Population Health Assessment and Prevention Project

Sample Answer

Part I Windshield Survey

Component Windshield Survey – Boundaries

Assessment

Gilroy city is located south of Morgan Hill and north of San Benito. It is centrally located at the southern gateway to Silicon Valley County.

Component Physical Characteristics

Assessment Findings

Community Existence Gilroy is a city in Northern California’s Santa Clara County. The city’s origin lie in the village of San Ysidro that grew in the early 19th century out of Rancho San Ysidro, granted to Californio ranchero Ygnacio Ortega in 1809.

Demographic Data In 2021, Gilroy had a population of 58.8k people, representing 3% of Santa Clara County. It has a median age of 35 years. From 2020 to 2021 the population of Gilroy, grew from 55,227 to 58,802, a 6.47% increase.

The five major ethnic groups in Gilroy, CA are White (Hispanic) (28.8%), White (Non-Hispanic) (26.7%), Two+ (Hispanic) (16.2%), Other (Hispanic) (12.1%), and Asian (Non-Hispanic) (9.69%). From the windshield survey, I see Americans, Hispanics, Indians, African Americans, and Asians.

We have a variety of nationalities. On the west side of town, there are more middle-class people. On the hillside, there are more financially stable. There are homeless people by the levy and on the edges of the freeways.

How Does the Community Look The community has police officers, nurses, retired people, and work from home that work for tech-savvy companies such as Google and Yahoo.

There is a hairstylist who works from home, on my block. There is white nationality, Hispanics, Asian, and Indian families. There are homes that are between 10-30 years old, and the houses still look nicely groomed and the neighbor hoods are clean, with clean yards and there is no trash on the streets.

Some buildings are accessible to people in wheelchairs and kept up and all stores have street-level accessible. The buildings are mostly full and occupied. There are coffee shops where young people and middle-aged people spend time together.

However, this is not the best location in town because it is right in downtown Gilroy. Nonetheless it is the older part of the town. It is very well kept up, and plenty of seating areas.

Component Psychosocial Characteristics

Assessment Findings

Religion The city has a historical church building built in 1857. There are about six modern churches and one mosque.

Health & Social Services There is a one main county hospital, St. Louise hospital. There are several clinics such as Valley Health Center, Bay Area community health, Gardner South County Health Center, Foothill Medical Clinic, Gilroy Neighborhood Health, Concetra Urgent Care, and general doctor offices.

I do see childcare facilities, one childcare facility just closed due to the government not having the funds for the facility. But there are several home childcares. The hospital is accessible to the community because in California, there is medical for the less economic status.

I do see homeless shelters at the South County Compassion Center and Gilroy Winter Shelter National Guard Armory. But it operates on first come first serve basis. The closest abuse shelter is about 30 miles away called next door solutions to domestic violence.

There is a food bank called Saint Joseph’s Family Center. There is a welfare office offering services for families in need on the eastern side of town. There are shopping centers mostly, and some liquor stores.

Economy The businesses in the city are major grocery stores, some family-owned businesses, and some chain businesses such as Starbucks, or 7/11. It is a thriving community, except the older part of Gilroy, is struggling due to economic status.

There are shopping centers on the East, south and middle of Gilroy. There is also an LGB farm, which is a family-owned business and offers vegetables and pies. Transportation There is only on one main road which passes through the center of Gilroy but not through neighborhoods. There are a lot of taxis or people using Ubers. Buses are the main form of public transport.

Safety

• The city has police officers dedicated to courageously ensuring the safety of the community.

Politics & Government

• This is a charter city operating under the guidance of an elected City Council consisting of 7 members.

Communication / Media

• The city has radio stations and a weekly local newspaper called the Gilroy Dispatch.

Education

• There are 14 public schools in the Gilroy Unified School District and five private schools.

Recreation There are so many parks within each neighborhood. The park is always full of young families and teenagers or older people walking around the tennis courts and exercising.

There is diversity as the neighborhoods have changed for the better. There are also restaurants where they serve the best tacos, pizza places, and a bowling alley where people like to drink and hang out.

Values The community is founded on the values of respect, integrity, accountability, and sustainability.

Part II County Health Data

• Go to https //www.countyhealthrankings.org/explore-health-rankings
  Review the data on the Robert Wood Johnson (RWJ) website and enter the values for your county and state as demonstrated below.
  
• For each indicator/cause of death Find one (1) inter-professional resource that delivers programs or provides information to address each key indicator.
• The resource should be from either an agency/facility in your county or from your own state Department of Public Health (SDPH), which you can find by searching here https //www.usa.gov/state-health.

List Your STATE California

List Your COUNTY Santa Clara

Demographics

Key Indicators Enter Data for your County & State List one resource* (county or state) for this key indicator. Include name of program/service and address (web or physical building)

Note: This is resource to address the key indicator not the source of the demographic data.

Example % Rural

Health data for Rural Health https

• //www.alabamapublichealth.gov/ruralhealth/health-data.html
• % < 18 years/age 20.3%

City of Gilroy California

• https //www.cityofgilroy.org/355/About-Gilroy
  

Gilroy City Hall

7351 Rosanna Street

• % 65 & older 15.1% City of Gilroy California
  
• https //www.cityofgilroy.org/355/About-Gilroy
  

Gilroy City Hall

7351 Rosanna Street

• % Non-Hispanic African American 2.4% City of Gilroy California
  
• https //www.cityofgilroy.org/355/About-Gilroy
  

Gilroy City Hall

7351 Rosanna Street

• % Hispanic 24.7% City of Gilroy California
  
• https //www.cityofgilroy.org/355/About-Gilroy
  

Gilroy City Hall

7351 Rosanna Street

• % not proficient in English 9% City of Gilroy California
  
• https //www.cityofgilroy.org/355/About-Gilroy
  

Gilroy City Hall

7351 Rosanna Street

• % Females 48.9% City of Gilroy California
  
• https //www.cityofgilroy.org/355/About-Gilroy
  

Gilroy City Hall

7351 Rosanna Street

• % Rural 1.3% City of Gilroy California
  
• https //www.cityofgilroy.org/355/About-Gilroy
  

Gilroy City Hall

7351 Rosanna Street

List the FIVE (5) LEADING CAUSES OF DEATH under age 75for your County. Look underHealth Outcomes then Premature Death (click on (i) to find the 5 leading causes of death in your county)

List one resource

(county or state) for each cause of death.
Include name of program and address (web or physical building)

This is a resource to address the cause of death. Example If car accidents was listed as one of the top five leading causes of death in your county, a resource to address might be safe driving initiatives in the county or educational programming to reduce impaired driving. Include the name and physical or web address.

• Chronic Lower Respiratory Disease Breathe California
  Website www.lungsrus.org
  1469 Park Avenue, San Jose, CA 95126
  
• Suicide Santa Clara County Public Health Department
  https //data-sccphd.opendata.arcgis.com/
  
• Firearm Related Deaths Santa Clara County Public Health Department
  https //data-sccphd.opendata.arcgis.com/
  
• Cancer Santa Clara County Public Health Department
  https //data-sccphd.opendata.arcgis.com/
  
• Coronary Heart Disease Right Care Initiative
  Center for Healthcare Organizational & Innovation Research
  1995 University Avenue
  

QUALITY OF LIFE & HEALTH OUTCOMES

Key Indicators Enter Data for your County & State List 1 resource* (county or state) for each key indicator; include name of program & web address / physical address (if available)

Note: This is resource to address the key indicator not the source of the demographic data.

Life expectancy Female- 84.8

• Male-81.4 Santa Clara County Public Health Department
  https //data-sccphd.opendata.arcgis.com/
• Low birthweight 7% Santa Clara County Public Health Department
  https //data-sccphd.opendata.arcgis.com/

Child Mortality 3900 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Diabetes Prevalence 1.48 million Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

HIV Prevalence 3,361 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

HEALTH BEHAVIORS

Key Indicators Enter Data for your County & State List 1 resource* (county or state) for each key indicator; include name of program & web address / physical address (if available)

Note: This is resource to address the key indicator not the source of the demographic data.

Adult Smoking 7% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Adult obesity 19% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Physical Inactivity 17% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Excessive Drinking 15% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Alcohol-impaired driving deaths 23% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Sexually transmitted infections 268.0 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Teen births 7 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Limited access to healthy foods 9.3 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Drug overdose deaths 1 per 100,000 people Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Motor vehicle crash deaths 23% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

CLINICAL CARE

Key Indicators Enter Data for your County & State List 1 resource* (county or state) for each key indicator; include name of program & web address / physical address (if available)

Note: This is resource to address the key indicator not the source of the demographic data.

Primary Care Physicians 930 1 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Dentists 780 1 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Mental health providers 230 1 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Preventable hospital stays 1893 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Mammography screening 37% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Flu Vaccinations 51% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Uninsured Adults 4% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Uninsured Children 4% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

SOCIAL & ECONOMIC FACTORS

Key Indicators Enter Data for your County & State List 1 resource* (county or state) for each key indicator; include name of program & web address / physical address (if available)

Note: This is resource to address the key indicator not the source of the demographic data.
High school completio8 89% Santa Clara County Public Health Department
https //data-sccphd.opendata.arcgis.com/

Unemployment 2.6% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Children in poverty 7% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Children in single-parent households 16% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Injury Deaths 44 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Homicides 55 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Suicides 1,474 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Firearm fatalities 6% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

PHYSICAL ENVIRONMENT

Key Indicators Enter Data for your County & State List 1 resource* (county or state) for each key indicator; include name of program & web address / physical address (if available)

Note: This is resource to address the key indicator not the source of the demographic data.

Severe housing problems 22% Silicon Valley At Home

• https //siliconvalleyathome.org/resources/santa-clara-county
  

350 W Julian St. #5, San Jose, CA 95110
Drinking water violations Yes Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Air pollution / particulate matter 9.2 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Driving Alone to Work 64% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Long Commute to Work 40% Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Traffic Volume 82-86 Santa Clara County Public Health Department

• https //data-sccphd.opendata.arcgis.com/

Home Ownership 64.6% Silicon Valley At Home

• https //siliconvalleyathome.org/resources/santa-clara-county

350 W Julian St. #5, San Jose, CA 95110

Severe housing cost burden 30% Silicon Valley At Home

• https //siliconvalleyathome.org/resources/santa-clara-county

350 W Julian St. #5, San Jose, CA 95110

Broadband access 70,000 Silicon Valley At Home

• https //siliconvalleyathome.org/resources/santa-clara-county

350 W Julian St. #5, San Jose, CA 95110

Other (any additional environmental concerns?)

Part III Community Member Interviews

• Component Community Member Interviews
• Community Member 1 Community Member 2 Community Member 3

Name John Clay

Position Grocery Store Owner

Contact Information Click or tap here to enter text.

Health/Illness Beliefs, Values, Attitudes and Practices

Believes healthy dietary patterns are key to good health.

• Community Strengths
• Access too healthy foods.
• Overall good infrastructure.
• Community Needs
• Better policies on firearms possession.

Level of Safety

• 7/10

General Concerns

• Increased suicide rates among young people.
• Name Mary Johnson
• Position High school teacher
• Contact Information Click or tap here to enter text.

Health/Illness Beliefs, Values, Attitudes and Practices

• Health education is crucial to changing lifestyle behavior among young people.

Community Strengths

• Good access to healthcare facilities.
• Accessibility to physical exercise facilities.

Community Needs

• Health education programs to increase knowledge and change behavior.

Level of Safety

• 8/10

General Concerns

• Increasing unhealthy behavior among teenagers and young adults.
• Name Peter Gray
• Position Insurance agent
• Contact Information Click or tap here to enter text.

Health/Illness Beliefs, Values, Attitudes and Practices

• Peter believes that access to health insurance is fundamental to a healthy community.

Community Strengths

• Access to well-equipped and staffed healthcare facilities.
• Access to nutritious foods.

Community Needs

• Policies to increase access to health insurance for low-income persons.

Level of Safety

• 8/10

General Concerns

• Increasing uninsurance rates in both children and adults.
• Summarize Findings (Complete on Template)

This should be a fully developed summary that shows analysis of the interviews from a population health perspective. The interviews from the community members reveal that residents of Santa Clara County have access to healthy foods, physical exercise facilities, and health care facilities.

Besides, the community has an overall good safety. However, interventions are needed to curb the increasing health uninsurance rates, suicide rates, and unhealthy behaviors among young people.

Part IV Population Health Prevention Strategies

POPULATION HEALTH PREVENTION STRATEGIES

• Identify indicators that present the greatest risks to population health across the lifespan for your state and county.
• Describe one evidenced based prevention strategy from government resources such as HP 2030, the CDC, or journal articles. Select sources

published within the past 5 years; cite using APA guidelines.

• Hint–look here first https //www.countyhealthrankings.org/take-action-to-improve-health
  
• Provide enough information to show you understand the recommended strategy. Clearly identify the specific population group and the strategy. Give specific information about what nurses can do to be most effective.

AGE GROUP

• KEY INDICATOR county / state data
• SPECIFIC POPULATION TARGETED
• DESCRIBE THE PREVENTION STRATEGY
• (Identify if it is primary, secondary, or tertiary)

AREAS TARGETED FOR STRATEGY

• DESCRIBE WHAT NURSES CAN DO
• REFERENCE IN APA FORMAT

PREGNANT WOMEN AND INFANTS

Severe maternal morbidity African/African Ancestry mothers Primary Providing preconception personal support, health promotion, and free antenatal, intrapartum, and postpartum services to African –American women of reproductive age. Healthcare facilities providing maternal services. Inform women of the free services and guide them on how to access the services and their benefits.

• Abraham, J. M., & Melendez-Torres, G. J. (2023). A realist review of interventions targeting maternal health in low- and middle-income countries. Women’s Health (London, England), 19, 17455057231205687. https //doi.org/10.1177/17455057231205687

CHILDREN

• Poor asthma self-care Children 5-10 years Tertiary Providing health education on self-management for asthma like allergen prevention and environmental hygiene. Outpatient clinics for child respiratory diseases. Educate parents and children on self-management measures to control asthma and prevent attacks. Liu, W. Y., Jiesisibieke, Z. L., & Tung, T. H. (2022).
• Effect of asthma education on health outcomes in children a systematic review. Archives of Disease in Childhood, 107(12), 1100–1105. https //doi.org/10.1136/archdischild-2021-323496

TEENS

Unhealthy sexual behavior Male and female teenagers 13-19 years Primary Providing comprehensive sexuality and contraception education to both male and female teenagers. Youth and Sexual reproductive health services clinics.

Planning and implementing education programs on sexual reproductive health and providing contraceptive methods. Mohamed, S., Chipeta, M. G., Kamninga, T., Nthakomwa, L., Chifungo, C., Mzembe, T., Vellemu, R., Chikwapulo, V., Peterson, M., Abdullahi, L., Musau, K., Wazny, K., Zulu, E., & Madise, N. (2023).

Interventions to prevent unintended pregnancies among adolescents a rapid overview of systematic reviews. Systematic Reviews, 12(1), 198. https //doi.org/10.1186/s13643-023-02361-8

WORKING AGE ADULTS

Sedentary lifestyle Working adults in office jobs. Primary Providing health education on lifestyle interventions like changes in diet and increasing physical activity. Community healthcare centers and organizations.

Educate adults on how to incorporate healthy dietary patterns and physical exercises in their lifestyle. Fruh, S., Williams, S., Hayes, K., Hauff, C., Hudson, G. M., Sittig, S., Graves, R. J., Hall, H., & Barinas, J. (2021). A practical approach to obesity prevention Healthy home habits. Journal of the American Association of Nurse Practitioners, 33(11), 1055–1065. https //doi.org/10.1097/JXX.0000000000000556

SENIOR ADULTS

over 65 years Ineffective diabetes self-care measures Older adults diagnosed with diabetes. Tertiary- Health education on measures to maintain optimal glucose levels to prevent complications linked to chronic hyperglycemia. Diabetes outpatient clinics. Educate senior adults with diabetes on self-care measures to help attain optimal blood glucose control and prevent diabetes complications.

These include education on diet, physical activity, foot care, cessation of smoking, and reducing alcohol intake. Celli, A., Barnouin, Y., Jiang, B., Blevins, D., Colleluori, G., Mediwala, S., Armamento-Villareal, R., Qualls, C., & Villareal, D. T. (2022). Lifestyle Intervention Strategy to Treat Diabetes in Older Adults A Randomized Controlled Trial. Diabetes Care, 45(9), 1943–1952. https //doi.org/10.2337/dc22-0338

Part V Collaborative Community Planning

Component Collaboration with Community Healthcare Team Member

• Community Health Member
  
• Name Charles Clarke
  
• Position Senior Community Health Worker
  
• Contact Information Click or tap here to enter text.
  
• Phone Click or tap here to enter text.
  
• Email Click or tap here to enter text.

Choose one prevention strategy listed in Part IV and develop a community diagnosis

Health risk for diabetes-related complications among senior adults above 65 years related to ineffective self-care as evidenced by poor glucose control.

What possible solution did you identify to address the targeted need?
Provide health education on self-care interventions to lower blood glucose levels and prevent complications.

Develop 1 expected outcome in the form of a measurable objective – delineate who, what, and when (outcome objective, process objective, management objectives).

By the end of six months, senior adults with diabetes will have attained optimal glycemic levels through self-care interventions.

Delineate 2 evaluation strategies (to determine if the intervention was successful).

Evaluate senior adults’ knowledge scores of the recommended self-care interventions for diabetes.

Evaluate glycemic levels of senior adults who have undergone education on diabetes self-care.

Identify potential resources/partners needed to address targeted need (list a minimum of 3).

Dietitians to provide health education on diet for diabetes patients.

Podiatrists to educate patients on foot care.

Community-based clinics for regular blood glucose screening.

References

• Abraham, J. M., & Melendez-Torres, G. J. (2023). A realist review of interventions targeting maternal health in low- and middle-income countries. Women’s Health (London, England), 19, 17455057231205687. https //doi.org/10.1177/17455057231205687
  
• Celli, A., Barnouin, Y., Jiang, B., Blevins, D., Colleluori, G., Mediwala, S., Armamento-Villareal, R., Qualls, C., & Villareal, D. T. (2022). Lifestyle Intervention Strategy to Treat Diabetes in Older Adults A Randomized Controlled Trial. Diabetes Care, 45(9), 1943–1952. https //doi.org/10.2337/dc22-0338
  Fruh, S., Williams, S., Hayes, K., Hauff, C., Hudson, G. M., Sittig, S., Graves, R.
• J., Hall, H., & Barinas, J. (2021). A practical approach to obesity prevention Healthy home habits. Journal of the American Association of Nurse Practitioners, 33(11), 1055–1065. https //doi.org/10.1097/JXX.0000000000000556
  
• Liu, W. Y., Jiesisibieke, Z. L., & Tung, T. H. (2022). Effect of asthma education on health outcomes in children a systematic review. Archives of Disease in Childhood, 107(12), 1100–1105. https //doi.org/10.1136/archdischild-2021-323496
  
• Mohamed, S., Chipeta, M. G., Kamninga, T., Nthakomwa, L., Chifungo, C., Mzembe, T., Vellemu, R., Chikwapulo, V., Peterson, M., Abdullahi, L., Musau, K., Wazny, K., Zulu, E., & Madise, N. (2023). Interventions to prevent unintended pregnancies among adolescents a rapid overview of systematic reviews. Systematic Reviews, 12(1), 198. https //doi.org/10.1186/s13643-023-02361-8