1. By Jill Lovano Emily Cornell Jennifer Housel Angela McColl

2. Introduction Heart disease affects one in two people in the United States (Healthy People, 2020). There are several modifiable risks that can aid in the prevention and management of Heart Disease such as smoking cessation, physical activity and healthy diet(Healthy People, 2020). In Kalkaska County, a rural community in Northern Michigan, Heart Disease is the leading cause of death and many residents are in need of assistance to change the modifiable risks in order to aid in prevention (Chartbook, 2013). The following is a plan to assist residents of Kalkaska County to reduce the overall risk of heart disease and death. The plan utilizes proven interventions based on a comprehensive assessment of the community, the use of theoretical models to ensure participation in interventions and community programs designed to promote healthy behaviors, and realistic measureable outcomes provided by DH#10 and Healthy People 2020.

3. Population 17,099 Primary town is Village of Kalkaska in the northwest corner of the county. Of the 17,099 residents in the county, only 2,020 residents live in the village. Rural area. (Suburbanstats.com, 2014). Assessment of Community

4. 16.2% of population lives below poverty level 39.8% of the population are overweight (having a BMI between 25 and 29.9 29.5% of population is obese (BMI of 30 or greater) 22.5% of the population lacks physical activity 31.4% of the population smokes 76.9% of the population has an inadequate intake of fruits and vegetables (Health Profile Chartbook, 2013) Assessment of Community

5. Theoretical Support Social Learning A small close-knit community like Kalkaska is likely to follow the Social Learning model. Social Support An important aspect of Social Learning, where others offer support of the desired behavior. (Harkness & DeMarco, 2012)

6. Theoretical Support Theory of Reasoned Action Behavior is determined by intention to perform that behavior. Intention determined by attitude and influence of environment. The ability to perform the behavior is critical for change to occur. (Harkness & DeMarco, 2012, p.78)

7. Theoretical Support Relapse Prevention Model Used to promote adherence to desired behavior. Addresses coping skills Negative emotional states Decreased motivation Stress High-risk experiences (Harkness & DeMarco, 2012)

8. Analysis of Findings Kalkaska County’s leading cause of death is Heart disease (Chartbook, 2013). Statistics show that residents are overweight, smoke, lack fruits and vegetables, and do not exercise (Chartbook, 2013). These are all factors that can contribute to Heart disease Weight loss of 5-10% of body weight can reduce blood pressure and blood cholesterol levels (Eckel, R. & Krauss, R., 2014).

9. Community Diagnosis Risk of heart disease among residents of Kalkaska County related to obesity as demonstrated by 29.5% of population with BMI of 30 or greater.

10. Goals and Smart Objectives The percentage of residents with a BMI of less than 25 in Kalkaska County will increase by 50% in the year 2015 compared to 2013. The percentage of reported cigarette smoking in Kalkaska County will be less than 10% in the year 2015 compared to 31.4% in 2013. The number of individuals living below poverty level in Kalkaska County will be reduced by 20% from 16.9% in 2013 to 13.5% or less in 2015. The number of individuals living an active lifestyle in Kalkaska County will increase by 20% from 77.5% in 2013 to 93% or higher in 2015. The number of individuals in Kalkaska County who consume adequate amounts of fruits and vegetables will increase by 50% from 23.1% in 2013 to 34.65% in 2015.

11. Resources Farmers Markets Cherry Street Market Clearwater Farm Market Kalkaska Farmers Market Spring Recreation Area Fitness Facilities Kaliseum Free or Low Cost Exercise Programs Commission on Aging -Aerobic Weight Lifting -Beginners Line Dancing -Zumba Gold Yoga Zumba Places to Walk Kaliseum Kalkaska High-School KART trail Weight Management Taking off pounds sensibly Weight Watchers- Kaliseum

12. Resources Mental Health Health and Healing Ministry Munson Behavioral Health Northern County Community Mental Health Substance Abuse Addiction Treatment Services Catholic Human Services Tobacco Cessation Resources Michigan Tobacco Quitline Freedom From Smoking

13. Evidence-based Interventions Primary Prevention Nutrition Kalkaska County community will offer farm markets with affordable prices twice a week. Community venues will offer healthier affordable food choices. Increased access to fruits and vegetables. Residents with seasonal gardens can volunteer to teach other residents to grow their own food. Kalkaska County will provide connections for community members with local farmers. (BMC Nursing, 2012, p. 8)

14. Evidence-based Interventions Primary Prevention, cont’ Physical Activity Kalkaska County will improve access and utilization of recreational facilities. Kalkaska County will offer affordable community fitness programs. County officials can identify safe rural roads and areas for walking or running. Kalkaska County will promote access to the city’s walking and biking trails. Promote buddy system fitness programs and activities within the community.(BMC Nursing, 2012, p. 8)

15. Evidence-based Interventions Secondary Prevention- Education Community education on healthy and affordable food choices. Community education on benefits of preparing home cooked meals verses eating out. Community education on heart disease and prevention through weight management by proper nutrition. Educate on all modifiable risk factors of heart disease, such as managing diabetes, cholesterol, blood pressure, weight, stress, and smoking. The community will educate residents on exercises that can be performed safely in the home for relapse prevention during winter months.

16. Evidence-based Interventions Secondary Prevention, cont’ Counseling Kalkaska County will provide counseling and programs on controllable risk factors for heart disease and how to promote a healthy lifestyle. Kalkaska County will offer counseling on eating habits and maintaining a healthy BMI. Kalkaska County will offer counseling physical fitness and active lifestyles. Kalkaska County will offer counseling on how to access the fitness programs, buddy system, and connections to local farmers. (Xanthos et al. 2010, p. 1475)

17. Evidence-based Interventions Secondary Prevention cont’ Counseling Kalkaska County will create programs based on the Relapse Prevention Model to ensure adherence of healthy activities during the winter months when outside activities are difficult. The community will offer space for indoor physical activities such as walking or running in addition to indoor gyms. The community will offer programs based on healthy eating during winter months when access to affordable fresh produce is limited.

18. Evaluation Plan will be evaluated by individual reports of lower cholesterol levels and reduction in weight. Assessments of individuals smoking status, diet, alcohol intake, and physical activity will be done periodically to evaluate the effectiveness of the plan. Programs and volunteer actions will be assessed by community nurses twice yearly to evaluate efficacy and adherence.

19. Conclusion Combating heart disease is a problem all nurses face in the United States. It is imperative that all nurses participate in the community by assisting with prevention programs and healthy behaviors. By using the social learning theory, nurses can lead by example and model desired behaviors in the community. By providing the community with few, simple behavior modifications such as increased physical activity and healthy diet the residents are more likely to succeed.

20. References Chan, B. C., Laws, R. A., Wililams, A. M., Davies, G. P., Fanaian, M., & Harris, M. F. (2012). Is there scope for community health nurses to address lifestyle risk factors? The Community Nursing SNAP Trial. BMC Nursing, 11(1), 4-12. doi:10.1186/1472-6955-11-4 District Health Department #10, (2013) Kalkaska county, let's live well healthy lifestyle community resources. Retrieved from http://www.livewell4health.org/#!kalkaska/c9zl Eckel, R. & Krauss, R. (2014). American heart association call to action: Obesity as a major risk factor for coronary heart disease. Journal of the American Heart Association. Retrieved from http://circ.ahajournals.org/content/97/21/2099.full Harkness, G.A. & DeMarco, R.F. (2012). Community and public health nursing: Evidence for practice. Philadelphia, PA: Wolters Kulwer Health/Lippincott Williams and Wilkins Health Profile Chartbook (2013). Kalkaska County. District Health Department #10.Retrieved from http://dhd10.org/dhd10-community-statistics Healthy People 2020. (2014). Heart disease and stroke. Retrieved from http://www.healthypeople.gov/ 2020/topics-objectives/topic/heart-disease-and-stroke/objectives

21. References Oregon Evidence-based Research Center, Center for Health Research, Kaiser Permanente Northwest. (2010). Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: Update of the evidence for the U.S. Preventive Services Task Force. (ARHQ Publication No. 11-05149-EF-1). Retrieved from http://0- www.ncbi.nlm.nih.gov.libcat.ferris.edu/pubmed/?term=Behavioral+Counseling+to+Promote +Physical+Activity+and+a+Healthful+Diet+to+Prevent+Cardiovascular+Disease+in+Adults %3A+Update+of+the+Evidence+for+the+U.S.+Preventive+Services+Task+Force Suburban Stats (2014). How many people live in Kalkaska village, Michigan for 2014, 2013. Retrieved from https://suburbanstats.org/population/michigan/how-many-people-live-in-kalkaska- village Xanthos, T., Pantazopoulos, I., Vlachos, I., Stroumpoulis, K., Barouxis, D., Kitsou, V., & Papadimitriou, L. (2010). Factors influencing arrival of patients with acute myocardial infarction at emergency departments: implications for community nursing interventions. Journal Of Advanced Nursing, 66(7), 1469-1477. doi:10.1111/j.1365- 2648.2010.05301.x