Assessment is a deliberate, systematic and interactive process that underpins every aspect of nursing care (Heaven & Maguire, 1996). It is the process by which the nurse and patient together identify needs and concerns and is seen as the cornerstone of individualised care. It is the only way that the uniqueness of each patient can be recognised and considered in the care process (Holt, 1995). The process of assessment requires the nurse to make accurate and relevant observations, to gather, validate and organise data and to make judgements to determine care and treatment needs. A nursing assessment should have physical, psychological, emotional, spiritual and cultural dimensions and it is vital that these are explored with the patient being assessed. When carrying out the assessment the nurse must at all times consider the patient as a unique individual, thereby supporting the notion of a holistic individual approach to nursing (Roper, Logan & Tierney, 1996).

When the nurse uses Roper, Logan and Tierney’s model she concentrates on the activities of daily living, basing the assessment on the patient’s usual abilities and routine. When the nurse ascertains what the patient usually does in relation to the activities of living a comparison can then be made based on what the patient is like now. When carrying out the assessment the nurse must at all times consider the patient as a unique individual thereby supporting the notion of a holistic individual approach to nursing (Roper, Logan & Tierney 1996).

Nicol et al (2003) suggest that the assessment is crucial to the whole nursing process. When the data has been collected and analysed this will allow the nurse with the patient (if appropriate) to identify problems and strengths of the patient. Assessment can take place anywhere, for example, in the hospital, in the patient’s home or in the workplace. Heath (2000) suggests that assessment is regarded as the data collection phase that allows the nurse to make judgements about the patient’s health situation, needs and wishes. Assessment also helps to establish priorities and allows the planning of care.

Holland et al (2003) suggest that frameworks like the Roper, Logan and Tierney model are essential tools to be utilised in the nursing process. The structuring of patient assessments is vital to monitor the success of care and to detect the emergence of any new problems. The structure of a patient’s assessment depends not only on the speciality and care setting but also on the purpose of the assessment. Different conceptual or nursing models such as Roper et al (2000) provide frameworks for a systematic approach to assessment such as Roper’s Activities of Daily Living, implying that there is a perceived value in the coexistence of a variety of perspectives. However, Chalmers et al (1990) claims ‘the nursing model may have been positively unhelpful to knowledge building in nursing by inhibiting alternative, more fruitful lines of theory development.’ There remains much debate about the effectiveness of such models for assessment in practice, with some arguing that individualised care can be compromised by fitting patients into a rigid or complex structure (Tierney, 1998; Kearney, 2001). Nurses therefore need to take a pragmatic approach and utilise assessment frameworks that are useful and appropriate to their particular area of practice. This is particularly relevant in today’s rapidly changing healthcare climate where nurses are taking on increasingly advanced roles, working across boundaries and setting up new services to meet patients needs (Department of Health, 1996). A different type of assessment would be required for an acutely ill patient where early recognition of potential or actual deterioration is absolutely essential (Ahern & Philpot, 2002).

The district nurse who visited the patient following his discharge from hospital carried out a thorough nursing assessment which was based on the Roper, Logan and Tierney Activities of Daily Living Nursing Model (2000). A single assessment form based on Roper, Logan and Tierney’s Activities of Daily Living was used. The form consisted of both questionnaire type and checklist type questions. Whilst the checklist questions offered limited options for answers the questionnaire type questions required more specific answers.

The patient was a fifty-four year old male, recently divorced and living alone in a ground floor flat. What follows is a summary of his health needs based on his assessment document.

Communication

At this present time has no problems with communication. Makes needs known. Will need to be reviewed.

Maintaining a safe environment

Has no problems maintaining his own environment and is able to recognise potentially dangerous situations.

Respiratory

Manages own airway. No difficulty breathing. Currently no need for intervention.

Cardiovascular

No problems identified.

Neurological

Has lived with MS for the last 10 years.

Endocrine

No problems identified.

Pain

Intense stabbing pain and burning sensations. Has suffered from chronic pain for the last 8 months due to worsening symptoms of MS. Currently prescribed Zomorph for pain relief by GP.

Nutrition/Fluid Assessment

Appetite has become poor over the last few months but is independent with regards to feeding himself.

Continence

Has no problems getting to the toilet. However, patient often constipated and at other times unable to tell when stool is about to be passed.

General/Oral Hygiene

Lives in flat with specially adapted bathroom facilities. Requires no assistance.

Mental Wellbeing

Experiences anxiety and depression. Currently taking Citalopram for depression.

Death and Dying

Would like to be resuscitated in the event of emergency.

Expressing Sexuality

Recently divorced and not in a relationship.

Sleeping

About 8 hours sleep per night. Falls asleep naturally but wakes frequently during the night.

The assessment process highlighted a number of issues regarding the current health state of the patient such as a reduction in his appetite and continued constipation. It also highlighted the chronic pain the patient had to endure daily. Additionally, it came to light that the patient had previously been diagnosed as suffering from depression following a relationship breakdown and had been prescribed anti-depressants (Citalopram) which he had been taking for some time on a regular basis. It was possible the patient was suffering from depression as a result of the relationship breakdown or maybe as a consequence of the persistent pain endured. Pain can cause long term distress and impact severely on quality of life. Self help may play an important role in pain control. Multiple Sclerosis sufferers who remain active and maintain positive attitudes report a reduction in the impact of pain on the quality of their lives (Benz, 1996). According to Dougherty and Lister (2008) some of the problems identified during the assessment process may be linked to the medical condition whilst others will be specific to the individual, their psychology and their social and cultural status.

Nursing diagnosis involves making a ‘decisive statement concerning the clients needs’ (George, 1995:21). With this statement being somewhat dated there has been little change in the way nursing diagnosis is defined. Some of the nursing diagnosis of this patient are based on NANDA (2009-2011) and are as follows with the major referrals that were made to other MDT members that needed to be involved to give optimal care to the patient.

Diagnoses

Chronic pain due to Trigeminal Neuralgia. A common condition among individuals with Multiple Sclerosis. Referred to Multiple Sclerosis specialist nurse and GP to be reassessed for management of pain and to draw up new treatment regime.

Loss of appetite associated with patient’s anxiety and depression which tends to suppress most biological functions such as eating and drinking. Referred patient to Multiple Sclerosis specialist nurse to help stress the importance of diet in the treatment of Multiple Sclerosis and to help draw up diet designed to possibly alleviate some Multiple Sclerosis symptoms.

Continence problems due to neuropathic nerve damage as a result of patient’s Multiple Sclerosis. Referred to Multiple Sclerosis specialist nurse to advise patient about incorporating bowel management strategies into daily routine.

Anxiety and depression probably due to the accumulation of a variety of factors. Some are related to patient’s psychological reaction to his Multiple Sclerosis whilst Multiple Sclerosis related nerve damage could also be a trigger. Recent divorce also made patient more susceptible to depression and emotional changes. Referred patient for counselling as per NICE MS Guidelines (2003). Also referred to GP in order to discuss alternative treatment regime.

Sleep disturbance due to anxiety, pain. Referred; councillor to allow the patient to discuss any anxieties, any problems they are currently experiencing and offer coping strategies.

Social isolation due to increased pain when mobilising, subsequent reduced mobility.

The assessment tool was adapted from Roper, Logan and Tierney’s activities of daily living nursing model. This model is useful in the assessment process as it allows the systematic identification of actual or potential problems that the patient may experience and allows the clear identification of nursing needs.

The Roper, Logan and Tierney model says little overtly about the principles that should guide nursing intervention and therefore could be argued detracts from its utility (Aggleton & Chalmers, 2000). The assessment form used to assess the nursing needs of the patient contained somewhat of an empty approach. It enables nurse to assess but does not give guidance on the type of things to look for, it guides planning yet provides little information regarding the form that care plans should take. It suggests interventions yet fails to specify what may be appropriate interventions in certain circumstances, it calls for evaluation without specifying the standards against which comparisons should be made (Aggleton & Chalmers, 2000). With this it could be argued that in order to get the best out of an assessment a further set of ideas about people and the factors that can cause health related problems to arise are needed.

Throughout the initial assessment with the patient many issues arose that needed further investigation and assessment, but the main issue that appeared to be affecting the patient’s ability to carry out activities of daily living was the pain that he had to endure on a daily basis. For the purpose of this assignment a focus will be put on the assessment of his pain. It will also provide a critical evaluation of how the assessment was carried out, looking at the pain assessment tool that was used in order to assess his pain, and finally evaluating the reliability and validity of the assessment tool.

During the assessment of the patient’s health needs the main issue that was highlighted was pain that he was currently experiencing and how this impacted on his carrying out simple everyday tasks and how he had become increasingly isolated. Pain is a personal experience and the only way in which health professional can judge the patient’s level of pain is to firstly rely on the patient’s perception of their pain and secondly observe their resultant behaviour (Jenson, 1999). Although no specific assessment tool was used to document the patient’s pain score, the structure that the assessment took could suggest that it was based on the Numerical Pain Rating Scale (NRS). The patient was asked to rate his pain on a scale of ‘0-10’ and this was then documented in his nursing notes. Higginson (1998) notes that taking assessment directly from the patient is considered the most valid way of collecting information regarding their current quality of life and by encouraging the patient to take an active role in his pain assessment could be one step to help him and make him feel part of his own pain management process.

The NRS consists of both written and verbal forms, the written forms are described as either a vertical or horizontal line with ‘0’ being no pain and ’10’ indicating severe pain (Doherty & Lister, 2008). When reviewing the patient’s pain and the issues surrounding it, not having an assessment tool available to document these issues on proved extremely difficult and a time consuming process as each issue needed to be documented in the patient’s notes. As a consequence subsequent visits proved difficult as the results would not be readily accessible, the results may be misinterpreted and could prove to be a time consuming process.

Higginson (1998) suggests that it is important to make an assessment of each pain separately, since the pain may need to be managed in a different manner and one analgesic will rarely be sufficient. Bearing this in mind it could be argued that by not reviewing each pain experienced by the patient, from pain experienced on mobilising through to pain experienced from trigeminal neuralgia, the assessment of his pain and in the interventions given to him would be insufficient and may lead to a further deterioration in his condition. By comparison if an assessment tool such as the McGill’s pain questionnaire (MPQ) were available, this could have been addressed as this tool was developed to capture the multi-dimensional nature of pain and specifically measures several features of pain (Doherty & Lister, 2008).

The NRS provides a figure to say if the pain experienced has increased or decreased and by how much, the information documented also serves as a regular re-assessment and evaluation tool throughout a patient’s illness (Aggleton & Chalmers, 2000). The initial measurement of the pain experienced can also be used as a baseline on which to assess future interventions. Jensen (1999) states that in general a pain test should be reasonably simple to undertake, and is directed at a level that most patients would understand and should also be accurate and reliable. An instrument is said to be reliable if the test scores provided by the same individual on two separate occasions are similar (Doherty & Lister, 2008). Furthermore, the simplicity of this assessment tool should not detract from its validity and reliability (Jensen, 1999).

In conclusion, by understanding that every individual’s experience of pain varies it could be argued that a more reliable tool to use in our patient’s case would have been the MPQ. This would have enabled the nurse gain a more in-depth analysis of the pain experienced by the patient and would have greatly enhanced the effectiveness of the overall assessment.

Cigarette smoking highly boosts the risk of coronary artery disease (CAD), and the associated risk is particularly high in subjects with diabetes mellitus (DM) (Mühlhauser, 1994). The prevalence of smoking worldwide is one and quarter billion adult smokers, 10% of them reside within South East Asian countries. Smoking prevalence in these countries is a range from 12.6% to 40% in Singapore and Laos, respectively. Malaysia is recording 21% adult current smokers (Southeast Asia Tobacco Control Alliance (SEATCA), 2008). Cigarette smoking is estimated to cause more than five million deaths, making it the leading cause of preventable mortality worldwide (Peto et al., 1996). Atherosclerotic cardiovascular disease, chronic obstructive pulmonary disease (COPD) and lung cancer consider the three relevant causes of smoking related mortality (Centers for Disease Control Prevention, 2008). It has well known that cigarette smoking increases the risk of microvascular complications in DM (ie, nephropathy, retinopathy, and neuropathy) probably by its metabolic effects (worsening diabetes control and insulin resistance) in combination with increased inflammation and endothelial dysfunction. It appears to be stronger in type 1 diabetic patients, while the enhanced risk for macrovascular complications, coronary heart disease (CHD), stroke, and peripheral vascular disease, is most pronounced in type 2 diabetic patients (Eliasson, 2003, Haire-Joshu et al., 1999, Solberg et al., 2004).

Smoking cessation can safely and cost effectively be recommended for all patients, and it is a gold standard against which other preventive behaviors should be evaluated. Stopping smoking at any age has a considerable impact on improving life expectancy, reducing morbidity and reducing health care costs associated with treating smoking related conditions (Asaria et al., 2007, Ward, 2008), but effective strategies are lacking cessation support (Everett and Kessler, 1997). There are several treatment interventions have been identified as essential to achieve cessation. These interventions include brief counseling by multiple health care providers, use of individual or group counseling strategies, and use of pharmacotherapy (Haire-Joshu et al., 1999).

Smoking cessation medicines are among the most cost-effective disease prevention interventions available (Fiore, 2000). There are several types of them assist in smoking cessation are available. (Wu et al., 2006). The 2008 update to Treating Tobacco Use and Dependence, a Public Health Service-sponsored Clinical Practice Guideline Panel identified seven first-line (FDA-approved) medications (bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline) and two second-line (non-FDA-approved for tobacco use treatment) medications (clonidine and nortriptyline) as being effective for treating smokers (Fiore et al., 2008). The most commonly used formulation is nicotine replacement therapy (NRT). It reduces motivation to smoke and many of physiological and psychomotor withdrawal symptoms usually experienced during an attempt to quit smoking, and therefore, may increase the likelihood of remaining abstinent (Gourlay and McNeil, 1990, West and Shiffman, 2001). NRT is currently recommended as a safe intervention to general populations and higher-risk groups, including pregnant and breastfeeding women, adolescents, and smokers with cardiovascular disease (National Institute for Health and Clinical Excellence (NICE), 2008). Systematic reviews show that all forms of NRT have been proven to be effective (Fiore et al., 2008) and it increase quit rate one and a half to two fold in comparison with placebo. There are many studies provide good evidence that smoking cessation pharmacotherapy enhance the success of quit smoking attempt (Cahill et al., 2008, Fiore et al., 2008, Hughes et al., 2007, Stead et al., 2008). Unfortunately, there are insufficient evidences to recommend one delivery system over another.

Literature review

This review will cover the aims of this research. Globally, it was estimated that there are about 1.3 billion smokers, half of whom will die from smoking-related diseases (Shafey et al., 2009). While in Malaysia, the Third National Health and Morbidity Survey has reported some decline in smoking statistics among general population (18 years and above) in Malaysia with an overall smoking rate of 21.5%; male and female smoking rates of 46.4% and 1.6%, respectively (Ministry of Health, 2006). To our knowledge, there is limited information about the prevalence of smoking among diabetes mellitus patients, but it seems to be mirror to general population, at least for young adults. Findings from the national Behavioral Risk Factor Surveillance System show that the prevalence of smoking in young adults with diabetes mellitus is similar to the prevalence in the general population (Ford et al., 2004). Other study in the United States found the age-adjusted prevalence of smoking was 27.3% and 25.9% among people with and without diabetes, respectively. The prevalence of smoking did not differ significantly between participants in both groups when they were stratified by age, sex, race, or education (Ford et al., 1994). Few studies examined the prevalence of tobacco use with diabetic patients, information that is critical for targeting prevention efforts. There is no estimated prevalence for smoking in diabetes mellitus patients in Malaysia.

Few studies was conducted about the knowledge and awareness of diabetic patients towards smoking cessation and its pharmacotherapies. There is a survey done in the United Kingdom to investigate awareness of pharmacotherapeutic aids to smoking cessation in diabetic cigarette smokers. A structured questionnaire-based interview was held by research nurse individually with current smokers in a private room. Of 597 diabetic patients attending a routine clinic, one hundred diabetic patients were current smokers. The majority of them were type 2 diabetic patients (96%). There were 66% and 54% had heard about NRT and bupropion, respectively. Those who had heard about NRT, only 49% considered it safe with diabetes, while who knew of bupropion 39% thought it unsafe in diabetic patients. Approximately 84% were aware of the UK National Health Service (NHS) quit line, but only 8% had used it. The authors conclude that this subpopulation has poor knowledge and awareness of NRT and bupropion as aids to quit smoking (Gill et al., 2005).

A qualitative study done in the United States, aimed to investigate beliefs about cigarette smoking and smoking cessation among Urban African Americans with Type 2 Diabetes. Focus groups and a short survey were used to assess cigarette use patterns, perceived smoking health effects, preferences for treatment, and attitudes toward smoking cessation among this subpopulation. Twenty five participants were included in this study. The mean age was (SD) 48.5 years (±10.23), 60% female, smoked 20.9(±12.54) cigarettes per day. Regarding the beliefs and knowledge about smoking and diabetes, Participants believed that smoking increased their risk for all health outcomes, though there was not a clear understanding of how. Furthermore, they believed smoking decreased their appetite and quitting smoking makes you gain weight, and that it would negatively affect diabetes. Regarding beliefs and opinions about stopping most participants desired to quit and believed it was important to quit, but were not motivated to quit or confident they could achieve cessation (Janet L. Thomas et al., 2009).

Another study established in the United States, aimed to assess what smokers believe about the health risks of smoking and the effects of smoking filtered and low-tar cigarettes, as well as their awareness of and interest in trying so-called reduced risk tobacco products and nicotine medications. It was conducted between May and September 2001. They gathered data on demographic characteristics, tobacco use behaviors, awareness and use of nicotine medications, beliefs about the health risks of smoking, content of smoke and design features of cigarettes, and the safety and efficacy of nicotine medications. The findings of this study showed a substantial percentage of respondents either answered incorrectly or responded ”don’t know” to questions about health risks of smoking (39%), content of cigarette smoke (53%), safety of nicotine (52%), low-tar cigarettes and filtered cigarettes (65%), additives in cigarettes (56%), and nicotine medications (56%). The smokers’ characteristics most commonly associated with misleading information when all six indices were combined into a summary index were as follows: those aged 45 years or older, smokers of ultra-light cigarettes, smokers who believe they will stop smoking before they experience a serious health problem caused by smoking, smokers who have never used a stop-smoking medication, and smokers with a lower education level. Those who believed they would stop smoking in the next year were more knowledgeable about smoking. The authors conclude that smokers are misinformed about many aspects of the cigarettes they smoke and stop smoking medications (Cummings et al., 2004).

Unfortunately, there is a dearth of information on the efficacy of smoking cessation pharmacotherapies in diabetic patients because large-scale studies involving this group do not report results separately for them. Additionally, there are few direct head to head comparison studies among them in this subgroup population.

In an open-label, randomized trial conducted in Belgium, France, the Netherlands, the United Kingdom, and the United States, compared varenicline with transdermal NRT for smoking cessation. Participants were randomized to receive either 12 weeks of varenicline or 10 weeks of transdermal NRT (Aubin et al., 2008). The primary end point was continuous abstinence rate (CAR) during the last 4 weeks of each treatment. Secondary end points were CARs from the last 4 weeks of treatment through weeks 24 and 52 and the 7-day point prevalence of abstinence assessed at the end of treatment, week 24, and week 52. The Minnesota Nicotine Withdrawal Scale (MNWS) and The modified Cigarette Evaluation Questionnaire (mCEQ) measures of craving, withdrawal, and smoking satisfaction were assessed at baseline and at each weekly visit through week 7 (or at early termination).

Data were analyzed in both the prespecified primary analysis population (all randomized participants who received at least 1 dose of study drug: 376 varenicline, 370 NRT) and the all-randomized population (378 varenicline, 379 NRT). CARs were significantly higher in the last 4 weeks of treatment of varenicline group compared with NRT group (55.6% vs 42.2%, respectively; Odds ratio (OR) = 1.76; 95% CI, 1.31-2.36; P < 0.001). At week 24, there was no significant difference in CARs (32.2% and 26.6%; OR = 1.33; 95% CI, 0.97- 1.82). At week 52, CARs were not significantly higher for varenicline over to NRT in the primary analysis population, although the difference in CARs remain significant through week 52 in all-randomized population analysis (25.9% vs. 19.8%; OR = 1.44; 95% CI, 1.02-2.03; P = 0.04). The 7-day point prevalence of abstinence at week 12 was significantly higher for varenicline compared with NRT (62.0% vs 47.0%, respectively; OR = 1.71; 95% CI, 1.27-2.30; P < 0.001). The differences in 7-day point prevalence of abstinence were not significant at week 24 or week 52.

For weeks 1 through 7, the average scores of MNWS and mCEQ for cravings, withdrawal symptoms, and the reinforcing effects of smoking were significantly lower with varenicline compared with NRT (all population analysis, P ≤ 0.001). Varenicline group had significantly lower MNWS subscale scores for negative affect and restlessness compared with NRT (both, P < 0.001); there was no difference between varenicline and NRT in the subscale scores for increased appetite or insomnia.

A guideline “Treating Tobacco Use and Dependence: 2008 Update” is a product of the Tobacco Use and Dependence Guideline Panel. This guideline contains strategies and recommendations designed to assist clinicians; tobacco dependence treatment specialists; and health care administrators, insurers, and purchasers in delivering and supporting effective treatments for tobacco use and dependence (Fiore et al., 2008). A meta-analysis displayed the effectiveness of the first-line smoking cessation medications compared with placebo at 6 months post-quit. They determined the estimated abstinence rate and odds ratio at 6 months post-quit (95% CI) compared with placebo estimated abstinence rate of 13.8% and estimated odds ratio of 1.0. Varenicline had the highest estimated abstinence rate and odds ratio (33.2% and 3.1), while nicotine gum had the lowest estimated abstinence rate and odds ratio (19.0% and 1.5).

Another multicenter, randomized, double-blind, placebo-controlled trial compared the efficacy and safety of varenicline with placebo for smoking cessation in 714 smokers with stable cardiovascular disease that had been diagnosed for > 2 months. Participants received either varenicline (1 mg twice daily) or placebo at ratio 1:1, along with smoking-cessation counseling, for 12 weeks. Follow-up lasted 52 weeks. The primary end point was carbon monoxide-confirmed CAR for last 4 weeks of treatment. The secondary outcomes were the CAR from week 9 through 52; CAR for weeks 9 to 24 and 7-day point prevalence of tobacco abstinence at weeks 12 (end of drug treatment), 24, and 52. The CAR was higher for varenicline than placebo during weeks 9 through 12 (47.0% versus 13.9%; odds ratio, 6.11; 95% CI, 4.18 to 8.93) and weeks 9 through 52 (19.2% versus 7.2%; odds ratio, 3.14; 95% CI, 1.93 to 5.11). The varenicline and placebo groups did not differ significantly in cardiovascular mortality (0.3% versus 0.6%; difference, _0.3%; 95% CI, _1.3 to 0.7), all-cause mortality (0.6% versus 1.4%; difference, _0.8%; 95% CI, _2.3 to 0.6), cardiovascular events (7.1% versus 5.7%; difference, 1.4%; 95% CI, _2.3 to 5.0) (Rigotti et al., 2010).

Nides and his colleagues conducted a multicenter, double-blind, placebo-controlled, trial to evaluate the efficacy and tolerability of three varenicline doses in adult smokers. Bupropion hydrochloride was included as an active control. Participants were randomized to receive varenicline 0.3 mg once daily, varenicline 1 mg once daily, varenicline 1 mg BID, bupropion SR 150 mg BID, or placebo for 7 weeks, with the option of participation in follow-up through week 52. The varenicline groups received active drug for 6 weeks, followed by placebo for 1 week. The primary efficacy outcome in this study was CAR for any 4-week period from baseline through week 7. Secondary efficacy outcomes involved the 4-week CAR for weeks 4 through 7, 4 through 12, 4 through 24, and 4 through 52; cravings and withdrawal symptoms, assessed using the MNWS and the brief Questionnaire of Smoking Urges (QSU-brief); reinforcing effects of smoking, assessed using the mCEQ; and changes in body weight (Nides et al., 2006). The findings of this study presented that the patients treated with varenicline (except of those who received varenicline 0.3 mg once daily) or bupropion SR had significantly higher CARs for any 4 weeks compared with placebo (P < 0.001 and P = 0.002, respectively). The CARs for any 4 weeks were 48.0% for varenicline 1 mg BID (OR = 4.71; P < 0.001), 37.3% for varenicline 1 mg once daily (OR = 2.97; P < 0.001), 33.3% for bupropion SR (OR = 2.53; P=.002), and 17.1% for placebo. No statistical comparison was performed between the varenicline and bupropion SR groups. Only varenicline 1 mg BID was significantly more efficacious than placebo throughout the entire follow-up period (P ≤ 0.01). Varenicline 0.3 mg once daily and varenicline 1 mg once daily were significantly more efficacious than placebo through week 7 (P ≤ 0.05), and bupropion SR was significantly more efficacious than placebo through week 12 (P ≤ 0.05). Scores on the MNWS and QSU-brief indicated reductions from baseline in cravings with varenicline 1 mg BID compared with placebo at each weekly time point during active treatment (week 2: P < 0.01; weeks 1 and 3-6: P < 0.001). Varenicline 1 mg BID was also associated with consistent improvements from baseline (the day before the TQD) to week 1 in scores on several subscales of the mCEQ compared with placebo, including satisfaction (mean change, -4.82; P < 0.05), enjoyment of respiratory tract sensations (mean change, -0.84; P < 0.05), and aversion (mean change, 0.82; P < 0.05). (The mCEQ was not used beyond week 1 of the active-treatment period.) There were no significant differences on any of the mCEQ measures between the lower doses of varenicline and placebo (Nides et al., 2006).

Rationale/Justification

Few studies examined the prevalence of tobacco use with diabetic patients, information that is critical for targeting prevention efforts. To our knowledge, there is no estimated prevalence for smoking in diabetes mellitus patients in Malaysia.

Most people today recognize major health risks from smoking, but this general knowledge does not necessarily translate into a belief that one is personally at high risk of becoming seriously ill as a consequence of smoking. Furthermore, general awareness of health risks does not mean that people are adequately informed about smoking in ways that might influence their smoking behavior. Because the knowledge, beliefs, and preferences of smokers facilitate maximum receptivity to programs, these are important considerations when developing effective cessation interventions. Therefore, we will investigate smokers’ knowledge about the health risks of smoking and their awareness of nicotine medications.

Unfortunately, there is a dearth of information on the efficacy of smoking cessation pharmacotherapies in diabetic patients because large-scale studies involving this group do not report results separately for them. Additionally, there are few direct head to head comparison studies among them in this subgroup population.

Objectives

General objectives

Determine the prevalence of smoking among diabetic patients in outpatient clinic at General Hospital Penang.

To investigate diabetic smokers’ knowledge about the health risks of smoking and their awareness of nicotine medications.

To estimate direct head-to-head comparison between varnicline and nicotine patch regarding to their efficacy in smoking cessation.

Specific objectives

Determine the prevalence of smoking among diabetic patients.

To assess the knowledge of diabetic smokers about the health risks of smoking and their awareness of nicotine medications.

To compare between varenicline and NRT in the abstinence rate of smoking.

To compare between varenicline and NRT in the cravings and withdrawal symptoms, assessed using the MNWS and QSU-brief.

To compare between varenicline and NRT in the reinforcing effects of smoking, assessed using the mCEQ.

To compare between varenciline and NRT in changes in body weight.

Research Methodology

Study design

This study comprises different types of study design according to the different objectives.

For estimating the prevalence of the smoking among DM patients, it will be achieved by review the medical records for all diabetic patients who attend the diabetic outpatient clinic during 2010. Besides assessing the smoking status, we will collect also specific demographic and diabetic-related data. Any medical records does not contain information about smoking status will be excluded.

The second objective in investigating knowledge and awareness of diabetic smokers about the health risks of smoking, smoking cessation and smoking cessation pharmacotherapies, the study design it will be cross-sectional survey. All the diabetic smoker patients who attend the outpatient diabetic clinic at General Penang Hospital in 2011 will be invited to participate in the survey. The questionnaire will be either distributed or interviewed by the clinical staff. The questionnaire will be based on another study. More detailed information on how the survey was conducted can be found elsewhere (Cummings et al., 2004). The questionnaire will be divided to two sections involving: socio-demographic, tobacco-related and diabetes-specific health information; knowledge and awareness towards the health risks of smoking and their knowledge of smoking cessation and smoking cessation pharmacotherapies.

The sociodemographic information will include (age, sex, race … etc); diabetic-related information, it will contain: type of diabetes, type of diabetic treatment, duration of diabetes; while for smoking related information will involve: number of cigarettes smoking per day, age started smoking, duration of smoking, are there any attempt to stop smoking for any period of time, Are there other smokers in the household.

To compare treatment effect of varenicline and nicotine patch in abstinence rate of smoking cessation for diabetic smoker patients and to investigate the impact of the smoking cessation on the diabetic control. The study design will be randomised, open-label, parallel group study. The participants will be randomized in a 1:1 ratio either to varenicline or nicotine patch treatments. Subject who will receive varenicline will administer 0.5 mg/day for 3 days, 0.5 mg twice daily for 4 days, then 1 mg twice daily thereafter. Full dosing was achieved by the target quit date (TQD) and continues up to 12 weeks. Participant who will receive nicotine patch applied transdermal patches each morning starting on the TQD for 10 weeks. Doses of NRT were 21 mg/day for the first 6 weeks, 14 mg/day for 3 weeks, then 7 mg/day for 3 weeks.

We choose these two treatments (nicotine patch and varenicline) for several reasons. Nicotine patch is the most commonly used pharmacotherapy for smoking cessation (Burton et al., 2000, Pierce et al., 1995, West et al., 2001). Given that many smokers in general population use this treatment to quit smoking, it is important to determine treatment effect of other agents relative to the patch. Furthermore, recent data suggest that there is decline in the efficacy of nicotine patch over the previous 10 years (Irvin et al., 2003, Jorenby et al., 1999, Pierce and Gilpin, 2002). Varnecline is selected in this study because yet there is limited studies publish about the effectiveness of this treatment in the diabetic smoker population. Also, varnecline was found to be the highest efficacy in the 2008 PHS Guideline meta-analysis (odds ratio 3.1) comparing to placebo (Fiore et al., 2008). Finally, smokers could be encouraged to seek out this prescribed agent, and insurers and health care systems could be encouraged to make this treatment more widely available, if it could be demonstrated that varnecline is more efficacious than over-the-counter medication (such as nicotine patch).

In this study we will collect three types of end points: efficacy, measuring of craving and withdrawal symptoms, and investigating the impact of smoking cessation on diabetic outcome.

The primary outcome for efficacy in the study it will be self-reported CAR, confirm by exhaled CO levels of 6 ppm or below, during the last 4 weeks of treatment (varenicline and NRT, weeks 9-12 after TQD)

The secondary is the CAR from the last 4 weeks of each treatment until 6 months. Other secondary outcomes are 7-day point prevalence of tobacco abstinence at weeks end of drug treatment and at 6 months. Continuous abstinence define as self-reported abstinence from any tobacco- or nicotine-containing product during the specific period and it will be verified by carbon monoxide (CO) level ≤ 10 ppm. If the CO level is more than 10 ppm will be classified as a smoker regardless of self-reported abstinence. Point prevalence abstinence define as self-reported abstinence from any tobacco- or nicotine-containing product in the past 7 days that was not contradicted by expired air CO > 10 ppm. These are traditional standards for assessing efficacy of smoking cessation interventions (Fiore et al., 2008, Hughes et al., 2003).

The Minnesota Nicotine Withdrawal Scale (MNWS) (Cappelleri et al., 2005) will be used to assess urge to smoke, depressed mood, irritability, anxiety, poor concentration, restlessness, increased appetite and insomnia. The modified Cigarette Evaluation Questionnaire (mCEQ) (Cappelleri et al., 2007) will be used to assess smoking satisfaction, psychological reward, aversion, enjoyment of respiratory tract sensations and craving reduction. The two previous questionnaires will be administered baseline visit and at each weekly visit through week 6 (after TQD) and at the end of treatment or at termination for participants who discontinued the study before week 6 (TQD). While the MNWS will be administered to all participants, the mCEQ will be administered only to participants who report smoking since their last completed questionnaire.

Furthermore, we will assess the level of the nicotine dependence by using the Modified Fagerström Test for Nicotine Dependence (Heatherton et al., 1991) that range to three score ranges: (0-3) score indicate to low dependent, (4-6) score indicate to moderate dependent and (7-10) score indicate highly dependent. It will be administered at the baseline of the study.

Schematic presentation of study design:

Screening all diabetic patients’ medical records to estimate prevalence of smoking among them

Interviewed structured questionnaire for all diabetic smoker to:

To know characteristics of diabetic smoker (sociodemographic, diabetic history and tobacco use history)

Investigate the knowledge towards smoking cessation and its pharmacotherapies

Patients who attend quit smoking clinic Assessed for eligibility

Excluded:

Did not meet entry criteria

Withdrew consent

Randomized at ratio 1:1

Allocated to Varnicline (2mg or 1mg)

(For 12 weeks) and arrange for quit date

Allocated to nicotine Patch

(For 12 weeks) and arrange for quit date

Follow up at the end of treatment (12 weeks) and at 6 months to assess:

Abstinence rate of smoking cessation

the cravings and withdrawal symptoms

the reinforcing effects of smoking

changes in body weight

Analysis

Inclusion criteria

The inclusion criteria it will be varying among the different objectives:

For investigating the knowledge and awareness towards smoking cessation and its pharmacotherapies, smoker and ex-smoker diabetic patients (either type I or II) of both sexes aged ≥18 years will be included.

For the direct comparison between nicotine patch and varenicline, Diabetic smokers of both sexes aged ≥18 years who smoke ≥10 cigarettes/day and willing to quit smoking.

Exclusion criteria

Patient is currently using any form of tobacco other than cigarettes; any form of NRT or other smoking cessation therapy.

Significant depression requiring behavioral counseling and those using medications with psychoactive effects (e.g., antidepressants, antianxiety agents). other active psychiatric diseases because of previously identified limitations with delivery of the specific counseling intervention in such subjects.

History of skin allergies or evidence of chronic dermatosis.

Patient has medical contraindications for any of the study medications.

Pregnant, breastfeeding women or at risk of becoming pregnant.

Drug abuse or HIV infected patient.

Recent (≤3 months) history of myocardial infarction, angina pectoris, serious cardiac arrhythmia, or other medical conditions that the healthcare provider deemed incompatible with study participation.

Participation within the last 12 months in a formal smoking cessation program.

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This student written literature review is published as an example. See

How to Write a Literature Review

on our sister site UKDiss.com for a writing guide.

In order to reflect upon my learning throughout this module, I will identify and critically discuss three Module Learning outcomes that reflect the range of possible issues of the Nursing and Midwifery Council (NMC) Proficiencies (2004). I will then identify appropriate literature and reflect on my learning and experience. This will enable me to identify personal strengths and areas for further development.

The first learning outcome is: ‘Recognise the importance of reflective practice and understand the process of reflection’. The second outcome chosen is: ‘Discuss the difference between data and information?’. The third outcome is: ‘Demonstrate appropriate non-verbal and verbal skills, including the use of silence, open and closed questions and summarising, to gather information’.

*Please note that the names of the patients mentioned in this essay have been changed in order to protect their identity for confidentiality reasons.

1 – Recognise the importance of reflective practice and understand the process of reflection

This outcome relates to the NMC Proficiency of ‘Demonstrate the responsibility for one’s own learning through the development of a Record of Achievement of practice and recognise when further learning is required’.

‘Reflection’ is a new method of learning for me. With regard to nursing, the term ‘reflection’ and ‘reflective practice’ has been defined by many academics, resulting in various models and theories being developed.

The Oxford Mini-dictionary for Nurses (2008) describes ‘reflection’ as the ‘careful consideration of personal actions, including the ability to review, analyse and evaluate situations during or after events. It is an essential part of the learning process that will result in new methods of approaching and understanding nursing practice’. Johns (2000) defines reflection as ‘a window through which the practitioner can view and focus self within the context of his/her own lived experience in ways that enable him/her to confront, understand and work towards resolving the contradictions within his/her practice between what is desirable and actual practice’. Schon (1983) proposed that reflection occurs ‘on action’ or ‘in action’. The first occurs after the incident whereas the latter occurs during the incident and is said to be the ‘hallmark of the experienced professional’ (Somerville & Keeling, 2004).

The more traditional theories and models base ‘reflection’ on critical incidents. Love (1996) states that a critical incident does not have to be negative or dramatic but should provide deep thought and raise a professional issue. Gibbs (1988) developed The Reflective Cycle. The model divides the reflective process into sections; Description, Feelings, Evaluation, Analysis, Conclusion and Action Plan (see Appendix 1). Johns (2000) developed a ‘Model of Structured Reflection’ (MSR) (see Appendix 2) As with Gibbs (1988) Reflective Cycle, the MSR uses a series of questions to guide an individual through the reflective process. Johns’ model is based on five cue questions; Description, Reflection, Influencing Factors, Could I have dealt with it better? and Learning.

The volume of studies and

models on ‘reflection’

demonstrates the value that is placed on this tool. Newell (1992) described the process of reflection to be ‘a cornerstone of nursing professionalism’. Gustafsson and Fagerberg (2004) support the notion that reflection is a vital tool and advantageous in terms of the improvement of a nurse’s professional development and patient care.

Many consider journal writing to be an effective reflection strategy (Johns 2000; Paterson, 1995; Cameron & Mitchell, 1993; Lauterbach & Becker, 1996). Journal writing is considered to ‘offer writers the opportunity to become participants/observers of their own learning, to describe a significant experience and to reflect on that experience to see what they can learn from having had it’ (Weisberg and Duffin, 1995). While in clinical practice, I have written a journal of my experiences. I recognise its value to aid reflection as I feel that the act of writing things down is important. This is supported by Somerville and Keeling (2004).

To demonstrate my understanding of reflective practice, I will now reflect on an incident that occurred while on placement when I was feeding a patient, named Tom*. I will utilise Gibbs’ (1988) model as this is my first experience of using reflection and feel that it is concise and appropriate at this stage.

Tom had dementia and had recently suffered a stroke, which had left him confined to bed. As Tom had difficulty feeding himself, I offered to assist him; he smiled, agreed and appeared to recognise me. Halfway through the meal, Tom became agitated and asked if the food was mackerel. I told him that it was turkey. He shouted aggressively that he wanted mackerel and then became verbally abusive towards me. I was unable to calm him so I left the room with an assurance that I would be back soon. I then asked a senior nurse for help.

This was the first time that I had fed a patient but felt comfortable. I knew Tom well and felt that I had built up a rapport with him. I was pleased that he seemed happy and relaxed. When he shouted I felt shocked, worried and conscious of other people’s reactions; they may think that I had done something wrong. Even though Tom was disabled he did have some use of one arm so I was afraid that he might become violent. I was upset that I had to stop feeding him and leave the room. When I left I felt relieved but also anxious that I may have contributed to the way Tom was feeling.

When evaluating and analysing the incident, I was pleased initially with the way the task started as on admission he had a poor appetite. The negative side of the situation was that Tom became angry and didn’t finish his meal.

I realise that dementia is a complex progressive illness and there may be times when a patient experiences sudden mood changes.

I believe that I would now do things differently if a similar situation arose. With hindsight, I questioned whether I should have just agreed with Tom that the turkey was mackerel then this incident may not have occurred. However, this raises ethical issues such as whether it can be acceptable to not tell the truth. A report published by the Nuffield Council on Bioethics (2009) discusses the ethics of dementia care and states that ‘

ethical dilemmas

arise on a daily basis for all those providing care for people with dementia’. Research suggests that challenging someone with dementia could be detrimental and cause unnecessary distress (Shellenberger, 2004). Naomi Feil developed ‘validation therapy’ between 1963 and 1980 as a technique to communicate with patients with dementia by recognising and accepting their view of reality of people with dementia in order to provide them with empathy and respect (The Validation Training Institute, Inc). In the future I could use this technique; for example, when Tom asked if it was mackerel he was eating I could have replied by asking him if he liked mackerel which would have avoided giving a direct answer.

With regard to strengths and areas of development, I feel that I have reflected successfully on this incident. However I would like to strive to reflect ‘in action’ as opposed to ‘on action’ as this is the most effective. In terms of development, I believe that it would be beneficial to patients and myself to learn more about caring for patients with dementia. The Dementia UK Report (2007) published by The Alzheimer’s Society states that ‘there are currently 700,000 people with dementia in the UK. The report also predicts that by 2025 there will be over 1 million people with dementia so it is inevitable that I will be caring for many dementia patients in my career.

In summary, although the models of reflection span over 20 years and vary slightly, the principle of reflection is very similar, which implies that reflection is a robust tool and still applies to modern nursing. I have learnt that reflective practice is a vital tool, particularly when associated with journal writing. Continuous reflection will allow me to develop skills and knowledge to enable me to provide the best care possible for patients and their families.

2 – Discuss the difference between data and information

This learning outcome links to the NMC proficiency of ‘Demonstrate literacy, numeracy and computer skills needed to record, enter, store, retrieve and organise data essential for care delivery’.

As a student I’m not involved in using my computer skills on the ward but eventually will be involved in audit and data entry. My literacy and computer skills are demonstrated throughout my portfolio and assignment. I demonstrate my literacy and numeracy skills when writing patient evaluations, calculating fluid balance and assisting with drug calculations.

There are many examples of data and information used within nursing care. Due to the broad nature of this area I have focused on a particular type of ‘data’ and ‘information’ to demonstrate my understanding of these terms. My focus is data collected from patients’ vital signs and the ‘information’ that relates to this. I will demonstrate how the process of giving ‘information’ to patients rather than just ‘data’ is an essential part of nursing.

Gathering, giving and recording both data and information accurately is vital. ‘Data’ can be described as ‘facts and statistics used for reference or analysis’. The term ‘information’ can be defined as the meaning applied to the data (Concise Oxford English Dictionary, 2008).

Observation data collected from patients includes pulse rate and rhythm, blood pressure, respiration rate, temperature and oxygen saturate percentage. These measurements are taken on admission as it is important to gain base-line readings to which future readings can be compared. It is necessary to apply meaning to this data to form information to be able to judge a patient’s condition.

Throughout the module I have learnt what data means in terms of acceptable values. As I now have the information about the data I can make judgments about data. For example, I now know that the information I can get from the blood pressure data of 160/110 mmHg is ‘high’ (Blood Pressure Association). However, this information needs to be put into context to allow use of the information to make a judgement. For example, if a patient has just completed cardiovascular exercise, this may account for a high blood pressure reading. With this information, the plan would be to wait for 30 minutes before repeating to gain more accurate data. Readings can vary temporarily due to a number of reasons; for example, medication, an existing health condition, fluid intake, exercise and alcohol consumption. However, a change in blood pressure can indicate deterioration in condition, which alerts health care professionals to investigate.

In order to show my understanding of the difference between data and information I will now give an example of an incident that occurred while on placement.

During observations of a 70 year-old lady named Eileen*, I noticed that her systolic blood pressure had dropped from 127 to 90 mmHg. Her other observations remained consistent. I informed a senior nurse who asked a doctor to review the patient. I discussed her fluid intake with her as this could have had an adverse effect on her blood pressure. As she had only drank a small amount I encouraged her to drink more and continued monitoring. Eileen’s blood pressure eventually returned to her baseline. This example shows how data, such as blood pressure readings, prompts gathering information which, in turn, enables problem solving.

As demonstrated, I need to have an understanding of the information gathered from the data but additionally I feel that it is important that patients understand what the data means. Bastable (2006) defined ‘patient education’ as the ‘process of assisting people to learn health related behaviours so that they can incorporate those behaviours into everyday life and achieve a goal of optimal health and independence in self care’.

I will now provide an example of my experience of patient education: During a blood pressure check on Paul*, who was hypertensive and took multiple medications, I asked him whether he would like to learn about blood pressures. He gladly agreed so I explained what the reading was and what can affect blood pressure. I explained that exercise, healthy eating, low salt intake and weight control would have a beneficial effect on his blood pressure. He was unaware of how his current lifestyle could have a detrimental effect on blood pressure and said that he now intended to make some lifestyle changes.

Research supports my thoughts about the benefits of giving patients information about aspects of their health rather than just the data. Florence Nightingale, who has been described as the founder of modern nursing, recognised the importance of educating about adequate nutrition, personal hygiene and exercise in order to improve well-being (Bastable, 2006). The Department of Health (2009) states that ‘giving people relevant, reliable information enables them to understand their health requirements and make the right choice for themselves and their families’. (Bastable, 2008). Partridge and Hill (2000) found that patients who are well informed are better able to manage their health, have improved psychological outcomes, have fewer exacerbations of their condition and less hospital admissions. Glanville (2000) states that ‘if clients cannot maintain or improve their health status when on their own, we have failed to help them reach their potential’. Abbott (1998) reported that by involving patients in their state of health by keeping them informed has been proved to improve patient satisfaction and concordance. However, there is research to suggest that providing information may not result in a change in health outcomes (Kole, 1995; Sherer et al. 1998). They found these reasons to be that patients don’t understand the information, are unable to absorb it due to pain, anxiety, or that they choose not to act upon it. Additionally, absorption of information is decreased when there is too much information; therefore health outcomes remain unchanged. The question is how much is too much information? This is difficult to determine.

In terms of personal strengths, I felt very satisfied that I had initiated this conversation which resulted in Paul considering lifestyle changes. On reflection, this incident highlighted the importance of patient understanding and has encouraged me to take time to educate patients where possible. It has emphasised the need for continuous learning so that I am able to answer questions and educate patients. Additionally, I am aware of my limitations and when to seek advice or refer patients to others. I also need to develop confidence in speaking to patients about sensitive issues such as weight management by researching this area.

3 – Demonstrate appropriate non-verbal and verbal skills, including the use of silence, open and closed questions and summarising, to gather information

This outcome relates to the NMC Proficiency of ‘Engage in, develop and disengage from therapeutic relationships through the use of appropriate communication and interpersonal skills’.

Communication is a ‘reciprocal process that involves the exchange of both verbal and non verbal messages to convey feelings, information, ideas and knowledge’ (Wilkinson 1999; Wallace 2001). In nursing, communication and information gathering is essential to provide quality care. Sheldon, Barrett & Ellington (2006) report that ‘Communication is a cornerstone of the nurse-patient relationship’.

Information gathering commences from when the nurse greets the patient. In order to communicate non-verbal and verbal cues are used. Non-verbal skills are portrayed with body language and impact on communication (Hargie & Dickson 2004). These include posture, facial expressions, head movement, eye contact and hand gestures showing active listening. Verbal skills include the use of silence, open and closed questions and summarising. The tone of voice and rate of response are significant.

The emphasis is on effective communication; the way we communicate can hinder or enhance the information we gather. Sheldon et al. (2006) state that ‘the power of effective nursing care is strengthened and enriched by good communication’. Maguire and Pitceathly (2002) suggest that clinicians with good communication skills identify patients’ problems more accurately, patients are more satisfied with their care and are less anxious. It has been reported that that ineffective communication can lead to patients not engaging with the healthcare system, refusing to follow recommended advice and failing to cope with the psychological consequences of their illness (Berry, 2007).

The scenario below demonstrates my understanding of appropriate verbal and non-verbal cues. It is part of a conversation with a patient on admission regarding current medical history.

When meeting Arthur*, a 78 year old, I smiled, introduced myself and explained the purpose of our conversation. I asked Arthur ‘Do you have any chest problems?’ he answered ‘Yes’. I then asked ‘What chest problems do you have and how do they affect you?’ he answered ‘I have emphysema causing wheezing and a cough. I also get breathless when walking and have oxygen at night’ I left a brief silence at this point. Arthur then disclosed ‘I cough up a lot of horrible phlegm in the morning which is embarrassing’. He then asked ‘will I get a chest x-ray’. I asked ‘Have you any particular worries about your chest?’ to which he replied ‘well I am quite worried about lung cancer’. I told him that I would pass on his concern to the doctor and then summarised our conversation.

With regard to verbal responses, I initially asked a closed question as I wanted a specific answer. Silverman et al. (2005) supports the theory that closed questions are appropriate when wanting to narrow the potential answer. Due to Arthur’s response I asked an open question to encourage him to go into more detail. An open question often results in a lengthy answer, so I used fillers such as ‘mmm’ throughout, to show active listening and to encourage him to continue. The brief pause was successful as it enabled Arthur to disclose his embarrassment. I summarised his response in order to clarify what Arthur had said for my own benefit but also to give the patient confidence that I had understood and opportunity to correct me if not.

With regard to my non-verbal communication, I kept an open posture with eye contact and leant forward slightly to show that I was listening. I also ensured that my facial expressions were appropriate. For example, when greeting Arthur I smiled, but during descriptions of distressing symptoms my facial expression was one of concern. Egan (2002) supports the notion that conveying these non-verbal cues in this way will facilitate emotional disclosure and encourage the patient to talk more freely. Egan derived the acronym SOLER to portray awareness of the non-verbal responses; facing squarely, maintaining an open posture, leaning slightly forward, having appropriate eye contact and being relaxed. There are approximately 700,000 different non-verbal cues that may or may not have meaning (Birdwhistell, 1970; Pei, 1997). As nurses, we must be aware of our use of non-verbal cues as they can convey unintentional meaning.

In addition to awareness of our responses it is imperative to be aware of patient cues, as this is part of the information gathering process. Arthur’s hesitancy indicated to me to remain silent to encourage further disclosure.

Being aware of patients’ verbal responses is more straightforward than what their non-verbal responses convey and it may be that patients’ body language contradict the spoken word (Miller, 1995).

Barriers to communication include anxiety, language, hearing, sight or speech impairment. During communication, I would like to think that I am non judgemental. According to Underman Boggs (1999) most of us have personal biases regarding others that are based on previous experiences. In relation to my scenario, Fuller (1995) suggests that health care professionals may underestimate the verbal capacity or abilities of older people, which results in their conversations being undervalued.

In terms of personal strengths, I feel fairly confident with the use of verbal and non-verbal cues and how these can deter or catalyse communication. I feel that I used silence successfully as Arthur disclosed embarrassment and mentioned about an x-ray, which he may not have done otherwise. I was able to reassure him that we would provide a disposable sputum pot and acknowledged his fear of cancer. I realise that it can be difficult communicating about sensitive information and this is an area of development for me, which I feel will improve with experience. Although at this stage of training I would not be expected to lead consultations for diagnostic purposes, it was informative to research ‘consultation models’. I intend to become more familiar with these models in order to utilise some of the communication skills (Newell, 1994).

To form an overall conclusion, I feel that through theoretical learning and clinical experience I have demonstrated my achievement of the NMC Proficiencies (2004). I have critically discussed and concluded each learning outcome in turn throughout the essay but to summarise; patient focus and effective communication are paramount. I feel that in terms of reflection, self-awareness is key (Rowe, 1999). This will enable me to look at my skills to recognise strengths and areas of development to ultimately provide best practice in patient care. I realise that I will gain experience and confidence as my training progresses.

Word Count: 3289

References

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APPENDIX 1

Gibbs (1988) model of reflection

C1 (4.1) Explain how the health and social care practitioner supports individuals with learning disabilities to overcome barriers.

Work within policies and procedures

Healthcare practitioner should support individual with learning disabilities to overcome the barriers they should work with the policies and procedures it allow them to understand what they should do when they are struggling to overcome the problems it is important to work with policies and procedures it give an ability to do something has policies and procedures gives guidance for decision making. Procedures can support a practitioner with identify the cause of disabilities, what action should they take, it shows emergency procedures if a practitioner are working police and procedures they can increase the number of accident and it can increase complaints, has policies and procedures enable the workfare to clearly understand individual and practitioner responsibilities and clearly written policies and procedures must be follow by the service. You need to follow the policies and procedures practitioner within health and social care in learning disabilities this is to make sure that every individual are safe also we are make sure that we stay keep the individual safe and they need to protect them they don’t protect themselves they will face different consequences it is important for health and social care practitioner to safeguard individual when they are working and supporting them.

In learning disabilities if we don’t follow policies and procedures it can cause lot of barriers to the individual such as not be able to provide wheelchair for the people who can’t walk. Polices and produces train to staff and individual who recently developed learning disabilities and it provide better opportunities for people with learning with the necessary level of support to live their lives as they wish and make informed choices and decisions also in case where the individual does not have the ability of capacity to understand the risk of learning disabilities for example practitioner can provide a person who can hear a hearing aids or sign language who can translate for them. Working within policies and procedures can prevent discrimination and to take away a stigmas has policies and procedures give equal opportunities the Equality Act 2010 is about giving individual equal treatment for the individual who has learning disabilities.

Care Plan

Care plan is important because it the practitioner to plan a activate for the patients who has learning disabilities it will help the person to overcome the problems and be able to follow the care plan easily, it ensure that patients gets the same care, care plan also to ensure that the care given is recorded it support the patients  and to meet the individual needs to they can achieve their outcome of care it is important that you has a practitioner involve them while you making their care plan for example ask them what they like to do when they are free or their likes and dislike this you will get to the patients and you will understand them. Having a care plan will help and support individual emotions it help them physically has they are more likely to do more different kind of activities such golf, fishing they will be socially active day-to-day has the duty of care provide the support, need for the individuals. In the Learning disabilities we have care plan  so we can help the vulnerable people and provide them their need such as medication, food it is also about keeping them safe away from danger and to communicate with the individual and to report the outcomes. To support a vulnerable person to overcome this barriers we the learning disabilities practitioner should provide support such as a Care Assistant who can plan your care orgisaning your active  and looking after your personal care and needs it is massively important that we provide support to the people who do not have the capacity to look after themselves whereas the care plan will support them with their personal care, needs providing care also their medical support, a care plan will identify the responsibilities of learning disabilities professional they tend to improve the person living by providing them with treatment.

Person-Centred Practice

Person centred practice is to put the person in the centre of care this will protect the individual from mistreatment or abuse, neglect and harm the healthcare professional will work together to improve the person health and welfare. The person- centred practices is important because everyone is different and unique this promote the rights of the child and young person to choose make contraction and communicate has this will help to plan for the individual need, people values and putting people at the centred of care to help them to develop their own health and we should ensure that the people are physically comfortable and safe the person centred practices help the individual access higher stranded support and we ensure that people get all the information they need in way that is accessible for them and to make decisions for their care and support. Within safeguarding we should values the person has this will allow us to understand them and to value the relationship with the clients and the counsellor or care provider also we should  respect the individual and congruence we should not be non-judgement in safeguarding we should show empathy has it will allow them to speak and trust us. The person centred practices involve lot of different people from different background such as the children, adults, young people, middles adulthood , late adults, professional people from different background every individual is different from each other we means that we need to have different plan for them to develop their own health and growth development.

Empowerment

Empowerment support individual with learning disabilities has it help to them develop their self-esteem and awareness children and young people tend to feel low confidant and helpless because they have learning disabilities it is important that in health care we encourage young people and children to self-care for themselves and approach them to try new things this way it will build their confidant and self-esteem. For example, a dementia patient is refusing to taking a medication a care assistant should approach this with care and advise them to take this medication so they can get better be able to do different activities by themselves, empowerment provide care and support and having equal opportunity empowerment is like a person centred of care the practitioner tend to put the person in the centre of care and they will work with different organisation to improve the person living. Empowerment is most lily to use in the residential care home where they approach residential to make their own decision this will protect their rights of choices also they will be informed choices has you are involving them in their decision, if the healthcare doesn’t approach the patients they will not look after themselves it is important that healthcare advice the patient to maintain the health and growth, welfare.

Advocacy

A advocacy is to empower people to ensure that their views and opinions are heard in any decision making they tend to support and put forward people with learning disabilities this is because healthcare service is making sure that every individual has right even if the person has disabilities has it help individual to speak out about things that negatively affect them this can be about themselves, treatment or even someone is not being treated rightly it representing the person wishes and feeling, it ensure a person rights and entitlement are being met. For example, a person who is deaf and blind can ask for advocate to guide them and be led by the person only doing what they request also to be friendly while still maintaining boundaries advocate must listen to the person wishes. There are different types of advocacy such as peer advocacy, informal advocacy, formal advocacy and professional/independent advocacy this is make sure that everyone have the same life opportunities as other for example some people with learning disabilities don’t get to the opportunity to go to school due to their desirability the Children Act 2014 say each child should be treated with respect and they should have same equal opportunity. The health and social care should support each with learning disability and listen to their problems should have an understanding with the person this you can build trust, their self- esteem and confident.

Partnership working

partnership working is when different companies work together to improves the best outcomes for the patients to improve the safeguarding setting we need to provide the best care for our patients has some service do not provide the care and equipment and has they may not respect the individual need or having a poor service as we are working with vulnerable in learning disabilities we tend to work with different people with different types of disability such as learning disability, mental health conditions, intellectual disability and autism spectrum disorder, we the learning disabilities practitioner work with different service that can be benefited for the individual has they are suffering from different abuse and neglect also harm working with health and social care service will help us to develop lots different idea such as how to improves the individual needs and support, keeping the individual safe we should value each individual input  we the learning disabilities practitioner making sure that each individual receive high quality of care and support. Partnership in learning disabilities is mainly working together sharing ideas and working  with other practitioner within that setting to make sure that patients get the right treatment has they will be meeting specific need of child, young person and adults partnership working is important if a child were to be cared for by ranges of people, has partnership working is about identifying the need for agencies to cooperate and work together in order to improve children wellbeing such as be healthy, stay safe, making positives contribution, in learning disabilities the health care service tend to look after vulnerable people who don’t have the capacity to make their decision its important to work with different organisation to improve the quality of health and welfare this will be benefited for the person and the organisation

Positive attitudes

we need to have a positive attitude in healthcare learning disabilities so we can encourage the person who has the disabilities to support them by providing care and needs the practitioner should an positive attitudes so they can provide care for the patients and to respect the patient personal information and their health states. Having positive attitudes will enable the person to control their mood and they will have the ability to handle patients with disabilities. if are the care giver you need to have positive attitude to respect the patients  and to support them also Individuals with a positive attitude will feel the impact on their health due to lack of disease and increased overall positive well-being having positive attitudes will help the person to a stress time it will support them. For example Nurse should have the positive attitude so they can provide care for the patients they should not panic if they see someone with lots blood or someone with a disability that is affecting their health and wellbeing.  Having a positive attitude will enable to show empathy for the person with disabilities you will be more patience and you will have the abilities or show respect for example you will knock on the door before you can see your doctor also mainly important if you have positive attitudes you will have the abilities to work under pressure.

Challenge discrimination.

Within learning disabilities vulnerable people tend to face discrimination because of their disability has the people may judge them and feel petty for them and you must always challenge discrimination whenever you come across and you must always  record and report discriminatory behaviour and comments for example when young children uses bad language teacher should tell them off and they should not shout at them and everyone in schools should be treated fairly and with respect, services providers need to make sure their setting is promoting equality and diversity  facing challenge discrimination can be hard buts you should be positive such as you can challenge discrimination by questioning.

Access to services, information, advice and guidance

Information, advice, guidance this is an information that tell you something about how to keep someone safe or perverting any risk having this information will support us in our daily live this information will guide us from any danger. In the mental health this would help us for example if a person has been sexual abuse then he/she can go to any local user to get help or he/she can look up online to get help such as NCPEE, Rape Crisis it advice you where you go and get support to support your health it is very important you get advice from professional or read the information to guide you if you have been abused or neglect has it will guide you where you should get help and how.  This will help individual with learning disabilities if they have been treated unfair it will guide them to go to right service that will help them with their disabilities also having to access to a service which mean having an access to life and ramps, lop system and communication barriers it is important that service have the access to the wheelchairs also access to blind people having braille.

Environment

Advocacy service is when someone speaks on behalf of you. They would keep it confidential unless you want them to share with others. For example, if you find it hard to speak to the doctors someone on behalf can speak for you example your parents and careers.

B1 (2.1) Discuss causes of learning disability.

Learning disability can be genetic which tend to run in the family or it could be that your whole generation has learning disabilities such as down syndrome is an genetic which is caused by the additional of an extra chromosome in the body cell has this is not an disease that will kill the person they tend to have a learning disability that will likely to affect their living such as need of extra support, not be able to write or read due to the chromosome in their body.

Complications during birth

Having complication during birth can be very relay because during not only this will affect on the child but also on the mother health and wellbeing, complication normal occur during the baby labor and delivery which can have severe effects on both if the complication results in brain damage to the child and the child may end up being diagnosed with cerebral palsy it is important for the both individual to have a healthy diet also practitioner need to make sure when they are delivering the baby they must be ready and need to extra care.  For example, complication during birth that lead to cerebral palsy can put the babies at an increased risk for cerebral palsy because it can affect their brain has it can happen due to the complications reduce or cuts off oxygen to the baby brain also it can cause physical trauma which mean that they can have movement also their brain they might not have the ability to do something on their own.  If you are worried during the labor it can affect the baby it is important that you attend you doctor appointment has it give the ability to the doctor to understand and screen the potential complication and to prevent them from causing harm to the baby and mom.

Illness

Illness you can be diagnosed by the environment or someone can pass on to you such as Tuberclosis which is a bacterial infection that can spread through the body and it can pass on to other individual and they may also be diagnosed (NHS 15/11/2016). Many of illness that we experience are short term and treatable. Such as coughs, cold and broken limbs can all be cured with the right medicine and treatment and we will not have any long lasting impact on growth or development. Some illness and disease can have much more serious consequences such as the genetics haemophilia downs syndrome and cystic fibrosis are all life- long conditions that cannot be cured and which will impact on the person health and wellbeing.  It is important that you see your doctor on time has illness may be the sign of disease. Also having illness can prevent the risk of disease has illness tend to happen when you have flu and cough if you don’t get treatment you may be ill for long term it is important in learning disabilities that children with learning disabilities is treat straight way due they can get easily affect also they can pass on the other individual has children with disabilities don’t have the abilities to speak and notice if they are ill they body tend to have an illness with may affect their learning disabilities.

Disease

Disease can be genetic or you can develop later in life diseases different types of diseases have different impacts health and wellbeing they are disease is form has you can die and it lead to long- term illness something a disease can be treatable by the medication such as Tuberclosis is treatable with medication with will kill the bacterial. Some learning disabilities are common in people who suffer from disease such as down syndrome this is disease which can cause by an extra chromosome in the person cells. Diseases will impact on the person living such it can effect on the person cognitive, emotional, social and physical development individual with diseases must likely to suffer from different health issues also diseases can be inherited for example two individual with learning disabilities are must likely to pass on to their children and they can develop learning disabilities. Has the disease is a disorder that control in the individual health and wellbeing which can affect the person mind and body which can lead to lot of different development, disease may have single cause for example heart disease it has different symptoms which effect the person physical and mental. Children with learning disabilities are at risk of health for example if they have disease it causes them health problems not only that children who has already has diseases if they develop a new disease it can impact on the mind, body and it grown on different parts of the body it is important that we keep the children with learning diseases has a healthy lifestyle by taking them to regular check-up which will help them to stay healthy.

Environmental/ Unknown

An environment and unknown cause of learning disabilities an environmental is when you develop it from the pollution which may cause disabilities to the individual. Drinking or taking drug is an environmental cause learning disabilities which affect the baby in womb and it can put the bay in risk for learning problems or even disabilities also some people may have learning disabilities later in life such as if some has accident and it may affect their brain due to the injuries.  Having a poor nutrition may lead to physical and cognitive development has it may show sign of learning disabilities many individuals tend develop environmental learning disabilities due to driving faster than usually it is important when a young person on the road they must wear their seatbelt which will prevent them hitting their head and damaging their brain.  Having poor diet which it impacts on the person living it impact on their cognitive, social, emotional and physical development some people may be underweight or obese having people who has obesity are more likely to have some serious health problems such as stroke, stroke may lead to learning disabilities it affects the person cognitive and physical development. Whereas the unknown cause of learning disabilities has no known cause it is because there are no known reasons as to why a learning disabilities has developed such as autism the healthcare practitioner doesn’t know the case of autism why children and adults suffer from autism it is unknown.

B2 (4.2 ) Describe the support available for individuals with learning disabilities.




A minimum of three (3) sources of support available for individuals with learning disabilities must be described.

Support groups, networks

The support that should be available for young people is it support children with learning disabilities who need support with their learning in primary school you tend to see a teacher working with one student to support them with their learning and to understand the concept learning.  Has not only healthcare learning disabilities practitioner not only provided support to the children but also the provide the medical treatment for them in case some children have been hospitalised care, a support groups, network is small service that provide children with support such playgroup, health problems, disabilities which movement and maintain their health as they go alone. Networks of support are groups organized around specific conditions or disorders, diagnosis, treatment, and prevention. Support networks, like other forms of patient education, allow patients to become more informed about their illness and play a more active role in their health care. It provides an opportunity to meet other children who has different types of learning disabilities children with learning disabilities tend to feel lonely, isolated, judge, and anxiety due to their disabilities. If a child is being involved in the support groups and network if will help them with their emotional development has they are improving their skills to cope with the challenges, talking openly and honestly about their feeling has when they are at the support group each person is supported by their needs and practitioner would support them with their learning disabilities

Day Care

A Day Care service provide vulnerable children and adults support to help and support them with their complex needs has it give new opportunities to the learning disabilities individual its allow them to develop new skills and quality(Belfast health and social care trust 2019). Learning disabilities practitioner will be working with children who has learning disabilities problems they will be helping to provide them with their basic needs which will allow them to understand their health problems day care service will support individual with learning disabilities with their personal care, serving food, drinks, being creative such as art and crafts, meeting other children with disabilities, gentle exercise to maintain their health and wellbeing. It is imporant that you has parents and practitioner to provide children with good quality of day care serivce which allow each child to become more independent, learning new skills and quality also it is to protect children from discrimination for example children with learning disabilities should have the to be educated even if they are disables no child should be isolated due to their disabilities under the act of Equality Act 2010 an healthcare organisation that provide serivce to the child they must not be discrimincate against them if they are disabled and they must provide adjustment such lift, ramps to ensure that they the same rights and learning opportunities as other children  also the Equality Act 2010 is making sure that each child with disabilities has the same right and opportunities.

Respite

.

Respite mean in learning disabilities taking care of someone for a short time of time or for a long time has respite means providing care for the individual who has learning disabilities and difficulty learning or finds it hard to live independently. Respite can be planned or it can be emergency temporary it can be provided to the children and adults it is a positive short time experiences for the person who is receiving care. It allow the person to take break from the person that they are caring for they tend to force on their own health has you will be having break from caring which mean if you are going away without the person you are for they may have temporary stay in residential care for example if you choose to go on holiday without the person you care for you would put them in residential care or day centre

B3 A minimum of two (2) relevant and traceable references must be included. A reference list must be included.

• Zebra(2019)Challenging Discrimination(Online)Available at:
  

  Courageous Conversations: Challenging Discrimination

  [date Accessed 01/2019]

• Northumberland County Council(2019)Policy, Procedure and guidance for Manager and staff(Online)Available at:
  
  https://www.northumberland.gov.uk/NorthumberlandCountyCouncil/media/Health-and-social-care/Policy-Procedure-and-Guidance.pdf
  
  [Date Accessed 02/05/2019]
• Continuous are for health(2019)what is patients empowerment(online)Available at:
  
  https://www.continuouscare.io/blog/why-empowering-patients-is-important/[date
  
  Accessed 27/04/2019]
• Bettal Quality Consultancy(2019)Learning Disabilities(Online) Available at:
  
  http://www.bettal.co.uk/care-service-products/learning-disabilities/
  
  [Date Accessed 21/04/19
• Seap advocacy(2019) what is Advocacy(online)Available at:
  
  https://www.seap.org.uk/im-looking-for-help-or-support/what-is-advocacy.html
  
  [Date Accessed 27/04/2019]
• Social care institute for excellence(2019)what do we mean by partnership work(online)Available at:
  
  https://www.scie.org.uk/publications/guides/guide23/messages/mean.asp
  
  [Date Accessed 27/04/2019]
• Lockton Afinity Health(2019) Benefit of positive attuide(Online) Available at:
  
  http://locktonmedicalliabilityinsurance.com/positive-attitude-in-healthcare/
  
  [Date Accessed 29/04/2019]
• Health line(2019) Complication during Pregnancy and delivery(online)Available at:
  
  https://www.healthline.com/health/pregnancy/delivery-complications#complications
  
  [Date Accessed 13/05/2019]
• NHS(2019)Overview Tuberculosis(online)Available at:
  
  https://www.nhs.uk/conditions/tuberculosis-tb/
  
  [Date Accessed 13/05/2019]
• Health knowledge(2019)Illness as social role(online)Available at:
  
  https://www.healthknowledge.org.uk/public-health-textbook/medical-sociology-policy-economics/4a-concepts-health-illness/section2
  
  [Date Accessed 13/05/2019]
• The BMJ(2019)social networking for patients(Online)Available at:
  
  https://www.bmj.com/content/354/bmj.i4201
  
  [Date Accessed 14/05/2019]
• Belfast Health and Social care Trust(2019)Day care Service for older people(Online)Available at:
  
  http://www.belfasttrust.hscni.net/services/DayCare-OlderPeople.htm
  
  [Date Accessed 16/05/2019]
• National institute on aging(2019)what is Respite care(online)Available at:
  
  https://www.nia.nih.gov/health/what-respite-care
  
  [Date Accessed 23/05/2019]

The World Health Organisation (2019) outlines that universal healthcare enables people to “have access to the health services they need (prevention, promotion, treatment, rehabilitation and palliative care) without the risk of financial hardship when paying for them.” The benefits of universal healthcare go beyond the maintenance or improvement of population health; the World Health Organisation recognises that, because of its affordability and effectiveness, there are also social and economic benefits that, especially in developing and third-world countries, could be crucial foundations for significant progress in society.

The World Health Organisation (2019) identifies five factors pivotal to the successful implementation of universal healthcare in a country/community: an efficient, well-run health system requires the placement of person-centred care at the forefront of treatment and the satisfaction of all health needs at all phases of healthcare; affordability of treatment through a financing system that prevents placing an economic burden on patients and their families. availability to “essential medicines and technologies” vital for effective treatment of patients; a sufficient workforce of trained, motivated workers to provide service tailored to the needs of the patient; “[actions] to address social determinants of health”, which can lead to the prevention of health problems and, hence, better functioning of society and health workplaces by decreasing the number of people needing health treatment.

Australia’s health system aims to practice affordable treatment for all populations through Medicare, which has been critical in the catering of healthcare for populations whose circumstances mean that the reception of healthcare could place a financial burden on them (Australian Government Department of Human Services, 2019). Medicare covers a range of essential healthcare treatments, such as visits to general practitioners and specialists, tests and scans and surgical or general procedures.  Through this, Medicare ensures that the burden placed on populations susceptible to health problems or financial hardship is reduced and that all Australians have adequate access to their personal healthcare needs. However, dental, ambulance and some doctor services, all of which could be essential to the treatment of an option, are have no or limited coverage by Medicare (Australian Government Department of Human Services, 2019). Hence, there is still the risk of placing an economic burden on populations whose social circumstances make them vulnerable to health problems as they may have to pay the full cost for expensive dental, ambulance or doctor services essential for the treatment of a patient.

There have been efforts made by the Mexican government and other organisations in the successful employment of universal healthcare, particularly through the addressing of social determinants affecting population health and access to services. The biggest exponent of Mexico’s employment of universal healthcare is the Seguro Popular scheme. This scheme addressed a problem concerning lack of health insurance coverage for a significant Mexican population, who had to pay largely out-of-pocket for essential healthcare because the only main source of health insurance came through employers (World Bank Group, 2015). For the poorer population, this created a significant risk of placing a financial burden on them. It has since been reported in 2012 that 72.3% of the poor population that did not have health insurance has benefitted from the introduction of Seguro Popular (World Bank Group, 2015).

However, Mexico faces challenges in the implementation of universal healthcare. One factor is wealth inequality and the significant amount of investment needed to provide healthcare for Mexico’s substantial poverty-stricken population. As of 2016, 58.2% and 39.2% of the rural and urban Mexican population, respectively, were reported to be in some form of poverty, and despite a 9.7% and 1.5% decrease in extreme poverty in rural and urban populations since 2010, only a 4.3% and -0.3% in decrease in those classified as being in some form of poverty in rural and urban populations respectively was reported. (Consejo Nacional de Evaluación de la Política de Desarrollo Social, 2016).

Alongside Seguro Popular, an initiative designed to aid the Mexican population in poverty is Prospera. By giving money to families as an incentive to send their children to school and health treatments, the Prospera program is encouraging and enabling families to invest money into nutritious food and housing amenities (World Bank Group, 2014). Through this, Mexican children in poorer families, are placed in a prime situation to be able to get their families out of poverty in the future. The World Bank Group (2014) reported that Prospera has had a positive impact on education, nutrition and, hence, health prevention: children are spending eight to ten months more in schools and poverty has been reduced in rural areas. Prospera has also expanded into alleviating the pathway to vocational training and formal employment (World Bank Group, 2014). This would further assist in eliminating poverty in families as it would allow children to have a set pathway to employment and financial security.

Alongside wealth inequality, obesity, which has risen in the last few decades to now affect nearly 30% of Mexicans, is also a major issue contributing to numerous preventable incidences of chronic illnesses and deaths and, thus, healthcare expenditure (DiBonaventura et al., 2017). It was reported that 276.9 deaths per 100,000 resulted from non-communicable diseases, a figure that has slightly decreased in the last 27 years, (Institute for Health Metrics and Evaluation, 2019).

Turnbull, Gordon, Martínez-Andrade & González-Unzaga (2019) highlight a number of social determinants and factors that have influenced behaviours such as increased sedentary behaviour, reduced physical activity and an unhealthy diet that has contributed to a growing obese population: unsafe environments, particularly in low-income areas, due to crime and underdevelopment, increased consumption and advancements in social media and video games, abundance of unhealthy foods and the idea of giving desirable food, usually unhealthy, as an expression of love. Whilst technological advancements would be a difficult barrier to overcome to increase physical activity levels as they are pivotal to the development of Mexican society, convincing parents not to feed their children unhealthy food, whilst it might conflict with personal values, can be overcome with the right education.

The Mexican government has only tried to rectify one of these determinants, unhealthy diet choices, through the introduction of a sugar tax on added-sugar beverages. The World Health Organisation (2018) reported a decrease in the purchase of added-sugar beverages, particularly amongst the poorer population, in Mexico after the application of a “1 peso per litre” tax.

The Australian Institute of Health and Welfare (2017) devised a health performance framework that can evaluate the current state of Australia’s health system to improve healthcare and ensure that it is inclusive and sustainable. One dimension within this framework is health status, and, with a focus on health conditions and deaths, it can be used in the analysis of Australia’s and Mexico’s practice of universal healthcare.

The current state of health conditions in Australia and Mexico reflect both the effectiveness of universal healthcare practice in both countries and the factors affecting these. Data from the Institute for Health Metrics and Evaluation (2019) reveal a stark difference in the prevalence of “15 neglected tropical diseases”, with an estimate of 0.02% and 16.3% in Australia and Mexico (16.2% decrease since 1990) respectively. The Institute for Health Metrics and Evaluation (2019) also revealed that Australia outperforms Mexico in essential universal health coverage (95.2% to 63.6%) and vaccines coverage (95.4% to 84.2%), thus it is apparent that whilst it has improved as evidenced by the 16.2% decrease, Mexico’s universal healthcare coverage is insufficient in rural populations, and hence essential treatments that enable the prevention of neglected tropical diseases are unavailable to Mexicans in rural areas. International Diabetes Federation (2019, 2019) data on the diabetes prevalence in the adult population show that 14.8% of Mexicans are affected by the health condition, compared to 6.5% of Australians. Whilst not all cases of diabetes are related to being overweight, both countries’ health systems could improve in the prevention of diabetes through the conception of solutions to tackle the problem of a substantial amount of people becoming overweight.

The causes of deaths in Australia and Mexico are an indication of the strengths and weaknesses of each country’s universal healthcare. According to data from the Institute for Health Metrics and Evaluation (2019), both countries perform poorly in self-harm deaths, which arises from a non-communicable disease, and it is more prevalent in Australia (10.8 per 100000) than Mexico (5.8 per 10000). This suggests that mental health problems are a major issue in both countries and, because Mexico’s only significant form of universal healthcare is Seguro Popular and Australia’s universal healthcare is geared towards equity and the prevention, and treatment of, biomedical risk factors and chronic conditions, both countries could improve in addressing mental health and investigating the factors leading to mental health illnesses to reduce the incidence of suicide (World Bank Group, 2015; Australian Government Department of Health, 2019). Data on cardiovascular-related non-communicable deaths from the Institute for Health Metrics and Evaluation (2019) show that, despite underperforming in overweight children aged two to four and a 9.6% increase in that statistic, Australia performs effectively in non-communicable deaths, with 190.8 deaths per 100000 compared to Mexico’s 276.9 deaths per 100000. Considering the statistics for diabetes for both populations, this demonstrates the effectiveness of universal healthcare, with the offered services and targets set by the Australia Government Department of Health (2019), which include Medicare and its Medicare Benefits Schedule and Pharmaceutical Benefits Scheme, and Mexico’s Seguro Popular scheme having a positive effect on health problems such as cardiovascular-related non-communicable diseases.

References:

• Australian Government Department of Health. (2019). The Australian health system. Retrieved from https://www.health.gov.au/about-us/the-australian-health-system
• Australian Government Department of Human Services. (2019). What’s covered by Medicare – Health care and Medicine. Retrieved from https://www.humanservices.gov.au/individuals/subjects/whats-covered-medicare/health-care-and-medicare
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  Rural poverty in Mexico: prevalence and challenges
  
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