University of Cincinnati Main Campus Rosenstock Health Belief Model Response

Review another student’s posting and provide a response that reflects critical thinking.

Provide a primary scholarly reference to support your response.

1. You are essentially providing a comparison of the usefulness of the theory you selected to the one that another student in your group used.

Correct APA 7th edition listing for your reference.

The student I need to respond to is below:

1. I selected the theory of chronic sorrow for this particular case study. I selected this theory for Mr. Smith’s situation since he recently had lost his wife and also had been diagnosed with type 2 diabetes 3 years ago. These are major stressors and he is experiencing sadness and sorrow in his life. The major concepts of this theory include: chronic sorrow, disparity, loss, antecedents, and internal and external management methods. The middle range theory was developed to help analyze responses of people who have experienced a chronic illness, loss of someone close to them, and caregiving responsibilities (Buckley & Stricklin, 2016). Nurses work with many patients experiencing chronic sorrow for a variety of reasons and they need to be aware that there are many triggers that can cause a resurface of this sorrow (Burke, Eakes & Hainsworth, 1998). In Mr. Smith’s case, he could have been experiencing chronic sorrow when he was diagnosed with diabetes and had trouble managing his diagnosis. When his wife died, this trigger could have caused him to struggle even more with caring for himself and his diabetes.
2. I chose this middle range theory because the scope is useful for analyzing individual responses to loss and major changes in one’s life. The article I chose deals with patients experiencing chronic sorrow, like Mr. Smith, who also have a chronic disease.

The purpose of the article I selected is to describe the ways which patients with Multiple Sclerosis deal with chronic sorrow. MS is a chronic disease that can progress to severe disability, which is similar to the possible manifestations of type two diabetes. Patients with MS have described feelings of sorrow related to their losses in physical ability caused by the disease (Isaksson & Ahlstrom, 2008). Sadness and denial related to a chronic diagnosis can lead patients to ineffective management of their disease, much like Mr. Smith in this case study. Mr. Smith not only is dealing with his diagnosis of type two diabetes, but also the recent loss of his wife. Chronic sorrow is a normal and ongoing disparity due to loss .The theory provides a framework to help guide patients experiencing chronic sorrow ( (Burke, Eakes & Hainsworth, 1998). 

Since Mr. Smith is not attending his appointments or checking his blood glucose levels, home health care visits may be helpful for him. He is experiencing extreme sadness and chronic sorrow after the loss of his wife and is not caring for his diabetes. Interventions such as home health care visits that include blood glucose checks, meal planning, and diabetes education can help Mr. Smith get his diabetes more under control. It is a possibility that Mr. Smith is not attending his visits because he is depressed and is unable to leave his home due to his overwhelming sadness from the loss of his wife. Another intervention could be to initiate counseling with Mr. Smith via telehealth so he can participate from the comfort of his own home. Counseling will help him find a coping plan to deal with his recent loss of his wife. We will could measure the outcomes of the interventions by comparing A1C levels from the beginning of the interventions and 6 months after. We can also measure the interventions by have Mr. Smith take a survey about his sorrow and sadness before initiations of counseling and 6 months after and comparing the scores.

• A strength that the theory of chronic sorrow possesses is it provides a better understanding of the sadness that patients may experience when faced with a loss or chronic diagnosis. This understanding leads to nurses providing interventions to help these patients overcome their sorrow and care for themselves better. A limitation to this theory is that people all handle stress and grief differently and chronic sorrow is very individualized. There is not only one way that nurses can help those suffering from chronic sorrow.

I learned quite a few things during this assignment about research and applying it to nursing practice. There are many nursing and borrowed theories that can be applied to situations such as Mr. Smith’s case. It is important to make sure the articles I use are from a reliable source and pertain to the topic at hand. 

• PICOT: For patients diagnosed with type two diabetes who are experiencing chronic sorrow, does counseling along with home health care visits help decrease their A1C within 6 months?

References

• Buckley, C. J., & Stricklin, S. M. (2016). when sorrow never stops. Journal of Christian Nursing, 33(1), 22–29. https://doi.org/10.1097/cnj.0000000000000231

Eakes, G. G., Burke, M. L., & Hainsworth, M. A. (1998). middle-range theory of chronic sorrow. Image: the Journal of Nursing Scholarship, 30(2), 179–184.

• Isaksson, A., &Ahlstrom, G. (2008). managing chronic sorrow: experiences of patient with multiple sclerosis. Journal of neuroscience nursing, 40(3), 180-192.

This is my original post 

• Rosenstock’s Health Belief Model was developed to conceptualize the factors that affect a person’s health-related behaviors (Rosenstock et al., 1988, p. 177). The key concepts that play a role in these behaviors are: perceived susceptibility, perceived seriousness, perceived benefit, barriers to action, cues to action, and self-efficacy (Rosenstock, 1974a). These individual beliefs are modified by demographic factors such as age, race, sex, socioeconomic status, and education level (Rosenstock, 1974b, p. 355). For example, when compared to other races, Caucasian clients are more likely to accept their health condition and to utilize care services (Rosenstock, 1974b, p. 355) If a client does not believe that they are likely to be affected by a disease or that they will have consequences from such disease, then they are suffering from a lack of perceived susceptibility and seriousness, respectively (Rosenstock, 1974a, p. 330). After disease acceptance, a patient might not believe that there is an effective way to manage the condition that will improve their quality of life, and this lack of perceived benefit stifles motivation to make meaningful change (Rosenstock, 1974a, p. 331). Barriers to action is the concept with the most complex set of contributing factors, which can include financial, personal, socioeconomic aspects, and fear of painful interventions (Rosenstock et al., 1988, p. 179). Before a client will start down the path towards modifying their health behaviors, there needs to be a cue to action that triggers them. These cues can stem from internal sources such as pain, or they can come from external sources such as an interpersonal interaction or seeing a commercial (Rosenstock, 1974a, p. 332). The size of the trigger needed to potentiate change in an individual varies based on the magnitude of the barriers they face (Rosenstock, 1974a, p. 332). Lastly, self-efficacy is the newest component added to the Health Benefit Model due to the increase in management of chronic health conditions (Rosenstock et al., 1988, p. 175). When a client possesses the confidence to implement long term changes for their health, they are more likely to be successful in their attempts (Rosenstock et al., 1988, p. 175).

The Health Belief Model is applicable to Mr. Smith because he is experiencing a breakdown in several parts of the model, thus leading to his worsening diabetes. Since Mr. Smith is already diagnosed with diabetes, it is unlikely that he is facing a lack of perceived susceptibility. As evidenced by the lack of follow up, non-compliant at-home monitoring, not adhering to prescribed medications, and an unchanged lifestyle, Mr. Smith may not believe that diabetes can have serious sequelae, or he may not believe that there is any benefit to these modifications. During the past year Mr. Smith endured many emotional hardships such as the death of his wife and his only son moving away. There are signs of depression on assessment as it is noted that Mr. Smith is experiencing a loss of interest in life and the desire for social interaction. Mr. Smith lives alone, has little interpersonal connections, and as a retiree, he might be experiencing financial strain. These are large barriers that may prevent Mr. Smith from achieving optimal health behaviors. The wound on Mr. Smith’s foot is an excellent internal cue that may be a large enough trigger to overcome some his previous barriers. The last part of the Health Belief Model that Mr. Smith needs to overcome is self-efficacy.

• The Health Belief Model is a particularly powerful because it includes a “component of motivation and the perceptual world of the behaving individual” (Rosenstock, 1974a, p. 329). This model will guide the nurse practitioner in creating a stepwise plan of changing perceptions, overcoming barriers, and increasing self-confidence with the end goal of improving Mr. Smith’s diabetes and overall health.

Article Application: An article written by Mohammadi et al. (2018) evaluated the effectiveness of a type 2 diabetes education program based on the Health Belief Model. The control group received the standard of care, which only included diabetes diet education. The participants in the intervention group received a total of 8 sessions that covered diabetes complications, self-efficacy, diet, activity, medication adherence, and blood glucose monitoring at home. The participants hemoglobin A1c (HbA1c), fasting glucose, lipid profiles, and body composition measurements were taken at baseline, week 12, and week 36. All participants also completed a variety of diabetes knowledge questionnaires, quality of life surveys, and a health belief diabetes disease scale which measured the five constructs of the Health Belief Model (Mohammadi et al., 2018, p. 547). At the end of the study, results showed the intervention group had improved fasting glucose, HbA1c, total cholesterol, LDL, triglycerides, and BMI (Mohammadi et al., 2018, p. 549). Additionally, the intervention group showed increased knowledge, perceived susceptibility, severity, benefits, improved self-efficacy, and improved quality of life scores. The intervention group also had lower perceived barriers (Mohammadi et al., 2018, p. 551). This article explicitly supports using the Health Belief Model to develop an education program that results in improved biophysical and lifestyle measures in patients with type 2 diabetes. This study provides high quality level II evidence that could benefit the treatment plan of Mr. Smith.

• Assessment: 

Mr. Smith has already undergone a thorough physical assessment with lab values. Due to his presentation of depressive symptoms, Mr. Smith needs a PHQ-9 depression scale assessment. Based on the findings in the previously referenced study, it would be beneficial to administer a diabetes knowledge assessment, quality of life assessment, and survey of self-efficacy. Mr. Smith should be interviewed about his financial resources, access to transportation, and awareness of community resources. These pieces of information will assess Mr. Smith’s perceptions of diabetes and the barriers that he may be facing in managing his condition.

Interventions: 

For a positive depression screen, Mr. Smith can either be started on medication, referred to a counselor, or both. If he is experiencing any financial burdens that prevent him from making lifestyle modifications or filling prescriptions, Mr. Smith should be given a social work consult for better access to community resources. It is important to reduce the barriers in Mr. Smith’s life so that he can change his health behaviors.

The diabetes knowledge assessment would yield results that demonstrate Mr. Smith’s level of perceived severity and perceived benefits. The nurse practitioner would use this data to provide further education on the consequences that arise from uncontrolled diabetes, such as the foot wound that he presented with at the clinic. This information should be presented in multiple formats for optimal comprehension. The NP should verbally explain the information in the office, but Mr. Smith should also be given a pamphlet with simple language and pictures where possible.

Mr. Smith may have a low quality of life score due to a high level of social isolation, recent retiring from his career, and loss of loved ones. He would benefit from referral to a peer-led support group that is specific to individuals living with diabetes or widowers.

Lastly, he needs to be enrolled in a diabetes education program that includes a self-efficacy component. The program should include multiple sessions that are ideally in person, occur once a week, and require a small amount of homework such as completing at home glucose monitoring logs, a food journal, and an exercise journal. The in-person sessions should include education on how to monitor blood glucose, how to measure and administer insulin, and how to treat hypoglycemia. To assess comprehension and to improve retention, the participants should be asked to perform a return demonstration of the skills and teach back to the instructor. The sessions should cover lifestyle modifications that start with small changes to increase feelings of self-efficacy and motivation. For example, instead of asking clients to switch entirely to a low carb diet, they could recommend swapping regular pasta for whole grain pasta. These incremental and achievable steps will lead to long term, sustainable changes. After the in-person sessions end, the clients should receive follow-up phone calls at bi-weekly intervals to provide continued support and accountability.

The NP originally recommended a 6-month follow up, but Mr. Smith did not show to that appointment. Due to his worsening labs, foot wound, and reported non-compliance, he should follow up in 1-2 weeks for re-evaluation of the wound and blood pressure. After that, the follow-ups should be every 2-3 months for repeated labs to establish a trend and evaluate the current treatment plan. Since the treatment plan for Mr. Smith is extensive and covers many areas of his life, the NP should set a goal with him for the next visit to increase his confidence. For example, the goal may be to schedule a counseling appointment or enroll in the diabetes education course by his follow-up in 1-2 weeks.

Outcomes: 

Within 1-3 months, Mr. Smith should see signs of healing in his foot wound, stabilized blood pressures, and an improvement on the PHQ-9 depression scale. Mr. Smith should present with at home glucose monitoring logs that show decreasing fasting levels. During this time frame, he should have attended the diabetes education class and established emotional support with either a counselor or a peer support group.

At 3-6 months, Mr. Smith should see a reduction in HbA1c levels, continued lowering of fasting glucose, and a reduction of total cholesterol, LDL, and triglycerides. Mr. Smith should see an increase in HDL as well.

At 1 year, Mr. Smith would have a normal BMI, a HbA1c between 7-8%, a blood pressure lower than 140/90, a normal lipid panel, and no further diabetic sequelae. During this time, he should have attended most of his follow-up visits at the clinic.

At each of these intervals, Mr. Smith should be given the diabetes knowledge assessment, the self-efficacy survey, and the quality-of-life assessment. Ideally, his scores should be increasing to reflect that the interventions are working for Mr. Smith. Although the NP wants to improve Mr. Smith’s physical condition, it is equally important to assess his perceptions of the disease, how it affects his life, and his confidence in managing his health. This is congruent with the concepts of the Health Belief Model.

Strengths and Limitations:

The Health Belief Model was originally designed as a preventive healthcare model, but it has since been used in managing patients with chronic diseases (Rosenstock, 1974b, p. 354). As a non-nursing theory, there are limitations when applying it to nursing sciences since the concepts are not defined within the profession.

As a strength, this model encompasses the perceptions and behaviors of the individual instead of solely focusing on the physical result. This encourages the NP to provide whole person care and create change from within the client. Another strength is that the Health Belief Model is widely applicable to multiple diseases and patient demographics.

PICOT Question:

For patients with type 2 diabetes (P), does an education program based on the Health Belief Program (I), compared to the standard education (C) affect the hemoglobin A1c level (O) after 3 months (T)?

References:

Mohammadi, S., Karim, N. A., Talib, R. A., & Amani, R. (2018). The impact of self-efficacy education based on the health belief model in Iranian patients with type 2 diabetes: A randomised controlled intervention study. Asia Pacific Journal of Clinical Nutrition, 27(3), 546–555. https://doi.org/10.6133/apjcn.072017.07

Rosenstock, I. M. (1974a). Historical origins of the health belief model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

Rosenstock, I. M. (1974b). The health belief model and preventive health behavior. Health Education Monographs, 2(4), 354–386. https://doi.org/10.1177/109019817400200405

Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15(2), 175–183. https://doi.org/10.1177/109019818801500203