Doctor of Nursing Practice (DNP) Final Projects

Obesity is a significant national public health crisis, affecting one-third of American adults. It is a complex and multifactorial disease that increases the risk of multiple chronic medical conditions including coronary heart disease, diabetes, and even leading to potential premature mortality. Moreover, increased health care utilization and escalating medical costs associated with obesity treatment are overwhelming an already burdened health care system. Obesity is nondiscriminatory, affecting individuals from various demographic and socioeconomic backgrounds, even extending to our unique population of active duty military service members and veterans.

Despite mandatory physical fitness and body composition requirements, active duty service members continue to experience an increasing prevalence of obesity. The obesity epidemic has considerable implications for military readiness, accession, and retention. Limited studies have examined weight-loss interventions including self-paced and provider-led interventions among active duty military service members with varying degrees of success. The purpose of this evidence based doctoral project was to examine the effectiveness of a twelve-week group lifestyle intervention involving education regarding healthy diet, physical activity and behavior change recommendations on weight and body mass index (BMI). The study demonstrated no significant differences in initial and post intervention weight and BMI.

The human papillomavirus (HPV) is a sexually transmitted infection (STI) that is associated with several types of cancer and genital warts. No cure exists for those currently infected with HPV, but a vaccine is available that can prevent the virus and development of cancers associated with HPV. Military servicemembers are at a high risk for contracting HPV; it is one of the most common STIs among active duty service members. The health consequences of HPV can impact a servicemember’s military readiness. The HPV vaccine is not required for military servicemembers, but it is offered free of charge. HPV vaccination rates among military service members remain relatively low.

The purpose of this evidence-based project was to increase the level of knowledge about HPV, improve health beliefs regarding HPV, increase HPV vaccine intention, recommendation, and uptake. Using the Health Belief Model as an organizing framework, a population targeted eight-minute education video on HPV and HPV vaccination was developed. It was implemented at an outpatient military treatment facility located in the southwest United States over a 6-week period, to newly reported service members. Participants included 116 military service members aged 18 to 45. A pretest and posttest questionnaire were used to assess the impact of the intervention. HPV level of knowledge increased significantly from pretest to posttest mean scores were 3.00 to 4.39 respectively (p < .001). HPV vaccine intention increased from 62% to 66% (p = .739). HPV vaccine recommendation increased from 62% to 85% (p < .001).

The human papillomavirus (HPV) is the most commonly spread sexually transmitted infection in the United States. Although the HPV vaccine protects against transmission of the most common strains of HPV that cause genital warts and numerous urogenital cancers, uptake in the United States remains suboptimal. Failure to vaccinate leaves individuals vulnerable to the virus and subsequent complications of transmission. The evidence demonstrates that provider recommendation alone increases rates of vaccine uptake. The literature does not suggest a specific method for provider recommendation delivery; however, best practice alerts (BPAs) were correlated with increased vaccination rates.

These findings have directed a proposed project that includes an electronic health record (EHR) change prompting internal medicine, family practice and women’s health providers to educate and recommend the HPV vaccine at a Federally Qualified Health Center (FQHC) in the Southwest United States. The project demonstrates that after the implementation of a practice change of a HPV BPA in the EHR, HPV vaccination rates increased. Practice settings pre and post were similar, making the increase clinically significant.

The strengths of this project include an increase in HPV vaccination rates, a sustainable intervention, and an intervention that can easily be replicated into other health maintenance tasks. There were some limitations including the BPA alert only catching the HPV 9 vaccine series and the BPA did not always capturing historical data. Despite these technical barriers the HPV BPA delivered an increase in the HPV vaccine to protect more individuals from the HPV virus, increased provider adherence to national guidelines, and provides a platform for BPAs to be utilized for other vaccines.

Purpose: The purpose of the project was to improve physical activity (PA), eating habits (EH) and self-efficacy (SE) by implementing short lifestyle modification education in a rural primary care setting.

Background: Although prediabetes awareness has slightly improved, the nationwide unawareness remains high. General knowledge about the disease and its risk factors and prevention are significant variables to adopt health-promoting behaviors. Lifestyle change intervention has been shown to be effective with the risk reduction behaviors in prediabetic population. However, it can be a daunting task to translate during short office visits.

Methods: Sixteen participants with risk for prediabetes or diagnosed prediabetes enrolled into a 5-minute education session in a rural health clinic. They received follow-up phone calls weekly for 4 weeks. Demographics, PA, EH and SE levels were measured before the education session. During the fourth week, PA, EH and SE were measured again. Frequency, descriptive analysis, and paired t-test were used for data analysis.

Outcomes: The mean age of participants was 56.6  13.0 years. Approximately 81% were female, and 62.5% identified as Caucasian. Over 80% reported married, and 56.3% described their health condition as good. The three quarters (75%) noted they have heard of the term prediabetes. The intervention had a significant effect on PA, EH and SE from the baseline to post intervention, p = .005, p = .008, and p = .003, respectively.

Conclusion: This DNP project illustrated that one time brief lifestyle change education could positively impact PA, EH and SE in people with high risk for prediabetes in a primary care clinic.

Human papillomavirus (HPV) is a prevalent sexually transmitted infection that affects many adolescents and adults worldwide. The consequences of contracting HPV have proven to be devastating, potentially leading to a variety of life-threatening genitourinary and oral cancers. As such, prevention via vaccination is critical. HPV vaccination is recommended for all adolescents beginning at 11 years of age. Although the immunization has proven to be safe and effective, HPV vaccination rates are substantially below target goals worldwide.

A literature review of evidence from the last five years was conducted to examine barriers and facilitators to HPV vaccine uptake. The most commonly cited barriers to vaccination included lack of knowledge about the vaccine and inadequate provider recommendation. Current evidence regarding interventions to increase HPV vaccine uptake reveal that best practices are multi-factorial and should include a combination of provider education and recommendation training. These findings led to the proposal of an evidence-based intervention aimed to increase adolescent HPV vaccination rates.

A one-hour educational program was conducted at a local pediatric primary care facility. Five healthcare providers participated in the program, which consisted of a PowerPoint presentation outlining the benefits of HPV vaccination and use of an interactive application from the CDC. The app taught participants how to offer a strong recommendation for the vaccine through active participation. Pre and posttests were administered to determine the providers’ intent to vaccinate and vaccination rates were monitored. Analysis of the data collected revealed a statistically significant rise in vaccination rates. These results reveal that provider education can improve recommendation techniques and therefore increase vaccine coverage. Further research is needed to see if one-time education is sustainable.

Background: 
Approximately 1 in 5 U.S. school-aged children are obese. There are many known health complications associated with obesity including premature death. Family-based obesity interventions that promote healthy lifestyle habits are effective at enabling children to make changes needed to avoid long-term health complications associated with obesity. The purpose of this evidence-based practice intervention was to evaluate the effectiveness of a family-based obesity intervention on familial lifestyle behaviors related to nutrition, physical activity, and screen time.

Methods:
Two overweight-obese children (according to CDC criteria) ages 8-12 years old visiting a pediatric primary care clinic in a suburban neighborhood located in the southwest region were recruited to participate in this evidence-based practice intervention based on inclusion and exclusion criteria. Familial lifestyle behaviors were assessed using the Family Health Behavior Scale (FHBS) prior to receiving an educational intervention addressing nutritional, physical activity, and screen time recommendations and again after following these recommendation for 6-weeks. Additionally, scheduled follow-up phone calls were made every 3 or 6-weeks addressing any parental questions that surfaced. Data was insufficient for statistical analysis, however, anecdotal recommendations for future implementation of this intervention resulted.

Results:
Of the two patients who participated, pre- and post-intervention data was only attainable from one patient. That patient did have improved scores within each of the 4 FHBS subscales (parent behaviors, physical activity, mealtime routines, and child behaviors). Overall, 11 of the 27 behaviors assessed improved, 12 behaviors resulted in no change, and 4 behaviors worsened. Recommendations related to a more successful implementation of this intervention in the future include improved provider participation (buy-in), utilization of broader inclusion criteria, consideration of the implementation time-frame, and application of the Health Belief Model for addressing existing barriers for each patient prior to implementing the intervention.

Conclusions:
In order to determine the effectiveness of this intervention a larger sample size and completed post-intervention data are needed. The small sample size and lack of post-intervention data inhibits proper data analyzation and significance from being determined.