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From the information you
have obtained about Joanne, what would you delineate as the factors that could
be influencing her lifestyle prior to the hospital admission. Discuss your
answer with reference to literature on health literacy. ?

World Health Organisation (WHO) defines health as “a state of complete
physical, mental and social well-being and not merely the absence of disease or
infirmity.” To attain the optimal health, the psychological, medical and
related health literacy should be provided to patients. Moreover, to enhance
the health of individuals, the active co-operation and informed view of the
public are important (Preamble to the Constitution of the World Health
Organization as adopted by the International Health Conference, 1948, page 100).

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according to the WHO, health literacy is defined as “the cognitive and social
skills which determine the motivation and ability of individuals to gain access
to, understand and use information in ways which promote and maintain good health.”
By refining people’s access to health knowledge and their ability to use it
effectively, health literacy is crucial
to empowerment (World Health Organisation, 1998).  Levels of general literacy and related
cognitive development influence health literacy of individuals. However, health
information and facilities are often unaccustomed, technical and complex, that make it problematic to
comprehend and act on, even for people with advanced levels of education (Nutbeam, 2000).

            Health literacy requires
understanding of several subjects including healthy actions for a better way of
life, the body and how health care works. Health literacy is affected by the
language we communicate, our ability to talk clearly and listen carefully, socioeconomic status, our age, cultural setting,
previous experiences, cognitive abilities, and mental health. All these elements influence
how we communicate, comprehend and react to health information (Howard,

            Crohn’s disease is a chronic disease
that cause inflammation and irritation of the gastrointestinal tract with
symptoms emerging in a relapsing manner. This disease can lead to bowel damage
and disability. Most commonly, Crohn’s disease affects the small intestines,
terminal ileum and colon however all parts of the digestive tract; mouth to
anus can be affected (Torres, Mehandru, Colombel & Laurent, 2017).

disease can develop at any age, but it usually occurs between the ages of 15
and 35. In developed countries the incidence of Crohn’s disease is higher than
in developing countries, also in urban areas than in rural areas. Moreover, people
who smoke cigarettes have a higher risk and it is more common in people of
northern European ancestry and those of eastern and central European Jewish
origin than amongst other ethnic backgrounds. The cause of this disease is
unknown but the interaction of several factors such as heredity, environmental
factors and intestinal micro flora might be the reason (Torres, Mehandru,
Colombel & Laurent, 2017).

most common signs and symptoms Crohn’s disease are: diarrhoea, abdominal pain
and weight loss. Other symptoms are: fatigue, anaemia, rectal bleeding or bloody
diarrhoea, eye redness or pain, joint pain and skin changes that involve red,
tender bumps under the skin. Research also imply that certain foods can
stimulate or worsen these symptoms. The nurse may advise a specific diet such
as high calorie, lactose free, low fat, low fibre and low salt. Also, avoiding
carbonated, or “fizzy,” drinks, high-fibre foods, drinking more water and eating
smaller meals more regularly (National Institute of Diabetes and Digestive
and Kidney Diseases, 2017).

            There are many
different treatment options available that can control Crohn’s symptoms. The
aim of treatment is to decrease inflammation in the intestines, avoid flare-ups
of symptoms and attain and maintain remission. Normally Crohn’s disease is
treated with medications, bowel rest and surgery (National Institute of Diabetes and Digestive
and Kidney Diseases, 2017). Drugs which can
be prescribed include: antibiotics, aminosalicylates, corticosteroids, immune
modifiers and biologic therapies (Crohn’s and Colitis, 2016). Also, bowel rest
generally allows the intestines to heal. During bowel rest the patient can only
drink certain liquids and cannot eat anything (National Institute of Diabetes and Digestive
and Kidney Diseases, 2017). Treating this
disease with medication and bowel rest are the first therapeutic routes however
surgery may be required if the patient doesn’t respond to medicines (Crohn’s
and Colitis, 2016).

the case of Joanne, Joanne was not following a low fat and low fibre diet which
could be the cause of such flare-up together
with stress caused by her husband leaving the house. Research suggest that
individuals undergoing stressful situations in their daily life can result in a
flare-up (Garrett, Brantley, Jones, et al,
1991). The reason of not adhering to this specific lifestyle may be due to lack
of health literacy.  The nurse should assess
the patient’s health literacy skills and should not assume or ask how far she
went in school. Joanne’s sons should have been encouraged to participate and
the nurse must check that the patient have understood.  Identifying the most effective methods is
crucial to educate patients. The health professional should respect, care and
be sensitive towards the patient, thus empowering the patient to contribute in
her own health care (Williams, Davis, Parker, et al, 2002).

            Moreover, Joanne was not compliant with
the treatment that was prescribed by the general practitioner. Patient
adherence describes the degree to which a patient follows medical instructions
prescribed by a health care professional. Adherence is influenced by several
factors, such as: patients lack of understanding of their disease and treatment,
beliefs about the benefits and effectiveness of prescribed treatments, side
effects of medications, depression and lack of social support. Joanne was not
taking her medications as they were making her gain weight, affecting her body image. Health literacy about the specific
disease and related treatment could have improved adherence. This knowledge may
be vital to help Joanne generate motivation and appropriate health actions
needed to improve compliance and better able to take part in the decisions
affecting her health (Miller, 2016).

has showed that low health literacy is related with poor health outcomes,
involving less use of preventive facilities, higher rates of hospitalization and
a greater risk of mortality (Brown, Teufel & Birch 2007 & Miller
2016). According to the National Institutes of Health
(2017), health literacy “Saves Lives. Saves Time. Saves Money.”

conclusion, all health care professionals must work together so that health
knowledge and services are delivered to all individuals. Eliminating barriers
and refining the way health care professionals, lecturers and media communicate
health information offer the best chance to attain a health literate society (Nutbeam, 2000).












Discuss how models of
self-care and theories of health behaviour, can be applied to empower Joanne to
engage in a healthier life-style behaviour. ?

person’s health and development are highly influenced by environmental and
social factors such as: age, family medical history, education, occupation and
living conditions (Larkin, 2016). Also, an individual’s lifestyle and
behavioural factors can greatly impact the person’s health. Examples include: cigarette
smoking, alcohol misuse, drug abuse, poor nutrition and lack of physical
exercise. These behaviours are usually used as they are effective in dealing with
stress. Good mental condition and resilience are essential to our physical
wellness, relationships, occupation, education and to attain our full potential
(Faculty of Public Health, 2010).

was hospitalized as she needed help to take care of herself. Dorothea Orem
describes the theory of self-care as the practice of activities that persons
perform to maintain their own health and wellbeing and also explains why individuals
require nursing care. This theory includes the relationship among the models of
self-care agency, self-care requisite and therapeutic self-care demand (The University of Tennessee at Chattanooga,
2016). The theory of self-care
deficit, indicates when nursing care is required. Nursing care is needed when
an adult is unable or limited in the delivery of continuous and effective
self-care. The theory also identifies how an individual can be assisted through
nursing using five methods: acting for and doing for others, guiding others,
supporting another, providing an environment promoting personal development in
relation to meet future demands and teaching another (Petiprin, 2016).

            The fact that Joanne was admitted to hospital with severe
abdominal pain together with a high body temperature, and investigations showed
that she has gastrointestinal inflammation which caused anaemia, an episode of a
flare up shows that she is self-care deficit. Joanne needs to gain control over
her life with the help of others to avoid such flare-up.

Health Belief model (HBM) is a psychological model that helps to explain and
predict a variety of health behaviours such as: preventive behaviour, illness
behaviour and sick role behaviour by concentrating on the attitudes and beliefs
of the person (Orji, Vassileva & Mandryk, 2012). The HBM is one of the oldest models of health
behaviour although it is the most used theory in health research (Hayden,
2014). This model addresses
behavioural difficulties that induce health concerns. It tackles the
willingness of an individual to act upon a health behaviour determined by the
perception of the following six variables: perceived susceptibility, perceived
severity, perceived benefits, perceived barrier, cue to action and self-efficacy
(Orji, Vassileva & Mandryk, 2012).

Perceived Susceptibility

susceptibility indicates the risk a person has concerning the likelihood of contracting
a disease as a result of engaging in a particular behaviour.  The personal awareness of risk tends to
influence the perception in promoting the adoption of a healthier lifestyle
behaviour. However, research suggests that individuals often underestimate
their own vulnerability
to illness (Orji, Vassileva & Mandryk, 2012).

Perceived Severity

severity refers to the person’s belief of the gravity of the condition and its possible
consequences. Some serious consequences that can affect the person’s life as a
result of a particular behaviour include: death, pain, distress, physical impairment,
financial burden and problems with family and social relationships (Orji,
Vassileva & Mandryk, 2012).

Perceived Benefits

            The concept of perceived benefits
refers to a person’s opinion of the usefulness of the alternative course of
action to lessen the chance of disease or the severity of its consequences
(Hayden, 2014).

Perceived Barrier

            Perceived barrier is the evaluation
of the problems a person might face while adopting to the new behaviour. In
order to engage in a new healthy behaviour, a person needs to believe that the
benefits of the target behaviour outweigh the perceived barriers (Hayden,

Cue to Action

cue is essential to act a trigger for health behaviour. Cues to action are events, people, or things
that cause the individual to change behaviour. Examples include: media reports,
information from other people, hearing TV or radio news and more (Hayden,


refers to a person’s belief about one’s capacity to execute the anticipated
behaviour. Self-efficacy reflects confidence in the ability to exert control
over one’s behaviour, motivation and social environment (Orji, Vassileva &
Mandryk, 2012). People with high self-efficacy tend to choose more challenging
tasks and recover quickly from setbacks while people with low self-efficacy are
more likely to avoid stimulating activities and quickly lose confidence in personal
abilities (Cherry, 2017).

            Initially, Joanne should admit that
she needs help to keep up with her health and so she needs to address the
problem. The fact that Joanne was hospitalized may act as an external cue to
take action about her health. For Joanne to engage in a healthier lifestyle behaviour she should get
proper nutrition as it is essential to help minimize the symptoms of the
disease, take treatment as prescribed as with medications she can keep Crohn’s
disease in remission, manage her stress levels with stress management
techniques like yoga to help her keep calm and see a general practitioner on a
regular basis for check ups and to help with her overall wellbeing.  These behaviours greatly increase the risk of
a flare-up which can have a severe impact on her health. Moreover, social
support from healthcare professionals, family and close friends is of utmost
importance (Szigethy,




























C) Discuss the role of the nurse in encouraging Joanne to develop more effective
self- health-care practices.

            The matter of behaviour change and how
to accomplish it is a difficult challenge for health care professionals. Helping
a patient develop effective self-care behaviour is not only useful for avoiding
future health complications but also in facilitating the course of long term
conditions.  Self-care affects health results
through numerous ways, for example: treatment adherence, upkeep of physical
health, monitoring symptoms to update treatment, dealing with stress and
emotional difficulties and cooperating with healthcare professionals. To
achieve this, social support networks are used as social support enhances
quality of life (Greaves, & Campbell, 2007).

            The Royal College of Nursing (n.d.)
defines self-management as “The systematic process of learning and practicing
skills which enable individuals to manage their health condition on a
day-to-day basis, through practicing and adopting specific behaviours which are
central to managing their condition, making informed decisions about care, and
engaging in healthy behaviours to reduce the physical and emotional impact of
their illness, with or without the collaboration of the health care system.”

            The nurse should develop a
personalized, collaborative action plan that involves detailed behavioural
goals and a specific plan for overcoming obstacles
and attain those goals. This is completed using the 5As approach. The 5As are
assess, advice, agree assist and arrange. The first A represents asses which
refers to the assessment of the patient’s level of behavior,
motivation and readiness for change. Following the assessment, the patient is
provided with information and advice based on their health risks. The nurse
will provide personally relevant, specific recommendations for behaviour change
including the potential benefits and risks (Stanton, Steed
&Mulligan, 2009). The third aspect: agree includes the use of shared decision making
strategies that involve collaborative goal setting based on the patient’s
willingness to change an unhealthy behaviour.  The nurse will assist the
patient to tackle barriers to change, increase motivation and other skills like
effective self-management support strategies (action planning) which can help
the individual succeed. During this phase problem solving and motivational interviewing
skills are important. The last A; arrange represents
follow up contacts to provide ongoing support and help, follow up on action
plans and on referrals. This will provide the chance for reevaluation and also
to monitor the progress of the patient (Glasgow & Whitlock, 2002).


            The nurse must encourage Joanne to follow
self-management tasks so she could live her life as fully and productively as
possible through taking care of her illness: medical management, carrying out
normal activities: role management and managing emotional changes: emotional
management (Linsley, Kane & Owen, 2011).  The first task for Joanne is to modify her
current diet to limit the risk of another flare- up. The nurse should referee her
to a dietician for nutritional support therapy. According to research, enteral
nutrition can be a very beneficial treatment to induce remission in motivated
patients. In addition, Joanne should go for regular screens for common
abnormalities such as malnutrition and iron deficiency anaemia
(Donnellan, Yann & Lal,2013). It is of utmost importance for Joanne to
improve treatment adherence as Crohn’s disease (relapsing-remitting disease)
requires lifelong treatment.  The nurse
must educate Joanne about the treatment she needs to take by adopting a mutual,
cooperative relationship and showing less control supremacy using written and
oral education. The nurse should help her devise suitable dosage regimes,
promote emotional and psychological care as needed and educate her sons with
her permission (Lakatos, 2009). The third task should be coping with stress as
stress can worsen symptoms and increase the risk of relapse. The nurse can help
Joanne by adopting active coping strategies for example: problem solving, discussing
with others, regulation of emotions and looking on the bright side of the
situation. These strategies are associated with less depression, less anxiety
and a higher general self-efficacy. The nurse can also referee Joanne to a psychiatrist to
help Joanne even more (Danesh, Gholamrezaei, Torkzadeh et al, 2015).  

            Moreover, the nurse should support Joanne to attend a
self- management programme to further acquire self-management skills such as:
early symptom recognition, relationships with healthcare professionals and
problem solving based on a structured action plan.  This programme is performed to help
individuals increase their self-efficacy and change health behaviour in order to control the disease and improve their health status. Also,
the self-management programme is tailored according to the patient’s need and
worries, the severity of the disease and related comorbidities. The individual’s
progress, goal setting, build up of self-confidence, motivation and problem
solving will be assessed regularly by the health professional leading the
programme (Bourbeau
& Palen, 2009).

            A collaborative relationship,
suitable verbal and behavioural communication between the patient and the nurse
are the most effective tactics to behaviour change and patient outcomes.  Research have indicated that patient-centred
care is related with improved adherence to behaviour change. Crucial
communication skills in patient-centred care involve finding common ground,
delivering knowledge and sharing decisions. Additionally, verbal and non-verbal
behaviours such as: empathy, reassurance, positive reinforcement, friendliness,
courtesy, encouragement, humour, summarising and clarification, listening and
psychosocial talk are linked with positive patient outcomes regarding behaviour
change. On the other hand, passive acceptance, antagonism, strict behaviour,
disruptions, frustration and dominance have been related with positive patient
outcomes (Davies, 2015).

            Healthcare professionals’ especially nurses, should have
the necessary skills and knowledge to be able to communicate effectively, recognize
people’s strengths and capabilities, deliver guidance on support networks,
allow individuals to cope with identified risks, promote choice and
independence and provide relevant and evidence based information (Richards,
2012). Improvements in patient self-care behaviour are needed to avoid the
future problem of lifestyle- related illness. Encouraging patients to take responsibility
of their wellbeing is vital (Greaves & Campbell, 2007)!



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