Determinants of health are the factors that influence the health of people i.e. who they are, what they do and conditions in which people are born. It is essential to understand the meaning of health.
Fundamental of Behavioural Sciences
Determinants of health are the factors that influence the health of people i.e. who they are, what they do and conditions in which people are born. It is essential to understand the meaning of health. Earlier, health was defined as the absence of disease but in 1946, WHO considered a positive approach, defining health as “‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
There are various models and frameworks that are used in explaining determinants of health (McFarland and MacDonald, 2019) but social model of health will be applied in describing Lottie’s current health experience and wellbeing. According to the summary of Dahlgren and Whitehead’s (1991), social determinants of health (SDOH) are represented in the figure below.
SDOH factors (adapted from Dahlgreen and Whitehead, 1991).
According to the scenario, Lottie suffers from anxiety and stress. Anxiety and stress are reported to be psychological issues and are normal part of life but if prolonged could be associated with increased occurrence of physical disorders (Bhattacharya, Shen and Sambamoorthi, 2014, Yaribeygi et al., 2017). Lottie’s gene predisposed her to being overweight and sex is also a contributory factor (Cruz, 2017). These factors are unmodifiable and it could mean that Lottie would naturally have a big body and this increases Lottie’s chances of being overweight.
Nevertheless, Lottie’s lifestyle could have contributed to her current health experience. Lottie engages in alcohol drinking and would not eat vegetables and fruits which are known to reduce energy intake and body weight (Schroder, 2010).
Friends and family live far away from Lottie’s neighbourhood making her lack their support which could further increases physical and psychological stress.
It could be concluded that the living of Lottie also contributes to physical stress because she has to take the children to school since they are not allowed to go on their own due to the presence of drug gang in the environment they live in and psychological stress of worrying about the children.
The socioeconomic, cultural and environmental conditions such as occupation, income, social class and values placed on health have been impacted by the Covid-19 pandemic. Keogh-Brown et al. (2020) reported that the pandemic resulted in global, national and economic recession causing Lottie and Robyn to lose their jobs. In Salari et al. (2020) words, covid-19 pandemic also takes its toll on the mental health of people due to fear and anxiety for individual and family health. These are the factors that could contribute to Lottie’s current health experience and wellbeing.
Considering the meaning of social model of health, the practice nurse at the GP would ask Lottie about who she is, what she does and conditions in which she is born, grow, live, work and age. Borrell-Carrio, Suchman and Epstein, (2004) explained that “the social model proposes that ill health arises from the interaction of causal factors at the biological, individual and social levels”. According to WHO (2018), there is need to address health inequalities which causes non-communicable diseases as in the case of Lottie. According to McFarland and MacDonald (2019), nurses have a responsibility of identifying and addressing the root causes of suboptimal health from an individual so as to take necessary actions. In the case of Lottie, an in-depth understanding of the causes of her health experience can make nurses partner with agencies to ensure that she and her family receive person-centered care that will meet their needs.
Aggression and cruelty towards other students are part of Gerry’s behaviour which suggested that he has experienced traumatic event. This claim has been established by Simsek and Evrensel (2018) who discovered childhood trauma to be a predisposing factor to aggression. Other behaviours of Gerry include; not mixing well with other children by not eating with them or getting involved in sports and missing classes. Gerry also feels increasingly stressed about his grandma’s safety.
This does not indicate a positive response to situation and could be due to traumatic events as indicated by Gilliver (2018) who stated that physiological damage to stress response mechanism could have been caused by traumatic events. Some of the traumatic events Gerry experienced are, physical abuse as he was being hit by his father while growing up and emotional abuse as he watches his father get drunk and engage in fights with his mother severally and having to hide most times in his house.
Gerry was also neglected by his parents and this prevented him from experiencing the parental bond necessary to develop future relationships with others and this has affected the way he relates in school.
These are examples of Adverse Childhood Experiences (ACEs) which according to Public Health Network Cymru (2017) are “traumatic events that can have negative, lasting effects on health and behaviour”. It could also mean the physical, emotional or sexual abuse of a child and growing up in a house with domestic violence, mental illness, alcohol and drug abuse or criminal problems.
ACEs are issues of concern as they have been identified to be linked with health issues such as chronic lung disease, depression and addiction in adulthood (Gilliver, 2018). It is therefore important to prevent the adverse effects of ACEs and to prevent future abuse on Gerry. Also, Gerry’s grandmother is an elderly woman who tends to forget things and would need to be safeguarded to ensure her safety. Safeguarding adults according to NHS England (2013) “involves protecting our most vulnerable individuals and communities as well as promoting the safety and health and wellbeing of all”.
It was further emphasized that all healthcare professionals have a duty of safeguarding vulnerable people and that nurses have a duty to “work with others to protect and promote health and wellbeing of those in their care, their families and carers, and the wider community” (Betts et al., 2014). Principles of care in safeguarding vulnerable adults are; empowerment, prevention, proportionality, protection, partnership and accountability (Department of Health (DH), 2011).
This principle can be applied to safeguard Gerry’s grandma who is likely to suffer neglect. However, Gerry is 15years and is a young adult and it is advisable that the healthcare worker is familiar with and follow safeguarding procedures of his/her organisation, work co-operatively with Gerry and his parents and also work collaboratively with other agencies including Gerry’s school representatives.
McMunn (2008) noted that “women aged 16-24 years consumed more alcohol than any other group” and Amina falls within this age group. Age is one of the factors described in the SDOH. It is worthy to note that not only does this group engage in alcohol drinking but most likely to “binge” on alcohol which has been associated with various problems including violence, accidents, fighting, walking home alone, unprotected sex and pranks (McMunn, 2008).
The report further explained that drinking six units or more of alcohol by women in a session is known as Binge drinking. Social interaction and environmental factors are other motivating factors of Amina to periods of excessive binge drinking. As explained in the scenario, Amina has new circle of friends she intends to keep and one of the ways to do this, is to go drinking alcohol with them, wanting to feel among or feel accepted is the social factor motivating Amina to drink excessive alcohol.
Another important factor is the environment which is Amina’s working place. The organisation has a culture of motivating its workers to work very hard and also play hard at the weekend, insisting that workers are rewarded with few drinks. The fear of losing the job also motivates Amina to drink more.
Whitehead (2018) explained that the use of health promotion considers the SDOH and takes place in various settings including the workplace, homes and communities. In the case of Amina, it is obvious that friends and work play important role in her binge on excess alcohol leading to pancreatitis.
It is therefore important to consider the SDOH and understand the influence of age, friends and work factors on the excessive drinking. Behaviour change interventions range from very brief to high intensity; requiring different level of competencies (Fuller, 2015).
In the case of Amina, brief intervention is recommended. Fuller (2015) described brief intervention as a verbal discussion, negotiation or encouragement which could last up to half an hour. A practice nurse will discuss with Amina based on the result of the examination and whether she is aware of the potential consequences of her excessive drinking on her health and wellbeing.
The nurse would further seek to understand if Amina is motivated to change and how she is motivated, the barriers that could cause her to embrace behavioural change and the support she is likely to need to be able to overcome excessive alcohol consumption.
However, the practice nurse will be careful not to appear judgmental and would not force her opinion on Amina. Other competencies which are required to engage in very brief intervention are; being alert to identify opportunities for brief advice, discuss patient’s views and feelings about their lifestyle, assess whether Amina is willing to engage in a discussion about the issue at the moment or would be invited later in the future and also provide appropriate additional support if required (Fuller, 2015).
Challenging behaviour has been defined as “‘any non-verbal, verbal or physical behaviour exhibited by a person which makes it difficult to deliver good care safely” (Hallett, 2018). It is a significant issue in the healthcare settings (Hallett, 2018).
The case of Frank is a patient exhibiting challenging behaviour as he sometimes verbally abuses his family members while refusing care and help from female staffs. It is first important to identify that there is a cause(s) to every aggression. In Harwood (2017) words, an abusive or aggressive patient maybe a result of distress or unmet need and dementia has been identified as one of the conditions that could be associated with this challenging behaviour.
Physical causes (e.g. sleep deprivation and needing to go to the toilet), cognitive factors (e.g. forgetfulness and disorientation), mental health problems, emotions (e.g. frustration) and environmental factors (e.g. unfamiliar places and restricted movement) are responsible for aggressions in patients (Harwood, 2017). It is worthy to note that Frank has the need to go to the toilet, waking up to ten times in a night shows that he also suffers from sleep deprivation, he is also not very familiar with the nursing home and restricted movement which could further lead to frustration could be factors that trigger aggressions in him.
Asides from these factors, Frank is likely to be affected by unrecognized triggers because he refuses care and help from female staffs. It is very important to prevent challenging behaviours and the harm that can result from it for healthcare organisations and individuals.
According to Harwood (2017), challenging behaviour can be prevented or de-escalated by identifying triggers of such of behaviours, identifying the needs and trying to anticipate or meet it. Primary, secondary and tertiary prevention are the three tiers of public health model of prevention that can be used to prevent challenging behaviour (Hallett, 2018). The primary prevention involves actions that prevent the occurrence of challenging behaviour, the secondary prevention consists of actions to reduce the risk associated with challenging behaviour and its potential escalation while tertiary prevention aims to minimize the physical and emotional harm caused by challenging behaviours (Paterson et al., 2004).
In order to calm Frank and maintain feelings of comfort and safety, positive behavioural support approach can be applied. This is carried out through a multicomponent framework described in table 1.
The first point of action is to understand the behaviour of Frank and the possible triggers to the challenging behaviour by assessing the social and physical environment. This can be done by carrying out a person-centered personalization assessment. Effective communication should also be used to engage Frank so as to build rapport with the staffs of the nursing home.
Also, Frank’s family should be involved in providing support for him while they also practice effective communication while speaking with him. He should be helped get to the toilet until he is familiar with the nursing home because this will reduce sleep interruption which is one of the triggers to the abusive behaviour of Frank.
Table1: support system for Frank
Developing an understanding of challenging behaviour of Frank based on assessment of the social and physical environment and broader context which challenging behaviour occurred
· A person-centered personalization assessment
· A curious approach to understanding what Frank is communicating
· Validating distress that Frank might be experiencing
· Taking time to understand his behaviour
· Setting it in the context to the environment
Inclusion of stakeholder perspective and involvement
· Orientating Frank to his environment
· Involving family, all staffs who care for Frank to understand how they can support Frank to achieving positive behaviour
Implementing personalized and enduring support system
· Providing support for Frank as at when required including when he needs to use the toilet
· Effective communication to build a rapport
· Taking Frank around the nursing home to be familiar with the environment
Evaluate the effectiveness of implemented support system
· A record of Frank’s behaviour to measure the effectiveness of the support system.
Bhattacharya, R., Shen, C. and Sambamoorthi, U. (2014). Excess risk of chronic physical conditions associated with depression and anxiety. BMC Psychiatry;14:10 Available at: 10.1186/1471-244X-14-10 [Accessed 04/02/2021].
Borrell-Carrio, F., Suchman, A. L. and Epstein, R. M. (2004) The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Annals of Family Medicine; 2(6): 576-582.
Dahlgren, G. and Whitehead, M. (1991). Policies and Strategies to Promote Social Equity in Health. Background Document to WHO – Strategy Paper for Europe. Institute for Futures Studies, Stockholm.
Fuller, S. (2015) Building brief intervention into your everyday work. Nursing Times; 111: 5, 23-25.
Gilliver; C. (2018). Trauma-informed care in response to adverse childhood experiences. Nursing Times; 114: 7, 46-49.
Hallett, N. (2018). Preventing and managing challenging behaviour. Nursing Standard; 32(26): 51-62.
Harwood, R. H. (2017). How to deal with violent and aggressive patients in acute medical settings. J R Coll Physicians Edind.; 47: 176-182.
Keogh-Brown, M., Jensen, H., Edmunds, W. and Smith, R. (2020). The impact of Covid-19, associated behaviours and policies on the UK economy: A computable general equilibrium model. SSM – Population Health, 12, p.100651.
McFarland, A. and MacDonald, E. (2019). Role of the nurse in identifying and addressing health inequalities. Nursing Standard [online]. Available at: doi: 10.7748/ns.2019.e11341 [Accessed 04/02/2021].
McMunn, V. A. (2008) Effect of alcohol consumption on young women’s behaviour. Nursing Standard. 23(10): 35-41.
NHS England (2013). Safeguarding Vulnerable People in the Reformed NHS. Accountability and Assurance Framework.
Public Health Network Cymru (2017). Adverse Childhood Experiences (ACEs) [online]. Available at: https://www.youtube.com/watch?v=XHgLYI9KZ-A [Accessed 30/01/2021].
Salari, N., Hosseinian-Far, A., Jalali, R., Vaisi-Raygani, A., Rasoulpoor, S., Mohammadi, M., Rasoulpoor, S. and Khaledi-Paveh, B., 2020. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Globalization and Health, 16(57): 1-10.
Schroder, K. E. (2010). Effects of fruit consumption on body mass index and weight loss in a sample of overweight and obese dieters enrolled in a weight-loss intervention trial. Nutrition; 26(7-8): 727-34.
Simsek, D. E. and Evrensel, A. (2018). The relationship between childhood traumas and aggression levels in adults. Medicine Science International Medical Journal; 7(1): 622–626.
Whitehead, D. (2018). Exploring health promotion and health education in nursing. Nursing Standard. doi: 10.7748/ns.2018.e11220.
World Health Organization (2018). Time to Deliver: Report of the WHO Independent High-Level Commission on Noncommunicable Diseases [online]. Available at: https://apps.who.int/iris/bitstream/handle/10665/272710/9789241514163-eng.pdf?sequence=1&isAllowed=y [Accessed 24/01/2021].
Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P. and Sahebkar, A. (2017). The impact of stress on body function: A review. EXCLI journal; 16(1): 1057–1072.