Reference no: EM133568554

Twin sisters Myra and Madeleine grow up in the same small Wyoming town and end up going to college together in the same mid-sized city. After graduation, Myra marries her high school sweetheart, and together they take over his dad's horse ranch. Madeleine moves to Denver and starts teaching in the classical languages at a private university downtown. As they approach middle age, the two sisters notice their health going in different directions. Myra's husband has a triple bypass, Myra has arthritis, and they both develop type 2 diabetes. Madeleine has had a successful recovery from breast cancer and knee surgery after a skiing accident. She also has type 2 diabetes.

As the two sisters compare notes, they discover that Myra and her husband take metformin and Januvia for diabetes control, and Myra takes Crestor to manage her triglyceride levels. "How come your doctor isn't prescribing any of these?" Myra asks, worried about her sister when Madeleine says her doctor is monitoring her every 4 months while she exercises and practices dietary modifications. When they get together for a family holiday, Myra is curious about how Madeleine manages her diabetes. But when Madeleine takes Myra with her to one of the fitness classes at her community health center, Myra ends up sitting on the sidelines, discouraged. "I could never move like that," she says afterward on the drive home. Madeleine doesn't say anything, but both sisters think about the extent of Myra's chronic disorders, including degenerative disk disease and osteoarthritis, and both believe this is probably true. Maybe Myra can't get strong enough to do what Madeleine does.

"What happened to me?" Myra says. All things being equal physically, these differences would still not be surprising. A study in 2014 (Smalls et al.) reported that social determinants based on community factors played a significant role in patients' self-care on glycemic control in adults with type 2 diabetes. Results indicated that neighborhood esthetics have a direct effect on glycemic control and that social support and access to healthful foods had direct effects on self-care (e.g., Madeleine's ability to use exercise and dietary modification to alter glycemic levels). Finally, the study also concluded that social support had an indirect effect on glycemic control via self-care-something that might also be more freely accessible to Madeleine in her current environment.

Source Smalls BL, Gregory CM, Zoller JS, Egede LE (2015). Direct and indirect effects of neighborhood factors and self-care on glycemic control in adults with type 2 diabetes. J Diab

1. What rural-urban health disparities are seen in this case study?

2. How do the sister's plans of care differ?

3. During her weeklong stay with her sister, Myra is impressed with the number of services Madeleine is taking advantage of: she still receives physical therapy for her knee, as well as attending monthly classes on "Cooking for Your Diabetes," which both sisters agree is actually fun. These are in addition to the yoga and senior fitness classes Madeleine takes every week. What evidence does this provide about how rural living may in some cases contribute to a less desirable health status in the United States?

4. According to the text, what changes in nursing research need to take place to develop population-focused programs that are available, accessible, affordable, and appropriate?

5. If you were working as a community health nurse in Myra's hometown, what are some examples of programs, classes, etc. that you think would be beneficial based on her needs?