Population Health Practice Problem Essay

Population Health Practice Problem Essay

Population Health Practice Problem Essay

Diabetes or diabetes mellitus is a group of chronic metabolic disorders characterized by increased blood glucose levels that affect how the body uses blood glucose. There are three types of diabetes; type 1, 2, and gestational diabetes. The complications of diabetes include heart disease, lower limb amputation, diabetic retinopathy, nephropathy, and diabetes-related depression, among others. Additionally, diabetes increases the cost of care for the system and the affected individuals. The conditions also affect individuals and populations significantly. The selected population, African Americans living in Jackson, Mississippi, is one of the populations mostly affected by diabetes. Therefore, there is a need to find evidence-based solutions to address the population health problem. This essay explores the selected population health practice problem, the social determinant risk factors, epidemiological factors, an evidence-based population health intervention, and relevant, measurable goals and objectives. The population, practice problem, epidemiology, goal and objective, evidence-based population intervention, and the evaluation of the efficiency of the intervention to address the problem will be presented.

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Population Description

The selected population is the African American population in Jackson County, Mississippi. The population entails 82.82% of the total population in Jackson. English is the main language spoken by the population. According to Citydata.com (n.d.), 35.86% of people below the poverty line are African Americans. 68.65% of African Americans have attained high school education, while 17.57% have at least a bachelor’s degree (Citydata.com, n.d.). Additionally, the median age in Jackson is 33.5, with the median age for males and females 32.2 and 34.8, respectively (Citydata.com, n.d).  

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Key Social Determinant Risk Factors Associated with the Population

Social determinants risk factors are the social determinants of health that can increase the risk for different health conditions. Various social determinant risk factors are associated with African Americans in Jackson, Mississippi. Discrimination and racism are social determinant risk factors in the population. Despite being the largest ethnic group in the community, African Americans are a minority population that may suffer issues such as increased health inequity and disparities. The risk factor may influence the accessibility of quality health services for members of the population.

The physical environment in Jackson is also a social determinant risk factor for the population. Since Jackson is an urban area, there are high levels of pollution, limited green spaces, and unsafe neighborhoods, among other urban-related issues. Therefore, African Americans are at an increased risk of health conditions affected by these factors. In addition, Monroe et al. (2023) note that food security is a social determinant risk factor among racial and ethnic minority populations. Similarly, Jackson has limited access to fresh, nutritious, and affordable food, which increases the risk for health conditions such as malnutrition.

Practice Problem

The selected national practice problem is diabetes. Diabetes is a national practice problem due to its effects on individuals, populations, and society. It is also associated with increased healthcare needs, leading to financial pressure on the healthcare system and individuals/their families. Its significance and prevalence are also felt at local, regional, and national levels, thus a need to develop evidence-based interventions to address the practice problem.  

Diabetes and its Effects on the Population

Diabetes as a national practice problem considerably affects the African American population. The primary effect of diabetes is a poor quality of life for African Americans. Diabetic patients have been seen to have a reduced ability to work, engage in other daily activities due to the related health restrictions and complications. Reduced working ability produces negative economic impacts such as reduced income and unemployment. Diabetes is also related to different lifestyle adjustments needed for appropriate diabetes management, which may negatively impact the population, especially when poorly managed.

Furthermore, the condition increases the risk for other health conditions, increasing the prevalence of these conditions. Barnes et al. (2020) note that the conditions associated with diabetes include cardiovascular disease, stroke, and kidney failure. Similarly, the problem leads to an increase in the prevalence of these diseases in the population. Additionally, diabetes complications such as amputation, kidney disease, and retinopathy increase healthcare costs for the population. These complications also lead to increased mortality rates and hospitalization in the population.

Significance of the Practice Problem Local Level

Diabetes is a major practice problem whose significance is felt at the global, national, regional, and local levels. In Jackson, diabetes is a significant public health concern, with increased new cases, hospitalizations, and related complications. The high cases of diabetes significantly exert financial pressure on the local healthcare system. More so, the overall burden of the disease is considerably high at the local level. Furthermore, diabetes increases the economic burden locally due to the direct healthcare costs and indirect costs related to loss of productivity and disability. There are also health inequities related to diabetes care due to disparities among different local populations.

 However, diabetes such as type 2 diabetes can be prevented or its progression slowed by lifestyle modifications and proper management (Hill-Brigs et al., 2020). Reducing the number of diabetes cases can improve the health and well-being of affected individuals, reduce healthcare costs for the system and individuals, and improve overall health for highly affected populations such as African Americans. Preventive efforts can also reduce the overall disease burden in Jackson.

Prevalence of the Practice Problem at the Regional Level

According to the American Diabetes Association (n.d.), 15.4% of the adult population, or approximately 371,662 people in Mississippi, have diabetes. Every 1 in 7 adults in Mississippi has diabetes. More so, it is estimated that 79 000 people in Mississippi also have diabetes but are unaware, and 810 000, representing -37.5% of the total adult population, have prediabetes (American Diabetes Association, n.d.). The local prevalence of diabetes in Jackson is not readily available. However, according to CityData.com (n.d.) Jackson is among the cities with high diabetes cases in the state. Therefore, the practice problem is significant and needs to be addressed.


The disease burden of diabetes is rising, with the estimated number of people with diabetes estimated to increase to up to one and a half times by 2045 (Forouhi & Wareham, 2019). The increase is mainly due to increased obesity prevalence, physical inactivity, and nutritional changes. According to Forouhi and Wareham (2019), type 2 diabetes accounts for more than 85% of the total diabetes cases, despite being preventable. Therefore, understanding diabetes distributions, patterns, and determinants of health-related issues in a population is vital in developing interventions to address the practice problem.

Epidemiological Principles and Measures

The epidemiological principles and measures to address the diabetes practice problem include diabetes prevention programs and diabetes self-management education and support (DSME). According to Aschner et al. (2021), diabetes prevention programs are used at the national, regional, and local levers to educate people on diabetes and how lifestyle factors influence it. These programs also create awareness of the lifestyle modifications that populations can engage in to prevent diabetes, thus reducing the number of new diabetes cases. Additionally, diabetes prevention programs may provide diabetes screening services or referrals for screening services to promote early detection.

Diabetes self-management education and support programs usually educate diabetic patients on proper diabetes management and offer social and emotional support to help them cope with the condition (Powers et al., 2020). As an epidemiological measure, DSME addressed the practice problem by reducing the rate of diabetes complications and improving the quality of life for diabetic patients. Consequently, the program reduces healthcare costs related to diabetes complications, hospitalizations, and morbidity and mortality rates.

The Use of Descriptive Epidemiology to Address the Practice Problem

Descriptive epidemiology is used to estimate the number of individuals affected by a disease, including the relevant health characteristics, the distribution of the disease, and its determinants. Green et al. (2021) note that prevalence and incidence are the key measures used in descriptive epidemiology. Using descriptive epidemiology to address diabetes in health populations entails organizing and analyzing data to describe the variations of the condition’s frequency among populations by geographical area over time. The prevalence and incidence of diabetes cases, direct costs, and diabetes-related complications data are analyzed and used to inform diabetes prevention and management programs, thus addressing the practice problem.

The use of Surveillance to Influence the Determinants of Health and Improve Health Outcomes

 The systematic and continuous collection, analysis, and interpretation of the data on diabetes events and risk factors can influence health determinants among African Americans in Jackson. For instance, the surveillance data can inform diabetes prevention and management programs by identifying the population that needs them most and directing the programs to them. Additionally, surveillance data on diabetes risk factors may inform policy decisions, including policies related to education, accessibility of healthcare services, and living conditions, thus influencing health. The health outcomes of African Americans can also be improved through these policies and focusing more funds and care services to them by using the surveillance data to understand the prevalence, incidence, and current diabetes trends in the population. Therefore, health interventions and policies will improve the health outcomes of the African American population.

Ethical Concerns Related to the Use of Surveillance Data

There may be ethical concerns with using surveillance data in the African American population. These concerns include surveillance data misuse, unclear expression of the reasons to collect and use the data, and failure to respect individual privacy while collecting the data. Surveillance data should be used for the intended purposes, and the intention for collecting the data should be clearly explained to the population. Additionally, collecting surveillance data should respect individual privacy, especially when dealing with records of diabetes complication cases, which may include personal identifiable information.

Healthy People 2030 Goal and Objective

The Healthy People 2030 goal that addresses the diabetes national practice problem aims at reducing the burden of diabetes and improving the quality of life for all people who have or are at risk for diabetes (Healthy People 2030, n.d.). The goal mainly focuses on reducing diabetes complications and death. Additionally, since racial and ethnic minorities are at increased risk for diabetes, the goal aims to improve these populations’ quality of life by promoting healthy activities such as appropriate nutrition, physical activity, and managing weight (Healthy People 2030, n.d.). The goal also promotes interventions that help diabetic patients to reduce the risk of complications and other related health issues, thus reducing the disease burden and improving life quality.


The objective that can help address the Healthy People 2030 goal mentioned above is To reduce the rate of diabetes complications by 25% by promoting lifestyle changes and diabetes screening within one year.

Evidence-based Population Intervention

One evidence-based intervention that can be used to achieve the above-stated goal and objective is population screening. According to Aggarwal et al. (2022), screening diabetes mellitus enhances early diagnosis, which helps the diagnosed patients begin treatment as soon as possible, thus avoiding complications. As mentioned earlier, there is a large number of people living with diabetes who are unaware. Therefore, screening would promote action-taking, thus improving the quality of life for diabetes patients and those at risk of diabetes in the population. The population-level screening intervention can be linked to awareness creation, whereby the newly diagnosed patients are educated on the treatment options and advised to begin treatment. More so, the influence of lifestyle on diabetes can also be taught to the people at risk, thus enabling them to take action and prevent diabetes through lifestyle changes.

The selected intervention is located at the screening part of the Minnesota public health wheel. Screening falls under case finding since it leads to the identification of the number of people affected by a condition. Population-level screening will address diabetes among African Americans since it will provide a clear picture of the disease burden in the population, thus further informing diabetes management interventions. Additionally, the screening will help the local healthcare system and other organizations to plan on the resources used for diabetes care and, more so, direct them to the most affected people. The intervention will also emphasize diabetes prevention programs to policymakers and encourage them to consider the impact of policies on health and health outcomes.


Evaluating an intervention’s effectiveness, efficiency, efficacy, and equitability is crucial. According to Grimani et al. (2019), effectiveness refers to the intervention’s ability to bring meaningful changes to patients. To assess the screening intervention’s effectiveness in reducing the number of new diabetes cases, I would analyze the proportion of the population screened. Efficiency would be evaluated by examining the intervention’s cost-effectiveness and whether it is economical to address the practice problem. Additionally, I would assess the intervention’s efficacy by determining if it is ideal for reducing new diabetes cases. According to Lehne et al. (2019), the equitability of an intervention is assessed by determining the impact of the intervention in addressing social inequalities in the community. Therefore, I would evaluate whether the intervention was equitable by defining its impact in addressing social inequalities and disparities among the African American in Jackson. 


Diabetes significantly affects the African American population in Jackson by increasing healthcare costs, diabetes-related complications, and the risk of other healthcare conditions. It also increases the economic burden due to loss of income, employment, and reduced work ability. Diabetes leads to poor quality of life and challenging lifestyle changes for affected individuals. Population-level screening would significantly reduce the number of new diabetes cases and related complications since it would encourage people to seek treatment and change their lifestyles to better prevent and manage diabetes.     


Aggarwal, R., Bibbins-Domingo, K., Yeh, R. W., Song, Y., Chiu, N., Wadhera, R. K., Shen, C., & Kazi, D. S. (2022). Diabetes Screening by Race and Ethnicity in the United States: Equivalent Body Mass Index and Age Thresholds. Annals of Internal Medicine, 175(6), 765–773. https://doi.org/10.7326/M20-8079

American Diabetes Association. (n.d.). The Burden of Diabetes in Mississippi. Accessed 1st August 2023 from http://main.diabetes.org/dorg/PDFs/Advocacy/burden-of-diabetes/mississippi.pdf

Aschner, P., Karuranga, S., James, S., Simmons, D., Basit, A., Shaw, J. E., Wild, S. H., Ogurtsova, K., Saeedi, P., & International Diabetes Federation’s Diabetes Epidemiological Guide Writing Group (2021). The International Diabetes Federation’s guide for diabetes epidemiological studies. Diabetes Research and Clinical Practice, 172, 108630. https://doi.org/10.1016/j.diabres.2020.108630

Barnes, J. A., Eid, M. A., Creager, M. A., & Goodney, P. P. (2020). Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease. Arteriosclerosis, Thrombosis, and Vascular Biology, 40(8), 1808–1817. https://doi.org/10.1161/ATVBAHA.120.314595

CityData.com (n.d.). Jackson, Mississippi Profile. Accessed 1st August 2023 from https://www.city-data.com/city/Jackson-Mississippi.html

Forouhi, N. G., & Wareham, N. J. (2019). Epidemiology of diabetes. Medicine, 47(1), 22–27. https://doi.org/10.1016/j.mpmed.2018.10.004

Green, A., Hede, S. M., Patterson, C. C., Wild, S. H., Imperatore, G., Roglic, G., & Beran, D. (2021). Type 1 diabetes in 2017: Global estimates of incident and prevalent cases in children and adults. Diabetologia, 64(12), 2741–2750. https://doi.org/10.1007/s00125-021-05571-8

Healthy People 2030 (n.d.). Diabetes; Goal and Objectives. Accessed 1st August 2023 from  https://health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes

Hill-Briggs, F., Adler, N. E., Berkowitz, S. A., Chin, M. H., Gary-Webb, T. L., Navas-Acien, A., Thornton, P. L., & Haire-Joshu, D. (2020). Social Determinants of Health and Diabetes: A Scientific Review. Diabetes Care, 44(1), 258–279. https://doi.org/10.2337/dci20-0053

Lehne, G., Voelcker-Rehage, C., Meyer, J., Bammann, K., Gansefort, D., Brüchert, T., & Bolte, G. (2019). Equity Impact Assessment of Interventions to Promote Physical Activity among Older Adults: A Logic Model Framework. International journal of environmental research and public health, 16(3), 420. https://doi.org/10.3390/ijerph16030420

Monroe, P., Campbell, J. A., Harris, M., & Egede, L. E. (2023). Racial/ethnic differences in social determinants of health and health outcomes among adolescents and youth ages 10-24 years old: a scoping review. BMC Public Health, 23(1), 410. https://doi.org/10.1186/s12889-023-15274-x

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A., Hooks, B., Isaacs, D., Mandel, E. D., Maryniuk, M. D., Norton, A., Rinker, J., Siminerio, L. M., & Uelmen, S. (2020). Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care and Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. JAAPA: Official Journal of the American Academy of Physician Assistants, 33(7), 1–20. https://doi.org/10.1097/01.JAA.0000668828.47294.2a

Appendix: Summary Table of Evidence

Practice Question: Among African Americans, does population-level mass screening, compared to routine management and prevention interventions, reduce the rate of diabetes complications within one year?

Date: 3rd August 2023


Article Number



Author and Date



Evidence Type


Sample, Sample Size, Setting

Findings That Help Answer the EBP Question  

Observable Measures





Evidence Level, Quality

175(6) Aggarwal (2022) Cross-sectional study The sample size entails 19, 335 US non-pregnant adults between the age of 18 and 70. The setting is the National Health and Nutrition Examination survey, done between 2011-2018




Population-level screening promotes early diagnosis.

Early diabetes diagnosis enables the patient to take action, thus avoiding diabetes complications. 

Screening was used to predict the prevalence of diabetes based on racial and ethnic differences.

The screening was based on BMI thresholds, whereby the prevalence of diabetes among African Americans with a BMI of 25 and above was 3.5%

The study limitation is that the sample was generalized, and therefore there could be bias in the results. Aggarwal et al. (2022) were appraised at level II evidence, Grade A quality. The study entailed a large sample, therefore, was more representative. Additionally, the results are well-analyzed and generalizable.

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week 5 Population Health Practice Problem



This assignment will allow for the exploration of a selected population health practice problem, encompassing social determinant risk factors, epidemiological factors, an evidence-based population health intervention, and relevant measurable goals and objectives.


Use the population (at the local, regional, or national level) you have engaged throughout the course thus far and develop a comprehensive analysis of the important population health concepts and propose an evidence-based intervention and evaluation plan.

The assignment should include the following components:


Introduce topic of paper.

Develop a focused one-sentence purpose statement.

Present subtopics that will be discussed.


Present the selected population in general terms.

Identify three key social determinant risk factors associated with the population.

Practice Problem

Explain the National Practice Problem and how it affects the population.

Explain the significance of the practice problem at the local, regional, or national level.

Explain the prevalence of the practice problem at the local, regional, or national level.


Explore the epidemiologic principles and measures used to address your selected practice problem.

Examine the use of descriptive and/or analytic epidemiology to address the practice problem.

Propose how you might use surveillance to influence the determinants of health and improve the health outcomes of your population.

Anticipate any ethical concerns that you might have related to the use of surveillance data in your population.

Goal and Objective

Explore and detail one Healthy People 2030 goal that addresses the selected practice problem.

Link (website):  Healthy People 2030 Links to an external site.   

Develop one measurable objective using the SMART format (review Week 4 Lesson) to help achieve the Healthy People 2030 goal that addresses the selected practice problem.

Evidence-Based Population Intervention

Identify one evidence-based intervention from a research study to achieve the goal and objective. (This research study must be at the population level and should not be one that was used in a previous course.)

Add the study to the Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool.

Link (Word doc): Johns Hopkins Individual Evidence Summary ToolLinks to an external site.

Identify where the selected intervention is located on the Minnesota Public Health Wheel.

Provide objective rationale for the evidence-based intervention to address the practice problem.


Describe how you would evaluate if your intervention were efficient, effective, and efficacious, and equitable.


Summarize the impact of the practice problem on the identified population.

Summarize the role of the evidence-based intervention to address the practice problem idea.


Identify and list four scholarly sources on the reference pages.

Identify and list other scholarly sources used in the paper on the reference pages.

List sources in alphabetical order.

Use correct hanging-indent format.

Appendix: Summary Table of the Evidence

Attach the completed Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool.

Provide a minimum of one research study describing the selected intervention.

Complete all sections completely for the source of evidence.

Identify both the quality and level of evidence for each scholarly source on the table.

Writing Requirements (APA format)

Length: 7-8 pages (not including title page or references page)

1-inch margins

Double-spaced pages

12-point Times New Roman or 11-point Arial font

Headings & subheadings

In-text citations

Title page

Reference page

Standard English usage and mechanics

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