Strengthening the Evidence for Community-Based Wellness: An Academic-Practice Approach to Support Evaluation and Dissemination
Vicki L. Simpson, PhD, MSN, RN, CHES
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Purpose: Chronic diseases remain a public health challenge, with 49.8% of the US population diagnosed with at least one chronic condition in 2012 and 11.7% diagnosed with three or more chronic conditions (Ward, Schiller, & Goodman, 2014). Additionally, in 2010 treatment of chronic diseases accounted for 86% of US health care costs (Centers for Disease Control and Prevention [CDC], 2016). Chronic diseases are generally very complex and require the generation of evidence to support the design of effective strategies for use by public health practitioners. The purpose of this study was to evaluate the effectiveness of a community- based wellness program offered by a local grassroots coalition in a rural, Midwest, largely Hispanic county to address chronic disease prevention and management. This county ranks 66/92 counties in Indiana in relation to health outcomes. The coalition began providing services to this vulnerable population in 2014 at a variety of sites including manufacturing, low-income housing, service,and faith-based institutions. Monthly health screenings and education as well as referrals to local resources are provided to address the multiple determinants which underlie chronic disease development. An academic-community partnership between a nurse researcher and the community-based coalition was created with the support of a collaboratively developed clinical and translational sciences grant. The grant provided support to enhance data collection, evaluate program outcomes, and disseminate evidence of best practices. Across the US, many community-based programs such as this one are supporting population health improvements and addressing health disparities, however these programs are often not evaluated with the rigor necessary to establish evidence of effectiveness nor are results disseminated for use by other communities. Academic-practice partnerships offer the ability for collaboration between nurse researchers and communities to support design and testing of such programs to develop practice-based evidence for dissemination (Ammerman, Smith, & Calancie, 2014).
Methods: A community-based participatory research approach (CBPR) was used to guide this repeated measures descriptive study to evaluate an existing community based wellness program provided by a community coalition.The CBPR approach was used to support equal engagement of community partners in the research. This approach is useful in rural settings to identify best practices to meet the needs and characteristics of rural populations (Young-Lorian et al., 2013). After receipt of the grant, multiple meetings were held between the nurse researcher and coalition members and providers. These meetings resulted in development of: 1) a research protocol, 2) an enhanced data collection system, 3) questions to more formally capture data concerning lifestyle behaviors, and 4) increased use of technology to easily capture data for analysis. Data from the screenings and lifestyle behavior questionnaires was collected over an 11-month period, de-identified and sent to the researcher for analysis. During the grant period, the academic researcher and coalition providers communicated frequently with several meetings to discuss any issues or concerns.
Results: In the 11- month time frame, 1,169 health screenings were completed for 457 unique individuals and three new sites were added. 23.02% of the individuals participated in at least two screenings and 12.03% participated in five or more screenings. The population was 67.18% female with a mean age of 50.33 years (SD 17.18) ranging from 38.38 (SD 11.08) to 68.56 (SD 14.26) across the sites served. Mean BMI was 30.26 (SD 6.43) with 33.62% of the population classified as overweight, 32.54% obese, and 6.29% extremely obese. A diagnosis of diabetes was reported by 11.06% of the population; 42.08% had a diabetes risk score indicating high risk for diabetes. Hypertension was also prevalent in the population attending the screenings with 42.08% classified as pre-hypertensive and 34.49% classified as hypertensive. Data related to lifestyle behaviors and intent to adopt healthy lifestyle behaviors captured changes related to smoking, diet and exercise. Of the 79 smokers who completed tobacco use surveys, 4 individuals reported efforts to quit smoking. 6.78% of the population reported making dietary and activity changes during the program including portion control and a decrease in "sugary" substances as well as increasing activity or joining Weight Watchers. 10.38% of the visits resulted in referrals to a variety of programs and providers including Diabetes Prevention Programs, Tobacco Cessation, clinics/physicians, prenatal programs and healthcare navigators. Additionally, information gathered during the screenings resulted in the provision of personalized education to 7.44% of the population. During meetings, program providers also shared evidence of policy, systems and environmental (PSE) changes occurring at several of the screening sites secondary to this wellness program including: 1) creation of lower cost healthier food items in the site cafeteria, 2) provision of information concerning health insurance in Spanish as well as English, 3) provision of awards to employees who adopted healthier behaviors, and 4) creation of smoke-free policies. To document the PSE changes occurring, the nurse researcher and coalition staff collaborated to successfully obtain a second grant to continue collection of data at the individual level and to design a protocol to capture PSE changes as they occur. There were many benefits and challenges during this project. The most significant challenge was related to data collection. Participants, particularly at the worksite settings did not have time to complete the lifestyle behavior surveys, while others had difficulty using the iPads to complete the surveys. Program staff had difficulty adapting to the excel worksheet to enter data, preferring paper and pencil entry of the data. Multiple errors were present in the data sent to the researcher, requiring extensive work to create a database valid for analysis. Benefits included the ability for providers to quickly identify those at risk via the enhanced excel-based data collection tool, allowing for on-the-spot education and referrals. This tool also provided support for analysis of changes over time and linkage to data from the behavioral surveys for analysis. Finally, the ability to aggregate the data collected to provide an overall view of the population being served has been useful to support the need for such a program in this community.
Conclusion: This study generated data which supported program impact and effectiveness. While there is not yet enough data to demonstrate gains at the individual level due to the long-term nature of the behavior change process, multiple PSE changes have been noted. This program is reaching vulnerable populations in the county including Hispanics, low-income elderly and the uninsured, allowing the ability to provide education, support and access to resources to successfully prevent or manage chronic disease. The academic-practice partnership has successfully created a strong relationship to support program evaluation at multiple levels as the second grant period begins. As well, the use of a CBPR approach in this project has helped to identify a community-based wellness program that is helping to reduce health disparities for the population. Currently, the nurse researcher and coalition providers are developing a toolkit for dissemination to support program replication in other communities.
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