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Mammary duct ectasis
Case study overview
A 60-year-old Latina female is concerned about the thick green discharge on her left breast, a situation she has experienced for the past month. The discharge happens spontaneously causing pain and burning around the breast. She reported to have breastfed all her children; she was not on any medication. However, occasionally she used Tylenol for treating arthritis.
The mammogram test done 14 months ago is within the normal limits. Physical examination indicates that there are slight redded and edematous around the left breast. A greenish-black is seen when palpation is done; there is an ovoid which is smooth, very mob that is not tender at 1cm nodule in the RUIQ at 11.00 5cm from the nipple. The patient is worried that she might be at risk of developing breast cancer.
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Diagnosis
Women over 50 years are likely to suffer from mammary duct ectasis; this is a condition that occurs when the breast dust becomes wider making its walls thicken causing fluid build-up around the breast (Stanford School of Medicine, 2016). Sticky and thick black or green discharge is an indication of mammary duct ectasis. In addition, the nearby tissues around the breast and the nipple will become tender and red. The hard lump caused by this condition is often confused with breast cancer (Patel, et al, 2015).
Treatment and management plan
The patient needs antibiotics for 10 to 14 days to treat the infection; pain medication includes acetaminophen or, ibuprofen, other drugs are Advil, Motrin IB among others. Acetaminophen is commonly prescribed to reduce the pain ,an adult dosage includes is 2 regular strength 325 mg after every four hours or 2 extra-strength of 500mg after every six hours but the maximum dosage should not exceed 4,000 mg in a day.
In mild cases, patients are advised to conduct warm compresses to help to manage the disease, however in severe cases, surgery will be recommended whereby an incision will be made at the edge of the colored tissue to release the built up fluids (Chougule et al, 2015).
Mammary duct ectasis is often confused with breast cancer, therefore women especially those that are above 50 years need to be educated about the differences in the presentation between the two conditions and urged to seek urgent medical attention whenever they have sysmptoms related to mammary duct ectasis.
References
Chougule ,A., Bal A, Das, A., Singh, G ( 2015). IgG4 related sclerosing mastitis: expanding the morphological spectrum of IgG4 related diseases. Pathology 47 (1): 27–33
Patel, B. K., Falcon, S., & Drukteinis, J. (2015). Management of nipple discharge and the associated imaging findings. The American journal of medicine, 128(4), 353-360.
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HPV Vaccine: Barriers and Mitigation
According to the Center for Disease Control (2012), the HPV vaccine has over 97% effectives in preventing cervical cancer cases in the globe. There is need for using the vaccine and convincing stakeholders to fully integrate its use in the community because of high levels of sexual activity among preteens and adults.
The stakeholders for the project are Hispanic pediatrics aged 10 to 13 years and their parents who would serve as advocates and champions of the vaccine. This section of the HPV vaccine based project will discuss the potential barriers to the implementation of the project. The stakeholders are likely to pose a challenge in the intended wide vaccination of preteens, thereby posing a need to addressing and preventing those barriers.
The stakeholders might hold insufficient information about HPV and therefore not know about the existing risks that are already posed by the pathogen. Such parents or guardians are also likely to be unaware of the wide prevalence of the disease, and therefore, the risks that it poses to their children’s health (Caitlin, Escoffery, Satsangi & Brownstein, 2015).
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The project will consider an education program that gives talks about the causes, transmission and prevention methods that can be used in fighting the Human Papilloma Virus. The project will involve Spanish speaking volunteers that can integrate Hispanic values into the dispensation of information about the condition (Butts, Janie, and Rich, 2010). The project will also enlist the assistance of religious organizations, politicians, local celebrities, and community centers. One of the reasons why HPV is highly prevalent is the low manifestation of symptoms among those that are infected.
Therefore, those that are infected are likely to infect a high number of partners especially if they do not practice safe sex. HPV poses the threat of causing cervical cancer which might be difficult to treat if it is detected late. If this information is dispensed through the correct avenues, it might contribute to the mobilization of the Hispanic parents (stakeholders) to allow their children to be vaccinated with the HPV vaccine.
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Breast Abscess Patient Diagnosis and Treatment
Journal Entry
In my 4th week clinic I have learned more about patient diagnosis and treatment. Breast abscess can be caused by several different factors. To begin with, it can develop as a defensive reaction against infections and similarly, due to presence of foreign objects which causes accumulation of pus in the breast tissue. In this case the effect manifested itself in form of a greenish drainage.
Abscess can occur anywhere in the body. However, most breast abscess develops in women who are lactating and breast feeding. Breast abscess occurring in non lactating women are a bit unusual and initially can be a sign and symptom for breast cancer. A woman who has undergone breast cancer treatment is likely to have the abscess (Bosma, Morden, Klein, Neal, Knoepp & Patterson, 2016).
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The abscess is normally accompanied with pain and breast tenderness. However, not all abscesses are accompanied by inflammation making their diagnosing a difficult matter. My patient’s pus in this case the greenish drainage will be collected and tested to know the type of infection. The type of bacteria causing the abscess should be examined so as to give the best treatment since same bacteria are prone to some kind of treatment (Bosma, Morden, Klein, Neal, Knoepp & Patterson, 2016).
Blood test and ultrasound can also be done to check the patents immune and determine what structures of the skin are being affected by the infection. The above information is more likely to relate to an individual living with breast cancer. My patient is likely suffering from breast cancer. Breast cancer does not only show itself through inflammations but also breast abscess especially in non-lactating women.
The collection of fluids in the breast that is the greenish fluid commonly turns out to be an invasive cancer. The complains of the abscess in breast cancer normally associate itself with non-healing breast abscess despite use of antibiotics; through the previous weeks, patients not lactating, elderly patents and breast abscess associated with hard lumps in the breast (Bosma, Morden, Klein, Neal, Knoepp & Patterson, 2016).
This discussion is very informative. According to the patient’s health history, your decision to put the patient on long-acting reversible contraception (LARC) method is appropriate. LARC method includes the intrauterine device (IUD) and birth control implant. The advantage of LARC method is that it is long-term, easy to use and reversible- that is if she wants to get pregnant she will just have them removed.
The long-acting reversible contraception methods are effective and is estimated that 1 in 100 women using LARC method becomes pregnant. In addition, LARC methods are 20 times effective than other birth conceptions methods such as the patch, pill or ring (Stoddard, McNicholas, & Peipert, 2011).
You have made a great discussion regarding IUDs including the available types (ParaGard and Mirena). These types if IUDs work by preventing the sperm from fertilizing the egg. For hormonal IUDs, they thicken the cervical mucus making it very difficult for the sperm to enter and to fertilize the uterus. The main challenge with this method of contraception is that it is associated as a high risk factor for pelvic inflammatory disease and some women may experience frequent bleeding in the first few months or amenorrhea (Schuiling & Likis, 2013).
Another option that can be explored is the birth control implant. This is a flexible rod that is inserted under the skin in the upper arm. The main challenge of this method is unpredictable bleeding pattern. In some women, they may stop bleeding completely. Other common side effects with this method are mood swings and headaches.
The benefits of long-acting reversible contraception methods is that once it is put in place, one needs to do nothing else to prevent pregnancy. It does not interfere with sex or daily activities and can be reversed when one wants to become pregnant. In addition, no one can tell that one is using contraception (Stoddard, McNicholas, & Peipert, 2011).
References
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecological health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers.
Diabetes self care us an integral part of diabetes therapy and entails active involvement of family members. Effective self management is associated with positive clinical outcomes in diabetic patients. However, effective self management can be challenging because of the naturally evolving and age appropriate attitudes as well as biological factors in young adults. Several studies have shown low self discipline and management which results into higher hemoglobin A1C (HbA1c) (Jackson, Adibe, Okonta, & Ukwe, 2014).
In addition, standard self care of diabetes management involves prescribing constant drug dosages, which are often titrated based to patients condition during their clinic visits. The clinical visits for most patients are usually 2-3 times every month. Consequently, the patient drug dosage is determined by only these visits, which is not the true representation of daily patient health needs. This is associated with significantly elevated levels of blood glucose and frequent recurrent admission episodes attributed to treatment failure (Hinshaw & Basu, 2015).
In this context, the study aims at investigating whether the use of social network (SocialDiabetes.com) can reduce the incidences of hypoglycaemia in adolescents patients diagnosed with diabetes type 1. The PICOT statement is as follows: In adolescent patients diagnosed with diabetes type 1 (P), is integration of social network (SocialDiabetes.com App) (I), in comparison with standard care (C), reduce hypoglycaemia incidences (O), in a period of eight months?
Literature review
De Jongh, T., Gurol-Urganci, I., Vodopivec- Jamsek, V., Car, J., Atun, R. (2012). Mobile phone messaging for facilitating self management of long term illnesses. Cochrane Database System Rev 12 (12) : CD007459. doi: 10.1002/14651858.CD007459.pub2.
This paper assesses the impact of mobile phone messaging applications in self management of chronic illnesses. The study evaluates the health outcomes and patients capacity to manage their health complication. This systematic review examined randomized controlled trials, quasi controlled studies, interrupted time series (ITS) and controlled before- after (CBA) studies to ass the effects of mobile phone messaging.
The paper found some limited information regarding the implication of integrating technology in improving self management for chronic diseases. However, the study found some significant knowledge gaps regarding long term effects, costs, acceptability and risks associated with these interventions.
Dobson, R., Whittaker, R., Jiang, Y., Shepherd, M., Maddison, R., Carter, K., Cutfield, R., McNamara, C., Khanolkar, M., and Murphy, R. (2016). Text message-based diabetes self management support (SMS4BG): Study protocol for a randomized controlled trial. Trials 17: 179. doi: 10.1186/s13063-016-1305-5.
According to this article, utilization of technology to deliver self management is an effective support strategy that allows people to have patient centered care. The Self- Management Support for Blood Glucose (SMS4BG) is a novel technology that is text message based, and is used to support people diagnosed with diabetes to support self management strategy and to achieve better glycaemic control as well as patient education that is tailored to individual patient needs and preferences.
This randomized controlled study was conducted in New Zealand Health districts, where one thousand participants were randomized into 1:1 ratio to receive SMS4BG and usual standard care. The study findings indicated that this technology is associated with better glycaemic control (HbA1c), enhanced self efficacy, diabetes distress, and perceived social support and improved health related quality of life.
Hinshaw, L., & Basu, A. (2015). Technology Use for Problem Solving in Adolescent Type 1 Diabetes. Diabetes Technology & Therapeutics, 17(7), 443–444. http://doi.org/10.1089/dia.2015.0175
According to this article, technology and use of social media in adolescent care has been associated with improved glucose control among the adolescents because it provides them with practical platform to solve their therapeutic issues, thereby improving their quality of life. The qualitative study evaluated the relationship between use of modern technology and glycemic control.
The study findings indicated that the modern technologies have significant impact in enhancing self care management because it provides an opportunity for individualized care for a given patient, making it need based and focuses. However, the paper warns that one size fits all approach in this approach may not effective due to unique health demands and preferences.
Jackson, I. L., Adibe, M. O., Okonta, M. J., & Ukwe, C. V. (2014). Knowledge of self-care among type 2 diabetes patients in two states of Nigeria. Pharmacy Practice, 12(3), 404.
This study aims at exploring knowledge of self care practices and factors responsible patients knowledge deficiency in patients diagnosed with diabetes type 2. The cross sectional survey was conducted on patients attending the University of Uyo teaching Hospital, where Diabetes Self Care Knowledge (DSCK-30) was used to assess the self care knowledge.
The study found that nearly 70% of the population had basic knowledge about self care, but it was associated with the level of education, household income and the length the patient has suffered from the disease. The study recommended for further investigations that will help enhance self care and individualize care based on patient’s health needs or demands.
Ng, S. M. (2015). Improving patient outcomes with technology and social media in paediatric diabetes. BMJ Quality Improvement Reports, 4(1), u209396.w3846. http://doi.org/10.1136/bmjquality.u209396.w3846
According to this article, there has been significant increase in the number of people diagnosed with diabetes Type 1 in Europe, but only small percentage of people attain better diabetes control. Recent studies have established novel digital strategies with the aim of improving overall patient health care.
The quantitative study evaluated 3 digital initiatives with the aim of implementing electronic diabetes information system that would help to undertake routine blood glucose values and calculate drug dosages with the aim of improving clinical outcomes. The study concluded that use of digital initiatives is effective in empowering patients, improving efficiencies, satisfaction, communication, reduction on emergency admissions, and to reduce diabetes related complications.
Marques, M.B., da Silva, M., Coutinho, J.V., & Lopes, M.V. (2013). Assessment of self-care competence of elderly people with diabetes. Revista da Escola de Enfermagem da USP, 47(2), 415-420. https://dx.doi.org/10.1590/S0080-62342013000200020
The prevalence rated of diabetes is highest among the USA population. Diabetes self care management is complex as it contains important recommendation for physical activity, nutrition, glucose levels and medications. Young adults and the elderly have issues that uniquely impact self care.
This is because as people age, their health status, mental abilities, nutritionl requirements and physical abilities change. Depression is also common among the diabetic patient is associated with the deterioration of self care behaviors. This descriptive cross-sectional and correlation study assess self care competencies among the population through Scale to Identify Diabetes Mellitus Patient’s Competence for Self Care as well as other factors associated with it.
The study findings indicated that only 6% of the participants had self competence, highlighting the need to integrate other health promotion activities that target this population, assess their skills and to encourage effective self care practices that enhance planning of health interventions.
References
De Jongh, T., Gurol-Urganci, I., Vodopivec- Jamsek, V., Car, J., Atun, R. (2012). Mobile phone messaging for facilitating self management of long term illnesses. Cochrane Database System Rev 12 (12) : CD007459. doi: 10.1002/14651858.CD007459.pub2.
Dobson, R., Whittaker, R., Jiang, Y., Shepherd, M., Maddison, R., Carter, K., Cutfield, R., McNamara, C., Khanolkar, M., and Murphy, R. (2016). Text message-based diabetes self management support (SMS4BG): Study protocol for a randomized controlled trial. Trials 17: 179. doi: 10.1186/s13063-016-1305-5.
Hinshaw, L., & Basu, A. (2015). Technology Use for Problem Solving in Adolescent Type 1 Diabetes. Diabetes Technology & Therapeutics, 17(7), 443–444. http://doi.org/10.1089/dia.2015.0175
Jackson, I. L., Adibe, M. O., Okonta, M. J., & Ukwe, C. V. (2014). Knowledge of self-care among type 2 diabetes patients in two states of Nigeria. Pharmacy Practice, 12(3), 404.
Ng, S. M. (2015). Improving patient outcomes with technology and social media in paediatric diabetes. BMJ Quality Improvement Reports, 4(1), u209396.w3846. http://doi.org/10.1136/bmjquality.u209396.w3846
Weinger, K., Beverly, E. A., & Smaldone, A. (2014). Diabetes Self-Care and the Older Adult. Western Journal of Nursing Research, 36(9), 1272–1298. http://doi.org/10.1177/0193945914521696
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“Morbidity refers to the prevalence or the frequency of a particular disease in a specific region or population. Medically it can be used to describe the medical complications that arise due to a special treatment” (Cancer Research UK, 2017). Mortality, on the other hand, involves the figure of deaths reported among a population within a set duration of time. Simply put, it is the state of being destined to pass away.
“Report on mortality can be based on people living in a specific area or country, people deceased from a particular illness, and deaths of a certain age or gender or ethnic population” (Cancer Research UK, 2017). The cause of both mortality and morbidity lies in several factors found within the surroundings, and this may include technological factors, pollution of the environment among others. However, the purpose of this study is to mainly look at the environmental, economic and social factors that impact the morbidity and mortality rate of the UK population.
Social factors
It is evident from past studies done in the policy paper, Healthy Lives, Healthy People: our strategy for public health in England – GOV.UK., by the UK government reveal that citizens of the UK are living longer and healthier than people from other nations (Bennett et al., 2015). The positive aspect brought by the decline in mortality and morbidity is associated with several primary enhancement in the social dimension of their lives such as they achieved high ratings for overall life satisfaction, the economy and personal finances.
“The decrease in the death rate of both infants and adults has attributed innovations within the public health that comprises of mass immunization initiatives, enhanced sewerage services alongside water quality that significantly minimized cases of infectious ailments” (Policy Paper-GOV.UK, 2017). The impact has been positive as social factors such as healthy living have prolonged life, therefore, reducing both morbidity and mortality rates. “For instance, 501, 424 deaths were recorded in Wales and England which is a 1.1% decrease compared to the 506, 790 deaths that were recorded in 2013” (Policy Paper-GOV.UK, 2017).
Economic Factors
People have put the interest of their health first, and as a result, they have invested heavily in it by increasing the spending to 8.9% in a report by OECD in 2015 (Devaux, 2015). Some opt for insurance and health schemes to ensure their health gets taken care of in the event of an illness. Investment in health helps in ensuring that the people can consume more and at the same time reduce the occurrence of illness. “The inequalities witnessed in the UK population reveal high levels of health inequalities, and the result of this is economic status” (Balia & Jones, 2008).
A person’s socioeconomic status directly correlates with the health care they receive. Therefore, based on the statistics of deaths reported and registered by the Office for National Statistics in the UK in 2017 indicated that the mortality rate rises from the highest social class as it goes down to the lowest social classes (McLaren, 2017). In some lower social classes, the death rate doubled the rate in the highest social class.
The same observation was also made in the morbidity rate as those in the lower social class had challenges in accessing proper care and healthy living due to their economic status. The table below provides statistics on the important findings on mortality rate based on socio-economic factors such as social classes, education, and gender.
Table 1. Percentage death rate in different socio-economic groups 2014-2015
Source: (“Death registrations summary tables – England and Wales- Office for National Statistics”, 2017)
The statistics on the table provides a clear picture of the number of deaths over the ten-year period. The data reveals that there are high death rates among the older generation compared with the younger population. However, there is a considerable general decline in the number of deaths reported in the ten-year period. A good example is the number of deaths reported among the age bracket of 10-14 whose death rates had reduced by 50% ((McLaren, 2017).
Environmental factors
These factors entail pollution of the environment through the use of toxic chemicals. Contamination of the environment affects water and the air of the affected region. Several deaths have been reported within the UK as a result of chemical, air and water pollution. However, such deaths and illnesses created by such pollution can be avoided.
However, the reduction in environment pollution in the UK has reduced deaths and diseases considerably making the nation a safe environment for its citizens. Therefore,, the effect on morbidity and mortality has been a positive one as it has reduced the rates in UK over the ten year period.
Review of statistical and research evidence
Research conducted in the field of health regarding eating disorders reveal the following facts. “People in the UK estimated to have an eating disorder are estimated at 725,000 in a report produced by PwC” (“Eating Disorder Statistics – Beat,” 2017). The report further identified the common types of disorders defined in the population as mainly (BED) Binge Eating Disorder, Bulimia, and anorexia.
However, the most common among the three eating disorders was binge eating disorder. The eating disorder was attributed to starting mainly among adolescents without negating the fact that even children young as six years and adults as old as 70 years could develop it. The level of eating disorders reflect on the reduced level of morbidity happening in the UK because of careful watch on their health.
In a correlated research carried out by Institute for Health Metrics and Evaluation in 2013, it was discovered that approximately two-thirds of the male and female population in the UK are overweight. “The study identified the largest victim of obesity being men with a representation of 67% while women came close with 57%” (Sedghi, 2014). In a cancer research, it was estimated that around 50% of cancer patients in Wales and England have survived for ten years or more.
However, in the UK the results are more positive as the rate of cancer survival has moved from 24% to 505 within the same duration of time. “The variation in survival of different types of cancer has grown further to 98% in the UK” (B-eat.co.uk, 2017). The improved rate of cancer survival has impacted the mortality rate in the UK hence reduced it substantially.
Patterned inequalities in health and illness
Bennett et al., among other authors have recognized variations in the delivery of health by age, gender, ethnicity and social class (Bennett et. al, 2015). Disparities in access to healthcare have become measured through application of many different outcomes such as mortality rates, infant deaths, morbidity, life expectancy, and disability.
The Black report in 1980 was done to identify the inequality challenge as the health of the nation had improved but not equivalent to societal classes (Sim, & Mackie, 2006). The findings revealed that standards of health care were linked directly to social class. “One of the leading causes of the inequalities involved unemployment, low income, substandard housing, poor education and poor environment (B-eat.co.uk, 2017).”
As for gender, research showed that men in industrialized countries such as the UK live shorter than women and show to less experience of the adverse condition. “Although men have greater death numbers from causes of deaths such as lung cancer and ischemic heart disease, more women than men feel pain from somatic grievances such as a headache, tiredness, and muscular aches (Bartley, 2004).”
Table 2: Selected developed countries by order oflife expectancy at birth in 2014
Source: (“Health status – Life expectancy at birth – OECD Data”, 2014).
Evaluation of sources
The sources for the information obtained above include the office for national statistics in the United Kingdom. The source is credible as it is a national website and information provided to the public has to be evaluated for credibility before posting. “The other sources entail data and statistics from research conducted by credible scholars in the field of economics and the field of health care (McLaren, 2017).”
The work by McLaren provides a detailed analysis of the health inequalities happening in the UK. A clear and structural look is provided by the policy paper supports the same information provided by McLaren that provide similarity and confirms consistency as well as reliability of the sources. Article reviews written by other authors have provided support to the applied sources. The reviews assist in making the sources applied credible as well as reliable.
Evaluation of contrasting reasons for health inequalities
• The structural material explanation.
“The argument entails the lack of proper housing and access to health facilities due to poverty contribute to health inequalities (Policy Paper-GOV.UK, 2017).” It requires assessment of factors such as the workplace, the neighborhood and the home environment. The attempt to reduce health inequality through reduction of health inequality is viable and reasonable. The explanation is not applicable in the modern environment as most of the health facilities have been upgraded to quality standards.
• The artefact explanation.
It attempts to account for the health inequalities as a creation of the process of measurement. It looks at the class differentials in two aspects, all-cause and specific cause data for both mortality and morbidity. “However, the explanation as reviewed by several critiques proved pervasive and complex (McLaren, 2017).” The application of this explanation is still relevant and applicable in the current period but its complexities requires proper understanding.
• The social selection report.
Social selection involves the concept of personal health affecting their mobility in the social setting, leading to a particular state in the social hierarchy which is an essential element that contributes towards social class variation seen in health care. It provides a clear framework of how social selection positions an individual in the society and results to health inequalities. The social selection report is very applicable today as social hierarchy still exists. Social variation remains a challenge in the society and the report provides a clear explanation.
• The behavioural-cultural explanation.
The description clearly describes the interconnection between culture and behaviour. The behavior of individuals such as association with aggressive and violence acts result to a culture of crime, and drug abuse will lead to discrimination in health care provision. The connection between behavior and culture is still a prominent factor in 2017 that contributes to health inequalities. Therefore, the behavioral-cultural explanation is a reliable explanation for the inequalities within the health care in UK.
Relationship between welfare inequalities and theories of health alongside health policies development
• Cultural/behavioral.
The cultural or behavior of an individual can be explained better using the social cognitive theory. The theory suggests that people learn from their experiences as individuals alongside the interaction with the environment. “It helps in the provision of self-efficacy and application of observational learning which can easily be applied to various populations and setting in the formulation of health policies (Sedghi, 2014).”
The cultural and behavioral theory provides observational data that provides foundation for health policies. An example is the policy regarding a culture of safety that heavily relies on data collected on behavior of patients.
• Material structural.
The material structure can well be defined through the use of the theory of planned behavior. The application of health policies requires determination of a pattern of individual behaviors within a specified population. Therefore, the material and structural model applied in solving health inequality will be suitable in ensuring that people receive the material support needed.
The material structural theory focuses on the established patterns which provide a framework that can be used in forecasting hence helps in formulation of health policies. An example of such a policy is an injury prevention policy done at the community level heavily relies on the material structural theory where individuals planned behavior are recorded.
• Collectivism.
The collectivism approach entails the use of class to define the constructs of a health belief. Therefore, the health belief model is appropriate in providing understanding on the health inequality concern in the UK. It is a theoretical structure applied in conducting health advancement and illness deterrence programs.
The constructs of health belief provided by the collectivism theory assist in establishing sound health policies within the required health guidelines. An example entails the stewardship as a policy in health that helps in ensuring that the health of people in the society is a social obligation.
• New Right.
The approach asserts that constant provision of aid by the government affects the process of a free market. “The argument states that regular provision of assistance contributes to perpetual poverty among the affected population” (Sedghi, 2014).
The policies within health care require quality attention, and when own standards of health care outperform those of public care, then health inequalities arise. The theory provides a framework under which health policies are formulated. Policies created that rely on family such as social policy heavily employ the New Right approach in the health sector.
Conclusion
The provision of health in the UK is perceived to have grown and improved tremendously. However, the Black Report in 1980 and the Acheson report in 1998 among others have identified that the improvement has several inequalities ranging from various factors such as economic, social, ethnic and environmental factors.
The differences can be seen across gender, age, social class, and ethnicity. The solutions and various explanations in the paper reveal that it is possible to bridge the gap created as a result of social class differences among other factors as highlighted through the use of the health theories.
Bennett, J. E., Li, G., Foreman, K., Best, N., Kontis, V., Pearson, C., … & Ezzati, M. (2015). The future of life expectancy and life expectancy inequalities in England and Wales: Bayesian spatiotemporal forecasting. The Lancet, 386(9989), 163-170.
Devaux, M. (2015). Income-related inequalities and inequities in health care services utilization in 18 selected OECD countries. The European Journal of Health Economics, 16(1), 21-33.
The class is made up of young adults ranging from 20-26 years. Some of the listeners are people with the condition but have not publicly spoken about it, or have close relatives or friends with the condition. Others might have the condition but do not know their status since they have not and cannot go for examination. This is a group that wants to learn about the various types of diabetes to adopt appropriate ways of living their lives better.
For those with the condition already, they want to understand the right course of action to take and for those without; they want to learn about how they can modify their lifestyles and prevent themselves from engaging in the way of life that can result in them acquiring the condition. Also, the fact that they are relatively young, most in their 20s, they are energetic and keen about life. For some too, this is the age to enjoy life without limits.
They lust for knowledge but must be handled with care so as not to antagonize them. Their opinions, whether well informed or not, must be listened to and accorded the respect. Thus, the best way to progress with the class is through discussion. It should be highly interactive to give room for them to air their opinions confidently.
Educational Setting
The setting of the class is a college. The staff working here are mostly degree and diploma holders depending in their area of specialization and the department they work. All the academic staff is made up of degree holders as a requirement by the government. The support staff, on the other hand, is mostly people with diplomas. However, we must face the fact that the students mostly meet with the teachers and interact more with them.
It is thus safe to conclude that they interact with well-educated and informed people in the school whether the academic or support staff. Another fact that cannot go unmentioned is that most of the staff is made up of young adults ranging from 30-45 years. It shows the institution’s aim of trying to integrate the student body and the staff better. Several in-service training for the staff exists to continuously equip the staff with necessary skills in dealing with the students.
Being college students, they are knowledgeable about diabetes. They are aware of the causes, and the fact that it has no cure is universal knowledge among all the students. However, most of them have never dealt or cared for a diabetic patient. They only feel it is beyond their league. They believe it is a specialty for the medical personnel. And others too feel it is an exaggerated illness. They believe diabetes is not a top killer as they consider cancer and HIV being the worse illnesses.
The learners come from diversified family backgrounds. It is quite hard to put them into categories regarding their education. Some parents are semi-educated while others are well educated. But one fact is, all the parents are socially educated. They know what is right and what is wrong with their children. However, most of these parents believe in some myths surrounding the diabetes calamity. The good thing is that they agree about the causes of the disease.
Learner Assessments
The class is made up of college students. At the end of their course, they will be qualified diploma holders. This is a relatively educated group, which can grasp the fairly complex material and do what is expected of them. If well taught about a certain subject, they will understand the concepts and how to implement the ideas.
Also, at this age, they are eager to conquer the world. They understand the importance of education and thus are eager to learn more. They want to show the world that they are knowledgeable and that keeps their academic thirst going. The reason for choosing this seemingly normal disease is that it resonates well with the class. The class is made up young people who are mostly dating. To most of them, it is a thrill being in a relationship, which is cool by itself. However, the peak of these relationships is engaging in harmful lifestyles about their diets and lack of exercises.
This is despite the fact that most cases of diabetes are caused by lack of proper exercise and the consumption of sugary food. The lesson is to question why this continually happens with parents and teachers guiding these young people. Can the prevalence be blamed on the teachers, parents or the students themselves? To fill this gap, the lesson is very vital since the answer lies in the minds of these students.
Topic Selection Rationale
The main teaching philosophy is through discussion. The discussion is the best method of delivery due to the nature of this sensitive subject. Despite the fact that the young people know the dangers of not exercising proper diet, it is still an increasing trend. Moreover, most people hate being guided in such intimate matters. They feel like the others are intruding into their private life.
They want to be left alone and do what they want with their lives. In any case, they say they are adults albeit naïve ones. The discussion thus becomes handy in such a situation. This becomes easier with college students since they are educated, eager to explore and ever ready to be heard. The discussion should start with a simple introduction. A brief introduction to the topic, reasons for the topic and specifically why the class is chosen.
It is to remove further any imaginary boundaries between the educator and the students that may exist in the minds of the students. The discussion should focus on a patient suffering from the disease. It should be a right scenario where the focus rotates on how the patient acquired such a disease. Also, on how he behaved upon learning of his condition and how he lives with the condition.
The discussion will be around a man living with diabetes known as Peter. He is 28 years of age, which is a small deviation from the age of some students. The only minor difference is that he was diagnosed with the disease while still in the university some five years ago. The description of his college social life leaves nothing to be desired though it clearly resonates with the young students.
He was a person that did not like practicing and used to consume a lot of sugary food. He slept with almost all of them who were too eager to be linked with the campus celebrity. Besides the lazy behavior, Peter was an alcoholic and would regularly be found in the clubs if he was not in his room sleeping. This behavior made him have a very poor hygiene with no regular exercises and the use various sugary foodstuffs besides the alcohol that had turned to be his best friend.
After some time, Peter developed some complications that were associated with often urination, regular feelings of thirst, blurry vision, extreme fatigue, loss of weight and numbness in the hands and feet (Herr, et al. 2013). This led to him being examined by the doctor for the symptoms of diabetes. After the examination, received the shock of his life when the results returned positive of diabetes mellitus.
He felt as if his celebrated life was over. It took some time and the efforts of his parents to make him accept the situation. He followed the doctors’ advice, and he coped well. His winning attitude helped a lot too. And now, he has four years to his name living with diabetes. His simple advice to young people is; avoid inappropriate diet and alcohol and also practice regularly through running or other field events.
Conclusion
The students discussed all aspects of this case above from the causes to the final stage of accepting one’s status. They found out that speaking out also helps a great deal. The discussion is fruitful if the class participates well. The interactions amongst themselves and also between them and the educator equip them with knowledge on diabetes. The discussion is the best mode of teaching a young class which is expected to impart this knowledge to others further. It gives them the freedom to think on any angle and widen their knowledge gap due to the peer discussion.
This campaign focuses on elderly falls. World Health Organization (WHO) defines fall as “an event that results in a person coming to rest inadvertently on the ground, floor or lower level” (2013). Many older adults fall, making them succumbs to severe injuries, many of which make them lose the ability to be self-independent and cause financial strains. On an annual basis, approximately 30-40% of the people aged over sixty-five years experience a fall at least once a year (Nicklett & Taylor, 2014).
Similarly, about 50% of those in nursing homes have experienced a decline in the within the last one year. Falls are recognized as the leading cause of accidental deaths in this age group, and in the UK, it is the 7th principal death cause. Studies indicate that 75% of the deaths among the elderly are associated with unintentional falls (Robertson & Gillespie, 2013).
Moreover, about 258,000 of the old people are admitted to hospitals annually as a result of hip fractures that result from falls (Rau et al., 2014). This hinders a high quality of life and causes immense medical costs. In 2013, direct medical expenses incurred from falls were as high as thirty billion (Robertson & Gillespie, 2013).
There is a projection that by 2020, over forty-four billion dollars will be dedicated towards these injuries (Robertson & Gillespie, 2013). These statistics make it apparent that falls among the elderly are a topic that needs to be campaigned on so that communities can take preventive measures. This would contribute to the lesser prevalence of the challenge.
Theories
Social learning theory
Social learning theory was developed by Albert Bandura (1977). Bandura explains that people learn in social environments by observing others and then imitates the behavior of others. In essence, this theory indicates that learning process is not just through reinforcement but also through influence from others (Cubas et al., 2015). There are four principles of social learning theory that have been developed namely attention, retention, reproduction and motivation. Inattention principle, learning will not occur if people are not focused.
Therefore, to obtain attention, it is important to design the training materials for patient fall prevention intervention differently so as to reinforce targeted group perceptions (Aliakbari, Parvin, Heidari, & Haghani, 2015). The targeted group includes nurses, elderly people representatives, unit nurse manager, registered nurses, nurse educators, orthopedic, physicians and community leaders.
The second principle is retention which states that people learn by internalizing the information stored in their memories. In this context, the training information will be designed in a manner that one can recall and respond appropriately (as taught). The third principle is reproduction which states that people actions are based on the information (behavior, knowledge or skills) previously learned (Aliakbari, Parvin, Heidari, & Haghani, 2015).
The training will be done in a way that it improves mental and physical rehearsal to ensure that the targeted populations reproduce the actions learned. Motivation is the last principle of this theory which states that most people’s actions are motivated, especially when they observe other people getting rewarded after for their actions. This motivation will help the people to do the same act (Cubas et al., 2015).
This theory works as a bridge between cognitive and behaviorist learning theories as it entails of motivation, memory, and attention. Therefore, when developing the campaign tool, one will focus on the novel as well as unique contexts that capture the targeted population attention in a manner that it stands out in their memory (Cubas et al., 2015).
The designing of the campaign tool will be done in a way that helps the targeted population to develop this self- efficacy individually through constructive feedback and confidence building. This concept in social learning theory is referred to as social modeling, and has been shown to be an effective method of education (which is the campaigns tool focus) (Aliakbari, Parvin, Heidari, & Haghani, 2015).
Stages of change model
The stages of change model also known as Transtheoretical Model was developed by James Prochaska and Carlo Diclemente in the early 1980s (Prochaska, 2013). According to this model, one should not assume that every person is ready for change because each individual has differing readiness to change. Therefore, when designing the campaigning tool, it is important to identify the target group position in the change process to match intervention to the people’s readiness to change. It is a bio psychosocial, integrative model for conceptualizing the intentional behavior change’s process (Lee, Park, & Min, 2015).
The stages of changes identified by this model included a) pre-contemplation, b) contemplation, c) preparation, d) action and e) maintenance. During the pre-contemplation, the target group is likely to be ignorant because they are not ready to adopt interventions foreseeable in the future (Prochaska, 2013). In this context, the campaigning tool is designed in a way that it encourages a re-evaluation of the existing behavior, explains, and supports self- exploration.
The contemplation stage is where the person is totally not ready for the change. The second stage is the consideration stage where people start becoming ambivalent to change. Therefore, the campaign tool is designed to ensure that it promotes the adoption of the suggested interventions (Lee, Park, & Min, 2015).
The third stage is the preparation stage which a stage where people are ready to change. In the action stage, people make specific overt modifications in their lifestyles (Prochaska, 2013). The campaigning tool is designed to enhance self-efficacy especially when dealing with obstacles and to help guard the frustrations. The last stage of this model is the maintenance stage which mainly focuses on the ongoing changes. In this case, maintenance will be reinforced through follow-up support (Lee, Park, & Min, 2015).
The rationale of the health promotion campaign based on stages of change model
This theory emphasizes on the role of other people during decision-making processes. The stages of change model apply in the elderly fall’s campaign. The first step was the presentation of negative impacts associated with old peoples’ falls. This is aimed at convincing the stakeholders about the urgency and need for change. Secondly, the theory helped one to expand people’s understanding of the social processes that influence the success of an implementation process (Prochaska, 2013).
Based on this model, some resistance is expected because most of the stakeholders already had a particular lifestyle and therefore making the changes needed to prevent falls would be met with some reluctance. The target group would move through the various stages as they try to weigh whether to change or not (Karlsson et al., 2013). The value of this approach is that it lays emphasis on professional communication where the caregiver’s providers can support one another. As such, offering them accurate information would be essential in promoting the change (Prochaska, 2013).
Effectiveness of the approved health promotion activity
The health promotion activity was sufficient because it explored the facilitators and barriers of elderly falls to develop strategic, evidence-based support aids in the reduction of the old falls (Prochaska, 2013). The training campaign on elderly falls preventive measure was useful because it was cost friendly (that is no huge costs are required to implement them) easy implementation process and it reached a large number of people at the same time (Balzer et al., 2012).
Own participation in the approved health promotion activity
The own primary involvement was through advocacy and mobilizing of the campaign to the stakeholders. The campaign took place at a community center hall for two days from 10.00Am to 3.00Pm. The participation involved creating rapport with the interested parties involved (nurses, elderly people representatives, unit nurse manager, registered nurses, nurse educators, orthopedic, physicians and community leaders).
This was critical in ensuring that they were open and at ease to discuss the factors that were contributing to elderly falls. This was vital as it made the target group and other involved stakeholders understand the importance of addressing the unique demands of older patients, which require patience as some of the seniors may have the hearing, language, and cognition problems. I also offered education on the strategic preventive measures against falls.
Whether the campaign was successful and had value and impact
The whole campaign was successful as detailed planning was done at every stage. The older adults and caregivers understood the reasons as to why falls had to be prevented. The campaign’s value and the impact were evident from the reduced prevalence of falls among the elderly, lesser hospitalizations, smaller costs dedicated towards falls, and an improved general wellbeing and health of the target group.
Strengths and weaknesses
The community members were able to learn a lot of insights about falls. The uptake of training on effective fall prevention measures was quite active; which increased awareness to the population that the aspect of fall is a healthcare concern (Gillespie et al., 2012). S
ome caregivers who previously did not have a caring attitude towards the elderly changed their attitudes and behavior after training, and most of the organizations were keen to implement some of the suggested change initiatives. However, a lot of time and resources had to be taken during the planning and implementation stages. This was quite strenuous. At the same time, reaching the seniors was a challenge due to their limited mobility.
Barriers and three recommendations on improving the campaign
The main obstacles were a lack of knowledge and motivation of healthcare providers, lack of change champions among the healthcare staff, language barriers, and lack of adequate resources. In future, the language barrier issues can be addressed by having a translator during any interaction with English non-speaking group. More efforts will be made so as to mobilize adequate resourced from stakeholders (Karlsson et al., 2013). This includes applying for funding from the government.
Lastly, leadership is an important aspect in implementing change in all organizations. The healthcare staff will be encouraged to attend leadership and management training so that they can understand better about their leadership roles and to offer a strong support and direction to the team members when implementing change. This will help the healthcare professionals to embrace their role as champions and facilitator in promoting and implementing change in their respective workstation (Karlsson et al., 2013).
Involvement in the campaign
The stakeholders involved in this campaign included; nurses, elderly people representatives, unit nurse manager, registered nurses, nurse educators, orthopedic, physicians and community leaders. Involving all the relevant stakeholders is very pivotal in promoting success. This is because they shape the direction of change in the early stages (Prochaska, 2013).
Involving the stakeholders will also ensure that all the project’s resources are available and provide insight about the probable reaction to project’s outcome or the necessary adjustments that must be made so as to win the community’s support. The benefits of all inclusive stakeholders involvement in this campaign is that it reduced distrust of the campaign’s outcome, increased commitment to the campaign processes and objectives and heightened the credibility of this campaign (Robertson &Gillespie, 2013).
Reflection
Collectively, this theory was useful in developing the multifaceted interventions that targeted change, promoted caregivers behavior, and ultimately improved the outcome of the campaign. An evaluation would be made after some duration after the changes have been embraced as a way of ensuring that the right things are being done appropriately (Balzer et al., 2012). Also, there are several elements identified after listening to other group’s presentation that we can adopt in the future. For instance, the use of pamphlets would have been effective as it would ensure that the information is widespread. Some groups used T-shirts to brand their campaign and to increase their coverage.
Conclusion
The campaign went well as the change model and theoretical frameworks used were correct for the topic. There are few aspects that many need to be refined according to our reviewer’s constructive criticism. However, participating in this activity was a good learning experience.
References
Aliakbari, F., Parvin, N., Heidari, M., & Haghani, F. (2015). Learning theories application in nursing education. Journal of Education and Health Promotion, 4, 2. http://doi.org/10.4103/2277-9531.151867
Balzer, K., Bremer, M., Schramm, S., Lühmann, D., &Raspe, H. (2012).Falls prevention for the elderly.GMS Health Technol Assess 8: Doc01.
Cubas, M. R., Costa, E. C. R. D., Malucelli, A., Nichiata, L. Y. I., & Enembreck, F. S. (2015). Components of social learning theory in a tool for teaching Nursing. Revista Brasileira de Enfermagem, 68(5), 906-912.
Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., et al. (2012).Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev.
Karlsson, M. K., Vonschewelov, T., Karlsson, C., Cöster, M., &Rosengen, B. E. (2013). Prevention of falls in the elderly: a review. Scand J Public Health 41: 442-454.
Lee, J. Y., Park, H. A., & Min, Y. H. (2015). Transtheoretical Model-based nursing intervention on lifestyle change: A review focused on intervention delivery methods. Asian nursing research, 9(2), 158-167.
Michael, Y. L., Lin, J. S., Whitlock, E. P., Gold, R., Fu, R. et al. (2010).Interventions to Prevent Falls in Older Adults: An Updated Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality (US).
Robertson, M. C., &Gillespie, L. D. (2013). Fall prevention in community-dwelling older adults. JAMA 309: 1406-1407
Nicklett, E. J., & Taylor, R. J. (2014). Racial/ethnic predictors of falls among older adults: The Health and Retirement Study. Journal of Aging and Health, 26(6), 1060–1075. http://doi.org/10.1177/0898264314541698.
Rau, C.-S., Lin, T.-S., Wu, S.-C., Yang, J. C.-S., Hsu, S.-Y., Cho, T.-Y., & Hsieh, C.-H. (2014). Geriatric hospitalizations in fall-related injuries. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 22, 63. http://doi.org/10.1186/s13049-014-0063-1
Prochaska, J. O. (2013). Transtheoretical model of behavior change. In Encyclopedia of behavioral medicine (pp. 1997-2000). Springer New York.
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How VITAMIN D Deficiency Affects the immune response in HIV patients
ABSTRACT
Vitamin D deficiency is a common issue in patients diagnosed with chronic conditions including Human Immunodeficiency Virus (HIV) infection. Research estimates that vitamin D deficiency in HIV infected people range between 12-100% (Lake & Adams, 2011). Generally, vitamin D deficiency is associated with various risk factors including age, race, overweight, geographical location and exposure to some antiretroviral therapy medication.
However, there is little research on the role of vitamin D in human immune system. This systematic review explores in depth analysis of on the factors associated with vitamin D deficiency. The paper also explores the role of vitamin D on the immune system (both adaptive and innate immune system).
However Ginde, Liu and Camargo(2009) believes, Vitamin D deficiency and supplementation in patients diagnosed with HIV is not well understood. The rationale of this dissertation is to provide to review current information on the role of vitamin D on HIV patient’s immune system. The aim of this literature review is to understand the impact of Vitamin D in HIV patients.
The key words that were used during literature search were structured the dissertation topic which was to find the impact of vitamin D on HIV patients. This included; Vitamin D, HIV, Vitamin D deficiency, Vitamin D role in innate immune system, Vitamin D in adaptive immune system, ; disease progression, pathogenesis of HIV, CD4, CD4+ T cells, CD$ count, Vitamin D supplementation, CD4 percent, role of Vitamin D,25(OH)D and the immune system, and factors that influence Vitamin D levels in HIV patients
Current strategies to help manage HIV
Regardless of the fact of progress in antiretroviral treatment (ART) in the last 10 years, HIV diagnosis is still very high. Recent studies stress on the importance of nutrition in HIV patients, especially the Vitamin D. Most of HIV patients are diagnosed with vitamin D deficiency. The deficiency has been shown to affect the immune cells (B cells and T cells) because the immunologic cells may not metabolize the active part of the vitamin D which is D3. There are many factors that contribute to vitamin D deficiency such as skin colour and diet. These limitations will be discussed in more detail in chapter 2.
Sun (2010) suggests, vitamin D has an impact in anti-inflammation and anti-infection which has newly founded and important movement for calcitriol receptor . Salahuddin (2013) suggests that vitamin D increases protective immune responses to Mycobacterium tuberculosis (TB) by reducing Interferon-gamma (IFN-g) and suppressing diseases linked with inflammation in the host. This study suggests, increased vitamin D dosage helped TB patients and enhanced their host immune response compared to deficient vitamin D levels. This suggests vitamin D can be used to treat TB. Vitamin D deficiency causes patients to be more susceptible to autoimmune conditions such as tuberculosis (Norman & Henry 2006; Aranow, 2016).
Vitamin D deficiency in HIV populations
The published rate of associated with Vitamin D deficiency/ insufficiency in HIV infected people range between 12% and 100% posted by Lake & Adams(2011). Generally Lake & Adams, (2011) suggest the rates of low 25 (OH)D in HIV patients is high and is associated with traditional risk factors such as age, race, overweight, seasonality, overweight and exposure to ART Research by Aranow (2011), suggests that the impact of Vitamin D status on health status of human being played a significant role.
Therefore, Ginde, Liu and Camargo(2009) believe the African community in Europe, UK, and USA are likely to be affected by the geographical location, such that their current vitamin D intake is low due to restriction due to high melanin content in their skin. In addition, the USA Black ethnic group is associated with vitamin D deficiency because they need longer exposure to produce the same level of vitamin D as the white ethnic people do.
For instance, in USA, the average 25(OH) D concentrations are low for blacks is 17.4 ng/ml as compared to 21.9 ng/ml d 28.3 ng/ml in fair skin tones respectively. Therefore Prietl et al(2013) suggests , HIV patients with darker skin pigment in these regions are likely to report Vitamin D deficiency These studies suggests that in the future, skin pigmentation is an effective strategy to identify people who are at risk of vitamin deficiency, especially among the HIV infected population so as to reduce further HIV related issues.
In some specific ART sessions and agents are associated with Vitamin D deficiency. Some studies have indicated that non-nucleoside reverse transcriptase inhibitor (NNRTI) is associated with 25OHD deficiency.
Giusti, Penco, & Pioli (2011), suggest that the protective function of Vitamin D against disease progression and mortality in HIV patients can be explained by its role in immune response. Djukic et al., (2017) suggest 1, 25 (OH) 2D is active in all organ systems and plays an important role in human immune system. Especially, 1, 25 (OH) 2 D reduces T cell activation and genes associated in cell differentiation and ability to spread.
Furthermore Djukic et al., (2017) believes it reduces the amount of pro-inflammatory cytokines such as Tumor Necrosis factor (TNF – α),Interlukin 2 and 12 (IL2, IL-12) and Interferons (IFN –γ) triggers the T cells to response to TH1 and TH2 responses; these responses also play an important function in controlling the immune cells and antimicrobial defense including monocyte chemotaxis and their differentiation into macrophages, releasing nitric oxide by macrophages and production of ß defensin 4 and cathelocidin and anti-microbial peptides that stops virus from copying. Due to these antimicrobial and anti-inflammatory functions, it has been suggested that Vitamin D deficiency has a great role in immune anti-inflammatory (Giusti, Penco, & Pioli, 2011).
Effects of vitamin D on immune response
Bailey et al., (2010) suggest that Vitamin D triggers the immune system. The results suggest that Vitamin D plays a major role in boosting the immune system. Many studies including Rathish(2012), have looked at human T cells in the lab to study the complex process of Vitamin D in innate and the adaptive immune system, and how the different cells fights infection. These findings are supported by the discovery of people with vitamin D deficiency tend to be more likely to have infections and that supplementation of vitamin D may boosts immunity. This chapter explores the role of vitamin D in innate and adaptive immune response.
The studies provided suggest that Vitamin D deficiency allegedly had an effect on immune cells and the reaction quickly destroys CD4 count and furthers the disease. Evidence from Langfordet,al,(2007) does provide that low CD4 is associated with low vitamin D in HIV paitents knowing that, CD4 count are low compared to intracellular pathogens .
Moreover Sun (2010) suggests, enough vitamin D can help increase that natural immune system, fight pathogens, regulate infected CD4 cells and other immune cells. Vitamin D can reduce the progression of HIV progression through CD4 response, recognizing cytokines secretions.
References
Diamond, T., Levy, S., Smith, A. and Day, P. (2000). Vitamin D deficiency is common in muslim women living in a Sydney urban community. Bone, 27(4), p.27.
Djukic, M., Onken, M. L., Schütze, S., Redlich, S., Götz, A., Hanisch, U. K., … & Bollheimer, C. (2014). Vitamin D deficiency reduces the immune response, phagocytosis rate, and intracellular killing rate of microglial cells. Infection and immunity, 82(6), 2585-2594.
Giusti, A., Penco, G., & Pioli, G. (2011). Vitamin D deficiency in HIV-infected patients: a systematic review. Nutr Dietary Suppl, 3, 101-111.
Holick, M.F. (2007). Vitamin D deficiency. New England Journal ofMedicine, 357, 266–281.
Holick, M. (2007). Vitamin D Deficiency. New England Journal of Medicine, 357(3), pp.266-281.Prietl, B., Treiber, G., Pieber,
