Running head: EPIDEMIOLOGICAL STUDY 1

City of Allentown: Epidemiological Study

Jeanine M. Diaz and Serena J. Hatcher

Cedar Crest College

EPIDEMIOLOGICAL STUDY 2

Abstract

An epidemiological study of Allentown, Pennsylvania is addressed in this paper. The community

was assessed initially with a windshield survey and then a data collection assessment was

performed. Insight into the physical city boundaries and residential inhabitants were gained

through subjective observations in the windshield survey. Statistical comparisons is made

between Allentown, or Lehigh County when city data was unavailable, to Pennsylvania in the

data collection. Data collection demographics, socioeconomic status, and health disparities were

analyzed to detect a relevant issue within the community. Data analysis revealed that

hypertension and hyperlipidemia among low-income, high poverty are at greatest risk for

developing heart disease. Evidence-based interventions are discussed to help manage heart

disease as a community.

Keywords: heart disease, evidence-based interventions, community health nursing,

EPIDEMIOLOGICAL STUDY 3

City of Allentown: Epidemiological Study

Heart disease was recognized as a problem area for the city of Allentown, Pennsylvania.

Heart disease or cardiovascular disease is related to arterial plaque build-up that can lead to heart

attack or stroke. Behavioral risk factors of heart disease encompass, sedentary lifestyle, poor

diet, alcohol and tobacco use. “The effects of behavioral risk factors may show up in individuals

as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity”

(World Health Organization, 2017). According to the data provided by the previous windshield

survey and data collection, the problem lies within the social determinants of health. The social

health determinants include the environment and socioeconomic factors (Havarnek, E.P., 2015).

The unbiased observations of Allentown in the windshield survey provided subjective data on

the food availability, housing, and lifestyle. In Downtown and East Allentown, the houses

observed were smaller, aged and weathered, and people were observed walking down the street

or sitting on porches smoking. Most of the food options in Downtown and East Allentown were

fast food, while the Hamilton District had a mixture of chain restaurants and cafes. Data

collection was used to compare Allentown, or Lehigh County when data was not specifically

available for the city, to Pennsylvania to highlight differences. Data on health behaviors,

biophysical, socioeconomic status, and demographics were evaluated to recognize a community

issue. In Lehigh County, with a mortality rate of 84.4 per 100,000 people, heart disease is the

second leading cause of death (Health Care Council of Lehigh Valley, 2016). With morbidity

rates of 30% and 25% in Lehigh County, high blood pressure and high cholesterol are the most

frequent health conditions (Health Care Council of Lehigh Valley, 2012). In Allentown, 18.7%

of residents have less than a high school education with 35.5% maxed out a high school degree,

11.1% earn less than $10,000 a year, 37.3% unemployment rate and a poverty rate of 26.5%
EPIDEMIOLOGICAL STUDY 4

(U.S. Census Bureau, 2010). Less education leads to lower paying labor jobs and inability to

afford healthy food (Havranek, 2015).

Identification of the Community Health Issue

The priority problem in the community is identified as, risk of cardiovascular disease

related to hypertension and hyperlipidemia in the City of Allentown, as evidenced by high rates

of poverty, low-income and low educational attainment that limit food accessibility (Stanhope &

Lancaster, 2014). City residents are at higher risk for heart disease, as the nursing diagnosis

indicates, they are not managing the socioeconomic factors and modifiable health behaviors.

According to the data collection, the presence of dental, children’s, and geriatric clinics, and a

community health and wellness center demonstrates community awareness of the problem.

However, with continued high rates of hypertension and hyperlipidemia, more needs to be done

at the community level to improve outcomes.

Heart disease is problematic for community health due to the high morbidity and

mortality rates (Stanhope & Lancaster, 2014). Healthy People 2020 included heart disease in 23

of the objectives (Stanhope & Lancaster, 2014). Downtown and East Allentown lacks a variety

of food resources. The nursing diagnosis can be supported by a need for community and school

initiatives for individuals at risk for or experiencing heart disease.

Desired Outcomes and Goals

First, there is a need to increase community social support from health care agencies for

families and individuals affected by homelessness. Second, creating a plan through established

guidelines of screening tools to identify individuals at risk for homelessness or unstable housing.

Finally, establishing comprehensive case management services to assist families and individuals

affected by homelessness to achieve stable housing. Primary and secondary interventions

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implement practice at the community-level to improve social support services and resources in

the community. Tertiary intervention implement practice at the systems-level to improve social

support services and resources in the community.

Primary Intervention

Primary intervention is designed to target the healthy food availability and education for

students in urban socioeconomically disadvantaged schools. Nurses in the community health

field collaborate with other community establishments to reach a goal. Therefore, a partnership

with Allentown School District to provide nutritious lunches, beverages and snacks to improve

eating habits among urban students at risk of developing obesity, hypertension, and

hyperlipidemia as they grow up (Guide to Community Preventive Services, 2017). Community

health nurses collaborate with the school district to change community attitudes, opinions, and

food choices.

An educational model is useful to establish significant changes throughout the district.

Therefore, the Shaping Healthy Choices Program (SHCP) by the Supplemental Nutrition

Assistance Program Education (SNAP-Ed) was selected as it helps to educate students on

nutrition, provide fresh fruits and vegetables and promote physical activity (Scherr, 2017). SHCP

is based in Social Cognitive Theory and Social Ecological Model that help to build a healthy

environment through a coordinated approach in the classroom, lunchroom, and community

(Scherr, 2017). The provision of healthier lunches and snacks alone is not as effective as a

comprehensive approach that encompasses nutrition education and promotes physical activity

(Scherr, 2017). This is a multifaceted and low-cost approach that includes, Discovering Healthy

Choices curriculum, Cooking Up Healthy Choices cooking demonstrations in the cafeteria, Team

Up for Families nutrition newsletters, and health fairs (Scherr, 2017). A district wellness
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committee with members from SNAP-Ed, community health nurses, parents, educators, and

administrators should be formed to review and enforce policy.

It is important to initiate SHCP training. The program training would be carried out by

SNAP-Ed. Community health nurses help integrate SNAP-Ed into the district. SHCP is a

California-based intervention model for elementary schools. However, as Allentown School

District is located in Allentown, Pennsylvania, the School Nutrition Policy Initiative (SNPI) is

the Pennsylvania-based intervention model (United States Department of Agriculture, 2016).

SNPI has a similar structure to SHCP designed for elementary and middle schools.

The goal of the intervention is to enhance student knowledge about healthy food choices,

increase fruit and vegetable intake, and decrease body-mass index (BMI). Diet and BMI

modifiable behavioral risk factors for hypertension, hyperlipidemia, and heart disease. It is more

beneficial to prevent chronic disease in children before it starts. The benefits of implementing

SHCP are evidenced-based. In a northern California elementary school that implemented this

program, there was a decrease in BMI of 17% and statistical significant improvement in healthy

food choices (Scherr, 2017). Similarly, community health nurses and the wellness committee

could evaluate the outcome of SNPI by analyzing BMI trends, fruit and vegetable intake, health

fair attendance, and scores on Discovering Healthy Choices curriculum quizzes.

The cost of food and food availability in the community can create a barrier to health

outcomes (Hardin-Fanning & Wiggins, 2017). Ford insecurity can be defined as “the state or risk

of being unable to provide food for oneself or family” (Hardin-Fanning & Wiggins, 2017). Many

families in low-income areas, like Allentown, are dependent on SNAP. However, SNAP has

many limitations. It is not often practical, especially in smaller markets like Elias and C-town in

Allentown, to be able to purchase healthy food options with SNAP (Horning & Fulkerson,
EPIDEMIOLOGICAL STUDY 7

2015). It is the role of the community health nurse to advocate for those low-income families in

the community for policy change. Rather than go by set prices, fresh fruit and vegetable

vouchers could help families afford healthy food options (Horning & Fulkerson, 2015). The goal

of this intervention is to increase the accessibility of whole food options with SNAP. This could

be evaluated monthly by trends of received SNAP vouchers.

The soda tax that has been implemented in various cities around the nation could

encourage healthy beverage choices. In Allentown, financial restraints may dictate grocery store

purchases. Unfortunately, many of the food and beverage choices that are low in nutrients are the

more affordable options (Long, 2015). Soda is a high sugar and high calorie beverage that

increases the risk of diabetes, obesity, and hypertension, all of which increase the risk for heart

disease (Long, 2015). The community health nurse could work with local government to enact

policy change to create the soda tax in Allentown. The goal would be to decrease soda sales and

could be measured by soda sales monthly in the city.

Secondary Intervention

Community health nurses utilize community resources in secondary prevention to

determine health risk factors and recognize community needs (Stanhope & Lancaster, 2014).

Health risk factor screening is the hallmark of secondary intervention, which would not be

possible without community health care agencies to organize outreach events. According to the

data collection, the Allentown Health Bureau in center city Allentown has a mission to “prevent

disease and injury and to protect and promote the public's health” (City of Allentown, n.d.). The

project would offer free blood pressure and lipid screening to the community members to

improve health outcomes and determine those at risk for heart disease.
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Individuals with hypertension and hyperlipidemia are more likely to develop heart

disease (Stanhope & Lancaster, 2014). The U.S. Preventive Services Task Force (USPSTF)

guidelines address the link between hypertension in individuals, 18 years of age or older, and the

increased risk of heart disease with the recommendation of annual blood pressure screenings

(Siu, 2015). Research shows the accuracy of the blood pressure measurement can be altered by

various factors. A calibrated sphygmomanometer with a measurement taken outside of the

clinical setting is shown to be the most accurate (Siu, 2015). Once a partnership is established

by indicating the importance of health care screenings for families and individuals affected by

homelessness, secondary interventions can be implemented. There are discrepancies on

screening recommendations for cholesterol. The USPSTF recommends that men age 35 and

older and women age 45 and older should be screened (Nelson, 2013). However, the American

Heart Association (AHA) recommends that all Americans be screened, especially if hypertensive

or positive for other risk factors (Nelson, 2013).

In the interest of cost, the Allentown Health Bureau could freely screen blood pressure

for any community member, regardless of age. If the individual has a high blood pressure

reading for their age bracket, overweight, or reports a family history of high cholesterol, that

would automatically qualify them for serum lipid testing. The community health nurse can

perform the phlebotomy for the serum lipid panel and obtain blood pressure measurements. The

goal of this intervention would be to discover individuals with hypertension and hyperlipidemia

that increase risk for heart disease. The trend of monthly screenings would measure utilization of

the service.

The advocation for universal blood pressure and lipid screenings in schools, starting in

fifth grade, in America aligns with current recommendations (Cottrell, 2013). The community
EPIDEMIOLOGICAL STUDY 9

health nurse could collaborate with administration to gain parental consent to organize annual

screenings for fifth graders. Children establish their lifestyle habits early that they will carry with

them to adulthood. Ideally, the primary preventions will successfully curb risk factors of

hypertension and hyperlipidemia among children in the community. Those children that would

normally go unnoticed will be identified with the secondary intervention screening (Cottrell,

2013). The aggregate data from all of the screenings can be used to create specific tertiary

interventions for the community.

Tertiary Intervention

When a problem has already happened, tertiary prevention functions to take community

action and to evaluate effectiveness of the program (Stanhope & Lancaster, 2014). Education and

support in small group sessions can be effective for those with heart disease. Research shows the

Chronic Disease Self-management Program (CDSMP) is supportive for individuals with heart

disease (Ahn, 2013). CDSMP helps participants to improve health outcomes by improving

behaviors and preventing hospital readmission (Ahn, 2013). The community health nurse could

facilitate these small-group sessions at a number of community centers around the city. The

Allentown Health Bureau, religious institutions, or the public library to name a few options.

Rotating sites might also provide those without transportation an opportunity to attend.

In Allentown, a land-locked city, going outside for physical activity might be an outdated

prospect. Additionally, when targeting a community of diverse ages from elementary school

through adulthood, unconventionality could be an advantage. In today’s world, technology is

important and revered. Therefore, a Wii exercise videogame could be just the fitness vehicle to

draw and maintain fitness membership (Bock, 2015). The community health nurse could pitch
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this idea to Allentown YMCA as a traditional fitness alternative. The YMCA would be the ideal

location, as they offer financial assistance to families and individuals who qualify. The goal of

this intervention would be to increase physical activity to lower blood pressure, cholesterol

levels, and BMI to lower the severity of heart disease (Bock, 2015). This could be measured by

monthly member check-ins to the YMCA.

In those individuals with hypertension, hyperlipidemia, and heart disease, medication

therapy is not uncommon. However, medication adherence is low among middle-aged adults

(Thakkar, 2016). The use of mobile text messages not only serve as reminders, but also can give

the receiver a sense of accountability to the sender (Thakkar, 2016). These combined effects help

to significantly increase medication adherence among middle-aged adults (Thakkar, 2016). The

community health nurse could be responsible for sending out the text messages. The goal of this

intervention is to increase medication compliance and could be measured by monthly

prescription refills.

Conclusion
Community health nurses find areas of concern amidst community health and partner

with organizations with similar goals. According to the evidence, the community health nurses’

ability to bring interventions to the community and school, help to alleviate the risk of heart

disease. The interventions for the community support continuing progress to challenge present

and upcoming issues (Stanhope & Lancaster, 2014). Community health nurses partner with

service organizations to balance community disparities and strengths and engage the community

members.
EPIDEMIOLOGICAL STUDY 11

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