Professional Documents
Culture Documents
Community-As-Partner Report
Introduction
project based on the Community-As-Partner (CAP) model within the Census Tract (CT) 38.01.
This project enabled us to assess the community and implement a needed nursing intervention
based on our findings. We began our assessment of the community at the end of January, by
conducting a windshield survey and key informant interviews, along with the use of nursing
diagnosis and created a program plan for an intervention based on the major stressor we
identified. This paper provides in-depth descriptions of each step of our community assessment
To assess the Core of the CAP Model within this community, we implemented the use of
nursing informatics to identify that the total population within CT 38.01 is 3,486 people. This
community has over twice the number of Hispanic or Latino residents than Pima County, and
Spanish is the predominant language spoken within this area. Compared to Pima County, almost
four times the number of people in this CT speak only Spanish at home. In the small community
that is CT 38.01, there are various ethnic food stores and restaurants, such as meat markets and
Hispanic food trucks. When completing our windshield survey, we observed a few community
members dressed in cowboy boots and hats, and many others in jeans and a T-shirt (Pima County
When assessing the Physical Environment of this community, it is important to note that
the boundaries of CT 38.01 are West President St, South 7th Ave, West Irvington Rd, and South
12th Ave. This CT has a larger percentage of older homes compared to Pima County. There is
COMMUNITY-AS-PARTNER REPORT 3
also a larger percentage of 1-unit structures and a smaller percentage of three or more unit
structures or mobile homes in this CT than in Pima County. From our windshield survey we
noted that there were a few vacant and boarded up structures on each street, trash in the yards of
some of the homes, and a few abandoned cars. Not only were there trees at the small park located
in the middle of the CT (Rodeo Wash Park), but there were also some trees within people’s
yards. However, there is more concrete than plants within the landscape of the Rodeo Wash
Park. (Pima County Health Department Public Health Nursing Community Profile CT 38.01,
2018).
The next subsystem of the CAP model being discussed is Health and Social Services. The
closest hospital to CT 38.01 that is available to the public is Banner University Center South,
which provides a large array of services, such as mental health and women’s health. Located at
the Richard Ortiz Barker Regional Complex, there are many health and social services available
to this community including a Senior Center, El Rio Health Center, and Clinica Amistad. The
Senior Center provides socialization, nutrition services, and support to senior citizens. El Rio
Community Health Center is a medical clinic that provides various services, including behavioral
health. Clinica Amistad is a free medical clinic for low-income and uninsured members of the
community. Other social services available at this complex include the City of Tucson
Community Services Department, Emerge Center, and the Department of Economic Security.
Within one to two miles outside of this CT this community has access to an urgent care,
pharmacy, dentist, and a food bank. Another resource for this community is the Theresa Lee
Public Health Office (Pima County Health Department Public Health Nursing Community
When assessing the subsystem of Education, it was identified that there is a greater
percentage of people living in CT 38.01 with an education less than ninth grade, than in Pima
County. This CT is within the Tucson Unified School District. For kindergarten through eighth
grade, half of this CT goes to CE Rose Elementary School, while the other half goes to Hollinger
Elementary School. All of this CT is in the attendance zone to attend Pueblo High School. One
of the many educational resources for the people in this community is the El Pueblo Library,
which is located right across the street from this CT (Pima County Health Department Public
There are several resources within this CT that fall into the Recreation subsystem of the
CAP Model. The El Pueblo Activity Center, located in the Richard Ortiz Barker Regional
Complex, contains multiple indoor basketball courts, a gym with a weight room, an indoor track,
a pool, and other various sport rooms, all of which are open to the community. The El Pueblo
Center also contains the Senior Center which provides recreation for seniors. In addition, El Rio
Community Health Center offers various exercise classes. Located across the street from the El
Pueblo Center, the Rudy Garcia Park has several play structures, baseball fields, softball fields,
soccer fields, picnic areas, and ramadas. In addition to this park, there is also the Rodeo Wash
Park that is right in the middle of CT 38.01. This is a very small park with only one play
structure, a half-court basketball court, and a water fountain that does not work (Pima County
Safety was a common theme brought up in many of the key informant interviews, which
is another subsystem within the CAP Model that we assessed. The Tucson Police Department
(TPD) Sergeant, at the South Tucson Santa Cruz Substation, spoke about the high burglary rate
in the area. He said he has seen up to 13 homes get broken into in the same day. TPD and Tucson
COMMUNITY-AS-PARTNER REPORT 5
Fire Department (TFD) are both less than two miles from our CT. While conducting our
windshield survey, we noticed almost every house had at least one beware of dog sign, private
property sign, or no trespassing sign, and there were about two Neighborhood Watch signs on
each street. According to the CrimeReports website statistics, there were 11 violent crimes, 25
property crimes, and 29 quality of life crimes, in this CT between January 19, 2018 and February
2, 2018. Additionally, there are four registered sex offenders in this CT (Pima County Health
In regard to the Transportation subsystem, this CT is located across the street from the
Roy Laos Transit Center. There are four bus routes along the south boundary of this CT,
including covered bus stops on the west and south boundaries. In the neighborhood, there are not
many sidewalks and no designated bike lanes. However, there are sidewalks and bike lanes on
the south and west boundaries of the CT. The roads within the neighborhood have many potholes
and roundabouts. Since this CT is bound by two major streets, Irvington Road and 12th Avenue,
there is a concern for pedestrian safety and motor vehicle accidents (Pima County Health
The Economics subsystem greatly affects the community within this CT. The median
household income in Pima County is almost double the amount in this CT. Similarly, the
percentage of all people living in poverty in CT 38.01 is more than twice that percentage in Pima
County. In terms of businesses in this CT, we found that there are a large number of fast food
restaurants in or near this CT. There are also a number of convenience stores, gas stations, liquor
stores, bars, restaurants, and laundromats in or near CT 38.01. There are no farmers markets,
community gardens, or health food stores within a close distance to this CT (Pima County Health
When assessing the Politics and Government subsystem, we identified that CT 38.01 is
within Tucson city limits and the majority of the CT consists of the Wakefield Neighborhood.
During our windshield survey, we did not see any signs of political activity. This CT is within
US Congressional District 3 with the representative being Raul Grijalva (Pima County Health
The last subsystem of the CAP Model that we assessed was Communication. From our
windshield survey we did not see any newspapers or payphones, however there is a free phone
tent on Irvington Rd. We noted one billboard along 12th Ave advertising for We Buy Ugly
Houses and Law Tigers and a billboard along MacArthur St advertising for the MacArthur Street
Apartments. The closest free Wi-Fi access is located at El Pueblo Library (Pima County Health
Community Strengths
While assessing the community, we identified three major strengths this community
encompasses including family, pride, and resources. A majority of the key informants mentioned
how important family is to this community. Many of the key informants also expressed how even
though the residents struggle with poverty, they take pride in what they do have and what they
have accomplished. One of the firefighters at the TFD stated that most of the people living in the
area are “resilient, family oriented, and take pride in what they do” (personal communication,
January 26, 2018). Through the windshield survey and some of the key informant interviews, we
found that the community has access to many resources. CT 38.01 is located right across the
street from the El Pueblo Center, El Pueblo Library, and El Rio Health Center, along with many
more services. The manager at El Pueblo Activity Center noted that there are “a lot of resources
COMMUNITY-AS-PARTNER REPORT 7
for the community, a little bit of everything for everyone” (personal communication, January 26,
2018). All three of the identified community strengths were common themes brought up in a
majority of the key informant interviews and validated while interacting with the community.
Community Stressors
The three most critical stressors we identified for CT 38.02 are diabetes, nutrition, and
poverty. Almost all of our key informants commented on diabetes being one of the major health
concerns in this community and how many of them struggle with managing their diabetes. A
firefighter at the local TFD commented that “someone could be missing a foot and they still
don’t check their sugars regularly,” (personal communication, January 26, 2018). Nutrition was
also identified to be a major stressor based on key informants reporting that unhealthy diets are
common in this community. The school nurse at CE Rose Elementary school noted that “we
have a kindergartner here that is 135 pounds,” (personal communication, January 26, 2018). This
stressor was further reinforced when we found a large number of fast food restaurants and no
health food/organic food markets in the area during our windshield survey. Poverty was
recognized as being a critical stressor by both the key informant interviews and the American
Community Survey. The percentage of all people living in poverty in CT 38.01 is more than
twice that percentage in Pima County and the median household income in CT 38.01 is half that
Care Table, which is included in Appendix A. Based on this table and our community
assessment, we identified diabetes as one of the most critical stressors in this community and one
that we have the ability to address. We formulated the following community nursing diagnosis
COMMUNITY-AS-PARTNER REPORT 8
for this stressor: risk for health complications from diabetes, among adults within the 38.01 Pima
County CT, related to lack of knowledge about diabetes management, insufficient funds to buy
healthy foods, and medication noncompliance, as evidenced by windshield survey data of 13 fast
food restaurants near/within the CT and lack of healthy food options within the immediate area, a
poverty level of 43% within the CT (compared to the Pima County poverty level of 19.1%), and
key informants reporting the community’s inability to afford necessary medications and an
increased number of calls to the Fire Department regarding hypo/hyperglycemia (U.S. Census
Bureau, 2018).
Good Goal
The Good Goal we developed to address this nursing diagnosis was to increase the
knowledge base about diabetes management among the adult population within the 38.01 Pima
County CT. The intervention for our goal was to educate adults on February 16, 2018, at the El
Pueblo Library right outside of the 38.01 Pima County CT about healthy food options in order to
Evidence-Based Article
approach would be the most beneficial way to educate adults about diabetes management.
adults in South Korea conducted by Lee, Song, and Im (2017), “health literacy can help [...]
randomized controlled trial (RCT) in South Korea that was completed with 51 adults who were
diagnosed with diabetes. The purpose of this study was to determine how taking into
COMMUNITY-AS-PARTNER REPORT 9
consideration the participants’ health literacy level affects the amount of knowledge the
participants gain from diabetes self-management education (Lee et al., 2017). Out of the seven
presentation, this RCT falls into the level II evidence category (Goldsmith, 2018). We applied
this evidence to our health education project by completing our poster board at a basic health
Our project was directed towards Healthy People 2020’s (HP2020) overarching goal of
“promoting quality of life, health development, and healthy behaviors across all life stages”
(U.S. Department of Health and Human Services, 2018a). The topic area applicable to our
project is Diabetes with the goal being “to reduce the disease burden of diabetes mellitus (DM)
and improve the quality of life for all persons who have, or are at risk for, DM,” (U.S.
Department of Health and Human Services, 2018b). The HP2020 objective that supports our
project is D-14, which is to “increase the proportion of persons with diagnosed diabetes who
receive formal diabetes education,” (U.S. Department of Health and Human Services, 2018b).
Policy/Legislation
The Minority Diabetes Initiative Act H.R.2351, was introduced to Congress on May 4,
2017. This bill is currently being considered by committees before it is sent on to the House and
Senate as a whole. The purpose of this bill is to authorize grants to provide treatment and
education on diabetes prevention and management (Civic Impulse, 2018). Our health education
project correlates with bill H.R. 2351 since we provided education on diabetes management to
the public.
SMART Objectives
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We developed two SMART objectives in order to help us evaluate the impact of our
health education project. The first objective was to provide education on diabetes management
through diet modification to a minimum of 15 adults at the El Pueblo Library on February 16,
2018. Our second objective was to have 75% of the participants report that they learned
something new about diabetes management after the presentation on February 16, 2018.
Program Plan
In order to implement the health education project, we developed the following program
activity statements:
1. By February 12th, 2018, the student nurses will schedule a time with the manager
library.
2. By February 14th, 2018, the student nurses will finalize the teaching plan for the
3. By February 15th, 2018, the student nurses will finalize the diabetes management
To evaluate the project, we counted the number of adults who stopped at the booth,
counted the number of people who took handouts, and asked each participant “have you learned
anything from this booth?” on February 16, 2018. This form of evaluation includes the
evaluation methods of observation and survey (Anderson & McFarlane, 2015). This evaluation
Collaboration
Throughout this project, we collaborated with multiple community partners. For example,
after every week we emailed our assigned Public Health Nurse (PHN) with updates on our
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progress and project presentation details. Additionally, we conducted key informant interviews
by coordinating set appointments and walk-ins with various members of the community without
difficulty. We encountered some challenges when scheduling the location and time of our health
education project. The information on resources that we distributed to those who stopped at our
poster board was provided to us from multiple PHNs at the Public Health Department.
Levels of Prevention
Our project was directed to prevent further health complications in individuals with
(McFarlane & Gilroy, 2015). This level of prevention correlates with the recovery or disability
stage of the natural history of disease (Centers for Disease Control and Prevention, 2012).
To complete our health education project, the required and available resources were
For our health education project, we educated the public about small diet modifications
for diabetes management utilizing a poster board and including handouts. We ended up
COMMUNITY-AS-PARTNER REPORT 12
interacting with 16 community members. It was a challenge to catch people’s attention at first,
but after moving closer to the entrance of the library, we were able to engage with more people
than we anticipated. The community was open and willing to learn about diabetes management,
and was respectful. The visual aids that were used during our health education project are
Following the health education that we provided, we evaluated the impact of our
intervention by asking the participants “Have you learned anything from this booth?” and
keeping record of their responses. Additionally, we kept a running tally of the number of
participants that visited our project, and those who took a handout. There were 16 people who
attended our project, 15 of which who stated that they learned something. This means that
93.75% of the 16 participants gained knowledge from our project, and therefore both of our
objectives were met. Since our evaluation method was face to face, one challenge that we
encountered was the possibility of acquiring skewed data due to response bias.
Throughout the completion of the CAP project, we gained insight on PHN as a whole. By
completing the windshield survey and key informant interviews, we learned that place truly does
matter. We also identified that while the CT of 38.01 has multiple stressors affecting the
community, there are also many strengths that have a lasting impact on the residents. If we were
to repeat the health education project, we would recommend establishing a sit down class rather
than a booth in order to provide health education. After completing our Community Profile and
evaluating our health education project, we emailed the results to our assigned PHN and the PHD
Nurse Manager.
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References
Anderson & J. McFarlane (Eds.), Community as partner: Theory and practice in nursing
Centers for Disease Control and Prevention [CDC]. (2012). Lesson 9: The natural history and
https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section9.html
Civic Impulse. (2018). H.R. 2351 — 115th Congress: Minority Diabetes Initiative Act. Retrieved
from https://www.govtrack.us/congress/bills/115/hr2351
https://d2l.arizona.edu/d2l/le/content/640851/viewContent/5589434/View
Lee, S. J., Song, M., & Im, E. O. (2017). Effect of a health literacy-considered diabetes self-
Anderson & J. McFarlane (Eds.), Community as partner: Theory and practice in nursing
Community Survey 5 year estimates [Census Tract 38.01, Pima County, Arizona].
Retrieved from
https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?fpt=table
U.S. Department of Health and Human Services. Office of Disease Prevention and Health
COMMUNITY-AS-PARTNER REPORT 14
Promotion. Healthy People 2020. (2018a). About health people. Retrieved from
https://www.healthypeople.gov/2020/About-Healthy-People
U.S. Department of Health and Human Services. Office of Disease Prevention and Health
Promotion. Healthy People 2020. (2018b). 2020 topics and objectives. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes
Running head: COMMUNITY-AS-PARTNER REPORT 15
Appendix A
Total score
health concern Pima outcome(s)
expression students’ of resources HP2020 Ideas for nursing intervention
or problem, County’s without
of interest in ability to relevant for Determinant (Use Minnesota Wheel)
(stressor, risk Health effort to
addressing address addressing of Health
factor, need, Needs address
problem2 problem problem category
determinant) Assessment1 problem
Note. 1 Score 1 point if consistent with report findings as a concern in Pima County. Score 2 points if 1 of Pima County’s 4 priority areas: Anxiety and
Depression; Substance abuse; Injuries and accidents; Diabetes. From “Pima County Health Needs Assessment Snapshot”. 2Community Expression of Interest
(second column) is double weighted to emphasize its importance. Key: 0 = low, 1 = moderate, 2 = high. Adapted from “Community Health Diagnosis in
Nursing” by M. A. Muecke, 1984, Public Health Nursing, 1, p. 31; and “Community Assessment and Evaluation” by G.F. Shuster, 2010, in M. Stanhope and J.
Lancaster (Eds.) Foundations of Nursing in the Community, Communitcy-Oriented Practice, 3rd ed., p. 232. St. Louis: Mosby/Elsevier/Evolve.
Running head: COMMUNITY-AS-PARTNER REPORT 16
Appendix B
Evaluation Tool
√√√√√√√√√√√√√√√√
√√√√√√√√√√√√√√
Yes: √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
No: √
COMMUNITY-AS-PARTNER REPORT 17
Appendix C
Appendix D
Appendix E
COMMUNITY-AS-PARTNER REPORT 20
Appendix F
Running head: COMMUNITY-AS-PARTNER REPORT 21
Appendix G
Running head: COMMUNITY-AS-PARTNER REPORT 22
Appendix H
Running head: COMMUNITY-AS-PARTNER REPORT 23
Appendix I