The understanding of health has evolved into a multi-factorial
concept. It is a concept influenced by several determinants such as; the social and economic
environment, the physical environment, and the person’s individual
characteristics and behaviours (World Health Organization, n.d.).
Chronic diseases remain one of the leading causes of
death and health complications within Canada. Chronic Renal Failure, also known
as Chronic Kidney Disease (CKD) falls under this umbrella. In
nuclear medicine, we can conduct several renal scans (including Lasix Renal
scans and Captopril studies) that assess a variety of kidney related diseases
and disorders such as renovascular hypertension, tumors or cysts, kidney
disease and the rejection of a kidney transplant. Therefore, I come in contact
with patients with CKD.
Chronic kidney disease is defined as the presence of
kidney damage or reduced kidney function for more than 3 months and requires
either a measured or estimated glomerular filtration rate (eGFR) of less than
60 mL/min per 1.73 m2, or the presence of abnormalities in urine sediment,
renal imaging or biopsy results.1 Between 1.3 million and 2.9 million Canadians
are estimated to have chronic kidney disease, based on an extrapolation of the
prevalence of end-stage renal disease. (Arora et al., 2013)
According to an online document found through the
Kidney Foundation of Canada, kidney disease is difficult to detect because
there are few symptoms. Age and gender, along with a simple blood test, can
determine valuable information about one’s kidney function. Individuals at risk
include:
-Those who suffer from diabetes or hypertension
-People over the age of 55
-Certain ethnic groups such as First Nations,
Hispanic, African American, Asian and Pacific Islanders (Aguzzi, n.d.)
The above-mentioned list indicates a higher prevalence
of this disease that are largely based on presence of previously existing diseases,
individual differences and socio-economic status. The document further explains
how persons may attempt to reduce their risk factors against this incurable
disease.
Social Epidemiology and Influences of Health
“Social epidemiology is the study of how social
factors contribute to health and disease over a period of time” (McGill
University, Faculty of Medicine, n.d.).
Spheres of Influence and socio-ecological
models have long been used in economics, politics, international relations and
health to determine how interrelations amongst a person and their physical and
socio-economic environment can have particular outcomes.
Persons who have CKD can be assessed using this model.
The socio-ecological model of health often contains four or five main levels:
Individual level, Interpersonal, Community level and the Societal/Policy level.
An Organizational level may be grouped together with either the Community level
or Society level.
Table 1. A Description of Social
Ecological Model (SEM) Levels.
SEM Level
|
Description
|
Individual
|
·
Characteristics
of an individual that influence behaviour change, including knowledge,
attitudes, behavior, self-efficacy, developmental history, gender, age,
religious identity, racial/ethnic identity, sexual orientation, economic
status, financial resources, values, goals, expectations, literacy, stigma,
and others.
|
Interpersonal
|
·
Formal (and
informal) social networks and social support systems that can influence
individual behaviours, including family, friends, peers, co-workers,
religious networks, customs or traditions.
|
Community
|
·
Relationships among
organizations, institutions, and informational networks within defined
boundaries, including the built environment (e.g., parks), village
associations, community leaders, businesses, and transportation.
|
Organizational
|
·
Organizations
or social institutions with rules and regulations for operations that affect
how, or how well, for example, MNCH services are provided to an individual or
group.
|
Policy/Enabling Environment
|
·
Local, state,
national and global laws and policies, including policies regarding the
allocation of resources for maternal, newborn, and child health and access to
healthcare services, restrictive policies (e.g., high fees or taxes for
health services), or lack of policies that require childhood immunizations.
|
(UNICEF, 2014)
Using the Bronfenbrenner’s Ecological Systems Theory (The
Psychology Notes Headquarters, 2013), these can further be placed into three main
systems beyond the individual level.
- · Microsystem- including direct interpersonal relationships
- · Exosystem- includes the community and physical environment
- · Macrosystem- including society, organizational and policy change.
The Individual
Unless a patient has some medical knowledge, a new
diagnosis of CKD may be very foreign to that person.
Patients newly diagnosed with CKD will have questions about how the kidneys work and, even at the early stages, often fear that they will need to begin dialysis soon. In the early stages, educate the patient and family about what happens in CKD and the strategies that can slow its progression. ("Management of Chronic Kidney Disease (CKD)", 2018)
Patients newly diagnosed with CKD will have questions about how the kidneys work and, even at the early stages, often fear that they will need to begin dialysis soon. In the early stages, educate the patient and family about what happens in CKD and the strategies that can slow its progression. ("Management of Chronic Kidney Disease (CKD)", 2018)
A person’s knowledge about the disease, awareness of
their disease progression and ease of access to renal health services are all
factors that contribute to the decision-making process for that patient.
A
multidisciplinary team of clinical experts from SelectHealth and Intermountain Healthcare
created a diagram that outlined some of the many care related decisions that a patient
may have to make. They may also choose to seek advice
and suggestions from family members and friends which incorporates the ‘Interpersonal’
level of influence on an individual.
("Management of Chronic Kidney Disease
(CKD)", 2018)
Interpersonal Relationships
During illness and times of need, it is normal for a
person to seek support and comfort from their family and friends. Spouses and
children may also have direct involvement in a patient’s care as persons often
make decisions, such as which facility (or particular times and/or dates) to
receive dialysis based on the availabilities of their family members to escort
them.
Social relationships, such as those found in close
families, have been demonstrated to decrease the likelihood of the onset of
chronic disease, disability, mental illness, and death… Prospective
cohort studies have confirmed the direct beneficial effects of various forms of
social support on global mental health, incidence of depressive symptoms,
recovery from a unipolar depressive episode, psychologic distress, psychologic
strain, physical symptoms and all-causes of mortality. (Unite For Sight, n.d.)
Though overall, interpersonal relationships for persons
with a chronic disease such as CKD are beneficial, they can be harmful to the patient
as well. A patient may choose treatments according to the requests of their
families vs. a treatment they would prefer to undergo or one recommended by
their physician. A person may miss appointments due to a family member or
friend not being able to provide transportation and/or support. Additionally,
persons experiencing stress due to family issues (such as a divorce) may worsen
their health.
“Problematic and non-supportive familial interactions
have a negative impact on health. There is increasing evidence that
poor-quality relationships can actually harm physical and mental health." (Unite
For Sight, n.d.)
Community
A person’s physical and cultural environment (including
acceptable social norms) play a role in a person’s health. Within a community,
adequate health care services such as hospitals or clinics for diagnostic testing,
pharmacies, as well as dialysis services prove to be critical in the management
of CKD.
Overall, the studies in this section show a clear
connection between neighborhood factors (such as housing access and quality, exposure
to environmental toxins, access to grocery stores and recreation centers, and community
social relationships) and health outcomes (such as asthma, heart disease, depression,
self-reported health, and mortality). (Flournoy & Yen, 2004)
Organization and Society
Health institutions and healthcare policies indirectly
influence a person with CKD. The Registered Nurses Association of Ontario
(RNAO) published a best practise guideline with this purpose:
To help nurses recognize patients with CKD experiencing decisional conflict related to situations in which there is more than one option available for managing their condition. To help nurses support patient involvement in reaching quality health decisions. Quality decisions are made using the best available evidence about the options and are consistent with the patients’ values. (RNAO, 2009, p.7)
To help nurses recognize patients with CKD experiencing decisional conflict related to situations in which there is more than one option available for managing their condition. To help nurses support patient involvement in reaching quality health decisions. Quality decisions are made using the best available evidence about the options and are consistent with the patients’ values. (RNAO, 2009, p.7)
Guidelines such as these help to provide training and
evaluation for nurses who care for patients with CKD and improve overall
patient care.
Organizational, provincial and local government
policies in regard to healthcare in a province or city can determine ambulance
availabilities, wait times and staff scheduling. According to Nicholas,
Kalantar-Zadeh & Norris (2015), “Increased awareness of social and
environmental factors that contribute to CKD disparities must be followed by
cost effective policies to improve CKD/ESRD prevention and care, especially in
the setting of increasing diversity and increasing disparities in wealth and
educational attainment”.
Adaptations of the social-ecological model
incorporates not only the determinants of health but provides an overview of
the inter-relation of several health influences as they apply to a particular population,
context or disease. We can only gain better understanding after exploring the
connections between them.
References:
Aguzzi, I. (n.d.). Kidney Disease: Quick Facts and
Stats. Retrieved from https://www.kidney.ca/document.doc?id=620&erid=0
Arora, P., Vasa, P., Brenner, D., Iglar, K.,
McFarlane, P., Morrison, H., & Badawi, A. (2013). Prevalence estimates of
chronic kidney disease in Canada: results of a nationally representative
survey. Canadian Medical Association Journal, 185(9), E417-E423. doi:
10.1503/cmaj.120833
Carleton University. (n.d.). Social Ecological
Model of Public Health. [Image]. Retrieved from https://apps.carleton.edu/ccce/issue/health/public-health-in-practice/?module_api=image_detail&module_identifier=module_identifier-mcla-ImageSidebarModule-mloc-sidebar-mpar-da9af63edc444779df2c954dfc8d4d40&image_id=1286677
Management
of Chronic Kidney Disease (CKD). (2018).[Image].
Retrieved from https://intermountainhealthcare.org/ext/Dcmnt?ncid=521395847
Management
of Chronic Kidney Disease (CKD). (2018). Retrieved from
https://intermountainhealthcare.org/ext/Dcmnt?ncid=521395847
McGill University, Faculty of Medicine. Social
Epidemiology. Retrieved from
https://www.mcgill.ca/epi-biostat-occh/research-0/social-epidemiology
Nicholas, S., Kalantar-Zadeh, K., & Norris, K.
(2015). Socioeconomic Disparities in Chronic Kidney Disease. Advances
In Chronic Kidney Disease, 22(1), 6-15. doi:
10.1053/j.ackd.2014.07.002
The Psychology Notes Headquarters. (2013). What is
Bronfenbrenner’s Ecological Systems Theory?. Retrieved from
https://www.psychologynoteshq.com/bronfenbrenner-ecological-theory/
UNICEF. What are the Social Ecological Model (SEM),
Communication for Development (C4D)?. (2014). Retrieved from
https://www.unicef.org/cbsc/files/Module_1_-_MNCHN_C4D_Guide.docx
Unite For Sight (n.d.). Family Dynamics and Health. Retrieved from
http://www.uniteforsight.org/gender-power/module1
World Health Organization. (n.d.). The determinants of
health. Retrieved from http://www.who.int/hia/evidence/doh/en/
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