literacy and limited English proficiency, educational materials should be tailored according with illustrated graphics, along with the use of teach-back methods to confirm patient understanding.” District nurses in delivering care to this diverse community, use trained integrated professional interpreters and also communicate cross-culturally by using verbal and non-verbal communication style. Choudhury et al (2016) mentioned that “culture may not only affect willingness to participate in prevention, but may also obscure the understanding of diabetes”.
Health beliefs in a diverse community is another challenge faced by district nurses. Harrison (2014) mentioned that healthcare professionals working with diverse groups with diabetes require an understanding of the various health beliefs and attitudes in order to adapt educational and consultation process. While there are many factors at play when it comes to a patient’s understanding of diabetes, cultural beliefs including religion play an essential role (Cha et al., 2012). For example, “balancing yin and yang are important to maintaining health in Asian cultures. Yin-medications and foods are key factors in re-establishing the imbalance created by diabetes, a yang disease”. Rebolledo and Arellano (2016) found that Hispanics considers the application of insulin to be a failure of the individual to manage his or her diabetes. Meetoo and Meetoo (2005) also found that “64% of Asian people supplemented their conventional treatment with food types that were perceived by them to be an effective hypoglycaemic agent, example grapefruit and okra” (Harrison, 2014). Culturally important and religious events, such as Ramadan place a social duty and dietary compliance on individuals, even those with diabetes to manage (Harrison, 2014). Dietary education becomes challenging and requires the nurse to be fully aware of the individual beliefs and the dietary advice given. Healthcare professionals, particularly nurses in the community are required to understand cultural and religious nuances that affect diabetes patients and acquire the skill to be able to educate with this understanding in place. District nurses in promoting health education liaise with other members of the multidisciplinary team to provide effective education. The National Diabetes Education Program (2014) pointed out that a team approach to diabetes care can effectively help people cope with the vast array of complications that can arise from diabetes. District nurses conduct joint visit with dieticians to promote education on healthy eating. Mary et al (2014) mentioned that there is a close association between obesity and type 2 diabetes and it has always been a major factor in the development of type 2 diabetes. There has been debates about using conventional methods of identifying obesity in diverse groups as different ethnic groups are associated with a range of different body shapes and different physiological response to fat storage (Gatineau and Mathrani 2011). District nurses being aware of the various health beliefs work alongside with the patient and referring them to activity groups and GP’s for further interventions.
DESMOND is education set up for people with diabetes old and newly diagnosed. Diabetes UK (2015) emphasised that it is a combined group act to develop prospects for education in order to assist individuals who has diabetes as well as the health care providers. Nice (2011) in their quality statement mentioned that adult with type 2 diabetes have their knowledge and skills improved through this organised education programmes. The programme helps to motivate individuals to take absolute control of their diabetes and self-manage it effectively. X-PERT course for diabetes is one of the education programmes that are group-based and improves glycaemic control, resulting in fewer complications and improved quality of life (Diabetes UK 2015). Patient in the inner-borough as part of their health education gets referred to these self-management programmes to enhance their knowledge in managing their condition. Health care professionals are in exceptional position to implement change to diabetic patients through cost-effective measures. Diabetes, UK clarified that cost correspondent to diabetes in health care system has significantly risen due to prolonged diabetes complications and management. District nurses through their health education and regular monitoring minimise the cost involved in diabetic treatment, by reducing diabetes complication which is very costly. This is supported by The Kings’ Fund (2013) that highlighted the need for diabetes management in order to prevent complications. It was stated that diabetic complications cost the NHS an extortionate amount due to prolonged stay in hospital.
Conclusion
This essay has critically explored health education as well as the key challenges in managing Type 2 diabetes within a diverse community.
It is clear that many of the challenges to promoting health education of Type 2 diabetes within a diverse community comes from the lack of understanding of the community. A full understanding of the diversity, cultural norms, religious background and educational level of my practice area will aid nurses to best address health education in the community. This essay highlighted the importance of being informed on the cultural and religious nuances that may act as a hindrance to the self-management of type 2 diabetes.
Community nurses working with diabetes patients and involving them in their care plan is a vital tool in health education and self-management. It helps to keep the patients informed as a crucial aspect of working with diabetes patients is presenting information in a manner that is understandable to them. This also addresses one the mentioned challenges; patients with low educational levels not being equipped to self-manage. Empowerment and involving patients in their care plan enables them to take control of their diabetes. However, involving the patients in the decision-making of their care also helps patient/health professional relationship. Power dynamic can be a barrier especially when patients become experts in their own self-care; the collaborative work will allow both the patients to feel in control and the nurses in the community to promote health education effectively.
One of the major challenges facing community nurses today and in practice area is staff shortage. The workload is increasing and the staff to cover the work is decreasing. This has place a high importance on health education in the self-management of type 2 diabetes; as analysed in the essay patients managing their own diabetes will alleviate some of the pressure on nurses. Daily homes visit will not be necessary if patients are able and trusted to self-care. This will free up workload and allow nurses to focus on more complex cases. Furthermore, the NHS management of diabetes is costly and will continue to grow if self-management is not actively promoted (Diabetes UK, 2012).
It is evident that district nurses as health professionals, needs to understand the theories underlying patients’ health education and the communication skills required to promote self-care and health education. District nurses’ inputs and education helps to reduce diabetes complications and improves quality of life.