Coronary Heart Disease is the leading cause of death in the U.S. Low income, rural, and minority residents are at particularly high risk, and county health departments play a vital role in providing preventive services to this population. However, with nearly one third of adult Americans in need of dietary treatment for hypercholesterolemia, health department nutrition services are inadequate to meet the need. Public health nurses could extend nutrition services, but limited nutrition knowledge as well as attitudinal and organizational barriers have limited this. We propose a randomized controlled trial to test the effectiveness and feasibility of a structured dietary assessment and intervention program -- the Food for Heart Program (FFHP). The program is designed to improve dietary management of hypercholesterolemia by public health nurses in country health departments who serve primarily low income and minority clients. The FFHP includes a validated Dietary Risk Assessment (DRA) that: is quickly and easily administered, scored, and interpreted by a non- nutritionist; identifies major sources of saturated fat and cholesterol in the diet of low income, southern individuals; and assesses misconceptions and attitudes which may serve as barriers to dietary change. Individualized diet counseling is conducted by public health nurses in three 15-20 minute sessions using color coded educational materials that link specific behavior change recommendations with major dietary problems identified by the DRA. This minimizes the amount of nutrition knowledge required of the nurse, and increases counseling efficiency. The FFHP is culturally specific for a southern client population with minimal reading skills and is designed to overcome barriers to diet counseling by health care providers. Behavior change theory guides the structured intervention, with a focus on individual tailoring, environmental shaping, gradual change, reinforcement, and social support. Reinforcement of the intervention during a one year follow-up period will include newsletters and an additional visit. The FFHP in its entirety (special intervention) will be compared to the DRA component of this program alone (minimal intervention) in the adult health clinics of county health departments. Fourteen health departments will be randomized to either intervention or minimal care (total 420 patients; 30 per health department). The primary outcome of this comparison will be change in serum cholesterol. Secondary outcomes will be change in body mass index and in dietary atherogenic risk. Impact of the intervention on knowledge, attitudes, and barriers to change for both nurses (n=56) and clients will be assessed relative to the comparison group. This will include pre-post measures of nursing job satisfaction. In addition, cost- effectiveness and acceptability of the intervention will be determined. Comparison group cost-effectiveness analysis per randomized client outcome will be used to assess costs, and logistic regression and log odds used for acceptability. If the FFHP proves effective and feasible when used by public health nurses in rural health departments, it could serve as a model for a variety of health care interventions in rural areas.
| Ammerman, Alice S; Keyserling, Thomas C; Atwood, Jan R et al. (2003) A randomized controlled trial of a public health nurse directed treatment program for rural patients with high blood cholesterol. Prev Med 36:340-51 |
| Keyserling, T C; Ammerman, A S; Atwood, J R et al. (1999) A cholesterol intervention program for public health nurses in the rural southeast: description of the intervention, study design, and baseline results. Public Health Nurs 16:156-67 |
