Running head: COMMUNITY OF TRINITY HEALTH ASSESSMENT

Community of Trinity Health Assessment

Paloma Garcia Duran, Kyle Garrow, Ashley Graham, Sury Hacker, Alexis Lopez, Kali Robinson
& Adam Trojacek
Sam Houston State University

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Table of Contents
Introduction....1
Assessment of the Community.......4
Windshield Survey.5
Community Demographics.......15
Key Informants Interviews......21
Determinants of Health.....25
Biological Determinants...25
Psychological Determinants.25
Environmental Determinants...25
Sociocultural Determinants.26
Behavioral Determinants.27
Health System Determinants...28
Interpretation of Data..28
Strengths and Weaknesses..28
Health Issues and Concerns28
Nursing Diagnosis..29
Nursing Care Plan..31
Evaluation..37
References.39

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Community of Trinity Health Assessment

Introduction
The community of Trinity has an approximate population of 2,700 and is located in East
Texas within Trinity County. It has an area of 3.8 square miles with two highways intersecting
the middle of the town, highway 19 and highway 94. Trinity is bordered by the town of
Riverside on the southwest side and the town of Lovelady on the northeast side. The town is
identified as a rural area that has the following manmade and natural boundaries surrounding the
community: (a) trees encircling the border towards the north, south, east, and west; (b) rivers on
the outer limits towards the southwest, northwest, north, and east; (c) lakes and ponds towards
the north, east, south, and west; (d) and roads that provide a border on the southwest, southeast,
northwest, and northeast.
The community was founded in 1873 and had a station on the Houston and Great
Northern Railroad with some of the early settlers employed in the lumber and agriculture
industries (Connell, 2010). Today, Trinity is still identified as a rural community where many of
the residents consider it a small town with strong moral and family values. The purpose of this
paper is to determine and identify the specific acute and chronic health issues, available
resources, and determinants of health including vital statistics within the community of Trinity.

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Figure 1. Map of Trinity

Retrieved from https://www.google.com/maps/place/Trinity,+TX+75862/@30.9387507,95.4048465,13z/data=!3m1!4b1!4m2!3m1!1s0x86479843c870b6a9:0x7204f4f01736eb0
Assessment of the Community
Trinity was assessed using direct information and data obtained from a thorough physical
assessment of the city and from several websites. This assessment will be used to help identify
strengths and weaknesses of the community in order to better understand its acute and chronic
health problems. From the assessment, a formal diagnosis and nursing care plan may be set forth
in order to help improve the overall health and well-being of the community.

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Windshield Survey

Figure 2. Welcome sign to Trinity

Environment. The environment immediately surrounding and inside of Trinity is rural
and secluded. The city has limited access roads located off of the main road Highway 19, which
divides the city in half. Although the roads and sidewalks are not in complete disrepair, they are
not readily maintained either. A strong sense of decay or agedness in most of the buildings,
homes, and vehicles is present in the city. The outskirts of town is mainly comprised of trees,
farms and wooded areas. The center of the city, or downtown, is mostly composed of buildings
in need of repair, some closed and some still functioning. Though there are adequate traffic
signals, a general lack of street lights, abundance of trash, and feral animals were observed
throughout the city. Overall, a sense that the community is of a low socioeconomic status can be
felt when walking or driving around the city.

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Figure 3. A side street in Trinitys downtown that is mostly abandoned

Figure 4. Abandoned building in Trinity

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People. Activity both in town and on the outskirts of the community is very limited. Only
small numbers of people were observed walking the streets, going in and out of businesses, or
enjoying the outdoors. The visible individuals are mainly Caucasian and seemingly of a lower
socioeconomic status based on the cars they drive and the types of clothing they wear. Trinity is
mostly a rural and farming community and many people wear hats, jeans, dirty t-shirts, and
boots. Some more scantily clad females wear hand-me-down tank tops and cut off shorts with
flip-flops. From a general observation, the diversity in the community seems limited. Only a few
African Americans and Hispanics are seen in the area, but they are not nearly as prominent as the
white population.

Figure 5. Trinitys city limit sign

Housing. Trinity has a great diversity of housing. The homes range from mobile homes
to brick homes, small bungalows, plantation-styles houses, and historical homes. Most homes are
on the smaller side, around 1500 square feet or less and appear to be single-family dwellings.

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Some houses are run down, falling apart, and in great need of repair. Others are only moderately
kept, and some are remodeled or newly constructed. Still others are vacant and in the midst of
repair or have been abandoned by the owners. Most of the homes and neighborhoods project a
country style of living where yard clutter and falling down porches are part of the norm. The
newly constructed or renovated homes definitely stick out as being unusual for the area. Clearly,
most of the community is of a low socioeconomic status based on the condition and sizes of the
houses.

Figure 6. A newly renovated farm-style home

Figure 7. Abandoned historic home

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Figure 8. Trailer home

Schools. Three schools are present in Trinity: Lansberry Elementary, Trinity Middle
School and Trinity High School. All three schools are part of Trinity Independent School District
and are located within the city limits. The elementary school is in the center of town, while the
high school and middle school are further outside of town, almost at the edge of city limits.
Trinity has no areas for advanced learning, but does have multiple daycares and family centers
for infants, toddlers, and school age children.
Stores/Business/Industry. Many businesses and stores are located around town and
dispersed throughout the community. Trinity has only one primary grocery store, Brookshire
Brothers, and all the rest of the markets and food sources are small stores, usually located within
gas stations and other businesses. Additionally, there are small family owned meat markets and
country grocers. The city offers a great variety of type of businesses: (a) many family owned
non-chain restaurants and bars, (b) chain fast food such as Subway, McDonald's, and Sonic, (c)

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beauty salons, (d) insurance agencies, (e) banks, (f) pet groomers, (g) gas stations, (h) motels, (i)
dollar stores, (j) pawn shops, (k) antique and resale shops, (l) a pecan farm, (m) taxidermy shop,
(n) veterinary office, and (o) steel mill. One notable aspect of the businesses in the community is
the abundance of auto repair, salvage, and sales businesses in the area. Just within a few miles
inside of town, there are over five auto/tractor repair and salvage business. Most of the
businesses and the stores in the community are small, partially run-down, and seem to be family
owned and operated. Few chain or commercial businesses are present in the area.

Figure 9. Main street; entering downtown Trinity

Figure 10. Example of one of the many auto salvage businesses in Trinity

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Figure 11. Example of one of the many auto repair shops in Trinity
Parks and Recreation. Just before entering downtown, there is a large Trinity
Community Center that has a park area with benches and grills, as well as a large recreational
sports field where intramural teams can play baseball, football, and soccer. Also, the Trinity
River runs through the community, providing an abundance of fishing and wildlife activities for
recreation. In addition, Trinity Plantation Golf Course appears to be a popular recreational site
for the few middle and upper class residents of the city.

Figure 12. View of Trinity River

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Figure 13. Trinity Community Center

Health and Social Services. A few miles outside of Trinity, in Riverside, there is a small
medical clinic associated with Huntsville Memorial Hospital that seems to be a common
resource for the residents of Trinity, since there are not many health services available within the
community. Inside Trinity city limits, there is a skilled nursing home, a home health facility, a
Life Check Drug Pharmacy, and the East Texas Medical Center (ETMC) Trinity Hospital. The
hospital offers emergency services (level IV trauma), inpatient and outpatient services, as well as
diagnostic testing and imaging services. Only a few primary doctors offices are located within
the city. In addition, Trinity has one drug rehabilitation facility called House of Hope, but the
city does not offer womens health services or other specialized care facilities. Also, local
churches offer most of the social services in the community and provide relief and counseling for
families or individuals in need. Additionally, the city provides a post office, county clerk offices
and one court.

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Figure 13. East Texas Medical Center Trinity Hospital

Figure 14. Huntsville Memorial Medical Clinic Riverside

Protective Services. Trinity has one police station and one fire station, both of which are
located in the downtown area. The Trinity Police Department, itself, does not appear to have a
heavy presence in the community. However, a high number of county Sheriff and Constable
vehicles are present in the area, which indicates a much heavier presence of higher-power
protective forces.

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Churches. This community has a great number and variety of churches. The churches
include most of the Christian orientations, such as Baptist, Methodist, Catholic, Episcopal, and
Tabernacle. Within the city limits, over 20 churches of all different sizes and denominations are
present. However, there are no Muslim, Buddhist, or Jewish representation in the city, which
indicates a lack of religious diversity outside of the Christian faith, and also indicates a lack of
racial diversity in the area.

Figure 15. Church in Trinity # 1

Figure 16. Church in Trinity # 2

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Community Demographics
According to the 2014 American Community Survey (ACS), 2,755 people live in Trinity
(United State Census Bureau, n.d.). The specific percentages per age range are detailed on Table
1. These percentages indicate that almost one fourth of Trinitys population is under 19 years of
age, meaning that there is a growing young population. However, Trinity has a significant
number of people over 65 years old, 20.3% of the population. In terms of gender, the city is
almost equally divided with 49.2% males and 50.2% females (United States Census Bureau,
n.d.). The races, or ethnicities, of this city are represented in Table 2. These statistics indicate
55.6% of the population is White, followed by 22.8% African Americans, and 21.3% Hispanics,
which means that minorities may be at risk of not being represented in the communitys
government. All these statistics represent biological determinants of health and may have an
impact on the community health of this population.

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Table 1. Trinitys age groups

Age Group

Percentage

Under 5 years

2.4%

5 to 9 years

7.7%

10 to 14 years

7.7%

15 to 19 years

6.0%

20 to 24 years

3.7%

25 to 34 years

7.3%

35 to 44 years

13.0%

45 to 54 years

14.6%

55 to 59 years

6.2%

60 to 64 years

11.1%

65 to 74 years

9.8%

75 to 84 years

7.1%

85 years and over

3.4%

Note. Table information obtained from

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

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Table 2. Trinitys Races/Ethnicities

Race/Ethnicity Group

Percentage

White

55.6%

African American

22.8%

Hispanic or Latino

21.3%

American Indian or Alaska Native

0.2

Asian

0%

Native Hawaiian and Other Pacific Islander

0%

Some other race

0%

Two or more races

0%

Note. Table information obtained from

http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF
In terms of education, the 2014 ACS indicated that 76.4% had an education level above
high school and 5.2% over bachelors degree, with a 4% imputed of educational attainment. The
average income in terms of education was estimated as: (a) $12,096 for those with less than high
school graduate, (b) $32,578 if high school, (c) $27,090 if some college, (d) $34,375 if at least a
bachelors degree. Of those people of and over 25 years of age, the poverty status determined by
educational attainment level was: (a) 19.9% less than high school graduate, (b) 12.1% high
school graduate, (c) 11.1% some college or associates degree, and (d) 0% bachelors degree or
higher. However, the highest percentage of at least bachelors degree educated people was found
among the population of 65 years of age and over (United States Census Bureau, n.d.). These
statistics indicate that the number of people with higher levels of education are not only limited
but also retired from the workforce. In addition, the lower the education level, the higher the risk
of being impoverished, with the exception of having some college education. Estimated statistics

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indicated that those with a high school diploma earned more than those with some college or
associates degree. All these data represent sociocultural determinants of health.
The statistics regarding employment derived from the 2014 ACS. This survey estimated
that 57.4% of the Trinitys population was in the labor force and 4.5% were unemployed. 81% of
Trinity workers commuted to their workplace, 15.3% carpool, and 3.6% used other means.
According to the 2014 ACS, no one worked at home, or walked or used public transportation to
commute to work. The type of occupation and industry in Trinity by percentage of workers is
represented in Table 3. The distribution regarding class of worker was: (a) 69.5% private wage
and salary workers, (b) 22.2% government workers, and (c) 8.2% self-employed in own not
incorporated business workers (United States Census Bureau, n.d.). These statistics are part of
the sociocultural determinants and indicate that the majority of the workers of Trinity work for a
salary, mainly in the service sector, and the number of business owners is low.

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Table 3. Trinitys Employment per Industry

Industry

Percentage

Agriculture, forestry, fishing and hunting, and mining

6.1%

Construction

6.9%

Manufacturing

4.8%

Wholesale trade

2.3%

Retail trade

10.7%

Transportation and warehousing, and utilities

8.6%

Information

1%

Finance and insurance, and real estate and rental and leasing

3.4%

Professional, scientific, and management, and administrative and waste

management services

2.8%

Educational services, and health care and social assistance

9.3%

Arts, entertainment, and recreation, and accommodation and food

services

32.6%

Other services, except public administration

0.4%

Public administration

11.2%

Note. Table information obtained from

http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF
The mean household income of Trinity residents was estimated to be $53,736 yearly, the
family income was $73,796, and the individual income was $19,888. When ranging the incomes
among Trinitys population, the percentages are as follow on Table 4. These percentages indicate
that most of the total household incomes were below $75,000. In addition, these incomes
originated from: (a) 66.3% earnings, (b) 45.7% Social Security, and (c) 21.9% retirement. A
significant number of the population received part of their income from the government: (a)
12.9% from supplemental security income, (b) 2.6% from cash public assistance income, and (c)

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11.9% from Food Stamps/SNAP benefits. These numbers regarding federal economic assistance
and the average income indicate that the majority of Trinity population belongs to the low
socioeconomic status. In fact, the 2014 ACS estimated that 13.1% of all the families in Trinity
and 17.9% of all individuals were below the poverty level, with children constituting the
majority of this number (United States Census Bureau, n.d.). All these statistics related to the
populations income represent sociocultural determinants of health.
Table 4. Trinitys Population Incomes
Income and Benefits

Percentage

Less than $10,000

10.3%

$10,000 to $14,999

14.6%

$15,000 to $24,999

13.9%

$25,000 to $34,999

15.5%

$35,000 to $49,999

12.6%

$50,000 to $74,999

10.2%

$75,000 to $99,999

9.8%

$100,000 to $149,999

4.8%

$150,000 to $199,999

4.8%

$200,000 or more

3.4%

Note. Table information obtained from

http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF
Regarding to the housing types, Trinity housed 1,071 households, of which 660 were
owned and 411 rented. 1,694 people lived in owner-occupied housing units with an average
household size of 2.57. 1,003 people lived in renter-occupied housing units with an average
household size of 2.44. The vacancy rates were 1.3 for homeowner housing and 10.8 for rental.

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The total average family size was 3.24. By looking at a breakdown of housing by type of
occupancy, the number of families was 645, and 267 of those families had children under 18
years of age. 374 were husband-wife families, 62 were male householder only, and 209 were
female householder only. 131 households in the husband-wife subsection had children under 18,
28 in the male only, and 108 in the female only. The number of nonfamily households was 426,
in which 361 live alone. A total of 157 males lived alone and 50 of those were males 65 years
and older. 204 women lived alone and 103 of those are > 65 years of age (United States Census
Bureau, n.d.). These numbers indicate single motherhood is prominent in Trinity by constituting
a 32.4% of the total families. In addition, 14.3% of the households are occupied by elders living
alone, which constitutes a risk for these individuals. These statistics represent environmental and
sociocultural determinants of health.
In terms of healthcare insurance coverage, estimated in the 2014 ACS are the following
numbers. 53.8% of the population in Trinity had a private health insurance coverage and 35% a
public coverage. 25.8% of the total population remained uninsured (United States Census
Bureau, n.d.). Thus, these health care determinants of health statistic indicate that one quarter of
the population in Trinity did not have health care insurance which may limit their access to
healthcare, especially at the primary prevention level.
Key Informants Interviews
Three interviews were performed about the community of Trinity. The informants were
asked the same questions and were provided with information about the purpose of the interview
and agreed to disclose the information shared. Two of our informants agreed to disclose their
names, however, one of them was kept confidential.

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Informant interview #1 Monique Huntley from HMH Medical Clinic Riverside.

What resources are already available in the community? There arent enough health
services in Trinity. If patients need specialized treatments that arent offered in Riverside/Trinity
they have to go to Huntsville, and if Huntsville doesnt offer them, they have to go even further
sometimes as far as Conroe, Houston, or Livingston. Many times patients dont have the
resources to go further either they dont have steady transportation or the money to travel long
distances. There is this clinic, a small hospital, and a few doctors offices. Even though this is a
rural area, I feel there could be more specialized care offered.
What are the main healthcare needs of the community and/or population? There
definitely needs to be more specialized care and education for problems such as diabetes,
hypertension, and generalized health care problems that are easily prevented if people
understand how the problems occur and how to prevent them. There also needs to be more
education and care for people with pain management and drug addiction problems. That is a
huge problem in this community that rarely gets addressed.
What are the weaknesses of the community? Overall, the largest thing that this
community lacks is education. It is a major weakness of the community because many people
either dont understand how to be proactive about their own healthcare or they dont know what
to do for general health problems Many times we see people coming in for ailments that just
need to take their own course, such as a virus. They think they need to come to the clinic for
things like this but really they just need to learn how to take better care of themselves on a daily
basis. Also, there needs to be more knowledge about the resources that are available to them
often times people dont know these clinics are available when they do have legitimate health
concerns and they go untreated. Also, a special point for me is womens care. I dont believe

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there is enough care specifically for women in this area and Id really like to move the clinic to
doing more work in that area.
What are the strengths of the community? The clinics and doctors that are available are
in a small town, so the relationship between the patients and the providers are generally relaxed
and friendlier the providers generally remember their patients and see them on a regular basis.
For instance, I have a friendly discourse with a large percent of my patients. They are never just
numbers to me. There is an understanding of the types of communication between patient and
provider that makes it easier for patients to come to me and talk to me in a way that they know I
will understand, and in turn, I am able to communicate with them in a way they understand.
Informant interview #2 Deandra from HMH Medical Clinic Riverside.
What are the main healthcare needs of the community and/or population? It varies a lot,
its difficult to say which health care needs are more common. Because it is such a small town,
people seek care for treatment of chronic illnesses, seasonal sicknesses, and follow-ups and the
age range can go from children to older adults.
What are the weaknesses of the community? Well, because it is a small community,
sometimes it seems like the amount of people that use drugs is high, and may make some people
think is an unsafe place to live. But I have never had any safety issues or concerns.
What are the strengths of the community? One of the things I like the most about Trinity
is that as a small community. As you can see, we all become familiar with the faces we see, we
really get to know the people around us. You cannot go to the store or the gas station without
seeing somebody you know.

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What resources are already available in the community? We have a small clinic, few
stores, gas stations, and several churches. Unfortunately, if I ever need to go to a big grocery or if
anyone needs to go to the hospital we need to drive to Huntsville. All the kids go to the same
elementary, middle school, intermediate school and high school.
Informant interview #3 Patient from Conroe Regional Hospital.
What are the main healthcare needs of the community and/or population? We have the
EMTC clinic in town, some of my friends go there to receive care. But if you need specialized
care like I do, you have to go the the hospital in Huntsville or come here. I fell down when I was
at home; I hit the left side of my chest and that caused my lung to collapse. I was transferred here
to the Emergency Department. It is unfortunate to have to commute this far to receive care, but
sometimes it also has to do with the type of insurance you have. I live on my own and I hope I
can build up the strength to get back on my feet and care for myself.
What are the weaknesses of the community? Not having many options of services
available, such as stores and clinics or hospitals.
What are the strengths of the community? Fortunately, even though as seniors we are
not the largest population, we do have a center where we get to meet other seniors, eat lunch, and
play games. I also have few friends that come to my house and play cards two to four times a
week. It is easy to get to know people in the community because we see each other all the time. It
is nice to have people to talk to when I go to the store and to be called by my name.
What resources are already available in the community? We have the senior center, a
clinic, stores with basic supplies, gas stations, and some fast food restaurants. The good thing is
that my daughter lives in Huntsville, she comes once or twice a week to check on me and takes
me to the store or wherever I need to go if its something I cant find in town.

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Determinants of Health
Biological determinants. Biological determinants of health are factors that influence
health and illness; these factors are aging, genetics, and physiological functions (Clark, 2015).
As indicated in the statistics section, almost a quarter of Trinitys population is under 19 years
old and another quarter over 65 years of age, meaning that half of the population may not work
because of age. In addition, according to City-Data (2016), approximately 24% of the adult
population is obese. This high incidence of obesity places a large part of the community at risk
for comorbidities, such as diabetes, hypertension, and cardiovascular diseases. Also, the United
States Census Bureau (n.d.) estimated that Trinity had a disability rate of 19.4% for those under
the age of 65 years between 2010 and 2014.
Psychological determinants. Psychological determinants include incidence and
prevalence of psychiatric disorders along with stress levels the population is experiencing and
how they cope with it (Clark, 2015). Obesity and other health problems tend to trigger or link
psychological health issues, such as depression and low self-esteem. Due to the large percentage
of obesity in the community, residents are at higher risk to suffer from these disorders. Also,
unemployment and poverty place the residents of Trinity at a higher risk for psychological
disorders related to high amounts of stress within the community. Regarding security, the
citizens of Trinity feel safe; one interviewee revealed I have never had any safety issues or
concerns.
Environmental determinants. Environmental determinants include location, type of
community (rural urban, or suburban, and size), climate, type and adequacy of housing, nuisance
factors, and any potential for disasters (Clark, 2015). After assessment of the environmental
factors, it was determined that Trinity is a small rural community near Huntsville, Texas. The

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housing within Trinity ranges from aged brick homes or broken down wooden shacks to mobile
RV homes. The community is mainly comprised of wooded areas and large farms. The
community lacks adequate sidewalks which inhibits city members from participating in activities
such as running and riding their bike safely. Throughout the community, litter and trash can be
found outside stores, homes, and businesses. In addition, the community has a high nuisance
factor of stray animals that contribute to feces in personal yards and community areas. During
assessment, the weather was 88 degrees and sunny and the residents of Trinity were dressed for
the most part appropriate for the weather, mostly in jeans and t-shirts, or tank tops and shorts.
Sociocultural determinants. Sociocultural determinants include language, employment
levels and occupation, income and education levels, family composition and marital status,
government/leadership, religion, transportation, and availability of goods and services (Clark,
2015). During observation of the community of Trinity and performed interviews, a lack of
goods and services were noticed. According to the 2014 ACS, language within the community is
mainly English with an 81.1% of the population. The other 18.9% of the population speaks
Spanish. In addition, 28% of those Spanish speakers have a low level of English proficiency.
These numbers suggest that a language barrier may be present within the community (United
States Census Bureau, n.d.). As seen previously in the statistics section and from the windshield
survey, Trinity has a high prevalence of poverty. Estimations indicate that 17.9% people in
Trinity are below poverty level. For those who do work, jobs consist primarily of labor force jobs
including farming. Residents travel by means of a car or walking locally with a average commute
time of 31.3 minutes (United States Census Bureau, 2015).

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Behavioral Determinants. Behavioral determinants of health are the personal behaviors

prevalent in the population that may interact with elements of the physical environment to cause
or exacerbate health problems, such as drug and alcohol use, exercise, and diet. (Clark, 2015). As
mentioned above in an interview with Deandra from HMH Medical Clinic Riverside, substance
abuse regarding drugs and alcohol is a behavioral factor that has negatively impacted the
community. The use of drugs and alcohol is a behavior that has an impact on every age group in
the community, whether it be first time users in the high school population or adults exposing the
abuse of alcohol and drugs in front of their young children. Due to the high prevalence rates of
substance abuse in the adult population, it has become a recurrent theme in Trinity that may
cause the younger population to partake in this behavior. The development of this behavior in the
younger population may lead to a lower amount of teens graduating high school compared to
other communities in Texas. Although the education system and various organizations teach the
population about the impact of substance abuse has on them and their families, this addicting
behavior still occurs in the Trinity community.
According to the Texas Department of State Health Services (2013) approximately 30%
of the population was considered obese in Trinity. This statistic is considered to be average for
the state of Texas. Factors contributing to this behavior are poor diets and lack of places to
exercise. In Trinity, the majority of the restaurants are either fast food chains, such as
McDonalds and Churchs Chicken or southern style mom and pop restaurants that serve a
variety of fried foods both of which contribute to poor diet choices. The gyms located in Trinity
are Curves and a mixed martial arts gym, but both lack adequate space for everyone in the
community to use.

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Health System Determinants. Health system determinants include factors related to the
health care delivery system that may affect the environment or the population (Clark, 2015).
Trinitys population includes 26.6% of residents who are under the age of 65 and without health
insurance (United States Census Bureau, 2015). This can hinder patient care if residents need
serious medical attention, especially for those below the poverty line. Medical resources that are
available to the community of Trinity include Avalon of Trinity, ETMC, and Trinity Memorial
Hospital. Avalon of Trinity is a nursing home as well as a rehabilitation center that is located on
the south side of the city. Trinity Memorial Hospital and ETMC are facilities that provide
services, such as a surgery center, emergency departments, inpatient care, radiology, and
laboratory work. These hospitals accept Medicare, Medicaid, and various other insurances,
which helps the out of pocket cost for healthcare for those who have insurance. Trinity County
also provides a service that helps people who are having trouble accessing health care. This
program is called Trinity County Indigent Health Care Program. As mentioned in the interviews
section, another problem the city has is the need of transportation for specialized treatments that
can suppose travel distances over 50 miles.
Interpretation of Data
Strengths and Weaknesses
The city of Trinity has several strengths. Three of the citys strengths are: (a) a strong
sense of community in the area manifested with all the businesses being family owned and
operated and habitants pointing that as an strength of the city, (b) a high number of churches,
which promote good morals and a tight, knit community, and also offer many social services and
free assistance for families in need, and (c) a great number of residents raising their own animals
and food, which allows them to participate in outdoor activities, such as hunting and fishing.

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Conversely, several weaknesses were identified in the city. One of these weaknesses is
the lack of access to fresh quality food, primarily meat and produce, for those who do not raise
and grow it themselves. Many of the small grocers and country stores only offer processed foods
and have a limited selection of fresh fruits and vegetables. Another weakness is the lack of
access to healthcare, in terms of general and specialized medicine. Most members of the
community would actually must leave the city in order to obtain health care. A third weakness is
the high presence of low socioeconomic status in the area which gives rise to decay and disrepair
of businesses and homes in the community. These signs of abandonment may represent a risk for
the community in terms of physical accidents that may hurt the residents of the town.
Health Issues and Concerns
The group identified the main health issues and concerns using direct data obtained from
HMH Medical Clinic Riverside. Within the clinic, the acute health problems that are most
prevalent are urinary tract infections and motor vehicle accidents/injuries. In addition, several
chronic health problems are prevalent in Trinity. Obesity, chronic obstructive pulmonary
disorder, diabetes, cardiovascular disease, cerebrovascular disease, congestive heart failure, drug
abuse, and hypertension are the most prominent medical conditions that put this population at
risk for other comorbidities and higher mortality rates.
Nursing Diagnosis and Level of Preventative Care
After assessment of data, two nursing diagnoses were identified in Trinity. The first
diagnosis is that the population of Trinity is at risk for increased incidence of obesity related to
lack of resources as evidenced by a high number of fast food restaurants, lack of available
facilities for physical exercise, lack of specialized healthcare resources, healthy grocery
establishments, 30% of the population being obese, and 19.9% of the population in poverty. The

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second diagnosis is that the population of Trinity is at risk for contamination related to poor
living conditions as evidence by housing in need of repair, trash in yards and around businesses,
nuisance of stray animals, and high prevalence of low economic status.
Primary prevention as defined by Clark (2015) is, the intervention aimed at preventing
health problems from occurring (p. 24). The most important part of primary prevention is
teaching. This allows the nurse to inform the community about lifestyle choices, such as proper
diet and exercise to prevent obesity. The community nurse can teach the community how a clean
environment can enhance living conditions and prevent illnesses from frequently occurring.
Primary prevention is a key aspect to improving the conditions of Trinity.
Secondary prevention as stated by Clark (2015) is characterized as focusing on the early
identification and treatment of existing health problems and occurs after the health problem has
arisen (p. 24). Secondary prevention is important because screening can allow for early
detection of prominent morbidities throughout the community and allow for the nurse to mitigate
the effects of the disease. Screening the population would help bring attention to the prevalence
of obesity, hypertension, and its effects on lifestyle. Through health fairs, community nurses
could implement both primary and secondary levels of prevention by performing blood sugars
screenings and blood pressure screenings, as well as teaching regarding proper nutrition and
exercise.
Tertiary prevention is an activity aimed at returning the client (individual or population)
to the highest level of function and preventing further deterioration in health (Clark, 2015, p.

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24). Through tertiary prevention, nurses can optimize the lives of the community members by
improving the effects of obesity and contamination. One important aspect of a community nurse
is to advocate for the community. Community nurses can advocate for a community by voicing
concerns about lack of available resources to optimize health. A community nurse in Trinity can
advocate for more grocery establishments with fresh products and safe places for physical
activity, such as adequate sidewalks and fitness centers. Also, advocating for maintenance crews
to decrease yard clutter throughout the community that will ultimately decrease the risk for
contamination.
Nursing Care Plan
After assessing the city of Trinity, two community goals were set: (a) healthy patterns of
eating will be identified and promoted within the community and (b) physical activity strategies
will be established and maintained within the community. To achieve these goals, two outcomes
and eight interventions were planned. The outcomes established for Trinity are that its
community members will demonstrate a change in eating patterns and will engage in regular
physical activity. Both outcomes are intended to be attained within one year of the plan
implementation.
One of the interventions designed for this community will be to educate the community
on healthy nutrition by implementing a nutritional education program. This intervention
addresses the behavioral determinant of health because the members of the community would
identify their current dietary practices and make changes as needed to incorporate healthy food
options. Also, this intervention addresses the primary level of prevention because educating the
community on nutrition focuses on preventing unhealthy eating habits that can result in health

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complications, such as obesity and hypertension. This intervention was chosen because in a
study by Meethien et. al (2011), a 3-month nutritional education program was implemented with
results concluding those who received the program had significantly healthier overall eating
habits, as well as healthier food selection, food preparation, and food consumption behaviors,
one week and 12 weeks after the program completion (p. 197).
A second intervention will be the implementation of discussion sessions to allow
community members to learn from each other and to adapt their eating behaviors. This
intervention addresses the psychological determinant of health because community members
could discuss how they perceive food as either a reward or a symbol of love and affection. In
addition, this intervention addresses the secondary level of prevention because the focus is on
identifying bad eating habits and changing them to become good eating habits. Discussion
sessions would be 45-60 minutes in length and consist of teaching community members about
the MyPlate nutrition guide, the 2015-2020 Dietary Guidelines for Americans, essential
nutrients, healthy food choices, food preparation, benefits and barriers to healthy eating, and how
to interpret nutrition fact labels. After the discussion is concluded, community members would
interact and give their viewpoints on the information they received and if it proved valuable to
them. This intervention design was based on the study by Meethien et. al (2011), which stated
that individuals are more likely to take on a recommended health promoting behavior if they
perceive the benefits of that behavior and if those perceived benefits outweigh the perceived
barriers (p. 198).
The third intervention will be to include family participation in healthy eating behaviors
to promote and maintain good nutritional intake of community members. This intervention
addresses the sociocultural determinant of health because culturally accepted modes of behavior

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that are specific to the community can be discussed by family members. Also, this intervention
addresses the secondary level of prevention because the focus is on treating obesity by changing
eating habits in a positive direction. The community nurse should emphasize the importance of
family support on eating behaviors, roles and responsibilities of family members in supporting
healthy eating, types of support needed, and strategies for providing support. The community
members should understand that making lifestyle changes regarding eating habits is influenced
significantly by the interpersonal relationships they share with family and friends. According to
Meethien et. al (2011), family members can assist by, solving problems and overcoming
barriers, adjusting menu plans, setting realistic goals, self-evaluation, and
performing/maintaining healthy eating behaviors (p. 198).
The fourth intervention will be to promote community access to healthy foods by
advocating for healthier food options through local churches. This intervention addresses the
behavioral determinant of health because the dietary practices of the community members will
be enhanced rather than undermined and would result in a positive adaption of eating habits.
Also, this intervention addresses both primary and secondary level of prevention because by
advocating for healthier food options for community members it focuses on preventing the
residents from making bad choices if there is ample supply of nutritious food and it replaces
unhealthy food choices with healthy choices, thus changing eating habits from bad to good. After
contacting local church representatives, a monthly donation cycle could be established with the
proceeds going towards healthy food options. Once the food items were purchased and collected,
items could be given out to community members that chose to engage in the activity. Gracias
(2013) stated that with collaboration with representatives of three neighborhood churches, a
monthly donation cycle was developed so that low-fat dairy, eggs, fresh fruits, and vegetables

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would be available to residents. The church resource proved to be a viable option to increase
healthy food access (p. 94).
The fifth intervention will be to create point-of-decision prompts, to include visual signs,
that encourage use of stairs by community members. This intervention addresses the behavioral
and sociocultural determinants of health because physical activity practices may be instilled in
those community members that lacked a physical activity regimen and the typical attitudes of the
residents would be emphasized since utilization of stairs scarce compared to utilization of
elevators. In addition, this intervention addresses the secondary level of prevention because the
aim is to reduce the obesity rates in the community by encouraging members to take the stairs
rather than the elevator to get physical activity. The text on the visual signs should include
information about the health and weight loss benefits of using the stairs and serves as a reminder
that stairs are available for use. According to the CDC (2011), there is strong evidence that
point-of-decision prompts are effective in increasing the number of people who choose to use the
stairs (p. 9).
The sixth intervention for Trinitys community will be to promote regular physical
activity within the community by implementing a nurse-monitored exercise training program
(ETP) in a local park or open outside area. This intervention addresses both the environmental
and behavioral determinant of health because the ETP would be done on terrain in the physical
environment within the community and it would allow for implementation of physical activity
regimens in the community members. In addition, this intervention addresses the tertiary level of
prevention because the focus is on restoring the health status of community members that are
obese and preventing further deterioration of their health. An ETP plan could be established
within the community and residents should participate in at least 3 sessions weekly. Each session

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would consist of: (a) walking for 10 minutes with intensity 4050% of maximum heart rate (b)
walking for 30 minutes with intensity 5565% of maximum heart rate (c) walking for 10 minutes
with intensity 4050% of maximum heart rate and (d) stretching for 10 minutes. The rationale
behind this intervention is based on the study by Rey-Moya et. al (2012) which concluded, over
40% of women who undertake a programmed ETP are likely to continue adhered to some such
programme at one year and that the likelihood of such adherence increases with the number of
ETP sessions completed during the intervention period (p. 2119).
The seventh intervention will be to establish a community-wide campaign that addresses
multiple levels of influence, including individual, interpersonal, institutional, and community
levels to promote physical activity. This intervention addresses the sociocultural, behavioral,
psychological, and health system determinants of health because societal attitudes, societal
norms, the internal and external psychological environment, exercise practices, availability,
accessibility, affordability, and adequacy of health institutions within the community would be
the focus of the campaign in order to promote physical activity. Also, this intervention addresses
the primary and secondary level of prevention because the campaign would focus on preventing
the various negative influences from impacting community members to make unhealthy lifestyle
behaviors in regards to physical activity and it would focus on identifying existing influences
that drive residents to not engage in physical activity. Strategies included in the campaign are the
following: (a) build support for new behavioral patterns by creating social support networks or
using existing social networks, (b) reinforce behavior through self-reward and positive self-talk,
(c) problem solve geared to maintain behavior change, (d) explore residents accessibility and
affordability to local health institutions for regular checkups in order to determine if their
lifestyle changes are being proven effective in reducing their obesity (e) verify that the adequacy

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of local health institutions are acceptable in regards to providing services that are tailored to
serve community members that are obese, and (f) prevent relapse into sedentary behaviors.
According to the CDC (2011), community-wide campaigns, are designed to promote and
eliminate barriers and have been found to be more effective than each single component (p. 13).
The last intervention will be to advocate for street-scale urban design and land-use
policies and practices support physical activity within the community. This intervention
addresses the environmental determinant of health because the focus is on advocating for
improvements in the physical environment within the community. In addition, this intervention
addresses the secondary level of prevention because the focal point is treating the existing
problem of obesity in the community by improving environmental structures in order to
encourage residents to engage in physical activity. Strategies to enhance the physical
environment to foster physical activity includes: (a) improving street lighting, (b) increasing ease
and safety of street crossings, (c) introducing or enhancing traffic calming, (d) enhancing the
aesthetics of the streetscape, and (e) ensuring sidewalk continuity. According to the CDC (2011),
street-scale urban design and land-use policies and practices may increase environmental
supports, such as safety, walkability, improved sense of community, decreased isolation, and
reduction in crime and stress (p. 29).
For those interventions that involve educating the population, there are several strategies,
which are based on the assessment function of public health, that will be taken into consideration
when designing the teaching plan. For children, games and role play would be included in the
teaching plan as tools to maximize the learning of this group. For adolescents, focus groups
would be organized to allow them to set appropriate diet and goals independently. For older
adults, ten-minute lectures would be provided on a weekly basis in the mornings to increase their

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information retention. For the working population, online sources and pamphlets would be
designed. All information administered in written form would be written on a fifth grade level
because of the low academic achievement present in this community (Clark, 2015).
Evaluation
Part of the planning of the nursing care plan for Trinity includes setting strategies to
evaluate the achievement of goals and outcomes. Because the nursing care plan set for Trinity is
to be achieved in one year, the plan would be evaluated during and after implementation of the
interventions. During implementation, the evaluation of the plan would consist on evaluating
public engagement in the interventions. For example, monitoring the number of participants in
subsequent forums. In case the number of participants decreases drastically, evaluation of the
reasons of lack of participation should be evaluated. Conversely, if the number of participants
increases beyond the amount expected to participate, it would signify an engagement of the
population. Another strategy that could be used to evaluate the plan is to provide surveys to the
target population. In such surveys, participants could express their opinions regarding the
interventions and make suggestions for any improvements.
At the end of the plan, the evaluation would be more objective than during
implementation of the interventions. For example, changes towards health patterns of eating
could be identified by assessing the number of healthy food products that were consumed on
average by the community members. These final numbers could then be compared to the initial
numbers to see if there was an improvement in food selection. In addition, the pre and post
incidence and prevalence rates of the most common health conditions, such as diabetes,
hypertension, and obesity, could be compared to see if there was a reduction in the rates of those
chronic conditions. Also, life expectancy would be impacted by this plan and is another rate that

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could be compared. Other data that can be compared is the utilization of local gyms before and
after implementation of the interventions. This comparison would be directed towards the second
goal, establishment of physical activity strategies.
Finally, this plan would be reevaluated yearly to see if the residents continued their
adapted healthy lifestyle choices. If they did not, the plan could be either implemented again or
modified. Long term maintenance of healthy lifestyle would indicate that the plan was successful
and new goals could be set for the community in order to improve the community members
quality of life.

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References
Centers for Disease Control and Prevention. (2011). Strategies to Prevent Obesity and Other
Chronic Diseases: The CDC Guide to Strategies to Increase Physical Activity in the
Community. CDC. Retrieved from:
http://www.cdc.gov/obesity/downloads/PA_2011_WEB.pdf
City-Data. (2016). Trinity, Texas. City-Data. Retrieved from
http://www.city-data.com/city/Trinity-Texas.html
Clark, M. J. (2015). Population and community health nursing. (6th ed.). Hoboken, NJ: Pearson.
Connell, S. (2010). Trinity, Texas (Trinity County). Texas State Historical Association.
Retrieved
from https://www.tshaonline.org/handbook/online/articles/hjt10
Gracias, M. J. (2013). A nursing intervention to improve nutrition for health promotion for a
vulnerable urban adult group. Doctoral Dissertation. Paper 11. Retrieved from
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Meethien, N., Pothiban, L., Ostwald, S. K., Sucamvang, K., Panuthai, S. (2011). Effectiveness of
nutritional education in promoting healthy eating among elders in Northeastern Thailand.
Pacific Rim Int J Nurs Res, 15(3), 188-202. Retrieved from http://www.tcithaijo.org/index.php/PRIJNR/article/view/6502/5654
Rey-Moya, L. M., Castilla-lvarez, C., Pichiule-Castaeda, M., Rico-Blzquez, M.,
Escortell-Mayor, E., & Gmez-Quevedo, R. (2013). Effect of a group intervention in the
primary healthcare setting on continuing adherence to physical exercise routines in obese
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Texas Department of State Health Services. (2013). Obesity in Texas. Texas Department of State

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Health Services. Retrieved from

https://www.dshs.state.tx.us/obesity/pdf/Obesity_In_Texas_InfographicV5-accessible.pdf
United States Census Bureau (2015). Quick facts Trinity County, Texas. United States Census
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http://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml