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Running head: HEALTH BEHAVIOR ANALYSIS 1

Health Behavior Analysis

Victoria M. Claeys

Bronson School of Nursing


HEALTH BEHAVIOR ANALYSIS 2

The presenting patient, A.L., is a 48 year old white male with type 2 diabetes. A.L. has a

history of being noncompliant with his medications, not attending follow-up appointments and

A1C re-checks, and regularly fails to refill prescriptions necessary to control his diabetes. When

A.L. first presented to DENSO Family Health Center, the NP, Bethany Hoffman, educated A.L.

on the importance of starting medications to control his blood sugar and became PCP. The NP

started A.L. on VICTOZA and GLUCOPHAGE in 2018 after diagnosing him and checking his

A1C, which in early 2018 was 5.7.

During the past two years A.L. has not been compliant with taking his medications and

has had an the following A1C results in the year 2019: A1C of 9.1 in April, an A1C of 12.4 in

August, an A1C of 12.9 in October. The NP and at the health center attempted to reach out to AL

many times over the course of the last two years to come to the health center for follow up

appointments, however AL was noncompliant. Due to his noncompliance, the patient developed

diabetic peripheral neuropathy, which the NP prescribed Gabapentin to treat. Noncompliance

also lead to dangerously high blood sugars which also necessitated higher and higher doses of

VICTOZA. During the infrequent visits that A.L. made to the health center the NP educated him

on the importance of controlling blood sugar by tracking sugar in foods and taking his

medications daily. She also stressed that it is not well for AL’s health to go weeks and months

without refilling and taking his medications, and that he is still able to receive refills without

coming to a follow-up appointment. While Bethany prefers to see her diabetic patients every

three months if their A1C is above 7, she also noticed his lack of following up, knows that he

believes that not coming in for follow-ups results in him not being able to get a refill. Because

AL has reached the highest dose of VICTOZA, Bethany will be adding another diabetic control
HEALTH BEHAVIOR ANALYSIS 3

medication to his regimen, and again stressing the importance of taking all of his medications

daily.

Analysis of the Behavior

After doing some research on both the Health Belief Model and the Health Promotion

Model, I decided that the Health Belief Model is the most appropriate model to use for this

patient. Research conducted by Revell, Alexander, Talley, Mobley in 2016 stated that all 46

Nurse Practitioners in the study agreed upon the efficacy of the Health Belief Model survey tool

in assessing patients with type II diabetes prior to implementing diabetes education. I also

believe that this model is appropriate for population focused health promotion considerations and

educational planning.
HEALTH BEHAVIOR ANALYSIS 4

THREAT (MOTIVATION)

Perceived susceptibility
*readiness for change*
 Many employees of DENSO who do
Demographic Variables not manage their weight and/or diet,
*Learner Characteristics* do not plan to quit smoking and do
 Low socioeconomic status, not monitor their blood sugars and
middle sugar intake, are not aware of/are
socioeconomic/working uneducated about the risks and
classes. causes of lung cancer, diabetes, Action/Behavior
 Male to female employee HTN, etc. This is an example of a
ratio of 6:1 ratio (DENSO, social dimension of adherence
2019)
 Average male age 43.7 years
and average female age: 34.9 Perceived Severity
years ((DENSO, 2019) *readiness for change*
 Most of the positions at  While many employees may not have
DENSO do not require any an appropriate perception of severity of
health issues such as smoking,
level of college degree, thus
uncontrolled HTN and diabetes, and
most of employees do not
obesity, the RN at DENSO FHC
have a higher education constantly provides education on the
((DENSO, 2019) severity of the health behaviors.
 Demographic variables such
as lack of higher education
and low socioeconomic status
represent one of the 5 Health
CuesMotivation
to Action
dimensions of adherence,
social/economic factors.
 An example of a patient
related dimension of RESPONSE
adherence is AL, who is EFFECTIVENESS
noncompliant due to personal Perceived Benefits
beliefs *Readiness for Change*
 widely known benefit of quitting
smoking is a dramatic amount of
Psychological Characteristics savings, many employees are aware
*Learner Characteristics*  for weight loss: feeling better, more
 More 3rd shift employees confidence
smoke than any other shift  health center offers a variety of
contests, promotions, and incentives
 Peer group pressure for
to enhance perceived benefits
those working 3rd shift trying
to quit smoking and/or lose
weight. This represents a
social dimension of
adherence Perceived Barriers
HEALTH BEHAVIOR ANALYSIS 5

One of the barriers to change that AL faces is working third shift. According the Sleep

Foundation, long term night shift work is associated change of metabolism and appetite, irregular

eating habits, and poor die all which increase the risk of metabolic problems (National Sleep

Foundation, 2020). Even when AL will be ready to improve his eating habits, track sugars and

begin taking his medications as prescribed, the schedule of his work is already a difficult barrier

for AL.

A motivator for AL would be a recent ER hospitalization which occurred on 02/10/2020.

The patient was confused, had severe abdominal pain, was nauseous and vomited numerous

times, and felt extremely fatigued with chest pains. He was rushed to the ER where lab tests

showed glucose in AL’s urine and a blood sugar level of 433. The experience was stressful and

very frightening for the patient, and he scheduled a follow up and requested to refill his

medications the next day. His follow up appointment was on February 12th, two days after the

incident. I believe that further education, when the patient makes it to the office visits, is crucial

for this patient. Possibly, had he known that an episode of diabetic ketoacidosis could be this

serious with such severe symptoms, he would be slightly more compliant with visits and

medications.

Intervention Effectiveness

Throughout the past two years the NP has had difficulty having adequate time with the

patient to provide education, try new interventions and see their effectiveness to be able to help

AL be successful in controlling his blood sugar. After his recent hospitalization and new fear, the

NP believes that she has a chance to attempt incorporating some more patient education and

requesting feedback from AL as to what he needs from her as his provider. She wants to see

where AL is with his readiness for change and if there are any new dimensions of adherence, she
HEALTH BEHAVIOR ANALYSIS 6

should be aware of, or was unaware of before. I brought up the use of Motivational Interviewing

while discussing AL’s chart and history with the NP and she was excited for the idea and

accepted it as a recommendation. Motivational interviewing works by allowing clients to work

through their issues and developing a plan which works for them. It is 'a person-centered, goal-

directive counselling method for resolving ambivalence and promoting positive change by

eliciting and strengthening the person's own motivation to change (Day, Gould, Hazelby, 2017).

Motivational interviewing is a great choice of a strategy for AL because of his past

noncompliance and difficulty managing his health and it will allow the NP to motivate AL from a

personalized approach. As nurse professionals we cannot always know and understand the reason

behind each patient’s unwillingness to change habits and follow medication regimens. However,

from a Motivational Interviewing mindset, unless a change is in the person's interest, it will not

happen. This may be contrary to currently accepted practice in district nursing, where the clinical

requirements of a district nurse's caseload may demand an emphasis on 'quick fixes' and

professionally led decision-making (Day, Gould, Hazelby, 2017).

An important point made by McCain, 2015, supporting MI is that there is a popularly

embraced belief that patient nonadherence is the result of knowledge deficits, which rationalizes

“patient education”. If this “deficit worldview” assumption were accurate, improving patients’

knowledge of their conditions and treatments should lead to improved adherence. Yet more than

100 published studies show no such association. While patient education is important and should

not be forgotten or missed, nurses and providers need to view patients as competent. From a

competence embraced belief, MI can be regarded as a technique for facilitating a patient’s

knowledge, beliefs, and capabilities in the direction of change (McCain, 2015). This research

supports my thoughts and recommendation for AL, that education is not enough and isn’t the
HEALTH BEHAVIOR ANALYSIS 7

most appropriate intervention for him, especially after many failed attempts at trying to change

AL’s behaviors in the past.

After many hours of reading peer reviewed articles, I have noticed that the US healthcare

system is becoming more aware of the widely accepted misconception that patients don’t follow

medication regimens and change their behaviors due to their lack of knowledge. Grant, 2016 also

noted this by stating that it is traditionally presumed that patients don't change because either

they don't know enough, or they don't care enough. For meaningful, long-term changes to occur,

we desperately need to focus on tailored self-management and overcoming the barriers to change

when it comes to issues such as eating habits, physical activity, medication use, insulin treatment,

substance misuse and psychological issues. Grant, 2016, praises and cites the textbook

Motivational Interviewing in Diabetes Care by Marc Steinberg William Miller, which provides

new approaches to problem solving that is designed to strengthen the patient’s own motivations

and commitment to change. Some HCPs may suggest that this form of persuasion is on the

spectrum of coercion, brainwashing or neuro-linguistic programming. However, the Grant argues

that this is not a way of tricking patients into doing what you want them to do, but rather a way

of harnessing people's natural motivations for health, change and positive behaviors (Grant,

2016).

I am motivated and thrilled do see the vast amount of research that has been done with

the use of MI to improve patient adherence. I was also pleasantly surprised at the amount of

research that has been conducted on using MI for diabetic patients of all demographics, teen

diabetic patients, African American patients, diabetic patients over the age of 65, and so on. I

firmly believe that research based motivational interviewing could be the turning point for AL’s

health and future.


HEALTH BEHAVIOR ANALYSIS 8

References

Day, P., Gould, J., & Hazelby, G. (2017). The use of motivational interviewing in community

nursing.  Journal of Community Nursing,  31(3), 59-60,62-63.

Global Social Report Data Compilation. (n.d.). Retrieved February 27, 2020, from

https://www.denso.com/global/en/csr/sociality-report/data/

Grant, P. (2016). Motivational interviewing in diabetes care. Clinical Medicine, 16(2), 205.

Retrieved from http://libproxy.library.wmich.edu/login?url=https://search-proquest-

com.libproxy.library.wmich.edu/docview/1780866390?accountid=15099

Living & Coping with Shift Work Disorder. (n.d.). Retrieved February 27, 2020, from

https://www.sleepfoundation.org/shift-work-disorder/what-shift-work-disorder/living-

coping-shift-work-disorder

McCain J. To heal the body, get into the patient’s head: motivational interviewing: to improve

adherence. Biotechnological Healthcare 2015; 9:10–12.

Revell, Cherial, D.N.P., F.N.P.-B.C., Alexander, Susan, DN, PANP. -B.C., A.D.M.-B.C., Talley,

Brenda, RN, PhD., N.E.A.-B.C., & Mobley, S., M.D. (2016). Using the Health Belief

Model for Patients with Type II Diabetes: A Provider Education Tool for Advanced

Practice Nurses. Endocrine Practice, 22, 70-71.

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