Problem Statement

Group 2 Tara Braun, Stephanie Bycroft, Kristine Cargill, Jeanette Depue, Jennifer Hanson, Laryn Phillips, Aundrea Robinson-Burris, Alicia WilliamsonNurs 340

Low income African-American residents of Kent County at risk of excessive rates of morbidity and mortality from Cardiovascular Disease R/T : • High rates of obesity • Lower rates of physical activity • Dietary choices • Limited access to health care • Genetic predisposition AEB • The rates of obesity in Kent County have increased from 17% in 1993 to 23.6% in 2008 (Kent County Health Department, 2010). • In Kent County, residents that earned less then $34,999 63.7% are obese • Low income African Americans with low income 35.2 % are obese • According to the Behavior Risk Survey in 2008, 54% reported inactivity in Kent County • African Americans rate of physical inactivity was 28.6% according to the Behavior Risk Survey in 2008 • One of the risk factors for heart disease is obesity. 31.3% of the Michigan population is obese compared to 27.8 % of the US population (Centers for Disease Control and Prevention, 2007). African Americans and low income residents (<$20,000) are at highest risks for obesity and heart disease (Kent County Health Department, 2010). Problem Statement

Who? Low Income African Americans

WHAT Heart Disease related to Obesity. Obesity is a modifiable risk factor for cardiovascular disease (Centers for Disease Control and Prevention, 2012c)

The African American community has an increased prevalence of these diseases in Michigan and in Kent County. • African Americans and low income residents (<$20,000) are at highest risks for obesity and heart disease (Kent County Health Department, 2010).

Physical inactivity and diet are modifiable risk factors of obesity" Centers for Disease Control and Prevention, 2009). • Obesity, physical inactivity and diet are all modifiable risk factors of heart disease and should be the focus of an initiative that seeks to reduce the prevalence of heart disease”(Centers for Disease Control and Prevention, 2009). WHY

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Currently Currently 31.3% of the Michigan population is obese compared to 27.8 % of the US population (Centers for Disease Control and Prevention, 2007). The rates of obesity in Kent County have increased from 17% in 1993 to 23.6% in 2008 (Kent County Health Department, 2010).

Obesity Risks are Disproportionate Among Minority and Low Income Populations ( Robert Wood Johnson Foundation, 2012)

These populations occupy the same areas and in high concentrations; which is central and Midwest Grand Rapids Take a look at the distribution of Low Income and Minority Populations in The Kent County Area on the following slide:

http://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Appendix_A_Clinic_Mapping_Project_Report_2005.pdfhttp://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Appendix_A_Clinic_Mapping_Project_Report_2005.pdf

Minorities are disproportionately represented in low-income neighborhoods and are most likely to be affected by programs that target low-income communities (Kent County Health Department, 2005). Interventions to prevent and reduce obesity in Kent County will reduce the prevalence and disparate impact of heart disease.

Community Health Centers “The community clinic catchment area includes 60% of Kent County’s low-income population and 74% of Kent County’s minority population" Kent County Health Department, 2006). • Using these clinics for intervention sites would make the intervention accessible to the target population. Location, Location, Location…

Secondary Prevention “MAXIMIZING HEALTH AND WELLNESS THROUGH STRATEGIES THAT ARE SET IN PLACE AT THE EARLY AND CHRONIC STAGES OF PATHOGENESISOF ILLNESS AND INJURY” (Harkness and Demarco, 2012, p 65). Primary Prevention “MAXIMIZING HEALTH AND WELLNESS THROUGH STRATEGIES THAT ARE SET IN PLACE BEFORE ILLNESS AND INJURY ARE PRESENT.” (HARKNESS AND DEMARCO, 2012, P 65).

Nutritional Education Classes (Baptist Health South Florida, 2012). • Fitness classes (Baptist Health South Florida, 2012). • Health Screenings for Heart Disease and Diabetes(Baptist Health South Florida, 2012). • “Transform marketing and messages about physical activity and nutrition.”(Robert Wood Johnson Foundation, 2012, )

“Integrate physical activity into people's daily lives.” (Robert Wood Johnson Foundation, 2012, ) THE PLAN

The Social Marketing Theory can best address the obesity and heart disease problem in the African American community in Kent County. • The strategy for achieving this is by eating less, eating healthier foods, and exercising more but the primary focus is the maintenance of healthy body weight and shape. In Theory

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Change based on research is a continuous system of assessment, policy development and assurance that the community needs to move from the preparation phase of change to the action phase of change.

Maintenance- program established and intended to continue Stages of Change:Transtheoretical Model Preparation-steps started to begin a program An integrative, biopsychosocial model to conceptualize the process of intentional behavioral change. Is an approach to behavior changes involving the timely readiness of the learner. (Harkness, G. A., & DeMarco, R. (2012)

The citizens of Kent County should begin improving their diet and physical activity between two and five years after the interventions have been initiated

Increase public access to places that enable people to participate in physical activity(Robert Wood Johnson Foundation, 2012) • Low income neighborhoods are 50% less likely to have close proximity to recreational facilities. (Active Living Research, 2012) • Communities that are socioeconomically disadvantaged are likely to lack clean sidewalks and scenery; factors which promote the involvement of its population to participate in physical activity (Active Living Research, 2012).

Nutrition Community Interventions The building of sporting facilities and playgrounds, mapping out of walking itineraries The offering of cooking classes to families, offering to 'at risk' families of counseling and overweight children. Changes to school menus, the introduction of fruit to menus Encouraging reductions in television watching and increases in physical activity after school . Food pricing adjustments such as subsidies on fruit and vegetables and taxation applied to energy-dense nutrient-poor food; Increasing exposure to healthy food (and decreasing exposure to unhealthy food) via zoning and restrictions on the display of foods in locations such as supermarkets Improving the image of healthy food (and making unhealthy food less attractive) via restrictions on advertising and the presentation of caloric contents of restaurant meals. (Walls, H., Peetas, A., Proietto, J., & McNeil, J. (n.d.).

South East Area Farmer’s Market • Targets underserved population of city • Participates in Double Up Food Bucks program • Grocery Store Tour program (Kent County Health Department, 2011) Kent County’s Obesity Initiative

Nutrition • “•In Los Angeles, California, several communities with high rates of obesity and poverty restricted proliferation of fast–food restaurants within a half–mile radius of existing fast–food restaurants. As a result, approximately 800,000 residents now have the benefit of reduced exposure to unhealthy food options, and retailers offering healthy options have an opportunity to enter the communities.” (Centers for Disease Control and Prevention, 2011). • “•In La Crosse County, Wisconsin, 21 convenience stores became members of Gunderson Lutheran Medical Center's "500 Club," which promotes healthier food options. Their participation will provide the over 113,000 residents of La Crosse County with greater access to healthy food.” (Centers for disease Control and prevention, 2011). • “•San Diego, California, is improving access to affordable healthy foods by increasing the number of farmers' markets that accept food stamps or Electronic Benefits Transfer (EBT) cards. EBT cards enable low–income residents to use food–stamp credits via a debit card. In a five–month period, EBT sales exceeded $29,600 at two farmers' markets. Four more markets are expected to accept EBT cards by March 2012.” • (Centers for Disease Control and Prevention, 2011). Programs That work

Europe adopted a program entitled “EPODE”, to reduce obesity in two towns in northern France (Dalton, 2009). The cities of Fleurbaixand Laventie implemented this program which targeted children and reduced the obesity rates from 11.2% to 8.8% between 1992 and 2004 (Dalton, 2009). • Two nearby towns that did not adopt the program increased their obesity rates during this same time period from 12.6% to 17.8% (Dalton, 2009). • The programs included an interpersonal program that provided dietitians and sports educators to counsel families in schools, implemented, “walk-to-school days”, and new sporting facilitieswere built within the city to make physical activity accessible (Dalton, 2009). Programs That work

Kent County Health Department • 4 Departments: Administration, Community Clinical Services, Community Nursing, Environmental Health (Kent County Health Department, 2011) Local Resources to Support Initiatives

RACE FOR HEALTHY KIDS Race for Healthy Kids takes place in Rockford, Michigan. It’s intent is to involve families in physical activity and fund raising for health promotion programs. http://www.raceforhealthykids.org/ The South East area Farmers Market The South East area Farmers Market offers locally grown fresh fruits and vegetables and has began accepting EBT and Bridge cards, allowing access to these healthy food choices among individuals who are low income. Healthy Kent 2020 http://www.healthykent.org/ Project Takeoff Coalition. In an effort to encourage physical activity and decrease obesity, Kent County has formed the Project Takeoff Coalition. Through this agency, a number of educational opportunities have been developed in Kent County to decrease obesity and improve overall health. The Kent County Health Department offers “Walking into Wellness,” nutrition and walking program that also offers cardiovascular screening. Other programs include Champion Health and Fitness for persons aged 17 and older, Gymco Sports for ages 18 months to adult, East Hills Athletic Club “Baby on Board,” and Priority Health-“Learn” which promotes lifestyle change through exercise and stress management. These programs may help to encourage motivation and social support. (Kikstra, A. The Project Takeoff Coalition accessed 10/20/12) STRIDES

Task Force on Health Care for People of Color The mission of this Task Force is “to examine the issue of health care for people of color, determine what the county is doing to resolve existing barriers and to develop proposals for community action “ (Task Force on Health Care for People of Color, 2005). http://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Task_Force_Final_Report_2006.pdf

Success! A successful intervention will reduce the number of new cases of heart disease in the Kent County African American community when monitored over a period of two to five years.

According to the research performed by Macdiarmid et al., improved health will likely not be seen until roughly five years after the interventions have been implemented (2010) • Improved health can be seen as weight loss, lower rates of obesity, lower blood pressure, lower cholesterol, and a decrease in the number of cases of diabetes • It takes many stops and starts before changes become permanent and the outcome of improved health is seen • Should be considered a long-term goal • Changes in people’s beliefs and attitudes will occur sooner (Centers for Disease Control and Prevention [CDC], n.d.) • Will likely be the first changes seen • Should be seen within one year of the interventions being initiated • Changing people’s attitudes about healthy eating, physical activity and their role in reducing obesity and heart disease should be a short-term goal When Will Changes be Seen?

The citizens of Kent County should begin improving their diet and physical activity between two and three years after the interventions have been initiated • The changes in behavior are intermediate goals (Macdiarmid et al., 2010) • This period of time is difficult as people struggle to maintain those changes • The rate at which change is seen is also effected by: • how quickly the message for change reaches the target audience • if it is easily understood • how long the message is advertised (CDC, n.d.) When Will Changes be Seen?

In order for a program to be effective, it must have measurable outcomes. This allows for review of results and ability to make adjustments to the program where needed. • Outcomes to measure include the availability of healthy food and drinks in schools, the facilitation of active transportation, the number of farmer’s markets accepting food benefits such as SNAP, EBT, and Bridge cards, and the physical activity requirements of schools. Evaluating Outcomes

Getting better and better Evaluating the effects of the interventions

Obesity rate Noticeable decrease in the obesity rate of the African American residents of Kent county. Due to improved diet practices and improved exercise practices.

There will be a marked decrease in new cases of heart disease among the residents of Kent county. As well as an increase in compliance to treatment of current residents with heart disease. Heart Disease: What to expect from an effective intervention

Short term outcomes contributing to diet-related behavior include attitudes, values, knowledge and skills (Devine, Brunson, Jastran, and Bisogni , 2006, p2) • It has been proposed that “a participant-centered approach could contribute to improved program management, accountability, and satisfaction.” (Devine et al. (2006, p. 2) • “Program context, as presented in participants’ current worlds, could make or break a program” (Devine et al. 2006 p.4) • “Outcomes related to content in resource management, diet quality, meal planning, food safety, parenting, and personal development” (Devine et al. 2006, pp. 4 -5) • “Motivational approaches may be most important for people who have yet to attend to or engage with nutrition” (Devine et al. 2006, p.6) • “In particular the many social outcomes that were expressed by these participants may have importance for reinforcement, social support, and sustainability of new practices.” (Devine et al. (2006, p.6) Measurable Outcomes for Change

Environments for ActionChange in the prevalence of heart disease in the African American community in The Kent County area requires a collaborative effort toward change in many factors that also influence obesity: Change in the schools, physical activity environments, food and beverage environments and the health care and work environments . These will all be influenced by the message environments to produce change in the health behaviors of this community

Centers for Disease Control and Prevention. (2007). Surveillance of Certain Health Behaviors Among States and Selected Local Areas: United States, 2005. Morbidity and Mortality Weekly, 67(SS4), 1-164 Retrieved from http://www.cdc.gov/mmwr/PDF/ss/ss5604.pdf • Centers for Disease Control and Prevention. (2009). Heart disease behavior. Retrieved from http://www.cdc.gov/heartdisease/behavior.htm • Center for Disease Control and Prevention. (2011c). CDC Newsroom, African-American Media Resources. Retrieved fromhttp://www.cdc.gov/media/subtopic/resources/aaresource.htm • Centers for Disease Control and prevention,. (2011). Communities putting prevention to work. Retrieved from http://www.cdc.gov/CommunitiesPuttingPreventiontoWork/action/index.htm • Centers for Disease Control and Prevention (CDC). (n.d.) Introduction to program evaluation for public health programs. Retrieved from http://www.cdc.gov/getsmart/program-planner/Step3.pdf • Dalton, M. (2009, November 10). Fighting obesity may take a village. Wall Street Journal , Retrieved from http://online.wsj.com/article/SB10001424052748703808904574525462710954426.html • Devine, C.& Brunson, R. & Jastran, M. & Bisogni, C. 2006 It Just Really Clicked: Participant-Perceived Outcomes of Community Nutrition Education Programs https://fsulearn.ferris.edu/@@/C46F23C6651BEFC64498D6EFC4C35BDD/courses/1/XLIST_80400.201208/db/_123273_1/It%20Just%20Really%20Clicked%20Participant-Perceived%20Outcomes%20of.pdf • Hanan, M. (2009). Interpersonal and mass media campaign for HIV/AIDS prevention: an integrated approach. Journal of Development Communication, 20 (1), 10-30. • Harkness, G.A., & DeMarco, R.F. (2012). Frameworks for health promotion, disease prevention and risk reduction. In Community and public health nursing: Evidence for practice (pp. 65-85). Philadelphia, PA: Wolters Kluwer Health/ Lipincott Williams & Wilkins. • Healthy Kent 2020(n.d.). Community Health through community action. Retrieved from http://www.healthykent.org/ References

Kent County Health Department. (2006). Health Care for people of color: Final report 2006. Retrieved from http://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Task_Force_Final_Report_2006.pdf • Kent County Health Department Task Force on Health Care for People of Color. (2005). [Spot map comparison of minority population concentration in Kent County]. Clinic mapping project report: Access to health care services. Retrieved from http://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Appendix_A_Clinic_Mapping_Project_Report_2005.pdf • Kent County Health Department Task Force on Health Care for People of Color. (2005). [Spot map community health centers in Kent County]. Clinic mapping project report: Access to health care services. Retrieved from http://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Appendix_A_Clinic_Mapping_Project_Report_2005.pdf • Kikstra, A., Kent County Health Department, The Project Takeoff Coalition, accessed 10/20/12 • Macdiarmid, J.I., Loe, J., Douglas, F., Ludbrook, A., Comerford, C., & McNeill, G. (2010). Developing a timeline for evaluating public health nutrition policy interventions. What are the outcomes and when should we expect to see them. Public Health Nutrition, 1-11. doi: 10.1017/S1368980010002168 • Race for Healthy Kids. (n.d.). Race for healthy kids. Retrieved from http://www.raceforhealthykids.org/ • Task Force on Health Care for People of Color. (2005). Clinic consortium clinic mapping project: Access to health care services. Retrieved from http://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Appendix_A_Clinic_Mapping_Project_Report_2005.pdf References

Problem Statement