Community Plan of Care Group Project

≈≈≈Obesity and Cardiovascular Disease in Lake

County, Michigan

NURS 340Ferris State University

Authors:

Kelly Jones, Karin Mogren-Kuzma, Noranne Morin, Maggie Siler, Angela Sokolowski

Problem Statement

Who is at risk:  The residents of Lake County, Michigan.

What is the risk:  The residents of Lake County are at high risk for obesity (43.1%

compared to Michigan’s rate of 31.7%), and cardiovascular disease (187.4 per 100,000 compared to Michigan’s rate of 206.5 per 100,000) as evidenced by statistics noted in the 2011 Annual Report from District Health Department #10.Changeable risk factors: • Lack of knowledge regarding sedentary lifestyle, poor dietary habits, and

overweight/obesity as risk factors for cardiovascular disease. • Lack of awareness regarding risk factors and symptoms for stroke/MI and the

importance of calling 911 in the presence of these symptoms.• Educating the entire population of Lake County, with focus on the youth, about

the risks of obesity to prevent future complications such as cardiovascular disease.

• Increase access to fresh and nutritious food for everyone.

Specific, measurable, achievable, relevant, time bound (SMART) (Harkness & DeMarco, 2012)

evidence based outcomes:  • Increase the measurable number of Lake County residents able to verbalize the

content/importance of a healthy diet, and regular exercise following a six month increase in public education including television ads.

• Decrease the percentage of obese and overweight individuals in Lake County by 5% in five years as evidenced by county statistics

• Initiate community walking groups immediately. Measure one year participation rates.

• Increase awareness of stroke/myocardial infarction (MI) symptoms and the necessity to call 911 when symptoms are noted.  This can be measured by increased activation of 911 and decreased ER arrivals by personal vehicle for stroke/MI patients after a six month public education push.

• Work with schools and local farmers to provide a healthier diet to our school age children. Measurable by a 50% increased use of local fresh fruit, meat, and vegetables in school meals over one year.

• Teach the importance of exercise to school age children by presenting current statistics and offering volunteer run after school/recess exercise programs. This can be measured by an increasing number of participating children annually.

NURSING

We hear with our hearts

Assessment of Community• District Health Department #10 is composed of ten counties in mid-

western Lower Michigan with an average population of 26,162 in 2011.

• Lake County’s total population in 2011 was 11,539.• 79.2% of Lake County is either overweight (Body Mass Index (BMI)

25-30) or obese (BMI 30 or greater) according to the District Health Department #10 2011 Annual Report. The average obesity rate for Michigan is 31.7% and the and the entire United States is 27.5%.

• Lake County has the second highest mortality risk for cardiovascular disease at 263/100,000 in District 10 in 2011. The mortality rate for all of Michigan is 276.2/100,000 for the same time period.

• Lake County is one of the poorest in Michigan, with a median income of $29.373, compared to the Michigan average of $45,254. It has the highest poverty rate of all counties in District 10, at 23.4%.

• Key risk factors for obesity and cardiovascular disease are; sedentary lifestyle, family history of obesity, easy availability of unhealthy foods and beverages, low income, and low self esteem (Barbis, 2012).

The following slides demonstrate the impact of obesity on the rate of cardiovascular disease in Lake County, Michigan. Poverty is a major risk factor for obesity and cardiovascular disease. Lake County is one of the poorest in Michigan. Our youth learn what they live, making primary prevention for them especially important. The following slides also underscore the importance of developing multilevel policies and programs supporting primary prevention (Pate & O’Neill, 2008). Such policies/programs are critical to reducing the dangerous trend of increasing obesity, and cardiovascular disease at both community and global levels (Burke, Thompson, Roos, & Troe, 2011). This presentation will further address; appropriate nursing diagnosis, and SMART objectives, evidence based interventions, including analysis of interventions, theoretical support for chosen interventions, policy implications, and evaluation of the groups process/plan based on the problem of obesity related to cardiovascular disease in Lake County, Michigan.

Assessment of Community and Analysis of Findings

Overweight and Obese - Lake County , Michigan

Incidence of Cardiovascular Disease in Lake County, Michigan

Cardiovascular Disease Hospital Discharges2007-2009

Percent of Children below Poverty by Agein Lake County, Michigan

Community Focused Nursing Diagnoses

• There is a risk of cardiovascular disease related to obesity among the residents of Lake County, Michigan as demonstrated in an obesity rate of 43.1% and an overweight rate of 36.1%

SMART Goal

• By the end of 2013, the people of Lake County will have the information necessary to understand the interventions that will be included in a plan to reverse the number of obese residents and the level of obesity in the community. The achievement of this goal will be evidenced by decreased BMI of 5% over 5 years in Lake County residents.

SMART objective related to Knowledge Deficit• Knowledge regarding the effects of and prevention of obesity

will be dispersed to the citizens of Lake County.• The number of citizens in Lake County who are able to

verbalize the effects of and prevention of obesity will be increased by 30% by the end of one year.

• Nursing interventions directed at achievement of this goal will be agreed upon by all stakeholders. A budget will be determined by the District #10 Community Health department.

SMART objectives related to Knowledge Deficit

• Increase awareness of signs and symptoms of cardiovascular diseases such as stroke and heart attack measure 911 activation for stroke/STEMI after a 6 month education push.

• Increase the number of people in Lake County who are able to verbalize the signs and symptoms of a stroke or heart attack by 30% by the end of one year.

• Include public health nurses, Lake County emergency departments, Emergency medical personnel, local urgent care staff, and senior center in distributing information.

SMART objective related to Poor Nutritional Status

• By the end of one year the people of Lake County will have increased access to the healthy foods that are needed to provide high nutrition, high energy, with decreased calories by instituting a dietary plan based upon the food pyramid.

• Community nursing will work with local farmers to achieve greater access to fruits and vegetables.

SMART objective related to Lake County children and obesity

• Community nursing will provide healthy lifestyle education, partner with local groceries and farm markets to provide greater access to fruits and vegetables, partner with staff who provide school lunch program to ensure a 50% increase in use local fresh fruits and vegetables in school lunches.

• Increase physical fitness in Lake County Children by the end of one year in school age children, by partnering with schools and local community centers to encourage one additional hour per day of physical activity either at school or in after school activities. Community nursing will reach out to schools to assess, plan, intervene, and evaluate the nutritional status of Lake County Children’s nutrition.

• Community nursing will reach out to schools to assess, plan, intervene, and evaluate the physical activity of Lake County children.

Beginning to Make Change

• Assemble a team• Gather a diverse community team to discuss how to make change.

• Develop a strategy• Decide whether to work as a whole team or to divide into subgroups.

• Gather Data• Gather data using multiple methods to insure accuracy.

• Review the gathered data• Brainstorm as a group and gather all opinions about data gathered.

• Document the gathered data• Keep all data collected documented accurately for further review.

Evidence Based Interventions

Behavioral Counseling• Primary care clinicians, nutritionists, or dieticians can provide dietary

counseling for adults with known cardiovascular and other diet related chronic illnesses.

Screenings• Blood Pressure (adults 18 and over) monitored weekly and documented • Lipid Panels for men and women over age 20 with recheck in one year• Fasting blood sugar with recheck in one year • Educating people about the increased risk of heart attack, diabetes, and

stroke with abnormally elevated valuesBehavior and Social Approaches to Increase Physical Activity

• Walking groups • Social networks to offer support with exercise• Mass media messaging• Distribution of free or discounted materials• Worksite programs for nutrition and physical activities• Worksite assessments

Educational Sessions• Families can be educated through school activities such as…• Reward systems such as coupons and vouchers for activities• Family record keeping in the form of charts to hang in the home• Take home packets with educational material• Family fun nights (such as roller-skating and sledding)

Point of Decision Prompts• Signs at elevators encouraging the use of stairs

Evidence Based InterventionsContinued

Environmental and Policy Changes Provide safe and convenient places for physical activity

Parks, side walks, and community centers

Analysis & Selection of EBP Interventions

Measurement of Effectiveness• Change in percent of people increasing their activity• Effectiveness of community wide campaigns• Increase of knowledge about disease• Increase of knowledge of current health (blood pressure and lipid

panels)

Selection of EBP• Healthy People 2020: Physical Activity ranked as leading health

indicator• Primary Prevention: reduce the cardiovascular risk factors and reduce

morbidity and mortality from cardiovascular disease in communities. • Secondary Prevention: Identifying, treating, and rehabilitating patients

at risk of reoccurrence.

Selection of EBP Continued

CDC’s Healthy Communities Program:• Respond to community needs through partnerships.• Implement large-scale interventions in multiple settings.• Reach diverse population groups to promote health

equity.• Make interventions sustainable.

Analysis of InterventionsIncreased activity • Associated with lowered risk of cardiovascular disease• Higher energy levels

Counseling• Increases adherence to programs of physical activity

Lower levels of Activity• Strong risk factor for cardiovascular disease

Exercise• Shown to prevent and treat elevated blood pressure and

cholesterol levels, insulin resistance and glucose intolerance, and fight obesity.

Diet• Consuming more fruits and vegetables and less saturated fats

and cholesterol decreases mortality by 30%

Implementing Evidence-Based Practice

Reasons for

utilizing EBP

• Increase in disease rates

• Restricted funds available

• Developing scientific basis for interventions

Key Elements for Success

• Engage the participants in the community assessment

• Engage the participants in decision-making

• Utilize data and information thoroughly

• Implement decisions utilizing the best evidence

• Apply program-planning based on theory

• Perform thorough evaluation

Health Promotion Model

Model focuses on the following areas (Pender, 2011)Individual characteristics and experiencesBehavior-specific cognitions and affectBehavioral outcomes

Observes each person has unique characteristics and experiences that relate to personal actions (Pender, 2011)Understands best predictor of behavior is frequency of past behaviors (Pender, 2011)

Assumptions of the HPM

• Participants look to control their own behavior

• Participants interrelate and alter their environment over time

• Medical professionals work with participants as well as put forth their influence over time

• Self-initiated changes of their personal environment is vital in changing the behavior

(Nursing Planet Nursing Theories, 2012)

Policy Implications

Assess current resource allocations within the communityPlace funds available towards education materials and staff

providing the education Implement supportive healthy public policy

Ensure public policy supports continuation of community programs

Assess current local resourcesDetermine medical staff and local farmers available to provide

education to the community Assess current grant opportunities for the community

Determine federal and local grants available for improving community health

Contact corporations to assess if any donations are available

Evaluation

• The ultimate goal for this community project is to improve the health of the residents in Lake County, Michigan. Lake County has a high rate of obesity and a high rate of cardiovascular disease compared to other counties in Michigan. By implementing evidence based interventions based on SMART objectives, the desired outcomes are to decrease the percentage of obese and overweight individuals and their risk of cardiovascular disease.• In order to assess whether the desired outcomes were

achieved, the results from nursing interventions must be evaluated.

Short Term Goals

According to Harkness and DeMarco, before any changes are measurable, community level interventions may require many years to reach desired outcomes (Harkness & DeMarco, 2012).

However, to evaluate adequacy of nursing interventions short term effects must continuously be assessed.

According to the Health Promotion Model, motivation for changing a behavior hinge on an individual’s perceived and anticipated benefits for changing a certain behavior. This is why short term evaluations of community programs are important, to reinforce the benefits, commitment, message of the program, and persistence in the plan of action (Pender et al., 2011).

Evaluation ToolsEvaluating interventions to improve knowledge deficits and

behaviors in regards to fitness and nutrition should be assessed before and after interventions are implemented.

Administering validated questionnaires pre- and post educational interventions is an effective way of assessing prior related, and target behavior and knowledge. Several questionnaires are available to measure dietary habits and physical activity among adults, children, and young adults (NOO, 2011).

Additionally, random telephone surveys will demonstrate community residents' knowledge and changes in reported behavior.

Evaluation Tools

Examples of assessment tools for physical activity for adults include:• Stanford 7-day recall (7-DR) • 7-day Physical Activity Diary

Physical activity assessment tools for children and young adults:• Youth Risk Behaviour Surveillance Survey (YRBSS)• The Teen Health Survey

Assessment tools for dietary habits in adults:• Five-a-day Community Evaluation Tool (FACET)• Dietary Quality Score (DQS)

Assessment tools for dietary habits in children and young adults:• Children’s Dietary Questionnaire (CDQ)• Child and Diet Evaluation Tool (CADET) (NOO, 2011).

Evaluating OutcomesPhysical Activity• Organizers of community walks are to assess and record number of

participants as well as participation trends to compare changes in behavior over time.

• Hours of physical activity in schools should be evaluated weekly to meet the desired objective of one additional hour per day.

• School nurses are to measure and keep record of student’s BMI.

Access to Fresh Food• Public health nurses and community organizers should document and assess

number of opportunities for local farmers to sale their produce at community events, and local farmers’ markets to improve the access of fresh, nutritious food to residents.

• Local stores and farmers are to specifically record sales of fresh vegetables and foods to measure adopted behavior of healthy eating habits.

• Daily school lunches are to be evaluated weekly for nutritional status and adherence to food pyramid guidelines.

Evaluating Outcomes

To measure the effectiveness of education programs in regards to awareness of stroke and myocardial infarction (MI) symptoms, acute health service facilities are to record numbers of individuals arriving by EMS and personal vehicles when seeking medical attention for acute cardiovascular related symptoms. These records are to be compared with data recorded before the six months of public education push.

BMI documented by primary care providers as well as health and wellness surveys will track weight loss and adopted behaviors from educational programs.

Long Term Goals

The long term goals for Lake County residents are to improve their knowledge and wellbeing about obesity and cardiovascular disease. Achievement in desired outcomes is confirmed with a community wide change in dietary habits and physical activity and improved knowledge. This will be evidenced by a 5% decrease in statistical numbers of obese individuals, as measured by BMI, and consequently a reduction in deaths from cardiovascular diseases related to obesity at the end of 2018.

To Conclude

In Lake County, a public health challenge is to prevent obesity and related chronic illnesses such as cardiovascular disease. The evidence suggests that interventions are most effective when approaches are multi-component such as addressing knowledge, diet, and physical activity together. Desire and motivation are prerequisites to change. By engaging residents in healthy behaviors by positive social influences will help support and sustain change and ultimately lead to improvement of health and wellbeing among the residents in Lake County.

References

Barbis, K. (2012). Get active Lake County - combat obesity. Retrieved March 30, 2013, from http://www.lcghd.org/Get_Active_Lake_County_and_Combat_Obesity.aspx

Burke, L., Thompson, D., Roos, S., Van Rijssen, A., Verdouw, H., & Troe, E. (2011, July/August). Global cardiovascular disease prevention: A call to action for nursing:multilevel policy change. The Journal of Cardiovascular Nursing, S15-21. http://dx.doi.org/10.1097/JCN.0b013e318213efb3

CDC - Chronic Disease - Healthy Communities - At A Glance. (n.d.). Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/aag/healthy_communities.htm

CDC's Healthy Communities Program - CHANGE Tool and Action Guide. (n.d.). Retrieved from http://www.cdc.gov/healthycommunitiesprogram/tools/change/downloads.htm

Clinical Evidence Handbook: Primary Prevention of CVD: Physical Activity - July 15, 2010 - American Family Physician. (n.d.). Retrieved from http://www.aafp.org/afp/2010/0715/p136.html

Community-based Intervention for Prevention and Control of Cardiovascular Diseases - Dongbo Fu. (n.d.). Retrieved from http://www.gfmer.ch/International_activities_En/Community-based_Prevention_Cardiovascular_Diseases.htm

Cottrell, L., Harris, C. V., Bradlyn, A., Gunel, E., Neal, W. A., Abildso, L., Coffman, J.W. (2012). Identifying the people and factors that influence children's intentions to make lifestyle changes. Health Promotion Practice. 13(2), 183-189

District Health Department #10. (2011). Health Profile Chartbook. Retrieved March 30, 2013, from http://dhd10.org/uploads/File/Community%20Health%20Needs%20Assessment/Lake%20Chartbook%20Feb%2013%202013.pdf

Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease. (n.d.). Retrieved from http://circ.ahajournals.org/content/107/24/3109.full

Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing evidence for practice. Philadelphia, PA: Wolters Kluwer Health / Lippincott, Williams, and Wilkins

Heart Disease and Stroke - Healthy People. (n.d.). Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/ebr.aspx?topicid=21.

Jacobs, J. A., Jones, E., Gabella, B., Spring, B., & Brownson, R. (2012). Tools for Implementing an Evidence-Based Public Health Practice. Preventing Chronic Disease, 9, 1-9.

Kahn, E. B., Ramsey, L. T., Brownson, R. C., Heath, G. W., Howze, E. H., Powell, K. E., Stone, E. J., Rajab, M. W., Corso, P., & Task Force on Community Preventative Services (2002). The Effectiveness of Interventions to Increase Physical Activity A Systematic Review. American Journal of Preventative Medicine, 22(4), 73-102.

Michigan Department of Public Health. District Health Department #10, 2011 Annual Report.

Muecke, M. (1984). Community health diagnoses in nursing. Public Health Nursing. (1)1, 23-35

National Obesity Observatory [NOO]. (2011). Measuring diet and physical activity in weight management interventions. Retrieved from http://www.noo.org.uk/uploads/doc/vid

Nursing Planet Nursing Theories (2012, January 31). Health Promotion Model. Retrieved from http://nursingplanet.com/health_promotion_model.html

O'Hara, P. (2005, May). Creating Social and Health Equity: Adopting an Alberta Social Determinants of Health Framework. Retrieved from http://www.who.int/social_determinants/resources/paper_ca.pdf

Pate, R., & O’Neill, J. (2008, January/February). Summary of the American Heart Association scientific statement: promoting physical activity in children and youth: a leadership role for schools. The Journal of Cardiovascular Nursing, 23(1), 44-49. http://dx.doi.org/DOI: 10.1097/01.JCN.0000305056.96247.bb

Pender, N. J., Murdaugh, C. L., & Parsons, M. (2011). Health Promotion in Nursing Practice (6th ed.). Upper Saddle River, NJ: Pearson.

Prevention of cardiovascular disease: an evidence-based clinical aid 2004 | Medical Journal of Australia. (n.d.). Retrieved from https://www.mja.com.au/journal/2004/181/6/prevention-cardiovascular-disease-evidence-based-clinical-aid-2004

Ryan, P. (2009). Integrated theory of health behavior change: Background and intervention development. Clinical Nurse Specialist, 23(3), 161-172. doi: 10.1097/NUR.0b013e3181a42373

The Joint Committee on Educational Evaluation, (1994). The program evaluation standards: how to assess evaluations of educational programs. Thousand Oaks, CA: Sage Publications

U.S. Department of Education. (2011). Public schoolsK12, Baldwin public Schools. Retrieved fromhttp://publicschoolsk12.com/all-schools/mi/lake-county

U.S Department of Health and Human Services. (12-02-10). Healthy People 2020 retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=29