SECOND OPINION:IN HENNING MANKELL'S detective novel, One Step Behind, Inspector Kurt Wallander is told he has diabetes.
He had been feeling unwell for months, always tired, drinking litres of water, and urinating a lot. Fatigue comes over him without warning and one morning he comes close to death when he falls asleep at the wheel of his car and almost goes off the road.
He is so frightened he goes to his GP, who tells him his blood sugar levels are off the charts and he needs to make drastic changes to his lifestyle. His doctor hands him a diet sheet and advises him to visit a dietitian. Wallander is shocked and wants to pretend it’s not happening.
He finds it very difficult to make the health behaviour changes required which are, as usual, eating healthily and being more physically active. He is weighed down with fatigue and imagines “little white icebergs of sugar floating around in his veins”.
On the morning he is given the diagnosis, a serial killer is loose in Sweden. Wallander has to lead the investigation and at the same time change his life. He continues eating his favourite pizzas and takes no exercise.
The book reminded me that people who are diagnosed with any chronic health condition have complex lives to live while simultaneously managing their condition. They are expected to, indeed must, fundamentally change their lifestyles and keep their real lives going.
Lives and lifestyles are not the same, although they are inextricably linked and most people need professional and social supports to integrate the two. A diet sheet, leaflet and patient education simply won’t do.
To complicate matters further, many people have two or more concurrent chronic conditions. Wallander has high blood pressure, his weight is verging on obesity and he is so overwhelmed by the changes he must make that he does nothing.
More than 200,000 people in Ireland have type 2 diabetes. While it is unlikely that many of them will be dealing with serial killers, they all have responsibilities, worries about bills and mortgages, stressful jobs or pressures due to unemployment, yet the supports they receive from the health system are about the disease and not the whole person.
Unless people receive holistic support that takes all aspects of their lives into consideration, their lifestyles will not change. This support should incorporate self-efficacy (SE) strategies. There is a very strong relationship between SE and health behaviour change. SE influences all health behaviours, including adopting new behaviours, stopping unhealthy behaviours, and starting again.
People have “high” and “low” SE in relation to specific contexts and a person might feel able to drink less alcohol but have a poor belief in their ability to eat more healthily.
Individuals with a low SE about a particular task may ruminate about their deficiencies rather than doing it. SE is learned through personal experience, for example achieving a small specific change that is the least difficult and making more changes bit by bit.
The HSE's Practical Guide to Integrated Type 2 Diabetes Carestresses the importance of patient education, but there is no sense that an SE model is being used. There is nothing about the person's belief in their abilities to change and their perceptions of the difficulties, which is what self-efficacy is about.
The 2008 report from the HSE's Diabetes Expert Advisory Group notes that the aim of patient education is to "understand the condition and its treatment . . . and to co-operate with healthcare providers". The 2008 report, Tackling Chronic Disease, is almost entirely disease focused. It says "that individual disease management plans should be prepared for each patient" and "the plan should include the patient's commitments to comply".
An SE model means the plan for change is designed by the person with diabetes. The most important part of this plan is social supports, as management of a chronic condition, not to mention several at once, occurs outside the health system, at home, at work, at school and in the community. The people with the condition are the managers, and health professionals should be the guides or “coaches”.
Type 2 diabetes is almost entirely caused by obesity and up to 80 per cent of diabetes can be prevented. A recent report shows that one in four Irish three year olds are overweight or obese. This problem is just going to get worse unless we start using effective behaviour change techniques. Seeing the whole person and not just the disease would be a good start.
Dr Jacky Jones is a former regional manager of health promotion with the HSE