Week # 6

Public Health Nurs. 2018;35:317–326. wileyonlinelibrary.com/journal/phn  |  317© 2018 Wiley Periodicals, Inc.

1  | BACKGROUND

Dietary intake is a major contributing factor to obesity and is as- sociated with chronic diseases (Department of Health and Human Services, National Institute of Diabetes and Digestive and Kidney Diseases, 2012). Consequently, nutrition is a national health pri- ority (HealthyPeople2020, 2017). Although most Americans could improve as least some aspect of their dietary intake, sev- eral social factors are increasingly recognized as barriers to

nutrition, which contribute to health disparities for some popula- tions (HealthyPeople2020, 2017). For example, obesity rates are disproportionately higher for women (Ogden, Carroll, Fryar, & Flegal, 2015), for those in rural communities (Trivedi et al., 2015), from diverse racial/ethnic backgrounds (Ogden et al., 2015), and who have low incomes (Ogden, Lamb, Carroll, & Flegal, 2010). Therefore, novel approaches are needed to promote healthy nutri- tion and dietary intake for those who are disproportionately at risk for or may already be overweight or obese.

DOI: 10.1111/phn.12410

S P E C I A L F E A T U R E S : C L I N I C A L C O N C E P T S

Description of public health nursing nutrition assessment and interventions for home- visited women

Melissa L. Horning PhD, RN, PHN1  | Jeanette M. Olsen PhD, RN2 |  Shay Lell BSN (Student)1 | Diane R. Thorson MS, RN, PHN3 | Karen A. Monsen PhD, RN, FAAN1

1School of Nursing, University of Minnesota, Minnneapolis, MN, USA 2University of Wisconsin-Eau Claire, Eau Claire, WI, USA 3Tail County Public Health, Fergus Falls, MN, USA

Correspondence Melissa L. Horning, School of Nursing, University of Minnesota, Minnneapolis, MN, USA. Email: [email protected]

Abstract Objective(s): The purpose of this manuscript was to describe: Public Health Nurse (PHN) home- visited, female client Nutrition Knowledge (K), Behavior (B), and Status (S); the number and types of nutrition interventions PHNs used with these clients; and the types of clients receiving nutrition interventions. Design and Sample: This descriptive study used PHN- generated Omaha System, electronic health record data from January 2012 to July 2015. The analytic sample contains 558 women who received home visits in a rural Midwestern U.S. county that employed universal nutrition assessment for clients. Measurements: Omaha System data included nutrition KBS scores (from 1 = low to 5 = high) and nutrition interventions delivered. Analyses included descriptive, bivariate, and multivariate analyses (means, frequencies, chi- squares, general linear models). Results: PHNs assessed nutrition KBS scores for 84.1% of clients; average Nutrition Knowledge was 3.4 (SD = 0.7), Behavior 3.7 (SD = 0.8), and Status 4.3 (SD = 1.0). PHNs provided 0- 36 nutrition interventions per client. Nutrition intervention pat- terns were detected by the type of visit clients received. Conclusions: Results suggest home- visited women have room to improve Nutrition KBS and PHNs utilize myriad nutrition interventions. Results also point to opportuni- ties to improve home- visited client care by providing more nutrition interventions, especially to those not receiving interventions, and revising standard care plans to reflect important Case Management nutrition interventions.

K E Y W O R D S

house calls/home visits, nutrition assessment, nutrition interventions, nutritional status, public health nurses

318  |     HORNING et al.

One such novel approach may be to work through public health nurse (PHN) home visitors to improve nutrition outcomes of their clients. Currently, PHNs work to promote overall client health and wellness (American Nurses Association, 2013b) through tailored, client- centered care approaches in which the PHN and the cli- ent are partners (Monsen, Radosevich, Kerr, & Fulkerson, 2011). PHNs, in collaboration with their clients, work to improve factors and determinants contributing to health, including those within the environmental, psychosocial, physiological, and health- related be- havior domains. PHN home- visited clients typically include pregnant women and parenting families, often those with social or medical risk factors (e.g., depression, low incomes/education levels, family or community violence), as well as those in need of disease prevention/ mitigation and aging adults at risk for or already experiencing disabil- ity or frailty. PHN home visitors work with clients across the life span, and therefore must be able to both assess and subsequently address client- specific nutritional needs for all (Ackley & Ladwig, 2014). For example, nutritional needs of clients with acute and chronic illnesses are different than those of aging adults, pregnant women, postpar- tum or breastfeeding women, and growing infants/children.

The research base supporting the effectiveness of home visiting for at- risk pregnant and parenting clients is well established. PHN home-visiting interventions have been associated with a variety of positive maternal and child outcomes including improved parenting and home environments (Sweet & Appelbaum, 2004), appropriate health care utilization and improved social emotional development (Avellar & Supplee, 2013). The evidence supporting the effective- ness of home visits for older adults and disabled elderly is slightly more mixed, with not all (Bouman, van Rossum, Nelemans, Kempen, & Knipschild, 2008), but many systematic reviews suggesting a va- riety of positive outcomes. For example, these outcomes include reduced mortality, improved functional status, and reduced nurs- ing home admission rates (Markle- Reid et al., 2006). Other positive home-visiting outcomes for older adults and disabled elderly include reduced pain, anxiety, depression, medication adherence, and qual- ity of life (Abbott & Elliott, 2017).

Despite support in the research literature for positive health out- comes resulting from PHN home-visiting programs, little is known about the PHN role in assessing client nutrition knowledge, behav- ior, and status or about the number and types of nutrition interven- tions completed. To- date, three studies have both examined nurse home-visiting interventions and included information about nutri- tion assessments or nutrition interventions to at- risk pregnant and parenting families. Two studies assessed the Nutrition problem of home- visited clients using Omaha System electronic health record data (Monsen et al., 2010, 2011), and one study reported on whether home- visited clients ate adequate servings according to dietary guidelines, although measurement of this outcome was unclear (Fetrick, Christensen, & Mitchell, 2003). The results of one study indicated 75% of clients were meeting dietary guideline recommen- dations (Fetrick et al., 2003). However, the results of the other stud- ies indicated nutrition problems were identified less frequently than other prenatal, postpartum, or parenting problems (Monsen et al.,

2010) or that nutrition problems were identified in 30% of high- risk clients but not at all in lower risk clients (Monsen et al., 2011). Although specific nutrition interventions were not described in two studies (Fetrick et al., 2003; Monsen et al., 2010), the other study found that regardless of whether the nutrition problem was identi- fied, both high- risk and lower risk clients did receive interventions targeting nutrition, but the number or descriptions of nutrition inter- ventions received by each client were not delineated, as it was not within the scope of the study (Monsen et al., 2011).

These maternal- child, home- visiting research findings suggest that when compared to other client problems, nutrition problems and intake have not been as frequently assessed by PHNs. Although only one aspect of the multifaceted job of a home-visiting PHN, nutrition concerns do arise on home visits and require intervention, which is within the scope of public health nursing practice (American Nurses Association, 2013a). Additionally, PHNs are able to employ evidence and theory- based nutrition and obesity prevention and mitigation interventions, including case management, teaching, guidance, and counseling, surveillance, and advocacy for policy changes. These multicomponent, multilevel interventions are aligned with interven- tion recommendations for effective nutrition and physical activity behavior change (County Health Rankings, 2017).

Even with multicomponent and multilevel interventions, work- ing with clients on behavior change can be difficult, but recent re- search indicates that PHN interventions account for 16% of the variability in client outcomes (Monsen, Chatterjee, Timm, Poulsen, & McNaughton, 2015). Additionally, PHN home visitors often work with clients during a time of transition or change in health status (e.g., pregnant and parenting families, recent diagnosis of latent TB), when clients may be more open to making a variety of health behavior changes. This may include increased openness to nutrition assess- ment and interventions to improve nutrition knowledge, behavior, and outcomes (Wilkinson & McIntyre, 2012). The Stages of Change Theory (Prochaska & Velicer, 1997) suggests when individuals move from a stage of precontemplation to contemplation, planning, or ac- tion, behavior change can be facilitated by providing support and resources, setting client- directed goals, working through obstacles or barriers, and celebrating victories. PHNs commonly engage with their clients to facilitate behavior change using such interventions. Therefore, it is important to understand the role and opportunities home-visiting PHNs have with nutrition assessment, intervention, and outcomes with their home- visited clients, especially home- visited women who are at higher risk for obesity and whose own nutrition commonly influences that of their families.

1.1 | Research questions

In 2010, a rural Midwestern U.S. county health department imple- mented a policy requiring PHNs to universally assess home- visited client nutrition knowledge, behavior, and status. It should be noted that the policy did not require PHNs to provide nutrition interven- tions as result of this assessment. Rather, PHNs used clinical judg- ment informed by a holistic client assessment (inclusive of nutrition)

     |  319HORNING et al.

to determine with the client which interventions to use based on each client’s multiple competing demands/needs. Nutrition assess- ments completed and interventions used were documented elec- tronically in client health records using standardized terminology. This electronic health record data allowed us to answer the following research questions: (1) What is the nutrition knowledge, behavior, and status of home- visited women? (2) What are the nutrition inter- ventions PHNs used with their female clients; and (3) Which types of clients receive nutrition interventions?

2  | METHOD

2.1 | Design

The present, descriptive study used existing data from women re- ceiving PHN home visits in a rural Midwestern County. This county has a total population of 57,511, a median income of estimated at $52,365, 10% of residents living with wages below the pov- erty level, and a median age of 46.7 years (United States Census Bureau, 2015). This study used de- identified PHN- generated data from routine documentation and as such was deemed exempt from review by the University Institutional Review Board. The client data were documented electronically using the Omaha System, a standardized, research- tested taxonomy to classify and docu- ment client problems, interventions, and outcomes (Martin, 2005). The Omaha System Problem Classification Scheme allows PHNs to identify and document up to 42 client problems, which include actual problems, potential problems, or areas for health promotion (e.g., Income, Pregnancy, Postpartum, Nutrition, Caretaking/par- enting) from one of four domains (i.e., Environmental, Psychosocial, Physiological, and Health- related Behaviors). The Nutrition prob- lem falls within the Health- related Behaviors Domain.

PHNs use the Problem Rating Scale for Outcomes to rate the cli- ent’s Knowledge, Behavior, and Status (KBS) for identified problems, which include actual problems, potential problems, or areas for health promotion, identified with the Omaha System Problem Scheme. The KBS rating occurs on an ordinal Likert scale from 1 to 5, with a score of one indicating least favorable outcomes. A rating of 1 for Knowledge = no knowledge, for Behavior = consistently inappropri- ate behavior, and for Status = extreme signs/symptoms (e.g., multiple signs and symptoms of poor nutritional health). A rating of 5 indi- cates best possible outcomes, for Knowledge = superior knowledge, for Behavior = consistently appropriate behavior, and for Status = no signs and symptoms (Martin, 2005). PHNs receive training to doc- ument and rate client problems consistently (Monsen et al., 2006).

Additionally, the Omaha System Intervention Scheme functions as both a care plan and way to document interventions. Each interven- tion addresses an identified problem (or potential problem or area for health promotion), using an intervention Category term (i.e., Teaching, Guidance, and Counseling; Treatments and Procedures; Case Management; and Surveillance), and a defined Target term (i.e., one of 75 terms that further specify the intervention), and a customizable client- specific information or care description term (Martin, 2005).

2.2 | Sample

Between January 1, 2012 and July 24, 2015 in a rural, Midwestern U.S. county, 562 adult female clients had at least one home visit with at least one KBS score documented for one or more of the 42 Omaha System problems. Four clients had conflicting, duplicate entries and were removed from the dataset, resulting in a sample of 558.

2.3 | Measures

2.3.1 | Client characteristics

Client characteristic variables of interest in this study include: cli- ent age and race, PHN- documented client problems, KBS ratings for each problem, length of time (measured in days) under PHN care, and the number of visits received. There were three calculated vari- ables: Total Problems, Behavior Profile, and Status Profile. The Total Problems variable was the sum of the number of problems with KBS scores documented on first visit (inclusive of the Nutrition problem). The Behavior Profile variable was calculated by summing the total number of problems where the Behavior score was 3 or lower on the first visit. Similarly, client Status Profile variable was calculated by summing the total number of problems where the Status score was 3 or lower on the first home visit. For example, if a client had four Problems (e.g., Income, Pregnancy, Physical activity, Substance use) rated on the first home visit and the Status ratings for three of the four problems were at or below the level of three (moderate signs and symptoms), the client Status Profile score would be three (Monsen, Swanberg, Oancea, & Westra, 2012).

2.3.2 | Nutrition measures

Nutrition KBS scores and total number of Nutrition signs and symp- toms were also retrieved from the Omaha System electronic record data.

2.3.3 | Visit types

Visit types were retrieved from the Omaha System electronic re- cord data. Visit types were categorized into the following groups for analysis: (1) high- risk, family home visits (i.e., receipt of any Nurse Family Partnership, Healthy Families America, or Family Home Visits), which generally include long- term follow- up and may also include an additional 1–3 telephonic breastfeeding sup- port visits for breastfeeding clients; (2) first- time parent home visits, which typically are just a one- time visit to lower risk, first- time parents but may also include an additional 1–3 telephonic breastfeeding support visits; and (3) home visits for reasons other than pregnancy or parenting (e.g., disease prevention and con- trol; latent tuberculosis; new refugee; waiver program; Patient Care Assistance authorization/reauthorization; and Minnesota Choice Visits, which were designed to help prevent nursing home admission).

320  |     HORNING et al.

2.3.4 | Nutrition interventions

Nutrition interventions were identified as any intervention ad- dressing nutrition or related concerns (e.g., with the problem of Nutrition, the Targets of dietary intake and feeding procedures for any problem, and any nutrition- related care descriptions, like food insecurity, eating habits, breastfeeding, regardless of problem or Target). The number of Nutrition interventions provided to each client was obtained by summing the total number of nutrition in- terventions, including those delivered on more than one visit that were documented in the client’s record. Because some clients re- ceived the same nutrition intervention(s) at more than one visit, the total number of unique nutrition interventions delivered to each client, which excluded repeat interventions, was also summed. For example, if a client received six total nutrition interventions throughout her work with the nurse, and one of those interven- tions was delivered on visit 1, visit 2, and visit 7, the total number of nutrition interventions delivered would be six and the total number of unique nutrition interventions delivered would be three.

2.4 | Analytic strategy

The analysis employed standard descriptive and inferential statis- tics. These included frequencies (percentages), which were used to describe categorical variables (e.g., visit type) and means (standard deviations) and ranges of continuous variables (e.g., age) for the total sample. Two variables, the number of nutrition interventions and number of unique types of nutrition interventions, were skewed and not- normally distributed. Both variables were discretized and re- coded into categories to minimize skewness. Specifically, the number of nutrition interventions provided to each client were recoded into categories from none to many (i.e., 0, 1–2, 2–4, 4–6, 6–9, 10–15, and 16 or more), as were the total number of unique types of nutrition interventions provided to each client (i.e., 0, 1–3, 4–5, more than 5).

General linear models were used to compare the least square mean estimates of client characteristics (age, number of visits, nu- trition KBS scores) across the three visit types (i.e., high- risk fam- ily clients, first- time parents, and clients receiving visits for reasons other than pregnancy or parenting). When nutrition interventions were used with more than 5% of the overall sample, chi- square tests were used to determine if specific nutrition interventions were more likely to be used based on the type of home visit received by a client. Statistical significance was set at 0.05.

3  | RESULTS

3.1 | Sample characteristics

Of the 558 clients, 519 (93%) had a visit type specified, and 469 (84%) had at least one nutrition KBS rating. Women receiving PHN home visits were on average 26.1 years old (SD = 7.0) and 10% iden- tified from a diverse racial/ethnic background. On average, women received 6.5 (SD = 12.2, median = 1) home visits, received services

for 189 (SD = 263.7, median = 26.5, mode = 1) days, and received 7.3 (SD = 7.5, median = 5) interventions. Most women (47%) received first- time parent home visits, 37% received high- risk family home visits, and 15% received home visits for reasons other than preg- nancy or parenting. The home- visited women had an average of 6.5 (SD = 3.3; median = 6) Total Problems with KBS ratings on their first visit. Clients’ average Behavior Profile was 1.7 (SD = 2.5) and Status Profile was 1.1 (SD = 1.5; see Table 1). In other words, on average, women had 1- 2 Omaha System problems for which Behavior and/or Status was moderately, severely, or extremely impaired.

3.2 | Nutrition KBS

On average, home- visited women’s Nutrition Knowledge scores were 3.4 (SD = 0.7; basic knowledge), Nutrition Behavior scores were 3.7 (SD = 0.8; inconsistently to usually appropriate behavior), and Nutrition Status scores were 4.3 (SD = 1.0; minimal signs/symptoms; see Table 1).

3.3 | Nutrition interventions delivered to home- visited women

Home- visited women received anywhere from 0 to 36 nutrition inter- ventions, with the average number of interventions delivered being 7.3 (SD = 7.5, median = 5; see Table 1). Interventions delivered to at least 5% of the clients are shown in Table 3 by Problem, Category, Target, and Care Description. These nutrition- related interventions were pri- marily for the Nutrition problem with targets of dietary management, laboratory findings, signs/symptoms physical, and behavior modification. Interventions with dietary management targets were also combined with the Caretaking/Parenting and Postpartum problems. Interventions with feeding procedures targets were combined with Caretaking/Parenting, Pregnancy, and Postpartum problems. Additional problem–target com- binations were identified based on nutrition- related care descriptions such as Income- finances, Pregnancy- support system, and Postpartum- wellness. Most Nutrition interventions fell within the Teaching, Guidance, and Counseling category. Few were Surveillance interventions, and none were Case Management. See Table 3 for specific details.

3.4 | Differences in nutrition intervention delivery by client characteristics

When assessing client characteristics by visit type, women who received PHN home visits differed significantly based on the type of home- visiting services received (Table 2). Many differences across visit type were noted across client demographic characteristics, number of visits received, number of problems identified on the first visit, and overall cli- ent Behavior and Status Profiles. However, specific to nutrition, women who received home visits for reasons unrelated to pregnancy/parent- ing had the lowest Nutrition KBS scores, had the most Nutrition signs and symptoms, and received the lowest number and types of Nutrition interventions. Women receiving high- risk family home visits had lower Nutrition KBS ratings than women receiving first- time parent home vis- its and received the most Nutrition interventions (Table 2).

     |  321HORNING et al.

Among the three groups of women visited by PHNs, high- risk fam- ily clients were the most likely to receive nearly all types of nutrition interventions across all problems (Table 3). The only exception was with breastfeeding- related nutrition interventions delivered as part of the Caretaking/parenting and Postpartum problems; as many as 88%

of first- time parent clients received one or more of these interven- tions and fewer high- risk family clients received these interventions. Women who received home visits for reasons other than pregnancy or parenting were less likely to receive diverse types of nutrition inter- ventions than other types of home- visited women (see Table 3).

TABLE  1 Demographic and variables of interest for home- visited women (N = 558)

Client characteristics Mean SD Freq % Range

Age 26.1 7.0 11–49

Race

Caucasian 502 90

Diverse 56 10

Number of visitsa 6.5 12.2 0–88

Length of time in programming (days) 189 263.7 1–1,155

Program/Visit typeb

High- Risk Family home visit 194 37

First- time Parent Family home visit 245 47

Other than for pregnancy or parentingc 80 15

Total Problems with KBS ratings charted on first visit

6.5 3.3 1–13

Behavior Profiled 1.7 2.5 0–12

Status Profile 1.1 1.5 0–9

Nutrition Knowledgef 3.4 0.7 1–5

Nutrition Behaviorf 3.7 0.8 1–5

Nutrition Statusf 4.3 1.0 1–5

Number of Nutrition Signs and Symptoms 0.3 0.7 0–4

No nutrition signs and symptoms 442 79

At least one sign and symptom 116 21

Number of nutrition interventions completed

7.3 7.5 0–36

0 98 18

1 ≤ 2 67 12

>2 ≤ 4 76 14

>4 ≤ 6 86 15

>6 ≤ 9 91 16

>9 ≤ 15 63 11

16 or more 77 15

Number of nutrition intervention types used

6.4 6.2 0–28

0 types of interventions 98 18

>0 ≤ 3 types interventions 106 19

>3 ≤ 5 types of interventions 112 20

>5 ≤ 9 types of interventions 123 22

> 9 types of interventions 119 21

aThe total number of visits variable was only reported for 436 clients. bProgram/visit type was only reported for 519 clients. cReasons for home visiting other than for pregnancy or parenting home visit programming included: disease prevention and control; latent tuberculosis; new refugee; waiver program; PCA authorization/reauthorization; and Minnesota Choice Visits, designed to help prevent nursing home admission. dBehavior Profile scores sum the number of problems documented with Behavior ratings ≤3 on first visit. eStatus Profile scores sum the number of problems documented with Status ratings ≤3 on first visit. fNutrition Knowledge, Behavior, and Status ratings were reported for 469 clients.

322  |     HORNING et al.

4  | DISCUSSION

This descriptive study using existing data examined PHN nutrition interventions and client nutrition outcomes for home- visited women in a rural Midwestern county. As a whole, all home- visited clients’ nutrition KBS scores on admission indicated room for improvement.

Overall, women had basic nutrition knowledge. PHNs used nutrition interventions with most clients, but the number, types, and kinds of nutrition interventions varied based on the reason for home visits. Study findings highlight four important and novel patterns of nutri- tion intervention among home- visited clients that present opportu- nity for further intervention and/or research.

TABLE  2 Demographic and variables of interest for home- visited women by home visit type (n = 519)

Client characteristics

Least square mean estimates by visit type Frequency (%) by visit type

pPHN HR PHN LR OTH PHN HR PHN LR OTH

Age 22.0 27.3 32.3 <.001

Race

Caucasian

Diverse

Number of visitsa 14.2 1.2 3.8 <.001

Total problems with KBS ratings charted on first visit

9.1 5.8 3.5 <.001

Behavior Profileb 3.3 0.4 1.8 <.001

Status Profilec 1.9 0.2 1.5 .01

Nutrition Knowledged 3.0 3.7 3.3 <.01

Nutrition Behaviord 3.5 4.1 3.1 <.001

Nutrition Statusd 4.2 4.6 3.1 <.001

Total nutrition signs and symptoms

0.4 0.1 0.8 <.001

Number of nutrition interventions completed

13.4 5.7 0.6 <.001

0 6 (4%) 3 (2%) 61 (76%)

1 ≤ 2 20 (10%) 30 (12%) 12 (15%)

>2 ≤ 4 11 (6%) 58 (24%) 3 (4%)

>4 ≤ 6 25 (13%) 58 (24%) 2 (3%)

>6 ≤ 9 17 (9%) 71 (29%) 2 (3%)

>9 ≤ 15 38 (20%) 25 (10%) 0 (0%)

16 or more 78 (40%) 0 (0%) 0 (0%)

Number of nutrition intervention types used

11.3 5.2 0.6 <.001

0 types of interventions 6 (3%) 3 (1%) 61 (76%)

>0 ≤ 3 types interventions 26 (13%) 56 (23%) 15 (19%)

>3 ≤ 5 types of interventions

25 (13%) 85 (35%) 2 (3%)

>5 ≤ 9 types of interventions

29 (15%) 90 (37%) 2 (3%)

>9 types of interventions 108 (56%) 7 (5%) 0 (0%)

PHN HR = public health nurse high- risk family home- visited clients (n = 194). PHN LR = public health nurse low- risk first- time parent home- visited cli- ents (n = 245). PHN other = public health nurse visited clients for reasons other than pregnancy or parenting (n = 80), which included: disease preven- tion and control; latent tuberculosis; new refugee; waiver program; PCA authorization/reauthorization; and Minnesota choice visits, designed to help prevent nursing home admission. aThe total number of visits was only reported for 436 clients. bBehavior Profile scores sum the number of problems documented with Behavior ratings ≤ 3 on first visit. cStatus Profile scores sum the number of problems documented with Status ratings ≤ 3 on first visit. dNutrition Knowledge, Behavior, and Status ratings were reported for 469 clients.

     |  323HORNING et al.

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Be ha

vi or

m od

ifi ca

tio n

Ex pl

or e

su pp

or ts

/b ar

rie rs

to d

ie ta

ry c

ha ng

e 34

(1 8%

) 0

1 (1

% )

<. 00

1

A lte

r e at

in g

ha bi

ts 61

(3 1%

) 2

(1 )

2 (2

% )

<. 00

1

(C on

tin ue

s)

324  |     HORNING et al.

Pr ob

le m

C at

Ta rg

et D

es cr

ip tio

n

PH N

H R

Re ce

iv ed

In

te rv

en tio

n PH

N L

R Re

ce iv

ed

In te

rv en

tio n

PH N

O th

R ec

ei ve

d In

te rv

en tio

n

p n

(% )

n (%

) n

(% )

Pr eg

na nc

y S

Fe ed

in g

pr oc

ed ur

es C

lie nt

v er

ba liz

es k

no w

le dg

e of

th e

be ne

fit s/

sk ill

s of

b re

as tf

ee di

ng 62

(3 2%

) 0

0 <.

00 1

Su pp

or t s

ys te

m Fa

m ily

/f rie

nd s

su pp

or t f

or b

re as

tf ee

di ng

58 (3

0% )

0 0

<. 00

1

TG C

Fe ed

in g

pr oc

ed ur

es In

fa nt

fe ed

in g

op tio

ns , b

en ef

its o

f br

ea st

fe ed

in g

42 (2

2% )

0 0

<. 00

1

Be ne

fit s

of b

re as

tf ee

di ng

fo r m

om a

nd

ba by

/b re

as tf

ee di

ng s

ki lls

61 (3

1% )

0 0

<. 00

1

Re st

/s le

ep N

ee d

fo r i

nc re

as ed

re st

d ur

in g

pr eg

na nc

y an

d br

ea st

fe ed

in g

71 (3

6% )

0 0

<. 00

1

W el

ln es

s Im

pa ct

o f b

re as

tf ee

di ng

o n

ph ys

ic al

h ea

lth /

w ei

gh t m

an ag

em en

t f or

th e

PP fe

m al

e 56

(2 9%

) 0

0 <.

00 1

Po st

pa rt

um TG

C D

ie ta

ry m

an ag

em en

t Ex

pe ct

ed w

ei gh

t c ha

ng es

, r ec

om m

en de

d fo

od /f

lu id

in ta

ke , p

os tn

at al

v ita

m in

s/ m

in er

al s

55 (2

8% )

30 (1

2% )

0 <.

00 1

Pe rs

on al

h yg

ie ne

Br ea

st /n

ip pl

e ca

re ; b

at hi

ng p

re ca

ut io

ns 53

(2 7%

) 31

(1 3%

) 0

<. 00

1

W el

ln es

s Im

pa ct

o f b

re as

tf ee

di ng

o n

ph ys

ic al

h ea

lth /

w ei

gh t m

an ag

em en

t f or

th e

PP fe

m al

e 35

(1 8%

) 18

(7 %

) 0

<. 00

1

Fe ed

in g

pr oc

ed ur

es Br

ea st

fe ed

in g

in fo

rm at

io n/

re so

ur ce

s pr

ov id

ed 93

(4 8%

) 11

0 (4

5% )

0 <.

00 1

S Fe

ed in

g pr

oc ed

ur es

C on

ce rn

s re

la te

d to

b re

as tf

ee di

ng 11

5 (5

9% )

19 1

(7 8%

) 0

<. 00

1

C ur

re nt

ly b

re as

tf ee

di ng

14 5

(7 5%

) 21

5 (8

8% )

0 <.

00 1

Fe ed

in g

pr oc

ed ur

es Fe

ed in

g ty

pe 27

(1 4%

) 62

(2 5%

) 0

<. 00

1

N ut

rit io

ni st

c ar

e Fa

m ily

e nr

ol le

d in

W IC

24 (1

2% )

54 (2

2% )

0 <.

00 1

C at

, c at

eg or

y; S

, s ur

ve ill

an ce

; T G

C , t

ea ch

in g,

g ui

da nc

e, a

nd c

ou ns

el in

g. PH

N H

R =

pu bl

ic h

ea lth

n ur

se h

ig h-

ris k

fa m

ily h

om e-

vi si

te d

cl ie

nt s

(n =

1 94

). PH

N L

R =

pu bl

ic h

ea lth

n ur

se lo

w - r

is k

fir st

- t im

e pa

re nt

h om

e- vi

si te

d cl

ie nt

s (n

= 2

45 ).

PH N

o th

er =

p ub

lic h

ea lth

n ur

se v

is ite

d cl

ie nt

s fo

r r ea

so ns

o th

er th

an p

re gn

an cy

o r p

ar en

tin g,

w hi

ch in

cl ud

ed d

is ea

se p

re ve

nt io

n an

d co

nt ro

l; la

te nt

tu be

rc ul

os is

; n ew

re fu

ge e;

w ai

ve r p

ro gr

am ; P

C A

a ut

ho riz

at io

n/ re

au th

or iz

at io

n; a

nd M

in ne

so ta

ch

oi ce

v is

its , d

es ig

ne d

to h

el p

pr ev

en t n

ur si

ng h

om e

ad m

is si

on (n

= 8

0) .

TA B LE  3  

(C on

tin ue

d)

     |  325HORNING et al.

The first pattern was that all women had room for improvement related to nutrition, as indicated by average Nutrition Knowledge and Behavior scores at the level of inconsistently appropriate (3.4 and 3.7, respectively). While previous research documented only 30% of high- risk clients and 0% of low- risk clients had nutrition problems (Monsen et al., 2011), universal assessment of client nu- trition KBS implemented by the agency in this study indicated that high- risk home- visited clients and clients receiving visits for rea- sons other than pregnancy or parenting had only basic Nutrition Knowledge and inconsistently appropriate Nutrition Behavior. This finding suggests among all other home-visiting PHN roles and re- sponsibilities, nutrition assessment may be one important area of focus for home- visited clients. In this study, a policy change by a spe- cific agency prompted PHN universal assessment of nutrition. Other agencies and future research could explore whether adding nutrition assessment to care plans, electronic health record documentation, and/or agency policy are most effective in increasing PHN nutrition assessment of home- visited clients.

The second pattern was that PHNs are using nutrition interven- tions, which aligns with previous research findings (Monsen et al., 2011). However, by using the care description data that is not often used in analysis, this study provides additional detail and descrip- tion of the many distinct nutrition interventions (listed in Table 3) delivered and documented under five different Omaha System problems including the Nutrition, Income, Caretaking/parenting, Pregnancy, and Postpartum problems. These findings suggest PHNs tailor their nutrition interventions to client needs and prob- lems. Future research should investigate the impact of PHN nutri- tion intervention on client nutrition and weight outcomes. Out of all the varied and distinct nutrition interventions used by PHNs, Case Management nutrition interventions (e.g., referring to WIC, the supplemental nutrition assistance program) were not utilized, or if they were, they were not documented. Given that multicomponent interventions are aligned with intervention recommendations for effective nutrition and physical activity behavior change (County Health Rankings, 2017), Case Management nutrition interventions should be included within documentation systems and as part of care plans to meet and document holistic nutrition interventions for home- visited clients.

The third pattern was that women receiving home visits for services unrelated to pregnancy or parenting were those with the lowest average nutrition behavior and status ratings and the high- est number of actual signs and symptoms of the nutrition problem. However, these clients were the least likely to receive any type of nutrition intervention. Because the agency policy change required all clients’ nutrition KBS be assessed, it was possible to identify the clients with most nutrition risk (e.g., those with the lowest nutrition KBS scores and most nutrition symptoms) and to identify the oppor- tunity for intervention with these clients. Future research is needed to determine why interventions are not documented for these high- nutritional risk clients.

The fourth pattern was that some breastfeeding interven- tions were used more frequently with high- risk family clients and

other breastfeeding interventions were used more frequently with first- time parent clients. Breastfeeding interventions were doc- umented under the Pregnancy, Postpartum and Caretaking/par- enting problems and were a routine part of PHN care within both the high- risk family and first- time parent home-visiting programs. Additional breastfeeding intervention captured in this manuscript occurred through telephonic visit(s) of 1- 3 support calls available only to women who were breastfeeding. Thus, the differences in delivering specific breastfeeding interventions by client type likely emerged for several reasons. For example, because first- time par- ent clients typically receive only one home visit in the postpartum period, Pregnancy problem breastfeeding interventions would not be used with these clients. In contrast, high- risk family clients often receive home visits during pregnancy, and specific Pregnancy problem breastfeeding interventions were used with 22%–36% of high- risk family clients (see Table 3). It is possible that, as a result of receiving breastfeeding interventions during pregnancy, high- risk family clients received fewer Postpartum and Caretaking/parenting breastfeeding interventions. However, it is also possible that high- risk family clients received fewer Postpartum and Caretaking/par- enting breastfeeding interventions because high- risk families can enroll for high- risk home visiting up to 3 months after the birth of their infant; thus, breastfeeding intervention may no longer be rel- evant if the family opted not to breastfeed or had chosen to stop breastfeeding. It is also plausible that the high- risk family clients may be facing other, more pressing concerns (e.g., related to other potential risk factors such as housing instability) in the postpar- tum period such that breastfeeding was not the immediate prior- ity. Finally, differences in breastfeeding intervention may indicate that there are differences in documentation of care plans across programs. Ultimately, breastfeeding intervention patterns by client type are complex; future research focused specifically on PHN de- livered breastfeeding interventions may help to unpack differences in breastfeeding intervention delivery and may help identify steps to improve upon breastfeeding interventions and more fully support all clients with breastfeeding goals.

4.1 | Strengths and limitations

Strengths of this study include utilizing real- world electronic health record data collected by PHNs to identify client nutrition KBS rat- ings, nutrition interventions utilized, and opportunities to improve care that may lead to improved nutrition KBS outcomes. This study also has several limitations common to all observational data sets. In particular, the data in the study represented women in one rural county, and therefore, results may not be generalizable to all public health home- visited clients. Additionally, 7% of clients did not have visit type specified. The study was cross- sectional in nature, and longitudinal evaluation is warranted to measure the impact of nutri- tion intervention with home- visited clients. Finally, although PHNs in this county receive training in Omaha System documentation to rate problems consistently, it is possible that there may be variability such as over- or underreporting by PHNs.

326  |     HORNING et al.

4.2 | Conclusion

Given the link between dietary intake and obesity, understand- ing PHN work around nutrition assessment and intervention with their clients is paramount. Existing research documents many positive health outcomes associated with home- visiting programs. While minimal previous research has assessed PHN nutrition as- sessment and interventions for home- visited clients, this study’s results suggest home- visited women have room to improve nutri- tion KBS and that PHNs already use many nutrition interventions with some but not all women. Results also point to opportunities to provide more multicomponent, nutrition interventions, especially for those not receiving interventions, and/or to revise care plans to reflect important Case Management nutrition interventions. Home-visiting PHNs provide a wide range of important programs/ services, and within this role, PHNs can assess and provide im- portant nutrition- related intervention, which may help to reduce nutrition and weight- related health disparities. Further research is needed to examine the influence of interventions on nutrition and overall outcomes.

ORCID

Melissa L. Horning http://orcid.org/0000-0002-8616-4297

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How to cite this article: Horning ML, Olsen JM, Lell S, Thorson DR, Monsen KA. Description of public health nursing nutrition assessment and interventions for home- visited women. Public Health Nurs. 2018;35:317–326. https://doi.org/10.1111/ phn.12410