Running head: PORT GROUP     1

Health Paper Project Part II: PORT Group

L. Cornatzer, T. Dowd, M. Estep, J. Ghartey, H. Healy, R. Lutzkanin, M. Strait, M. Voellm

Old Dominion University

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Health Project Paper Part II: PORT Group

America is aging, and with advancing age comes the complications of chronic conditions

such as hypertension (HTN) and diabetes mellitus (DM), which have devastating implications

for populations with limited resources. The homeless population in Newport News suffers from

these two common complications, amongst a myriad of others, without the health literacy,

financial resources or social stability necessary to manage them effectively. The Old Dominion

University School of Nursing partnership with People Offering Resources Together (PORT)

provided an opportunity for nursing students to provide much-needed health education and

screenings to this underserved population while helping train them to readily identify and assess

social factors which interfere with improved health outcomes in this population. The results of

this assessment yielded several common themes, noted in part one of this project. They included

a low health literacy, poorly managed chronic diseases, and poor dietary intake, compounded by

limited financial resources and little knowledge of and access to the health resources available to

them.

Planning

Health Problems

The homeless population in Hampton Roads closely resembles that of the national

homeless population. They are most frequently individuals rather than families, with

disproportionate subpopulations of veterans and people with mental and substance abuse

disorders. They are primarily Caucasian and African American males over the age of 25 (Henry,

Cortez, & Morris, 2013; Paquette, 2011) (See Appendices A, B, & C). Prior to planning

interventions to help this aggregate, it is necessary to understand their needs. This was

accomplished by performing a needs assessment and addressed in part one of this project. The

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evidence for the identification of the aggregates’ health problems was obtained by conducting

one-on-one interviews with its members in addition to collecting their blood pressure (BP)

readings, basic health histories and collecting aggregate-level observational data. Based on the

assessment of the 209 members of the aggregate, three priority nursing diagnoses were

identified: ineffective health maintenance, deficient knowledge of health care, and disturbed

sleep pattern.

Ineffective health maintenance. Ineffective health maintenance was evidenced by the

high incidence of chronic illnesses among the aggregate. Out of the 209 members, 99 (or 47%)

reported having at least one chronic medical condition, 28% of them claimed HTN and the

second most frequently noted disease was DM, at 8%. These conditions were either untreated or

undertreated by the individuals in the population. Thirty-five (17%) of the individuals who

reported a chronic condition stated that they were currently taking medication for HTN, many of

whom indicated that they did not have the financial means to take them as directed by their

prescriber. Only 38% of the aggregate claimed to be current with their medications,

overall. Individuals who reported having DM were not able to articulate recent blood glucose

values due to financial barriers, and were therefore not monitoring their levels as is needed to

effectively manage their DM. Many also displayed disinterest in seeking primary or secondary

health care due to other, more pressing priorities. The most frequently cited priorities were

finding shelter, food, and a source of income. They chiefly sought treatment in the emergency

room for acute issues that arose, such as injuries secondary to falls or acute exacerbations of

poorly managed HTN or DM. The aggregate attributed their ineffective health maintenance to

the high cost of medications and equipment, such as glucometers and test strips combined with

insufficient financial means, whether they paid directly out-of-pocket or in concert with medical

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insurance. Furthermore, many expressed that they did not know where to go to secure less-

expensive primary health care. Their health issues were further compounded by adverse

personal habits, such as smoking, drug or alcohol abuse, and poor dietary habits and limited

dietary options. Poor personal hygiene secondary to a lack of access to running water was also

noted by the group.

Deficient knowledge of health care. The aggregate demonstrated deficient knowledge

of health care in their inability to accurately verbalize information about the pathophysiology of

their conditions, what risk factors and current habits they had that attributed to their conditions,

the normal values for BP and blood glucose levels, and where to seek reduced-price or free

health care. Many members were not initially aware that their BP readings were considered

high; while 58 members (28%) reported being medically diagnosed with HTN, a total of 84

(40%) showed at least one hypertensive BP reading during the screenings. The majority did not

know whether their readings were within the normal range until they were told what the numbers

meant; many were surprised to have high readings. Some were surprised, despite a positive

family history of HTN, a common non-modifiable risk factor for the condition (Chen et al.,

2012). They also showed a need for further information by asking many health-related

questions. Their deficient knowledge was largely related to a low health literacy and

unfamiliarity with and lack of access to the available health resources. For some, it was seen as a

compromised emotional state related to their mental health status in response to stress which

negatively affected their motivation, while with others it was an inability to seek or retain this

knowledge. Additionally, others experienced barriers to increased knowledge such as functional

or literal illiteracy, a common problem to homeless aggregates (Coalition for Literacy, 2015;

Sinclair, 2014).

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Disturbed Sleep Pattern. The aggregate were faced with disturbed sleep pattern as

evidenced by their complaints of fatigue during the day and not feeling well rested from the

previous night. This is related to their suboptimal sleeping arrangements. The individuals were

each provided with mats to sleep on the floors in a single large room with an average of fifty

people on any given night, though they were divided by gender and age with women and

children separate from the men. Some individuals were unable to sleep throughout the night,

sometimes in relation to crying children which added noise to the already uncomfortable and for

some, unfamiliar environment. The designated sleeping hours of 8:30 pm to 4:30 am were also

cited as being a barrier to their quality and quantity of sleep.

Selection of Health Problem

The health problem, or nursing diagnosis, chosen as a focal point for intervention was

deficient knowledge of health care, principally addressing the two largest health care needs of

the aggregate, HTN and DM. (See Appendix D) The ultimate goal of the interventions was to

increase the knowledge base of the aggregate in the hopes that increased knowledge would

facilitate both an increased motivation for individuals to improve their modifiable risk factors as

well as provide them the educational foundation to make the changes. Many members of this

homeless population had undiagnosed or uncontrolled high BP and many were uneducated about

how to manage their condition. In addition, those who chose to participate in the BP screenings

showed an increased desire to learn about inexpensive options to reduce the effects of or outright

stop their HTN. In collaboration with the desires and needs observed during individual informal

interviews with the aggregate, the group agreed upon the use of a pamphlet and oral teachings

combined with evaluative crossword puzzles to measure the amount of knowledge that the

aggregate gained through the teaching interventions. Two pamphlets and two crossword puzzles

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(See Appendix E) were created to provide information and a means of evaluating retention of the

teachings on HTN and DM. The expected outcome was that the crossword puzzles would

provide an opportunity for the group to assess the degree with which the aggregate owned the

material taught to them and that the intervention itself would provide a conduit for further

discussions and questions with the aggregate. Specifically, the goal was the successful

completion of 50% of the crossword puzzles and the initiation of at least two conversations

regarding personal health care needs or practices with an aggregate member per night. The

original intent was to score the percentage of correct answers found on the puzzles, but as the

intervention progressed, it became apparent that the parameters of the design (requiring the first

person who completed the puzzles correctly to turn it in for a prize) left many puzzles only

partially completed while the ones directly turned in were 100% completed.

Alternative Interventions

Alternative interventions utilized at an individual level were to provide person-specific

teachings during the free BP screenings and providing consistent presence in the program to

encourage individuals’ trust and motivation to seek out the group for health education

assistance. The aggregate was subdivided into groupings of familiar friends and

acquaintances. These connections were utilized to increase program efficacy by establishing

trust with key informants who then utilized their social standing within the subgroups to

encourage others to participate in the informal interviews and screenings. These key informants

received greater time with the group and were provided more in-depth health-education in

accordance with their increased personal desires to participate. This reward of motivation with

information served as an vector to improve both relations and general subgroup esteem of the

importance of participation in the interventions and participation overall with the aggregate. On

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an aggregate-wide level, facility directors were enlisted to help promote the free services of the

group and to encourage a greater awareness of the group’s purpose and usefulness to the

individuals in attendance each night.

Dietary Logs. Other outcomes which addressed peripherally-associated health

objectives were also planned. For example, a log was maintained which recorded the nightly

meals provided to the aggregate in an effort to collect data on the opportunities and limitations

for healthy eating placed on the aggregate. The primary objective of this tracking was to

increase the awareness of the healthy eating habits, or lack thereof, of the group. To that effect,

the group utilized the tracking of the data to initiate at least one conversation with an aggregate

member or with the volunteers providing food each week. Additionally, from this log a menu

was created to provide healthier alternatives which could be utilized by the volunteer staff who

prepared the meals for the aggregates each night.

BP Screenings. Free, nightly, BP screenings were an essential tool not only to gain

access to the aggregate and thereby form partnerships with individuals, but also as a teaching

tool and point of reference of the health status for individuals. It was anticipated that the

increased frequency of BP screenings would increase aggregate awareness of their risk for or

presence of HTN and yield increased opportunities to speak with members regarding their health

concerns. This was planned in the efforts to assist in the reaching of a minimum goal of two new

health-related conversations per night. The BP screenings were in of themselves a goal and

intervention. They served as a tool to increase access to the aggregate, and as each BP

measurement was logged, they also served to track trends for those members of the aggregate

who wished to participate in the monitoring of the health in a greater depth.

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Finally, it was expected that in order to effectively decrease the percentage of the

population who suffered from HTN and DM, they would need greater access to primary health

care. Therefore, a goal of providing informational sheets with the contact information for local

primary health care options was established. To that effect, two hand-outs of local resources

were created and provided to the members of the aggregate which listed free or reduced-price

primary care clinics and a list of veteran resources available locally to the aggregate. The goal

included essential follow up with the aggregate members to confirm that their access to

healthcare needs were met.

Alternate interventions not utilized, but related to the primary intervention of education

that has the highest probability of success are: an oral teaching of HTN and DM concepts with a

post-discussion open-forum for questions and answers and aggregate-wide informational

sessions which encourage a grander-scale participation in the interventions. It would be optimal

to provide randomly-generated opportunities to win prizes, such as a raffle ticket system, after

each teaching session to increase participation and to reduce the percentage of individuals in the

aggregate who disengage with the intervention once a prize is no longer available.

Interventions

Implementation of Intervention

Most of the above planned interventions were implemented throughout the PORT clinical

with the aggregate. However, based on the assessment of and mutual goal setting with the

aggregate, health education through the use of pamphlets, individual educational interviews and

evaluative crossword puzzles, emphasized on primary and tertiary levels of prevention were the

focused interventions applied. Individualized teaching sections were provided to all the

aggregate that received BP screenings every evening the group was present at PORT. An

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average of 10-12 individuals within the aggregate received teaching each night at

PORT. Aggregate members involved in the interventions included: those diagnosed with HTN;

those diagnosed with DM; those with high BPs, but not diagnosed with HTN; and members with

normal BPs and various other health concerns. The teaching sessions were geared towards

prevention and chronic management of HTN and DM. Pamphlets containing information about

HTN and DM were given to the aggregate after the teachings were done to be use as reference

for both the completion of the crossword puzzles and as later reference materials. Information in

the HTN pamphlets included: what HTN is, signs and symptoms, management of the condition,

complications of unmanaged high BP, and how to prevent HTN. (See Appendix E) Information

in the DM pamphlets included: what DM is, signs and symptoms of high blood sugar level, signs

and symptoms of hypoglycemia, when to check blood sugar levels, management of

hyperglycemia and hypoglycemia, and prevention of the disease. (See Appendix E) All the

information in both pamphlets were written and presented below 8th grade level with bigger fonts

and pictures that made it easy to read and understood by the aggregate.

The primary rationale for implementing training on HTN and DM were the high

aggregate-specific instances of these diseases and the high incidence of interviewed individuals

within the aggregate who demonstrated a knowledge deficiency and a desire to learn more about

these two diseases (See Appendix F). HTN and DM are chronic diseases that impact daily living

and their management through the use of medication and life style modifications is essential to

improvement of quality of life. The medications for both diseases must be adhered to by the

patient in order to prevent complications such as metabolic syndrome or strokes (Gulanick &

Myers, 2014). Both diseases are preventable through life style changes like exercises, and a

healthy, balanced diet.

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Research for Implementation

Education was the most useful and cost-effective tool available to proactively improve

the health of the aggregate. A linear regressions study examined the effects genetic ancestry and

education has on predicting HTN in African Americans. It was discovered that genetic ancestry

does not predict HTN in African Americans, but education does significantly predict BP

variations in this population (Non, Gravlee, & Mulligan, 2012). In a randomized non-blinded

trial that consisted of 360 HTN patients in low socioeconomic standing, the participants were

divided into three community-based educational groups. Of the three groups, the educational

program that met monthly and held an interactive educational workshop was most proficient at

decreasing the rate of HTN among participants. Meanwhile, the group that involved self-

learning reading interventions did not have a decrease in HTN (Chu-Hong et al., 2015). This

reinforces the appropriateness of educational interventions provided by the group, particularly

the utilization of teaching workshops followed by easy-to-read pamphlets that reinforce the

information taught.

The educational interventions focused on providing the aggregate with knowledge of

modifiable risk factors in lowering their BP, such as diet, medication adherence, and

environmental factors. When the partnership began with this aggregate, many stated that they

had or should be on medication for their HTN, but did not take the medication due to financial

hardships which limited their reliable access to health care providers and paying for the

prescriptions themselves; and various health literacy gaps such as an unclear understanding of

their prescribed dosing schedule or the importance of keeping a continuously steady amount of

the drug in their bloodstream. A study which examined the beliefs of medication adherence for

HTN in African American males over 45 years of age who were prescribed antihypertensive

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medications found that, while financial difficulties did play a role in medication adherence, the

primary theme was a lack of understanding. When the participants were able to recognize the

symptoms of HBP and understand the seriousness of the disease, they were more likely to take

their medications (Bennett, 2013). After a consistent presence through providing nearly daily BP

screenings with concurrent one-on-one education of the individuals with HTN had been

established, there was an increase of individuals who reported taking their medications

consistently to manage their BP.

Throughout the group’s time with the PORT aggregate, it was noticed that adjustments to

their sodium intake could be made to better aid in the management of their HTN. As per Qin et

al. (2014), a cross-sectional study with 2502 subjects was performed to evaluate and examine the

subjects’ salt intake and knowledge about salt intake and HTN. It was found that 70% had a

sodium intake of greater than 6g/d and while the majority knew that excessive salt intake can

lead to or worsen HTN, only 35% knew what their parameters were for sodium intake. Subjects

that consumed less than 6g/d of sodium had a higher control rate of HTN and those who were

educated about appropriate sodium intake better managed their BP (Qin et al.,

2014). Implementing education about managing sodium intake for this population was a focus,

but as the involvement continued the focus was adjusted to incorporate the simultaneous

education of the volunteers, as they provided the nightly meals to the aggregate.

As previously mentioned, DM was the second most prevalent disease in the

aggregate. This finding is in accordance with the findings nationwide. In fact, HTN and DM

prevalence in the homeless population has been steadily increasing over the past 30 years,

highly-attributable to the aging of the nation’s population (Bernstein, Meurer, Plumb, & Jackson,

2015). Homeless populations are at an increased risk from complications, as they are

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experiencing limited access to the health resources necessary to identify and properly treat their

diseases. As such, education-based interventions with homeless or underprivileged populations

experience an increased positive effect on planned health outcomes across a wide variety of

educational topics (Speirs, Johnson, & Jirojwong, 2013). Finally, DM management education

promoted by the group focused on simple, daily lifestyle changes that were achievable by the

population, as accounting for social and structural factors such as reduced access to a wide

variety of foods and healthcare services has an exaggerated importance in the homeless

population due to their extreme lack of resources (McNeil, Guirguis-Younger, Dilley, Turnbull,

& Hwang, 2013).

Another topic discussed with the aggregate included finding adequate day-time shelter in

order to reduce the stress that exposure to the elements in an urban environment can cause. A

study looked at how traffic noise and nitrogen dioxide (NO2) can affect BP. It was discovered

that long-term exposure to NO2 was associated with HTN and that and there was a strong

correlation between indoor noise and an increase in systolic BP (Foraster, et al., 2014). Inside

the PORT program facilities where the aggregate stays, it is usually loud and there is a lot of

movement. It is common to see people exhibiting signs of stress overload after spending their

days in such a hectic environment with no reprieve. A large number of people were seen who

had a high systolic BP and a normal or near-normal diastolic BP who, after talking with them,

expressed that they were stressed or appeared to be on edge. (See Appendix G) Doing one-on-

one stress management teaching and helping them find ways to relieve stress aided in the

normalization of their BP.

Barriers

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Working with the PORT population was one of the most rewarding experiences in which

a group of community health nurses could hope to participate. However, attempting to educate

the aggregate did not come without its challenges. During the implementation phase, one of the

most prevalent challenges that arose while attempting to provide education on DM and HTN was

the outright refusal to participate. The educators found that those who had previously been

diagnosed with HTN were not interested in having a BP reading. After discussing this with some

of the more willing participants it was found that those diagnosed with the condition were much

less willing due to the fear that a high reading would result in the educators calling an

ambulance. The cost of the potential ambulance ride deterred quite a few participants. This has

been an obstacle since the beginning of this project, but in recent times the educators have

attempted to explain that the cost of the ambulance would not fall on the PORT participant. This

has resulted in swaying a few more members into having a BP reading, but there are also those

who have remained adamant about not having his or her BP monitored.

During the implementation phase, the educators began to incorporate short bits of

teaching about DM and HTN as appropriate while performing BP screenings on the members of

PORT. Unfortunately, these education sessions seemed to be unsuccessful at times. Members

would not sit through the information or would expressed that he or she was not concerned with

learning about the conditions or preventative measures for each. Through much investigation and

conversation, the community health nurses were able to determine the main reasons the

aggregate had for not becoming involved in the education sessions. Multiple members of the

PORT population stated that because of previously being diagnosed with these two conditions,

further education was not needed. There was also report that spending the extra time on

education sessions would cause the individual to fall to the back of the food line. After hearing

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these two reasons for avoiding the planned education sessions the educators decided to address

this issue and provide additional motivation by supplying the first participant to complete the

educational crossword puzzles with a five-dollar gift card to Walgreens. This appeared to

motivate many of the PORT participants and the participation rate increased drastically. The

members were now able to take the puzzles back to the dining tables instead of sitting through

the five minute teaching sessions. This intervention allowed each member to swiftly get through

the food line and allowed the aggregate to obtain the educational material at his or her own rate.

However, even after increasing the participation rate through the use of the gift card,

other issues developed and resistance was met. The participants reported that even though the

puzzles could be completed at one’s own pace, there was not much time between dinner, smoke

break, and bed. There were also statements made by the members of PORT reporting that the

puzzles were too much work for only a five-dollar gift card. Unfortunately, as with the BP

screenings, the same few people participated in the educational crossword puzzles each

night. The PORT members would have a BP screening, get dinner, and then fill the puzzle in

from memory from the previous night. To address this issue, the educators had to place a one-

time limit on the number of times one person could win the gift card.

Another huge factor that affected the amount of time spent on the puzzles was the literacy

rate. The literacy rate varies greatly among the members of the PORT population. Many of the

PORT members expressed concern about not having enough time to complete the puzzles

between obtaining the puzzle and the departure of the community health nurses. The information

needed to complete each crossword could be found in two corresponding pamphlets. To address

the literacy deficit found within the population, the information was presented in a less formal

fashion. The crossword puzzles were also designed to directly correlate with the pamphlets. The

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majority of the answers to the crossword were simple fill in the blank answers. After assessing

the depth of the literacy deficit, the educators made the decision to have the educational puzzles

focus much less on critical thinking and much more on providing straightforward,

comprehendible information that the aggregate would find applicable and relevant.

Evaluation

Plan for Evaluation

Evaluation of interventions is an essential component of any nursing process. The

overlying objectives of the interventions were to increase: the health care knowledge of the

aggregate; the dialogue between the aggregate and the educators or group; the aggregates’

awareness of the local health resources available to them as well as eating habits which were

healthy and supported the reduction of some of their more common chronic conditions. The

expected outcomes intended for this experience were: that at least 50% of each HTN and DM

puzzle was completed correctly (this goal was partially met); that each night at least two people

would engage in a conversation with the group about their health improvement (this goal was

met); that every aggregate member who had a health resource access question was provided a

referral to a local resource to their satisfaction (this goal was met); and finally that conversations

regarding healthy eating habits between group members and the aggregate or a PORT volunteer

resulted in one new piece of health or nutrition knowledge being conveyed (as demonstrated

through reiteration of the concept or through conversation indicating how that practice could be

implemented by the individual into their life) at least once per week (this goal was also met).

These goals or outcomes were evaluated primarily through informal interviews and open

discussions. Specifically, the knowledge attainment was evaluated through the use of literature

(the pamphlets and crossword puzzles), individualized teachings and screenings. The rationale

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for using these methods was that increased contact with educational content would improve their

retention of the materials presented, or “practice makes perfect”. Through the increased

dialogue, the group was provided the opportunity to actively question and monitor their

understanding of concepts presented to them. This increased conversational time was essential

to the interview process and in attaining higher levels of disclosure, trust and information from

the aggregate members. The group emphasized the follow-up with members who requested

information regarding access to local health care resources so greatly, because it was through

meeting their needs that the group was able to increase bonds of trust. Reliability gave way to

relationships between the group members and the aggregate. Finally, recording nightly meals

provided to the aggregate was essential to establishing a case for the improvement of the

nutritional value of the foods provided to the aggregate. Collecting data not only enables

reflection, it also created an opportunity to replace commonly eaten items with healthier

versions.

The primary intervention to improve the aggregates’ health knowledge deficit was the

implementation of two crossword puzzles, which were offered with adjoining educational

literature (two pamphlets) and individualized sessions to the participants. The two main

objectives were to see at least 50% of each the puzzles completed correctly before the end of

each session and to increase aggregate dialogue regarding their health and health to one

conversation with at least two individuals from the aggregate per night. Many barriers prevented

the effective evaluation of the first half of this intervention. The participants were not timed, but

they were encouraged to complete it as quickly as possible as the first one to complete both

puzzles correctly received a $5 gift card to Walgreens. This site was chosen, in particular, due to

the restrictions on gifts card use at the stores which disabled participants’ ability to buy alcohol

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(a prohibited item at the PORT locations). The educational interventions were evaluated as

highly successful in their effectiveness in opening new lines of communication with the

participants and increasing overall HTN and DM awareness within the population, despite the

fact that their direct efficacy in assessing knowledge owned by individuals was unable to be

adequately evaluated. The two topics of HTN and DM were chosen due to the increased

incidence of these diseases in homeless populations overall as well as the increased incidence in

this aggregate in particular (Bernstein et al., 2015). (See Appendix F) The two crossword

puzzles, while ultimately ineffective in measuring the level of concept mastery, were appropriate

in that they allowed aggregate members to complete the intervention while they ate dinner and

therefore didn’t compete with their more pressing priorities.

Peripheral interventions, such as the use of free BP screening and health counseling, the

use of key informants and PORT volunteers to spread the health improvement messages of the

group, the monitoring of daily meals and creation of a healthy-alternative menu, and the

provision of informational sheets with list of reduced-price health resources such as local health

clinics and veteran’s contact points, were implemented with success. All of these measures were

effective as intended in that the increased dialogue and awareness of the resources, educational

tools and lifestyle changes that could relatively easily be incorporated into the aggregate

members’ lives.

Limitations

Some recognized limitations to the evaluation process were with the tools themselves (the

crossword puzzles) and other various hurdles elsewhere within the process. The puzzles used

required a certain level of literacy that some of the aggregate members did not possess. For

example, when asked to read aloud text from the pamphlet during an informal assessment of the

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aggregates reading level, a few of them flat out refused to read, a likely indicator of a low

functional literacy level. This issue could have been resolved by offering an alternative oral or

pictorial means of evaluation to still allow those with limited literacy an opportunity to

demonstrate mastery of content.

Limitations were also present in how the evaluation tool was distributed. The crossword

puzzles were only given to those who visited the table and were not advertised beyond that. This

could have been fixed by making announcements, whether written or oral, of what the group had

to offer or by going around from table-to-table to invite more to participate. Prior advertisement

of the intervention with the aggregate before its initiation could have also improved participation

rates. The time-sensitive nature of the first person winning the prize placed slower individuals at

a disadvantage and may have discouraged some from participating. Offering some sort of

smaller reward for all participants who completed the puzzles regardless of how long it took or

handing out the evaluation to everyone interested at one single time each night after allowing the

intake process to finish could help correct this limitation.

Furthermore, evaluation of the outcomes was restricted by the aggregate’s level of

participation. This was attributed to either not wanting to be burdened to carry around more

paperwork, to not being motivated enough to complete the evaluation or forgetting to complete

it. In the case of not wanting to carry papers, it could be emphasized that the evaluation is to be

turned in the same night. To increase motivation, inexpensive or donated yet still attractive

rewards could have been offered just for participation instead of just giving a single prize early in

the night. For those who needed some reminding or motivation, a tracking system of those who

had the forms could have been implemented and utilized to check on their progress, provided

assistance and encouragement as appropriate.

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As mentioned in the previous section, part of the evaluation method involved the

activities’ effect on communication with the aggregate. While going over the information

presented in the pamphlets, new lines of communication with those who participated were

developed. Many found what was in the pamphlets to be eye-opening and started a discussion

about what changes could be made in their lives to prevent or manage their HTN or DM. For

some, it opened a dialogue about the challenges of being homeless that make health management

extremely difficult. Others were even inspired to seek out available clinical help on site and

wanted to learn more. Limitations with this aspect of the evaluation process were not as

prominent but still existed in terms of the participants' ability to read the pamphlets, which

simply orally or graphically relaying the information and talking it over could address, and their

willingness to open up about personal matters in their lives as it relates to their health, which

being empathetic, active, nonjudgmental listeners could encourage.

Recommendations for Further Actions

As previously mentioned, considering that literacy levels are disproportionately lower in

homeless populations, a significant limitation of the intervention used was the requirement that

these individuals read and write to participate in the intervention (Coalition for Literacy,

2015). Future iterations of these interventions would benefit from establishing a verbal means of

conveying and evaluating this health information. Alternatively, the same tools could be used in

a group setting with a poster-board version of the crossword. Individuals running the session

could fill in the blanks for the participants as they verbally communicate their answers. It is

possible a significant portion of the population was deterred from participation due to the

methods used to evaluate their knowledge post-intervention.

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Other interventions which were peripherally addressed by the group could be expanded to

improve the baseline health status of the aggregate. Education on implementing dietary changes

which support the reduction of HTN and DM for both the aggregate and for the facility

volunteers who are providing the dinners each night would provide significant improvements to

the health of the population. While continued BP screenings are highly recommended, a

limitation to the quality of the measurements was noted by the group. Large BP cuffs were not

available, but greatly needed to support accurate measurements of the members of the aggregate

with larger arms. Several of these individuals were believed to have falsely increased BP

readings due to inadequate equipment. It is strongly recommended to those who continue in this

program to obtain at least one large or extra-large BP cuff before continuing the screenings. In

an effort to increase access to healthcare resources for the aggregate, a list of free or reduced

priced health clinics and a list of resources specifically for the large subpopulation of homeless

veterans were compiled. Greater investigation of these facilities and networking with their staff

may create further opportunities for connections between the aggregate and the available local

health resources.

Implications for Community Health Nursing

As community health nurses seek to positively affect the health literacy of this homeless

population, it is essential that not only their limited financial resources be considered. The

disadvantages which caused many of these individuals to become homeless continue to deter

their attainment of housing. Lower levels of literacy impede their ability to function in most

workplaces. Nurses should seek not only to provide health services, but to also address the

educational limitations the population is facing in order to improve their overall health

status. Their lack of knowledge on where to go for free or reduced-price healthcare in

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combination with their financial distress prevents them from seeking the primary care which

could avoid many of their complicated health problems. The authors compiled a list of local

clinics for the program attendees, but those who were illiterate would find this aid

useless. Bringing more healthcare out to the homeless populations where they congregate could

be a superior method of providing preventative healthcare to these individuals. Community

health nursing is aptly named, as it is best performed out in the community. Nurses need to seek

out opportunities to incorporate themselves into the lives of this highly-afflicted population if

they are to ever make a significant positive impact in their lives.

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References

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with high blood pressure. Med-Surg Matters, 22(3), 4-10.

Bernstein, R., Meurer, L., Plumb, E., & Jackson, J. (2015). Diabetes and hypertension

prevalence in homeless adults in the united states: A systematic review and meta-

analysis. American Journal of Public Health, 105(2), e46-e60. doi:10.2105/AJPH.

2014.302330)

Chen, X., Zhang, Z., George, L. K., Wang, Z., Fan, Z., Xu, T., & ... Zeng, Y. (2012). Birth

measurements, family history, and environmental factors associated with later-life

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Chu-Hong, L., Song-Tao, T., Yi-Xiong, L., Mian-Qiu, Z., Wei-Quan, L., Sen-Hua, D., & Pei-Xi,

W. (2015). Community-based interventions in hypertensive patients: A comparison of

three health education strategies. BMC Public Health, 15(1), 783-799.

doi:10.1186/s12889-015-1401-6

Coalition for Literacy. (2015). Retrieved from http://www.coalitionforliteracy.org/

Foraster, M., Künzli, N., Aguilera, I., Rivera, M., Agis, D., Vila, J., & ... Basagaña, X. (2014).

High blood pressure and long-term exposure to indoor noise and air pollution from road

traffic. Environmental Health Perspectives, 122(11), 1193-1200.

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Gulanick, M., & Myers, J. (2014). Nursing care plans diagnoses, interventions, and outcomes. (8

ed.). Philadelphia, PA: Elsevier

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Henry, M., Cortez, A., & Morris, M. (2013). US department of housing and urban development.

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McNeil, R., Guirguis-Younger, M., B Dilley, L., Turnbull, J., & Hwang, S. W. (2013). Learning

to account for the social determinants of health affecting homeless persons. Medical

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Salt intake, knowledge of salt intake, and blood pressure control in Chinese hypertensive

patients. Journal of The American Society Of Hypertension, 8(12), 909-914.

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Sinclair, H. (2014). Homeless people need better skills opportunities. Adults Learning, 25(4), 40.

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Appendix A

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Appendix B

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Appendix C

Age Distribution of Aggregate

         

 

 

 

 

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Appendix D

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Appendix E

Blood Pressure Pamphlet

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Diabetes Pamphlet

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BP Crossword Puzzle

Hypertension    

Across

4. TAKE YOUR MEDICATIONS, EVEN IF YOU ARE FEELING GOOD

6. THE MEASUREMENT OF FORCE APPLIED TO ARTERY WALLS

8. TO BETTER CONTROL YOUR BLOOD PRESSURE YOU SHOULD LIMIT YOUR _________ INTAKE

9. EAT MORE _______ _______ SUCH AS WHOLE WHEAT BREAD AND BROWN RICE

Down

1. TOP NUMBER IN BLOOD PRESSURE

2. UNCONTROLLED BLOOD PRESSURE CAN CAUSE A LOSS OF _______

3. BOTTOM NUMBER IN BLOOD PRESSURE

5. LIMIT ____ ______ SUCH AS PORK AND BEEF

7. TO BETTER CONTROL YOUR BLOOD PRESSURE YOU SHOULD WATCH WHAT YOU ____

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DM Crossword Puzzle

Diabetes  

Across

2. IF YOU FEEL LIKE YOUR BLOOD SUGAR IS LOW YOU CAN CONSUME ONE TABLESPOON OF ______

4. HAVING A _______ ODOR TO YOUR BREATH MAY BE A SIGN OF HIGH BLOOD SUGAR

5. WHEN YOUR BODY IS UNABLE TO CONTROL YOUR BLOOD SUGUAR LEVELS

8. HAVING BLURRY ______ MAY BE A SIGN OF LOW BLOOD SUGAR

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Down

1. BEING EXTREMELY _______ MAY BE A SIGN OF HIGH BLOOD SUGAR

3. THIS IS ONE WAY YOU CAN MANAGE HIGH BLOOD SUGAR

6. YOU SHOULD ALWAYS CHECK YOUR BLOOD SUAGR BEFORE ______

7. YOUR BODY'S CELLS NEED _____ TO SURVIVE

9. YOUR PANCREAS SECRETES THIS HORMONE

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Appendix F

Proportion of Screened Aggregate Who Self-Identified Most Common Diseases

 

 

 

 

 

 

 

 

 

 

 

 

 

Hypertension  28%  

Diabetes  Mellitus    

8%  

 

Both  

5%  

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Appendix G

14%  

45%  

31%  

10%  

Blood  Pressure  Ranges  of  Aggregate  Screened  

Normal  Ranges  

Prehypertensive  Ranges  

Hypertensive  Stage  1  Ranges  

Hypertensive  Stage  2  Ranges