In the United States (U.S.), national data demonstrate high mortality rates and poor health outcomes from chronic diseases among persons without insurance or fragmented access to healthcare (Bittoni, Wexler, Spees, Clinton & Taylor, 2015). The era of accountable care emphasizes health promotion and new strategies to build capacity for equitable population-focused care in the primary care and community health setting (Edmonds, Campbell & Gilder, 2016). A key principle in patient engagement for health includes a sense of belonging and authentic participation that is associated with better outcomes and quality of life (Porter, Pabo, & Lee, 2013). A growing body of evidence documents that culturally relevant community-based nutrition education (Ball, McNaugton, Le, Abbott, Stephens, & Crawford, 2016; Ko, Rodriguez, Yoon, Ravindran & Copeland, 2016) and physical activity programs (Conn, Chan, Banks, Ruppar & Scharff, 2014) are effective strategies in low income populations. Emerging data also show that social media strategies, such as text messaging, support successful health outcomes (Head, Noar, Iannarino & Harrington, 2013). As health advocates, nurse practitioners (NPs) are providers grounded in health promotion, system thinking and community-based care that are well-positioned to implement culturally-relevant health promotion interventions to the underserved communities and patients they serve. Purpose: Guided by the social-ecological framework, the purpose of this project was to initiate nurse practitioner-led interventions to support accountable care and improve nutrition and physical activity health outcomes in a diverse underserved population receiving care in an urban free primary care clinic.
Methods:
We used a multi-level approach to engage the populations receiving care at the clinic along with the administrative and clinical staff, and established partnerships with community-based organizations to support the planned health interventions. A quasi-experimental pretest-posttest study design was used. We enrolled three cohorts of diverse participants (ages 19-64 years) in a 13 week program: seven weeks of nutrition education/cooking classes that included a curriculum customized to the clinic population and six weeks of physical activity (gentle yoga, pedometer-guided walking programs). The groups met weekly for two hours. Ethnically diverse professionals: registered dietitians, a professional chef and yoga instructor supported the program. The nurse practitioners sent weekly text messages that were either spiritual or motivational in nature to reinforce the program content. System-level interventions included implementing participant identification cards and patient satisfaction surveys revisions. Clinical outcomes included nutrition knowledge, perceived stress, steps walked, blood pressure, and body mass index (BMI). System level outcomes addressed program evaluation and patient satisfaction. Data were analyzed with descriptive statistics and paired t-tests.
Results:
The 42 participants were primarily female (81%; N=34) with eight men and included blacks (76%), Hispanics (14%) and whites (10%). Three patients were homeless. Participant were on average 50 years old and obese (mean BMI: 31.6 kg/m2). Nutrition knowledge improved from baseline (58.6+13.7 vs. 83.5+14.0; p<0.001) as did steps walked (4448.6 + 2719 vs. 7564.6 + 4151.1; p=0.03). Systolic and diastolic blood pressure values did decline as did BMI but did not achieve significance. Perceived stress levels were unchanged. Program satisfaction data was positive. Participants reported the yoga relieved muscle aches and pains, they felt cared for and were pleased and relieved to have identification cards. The community agencies and the clinic were able to secure ongoing partnership agreements.
Conclusion:
Nurse Practitioners are well-positioned to organize and implement culturally-relevant and evidence-based patient and system level innovations in community settings that are customized to promote health outcomes among the uninsured and underserved.
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