NURS FPX 6011 Evidence-Based Population Health Improvement Plan IDA

NURS FPX 6011 Evidence-Based Population Health Improvement Plan IDA

Evidence-Based Population Health Improvement Plan

NURS FPX 6011 Evidence-Based Population Health Improvement Plan IDA

While a low-maintenance unhealthy lifestyle is easier to maintain, there is a higher risk of acquiring diabetes leading to additional complications when under-treated or untreated. A healthy lifestyle frequently calls for effort, change, and adapting newly learned habits. Diabetes in the African American (AA) community is a national health issue that should be addressed using culturally relevant interventions. African Americans make up 13.4 % of the United States (United States Census Bureau, 2021) and 12.1% (Centers for Disease Control and Prevention [CDC], n.d.) of estimated diabetes in the states. Despite the prevalence of these conditions among different racial and ethnic groups, the African American community is disproportionately affected more than other races (CDC). In 2017-2018, it was reported that in comparison to non-Hispanic whites, AA people tend to experience 60% more diabetes-related complications such as limb amputations, neuropathy, blindness, and end-stage renal failure (Centers for Medicare & Medicaid Services Office of Minority Health [CMS], 2017). According to (Hopkins, 2020), the risk of diabetes is 77 percent higher among non-Hispanic Black Americans than in non-Hispanic white Americans. Diabetic risk can be attributed to environmental, genetic, psychosocial, and socioeconomic factors. 

Complications from undertreated and untreated diabetes can be attributed to lack of sincerity, misinformation, access to health, and diet. Achieving or maintaining a healthy body weight matters when preventing diabetes. African Americans may imply diabetes as a normal part of aging and refuse to pursue interventions. Many African Americans celebrate family and community with Sunday dinners or other celebrations with traditional foods that tend to be high in carbs and low in fiber and vegetables. Often there is a lack of understanding that food low in carbs and high in fiber will help control blood glucose and weight and delay diabetes from progressing. Another factor contributing to disparities for African Americans is that most African Americans live in high-poverty neighborhoods, which amplifies the probability of developing diabetes. Impoverished neighborhood environments are sometimes called food deserts or food swamps. These areas are permeated with convenience stores, fast food restaurants, and limited choices in grocery stores. In addition to those circumstances, walkability, community resources, integrated health system, employment opportunities, and other disparities lead to unnecessary mortality and morbidity in these communities. Racial inequality in a combination of factors mentioned may be exacerbated by healthcare practitioner bias, stereotyping, prejudice, and clinical confusion, triggering mistrust and refusing treatment.

Decreasing diabetes-related complications in African Americans depends on changing lifestyle through education. The community needs to change how it thinks about diet, weight, and exercise. African Americans must understand that adhering to healthier lifestyles decreases the effect of acquiring diabetes and future complications. 

Tackling health disparities requires a team-based, multidisciplinary approach. Clinicians, physicians, pharmacists, and other community health practitioners need to address health disparities collaboratively so that health care will become effective in advancing the health of African Americans. Diabetes management and prevention, medication management, health and wellness, and patient support will be the plan’s goals to tackle diabetes and related complications.


In the program I oversee, the main goal will be to prevent diabetes and complications within the AA community. Other targets will be reducing HbA1C if diabetic, losing fifteen lbs., walking 30 minutes for at least five days a week, lowering blood pressure and triglycerides, and understanding healthier nutritional choices. The first course of action is to assemble a focus group/committee through advertisement and outreach to identify the community’s needs and gather their thoughts on exercise, health, and wellness. This focus group is made up of members of the community, community leaders, religious leaders, and healthcare professionals. Feedback from the focus group will assist in adapting the appropriate format to help create a cultural and linguistic foundation for presenting the program. Religious leaders are essential since they can be a resource in encouraging and involving the community and providing a safe space for implementing the program (Blanks et al., 2016). Since the church is an essential part of the AA culture, the program will take place at the church for 1-2 hours for twelve weeks. Diabetes Prevention Programs in faith-based settings can result in a weight loss equivalent to that seen in other communities (Dodani & Fields, 2010). Family, men, or women will separate three groups. Participants will have the choice to choose the group that they feel more comfortable with. Childcare will be provided as well as transportation to the program. Those unable to participate in person will have the option of partaking through teleconference. Weekly food and activity diaries, a fat and calorie counter book, a pedometer, and a resistance band were given to participants as intervention-enhancing items. A $100 Amazon gift card will be issued to complete the program. Life coaches and church health advisors who can relate to the group will lead the sessions, starting with a prayer and reciting a motivational scripture. Barriers will be explored, and presentations will be given by the diabetes specialist, dieticians, nurses, exercise specialists, and mental health specialists. This program will follow the Fit Body & Soul program. This culturally competent diabetes education program will address the needs of African American/Black communities in health literacy, awareness, and self-management of diabetes. Fit Body and Soul program in a semi-urban African American church using a community-based participatory approach. Challenges that may be posed to the program may be the participants that are not in person. Not being physically in person may lead to disengagement and poor outcomes.

Value and Relevance

Out of 40 Fit Body and Soul program participants at the Gospel Water Branch Baptist Church in Augusta, GA, with a BMI > or = 25, 35 attended at least ten sessions and provided the information required for the study (Dodani & Fields, 2010). “Of the 35, a total of 48% lost at least 5% of baseline weight, 26% lost 7% or more, and 14% lost >10% of baseline weight” (Dodani & Fields, 2010, Results section). Another study found that Fit Body & Soul user participation resulted in 3%-5% weight loss and maintenance after a year. Secondary consequences were reduced waist circumference, hemoglobin A1C, fasting plasma glucose, blood pressure, and, as well as increased quality of life, physical activity level, and cost-effectiveness (Dodani & Fields, 2010). Both studies justify the value and relevance of this population health improvement plan. However, there was no mention of which participants had diabetes, were at risk for diabetes, or had no risk, which can cause conflicting data.

Evaluation of criteria

NURS FPX 6011 Evidence-Based Population Health Improvement Plan IDA

Evaluation of criteria to see if Fit Body and Soul work for my group of participants rely heavily on communicating with participants, religious leaders, church health advisors, and primary care physicians. Participants must be diligent in keeping track of journal activity and progress, making literacy important in this plan. As the Population improvement plan continues, it is also vital to maintain regular meetings with committee members. Whether in person or via teleconference, evaluating any barriers, complications, and what has been successful is imperative. Checking in will ensure that participants continue to be engaged and outcomes are met. Requiring participants to sign a release of information with primary care physicians or bringing lab work and vital signs to sessions while performing weekly weigh-ins would help determine whether participants are achieving changed outcomes. Potential difficulties in communication with community members and healthcare workers would be lack of time, bias,’ lack of sincerity, or importance to the program. These challenges would be met by requesting personal one-on-one meetings with healthcare providers and community members and presentations about the program, including focusing on the AA community’s disparities. 


In conclusion, African Americans face many disparities. By taking a collaborative approach, diabetes and diabetes complications can be reduced and eliminated. Communities can work together to create population health plans to help the communities in them become educated and healthier. 


Blanks, S., Treadwell, H., Bazzell, A., Graves, W., Osaji, O., Dean, J., McLawhorn, J. T., & Stroud, J. (2016). Community-engaged lifestyle modification research: Engaging diabetic and prediabetic African American women in community-based interventions. Journal of Obesity, 2016, 1–8.

Centers for Disease Control and Prevention. (n.d.). CDC diabetes basics. Retrieved June 10, 2022, from

Centers for Disease Control and Prevention. (2008). Road to health user’s guide. Department of Health and Human Services, Centers for Disease Control and Prevention.

Centers for Medicare & Medicaid Services. (n.d.). Diabetes prevention programs: equity tailored resources [pdf].

Centers for Medicare & Medicaid Services Office of Minority Health. (2017). Racial and Ethnic Disparities in Diabetes Prevalence, Self-Management, and Health Outcomes among Medicare Beneficiaries. Data Highlight, 6, 1–22.

Chow, E. A., Foster, H., Gonzalez, V., & McIver, L. (2012). The disparate impact of diabetes on racial/ethnic minority populations. Clinical Diabetes, 30(3), 130–133.

Dodani, S., & Fields, J. (2010). Implementing the fit body and soul, a church-based lifestyle program for diabetes prevention in high-risk African Americans. The Diabetes Educator, 36(3), 465–472.

Hopkins, T. E. (2020, July 24). Diabetes in Black Americans: how to lower your risk. Everyday Health. Retrieved June 10, 2022, from

Marshall, M. C. (2005). Diabetes in African Americans. Postgraduate Medical Journal, 81(962).

Murimi, M., Chrisman, M. S., McAllister, T., & McDonald, O. D. (2014). Fostering healthy lifestyles in the African American population. Health Education & Behavior, 42(1), 109–116.

Nation Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Diabetes prevention program. Diabetes Prevention Program. Retrieved June 10, 2022, from

NURS FPX 6011 Evidence-Based Population Health Improvement Plan IDA

Two Feathers, J., Kieffer, E. C., Palmisano, G., Anderson, M., Sinco, B., Janz, N., Heisler, M., Spencer, M., Guzman, R., Thompson, J., Wisdom, K., & James, S. A. (2005). Racial and ethnic approaches to community health (reach) Detroit partnership: Improving diabetes-related outcomes among African American and Latino adults. American Journal of Public Health, 95(9), 1552–1560.

U.S. Department of Health and Human Services Office of Minority Health. (2021, February 22). Diabetes and African Americans. Minority Health. Retrieved June 10, 2022, from

United States Census Bureau. (2021, August 12). Improved race and ethnicity measures reveal U.S. population is much more multiracial. United States census bureau. Retrieved June 10, 2022, from

Williams, L., Ph.D., FNP-BC, Garvin, J., Ph.D., FNP-BC, Marion, L., Ph.D., RN, Dias, J., Ph.D., Joshua, T., MS, & Sattin, R., MD. (n.d.). Fit Body and Soul: A randomized controlled diabetes prevention program in southeastern African American churches. Georgia Regents University. Retrieved June 10, 2022, from


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