Submitted by Ruth L. Brosig and Jessica Cossette
The purpose of this pilot study was to use motivation and coaching strategies to encourage Detroit African-American adults who are at high risk for hypertension and diabetes to change their dietary patterns. Oakland University Accelerated BSN (ABSN) student nurses designed and implemented the project to bring health coaching to the urban Indian Village community. Interventions included nutrition presentations and healthy soul-food cooking demonstrations. Information about program effectiveness was obtained through surveys. Survey scores increased for ninety percent of the participants from pre to posttest, indicating a corresponding increase in nutrition awareness. Future research is needed to determine the long-term effectiveness of the intervention strategies. The Healthy Cooking pilot project has the potential to facilitate research that will educate nursing students as well as citizens of Detroit's Indian Village.
Key Words: Community Health Education; Community Health Nursing; Health Promotion; Nursing Education Research
Nutrition education is integral to the treatment of chronic diseases such as diabetes mellitus and hypertension (Horan et al., 2006). Motivating people to practice recommended dietary changes, including lowering fat and sodium while increasing fruit and vegetable intake, remains a challenge. The purpose of this study was to use motivation and coaching strategies to encourage Midwest urban African-American adults who are at high risk for hypertension and diabetes to change their dietary patterns. Using the guidelines of the Dreyfus Foundation's Problem Solving for Better Health in Nursing (PSBH-N™) workshop, student nurses enrolled in an Accelerated BSN (ABSN) program designed and implemented a pilot project to bring health coaching to Indian Village, a Detroit community. Undergraduate student nurses led the research with faculty support. The pilot program was an experiential learning encounter whereby student nurses learned the research process through producing their own study.
Nutrition Education Key to Chronic Disease Management
The prevalence of diabetes and hypertension throughout Detroit leads to higher death rates from these diseases and indicates a need for chronic illness prevention in this community. According to data posted by the Michigan Department of Community Health (2008), from 1989 to 2007 the death rate for diabetes and heart conditions was consistently higher in Wayne County compared to the State of Michigan. In 2007, there were over 3,000 deaths and more than 18,000 hospitalizations in Wayne County linked to heart disease (Michigan Department of Community Health, 2008). In 2004 alone, over 70,000 African Americans living in Detroit had been diagnosed with diabetes (Kieffer et al., 2004). The Center for Disease Control's Behavior Risk Factor Surveillance System revealed in 2009 that more than 32% of Wayne County respondents had been told that they have high blood pressure (Center for Disease Control, 2009).
Although unhealthy eating patterns may be more popular and less expensive than healthy eating patterns, it is important to note that nutrition plays an important role in the management of chronic illness such as diabetes and hypertension (Artinian, Schim, Vander Wal, & Nies, 2004). At-risk populations may be unaware of the effect that their nutrition choices have on their overall health. Education regarding healthy eating patterns allows at-risk populations the opportunity to gain necessary knowledge to make better nutritional choices (Kieffer et al., 2004).
The study was designed to answer the question: Will an educational demonstration of healthy soul food cooking for 20 members of a local church in the Detroit Riverview community increase awareness of healthier cooking options among adults over the age of 40? Soul food cooking demonstrations were chosen as a practical means to relate beneficial dietary changes to the surrounding neighborhood. Oakland University's ABSN program had recently relocated to the former Riverview Hospital in Detroit and had not previously been engaged in community research with this local population. The Healthy Cooking initiative provided a point of convergence between the program's community nursing and research curricula, and served as an introduction for the ABSN program to the Indian Village community.
The researchers conducted a search of the CINAHL database for nursing studies that used nutritional education and coaching to demonstrate positive dietary change in patients with the chronic diseases of hypertension, diabetes, or cardiovascular disease. Search terms included community nursing, nursing nutrition education, hypertension, diabetes, and Detroit cardiovascular disease. Literature was screened to capture studies targeted to African-American adult populations in the community setting. The literature review revealed one study published during the past 10 years that included Detroit African-American communities in nutritional education and coaching to demonstrate positive change for diabetes management (Two Feathers et al., 2005). The Healthy Cooking pilot project thus addresses a current gap in the literature.
Two Feathers et al. (2005) detailed results of diabetes educational interventions led by Detroit lay health educators in conjunction with the Center for Disease Control's Racial and Ethnic Approaches to Community Health (REACH) partnership. The Detroit REACH partnership targeted African-American and Latino neighborhoods with a five-session workshop about lifestyle adaptations to control diabetes. Educational topics included the benefits of exercise, increased fruit, vegetable, and whole-grain consumption, and reducing fat and sugar consumption. The researchers found an increase in diabetes knowledge and healthy lifestyle behaviors among the participants. Participants also improved their glycemic management, as measured by HbA1c, when compared with the control group. Two Feathers et al. noted that these findings were consistent with other studies and indicated a need for targeted research to uncover specific interventions that yield the most benefit (Two Feathers et al., 2005).
Peterson, Atwood and Yates (2002) discovered that health promotion interventions conducted in faith-based communities offer positive health outcomes. Peterson et al. (2002) emphasized the importance of a partnership between church and health professionals to facilitate success. Peterson et al. noted that African-American churches are especially willing to participate in health-promoting activities, and that clergy endorsement of health promotion positively influences lifestyle changes in the congregation. The study concluded that faith-based health promotion successfully affects minority and other vulnerable populations that may be difficult to engage (Peterson et al., 2002).
Nursing research is a mandatory component of most graduate programs (Thompson, McNeill, Sherwood, & Starck, 2001). The Healthy Cooking Project was unique in that it offered undergraduate nursing students an opportunity to formulate and complete their own research project. McCurry and Martins (2009) chronicle the need for team-oriented, experiential approaches to nursing research education. Experiential learning assignments are especially effective in increasing student perceptions of nursing coursework relevance, and participation in the research process leads to positive attitudes regarding research (McCurry & Martins, 2009; Thompson et al., 2001). It is important to note that the Healthy Cooking researchers exceeded the requirements of their research curriculum by obtaining Institutional Review Board (IRB) approval, implementing, and evaluating their study. IRB approval and implementation was a voluntary part of the research and community-nursing curricula.
The target population of this pilot project was adults over 40 years of age living in the Detroit Riverview community. Mt. Olive East Baptist Church, located in Indian Village, has a congregation with many members over the age of 40. Most members of the congregation are of African American descent. The Indian Village community is a neighborhood directly surrounded by the city of Detroit. Covering four square blocks there are 352 homes within Indian Village, many of which were built by craftsmen and designed by architects for specific families in the late 1800’s. The income level of those living within this specific community is above the median for Detroit (Lichtenstein et al., 2006). Since not all members of Mt. Olive church reside within Indian Village, the researchers considered the cost of recommended foods when planning their interventions.
The Healthy Cooking program was designed to raise awareness of the importance of dietary change and how incremental change can benefit overall health. The Pastor indicated that the health needs of the parish encompassed the chronic diseases of hypertension, cardiovascular disease and diabetes. Healthy Cooking for the Soul addressed these needs by using demonstration, presentation and open dialogue to educate the parishioners about healthy choices that could be incorporated into their traditional diet. Participants were selected by convenience sample for the pilot study. A research flier promoting the Healthy Cooking project was inserted into Sunday bulletins at Mt. Olive for two weeks prior to the program date. The program was held after a Sunday church service. Participants were asked to sign a consent form and to fill out a 14-question pretest survey. To maximize experiential learning and participant interaction, interventions included a menu of traditional soul food prepared with lower total calories and grams of fat. Menu items included black-eyed pea salad, fried chicken, sweet tea and sweet potato pie. Some soul foods, such as the black-eyed pea salad, were prepared in non-traditional ways, while other foods, such as fried chicken and sweet potato pie, were traditional recipes modified to reduce fat and sugar. While the participants ate, the researchers discussed the preparation of each food and presented a brief lecture regarding the benefits of reduced sodium, fat, and sugar intake for managing hypertension, diabetes, and cardiovascular disease. The researchers endeavored to make these health promotion interventions as meaningful as possible to the congregants. The presentations highlighted measurement of portion sizes and reading food labels for total fat, carbohydrate, and sodium intake. The benefits of moderating caffeine in the diet were incorporated into the interventions, especially by reducing sugared and caffeinated soda consumption. The benefits of exercise were included, emphasizing incremental increases in activity that would lead to long-term weight control. A question and answer period followed each presentation. Recipe comparisons and statistics regarding increased physical activity and weight loss were presented. After the soul food luncheon and concurrent presentations, participants completed an 11-question post survey to ascertain new learning and changes in health beliefs resulting from the interventions. The same survey tool was used in the pre and post surveys to measure participant change in health beliefs following the presentation. Demographic information regarding the participants was requested as part of the survey tool including age, race and gender.
The survey tool was designed by a member of the research team and utilized a self-rated five-point Likert scale. Survey questions were rated on a scale from one (strongly disagree) to five (strongly agree). The pre- and posttests contained eleven questions common to both surveys, yielding eleven survey score sets for pre- and posttest. Three pretest questions, relating to alcohol and tobacco consumption and the ability to cook meals, were not repeated in the posttest. The maximum survey score for a participant who strongly agreed with all statements was fifty-five. The surveys contained questions regarding physical activity, alcohol consumption and smoking, caffeine intake, daily fruit, vegetable and whole-grain intake, and perceived energy level and vitality. Participants were asked if they were able to choose the items that they ate. Participants were also asked if they were willing to try new behaviors to improve their health, such as modified cooking techniques and incremental increases in activity. The surveys contained a maximum of 14 questions in order to increase the likelihood of survey completion. Researchers anticipated that participants would show an increase in health and nutrition awareness by the end of the demonstration.
A total of 19 participants attended the demonstration. Sixteen participants (84%) completed both pre- and posttests. Participants were female (68%) and African-American (90%). Fourteen participants (74%) indicated that they did not smoke or drink alcoholic beverages, an expected outcome. Low rates of alcohol consumption and smoking are consistent with previous research findings in church groups (Hope & Cook, 2001). The age range of adult participants was 22 years to 88 years; the median age for the participant group was 52 years.
Pretest mean scores were 43 and posttest mean scores were 52 resulting in an overall increase of 9 points. Survey trends were positive. Thirty-seven percent of participants experienced a double-digit increase in survey scores, indicating that they agreed more strongly with the survey statements after the interventions. Central tendency of the surveys increased 10 points from pretest to posttest. Especially interesting is the posttest mode, 55, which occurred five times in the sample, compared with the pretest mode of 44. According to the surveys, after the interventions all participants desired to try one or more strategies in order to improve their health. Statistical significance as measured by t test was not present, an expected finding due to the small sample size of this pilot study and the construction of the survey tool. Sixty-eight percent of pretest respondents resulted scores within one standard deviation of the mean. The posttest scores were positively skewed; posttest score results within one standard deviation were 82%. Researchers reviewed the measurement tool for content and face validity prior to implementation and believe that further refinement of the survey tool is necessary.
Researchers noted the largest score increases in the area of physical activity (75% of participants) and fruit and vegetable consumption (56% of participants), indicating that the participants were more aware of the importance of physical activity and fruit and vegetable intake after the interventions. Fifty percent of participants indicated a desire to increase whole-grain consumption and to limit caffeinated drinks to once daily, instead of the average of two to three caffeinated beverages daily which was indicated on the pretest. According to the pretest survey, 31 percent of participants did not eat breakfast more than two times per week. After the interventions, all participants realized the importance of breakfast for healthy nutrition and pledged to eat breakfast at least 4 times per week.
The improvement of mean scores demonstrates an increase in awareness for the participants in the Healthy Cooking project. The Healthy Cooking pilot project was successful, and replicated studies are needed. By bringing health education into the community, the Healthy Cooking project has the capacity to improve health outcomes for Detroit residents. The pilot project needs to be expanded not only to educate, but to create sustainable behavior change. Especially beneficial would be an interrupted time study over several months, to see if the educational interventions provoke lasting dietary change. The pastor of Mt. Olive has expressed a desire to continue the research on a weekday evening involving members of several neighborhood churches.
For the researchers, the Healthy Cooking Project served a dual purpose: as a first contact for the ABSN program with the surrounding community, and thus a springboard for future research; and as a learning environment for the researchers themselves. The ABSN students identified the nursing research process through originating and completing their own project. The students formulated their research question with guidance from faculty facilitators during a seminar presented by representatives of the Dreyfus Foundation's Problem Solving for Better Health. The university students then followed this question through their research curriculum by performing literature reviews and analyses, participating in a poster presentation, and obtaining IRB approval. Each member of the seven-person team was responsible for some facet of the study. After implementation, the project leaders analyzed research data with help from their research professor, and together the group formulated a summary presentation as part of their community nursing curriculum. The Healthy Cooking Project thus united nursing research and community nursing curricula. It demonstrated the relevance of academic research coursework as the students applied their new theoretical knowledge to community-based nursing. The ABSN students also realized the urgent need for patient education within both acute care and community settings.
The Healthy Cooking pilot project has the potential to grow into a community nursing program that would educate ABSN students as well as members of the Indian Village neighborhood. A learning needs assessment could be conducted in the future, with programs tailored to the residents’ concerns. The university now has an introduction to the neighborhood. That introduction could develop into a true outreach partnership with the citizens of Detroit’s Indian Village.
In summary, the ability for student nurses to gain research experience throughout their entire academic curriculum has merit. Students engaged in the program were able to create actual research projects with faculty. While the initial concept was provided through the Dreyfus Health Foundation, the student researchers acted as the leaders of every aspect of the research. They were given the opportunity to complete the entire research process from beginning to end. The Healthy Cooking Project allowed the ABSN students to have a clear picture of the research process and all that encompasses sound evidenced based practice. Having experienced the fundamentals of nursing research, these BSN students are uniquely qualified to advance nursing scholarly activity in future projects.
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The authors gratefully acknowledge Oakland University Faculty:
Claudia Grobbel, DNP, RN
Barbara Penprase, PhD, RN, CNOR
Rosalind Woodson, MSN, RN
Dreyfus Foundation Problem Solving for Better Health in Nursing (PSBH-N™):
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN
Healthy Cooking Research Team:
Marcell Bahoura, BSN, RN
Marie DeMello, BSN, RN
Jennifer Howard, BSN, RN
Rachel Merritt, BSN, RN
Andrew Norris, BSN, RN