N492 Module 8 assignment: community assessment paper, a full sample

Ten Blocks Around the Library: A Community Health Assessment of a Small-City Neighborhood Using the Community as Partner Model

Student Name

RN to BSN Program, Aspen University

N492: Community Health I

Instructor Name

Month Day, Year

Ten Blocks Around the Library: A Community Health Assessment of a Small-City Neighborhood Using the Community as Partner Model

A community assessment is the public health nurse's version of a patient assessment: a structured collection of data about a population, its environment, and its resources, used to identify health needs and plan with the community to meet them. This paper assesses a composite neighborhood called Eastside, a residential area of about 6,000 people in a small Midwestern city; the neighborhood, the figures, and the interviews are illustrative and describe no real place or person. The assessment uses both gathered data, meaning existing information from sources such as census and county health reports, and generated data, meaning information the nurse produces directly through observation and interviews. It follows the Community as Partner model (Anderson & McFarlane, 2019), analyzes findings through the social determinants of health, and ends with a community nursing diagnosis and a proposed intervention.

Defining the Community

Eastside is bounded by a rail line to the north, a four-lane state highway to the west, and a river to the south and east, physical boundaries that residents describe as making the neighborhood feel like its own town. Most housing is small single-family homes built in the 1940s and 1950s for workers at a manufacturing plant that closed two decades ago, along with two newer apartment complexes. In the illustrative profile used here, the population is about 55 percent White, 25 percent Hispanic or Latino, and 15 percent Black, with a growing number of older adults aging in place and young families renting. Median household income is well below the city average, and about one in four residents lives below the federal poverty level.

The focal point for the windshield survey is the Eastside branch of the public library, a one-story building at the neighborhood's main intersection. The survey covered ten blocks in each direction from the library, and resources outside that radius were noted with their distance.

The Community Core

In the Community as Partner model, the core is the people: their history, demographics, values, and beliefs (Anderson & McFarlane, 2019). Eastside's history is a working-class one. Many older residents worked at the plant and describe the neighborhood as close-knit, with churches, a union hall, and a corner grocery that anchored daily life. The plant's closure removed stable jobs, the union hall became a storage building, and the grocery closed five years ago. Newer residents include Spanish-speaking families drawn by lower rents, and the two largest churches now offer services in both English and Spanish. Residents interviewed for this assessment valued self-reliance and neighborliness, and both expressed pride in the neighborhood alongside frustration that services have left.

Findings by Subsystem

Physical environment. Housing is modest and mostly maintained, though several homes near the rail line are vacant with boarded windows. Sidewalks are continuous on main streets but broken or missing on side streets. The riverfront park is large and green, with a walking path used heavily in the evenings.

Health and social services. There is no primary care clinic within the survey area. A free clinic operated by volunteers is open two evenings a week in a church basement, and the nearest hospital and federally qualified health center are about three miles away across the highway. A food pantry operates from the same church three mornings a week. One pharmacy, inside a dollar store, fills prescriptions.

Economics. The survey area contains three dollar stores, two convenience stores attached to gas stations, a check-cashing store, and no full-service grocery store. The nearest supermarket is 2.6 miles away. Several small businesses along the main street have closed.

Transportation and safety. Two bus routes pass the library, but buses run every 40 minutes and stop by 7 p.m., and there are no shelters. Many older residents do not drive. Streetlights in the park and on two side streets were out during the evening survey, and a resident noted that people avoid the park after dark.

Politics and government, education, communication, and recreation. Eastside has one city council member and an active neighborhood association that meets monthly at the library. An elementary school sits within the survey area; the middle and high schools are across the highway. Residents get local information through church bulletins, a neighborhood social media group, and the library's bulletin board. Recreation centers on the park, a youth soccer league, and the library, which offers children's programs, computer classes, and free internet access.

Resources Outside the Survey Area

Several important resources lie beyond the ten-block radius, and how residents reach them matters as much as where they are. The nearest supermarket is 2.6 miles west, across the highway, reachable by one bus route with a transfer. The federally qualified health center, which offers sliding-scale primary care, dental care, and behavioral health, is about three miles away on the same route, and its last appointments end before the final bus leaves. The county health department's immunization and sexual health clinic is downtown, about four miles away. A senior center with a congregate lunch program is two miles north, across the rail line, and offers a van only to members who register in advance.

For a resident with a car, none of these distances is large. For an older adult who no longer drives, or a parent with young children and no vehicle, a trip to the supermarket or the health center can take most of a morning. Distance, in other words, is a transportation problem before it is a geography problem, and the assessment treats it that way.

Community Member Interviews

Two community members were interviewed about their perceptions of the neighborhood's health and safety needs and its strengths. The first, the branch librarian, described the library as the neighborhood's living room. Older adults come for the air conditioning in summer, families use the computers to apply for benefits and jobs, and staff are regularly asked health questions they are not trained to answer. She identified isolation among older adults and difficulty getting healthy food as the greatest needs, and named the library, the churches, and neighbors' willingness to help each other as the neighborhood's strengths (personal communication, date withheld).

The second, a volunteer at the church food pantry who has lived in Eastside for 40 years, said that demand has doubled in recent years and that many clients are older adults on fixed incomes and working families who cannot reach the supermarket without a car. She noted that the pantry receives far more canned goods than fresh produce and that clients with diabetes and high blood pressure often ask for foods the pantry cannot supply. She described the neighborhood's greatest strength as "people who still look out for each other" (personal communication, date withheld).

Determinants and Equity in Eastside

Healthy People 2030 groups the conditions that shape health into five domains (Office of Disease Prevention and Health Promotion, n.d.), and Eastside offers an example in each. Economic stability: the loss of the plant and the high share of residents in poverty limit what families can spend on food, housing, and health care, a negative effect on equity. Education access and quality: the elementary school is within walking distance, a positive factor, but older students must cross a four-lane highway to reach school, a safety barrier that falls hardest on families without cars.

Health care access and quality: with no primary care in the neighborhood and limited evening bus service, residents without cars depend on a two-evening free clinic, which widens gaps in chronic disease management. Neighborhood and built environment: the absence of a grocery store, combined with three dollar stores, means that affordable fresh food is hard to reach, while the park is a genuine asset for physical activity that is undermined by broken lighting. Social and community context: strong ties among longtime residents, active churches, and the library are protective, while language barriers and the isolation of older adults who no longer drive are risks.

Taken together, the findings show that Eastside's health risks are concentrated among residents without cars, older adults living alone, and Spanish-speaking families, the same groups least able to reach resources across the highway. Libraries have been described as underused community-level resources for population health because they are trusted, free, and open to everyone, and many already help residents with health information and social services (Philbin et al., 2019). Eastside's library fits that description closely.

Community Nursing Diagnosis and Proposed Intervention

Community nursing diagnosis: Limited access to affordable fresh food and to chronic disease support among Eastside residents without cars, related to the loss of the neighborhood grocery, limited transit, and the absence of primary care within the neighborhood, as evidenced by the lack of a grocery store within 2.6 miles, food pantry reports of rising demand and requests for fresh food, and the librarian's and volunteer's identification of food access as a leading need.

The proposed intervention is a library-based food and health hub developed with the library, the food pantry, the free clinic, and the county health department. It has three parts. First, a weekly mobile produce market in the library parking lot, run in partnership with a regional food bank, accepts nutrition assistance benefits and offers matching dollars for fruits and vegetables. Second, a produce prescription program allows the free clinic's nurse practitioner to write prescriptions for fresh produce for patients with diabetes or hypertension, redeemable at the mobile market. A systematic review and meta-analysis of healthy food prescription programs found increased fruit and vegetable consumption and modest improvements in body mass index and other cardiometabolic measures, although most included studies lacked control groups (Bhat et al., 2021). Third, a public health nurse holds monthly blood pressure checks and nutrition sessions at the library, in English and Spanish, timed with the market.

The nurse's role spans planning, partnership building, direct education and screening, and advocacy. Advocacy includes bringing the assessment to the neighborhood association and city council to request extended evening bus service and repaired park lighting, two low-cost changes that would improve access to both the market and the park.

Evaluation

Evaluation uses measures that partners can collect without new systems. Process measures include the number of market days held, the number of shoppers and benefit transactions, and the number of produce prescriptions written and redeemed. Short-term outcomes include participants' self-reported fruit and vegetable intake, measured with a brief validated screener at enrollment and after six months, and the number of residents screened for high blood pressure and referred for care. Longer-term outcomes, tracked by the free clinic, include changes in blood pressure and hemoglobin A1c among produce prescription patients. The assessment will be repeated in two years, including a new windshield survey and interviews, to see whether the community's own description of its needs has changed.

Limitations of This Assessment

This assessment has limits that shape how its findings should be used. The windshield survey covered a single weekday afternoon and one evening, so weekend patterns and seasonal changes, such as winter isolation, were not observed. Only two residents were interviewed, both connected to established institutions, and the voices of Spanish-speaking families and younger renters are therefore underrepresented. Before the intervention is finalized, the nurse should hold a listening session at the library with Spanish interpretation and invite residents who do not usually attend neighborhood meetings. Gathered data from census and county sources describe the wider area and may blur differences between Eastside and neighboring tracts.

Conclusion

Eastside is a neighborhood with real assets, a trusted library, active churches, a large park, and residents who look out for each other, and real gaps created by economic decline and distance from services. The Community as Partner model organized the findings, the interviews supplied what observation could not, and the social determinants of health showed which residents carry the greatest burden. The proposed library-based food and health hub builds on the community's strengths to address its most pressing need, and it gives the public health nurse a place in the neighborhood where residents already gather. A community assessment is only the first step, but done with the community rather than about it, it points to changes that residents are ready to support.

References

Anderson, E. T., & McFarlane, J. (2019). Community as partner: Theory and practice in nursing (8th ed.). Wolters Kluwer.

Bhat, S., Coyle, D. H., Trieu, K., Neal, B., Mozaffarian, D., Marklund, M., & Wu, J. H. Y. (2021). Healthy food prescription programs and their impact on dietary behavior and cardiometabolic risk factors: A systematic review and meta-analysis. Advances in Nutrition, 12(5), 1944-1956. https://doi.org/10.1093/advances/nmab039

Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Healthy People 2030. U.S. Department of Health and Human Services. Retrieved from https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

Philbin, M. M., Parker, C. M., Flaherty, M. G., & Hirsch, J. S. (2019). Public libraries: A community-level resource to advance population health. Journal of Community Health, 44(1), 192-199. https://doi.org/10.1007/s10900-018-0547-4