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Victoria M. Claeys
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
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
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.
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.
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
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).
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
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
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
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
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
References
Day, P., Gould, J., & Hazelby, G. (2017). The use of motivational interviewing in community
Global Social Report Data Compilation. (n.d.). Retrieved February 27, 2020, from
https://www.denso.com/global/en/csr/sociality-report/data/
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
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