Windshield Survey to Identify a Population and its Primary Health Concern

NUR 492 Windshield Survey

COMMUNITY NAME AND LOCATION ASSIGNED IN CLINICAL: – Borough Park

PLACE:  Borough Park, as a community, has manmade borders with Maimonides Medical Center, located at 4802 Tenth Avenue, Brooklyn, NY 11219, serving as the main acute care health facility.  On the whole, health care facilities, including a hospital, doctors, dentists, and even specialists, are all available within the borders of the Borough Park community, and all health facilities are all accessible by car and public transportation, including subways and buses.  

I noted limited garden landscaping and very few animals while walking through the community.  The lack of space for landscaping lessens the threat of poisonous plant availability or soil to threaten children and animals with plant or soil borne disease.  Similarly, I saw only a few stray cats, and no dogs or rats limiting the possibility of disease spread through animals.    

There are numerous private schools in, and surrounding, zip code 11219 but only a few public schools.  I found no reports of overcrowding in the public school system, though World Media Group, LLC (2013) reports that the public school system in zip code 11219 is ranked above average.  All school buildings, private and public, appeared in good repair though, in some instances, there was limited space for children to play outside.  Public protection is evident with numerous EMS services, including several volunteer ambulance services.  One police precinct is located in zip code 11219.  The closest Fire Department is in Sunset Park.   

PEOPLE:  At 4pm mostly women and children were on the street.  Many of the women were dressed modestly and tastefully with long skirts, jackets, and hats.  Many students in the streets were wearing uniforms and backpacks.  Near Maimonides many workers were leaving the hospital wearing scrubs.  The few men that I encountered varied in appearance from suits with long coats and hats to plain clothes or scrubs.

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The population observed was overwhelmingly white, with some Hispanic, African American, and Asian people were observed.  The groups are residentially located with the highest concentration of white, residents at the center of Borough Park and other groups dispersed throughout the community with a concentration of non-white residents at the edges of Borough Park.  Racial and ethnic characteristics of the community are most evident at synagogues and private schools, many of which depict the institution names in Hebrew or Yiddish.  On the fringes of Borough Park I saw one store with Chinese characters on the awning.  I saw no churches during my walk through Borough Park.  The Synagogues varied by groups including Hassidic, Sephardic, and Ashkenazi Jewry.

The World Media Group, LLC (2013) reports the “per capita income of 11219 Zip Code is $12,678, which is much lower than the state average of $23,389 and is much lower than the national average of $21,587;” however, the fancy stores, large homes, and luxury cars I saw indicate that some of the community members are very wealthy.  This became more apparent as I moved from the lower avenues and streets up to the higher avenues and streets of the community.  Around Maimonides Medical Center I saw evidence of mental illness and disease, particularly when one gentleman on the street, who looked poorly kempt and disheveled, with a flat affect, started to suddenly yell at his cell phone.  However, in general, once over one block away from the hospital I did not see any evidence of drugs, violence, disease or mental illness.

ENVIRONMENT:  There are no large industrial factories in Borough Park.  Smaller industry that effects the environment mainly consisted of paint stores, photo developing companies, dry cleaners, and artisan stores such as monument and window stores.  The chemicals used in paint, photo, and dry cleaner stores can all effect workers and individuals living the apartments above the stores.  The roads are well marked but narrow and are not adequate to accommodate the high volume of traffic associated with the large population living in Borough Park.   

HOUSING:  The housing and architectural style of houses varies by section of the neighborhood.  Multi-family homes and apartment buildings are most common.  I saw no vacant houses, very limited retail space, and no apartments being advertised for rent.  The apartment buildings and homes can be quite old, with 90 years or older not being uncommon.  However, new homes and apartment buildings can be seen sporadically creating a montage and varying array of architectural styles throughout the community.  Most houses and apartment buildings are in good to excellent repair.

SPACE USE:  Land in Borough Park is mainly residential and commercial with no large industrial buildings and very limited public parks.  Most space is private and there is almost no open space, even on private residences.

COMMON AREAS:  The main “hangout” places appear to be yeshivas, the park, sidewalks outside residences, and restaurants in the area, particularly pizza shops and ice cream stores. 

“Hangouts” may differ by socioeconomic status since eating out is expensive.  Public areas such as the park, sidewalks, and restaurants are open to strangers.   

TRANSPORTATION:  Members of the community own cars, use public transportation, or walk in order to get around, and in and out, of the community.  The streets and roads are able to facilitate transportation through the community, though due to the high density of the population and narrow streets congestion is common.   

SERVICE CENTERS:  There are many community run social agencies and health facilities.  However, there are limited recreation centers and after school activities.  There are many offices for doctors, dentists, and specialists, generally on the first floor or basements, of multi-family residences.  I did not see any palmists or spiritualists.   

STORES:  Many residents shop locally.  There are a myriad of food shops, restaurants, home furnishing shops, clothing, music, toy, artisan shops, medical supply stores and specialty stores in the 11219 zip code area.  Community members walk, drive, or take public transportation to shop in the community   

STREET SENSE:  The majority of people on the street were women, mothers, babies, children, and students.  Near the hospital both men and women wearing scrubs or plainclothes were exiting the hospital.  All people were what you would expect to see on the streets at 4pm.  People were dressed appropriately for the time of day and locations where I saw them.  The only animals I saw on the streets were a stray cat or two.   

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COMMUNITY GROWTH:  I come across a few remodeled homes or newly built apartment buildings.  Street repairs were just completed in the month of September, and there were limited political posters.  There was some garbage on the sidewalks, but otherwise I saw no abandoned cars, real estate signs, or abandoned houses.  Many houses and buildings house stores on the bottom or basement floors.   

POLITICS AND MEDIA – COMMUNITY PERSONALITY:  Few political campaign posters were posted on houses or in store windows.  Party affiliations were not readily apparent.  Widely available newspapers include Hamodia, Yated, and the Jewish Press.  Magazines available include Ami, Bina, Jewish Actions, and Binyan.  Hebrew and Yiddish newspapers and magazines are also available.  Print media is definitely the most important.  

Walking through Borough Park is a multisensory experience.  The elevated subway trains, traffic, honking, and busses all make a lot of noise.  Borough Park does not smell. The higher avenues and streets are much quieter and have more greenery which makes them look lovely and inviting.  Borough Park has a nice feeling overall and parts make you feel like you are in a foreign city and culture.  The community gave me a good feeling, with the higher avenues and streets being most pleasant.  This was mainly because the upper avenues and streets were less crowded, and much cleaner, with higher end stores.

HEALTHCARE STATISTICS

Based on Take Care Borough Park, published by the New York Department of Health and Mental Hygiene (NYCDHMH), the leading causes of premature death (meaning death that occurs before the age of 75) in the community of

Borough Park is cancer, ranking at 24%, and then heart disease ranking at 21%.  “Other causes” equal 42% of deaths, which include accidents (5%), HIV-related deaths (3%), homicide (3%), suicide (2%), pneumonia and influenza (2%), and other (25%)(Olson, Van Wye, Kerker, &

Frieden, 2006, p.4).   

            These diseases, which and cause premature death, affect both males and females, mainly between the ages of 45-64.  Cancer and heart disease are the two leading causes of death in both sexes at the age of 65 and older (New York City Department of Health, 2002).  The cancers most prevalent in men, from the highest to the lowest, are lung, colorectal, and prostate.  For women, breast, lung, and colorectal cancers are most prevalent.  The category of ‘other’, constituting the majority of premature deaths in the community of Borough Park, is relevant to the elderly population, those 65 years of age and older, and pertains to injuries sustained from falls and/or other accidents (Olson, Van Wye, Kerker, & Frieden, 2006,  p.11).

Cultural concerns for the Borough Park community, related to religious beliefs, sometimes prevent community members from fully utilizing the healthcare system.  Similarly, a lack of health literacy and knowledge of the healthcare system can be a barrier to care.  Coalitions with community and religious leaders to improve health status maintenance, and increase knowledge related to the leading causes of death and/or disease in the community, such as addressing the need for maintaining a healthy heart and assessing and treating cancer through early detection and intervention, are imperative.  Similarly, high blood pressure and high cholesterol, two of the greatest contributing factors to heart disease, need to be screened for and maintenance programs established. 

The educational background of Borough Park residents is varied.  The majority of community members have either graduated from high school (28%) or obtained some college education (42%) with 23% of residents aged 25 and older having completed a college degree. 

(Olson, Van Wye, Kerker, & Frieden, 2006,  p.2).  

In 2006 it was reported that 15% of Borough Park residents were uninsured.  This number is likely to change with the implementation of the Affordable Care Act.  Insurance aside, only 4% of residents sought routine health care in the Emergency department in comparison to 8% in New York City overall.  In total, 20% of adults in the borough park population do not have a primary care provider which just about meets the TCNY target, indicating that Borough Park residents have better access to care, on average, in the community setting which leads to fewer

ED visits (Olson, Van Wye, Kerker, & Frieden, p.5).

Screening, case finding, and teaching by nurses tend are focused on current health risks that trouble the community.  For example, fall hospitalizations in older adults were the highest in Borough Park among all areas of Brooklyn (1235 hospitalizations per 100,000 ppl), with the rate of hospitalizations 25% higher in Borough Park than in Brooklyn overall. Furthermore, 30% of fall hospitalizations were for hip fractures (Olson, Van Wye, Kerker, & Frieden, 2006, p.14).  Additionally, Borough Park adults are less likely to have HIV screening performed as evidenced by the fact that only 15% were tested in the past year, and 57% of individuals who reported having sex with multiple partners reported not using condoms, which is 17% higher than the

Brooklyn average and 19% higher than NYC (Olson, Van Wye, Kerker, & Frieden, 2006, p.8).  Equally important, in 2008 the TCNY goal of immunization rates for influenza and pneumonia in adults older than 65 was more than 20% below the target of 80% (Olson, Van Wye, Kerker, & Frieden, 2006, p.12).  Taking this into account, nurses must initiate case finding activities and then provide appropriate patient education.  For instance, once and older adult is identified as being at risk for falls, the nurse can teach the patient to reduce the chance of falls by exercising regularly, reviewing medications with their doctors, attending an annual eye exam, and creating a fall-proof home.  Furthermore, older adults can lower their hip fracture risk by getting adequate calcium and vitamin D from food or supplements, doing weight bearing exercise, getting screened and treated for osteoporosis (“Older Adult Falls Publications,” 2013).

There are various future needs which should be addressed in the Borough Park community.  The number of hospitalizations due to falls, lack of insurance, low immunization rates, and lack of HIV testing are all areas that require improvement.      

            The primary care practitioners in Borough Park include physicians, physicians assistants, and nurse practitioners.  A comprehensive list can be found by performing a Google search for primary care providers in zip code 11219.  Access to PCPs influences family compliance with medical regimes.  For example, as noted previously, only 20% of adults in the borough park population do not have a primary care provider, which is just about meeting the TCNY goals, and only 4% of residents go to the ED when they are sick.  This indicates an above average prevention of avoidable hospitalizations with Borough Park ranking 7^th out of 42 NYC neighborhoods (Olson, Van Wye, Kerker, & Frieden, 2006, p.5).  Late maternal prenatal care has decreased by 25% (Olson, Van Wye, Kerker, & Frieden, 2006, p.13) by 2006 and the heart disease rate in Borough Park has decreased by 15% (Olson, Van Wye, Kerker, & Frieden, 2006, p.6) between 1996 and 2006.  These statistics seem to indicate an increase in family compliance with medical regimes which has resulted in improved health status for the community.  

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A community health nurse can reach out to the president, council members, and community leaders of Borough Park in an effort to reach out to the community via meetings, seminars, and school presentation, which will facilitate community education and bring about awareness about major community issues.  The need for more accessible health insurance and free STD and HIV screening clinics, as well as increased health education needs to be implemented.  Similarly, the importance of regular doctor’s visits and health screenings should be emphasized through community health initiatives.   The elderly may be in need of services like home health aides, assisted living, or tele-health technology.    Utilizing community resources and health initiatives would enable the neighborhood to be educated as well as be involved in disease management which will bring about positive changes.

While there are many community concerns that the public health nurse can address, the fact that Borough Park suffers from the highest prevalence of falls in all of Brooklyn, is very worrisome.  Therefore, the nursing diagnosis that we chose to address is: Risk for falls R/T health problems, unsafe use of medications, and unsafe environment, AEB 1235 hospitalizations per 100,000 ppl, with the rate of hospitalizations 25% higher in Borough Park than in Brooklyn overall (Olson, Van Wye, Kerker, & Frieden, 2006, p.14).

CARE PLAN:  This care plan was developed using “Gerontological Nursing” written by Eliopolus (2010).

Assessment:  See Community Assessment.

Nursing Diagnosis:  See previous paragraph.

Goal:  Reduce falls leading to hip fractures and hospitalizations in Borough Park, Brooklyn at 1 year and 5 years from date of implementation.

Interventions:  Create coalitions and pursue health promotion education with community leaders to create health initiatives that teach fall prevention strategies.  The following elements should be included:

• Create education programs and materials for older adults to make necessary changes in environment to improve home safety (i.e., remove throw rugs). Rational: These measures prevent injury to patient. Provide adequate supervision to prevent injury to the patient.
• Teach patient with an unstable gait how to use assistive devices properly. 

Rational: Improper use of assistive devices can put the patient at greater risk of falling.

• Teach patient and family about the use of safe lighting. Advice patients to wear sunglasses toreduce glare. Encourage patients to wear prescribed eyeglasses, hearing aids and prosthetic devices.  Rational: Proper lighting is always considered as a preventive measure.
• Teach patient to ask about medications that have been prescribed for him or her.

Overmedication in older adults is one of the major risk factors in falls.  Rational:

Understanding on the part of the patient and family can reduce the incidence of falls in the home.

• Enable social service/case manager to make a home visit to help improve the home environment for the patient’s safety. Refer patient and family to community resources that may offer assistance to the patient when needed.

Evaluation: The care plan and intervention is considered successful if the community hospitalization rate due to falls decreases at the 1 year and 5 year benchmarks.

            WHO INITIATIVE HEALTHY CITIES ELEMENTS  

            In conclusion, the community assessment indicates that Borough Park meets most of the WHO Initiative Healthy Cities Elements.  The community has a high quality physical environment, and a stable and sustainable ecosystem.  The community is strong, non-exploitive, mutually supportive, and meets basic needs for water, food, shelter, and safe work environments for the population.  The population is involved in health initiatives, as indicated by dropping risk factor statistics, and the majority of the community has access to a variety of healthcare services, with good communication and positive interactions.  The economy is diverse, innovative, vital, and self-contained.  Furthermore, the city is connected to its past, and the current structure is congruent with and enhances the elements above.  The community has a good overall health rating, and while not perfect, appropriate public health and healthcare is accessible to the entire population.  Continued improvement and increased participation in health initiatives, improved cleanliness, increased income, community safety, and continued access to healthcare are all long term elements that should continue to be addressed. 

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References

Eliopoulos, C. (2010). Gerontological nursing (7th ed.). Philadelphia, PA: Wolters Kluwer

Health/Lippincott Williams & Wilkins. 

New York City Department of Health. (2002, June). New York City Neighborhood Health

Profiles: Brooklyn, 2000 (Rep.). Retrieved November 11, 2013, from The City of New

York website: http://www.nyc.gov/html/doh/downloads/pdf/data/2000nhp-brooklyn.pdf 

New York City Department of Health and Mental Hygiene. (2006). 2006 New York City

Community Health Profiles. New York City Department of Health and Mental Hygiene. Retrieved November 4, 2013, from http://www.nyc.gov/html/doh/html/data/nyc-healthprofiles.shtml

Older Adult Falls Publications. (2013, October 29). Centers for Disease Control and Prevention. Retrieved November 12, 2013, from http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html

Olson, E. C., Van Wye, G., Kerker, B., & Frieden, T. R. (2006). Take Care Borough Park. NYC

Community Health Profiles, Second Edition: Borough Park (42nd ed., Vol. 13, pp. 1-16, Rep.). Retrieved November 4, 2013, from http://www.nyc.gov/html/doh/downloads/pdf/data/2006chp-206.pdf

Police Department of the City of New York. (n.d.). CompStat. NYPD. Retrieved November 26,

2013, from http://www.nyc.gov/html/nypd/downloads/pdf/crime_statistics/cs066pct.pdf

Ritzel, S. (2007). Report card on Brooklyn’s health (Rep.). Retrieved November 4, 2013, from

SUNY Downstate Medical Center website:

Ritzel, S., Nasrallah, H., & Youdelman, D. (2007).BROOKLYN COMMUNITY HEALTH(Rep.).

Retrieved November 4, 2013, from E Office of Institutional Advancement and the Office of Planning SUNY Downstate Medical Center website:

World Media Group, LLC. (2013). 11219 Zip Code. 11219 Zip Code. Retrieved November 4,