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Running head: CAP PAPER 1

Community Assessment Paper: Phase I

Harper Allen, Jamie Grill, Brenda Kigen, and Aubrey Straw

Auburn University School of Nursing


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Abstract

Notasulga is a rural community located in Macon County, Alabama. The population faces

many challenges including financial burden due to lack of jobs, decline of health status due to

the lack of access to preventative healthcare, and poor nutrition related to the lack of the quality

and quantity of appropriate food sources. This paper discusses the methods that were used to

assess the community including health and population profile data, a windshield survey, and an

interview with a key informant. This paper also includes three key nursing diagnoses that related

to the community assessment, and a discussion of the chosen Healthy People 2020 goal, which

includes how the community compares to the goal and the importance of the goal, followed by a

summary of the findings. While conducting a windshield survey and collaborating with an active

member from the community, it was established that Notasulga will fail to meet the Healthy

People 2020 goal of access to healthcare for all people unless certain measures are taken in

providing education and screening services to the community. The purpose of this paper is to

dissect what factors contribute to the health disparities of Notasulga and provide the community

the opportunity to reach the Healthy People 2020 goal.

Keywords:​ preventative healthcare, access, Healthy People 2020


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Community Assessment Paper: Phase I

Notasulga, Alabama is a rural town located in Macon County and is about 30 minutes

from Auburn, Alabama. The students conducted a windshield survey of Notasulga, an interview

with a key informant in the community, and established three nursing diagnoses from the

windshield survey and key informant interview. Based on the results, it was established that the

Notasulga community did not have adequate access to healthcare and do not partake in

preventative measures such as blood pressure checks and dental checks. This paper will discuss

why Notasulga community faces these problems by providing a full community assessment of

Notasulga including what was seen during the windshield survey, information relayed from the

key informant, and the importance of reaching the Healthy People 2020 people goal of access to

healthcare.

Community Assessment

The major problem within the Notasulga community is the lack of health care services.

At the beginning of the assessment of this community, it was noted that there is only one health

care facility located in the town. The Notasulga Healthcare building is located in the middle of

town and consists of only one nurse practitioner as the primary provider (see appendix A).

Problems with this include: long wait time, limited scope of practice, and short visitation time

with the provider. While speaking with the key informant, it was stated that the population does

not value the opportunities of preventable health care (key informant, personal communication,

February 24, 2018). This includes trips to the dentists twice a year, receiving proper eye care and

monitoring blood sugar (see appendix B). A concern that was voiced during the interview was

the problem with the lack of health care services due to the inability to pay for doctor visits and
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the appropriate medicine each individual need. This particular issue is also seen throughout the

country, as described in the article “Perceptions of Health Care and Access to Preventive

Services Among Young Adult” (Luquis & Kensinger, 2017). It is shown through the research

that if a patient seems healthy enough in the patient’s eyes, the patient will pay for food and

housing over health insurance, which in the long run will result in the patient avoiding the doctor

when the patient gets sick (Luquis & Kensinger, 2017, p. 2).

Looking at community nutritional assessment, Notasulga community has one Dollar

General, but the Dollar General does not have fresh fruits and vegetable to maintain adequate

nutrition. Many residents drive to the Auburn/Opelika area to buy groceries; however, there is a

Carmack’s and a local farmer’s market where residents can buy food (key informant, personal

communication, February 24, 2018). Commuting to the grocery store can pose a problem since

some residents, especially the older adult population does not have transportation to get to the

store (key informant, personal communication, February 24, 2018). The lack of access to healthy

foods is evidenced by high percentage of obesity in Macon county with 40.2% of adults being

obese (“Notasulga, Alabama”, 2018).

health profile worksheet

The overall life expectancy at birth for residents of Notasulga, AL is 73.2 years, which is

lower than the state average of 75.3 years (“American FactFinder”, 2016). The number of

females with cardiovascular diseases living in Notasulga is 32 and males with cardiovascular

diseases is 38 (“County Health Profiles”, 2009). There are six females and six males living with

diabetes in Macon county (“County Health Profiles”, 2009). The percent of adults that are obese

in Notasulga is 40.2% (“Notasulga, Alabama”, 2018). Obesity predisposes individuals to other


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chronic conditions such as heart disease and diabetes (Hoffman & Sullivan, 2017, p. 1498) .

With already high costs of health care, these added chronic illnesses could further increase the

amount of money people have to pay for care. In Notasulga, 8.6% of the population does not

have any form of health insurance (“American FactFinder”, 2016). Not having insurance means

going to the doctor for preventative care might be too expensive, and thus individuals may not

attend these preventative care appointments (Hoffman & Sullivan, 2017, p. 42-43). From 2004 to

2013, there have been 1,054 incidences of all cancers in Macon County, with 131 incidences of

breast cancer, and 197 incidences of prostate cancer (“Alabama Cancer Facts and Figures”,

2015).

population profile worksheet

In the Notasulga community, 24.0% of individuals live below poverty and 19.6% of

families live below poverty. Both of these statistics are above Alabama’s state percent of 18.4%

and 14.0%, respectively (“American FactFinder”, 2016). These statistics are relevant because it

shows how nearly a quarter of the community lives below the poverty line. Living below the

poverty line indicates that these people cannot get the adequate healthcare that they need or

afford the nutritional food their bodies need (key informant, personal communication, February

24, 2018). Additionally, 7.1% of the population is unemployed, which is above the state rate of

4.8% (“American FactFinder”, 2016). The majority of the residents work in production,

transportation, and material moving occupations (24.0%), and the median household income is

$40,938, which is below the state rate of $44,758 (“American FactFinder”, 2016). In Notasulga,

100% of the population speaks English only, 65% of residents are White, and the median age of

residents is 41.9 years (“American FactFinder”, 2016). There are 272 family households and 158
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non-family households (“American FactFinder”, 2016). Of the homes in this community, 76.6%

were built between 1950 and 2014 with the median value of the homes at $96,700 (“American

FactFinder”, 2016).

Windshield Survey

The community of Notasulga is a small rural community in Macon County, Alabama that

is about 30 minutes away from Auburn, Alabama. Notasulga is accessible from Auburn via

Highway 14. Upon arriving in the town of Notasulga, the students entered into the town center

where there are one or two stores and restaurants that are running businesses. There are many

houses in Notasulga ranging from over thirty years old to about five years old. There were not

any established neighborhoods, the houses were along the roads in the town. A green space was

located by one of the churches in town, and a baseball field and football field were behind the

high school. Driving through Notasulga, the people tended to congregate toward the churches to

have meetings and spend time with each other. Also, the people in town went to the restaurant in

the downtown area to enjoy a meal. The people in the town drove their cars to get to and from

places because there were not many sidewalks in the community. Highway 14 runs through the

town and provides transportation to Auburn, Alabama. As for service centers, there was not a

central recreation center but the school had fields behind it. The town had one healthcare clinic

in the downtown area and a volunteer fire station. For shopping, the people would have to drive

to the Dollar General or Carmack’s to get some groceries, however there is not a central grocery

store like Publix or Kroger in the town. The people in the town were sitting on their porches, but

they were not out walking because there are not really any sidewalks throughout the town. When

driving through Notasulga, the people seen were African American but some Caucasians were
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present as well. The town has two churches: Methodist and Baptist. A health clinic was in the

middle of town, but if the community wanted to go to a hospital, they would have to travel to

Opelika or Tallassee. Throughout the town, signs were up showing a candidate running for state

representative, but a predominant party affiliation was not identified. Notasulga did not have a

local newspaper, and many houses showed no sign of antennas or satellites. In Notasulga, the

high school, middle school, and elementary school are all located in the same spot and the

schools connect with one another (see Appendix A).

Key Informant

The key informant of Notasulga grew up in the community and currently lives in the

community. When asked what the role of the key informant was in the community, the key

informant said that they were a town council member of district 2. The key informant stated that

some of the strengths of Notasulga included proximity to interstate 85 and state roads 14 and 81,

proximity to Auburn and Montgomery, railroads that run through the town, potential for Macon

County to get Leonardo T-100 Trainer to build trainer jets, which would produce 750 jobs and

the ability for the town to make money, new home construction has increased, and senior citizen

center on Highway 12 that provides occasional health checkups. When asked are there areas of

improvement in the community, the key informant responded that Notasulga needed better cable

services, cell phone service, its own water source, more recreation opportunities, and better

education. The key informant said that the major concerns of community members included

access to health care, the failing school system, issues related to the aging population (key

informant, personal communication, February 24, 2018).


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The key informant was asked if they believe there is adequate access to healthcare and

they responded with the answer, no. The key informant elaborated stating that there is a lack of

preventative health care due to financial issues, and the population does not value preventative

health care including trips to the dentist, eye care, and blood sugar checks. The key informant

also stated that the population does not go to the doctor in a timely manner and the older

population lacks transportation to go see a healthcare provider. When asked if there are any

special concerns related to health among the residents in their community, the key informant

responded that transportation, lack of IT service, nutrition/diet, preventative care, ability to pay

for medications and doctor visits, aging populations, and support systems. We asked the key

informant about the community barriers and facilitators to reaching the Healthy People 2020

goals of living longer, healthy lives, and the key informant responded with the lack of IT

infrastructure, low income of resident, and less interest in preventative care would prevent the

community from reaching their goals. Finally, the key informant was asked if they would like to

add anything else, and she responded with the major issue is the community’s lack of interest in

preventative health care. For more information on the key informant’s answers, direct attention

to Appendix B (key informant, personal communication, February 24, 2018).

Community Health Nursing Diagnosis

One of the nursing diagnosis for the community of Notasulga, AL includes a risk for

non-compliance in adults living in Notasulga, AL related to a lack of access to health care

resources and 19.6% of the population living below the poverty line, as evidenced by the

interview with the key informant and the high rates of preventable, chronic diseases such as

diabetes (52.7%) and hypertension (39.5%) (“American FactFinder”, 2016). The second nursing
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diagnosis is a risk for ineffective health maintenance in the adult population of Notasulga, AL

related to a neglect for preventative health care and rural location of the community as evidenced

by information from the key informant that states, “the people in this community don’t get their

blood sugars checked regularly, and don’t go to the doctor until they are deathly ill” (key

informant, personal communication, February 24, 2018). An additional nursing diagnosis is a

risk for a nutritional deficit in adults in Notasulga, AL as related to the percent of families living

below the poverty line (19.6%) and a lack of grocery stores in the proximity that carry fresh

produce, as evidenced by the percent of obese males (39.9%) and females (53.9%) (“American

FactFinder”, 2016) (see Appendix C for complete nursing diagnoses). Of these diagnoses, the

risk for ineffective health maintenance in the adult population is the most important because it

directly relates to the Healthy People 2020 goal of access to healthcare for all. Without access to

healthcare, the community is at greater risk for improperly managing chronic and acute diseases.

Healthy People 2020 Objective

An objective that applies to Healthy People 2020 in the Notasulga community is access to

health services because it is a rural area. There are three main aspects of the access to health

services objective. The first is access to coverage, which is associated with preventative health

care, and lack of health insurance. With chronic diseases deficient access results in increased

pain, worsening of the condition and increased risk of additional health problems. To solve this

patients need prescription medication access and compliance, which is most of the time only

possible with reliable coverage. The second aspect is providing services like yearly health

promotion screenings, and health promotion teaching on overall health such as exercise, and diet

to prevent cardiovascular diseases. This can be done through community programs organized by
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health departments in colleges and universities. Also, programs that teach pediatric population

about hygiene and how to avoid injury and accidents such as burns, motor vehicle accidents, and

contact sports injuries are important to preventative care. The third aspect consists of working

with the health care system in providing timely care to patients, which is made possible by

increasing the number of health professionals in the community, and building more community

health centers equipped with health resources and equipments (“Access to Health Services”,

2014).

Comparison of Notasulga, AL to Healthy People 2020 Goal

An article by Bolin et al., (2015) discusses a survey that was conducted regarding what

rural residents considered as the most important aspects of health care. With 17% of the U.S.

population living in rural areas and only 9% of doctors practicing in these communities, it is no

surprise that the overwhelming majority of survey participants selected access to healthcare as

their most important factor of healthcare (Bolin et al., 2015, p. 326). Bolin’s article emphasizes

how the the community of Notasulga, AL does not meet the Healthy People 2020 goal of

ensuring all people have access to adequate healthcare. As a rural community with one small

health clinic, Notasulga residents are geographically disadvantaged. If a resident were to seek

either preventative care or emergency services, the resident would have to drive to the

Auburn/Opelika area or call an ambulance -both of which are costly. The key informant further

reinforced the struggle that community members face with the lack of nearby healthcare services

by discussing how residents often lack transportation, and have to pay others to take them to

doctors’ appointments, which prevents people from attending preventative care appointments

(personal communication, February, 24, 2018). Notasulga residents are also economically
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disadvantaged; with an unemployment rate of 7.1% and 19.6% of families living below the

poverty line, access to preventative healthcare becomes a question of financial resources

(“American FactFinder”, 2016). According to our key informant, the Notasulga community

members struggle with valuing preventative health care and nutrition; combine this with the high

cost of these services, and preventative care gets placed on the backburner (personal

communication, February, 24, 2018). The geographic location plus economic disadvantage

further prohibits Notasulga from reaching the Healthy People 2020 goal of access to adequate

healthcare for all.

Importance of Healthy People 2020 Goal

People who do not have health insurance often delay preventative care; for example,

women may lack health insurance, and as a result do not have access to screenings such as Pap

smear tests to detect cervical cancer at early stage (Okoro, Guixiang, Fox, Eke, Greenland,

Town, 2017.) According to the article by Shepherd, Locke, Zhang, and Maihafer (2014), lack of

preventative care can delay detection of chronic diseases, which may lead to increased pain,

worsening of the condition, and increased risk of additional health problems. To solve this,

patients need access to affordable preventative care and medications, which is often only

available to those who are insured (Shepherd, Locke, Zhang, and Maihafer, 2014). Shepherd, et.

al., (2014) says that community health centers have been a success in linking health care

providers to the underserved population; this in turn provides quality health care to the

community. For example, community health centers in Washington, Montana, and West Virginia

have implemented pharmaceutical programs to help the underserved communities to access

medications (Shepherd, Locke, Zhang, and Maihafer, 2013). Notasulga has only one health clinic
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that services the town. Increasing the access of community centers in Notasulga that can provide

preventative care will grant timely screening to the underserved population and help the

population reach the Healthy People 2020 goal (key informant, personal communication,

February 24, 2018).

Summary

The community of Notasulga, AL is located in a rural area with limited access to grocery

stores and healthcare, which places the community at a disadvantage for meeting the Healthy

People 2020 Goal of access to healthcare for all people. According to information gathered from

the windshield survey, key informant interview, and health and population profile worksheets,

Notasulga has a high poverty rate, high rates of preventable diseases such as hypertension and

diabetes, and does not value preventative care. The Healthy People 2020 goal of adequate access

to healthcare is important to Notasulga because access to preventative healthcare can decrease

rates of chronic diseases and improve outcomes for treatment of current diseases in this

community. The students hope that by increasing access to preventative care in the community,

Notasulga can take another step towards reaching the Healthy People 2020 goal of access to

healthcare.
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References

Access to Health Services. ​(2014). Retrieved from:

https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

Alabama Cancer Facts and Figures​. (2015). Alabama Department of Public Health. Retrieved

from: ​http://www.alabamapublichealth.gov/ascr/assets/FactsFigures2015.pdf

American FactFinder: Poverty Status in the Past 12 Months.​ (2016). Retrieved from:

https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF

American FactFinder: Selected Economic Characteristics.​ (2016). Retrieved from:

https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF

Bolin, J.N., Bellamy, G.R., Ferdinand, A.O., Vuong, A.M., Kash, B.A., Schulze, A., & Helduser,

J.W. (2015). Rural Healthy People 2020: New Decade, Same Challenges. ​The Journal of

Rural Health, 31(3),​ 326-333. doi: 10.1111/jrh.12116

County Health Profiles. (2009). Alabama Department of Public Health Statistics. Retrieved from:

http://www.adph.org/healthstats/assets/chp09.pdf

Gamble, S., Mawokomatanda, T., Xu, F., Chowdhury, P. P., Pierannunzi, C., Flegel, D., & Town,

M. (2017). Surveillance for Certain Health Behaviors and Conditions Among States and

Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2013

and 2014. ​Morbidity And Mortality Weekly Report. Surveillance Summaries​, ​66​(16),

1-144. doi:10.15585/mmwr.ss6616a1

Hoffman, J.J., Sullivan, N.J. (2017). Ethical Concepts. ​Medical-Surgical Nursing​ (p.42-43).

Philadelphia, PA: F.A. Davis Company


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Hoffman, J.J., Sullivan, N.J. (2017). Managing Care for the Adult Patient with Obesity.

Medical-Surgical Nursing​ (p. 1497-1507). Philadelphia, PA: F.A. Davis Company

Luquis, R. R., & Kensinger, W. S. (2017). Perceptions of Health Care and Access to Preventive

Services Among Young Adults. 1-9. doi:10.1007/s10900-017-0371-2

Okoro, C. A., Guixiang, Z., Fox, J. B., Eke, P. I., Greenlund, K. J., & Town, M. (2017).

Surveillance for Health Care Access and Health Services Use, Adults Aged 18-64 Years

-- Behavioral Risk Factor Surveillance System, United States, 2014. ​MMWR Surveillance

Summaries​, ​66​(7), 1-41.

Shepherd, J., Locke, E., Zhang, Q., & Maihafer, G. (2014). Health Services Use and

Prescription Access Among Uninsured Patients Managing Chronic Diseases. ​Journal Of

Community Health​, ​39​(3), 572-583. doi:10.1007/s10900-013-9799-1


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Appendix A

Windshield Survey Worksheet


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Appendix B

Key Informant Interview

Potential Questions Summary of Answers


What is your role in the community? Town council member district 2
What do you believe are some strengths Proximity to I85 and state roads 14 and 81;
of the community? proximity to Auburn and Montgomery; railroad
runs through town, potential for Macon county to
get Leonardo T-100 Trainer to build trainer jets,
which would produce 750 jobs and ability to
make money; new home construction is up;
senior citizen center on Hwy 14 which receives
health checkups periodically; land is affordable,
and there is potential for growth from Lee county
Are there areas of improvements in the Yes, need better cable services, cell phone
community? service, need own water source; more recreation
opportunities, education system is failing; clean
up dilapidated properties
What are the major concerns of Access to health care, school system needs
community members? improving, roads, aging population and related
issues
Do you believe there is adequate access to No, several hospitals in area in Montgomery,
health care? Jackson, EAMC, Notasulga health care clinic for
wellness checks, health department in Macon
county. There are ambulance services such as
CARE and EMS out of Opelika. Lack of
preventative health care due to financial issues,
and the population doesn’t value preventative
health care, such as trips to the dentist, eye care,
blood sugar checks. The population doesn’t go to
doctor in timely manner. Older population has a
lack of transportation (have to pay people to take
them to doctor); inadequate cell service prevents
telehealth
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Are there any special concerns related to Transportation, lack of IT service, lack of concern
health among residents in your about nutrition/diet, preventative care, low ability
community? to pay for medications and doctor visits, aging
population and support system

Healthy People ​provides science-based, Few, if any facilitators to reaching goals, no IT


10-year national objectives for improving infrastructure, low income, less interest in
the health of all Americans. The vision of preventative areas
Healthy People 2020​ is to have a society
in which all people live long, healthy
lives. What are some community barriers
and facilitators to reaching this vision in
this community?
Is there anything else you would like to No, major issue is residents’ lack of interest in
add related to your community and the preventative health care
health of the residents in your
community?
Other Question? Where does the local Dollar general and farmers market in Opelika,
population get groceries? and a Carmack’s. Some people go to Kroger and
Publix in Auburn
Other Question? What do you believe is Quality of education is not good. Teacher
wrong with the local school system? retention is low, and most families send children
elsewhere for education
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Appendix C

Community Health Nursing Diagnosis Worksheet

Health Problem Nutritional Deficit

Population/Community Adults in Notasulga, AL

Etiological Factors Percent of families below the poverty

line (19.6%), lack of grocery stores

with fresh fruits in vegetables,

Signs and Symptoms of the 53.9% of females are obese and 39.9%

Problem of males are obese

Community Health Nursing Diagnosis

Risk for nutritional deficit in adults in Notasulga, AL as related to 19.6% of

people living below the poverty line and a lack of grocery stores in the area as

evidenced by 53.9% of females and 39.9% of males being obese.

Health Problem Non-Compliance

Population/Community Adults in Notasulga, AL


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Etiological Factors Lack of a local major hospital, lack of a local

major pharmacy, cost of transportation to

hospital/doctors/pharmacies, cost of

medications, percent of families below the

poverty line (19.6%)

Signs and Symptoms of the Key informant’s personal experience, high

Problem rates of chronic illnesses such as heart

disease (330.4%), diabetes (52.7%), and

hypertension (39.5%)

Community Health Nursing Diagnosis

A risk for non-compliance in the young and older adults in Notasulga, AL, as

related to a lack of a local major hospital and pharmacy, the cost of transportation

to the hospital/doctor appointments, the cost of medications, and the percent of

families below the poverty line (19.6%) as evidenced by our interview with our key

informant, and high rates of chronic, preventable diseases such as heart disease and

diabetes.

Health Problem Ineffective health management

Population/Community Adults in Notasulga, AL


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Etiological Factors Our interview with our key informant

talks about how the population doesn’t

go to the doctor until they are very sick,

because of a neglect of preventative

health care, and the rural location of the

community.

Signs and Symptoms of the Informant states, “population with

Problem diabetes doesn’t regularly check blood

sugars”

Community Health Nursing Diagnosis

Risk for ineffective health management in the adult community in Notasulga, AL

as related to a neglect for preventative health care and the rural location of the

community as evidenced by information from our key informant that states,

“people in the community don’t get their blood sugars checked regularly, and

don’t go to the doctor until they are deathly ill.”