United Neighborhood Health Services

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Women Connecting in the Community Program

Location: Nashville, Tennessee

United Neighborhood Health Services, a private, nonprofit network of primary care clinics in Nashville, offers comprehensive health care services in low-income neighborhoods in Nashville. The Women Connecting in the Community Program sought to increase African-American women’s diabetes self-management goals by increasing physical activities. A fitness coach developed individual physical activity programs for participants as well as group activities in the community and provided in-home consultations. There was a statistically significant improvement in HbA1c levels among high risk participants.


United Neighborhood Health Services (UNHS) is a private, non-profit network of primary care clinics and health programs in Nashville, Tennessee.  UNHS began its Women Connecting in the Community program to help women in the East Bank area of Nashville focus on increasing physical activity as a strategy for improving their diabetes and overall health status.  The East Bank is an area of high poverty and need; 28.6% of families live below poverty and over 50% below twice the poverty level. Disparities in income, education, and transportation are significant; 39% of families have annual incomes less than $25,000 and 17% of households do not own a vehicle.  UNHS brought this special program to four of its clinics in the East Bank area and recruited 208 African American women with type 2 diabetes to participate.


This project used a multi-disciplinary healthcare team to address diabetes in a comprehensive way.  A diabetes case manager worked with participants on the development of self-management goals, general self-management education and follows-up to achieve the goals set. A fitness coach organized physical activity classes and walking clubs and coordinated patient-specific physical activity programs.  Clinicians provided routine diabetes care and referrals as necessary, and family members were engaged to provide social support. UNHS expanded the program to include individualized in-home physical activity consultations and support.


The Women Connecting in the Community program engaged program participants in comprehensive diabetes care, with a special emphasis on increasing their physical activity.  Learnings from this project include:

  • Meeting program participants where they are (i.e., within their homes and neighborhoods) is important for minimizing barriers to engaging in physical activity and reaching vulnerable women, especially in low-resource areas.
  • A multi-disciplinary health care team, including a health care provider, diabetes case manager/health educator, fitness coordinator, behavior health counselor, and other team members, that can address the multi-faceted issues of diabetes management is a promising approach to helping women successfully manage their diabetes.

Building bridges between the medical and non-medical resources in the community was an important aspect of the project that enabled UNHS to successfully motivate, support, and encourage participants’ efforts to manage their diabetes.