Running Head:
COMMUNITY ASSESSMENT
Community Assessment
Carolina Duque
Capella University
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Table of Contents
Community Assessment….…………………………………………………………………..3
Nursing Care Plan……………………………………………………………………………16
Reference………………………………………………………………………………...…..18
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The community I have chosen to analyze is a region within the Bronx borough called the South
Bronx. The South Bronx takes up an area of about 2.2 square miles, and according the New York City
Department of City Planning, this area has a population of approximately 91,497, an increase of
roughly six percent since 1990. The South Bronx includes several neighborhoods like Mott Haven,
Melrose, and Port Morris (New York City Department of City Planning, 2013).
In the South Bronx of New York there are three major health problems that have been
identified. Obesity, diabetes and smoking are the three health issues to be discussed in this paper.
Increasing numbers of people with diabetes has been noted within almost all cultures across the United
States, but the South Bronx experiencing increasing numbers overall. According to Bronx Health
Reach coalition, the South Bronx has one of the highest rates of residents diagnosed with diabetes
(16%), compared to the Bronx (12%), New York City (9%), and state and national rates which
are under 8% ( US Census Bureau, 2014). A nursing diagnosis for obesity is that of imbalanced
nutrition with there being more than the body requires. A nursing diagnosis for diabetes is that of
activity intolerance related to physical weakness.
One of biggest health problems noted within this community is that of asthma. According to
the American Lung Association in New York, using information from New York City Department of
Health and Mental Hygiene, the South Bronx has one of the highest smoking rates in the city, along
with a very high rates of exposure to secondhand smoke. Currently the tobacco smoking rate in the
South Bronx is 19%, much higher than the NYC rate of 14% (American Lung Association,
2010). The South Bronx community has one of the highest levels of pediatric asthma in the country,
with asthma-related deaths being approximately three times higher than the national average (American
Lung Association, 2010). A nursing diagnosis for smokers is that of altered oxygenation.
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Community Issues and Interview Questions
A key informant used for this project is named Jenecia Valle. Ms. Valle is a fellow Registered
Nurse, who grew up in the area considered Mott Haven and still lives in the area. Question 1: Do you
feel safe in your neighborhood? “I do not always feel safe, but since I grew up here I feel that I can
handle myself”. Question 2: Do you feel that there are a lot of community resources? “There is
certainly more available to the community since I first moved here from Puerto Rico 30 years ago. It
does not feel like it is enough. Many people don't use the internet to find out about available services,
nor do they speak English”. Question 3: Do you consider yourself to be at risk for Asthma? “I
experienced Asthma as a child. When I lived in Puerto Rico I never had asthma. My son also had
severe asthma and we were always visiting Lincoln Hospital's emergency room for his asthma”.
Question 4: Do you consider yourself at risk for Diabetes? “I try not to think about it, but I guess I am
at risk for Diabetes, but I get a physical every year and so far I have been fine.
Jenecia Valle is of Puerto Rican cultural background and therefore ethnically she does have
increased health risks of Diabetes and Cardiovascular disease. Her father died of an MI at the age of
66. Ms. Valle states her mother is at good health. Ms. Valle admits to being “heavy”, and that her
BMI is at 30 which places her into the category of obese. She admits to eating high fat and high carb
foods regularly, and denies consistent exercise routine. The lifestyle factors identified place the subject
at increased risk for cardiovascular disease and diabetes.
The other informant interviewed is named Onofra Gil. She is also a registered nurse who has
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been working several years as a Care Manager specializing in Diabetes management. Ms. Gil grew up
in the South Bronx after immigration from Dominican Republic when she was thirteen years old.
Question 1: Is Diabetes a worsening problem for the area? “Absolutely. As each year progresses we
add more and more patients to our system that have been newly diagnosed with diabetes.” Question 2:
Do you think there are enough services available for the community in regards to diabetes? “Of course
not. The population here continues to explode with increasing numbers of diabetics. Those affected
are getting younger and younger as well”. Question 3: Why do you think patients have issues with
managing their diabetes? “When it comes to prevention we need resources to help with education and
prevention of the illness. The people here need more access to better food choices and exercise. When
it comes to management, many patients face issues with time management, family support and
insurance issues”.
The informants were very helpful in putting into perspective my observations and the reality of
the South Bronx. They were also special because they use their personal experiences and frame it into
the perspective they have as educated registered nurses.
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Community Boundaries
Notes
Boundaries
Boundaries
Describe the boundaries of the area being
surveyed.

Is the area a named
neighborhood? Are the boundaries
determined by geography, or economic
status?
The South Bronx is the southern most part of
the Bronx. Its northern physical border is
considered the Cross Bronx Expressway. The
three neighborhoods of the South Bronx are
MottHaven, Port Morris, and Melrose.
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Environment and Culture
Housing
Describe the houses in the area including:

Age of the houses.

Overall condition of the houses.

Types of housing (single family,
multiple family).

How many are for sale or
vacant, etc.

From the housing, what could
be assumed about the economic status
of the area?
The majority of homes appear to have been
built around the 1950s. There are
many apartment buildings. Many of
the buildings are public housing
complexes. There are a few streets
that always have single family row
homes. Based of the housing one can
see that the area is mostly low income.
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Besides the housing, what is the general
condition of the area? Do you notice things
like garbage or junky cars in the area?
The general condition of the area is not good.
There are many overflowing garbage cans,
with a lot of litter on the ground. There are
quite a few people begging for money on the
streets as well.
Parks and Recreational Areas
There are limited amounts of green spaces
which is typical for an urban environment.
Signs of Decay
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Describe any parks, playgrounds or other
green spaces you notice. In your description
make note of the condition of these areas, and
if they seem to be used. Are there any other
types of recreational areas?
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There is a large green park that encompasses
10 city blocks. Otherwise there are scattered
playgrounds throughout the area, within the
public housing complexes.
Transportation
Describe the transportation in the area, and
the condition of the streets. Do you see
anyone using public transportation? Is public
transportation available? Is this a heavily
traveled area?
This is a heavily traveled area. There is a
large shopping area that is heavily used.
There are several train stations, and several
bus routes.
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There are many autobody, and mechanics
within this area. Waste handling is one of the
largest industries in the area.
Economics
Are there any industries in the area?
The South Bronx has 55 schools. 20 schools
are elementary. 27 schools are highschools.
Schools
List the type, level, and number of schools.
List the number and types of religious
facilities.
Churches don't appear to be very obvious in
the area, but there are quite a few. There are
roughly 38 religious facilities in the area.
There are churches for many different
denominations including Lutherans, Catholics,
and Jehova's Witnesses
General
There are a lot of young people in the street,
but no obvious signs of gang activity. Recently
there have been several random slashings that
are said to be related to gang activity. The
majority of the people in the area are of
Hispanic and Black backgrounds.
Religion
Do you see any evidence of gang activity?
Describe it. What types of billboards/signs do
you see, and how do they reflect the
atmosphere of the area? What cultural and
ethnic groups live in this area?
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Community Health
Environmental Health Factors
Do you see anything in the environment,
positive or negative, that might be contributing
to the health of community residents?
Describe how the factor could be impacting
the health of residents. An example of a
positive environmental factor might be a park
where children are playing and exercising. An
example of a negative health factor might be
the air pollution from a coal burning power
plant. Environmental factors could extend to
things like types of business in the community
as well. For example, how might a prevalence
of liquor or tobacco stores contribute to the
health of the community?
Many of the people in the street are smoking,
especially young people. There is also a lot of
car and bus traffic. These two factors
contribute to air pollution, and can have
something to do with the notoriously high
number of asthmatics in the area. There are
also many tobacco and alcohol stores that can
be affecting the health status of the community.
General Resident Health Observations
Do you notice any general positive health
behaviors or appearances across community
residents? For example, a community garden
or multiple residents outside being physically
active. Describe them. Do you notice any
general negative health behaviors or
appearances across community residents?
For example, numerous people smoking, or a
prevalence of obese residents. Describe them.
No one in the area was observed jogging or
exercising outside. There are no bike lanes
encouraging bicycling. There are several
gyms in the area though that appear to be
popular. The smaller parks were observed to
only have children playing. Many people were
seen smoking, and drinking alcohol on
benches. Large prevalence of obese people
noted, with many fast food restaurants in the
area.
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Community Health Issues
Based on your observations, what health
issues might you expect to be prevalent in the
community?
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The health issues that may be prevalent in the
area are that of high blood pressure, asthma
and diabetes based.
Community Assets and Obstacles
Services
Describe any type of social service, health
care service and protective service (fire and
police) that is in the area.
Community Needs
Based on your observations, identify any
problems in the community.
There are several fire stations in the area as
well as police precincts. The major hospital is
Lincoln Medical and Mental Health Center.
This hospital provides many services to the
community.
Problems of the community noted is that of
overcrowding, and not enough outdoor public
spaces. Crime is always a problem in NYC,
but the South Bronx is in general considered a
very dangerous area.
Community resources are not very obvious but
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they do exist. There are several shelters in the
area. There are also many schools that offer
free after school programs, as well as a YMCA.
Community Strengths
Did you notice any community resources that
might address the problems you identified?
Community Crisis Response

What assets exist in the
community that would be beneficial for
ensuring that health care services are
appropriately delivered during a
community crisis?

What potential obstacles exist
in the community with regards to
providing health care services during a
community crisis?
Subjective Feeling

How did you feel, being in the
area?

Were you comfortable?

Were you nervous?

Did the people seem friendly?

Would this be an area where
you would like to live or work? Explain.
Lincoln Hospital is a great asset to the
community that the area greatly depends
upon. There are a few antiviolence crisis
management initiatives that deal with gun
violence and helps prevent retaliation like the
S.O.S program (John Jay Research &
Evaluation Center)
There are also several mobile crisis vans
available that assist with people that are
experiencing mental crisis. In the event of
severe community crisis it would be very
difficult of reach out to all the people in this
densely populated area. The area in very
overpopulated, with many people who do not
speak English. Language issues would be a
possible obstacle
Subjective Feeling
I am not from this area, but I have been
working in the area and serving the community
for a few years now. When I first started
working here I used to feel nervous walking
around this neighborhood. The people for the
most part have always been neutral, not very
friendly which is pretty normal for the area.
I would not wish to live here. The area has
notorious levels of pollution and crime.
Although, due to these negative issue, housing
is much more affordable in this area.
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Care Plan for Diabetic management
One of the many goals of Healthy People 2020 is to “achieve healthy equity, eliminate
disparities, and improve the health of all groups” (U.S. Department of Health and Human Services,
2013). The South Bronx in particular is a place that would greatly benefit from the goals of Healthy
People 2020. The South Bronx is a community that has a statistically higher percentage of foreign
born, with the largest Hispanic community, and with more people living beneath the poverty level than
any other part of New York City. This area also experiences higher levels of health disparities on
almost every health indicator. In order to be able to make changes towards achieving the goals of
Healthy People 2020, the South Bronx needs to be understood with its unique cultural history, and its
existing disparities.
Health disparities in regards to Diabetes are highly evident among Hispanics and Blacks in New
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York City. Hispanic New Yorkers are more than twice as likely to have diabetes as White New
Yorkers. Disparities in diabetes is widening: From 1999–2001, Black New Yorkers were about 3 times
as likely to die from diabetes as White New Yorkers (New York City Department of Health and Metal
Hygiene, 2004). Increasing numbers of people with diabetes has been noted within almost all cultures
across the United States, but the South Bronx experiencing increasing numbers overall. According to
Bronx Health Reach coalition, the South Bronx has one of the highest rates of residents diagnosed with
diabetes (16%), compared to the Bronx (12%), New York City (9%), and state and national rates which
are under 8% (2014).
There are many lifestyle changes that patients need who have diabetes. Increasing exercise and
diet changes are a very important part of managing Type 2 diabetes (Rahati, Shahraki, Arjomand, &
Shahraki, 2014). People who are overweight have increased chances of developing diabetes, and
regular physical activity has been shown to lower glycemic levels short term and long term ( Rahati,
Shahraki, Arjomand, & Shahraki, 2014). Once diagnosed with diabetes, many people have difficulties
making healthier choices, and exercising. For Hispanics changing diets can be very difficult. Typical
Hispanic diets include a large amount of simple carbohydrates that create spikes in blood sugar levels.
Diabetes and its pharmacological treatment requires a lot of planning. Patients must commit to
monitoring their blood glucose levels on a regular basis, and they must understand the importance of
following up with their providers. Patients also need to understand the role their diets play in managing
their diabetes. Nurses and other medical providers play an important role in reminding patients to be
compliant with their medications and their diets.
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References
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to
planning care. St. Louis, Mo: Mosby/Elsevier.
American Lung Association.(2012). Expanding Smoke free Communities Community Profiles: South
Bronx, New York. Retrieved January 30, 2016 from www.lung.org/stopsmoking/tobacco.../profiles-south-bronx-ny.pdf
Bronx Health Reach (2014). Retrieved on Jan 30, 2016 from :
http://www.bronxhealthreach.org/about-us/our-community/
John Jay Research and Evaluation Center. (n.d.) Implementing the New York City Crisis Management.
retrieved Jan 30, 2016 from: http://johnjayrec.nyc/nyc1_bronx1/
New York City Department of City Planning. (2013, June). Community District Profiles. Retrieved
January 30, 2016 from
www.nyc.gov/html/dcp/html/lucds/cdstart.shml
Rahati, S., Shahraki, M., Arjomand, G., & Shahraki, T. (2014). Food Pattern, Lifestyle and Diabetes
Mellitus. International Journal of High Risk Behaviors & Addiction, 3(1), e8725.
http://doi.org/10.5812/ijhrba.8725
US Census Bureau. (2014). State and County QuickFacts: New York and Bronx County. Available
from the United States Census Bureau website. Retrieved Jan 30, 2016 from:
http://quickfacts.census.gov/qfd/states/36/3651000.html
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