College Health Clinic Population Health Improvement Plan Project

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A college community health improvement plan (CHIP) focusing on the indicators of nutrition and weight status, and physical activity and fitness is designed with the goal of reducing obesity risk, improving health, and preventing chronic disease. The precede proceed model, logic model, innovative care for chronic conditions model, self-care theory, and Bandura’s social cognitive learning theory were used as a research design framework for assessing, planning, and managing sustainability through a two-year college health clinic. The research questions were: what are the current health promotion inputs and activities in terms of environment, ecology, education, and policy and could be supplemented to improve outputs and health outcomes? An integrated review of the literature, observation of the site, regulatory investigation, and focus group sessions were the methods of data collection. The precede-proceed model provided the analytical strategies to assess initiatives and resources, and to determine supplementary initiatives and resources. Results showed that environmental, educational, administrative, and policy resources were available but limited and not well promoted. Conclusions were that health promotion, wellness staffing, and education exist, but are underutilized, under promoted, and funding is necessary. Recommendations include a wellness program, increased activity initiatives, case management, grant funding, and increased community partnerships. The contribution to nursing is to fill a gap-in-practice for health planning in 2-year colleges. The implications for positive social change are improved knowledge, sustained health behaviors, decreased amount of obesity, improved health outcomes and quality of life, decreased chronic diseases, and lower healthcare costs.
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Walden University College of Health Sciences This is to certify that the doctoral study by Kathryn Flynn has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made. Review Committee Dr. Oscar Lee, Committee Chairperson, Nursing Faculty Dr. James Ronan, Committee Member, Nursing Faculty Dr. Catherine Garner, University Reviewer, Nursing Faculty Chief Academic Officer Eric Riedel, Ph.D. Abstract College Health Clinic Population Health Improvement Plan Project by Kathryn Flynn MSN, Western Governors University, 2014 BSN, Thomas Jefferson University, 1985 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University June 2017 Abstract A college community health improvement plan (CHIP) focusing on the indicators of nutrition and weight status, and physical activity and fitness is designed with the goal of reducing obesity risk, improving health, and preventing chronic disease. The precede- proceed model, logic model, innovative care for chronic conditions model, self-care theory, and Bandura’s social cognitive learning theory were used as a research design framework for assessing, planning, and managing sustainability through a two-year college health clinic. The research questions were: what are the current health promotion inputs and activities in terms of environment, ecology, education, and policy and could be supplemented to improve outputs and health outcomes? An integrated review of the literature, observation of the site, regulatory investigation, and focus group sessions were the methods of data collection. The precede-proceed model provided the analytical strategies to assess initiatives and resources, and to determine supplementary initiatives and resources. Results showed that environmental, educational, administrative, and policy resources were available but limited and not well promoted. Conclusions were that health promotion, wellness staffing, and education exist, but are underutilized, under promoted, and funding is necessary. Recommendations include a wellness program, increased activity initiatives, case management, grant funding, and increased community partnerships. The contribution to nursing is to fill a gap-in-practice for health planning in 2-year colleges. The implications for positive social change are improved knowledge, sustained health behaviors, decreased amount of obesity, improved health outcomes and quality of life, decreased chronic diseases, and lower healthcare costs. College Health Clinic Population Health Improvement Plan Project by Kathryn Flynn MSN, Western Governors University, 2014 BSN, Thomas Jefferson University, 1985 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University June 2017     ProQuest Number: 10604260     All rights reserved  INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted.  In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion.      ProQuest 10604260  Published by ProQuest LLC (2017 ). Copyright of the Dissertation is held by the Author.   All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code Microform Edition © ProQuest LLC.   ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI 48106 - 1346 Table of Contents List of Tables ..................................................................................................................... iv List of Figures ......................................................................................................................v Section 1: Nature of the Project ...........................................................................................1 Problem Statement .................................................................................................. 4 Purpose Statement ................................................................................................... 6 Project Objectives ................................................................................................... 8 Guiding Practice.................................................................................................... 10 Definition of Terms............................................................................................... 12 Assumptions, Limitations, and Delimitations ....................................................... 14 College Health Clinic Population Health Indicators ............................................. 15 Sources of Indicators............................................................................................. 15 Priority Indicators ................................................................................................. 18 Significance of the Project .................................................................................... 21 Summary ............................................................................................................... 23 Section 2: Review of Literature and Theoretical and Conceptual Framework ..................25 Background Content ....................................................................................................25 General Literature ........................................................................................................25 Specific Literature ................................................................................................. 28 Theoretical and Conceptual Framework ............................................................... 32 Summary ............................................................................................................... 37 Section 3: Methodology .....................................................................................................39 i Objectives ....................................................................................................................39 Project Design and/or Methods ............................................................................. 40 Population ............................................................................................................. 50 Data…. .......... ……………………………………………………………………51 Data analysis, Reliability, and Validity of the Review of the Literature .............. 52 Summary ............................................................................................................... 53 Section 4: Findings and Recommendations .......................................................................56 Introduction ..................................................................................................................56 Gap-in-practice purpose ........................................................................................ 56 Sources of Evidence .............................................................................................. 59 Phase one social assessment ................................................................................. 61 Phase two epidemiological assessment ................................................................. 62 Phase three educational and ecological assessment .............................................. 64 Phase four administrative and policy assessment ................................................. 67 Findings and Implications ..................................................................................... 69 Recommendations ................................................................................................. 86 Evaluation Recommendations ............................................................................ 104 Limitations and their Potential Impact on the Findings ...................................... 108 Implications Resulting from the Findings........................................................... 108 Contribution of the Doctoral Project Team ........................................................ 111 Strength and Limitations ..................................................................................... 114 Section 5: Dissemination Plan .........................................................................................118 ii Appropriate Audiences and Venues.................................................................... 118 Contributions to Nursing and Society ................................................................. 119 Analysis of Self ................................................................................................... 121 Summary ............................................................................................................. 121 References ........................................................................................................................123 Appendix A ......................................................................................................................132 Appendix B ......................................................................................................................133 Appendix C ......................................................................................................................134 Appendix D1 ....................................................................................................................135 Appendix D2 ....................................................................................................................137 Appendix E: .....................................................................................................................141 Appendix F: .....................................................................................................................142 Appendix G: .....................................................................................................................144 iii List of Tables Table 1. Nutrition and Weight Status Data ………………………………………….136 Table 2. Physical Activity and Fitness Data…………………………………………142 iv List of Figures Figure 1. The precede-proceed model ...............................................................................41 Figure 2. The chronic care model……………………………………………………......46 Figure 3. The innovative care for chronic conditions model…………………………….47 Figure 4. CHIP planning Gantt chart………………………………………….………..143 Figure 5. CHIP Implementation Gantt chart……………………………………………145 v 1 Section 1: Nature of the Project Community health improvement plans have been designed, constructed, implemented and evaluated by health providers to improve health outcomes of a specific geographical population. Providers at college health clinics focus on the students and their health care needs. The student population at a post-secondary institute of education have determinants of health as determined by Healthy Campus 2020 (2016) such as immunizations for enrollment, exercise and fitness, weight and nutrition, substance use and abuse including smoking, mental health, and accident and injuries. Illness prevention and health promotion programs can be designed, planned, and implemented to improve health outcomes for the students to be successful and healthy. Important determinants of health that are essential to the college health population are nutrition and weight status, and physical activity and fitness (Healthy Campus 2020, 2016). Fardet and Boirie’s (2013) meta-analysis of the literature reflected that most chronic diseases and subsequent health care costs correlate with obesity and inactivity. Additionally, Bandura (2004) asserted that early adoption and reinforcement of healthy skillsets in children and young adults increases the likelihood of sustainable healthy behaviors over a lifetime. After a comprehensive review of the current literature, I chose weight, nutrition, physical activity, and fitness, as the foci of this project for young adults in a college health population setting as a focus for establishing heathy behaviors for life- long wellbeing. A college health improvement plan (CHIP) is designed by me with a goal of improving the health of students with focus on the indicators of nutrition and weight 2 status, and physical activity and fitness. The Centers for Disease Control (The Centers for Disease Control [CDC], 2013) has identified the precede-proceed model and logic model as appropriate for health planning as well as model theoretical frameworks for program planning. The innovative care for chronic conditions (ICCC) model and Bandura’s social- cognitive model and self-care theory are relevant theories to explicate the education and behavior change activities of the students, as well as sustainability of the behavior change (Bandura, 2001; Epping-Jordan et al., 2004; Riegel, Jaarsma, & Stromberg, 2012). The behavior change at a young age will increase the likelihood of retaining the behaviors as adults and lead to sustainability (Bandura, 2004; Epping-Jordan et al., 2004). The educational portion and self-care model are both important to improve outcomes (Bandura, 2001; Epping-Jordan et al., 2004). The educational portion is not enough; the students must have behavior change and self-maintenance as well (Bandura, 2001). New practice strategies such as specific health improvement programs based on measured need can improve health care quality by targeting care to actual needs, not just assumed needs of the community (Kattelmann et al., 2014). Additionally, the ICCC model is essential for health providers to restructure care delivery of the college health clinic so that healthy behaviors are managed to ensure sustainability of optimum outcomes that are proven practices identified in the literature (Epping-Jordan et al., 2004). Key features of the ICCC model are health systems and community resources optimization through utilizing clinical information systems for managing and tracking, collaborative decision support, delivery system design that insures individual case management, and enhanced self-management support (Epping-Jordan et al., 2004). The 3 structural practices outlined in the ICCC model are proven clinical outcomes not only for chronic illness management, but for primary health care and prevention initiatives as well (Epping-Jordan et al., 2004). A strategy based on the precede-proceed model with the logic model constructs is the framework and model used by me to create health initiatives for a college health services community (CDC, 2010; Green and Kreuter, 2005). A policy, systems, and environmental change strategy and the constructs of inputs, activities, outputs, and outcomes are the components of the logic model framework used by me to create health initiatives (CDC, 2010). The self-care model and Bandura’s social cognitive theory have been used as underpinning frameworks to guide the health promotion education and activities in the plan (Bandura, 2001; Riegel, Jaarsma, & Stromberg, 2012). Bandura’s social cognitive learning theory states that persons are agents with a capacity for decision making to control their own destiny, and learning has a social aspect as well that is impacted by observing others in the community (Bandura, 2001). Bandura (2004) posited that learning behaviors in childhood and young adulthood increases the likelihood that behaviors will continue into adulthood. The project design includes the needs assessment and objectives from Healthy Campus 2020 (2015a) and target goals for the population. I used SMART objectives, specifically objectives that are specific, measurable, achievable, realistic, and time phased. The design allows for stakeholders and community partners involvement in program planning and implementation. Leadership is necessary and was used by me to 4 plan health initiatives and accomplish improvement plan approval. Leadership is also required to highlight research and attain funding for projects. Problem Statement The college health clinic at the two-year college project site provides wellness initiatives, but should base initiatives on a synthesis of existing evidence to discern which wellness initiatives are necessary to promote improved health outcomes, and how resources should be allocated based on priority needs of the community members. Healthy People 2020 compiled data and found that problems and leading health indicators related to college health services are access to health services, immunizations, injury and violence, mental health, nutrition, physical activity and obesity, reproductive and sexual health, and substance and tobacco use (US Department of Health and Human Services [USDHHS], 2014c). Healthy Campus 2020 (2015a) is an extension of Healthy People 2020, and is focused on the college student population based on American College Health Association (2015) research that reveals similar college health indicators (American College Health Association, 2015). The Healthy Campus 2020 (2016) indicators that are the focus of the current project CHIP are nutrition and weight status, and physical activity and fitness. I chose the indicators as a focus of the project because poor nutrition, obesity, and inactivity are risk factors for diabetes and are associated with other chronic diseases such as cardiovascular disease, cancers, and many others (Fardet and Boirie, 2013; World Health Organization [WHO], 2010). In addition, chronic disease accounts for 50% of all health care dollars spent (WHO, 2010). Therefore, if nutrition and weight status, and physical activity and 5 fitness behavior is modified, the risk for chronic disease may potentially decrease, as well as chronic disease spending. The college does not have a wellness and health promotion initiative currently, and has not had one in the past, even though a Health Services Department exists. I was the project coordinator and designed and planned the CHIP. The plan will be implemented at a future date, as finances allow, by Health Services staff of the full-time college nurse and health assistant. The determinants of immunizations, substance abuse, suicide, and others are under the purview of different student services and counseling departments within the college, and for this reason were included in the health services CHIP. However, students with these needs are referred to other departments by the college health clinic providers, who remain responsible for the comprehensive health needs of each student. Preventative health initiatives are valuable because promoting health, preventing illness, and decreasing healthcare costs related to disease gets more complex as diseases get worse (USDHHS, 2011). McTighue, Garrett, and Popkin (2002) followed a cohort of young adults and found that being overweight between the ages of 20-22 years correlated with increased risk of obesity between the ages of 35-37 years. Fardet and Boirie (2005) have found that obesity is associated with 10 chronic diseases and contributes to 50% of all health care costs. In the 2010 college population, 11.6% of students were obese, 38.4% were at an unhealthy weight (over 24.9 BMI), and only 6% ate five or more servings of the recommended fruits and vegetables per day (Healthy Campus 2020, 2015). There is 6 currently no data on the college population at the project site. The goals of Healthy Campus 2020 (2015) were to increase the percentage of students who are at a healthy weight and the percentage of students who eat five or more servings of fruits and vegetables per day by 10%. Regarding the indicator of physical activity and fitness, 51.3% of students do not engage in the recommended 30 minutes of aerobic physical activity on 5 or more days a week (Healthy Campus 2020, 2015b). Moreover,
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