After the religious reformation of Christianity in Germany, a ship of Mennonites and Quakers fleeing persecution came to Philadelphia in the pursuit of starting over. These original settlers divided and tended to new land, while physically increasing the population. Many schools, including the prestigious Germantown Academy that exists today, were created by these original German settlers. Most of the educational institutions were deeply rooted in both Quaker and Mennonite beliefs, resulting in the palpable protestant Christian culture still seen and felt in Germantown today (Hemp, 2017).
Today, Germantown is a vastly African American community with whites and other various races mixed in at a smaller quantity. While the area has managed to preserve and showcase many historical sites, homes, businesses, and schools, a look of destitute has overcome the scene. According to Philadelphia Neighborhoods, a publication of Temple University’s Multimedia Urban Reporting Lab, the reasoning for there being a majority of African Americans living in the area even though it was historically founded by white Anglo-Saxon protestants, can be traced back to the “white flight” of the 1960’s. The term “white flight” is used to describe the movement of white people from cities to the suburbs following the civil rights movement. The white community dwellers had established business and schools and when they fled to the suburbs in fear of the African Americans who had just obtained equal rights, any economic means to keep these things operating left with them. An example of this can be seen in the abandoned Germantown High School, which was once a large building with grand white pillars. It now sits empty and disheveled due to its shut-down because of funding and violence issues (Philadelphia Neighborhoods, 2015).
Windshield Survey
Germantown is a borough of grand historical proportions located in the Northwest section of the city of Philadelphia. Upon windshield survey while driving down Germantown Avenue (a cobblestone street that drives through the heart of town), one may observe a diverse array of buildings, housing, businesses and places of worship as it seems to weave in and out of pristine colonial construction and a low-income urban appearance. Historical places such as the Dreshler-Morris House (previous residence of President George Washington), or Saint Peter’s Episcopal Church (built in 1873 and designed extravagantly with pre-Vatican II architecture) can be viewed within the same vicinity as run-down consignment stores, pawn shops, and quick-cash and loan businesses. On the sides of various building walls one can see several advertisements for ethnic hair products along with many eye-catching murals. One in particular, and perhaps the most famous, is named “Healing through Faith and Spirituality” by Joe Brenman. It is a stunning mural that pulls an array of colors, shapes, patterns and dimensions together to bring physical brightness to an otherwise grey-toned landscape.
Additionally, throughout our drive of Germantown we took note of many signs outside of various Christian churches of several denominations stating “Hate Has No Home Here”, “Black Lives Matter”, “Immigrants and Refugees Welcome”, “Act with Mercy, Seek Justice” ultimately giving surveyors of the community a peak into the political and social climate of this specific area.
The individuals we observed were mostly black men, women, and children. While we traveled on foot down Germantown Avenue, we got a closer look at the interactions between the people. It was a chilly October afternoon but various people from all age groups were out and about. We observed a group of men standing on a corner and waiting to cross the street while drinking fruit smoothies, a pack of children followed their mother while giggling and chatting as they walked down the sidewalk, and other people moved in and out of the shops and eateries. The overarching tone of the town on this day appeared content.
Physical Environment
Boundaries and Location
Germantown is a section of Northeast Philadelphia, approximately six miles outside of center-city. Germantown is bordered by the roads Wissahickon Avenue, Germantown Avenue, West Johnson Street, and a part of Lincoln Highway.
Industry and Commercial
Continuing on, some physical characteristics noted were that Germantown is mostly a suburban location, while the “main street” or “downtown” area is more commercial. There are no natural boundaries in Germantown and the most abundant flora and fauna to be seen is within the two parks named “Vernon Park” and “Fairhill Park”. Along the main street, as stated previously, is commercial and lined with stores such as “Bargain Thrift” (a second-hand shop), “Pik-A-Panel True Value Hardware Store”, and an assortment of multi-cultural restaurants featuring Indian, Caribbean, Pakistani , African, and Southern “soul food”, just to name a few.
Housing
The streets appear to be set up like a grid, a natural finding within Philadelphia, with easy to navigate roads that either go horizontal or parallel. The housing that makes up the blocks within the grids are townhomes or apartment complexes which appear dingy and worn-out. The largest low income housing in Germantown is called “Germantown House” which is owned by the Philadelphia Housing Authority. The Philadelphia Housing Authority is a federally funded housing agency that offers leasing to the elderly, disabled, and economically disadvantaged families and individuals (Philadelphia Housing Authority, 2017).
Community Services
On top of low income housing, the underprivileged of Germantown can find aide in a handful of privately and publicly funded social service centers. Within our visit of Germantown we were fortunate enough to stop into “Face to Face”, an organization that was created in response to the fact that “over a quarter of Germantown lives in deep poverty”, according to Face to Face social worker Tara Monihan. According to the Face to Face Annual Report of 2016, services that are offered include a dining hall that serves hot meals five days a week, a health center (composed mostly of nurses and nursing students) who provide hypertension screenings and diabetes education, a legal center that works with individuals on getting their birth certificates and other legal identification, and of course a social services office that helps with issues of homelessness, mental health and employment opportunities.
Other community services for low income individuals include a local welfare assistance office which is called the Public Assistance Department of Social Services and a local US Social Security Office, both located on Chelten Avenue.
Other community services and recreational facilities geared towards the general population include Joseph E. Coleman Public Library, three Boys and Girls Clubs, and the Germantown Historical Society.
The public high school in Germantown is named Martin Luther King High, and one attractive program the school offers for students is an arts and murals program where students are provided with the chance to permanently showcase their artistic abilities by painting various hallways within the school building. Photos of the colorful and playful mural art can be seen on the high school's website.
Another respected Martin Luther King High program that is offered is the Junior Reserve Officers Training Course (JROTC). This organization strives to “Motivate Young People to be Better Citizens”, by offering structure and leadership development to young people who are seeking to join the military and attend college after high school graduation (“Martin Luther King High School- ROTC”, 2017).
While Germantown is technically considered a section of the city of Philadelphia, it is also 16 miles from the heart of the city known as Center City, which means that mass transit is abundant. Most public transportation is provided by the Southeastern Pennsylvania Transportation Authority (SEPTA). SEPTA offers train stations, bus routes, and parking lots around the area. Transportation by train can be found at Germantown Station on 150 E. Chelten Ave. Bus routes include the Chestnut Hill West Line, the Chestnut Hill East line, and the Manayunk/Norristown Line. Parking lots for individual vehicles are offered at the above train station free of charge, and on the sides of the streets (Southeastern Pennsylvania Transportation Authority- Germantown Station, 2017).
In regards to safety, the city of Philadelphia has a police department that is designated for the Germantown Area called District 14. On the Philadelphia Police Department website, anyone can see the districts captain, missing people they are currently trying to locate, and articles and letters about the accomplishments the district.
Religious
Continuing on, Germantown has various houses of worship in all three of the world's main faith traditions: Christianity, Judaism, and Islam. The area holds more physical emphasis on Protestant Christianity and Islam. Historically speaking, Germantown was founded by Quakers and Mennonites, so it comes to no surprise that there is a plethora of protestant churches that include the denominations of Episcopalian, Presbyterian, Baptist, and of course Mennonite and Quaker (Hemp, 2017). There are also a few Catholic churches in the area, two of them being the Shrine of the Miraculous Medal and Saint Vincent de Paul. One of the mosques is called Germantown Masjid.
Environmental Factors
In regards to environmental factors in Germantown, the Philadelphia Water Department provides maintenance, testing, and distribution of water and sewage disposal to the city and surrounding towns that include Germantown (City of Philadelphia, 2017). Trash disposal is handled by The Philadelphia Streets Department and provides services like, “curbside trash and recycling collection, maintaining all traffic control devices and street lighting, the construction and maintenance of 320 bridges and 2,525 miles of streets and highways and snow and ice removal” (Philadelphia Streets, 2017).
According to Air Now, a website and tool created by the United States Environmental Protection Agency to share real-time air quality data and forecast, one can see that Germantown, Philadelphia has moderate air quality. There is a complex algorithm that goes into the creation of this air quality index, but essentially moderate (according to the website) implies that “air quality is acceptable; however, for some pollutants there may be a moderate health concern for a very small number of people who are unusually sensitive to air pollution” (Air Now, 2017).
Health Services
In regards to formal healthcare, Germantown has a community health center named Health Center 9 that offers an extensive set of services to the public that range from food protection to family planning (Ambulatory Health Services, 2017). Additional health care agencies include Children's National (a pediatric medical clinic) and Holy Cross Germantown Hospital.
The Population
General Characteristics
In regards to Germantown’s general characteristics, theres a total of 69,018 people living within its defined borders (Germantown, Philadelphia, 2016). Of this population, the median age is about 37 years old, just slightly above its surrounding county of Philadelphia’s median age of 34 (Germantown, Philadelphia, 2016). Another statistic related to the age of Germantown’s population is that only 3.5% of its population is 84 years old or greater while 19.8% of the population is less than 5 years old, making the general population increasingly younger (Germantown, Philadelphia, 2016). Due to this younger population, the majority of the households are one-person (Race and Ethnicity in Germantown, 2015). One-person households account for 43.9% of the populations household types and of these households, 25.6% are single females and 5% are single males (Race and Ethnicity in Germantown, 2015). With that being said, the gender ratio is almost an even split with a ratio of 0.9 males to every 1 female (Germantown, Philadelphia, 2016). Although the gender ratio may be almost identical, Germantown is not what you would call a “melting pot” of cultures. In addition, 11.86% of the population is Caucasian and 83.17% is African American (Germantown, Philadelphia, 2016). After these two percentages, it leaves us with minutiae numbers for other races such as: American Indian at 0.28%, Native Hawaiian at 0.03% and other races with 1.97% (Germantown, Philadelphia, 2016).
Within the population as a whole, from ages 25-64, 44.3% are employed while 10.9% are unemployed and 0.1% has joined the armed forces (Race and Ethnicity in Germantown, 2015). Of the percentage that is employed, 75.7% have earned a bachelor's degree (Race and Ethnicity in Germantown, 2015). On the other end of the spectrum, a surprising 29.3% of this population does not have a high school diploma (Race and Ethnicity in Germantown, 2015). With the remaining educational subsets of the population over 25 years of age, whether employed or not, 22.2% have a higher degree than a high school diploma, 58.3% have attained a high school diploma, while 19.5% have no high school diploma (Race and Ethnicity in Germantown, 2015). In addition to these statistics, 37% of the population with higher degrees than a high school diploma was females while 38% of the population with no high school diploma came from males (Race and Ethnicity in Germantown, 2015). To add onto the demographics, the chance of being a victim of a violent crime in Germantown is 1 in 78, the chance of being a victim of property crime is 1 in 25, and the chance of being a victim of crime is 1 in 19, giving Germantown a 30% safety rating down in the red zone (Germantown, Philadelphia, 2016).
Health Characteristics
In terms of health characteristics, causes of mortality, morbidity and health indicators were not specific to Germantown. Instead, they were incorporated and generalized from the whole city of Philadelphia since Germantown is located in the Northwest region of Philadelphia. With that being said, the five leading causes of mortality in 2014 that were generalized in the community were as follows: diseases of the heart, cancer, CLRD (Chronic Lower Respiratory Disease), stroke, and accidents Pennsylvania and County Health Profiles, 2016). Next, the five leading causes of morbidity that were generalized to this specific community were as follows: campylobacteriosis, Chlamydia, HIV, salmonellosis, and syphilis Pennsylvania and County Health Profiles, 2016). A census from 2012-2014 concluded that some leading health indicators for this community were as follows: obesity, smoking, never being tested for HIV, not visiting a doctor within the past 2 years, and no health insurance intertwined with the cost of routine visits Pennsylvania and County Health Profiles, 2016).
Vulnerable Populations
Based on the information provided, the vulnerable populations in the community would correlate to the low income families/person with children or disabled persons that are unable to work. Since the average income per capita is $16,861 (Germantown, Philadelphia, 2016), with just one source of income it makes it tough to provide for more than one person let alone more than that per year. This vulnerable population that is subjected by poverty is provided with food stamps, which accounts for 58.7% of the food stamps that are given out in the Germantown area (Race and Ethnicity in Germantown, 2015). On the other note, disabled persons account for 45.1% of the food stamps that are distributed within Germantown (Race and Ethnicity in Germantown, 2015).
Health Problem Identification
Actual Health Problems
During the gathering of data, there was not any specific health indicators identified about actual health care problems only within the Germantown community; instead generalized information was collected about the whole city of Philadelphia. Actual health problems in the city of Philadelphia include sexually transmitted diseases, in particular HIV, Chlamydia, and gonorrhea. According to County Health Profiles of 2016, there were a total of 59,308 cases reported between 2012 and 2014 of Chlamydia and the rate was 1272.4. According to County Health Profiles of 2016, there were a total of 19,557 cases of gonorrhea reported between the years of 2012-2014 and the incidence rate was 419.6. In addition, there were a total of 1,959 cases reports of HIV in 2012-2014 and the incidence rate was 42.0. The number of these STDs cases exceeded the reported cases of these diseases in the state of Pennsylvania within those 2 years. Other major healthcare problems include cancer (specifically breast, lung, and prostate), stroke , obesity, diseases of the heart, accidents, and chronic lower respiratory disease. The average incidence rate annual in Philadelphia in 2009-2013, there were 4,451 total cases of lung cancer, 290 were men and the rate was 8.6. The number of lung cancer cases and incidence rate was higher than any other county in Pennsylvania reported to the CDC within those years. Prostate cancer is another type of cancer that is one of Philadelphia’s major health problem, in which The County Health Profile of 2016 states from the year of 2009-2013, there were a total of 5,273 cases of prostate cancer and the incidence rate was 154.9 which also exceeded the CDC reports.
Potential Health Problems
Potential health problems that could occur include: increased incidence of diabetes, increase incidence of HIV infection throughout the population and deterioration of any existing health conditions such as cancer and or any co-morbidities. As stated previously, according to The County Health Profile of 2016, the median age population age of Philadelphia is about 34 years old. The median age of the Germantown community is about 37 years and the overall population is relatively younger than 65 years old. Based on the information presented, the population that would be susceptible to the actual health care problems and potential would be young adults and middle-aged adults that are poor or have low income with or without children, disabled that cannot work, and those that cannot due to insurance cost visit a doctor routinely.
Proposed Intervention
Health Problem and Goal
The authors have identified an increased incidence of sexually transmitted diseases such as HIV, Chlamydia, and gonorrhea as a telling health problem. The goal of the educational program that will be carried out is to reduce the number of reported HIV, Chlamydia, and gonorrhea cases by 5% within one year.
Nursing Diagnoses
After examining the community of Germantown and the surrounding area, the senior nursing students have identified the issue of sexually transmitted diseases and infections as being a concern. Two pertinent nursing diagnoses for this community include:
1. Risk for infection transmission related to sexual contact exposure, multiple sexual partners, or unprotected sexual intercourse.
2. Knowledge deficit of safe sex practices related to lack of available information as evidenced by County Health Profiles data regarding sexual diseases and infections.
Interventions
Primary
In order to combat this concerning issue, nurses can provide a free sexual education class to bring awareness to the issue and teach safe sex practices. Primary intervention in the form of an educational program is an excellent way to help decrease the problem of sexually transmitted diseases. A goal for this program would be to increase knowledge regarding safe sex by the end of the educational seminar. To measure the success of this program, a pre and post quiz could be utilized in order to see if there was an increase in knowledge after the class. The target population for the sexual education course would be anyone in the community who is sexually active or planning on becoming sexually active. Parents should be encouraged to attend with their teenage children in order to provide education to a vulnerable group. Instead of focusing on abstinence, nurses should focus on safe sex and contraceptive methods. Additionally, nurses can provide pamphlets on signs and symptoms of STD’s and STI’s as well as testing options and free or low cost clinics so that members of the community know what to look for and how to get help.
In order to make sure that cost is low, nurses could ask local buildings if one of them would be willing to donate a room for the class. Additionally, nurses could ask for volunteers to make posters and signs that they could post around the community to increase attendance. Nurses could volunteer their time to teach the class. A pre and post quiz would be developed by the nurses in order to determine if their teaching has been effective. Important topics to include in the educational seminar would include the importance of healthy relationships, the efficacy of condoms and how to properly use them, different types of STD’s and STI’s as well as how they are transmitted and treated, the importance of reproductive health and the benefit of limiting the number of sexual partners.
A Healthy People 2020 objective that relates to the program is that, innovative communication strategies are critical for addressing issues of disparities, and normalizing perceptions of sexual health and STD prevention and to help reduce health disparities. One of the most important social factors that may contribute to serious obstacles of STD prevention in the U.S is the general discomfort of discussing intimate aspects of life particularly related to sex. To help normalize the topic of sex education, during the seminar a portion of it can be split into two sections. One section would be nurse educators teaching the various topics of sexual education so that the community is able to participate in the pre and post quiz. The second half can include open dialogue between nurses, parents, members of the community, and in particular the vulnerable population to explore the feelings of the issue raised and takes advantage of any curiosity at this time about sexuality, intimacy, dating relationships and STDs. To create a nonjudgmental environment and generalize the dialogue to everyone, it will be directed from anonymous questions, statements or concerns that the community writes down. After the first half of the seminar is complete, the attendees will be given pieces of paper and will be instructed to not write their names, and will have 10-15 minutes to write down any questions, topics, situations or statements they would like to talk about in the open dialogue. The papers will be collected in a plastic bin, they will be shuffled by the nurse educators and a paper will be picked out one by one and read to the attendees. The attendees will have a chance to speak about what read aloud to them and after the crowd is done, the nurse educators will then speak.
An additional Healthy People 2020 goal that relates to the program is having access to high-quality health care being essential for early detection, treatment and behavior-change counseling for STDs. Groups with the highest rates of STDs is often the same groups for who access to or use of health care services is most limited. To maintain sensitivity and privacy to the community attendee’s financial information, along with the intervention of the seminar, a brochure pamphlet will be passed out to the community attendees including information about local clinics that accepts most of all insurance or patients without insurance regarding STD testing, resources of contraceptives, treatment and any sexual counseling. The goal of this intervention is to inform the community of the options and resources they may qualify for to help reduce the uncertainties they may have about sex, promote safe sex along with preventive strategies of STDs, and to help with early detection and treatment of any STDs.
Secondary
Secondary interventions include things like screenings and treatment. Nurses can explain the different types of screening available to the community members in the event that they may be concerned about exposure. The CDC recommends the following screenings for HIV, Chlamydia and Gonorrhea. All adults and adolescents from ages 13 to 64 should be tested at least once for HIV.
Sexually active gay and bisexual men may benefit from more frequent HIV testing such as every three to six months. Anyone who has unsafe sex or shares injection drug equipment should get tested for HIV at least once a year. Annual chlamydia screening of all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection. Annual gonorrhea screening for all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection (CDC 2017). Providing information such as this allows nurses to explain the process to community members and ensure that they are well informed.
Tertiary
The tertiary intervention would include the treatment of all three diseases mentioned in the original health goal. The medical treatment for HIV includes the administration of antiretroviral drugs, for Chlamydia it includes the administration of a seven day course of antibiotics, and for gonorrhea it includes the administration of ceftriaxone and azithromycin (CDC, 2017).
While a physician will have to prescribe all medications, nurses may participate in the administration and education about each of the drugs. To carry out this intervention, nurses must be knowledgeable of public health clinics that offer low cost or free sexual disease treatment. The same group of nurses who participated in the primary intervention of this health problem will offer their time and skill as volunteer work in local public health clinics that already exist such as Philadelphia Fight (a non-profit that specializes in prevention and treatment of HIV).
Evaluation
One way nurses can evaluate the effectiveness of their interventions is to simply keep track of the number of new sexually transmitted infections that occur following the sexual education class. Additionally, nurses can keep track of how many individuals utilize services such as sexual health counseling and safety following the sexual education class within their public health centers.
If the interventions were successful, the outcomes that would be expected would include a decrease in sexually transmitted infections such as HIV, Chlamydia, and gonorrhea over 5% or more, and increase in the number of individuals engaging in conversation with their healthcare providers in safe sex practices and methods.