Introduction
Diabetes is a long-term condition associated with significant changes in lifestyle and quality of life. Due to its numerous social and psychological implications, it requires multifaceted care in order to be successfully treated. The following paper critically explores the components of long-term care and their impact on the quality of life of patients.
Aetiology and Disease Progression
Diabetes is a condition caused by abnormal levels of blood sugar. Two types of diabetes are commonly recognised, referred to as Type 1 and Type 2 diabetes. The causes and symptoms of the conditions are relatively similar, which complicates the differentiation between the two (Diabetes.co.uk, n.d.). However, a set of common characteristics exists that can be used to determine each type. For instance, Type 2 diabetes is more often diagnosed in older populations, is commonly associated with excessive weight and high blood pressure, and is treated with lifestyle changes, as well as medication (Diabetes.co.uk, n.d.).
There are also several aetiological differences that are more difficult to spot without professional medical assistance. Most prominently, Type 1 diabetes is caused by insulin deficiency, whereas Type 2 is characterised by insulin resistance, with relative deficiency playing a secondary role (BMJ Best Practice, 2017). Type 2 is also aggravated by ageing and lack of physical activity, which allows for treatment via the introduction of a healthy lifestyle and diet (BMJ Best Practice, 2017).
Since insulin resistance can be lowered through weight reduction which, in turn, decreases the severity of the condition, it is also often incorporated into the long-term care of patients with Type 2 diabetes. These differences also impact on the progression of the disease. As the body is able to produce more insulin to account for the resistance, Type 2 diabetes does not produce visible symptoms. For a person with the disease, this means that it can remain undetected for a long period of time. Unfortunately, such a scenario also means that a person cannot address the condition at a stage where it could be alleviated by simple lifestyle changes such as exercise and a healthy diet.
Consequently, by the time the condition is identified, such intervention would likely be insufficient and the person would require the introduction of medication such as injections (Curry, 2015). The condition worsens over time as the insulin resistance prompts the beta cells to generate more insulin, leading to their eventual failure. In this case, the injection provides necessary recovery time for the cells and prevents, or, at the very least, delays, their failure. Currently, the effects of treatment are transient, and while evidence exists that the condition is reversible, no reliable method has yet been established (Curry, 2015).
Psychological and Social Implications
Living with a long-term condition like Type 2 diabetes presents an individual with numerous challenging issues. The psychological and social implications created by the condition need to be acknowledged in order to ensure the effectiveness of treatment and account for any possible gaps in care.
The most evident psychological aspect of diabetes care is depression. A systematic review by Roy and Lloyd (2012) revealed that the rate of depression is much higher in individuals who suffer from diabetes, with a threefold increase among Type 1 diabetes, and an almost twofold increase in Type 2 sufferers. While the exact mechanism behind this relationship is yet to be established, the most likely reason is the decrease in quality of life associated with the chronic nature of the condition.
The majority of diabetes-associated effects decreases life expectancy and imposes serious limitations on lifestyle, the need for medication administration being the most recognised one. Since depression is also known to have a detrimental effect on the quality of life, the vicious circle scenario is possible, where negative effects become self-sustained (Roy and Lloyd, 2012). Finally, because certain unhealthy lifestyle choices, such as overeating, contribute to the development of the disease, it is possible that depression may aggravate the effects of diabetes, which is especially dangerous for individuals who already have Type 2 diabetes in the early phase but are still unaware of it and are not seeking treatment (Roy and Lloyd, 2012).
A follow-up study by de Groot et al. (2015) largely confirmed the findings of the previous researchers with some notable additions. Specifically, their findings suggest that patients suffering from both Type 2 diabetes and depression are less likely to be successfully treated with antidepressant medication and experience more complications with regards their overall care (de Groot et al., 2015).
According to Chew, Shariff-Ghazali, and Fernandez (2014), the efficiency of the provision of psychological support also decreases due to the additional challenges posed by the disease. At the same time, such deterioration of the psychological climate makes long-term care less effective due to the lower involvement of the patients, self-regulation, and self-cognition (Chew, Shariff-Ghazali and Fernandez, 2014). Simply put, the depression makes it more difficult for the impacted individuals to participate in long-term care and, by extension, lowers their chances of recovery.
The compromised emotional climate, combined with numerous new requirements (such as medication administration), can become an additional strain for the impacted individuals and their family members and lead to several social implications. A study by Mayberry and Osborn (2012) revealed that the support demonstrated by family members had a direct relationship with successful glucose control and medication adherence.
By contrast, patients who are subject to non-supportive behaviour of their relatives have more difficulties in maintaining a medication intake schedule and fail to measure blood glucose levels regularly. Taking into account the fact that some of the components of long-term care, such as injections and constant monitoring of blood glucose, are already difficult to maintain without disrupting established routines, it becomes apparent that unsupportive family can seriously lower the chances of successful treatment and, indeed, contribute to the worsening of the condition. A similar conclusion was made by Palladino and Helgeson (2012) after reviewing the results of the qualitative studies of adolescents with Type 1 diabetes.
The review results indicated an adverse effect of Type 1 diabetes self-care practices, such as injection self-administration, on relationships with peers. On numerous occasions, teens with the condition reported that their peers’ attitude could influence the effectiveness of self-care. While the study found no conclusive quantitative data to confirm these findings, it is reasonable to assume that the reported perception would be sufficient to disrupt both the efficiency of long-term care and social life, at least in some cases (Palladino and Helgeson, 2012).
The report issued by the Work Foundation further expanded the list of social issues pertinent to long-term conditions. The focus of the report was on the labour market, but several of the findings display an evident link to the social domain. For instance, people with long-term conditions retire earlier, note often going to work feeling ill, and report more difficulties in career growth and finding employment opportunities (Bajorek, Hind and Bevan, 2016).
By extension, their self-fulfilment opportunities are understandably limited. The decreased quality of life discussed above further limits employment options and decreases productivity and satisfaction (Bajorek, Hind and Bevan, 2016). For diabetic patients, in particular, the barriers to employment also minimise the possibilities of a healthy lifestyle and social interactions, contributing to an overall negative effect.
It is worth mentioning that the situation is not always acute. Many individuals with diabetes report little complications associated with the condition. In some cases, the insulin injections could be performed discreetly with little disruption of social interactions. Nevertheless, in all cases, a certain amount of skill is required to reach the level of proficiency and experience allowing for seamless self-care. In addition, these accounts do not provide a complete picture, and it is reasonable to expect that such alignment of care with social life is more uncommon.
Care and Treatment of Diabetes
The complexity of implications posed by long-term conditions, combined with the wide impact they have on a person’s life, requires an equally comprehensive approach to care. Numerous practices and approaches have been put forward in an attempt to account for these multiple impacts, ranging from professional guidelines to political directives.
Person-Centred Care
Currently, person-centred care is one of the most widely accepted and readily recognised components of long-term care. Interestingly, despite its wide adoption, the concept lacks a precise definition. This can be partially attributed to the fact that the concept is currently in the early stages of development and differs significantly across the areas of application depending on the individual preferences of each patient. Patient-centred care can be loosely defined as consisting of offering compassion and respect, ensuring personalised and coordinated care, and enabling individuals to recognise and utilise their strengths and abilities.
The NICE guidelines on the management of diabetes in adults acknowledge these components by pointing out that they were formed using the data from studies performed on younger adults (NICE, 2017). While there are reasons to expect some flexibility, enabling the application of the guidelines to wider age groups, a certain degree of caution is to be exercised in dealing with the older population (NICE, 2017).
This point is further emphasised in the first recommendation, where some of the most likely areas of individualisation are identified. These include personal preferences, the presence of other long-term conditions, reduced life expectancy, and various disabilities, such as visual impairment (NICE, 2017). In practice, the administration of insulin injection would create an additional challenge for an individual whose vision is in decline, so it would be necessary to account for this fact in their treatment plan. The principle is also partially visible in other recommendations, such as with dietary advice, where individualised nutritional advice is recommended, or in the complications section, where additional attention is advised in monitoring certain conditions, with specified deadlines for a referral to respective specialists (NICE, 2017).
For diabetes sufferers, such an approach would ensure a timely response to adverse health conditions and maintain, more effectively, consistent quality of life. Importantly, such an approach would also safeguard their rights as laid out in the NHS Constitution for England. For instance, person-centred care will ensure that patients are making informed decisions about their disease (or, in the case of patients under 16 years of age, that their family can provide adequate support to help their child with any decisions).
Person-centred care has been shown to improve patient outcomes on several occasions. In a study by Eaton, Roberts, and Turner (2015) the implementation of personalised care in 31 practices in Tower Hamlet, London, has yielded an increase from 52% to 82% in involvement in care. The outcomes of the patients improved after the introduction of the approach, and overall employee satisfaction also increased. Interestingly, such an approach does not necessarily result in increased expenditure, since additional time necessary for personalised care can be obtained through reorganisation of the practice (House of Commons Health Committee, 2014).
There is also evidence that person-centred care can, in some cases, provide necessary relief from tightly-controlled care plans. In some cases, such as when the declining diabetes condition opens up the possibility for more relaxed glucose goals, the person-centred approach provides the necessary relief of self-care burden, whereas in a more health-threatening scenario the intensification can be introduced to achieve the desired outcome (Hackel, 2013).
Simply put, the person-centred approach increases the flexibility of a long-term care plan and can decrease the intensity of treatment in cases where excessive rigour and tight control is unnecessary without creating a threat to patients’ health. By extension, it is possible to view this opportunity as a way to alleviate pressure from the patient and minimise some of the psychological and social implications discussed in the previous chapter.
Self-Management
Another important aspect of long-term care is self-management. As was discussed above, the condition requires constant care and, in most cases, the administration of medication. This requires a significant allocation of resources from care providers and disrupts established daily activities. Self-administration, on the other hand, requires commitment and a certain level of understanding that is rarely achievable without the patients’ active involvement in care delivery.
However, medication is not the only factor requiring self-management. Shrivastava, Shrivastava, and Ramasamy (2013) identify seven behaviours associated with positive outcomes – healthy diet, physical activity, responsible medication administration, blood sugar monitoring, coping skills, problem-solving skills, and risk avoidance. Notably, only the first four of these behaviours are apparently linked to medical practices, while the latter three exhibits an indirect connection. Nevertheless, all seven contribute to improved disease management, reduced complications, and an enhanced quality of life. Unfortunately, despite the evident benefits, these behaviours are not adhered to consistently and require the promotion on the part of clinicians in order to be observed.
The most evident way of promoting self-management is through patient education. NICE guidelines specifically mention the development of diabetes self-management skills in their education section (NICE, 2017). According to the Health Foundation, the strategies for self-management promotion can be broken down into four core categories: technical skill, self-efficacy, information provision, and behaviour change (de Iongh, Fagan and Fenner, 2015).
For instance, self-administered insulin injections would require technical proficiency, whereas the success of searching for additional information online would depend on both technical skills and information provision. Self-management can be facilitated through generic educational events which provide generalised information on long-term care, or through diabetes-specific courses that would focus on specific issues such as the ability to estimate food intake times with regard to insulin injections when eating out.
Motivational Interviewing
As is evident from the information above, self-care is a cornerstone to the effective long-term care of people with diabetes. Thus, numerous counselling practices have been looked into in an attempt to promote it. One such practice, motivational interviewing (MI), has yielded consistently positive results. Interestingly though, the exact effect of the practice is not yet clear. A study by Li et al. (2014) established a significant improvement in the Homeostatic Model Assessment-Insulin Resistance scores, as well as the elevation of self-management activities rating in the patients subjected to MI, but did not detect improvements in BMI scores and HbA1C levels.
On the other hand, a randomised controlled trial by Račić et al. (2015) identified improvements in both fasting blood glucose levels and HbA1c levels, as well as a positive effect on blood pressure. Nevertheless, it is generally agreed that the straightforward nature of counselling practice, as well as its orientation towards identification and resolution of ambivalence in patients, is primarily responsible for its high efficiency (Mitchell, 2012). The emphasis on the promotion of autonomy empowers the patients to adopt a proactive stance and increases their independence. Another important aspect of motivational interviewing is the possibility to improve health outcomes without pharmaceutical intervention or any significant change in daily routines.
Partnering
The far-reaching implications associated with long-term care have led to the introduction of the partnership concept. From this perspective, the collaboration between a care provider and a patient (commonly referred to as person-centred care) is viewed as a partnership, where the power and responsibilities are shared in an attempt to achieve the desired outcome. For the patient, such redistribution of responsibilities communicates equality and, by extension, communicates trust. However, at least two more partnering dimensions are needed to reach the desired level of improvement. First, partnering with other providers is recommended.
When facilitated with providers from other professional disciplines, such partnerships diversify the capacity of the organisation (World Health Organization, 2005). From the patients’ perspective, such a move introduces options that are otherwise unavailable and synchronises the efforts of different departments. As a result, long-term care becomes more consistent and focused on specific goals. In addition, the providers become more informed and are able to coordinate their actions.
Second, partnering with communities is defined as a separate category. Aside from the better connection to the families of the patients, it offers a better understanding of the cultural and social environment, which adds to the overall effectiveness of care. Such cooperation provides access to community organisations such as faith-based groups, local government, and media representatives, which further broadens the possibilities of care providers.
Assistive Technology
The development of informational technology in recent decades has provided additional opportunities for long-term care. For patients with diabetes, two main directions can be identified. First, communication technology has become more advanced. According to Lindberg et al. (2013), it enhances the convenience and reliability of communication between people with the condition, their families, and the healthcare professionals. For the former, such enhancement offers better security (since patients can easily and reliably contact their providers in an urgent situation) and access to information (as they can conveniently request clarification or further assistance).
Second, the technology known as telemedicine has reached a level of convenience and accessibility that allows its widespread adoption. For people with diabetes, it offers enhanced monitoring capabilities, where readings of blood glucose levels are automatically gathered, logged, and sent to a provider if necessary. Aside from the purely medical applications, such technology also allows lifestyle monitoring, which is especially important for elderly patients with Type 2 diabetes since it offers a cost-effective automated assistance solution. It is also worth noting that the automated nature of the assistive technology contributes to the safety of patients by eliminating human error – there is a smaller risk of patients with declining memory missing an important change in their physical condition.
Conclusion
Diabetes is a condition that requires comprehensive long-term care due to its aetiology. Both types of condition require significant changes in lifestyle and introduce the patient to several medical practices that can be challenging for them, both psychologically and socially. To account for this, long-term care follows a person-centred approach, emphasises self-management, utilises assistive technology, and encourages partnerships between community and care providers. The combined effect of these components ensures the successful mitigation of adverse health effects without compromising the quality of life of the impacted individuals.
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