NURS FPX 6011 Assessment 2 Evidence-Based Population Health Improvement Plan

Name

Capella university

NURS-FPX 6011 Evidence-Based Practice for Patient-Centered Care and Population Health

Prof. Name

Date

Evidence-Based Population Health Improvement Plan

Hello, everyone. I hope you are all doing well. My name is ABC, and I am a master’s-prepared nurse. My role empowers me to expand the scope of practice by implementing evidence-based approaches to enhance public health outcomes while delivering direct patient care. This presentation outlines a strategic initiative improving population health in West Virginia. It focuses on Type 2 diabetes. The plan emphasizes patient engagement, equitable access to healthcare services, and the use of effective self-management techniques. By integrating technology with community-driven interventions, this effort aims to strengthen health literacy and optimize glycemic control among adults aged 41 to 65, promoting long-term wellness.

Community Data Evaluation

Factor	Data/Statistics	Source
Diabetes Prevalence	Almost 223,338 adults in West Virginia, or 15.8% of the state’s residents, were detected with type 2 diabetes.	(American Diabetes Association, 2023)
Obesity Rate	41.2% of adults in West Virginia have obesity, with a Body Mass Index (BMI) of 30 or higher on their stated height and weight.	(America’s Health Rankings, 2025)
Healthcare Access	In West Virginia, 5.9% of the population lacks private or public health insurance.	(America’s Health Rankings, 2023)
Socioeconomic Factors	West Virginia faces high poverty (16.7%), low median income ($57,917)	(Census Bureau, 2020)
Food Security	In West Virginia, 13.7% of households experience food insecurity.	(America Health Rankings, 2025a)

The table below outlines critical demographic and ecological determinants influencing the widespread occurrence of Type 2 diabetes in West Virginia.

Type 2 diabetes represents a significant healthcare crisis in West Virginia. It is driven by elevated obesity rates, restricted healthcare availability, and socioeconomic inequalities. These interwoven factors contribute to greater percentages of hyperglycemic problems, hospital admissions and fatalities. A substantial barrier is the state’s high percentage of uninsured individuals. It prevents many from accessing essential diabetes screenings, treatments, and educational support, leading to suboptimal disease management. Food insecurity and the incidence of nutritional deficits aggravate the problem by restricting access to nutritious food. It encourages inhabitants to rely on processed nutrients, which increases the risks of obesity and diabetes (Census Bureau, 2020).

Economic hardships worsen these issues, as individuals facing financial instability struggle to afford health insurance, essential medicines, and nutritious dietary options. The absence of accessible parks, pedestrian-friendly sidewalks, and recreational infrastructure in urban areas delays physical activity. It increases susceptibility to diabetes (Lee & Hale, 2022). Addressing these environmental and social determinants through targeted interventions can help West Virginia lessen the incidence of Type 2 diabetes and enhance public health outcomes. Expanding Medicaid coverage and executing community-based diabetes prevention programs can improve access to screenings, education, and early interventions. Establishing subsidized farmers’ markets and urban gardening initiatives can enhance food security and promote healthy eating habits (Rollins et al., 2020).

Meeting Community Needs

The widespread incidence of Type 2 diabetes in West Virginia stems from inadequate healthcare access, food insecurity, financial constraints, and limited opportunities for physical activity. Addressing diabetes-related health disparities requires a community-driven strategy that integrates ethical solutions to mitigate these critical factors. Various environmental challenges contribute to the state’s rising diabetes rates. In food desert regions, fewer than half of low-income individuals have access to fresh, nutritious foods, making it challenging for them to adhere to recommended dietary guidelines.

West Virginia’s high poverty rate (16.7%) and low median household income ($57,917) discourage families from purchasing healthier food options. It leads to increased consumption of processed products (Census Bureau, 2020). The scarcity of healthcare services is another pressing issue. A considerable portion of the population remains uninsured. It limiting their ability to receive essential diabetes screenings, treatment, and educational resources. The lack of well-maintained sidewalks, recreational centers, and public parks restricts physical activity, contributing to the rising obesity rates in the United States (America’s Health Rankings, 2025). Addressing these systemic barriers is crucial to enhancing diabetes-related health outcomes and reducing the disease burden in West Virginia.

The community’s diabetes-related challenges require ethical interventions that enhance accessibility, inclusivity, and the efficiency of services. First, launching free diabetes programs with multilingual materials in churches and community centers can provide culturally responsive education for individuals aged 41-65. Partnering with faith-based and cultural organizations fosters trust and strengthens community participation (Shubrook et al., 2023). Second, increasing the availability of affordable, nutritious food can be achieved through mobile farmers’ markets in underserved areas, subsidies for low-income families, and collaborations between local grocers and food banks to lower produce costs. A Healthy Corner Store Initiative can guide convenience stores in stocking healthier food options to improve dietary choices (Rollins et al., 2020).

Expanding healthcare accessibility can be achieved through outreach initiatives that assist individuals in enrolling in Medicaid, Affordable Care Act (ACA) plans, prescription assistance programs, and telehealth-based diabetes management services. It alleviates treatment barriers (Lee & Hale, 2022). Strengthening infrastructure for physical activity is another essential component. Promoting fitness opportunities in underserved neighborhoods should include community-driven programs, such as BIG-5 and GESTALT. It offers walking groups and dance sessions to encourage physical activity (Till et al., 2022). These interventions work together to enhance diabetes care efforts and treatment approaches tailored to the needs of West Virginia’s residents.

Organizations must account for cultural influences. They impact the efficiency of health interventions. Diabetes education becomes more accessible when healthcare materials are available in both English and Spanish, supplemented by interpreter services. Trusted community leaders are vital in enhancing engagement and ensuring the accurate dissemination of health data. Health initiatives achieve greater success when they incorporate budget-friendly workshops that showcase culturally tailored recipes using locally sourced ingredients and collaborate with faith-based groups to integrate diabetes education into their outreach efforts.

Measuring Outcomes

Outcome Criteria	Measurement Strategy
Increased diabetes screenings	Monitor the frequency of screening initiatives and the count of attendees.
Improved access to healthy food	Assess engagement in mobile food markets and collaborations with grocery stores.
Enhanced healthcare access	Track the number of fresh Medicaid registrations and virtual healthcare appointments.
Greater physical activity engagement	Follow participation in no-cost exercise initiatives.
Reduction in diabetes-related ER visits	Examine medical facility records before and after the intervention.

The effectiveness of the health enhancement strategy will be assessed using essential performance benchmarks. The progress of diabetes screening will be tracked by evaluating the frequency of screening initiatives and the volume of attendees. Increased access to nutritious food will be gauged by monitoring engagement in mobile food markets and partnerships with grocery retailers. Healthcare accessibility will be reflected in the number of individuals enrolling in Medicaid and the utilization of virtual medical consultations. Physical activity improvements will be determined by tracking enrollment in complimentary exercise initiatives. Variations in diabetes-related emergency room admissions will be analyzed by comparing hospital records before and after the rollout of the intervention (Rollins et al., 2020).

The assessment criteria rely on quantifiable public health statistics gathered from official records and participation logs to ensure accuracy. This initiative focuses on tangible community progress. It includes enhanced healthcare services, expanded nutritious food options, and increased engagement in physical activity. Sustained reductions in emergency visits and diabetes rates will indicate that the intervention fosters lasting progress in community well-being.

Communication Plan

Diverse strategies will be implemented to ensure ethical and inclusive communication that honors cultural differences in the population health advancement initiative. Key stakeholders, including healthcare experts, faith-based representatives, local policymakers, educators, and nonprofit groups, will be engaged from the project’s outset. Community meetings and educational sessions will be held in churches and neighborhood centers to maximize accessibility for adults with diabetes aged 41-65. To overcome language barriers, bilingual resources in English and Spanish will be provided, along with interpreter services (Nigussie et al., 2024). The initiative will utilize clear, simplified language and visual tools to convey medical concepts. It ensures comprehension among individuals of varying literacy levels and those with disabilities.

All messaging will adhere to ethical guidelines by safeguarding patient confidentiality through strict compliance with HIPAA regulations when handling health information. Before data collection, participants will provide informed consent, and community members will be informed about how their information will be used (Rezaee et al., 2023). The organization will facilitate open forums and interactive feedback sessions. It ensures individuals can voice their concerns and perspectives. Achieving full stakeholder participation and fostering a community-driven approach to health initiatives will be possible through transparency, established trust, and culturally responsive communication strategies.

Evidence

 Value and Relevance

The population health enhancement initiative relies on nationally recognized data sources to shape hospital-based interventions that tackle West Virginia’s pressing health concerns. Around 223,338 adults, representing 15.7% of the state’s inhabitants, have been identified with type 2 diabetes (American Diabetes Association, 2023). Moreover, 41.2% of individuals in West Virginia are classified as overweight, with a BMI of 30 or higher (America’s Health Rankings, 2025). These alarming figures underscore the necessity for implementing directed diabetes care plans. According to America’s Health Rankings, healthcare accessibility remains a major challenge, with 5.9% of residents lacking private or public health insurance (America’s Health Rankings, 2023).

West Virginia struggles with high poverty rates (16.7%) and a low median household income of $57,917 (Census Bureau, 2020). These socioeconomic barriers highlight the need for strategies such as Medicaid enrollment assistance and prescription affordability programs to expand access to medical care. The state has a lower percentage of individuals with bachelor’s degrees compared to national averages. It contributes to health literacy challenges. In West Virginia, 13.7% of households experience food insecurity, meaning they are unable to deliver sufficient nutrition for one or more domestic members due to a lack of sources. It is increasing the risk of diabetes (America’s Health Rankings, 2025a). Given these conditions, healthcare systems must implement mobile farmers’ markets, nutritional subsidy initiatives, and collaborative efforts with grocery retailers to ensure healthier food choices are accessible in underserved areas.

A comprehensive analysis of West Virginia’s diabetes crisis and its underlying social determinants emerges from multiple credible sources. Data from the U.S. Census Bureau highlights economic and healthcare accessibility challenges, while findings from America’s Health Rankings emphasize the need for interventions to improve food security. These datasets collectively inform targeted strategies that address both medical and lifestyle factors. By integrating evidence-based solutions with community engagement efforts, the initiative aims to create long-term, sustainable improvements that tackle diabetes at its root causes.

Conclusion

The successful implementation of the inhabitant’s well-being development strategy for Type 2 diabetes in West Virginia depends on a comprehensive approach that addresses socioeconomic disparities, healthcare accessibility, and lifestyle modifications. By integrating community-driven interventions, technological progress, and culturally responsive strategies, this initiative aims to enhance diabetes management. Expanding diabetes screenings, increasing access to nutritious food, improving healthcare coverage, and promoting physical activity are critical measures for achieving sustainable public health improvements. 

References

America’s Health Rankings. (2023). Explore Uninsured in West Virginia | AHR. Americashealthrankings.org. https://www.americashealthrankings.org/explore/measures/HealthInsurance/WV

America’s Health Rankings. (2025a). Explore Food Insecurity in West Virginia | AHR. America’s Health Rankings. https://www.americashealthrankings.org/explore/measures/food_insecurity_household/WV

America’s Health Rankings. (2025b). Explore Obesity in West Virginia | AHR. America’s Health Rankings. https://www.americashealthrankings.org/explore/measures/Obesity/WV

American Diabetes Association. (2023). The Burden of Diabetes in West Virginia. https://diabetes.org/sites/default/files/2023-09/ADV_2023_State_Fact_sheets_all_rev_West%20Virginia.pdf

Census Bureau. (2020). Explore Census Data. Data.census.gov. https://data.census.gov/profile/West_Virginia?g=040XX00US54

Lee, J., & Hale, N. (2022). Evidence and implications of the Affordable Care Act for racial/ethnic disparities in diabetes health during and beyond the pandemic. Population Health Management, 25(2), 235–243. https://doi.org/10.1089/pop.2021.0248

Nigussie, E. M., Demeke, M. G., Adane, T. D., Mengistu, B. T., Goshu, A. T., Dessie, Y. A., Worku, B. G., & Asefa, E. Y. (2024). Diabetic health literacy and associated factors among patients with diabetes attending follow-up in public hospitals of Northeastern Ethiopia: a multicentre cross-sectional study. BMJ Open, 14(10), e084961–e084961. https://doi.org/10.1136/bmjopen-2024-084961

Rezaee, R., Khashayar, M., Saeedinezhad, S., Nasiri, M., & Zare, S. (2023). Critical criteria and countermeasures for mobile health developers to ensure mobile health privacy and security: Mixed methods study. JMIR MHealth and UHealth, 11, e39055. https://doi.org/10.2196/39055

Rollins, L., Carey, T., Proeller, A., Adams, M., Hooker, M., Lyn, R., Taylor, O., Holden, K., & Henry Akintobi, T. (2020). Community-based participatory approach to increase African Americans’ access to healthy foods in Atlanta, GA. Journal of Community Health, 46, 41–50. https://doi.org/10.1007/s10900-020-00840-w

Shubrook, J. H., Patel, M., & Young, C. F. (2023). Community-based diabetes awareness strategy with detection and intervention: The mobile diabetes education center. Clinical Diabetes, 42(1). https://doi.org/10.2337/cd23-0020

Till, M., Omar, K. A., Maul, A. H., Fleuren, T., Reimers, A. K., & Ziemainz, H. (2022). Scaling up physical activity promotion projects on the community level for women in difficult life situations and older people: BIG-5 and GET-10—A study protocol. Frontiers in Public Health, 10, 837982. https://doi.org/10.3389/fpubh.2022.837982