HEALTH PLANNING

Health Planning Discussion Seun Aransiola, Amanda Coffin, Joseph Crossman, Sid Eugene, Natalie Eyer, Jessica Fluharty, Vanessa Gonzales, Emily Plemmons, Kayla Vadney, and Jenifer Wessling Old Dominion University

Submitted in partial fulfillment of the requirements in the course Nurs 470: Community Health Nursing Old Dominion University NORFOLK, VIRGINIA Fall, 2013

HEALTH PLANNING The purpose of this assignment is to allow the nursing students of Old Dominion University the opportunity to become involved with a selected community group. Tasks of the

nursing students will include: identifying the aggregate within the community, assessment of the aggregate, analysis of the aggregate, assignment of nursing diagnoses to the aggregate and nursing intervention and evaluation. The nursing diagnoses will be prioritized by the students based on assessment of the aggregate and relevant literature data. Interventions planned by the students will work to address priority nursing diagnoses. This paper will discuss detailed assessment of the assigned aggregate, relevant nursing diagnosis, and relevant nursing interventions. Assessment: Identify the Aggregate The aggregate selected for the study were the residents of Barrett House transitional home, located in Norfolk, Virginia. This community group was selected by Old Dominion University for the nursing students. Barrett House is intended to help homeless women, up to ten, who may have suffered from issues of mental health, domestic violence, unemployment, poor credit, or substance abuse. In addition, Barrett House offers haven to pregnant women; although there were no pregnant women housed when the nursing students worked with the aggregate. The purpose of Barrett House is to help women become self sufficient by providing shelter, food, counseling, and a structured environment. The women are offered these services, and in turn the women are required to do community service, attend group meetings, actively seek employment, and adhere to rules such as bedtime, dinner time, etc. The women are allowed to live Barret House for two years to utilize supportive services to assist with reintegration into the community. Being that the aggregate was already defined; the nine women of Barrett House, the initial goal of the nursing students was to gain entry with the aggregate. Gaining entry with the

HEALTH PLANNING women of Barrett House was approached in a few different ways. Initial contact was established by holding a group meeting with management of the house. All of the students attended this

meeting along with the clinical instructor. During the meeting the students were able to introduce themselves and convey their goals and hopes of working with the women. In addition, the students were able to learn more about the aggregate and hear from the director and case manager of what their goals and hopes were for the nursing students. During this meeting it was suggested by the director that the students pair up with the women on a one-to-one basis in order to establish more trusting, intimate relationships. The students felt this was a great idea and agreed to submit a small about me blurb to the director so that she could pair up the students accordingly to the women of Barrett House. These assignments were given out in the nursing students attempt to gain entry. Another strategy utilized to gain entry with the women was the hosting of a pot luck dinner at Barrett House. Each of the students brought a dish and ate dinner with the women whom were present at the house that evening. The purpose of the pot luck was to casually get to know the women by socializing in a carefree and relaxed environment. In addition, the students were able to explain to the women their role as nursing students and how long they would be working with them. The students asked the women what their personal learning needs were and asked them what personal goals and accomplishments they would like to achieve. Following the pot luck, the director posted the students emails on the bulletin board in the house so that the women would have the students contact information. If the assigned partner was present, contact was initiated by the matched student and means of communication were established. From there on out, each student worked to establish a relationship with their partner. For some of the students this was an easy task; their partner was very receptive, communicated

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well, or had specific needs. However, establishing one-on-one relationships for others was not as easy for various reasons such as: lack of trust, conflicting schedules, and poor communication. The students used various methods such as establishing rapport, identifying boundaries, explaining confidentiality, and trust building in order to build partner relationships. Gaining entry with the women on a one-on-one basis was a complex, ongoing task that was very individual to each match. Assessment: Socio-Demographic Characteristics Socio-demographic characteristics will be discussed in relation to the surrounding community of Barrett House and the aggregate itself. Data was collected in order to reveal information about race, gender, socioeconomic status, and modes of transportation available to the area and aggregate. The following four types of data collection were used: United States (US) Census Bureau, Windshield Survey of the community, conversations between the nursing students and aggregate, and observations made by the students. The US Census Bureau and Windshield Survey were used to reflect socio-demographic data of the surrounding community of Barrett House, while the nursing students observations and conversations with the women were used to reflect socio-demographic data of the aggregate. The socio-demographic data from the US Census Bureau will be discussed first. Data reported from the US Census Bureau will be a reflection of the city of Norfolk. In 2010, the US Census Bureau reported a racial demographic of 47.1% Caucasian, 43.1% African American, and 3.3% Asian. Gender data revealed 48.2% females and 51.8% males, with a median age of 29.6 in 2010. Education demographics revealed 27.3% of the population held a high school diploma or equivalent, 15.5% held a bachelors degree, and at least 9.9% held a graduate degree. As a reflection of socioeconomic status, less than 20% of the population lived in poverty;

HEALTH PLANNING with poverty being defined as individuals making less than $11,500 per year in income. Transportation data revealed 4.1% of the population walked, 5.5% used a form of public transportation, and 70% used automobiles (US Census, 2013). The Windshield Survey was the second method used to define socio-demographic characteristics of the area. This was conducted by the students before meeting the aggregate by driving around the area of Barrett House and making general observations. Some of the observations pertaining to socio-demographics specific to the Windshield Survey were housing, transportation, and neighborhood life. Observed conditions of the homes were predominantly single family homes; most in poor condition with pealed/crack steps or boarded up windows. Barrett House itself, however, appeared to be in good condition. In the Barrett House driveway there was one car owned by a resident and one van used for transportation of the women as needed. Public transportation appeared to be readily available; with formal bus stops, light rail, and Hampton Roads Transit (HRT) buses. During working hours there were many African Americans males socializing on the street or outside of the houses. The age of the males appeared to range from 20-60. Also, within the neighborhood there were many cats roaming freely (See Appendix A). The next form of socio-demographic data collection was observations by the nursing

students after meeting the aggregate. Barrett House has nine homeless women ranging from early 20s to mid 60s; 7 of African American ethnicity and two of Caucasian ethnicity. 8 out of the 9 women are working at least part time as part of the requirements to maintain housing at Barrett House. In addition, the students observed that the aggregate utilized various modes of transportation to commute, such as the HRT and Barrett House van.

HEALTH PLANNING The last form of socio-demographic data collection was conversations with the women. Based on the conversations with the women, their education ranges from high school diploma, General Education Development (GED) certification, and trade school certifications. At least three out of the 9 women are current students working on medical assisting or nursing school prerequisites. Currently, two out of the 9 ladies have their bachelors degrees, with one of the two working on her masters degree. Assessment: Socio-Demographic Health Status The women of Barret House have several health status concerns, but the concern that impacts them the most is unhealthy eating habits. Of the 9 women, one has been diagnosed as a diabetic, but all of the women practice eating habits that are unhealthy. During observed time at the house, it was noted that there was an abundance of cakes, sweet snacks, and other bakery goods in supply. Each week, the house receives donations of food including: boxed sweets, baked goods, meats, vegetables, bread, and fruits. The boxed sweets and baked goods were the

observed dominant foods picked out by the women. It was also observed that the vegetables were usually discarded after a short while. The nursing students conducted a food pantry clean-out to assess the types of canned foods present, and it was discovered that many of the canned fruits and vegetables were expired by years. This finding suggests that the women did not utilize the pantry as a resource and relied heavily upon the sweet cakes and other higher fat foods for their intake. Unanimously, the women expressed concern and desire to eat healthier. They frequently asked questions regarding eating healthily and expressed that they felt they lack the knowledge required to eat health-consciously. However, even after instruction, it was observed that the women made very little changes to their eating habits. Using this observed information, it is concluded that the women perceive they have unhealthy eating habits. The nursing students

HEALTH PLANNING actual assessment of the womens health status revealed this same finding. The students also concluded that the women lack the understanding of implications of poor eating habits. In addition to healthy eating, exercise was another deficit both observed by the students and reported by the women. The women verbally acknowledged to the students the desire to exercise; however, expressed a lack of resources, as the only exercise tool available to them was

the Nintendo Wii. Other barriers reported by the women regarding exercise were the lack of time and the lack of knowledge to do so. In conclusion, the aggregates perceived health status in regards to exercise was that it was lacking. Actual health status assessment made by the students revealed the same finding. Assessment: Socio-Demographic Internal and External Influences In addition to sociodemographic and health characteristics, this semester also focused on collecting information on the community surrounding Barrett House and its influence on the women who live there. For the Barrett House residents there are both internal and external influences which grossly affect their lives and contribute to the characteristics of the women; individually and the house as a whole. External influences include factors outside of Barrett House within the community of Norfolk that pose some sort of impact on the women, while internal influences are aspects of the house itself that affect the women. One significant external influence for the women is that the house is located in a large residential district which provides very little access to valuable commercial resources, such as healthy foods, healthcare, and places to exercise. The commercial establishments within walking distance of Barrett House are few and far between and mostly consist of schools, fast food restaurants, and gas stations. Fortunately, there is a bus stop less than one block from the house in which the public buses can take the women to other areas of Norfolk which are more

HEALTH PLANNING populated with commercial resources. However, that is just about the only option for the Barrett House residents, because many of them do not have cars. It is very convenient that the women have access to buses, but for some this is an additional financial burden. Therefore, this external factor influences the women by either making them walk long distances to avoid bus fees, spending money on bus fair, settling for the resources close to the house, or refraining from leaving the house all together when not completely necessary. Another significant external influence on the Barrett House residents is the community interactions that the women have made since living at the house. The women are required to either find employment or continue their education, while participating in community service. Therefore, the women have had substantial opportunities to interact with members of the community and build lasting connections and relationships. For example, most of the women have full or part time jobs in which they have to interact with coworkers and customers on a weekly basis. Some of the other

women attend community college in which they have to participate in group projects and interact with professors and classmates. Both of these external interactions influence the women by allowing them the opportunity to meet a variety of types of people and learn to interact with members of the community and build trust. This will be essential for the women once they are required to leave the house and be self-sufficient. In conclusion, many of the external influences allow the women to integrate back into the community by meeting new people to broaden their ability to trust and communicate effectively. Although the women are highly encouraged, and to some degree, required to facilitate external relationships due to employment or education, the women also have strong internal relationships and influences within the house. The women are able to communicate and confide in the staff, and the staff in turn poses efforts to gain and keep the trust of the residents to help

HEALTH PLANNING them succeed. The house residents also interact heavily with each other by cooking together, playing games, participating in other group activities, and having long conversations about their interests. Although the womens transportation options are limited, Barrett House does have access to a van which is used frequently to take the women to certain group activities, such as mock job interviews to help them practice interpersonal skills and to teach them how to showcase their strengths to obtain employment. This influences the women by allowing them several opportunities to better themselves so that they can be self-sufficient. Another internal contribution to the women is the access to a computer in the house so that the women may research job opportunities, do homework, or participate in other productive online activities.

Food access in the house also contributes to the characteristics of the women who live there. The abundance of pastries and breads available to the women influences the women by encouraging them to either develop or sustain poor eating habits, which contributes to poor health. In conclusion, it is evident that many of the internal influences allow the women to have a safe and comforting haven to come home to, in which they can interact with familiar and trusted people to remove themselves from their individual life stressors. In contrast, the internal influence of the high availability of sugary snacks negatively impacts the women by promoting poor eating habits. Assessment: Literature Review There are many factors within the women of Barrett House that contribute to their health and emotional status. Some of the factors that contribute to their physical and emotional heath include: depression, homelessness, feeling that they have lack of control over their life, access to healthy food, loss of identity, and inactivity. Deficient knowledge related to healthy food choices seems to play a major role in how they manage their health, which in turn affects their

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mental health. Health problems that are found among low socioeconomic populations include but are not limited to, hypertension, diabetes, heart disease and obesity. Upon assessment of the overall characteristics of Barrett House, it was observed that powerlessness was a common theme found among the women. Many of the women in the house are African American, and in talking to the director of the house, this minority group has the largest amount of occupants on a continual basis. A current research study hypothesized that lifemanagement and group enhancement interventions would help minority homeless women overcome homelessness. The study aimed to identify if group interventions and social interaction would help the feeling of hopelessness and guide the women towards self-confidence and personal control. They found that the women who participated in the intervention groups showed greater confidence, a heightened sense of control, and used this to further enhance their health, social and self-management skills (Washington, Moxley & Taylor, 2009). Similar group interventions are provided to the women of Barrett House to assist with empowerment. If the women are not able to overcome hopelessness, they will struggle in coping with other issues, such as nutritional deficits which will be discussed next. Studies have shown that obesity continues to be a leading cause of public health problems, particularly among low-income women. This correlates with our aggregate, because the majority of the women are obese. A relevant study that will be discussed focused on health and eating behavior differences between lean/normal and overweight/obese low-income women living in food-insecure environments (Dressler & Smith, 2013). According to the United States Department of Agriculture (2013), food insecurity is defined as consistent limited access to adequate food by lack of money and other resources at times during the year. Because the women of Barrett House are at the mercy of donations and have a low income, they are living in

HEALTH PLANNING a food insecure environment. The study found that there were many factors that contributed to

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the rising rates of obesity among low income women; the most prominent being aberrant eating behaviors, or emotionally-controlled eating behaviors (Dressler & Smith, 2013). This is a potential issue for the women of Barrett House, because many of them suffer from emotional instability. It was also found that the higher the body mass index, the less the women seemed to know about healthy eating habits. In addition, the participants of the study had the misconception that weight control had to do more with genetics rather than healthy eating and exercising (Dressler & Smith, 2013). These two findings were consistent with the beliefs of the aggregate after student assessment. Assessment: Comparison with Other Communities As mentioned previously, the health status of the women of Barrett House is common in that all of them consume foods which have low nutritional density, and are high in calories, fat, and sugar. In addition, most of the aggregate is overweight or obese. Some of the women also suffer from hypertension, diabetes, and hyperlipidemia. In addition, the women participate in minimal physical activity. It is possible that the root for health-related deficits is due to the lack of empowerment and low quality of life of the residents. Statistics of the nation, state, and local community reflecting quality of life and health deficits will be discussed to address both issues. According to the Centers for Disease Control, adult obesity rates show that over one-third of people in the United States are obese, including the homeless women population (Centers for Disease Control, 2013a). These numbers are higher among those with low socioeconomic status, and non-Hispanic blacks, which are groups of which most women in the Barrett House are a part. In Virginia, the obesity rate is 27.4 percent. Locally, in the Hampton Roads area, the obesity rate is around 29 percent (Council on Virginia's Future, 2013). These rates make sense considering

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Americans as a whole consume food with high calories and low nutrients. In fact, in Virginia, the average person eats 1.1 fruits per day, and 1.7 vegetables a day (Centers for Disease Control, 2013c). Observation shows that the women at the Barrett House eat a similar number of fruits and vegetables a day. Physical inactivity factors into the obesity rates as well, with only 20.6 percent of Americans getting the daily recommenced activity (Centers for Disease Control, 2013b). Our aggregate has lower percentages than this, with little to no aerobic and muscle building activity on a daily basis due to a multitude of factors. Overall, the Barrett House reflects the patterns of nutritional deficit and obesity present in the US. Quality of life statistics will be discussed in relation to the nation, state, and local community. The Better Life Index (BLI) measures life satisfaction, which encompasses quality of life related to health, education, income, personal fulfillment, and social conditions. For the United States, Americans rated a BLI at an average of 7 out of 10, with 83% reporting more positive as opposed to negative experiences during their day. It was found that increased education yielded and increased BLI with no gender differences (OECD, 2013). For local data, various statistics will be examined of the Hampton Roads area that is a direct reflection of quality of life, such as statistics of crime rate, unemployment, suicide, and education. Crime rate in the Hampton Roads area is above average with a rate of over 3,000 incidents per every 100,000 people, as compared to the state average of 2,250. Unemployment is below average compared to state at 6.6%. Suicide is ranked as the third lowest rate in Virginia, and education is ranked second highest for high school diploma achievement. Hamptons roads is ranked third highest in the state for bachelors degree achievement (Hampton Roads Performs, 2013). All of these statistics are a direct reflection of quality of life in the area. Educational and employment data of the aggregate has already been discussed, and because the students are still in the process

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of establishing rapport with the residents, statistics of crime rate and suicide cannot be compared with local data. Therefore, further investigation of quality of life for the purpose of empowerment is indicated. Assessment: Identification of Health Problems Prior to meeting the aggregate, the students hypothesized possible nursing diagnoses based on the specific criteria that determined the aggregate; such as homelessness, domestic violence, and drug abuse. Based on this, the students hypothesized possible nursing diagnoses in the psychosocial category. After meeting with the aggregate, the women identified that they would like to work on better eating and nutritional habits along with the incorporation of exercise. Upon actual assessment of the aggregate, the students agreed that psychosocial issues had a profound impact in the all of the womens lives as previously hypothesized. The students felt that focus of nursing diagnoses and intervention of the aggregate should be based both on the desires of the women and assessment made by the students. Henceforth, the two nursing diagnoses determined by students were: altered nutrition and readiness for enhanced power. Because altered nutrition and related factors have been discussed previously, the focus will be on the diagnosis of readiness for enhanced power. Readiness for enhanced power is defined by NANDA (2013) as a pattern of participating knowingly in change that is sufficient for well-being and can be strengthened. The priority and precedence for the nursing diagnosis of readiness for enhanced power was determined by the first meeting between the students and Barrett House management. During the meeting, Barrett House management suggested that individualized attention was necessary for all members of the house, but management identified that it could not be provided due to a lack of manpower. As noted previously, it was decided that pairing up each nursing student with a

HEALTH PLANNING member of the house would be beneficial by providing individualized care to the women. The priority determinant that solidified readiness for enhanced power as an appropriate nursing

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diagnosis was managerial report of the womens excitement and eagerness of working with one student. Another factor that helped the nursing students solidify readiness for enhanced power as a priority was a rapid increase in the morale of house members when the students decided to hold a potluck (as previously mentioned) and take a day on the weekend to conduct yard work. Management reported a significant boost in morale after student involvement in both of these cases. In addition, the students observed the womens boost in morale during both of these activities. The following study by Speirs, Johnson, and Jirojwong (2013) conducted a systematic review on studies that focused on specific interventions for homeless women. The interventions included both physical and psychosocial. The study explained that women become homeless as a result of domestic violence, abuse, and financial misfortune. While there are temporary places offered to homeless women, it was found that women became more psychologically distressed by living in temporary settings. The studys aim was to identify appropriate interventions that community nurses can implement to support homeless women within the community. Effective interventions identified in the study were structured group sessions, therapeutic community, and advocacy. Structured group sessions provided health teaching to the women and also provided them with community resources; some of the sessions included cognitive behavioral therapy, which included coping skills, negotiation skills, and challenged their motivation. Therapeutic communities allowed for women to be isolated from any harmful relationship and to live with other homeless women. Advocacy allowed for one-on-one sessions or personalized group sessions. All of these interventions encouraged empowerment and decreased the incidence of

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psychological distress among the women (Speirs et al., 2013). The women at Barrett House are provided with a therapeutic community, group sessions that are held every Tuesday and Thursday, and now, advocacy within the nursing students one-on-one meetings. The study is applicable to the women of Barrett House in that structured interventions, which are currently being implemented by management and the nursing students, are beneficial in encouraging empowerment. Based on the womens participation and fulfillment of the structured requirements and interventions to be a resident of Barrett House, the students can identify readiness for enhanced power within the women. The article titled Correlations between spirituality and health-promoting behaviors among sheltered homeless women correlates very well with the aggregate. The study examined the relationship between spiritual empowerment and health-promoting behaviors in a convenience sample of 90 sheltered homeless women (Hurlbut, Robbins, & Hoke, 2011). The research proved that there is a positive correlation between spiritual well-being and overall health promoting lifestyle (Hurlbut et al., 2011). The findings of the study suggest that the nursing students should first do interventions of empowerment for the women so that physical health improvement will follow. Planning: Nursing Diagnosis The priority nursing diagnosis for the aggregate was readiness for enhanced power related to the desire to take control over life decisions, as evidenced by the willingness and action of the aggregates fulfillment of the Barrett House residential requirements. The first measurable objective for the aggregate is that the individuals are able to identify issues of powerlessness, hopelessness, or other personal issues by March of 2014. The second objective for the aggregate is that they will identify three coping mechanisms for the identified issues by

HEALTH PLANNING April of 2014. The last objective is that the aggregate will implement or begin to implement coping mechanisms by the end of the semester; May of 2014.

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In order to accomplish the objectives stated above, specific interventions directed toward empowerment will be implemented. Power is defined as the ability to exercise control over ones life situation (Hildebrand & Markovic, 2007). The overall goal of the nursing interventions will be to empower the women. When individuals feel empowered, they are more able to take control over identified problems (Thomas & Gonzalez, 2009). As further identified by Thomas & Gonzalez (2009), a perceived control over ones life situation leads to less emotional stress. Some of the specific interventions that will be used with the aggregate include: assessing the aggregates needs for control, developing positive relationships that can promotes empowerment, assisting the aggregate in identifying resources that are needed in accomplishing individual goals, helping individuals within the aggregate identify those situations that may cause them feelings of powerlessness, and promotion of the sense of empowerment by allowing the aggregate to take control of their environment. When the aggregate is able to identify those situations that make them feel powerless, they are indirectly taking control of their life situation. This self-awareness will promote empowerment (Hildebrand & Markovic, 2007). Planning: Alternate Interventions There are several alternative interventions our group can implement in order to accomplish this goal. One of the interventions is the Photo Voice Project, in which the women are each given a disposable camera. Then, throughout the week, they take pictures of what is important in their own life. Captions are then written for each picture and the women can explain why it is important to them. This project is excellent for empowering the women at Barrett House, because it gives them a chance to tell their own stories. The women can show life from

HEALTH PLANNING their perspective through images, which may be more rewarding and less intimidating than writing their stories out on paper. Photo Voice has the potential to give the women at Barrett

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House a voice, possibly the first one they have had during their lifetimes. It will give the women a sense of accomplishment as they take control of their stories and their lives. In addition, it will give the students insight into the womens lives so that they are better able to assist them with empowerment. Once the aggregate has become empowered, alternative interventions of nutritional enhancement will be implemented to fulfill the womens desires. Alternative interventions like a recipe exchange can be used to encourage healthy eating. With this intervention, Barrett House women will place their favorite recipes in an envelope for the students to view. After reviewing the recipes, the students can suggest healthier substitutions while still keeping the same great flavor of the womens favorite foods. Another option is to create recipes with the food readily available in Barrett Houses B-Mart. This intervention will be the most effective, because the women will know that they already have the necessary resources for healthy meals. Using resources and saving money will empower the women to make healthier meal choices. In the end, teaching the women to make better food choices will give them a sense of control of their health status and ultimately their lives; thus further creating empowerment. Conclusion After vigorous assessment of the Barrett House residents, various conclusions were made by the nursing students. Firstly, the women all seemed to display a readiness for enhanced power. This portrayal of readiness led the students to consider interventions of empowerment, including interventions such as: promoting positive relationships, identifying resources, and promoting the expression of feelings through the Photo Voice project. Assessment of the

HEALTH PLANNING residents also revealed that the women both needed and wanted nutritional advice and intervention. The students recognized that interventions of empowerment would also empower the women to make better health-related decisions. The students planned additional alternative

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nutritional interventions to meet their needs and further encourage empowerment. Interventions of empowerment and nutritional advice have already been initiated by the students, with plans to fully carry out the interventions during the next semester.

HEALTH PLANNING References Centers for Disease Control. (2013a). Adult obesity facts. Retrieved from http://www.cdc.gov/obesity/data/adult.html Centers For Disease Control. (2013b). Exercise or physical activity. Retrieved from http://www.cdc.gov.nchs/fastats/exercise/htm Centers For Disease Control. (2013c). State indicator report on fruits and vegatables 2013

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[PDF]. Retrieved from http://www.cdc.gov/nutrititon/downloads/State-Indicator-ReportFruits-Vegetables-2013.pdf Council On Virginias Future. (2013, November 14). Obesity. Retrieved from http://vaperforms.virginia.gov/indicators/healthfamily/obesity.php Dressler, H., & Smith, C. (2013). Health and Eating Behavior Differs Between Lean/Normal and Overweight/Obese Low-Income Women Living in FoodInsecure Environments. American Journal Of Health Promotion, 27(6), 358-365. Hampton Roads Performs. (2013). Healthy & Family. Retrieved from http://hampton roadsperforms.org/extras/Scorecard/HR-Scorecard.htm Hildebrand, J., & Markovic, D. (2007). Systemic therapists' experience of powerlessness. Australian & New Zealand Journal Of Family Therapy,28(4), 191-199. Hurlbut, J. M., Robbins, L. K., & Hoke, M. M. (2011). Correlations Between Spirituality and Health-Promoting Behaviors Among Sheltered Homeless Women. Journal Of Community Health Nursing, 28(2), 81-91. doi:10.1080/07370016.2011.564064 NANDA (2013). Defining the Knowledge of Nursing. Retrieved from http://www.nanda.org/ Speirs, V., Johnson, M., & Jirojwong, S. (2013). A systematic review of

HEALTH PLANNING interventions for homeless women. Journal Of Clinical Nursing, 22(7/8), 1080-1093. doi:10.1111/jocn.12056 The Organization for Economic Cooperation and Development (OECD). (2013). Life Satisfaction. Retrieved from http://www.oecdbetterlifeindex.org/topics/lifesatisfaction/ Thomas, S. A., & Gonzalez-Prendes, A. (2009). Powerlessness, anger, and stress in African

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American women: Implications for physical and emotional health. Health care for women international, 30(1/2), 93-113. doi:10.1080/07399330802523709 United States Department of Agriculture. (2013, September 04). Economic research service, food security in the U.S. Retrieved from http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-theus.aspx United States Census Bureau. (2013). Retrieved from http://factfinder2.census.gov/faces tableservices/jsf/pages/productview.xhtml?pid=ACS_12_3YR_NP01&prodType=narrative_profi le Washington, O., Moxley, D., & Taylor, J. (2009). Enabling older homeless minority women to overcome homelessness by using a life management enhancement group intervention [corrected] [published erratum appears in ISSUES MENT HEALTH NURS 2009 May;30(5):351]. Issues In Mental Health Nursing, 30(2), 86-97. doi:10.1080/01612840802597580

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Appendix A Windshield Survey Form Observers: Seun Aransiola, Amanda Coffin, Joseph Crossman, Sid Eugene, Natalie Eyer, Jessica Fluharty, Vanessa Gonzales, Emily Plemmons, Kayla Vadney, and Jenifer Wessling Weather: Sunny, warm, some clouds Temperature: 80 degrees or so City: Norfolk, VA Neighborhood: Ballentine Place Day/Date/Time: Day and evening hours a few times between 8/29/13 and 9/19/13

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A. Neighborhood Boundaries What are the boundaries of the neighborhood? The Barrett House is located on Vincent Ave in Norfolk. Although according to Norfolk City Neighborhood Maps Barrett House is located within the boundaries of Ballentine Place neighborhood, there is no sign or obvious boundaries. The house sits on the border of the official southern boundary line with three blocks to the west and about a mile north and east. However, it is very difficult to distinguish these boundaries in person and where the map says there are other neighborhoods, it appears in person to be part of Barrett Houses community. The boundaries of the specific property of Barrett House include the house itself, both a front and back yard, as well as an adjacent parking lot and field. Are there commercial streets or areas? The Barrett House can be found right off of Princess Anne road and is also near Military Highway. The nearest shopping center is on Military Highway. Other than the shopping area on Military, there are a few businesses such as: FishnFin, a seafood and chicken restaurant, and Hardees. Does the neighborhood have an identity, a name visible? There is no neighborhood name visible; just the street name. The house does however have a sign on the fence that reads, Barrett House. The sign appears to be hand made by the residents.

B. Housing What is the age of the houses, type of architecture, construction material of houses? How many stories? Most of the houses immediately surrounding the Barrett house are post war houses made in the 50's to

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60's. Most are traditional minimalist or small ranch houses. Some houses are brick, others appear to be vinyl siding, and most are small two stories. Further out from the Barrett house there are some town homes that appear to be in construction. There are also some larger two-story homes around Vincent avenue which are vinyl and appear to be made in the 80's-90's. Are there single, multifamily dwellings, mobile homes?

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Most are single-family homes, which are freestanding. There are some homes, which connect and hold two to three families. The Barrett house appears to be one of the only homes, which holds multiple adults. Do houses have space/lawns around them? Are they well groomed? Many of the houses have fairly large lawns with front and back yards, and an average amount of space in between them. Yard grooming really depended on the house, some had well manicured lawns and others had higher grass and junk in the yard. What is the general condition of the houses? Are there signs of disrepair (broken doors, windows, railings)? Generally, the houses are in fair condition. Some of the houses had peeling paint and cracked steps. There are some businesses that are on the same street, however, which are in disrepair. Are there cars in the driveway? Does it appear everyone is at work? It appears most people are at work that live in the homes. However, while I was driving I noticed multiple people walking, sitting, or bike riding on the street, a couple of which were drinking out of brown bags. Are there vacant houses, boarded up or dilapidated buildings? There did not appear to be any vacant houses. But there were some buildings on the same street as the Barrett house which had boarded up windows and peeling paint. Are there many houses for sale? The neighborhood did not appear to have an issue with large amounts of houses for sale, or foreclosed upon. Are there streetlights, sidewalks, curbs, gutters, open drainage ditches? There were streetlights, sidewalks, curbs and gutters in the area surrounding Barrett house.

C. Open Spaces How much open space is there? There was not a lot of open space. Most space was occupied by buildings, houses and parking lots. The

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open space I saw were just random small fields of grass scattered throughout the area. Are there parks and recreational areas in the neighborhood? Are they lighted? There is one park in the area that includes playground equipment and a basketball court, but this area is not lighted. There are several schools nearby which have lighted recreational areas. Is the open space public or private? Who uses it?

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These spaces are public and it appears a great deal of people use them on any given day. More people were using the neighborhood park rather than the school recreational areas from what I could tell. These people included young adults and children. Is there trash, rubble, or abandoned cars in the open spaces? I did not see any abandoned cars but there was a bit of litter surrounding the area.

D. Shopping Areas What types of stores are in the area (shopping centers, neighborhoods stores, grocery stores, drug stores, laundries, etc.)? There are several fast food restaurants, a tax center, a community center that is currently under construction; a bank, a convenience store, and a barber shop were all within walking distance. Fast food restaurants consisted of 2 fried chicken chains and a seafood restaurant. How are these resources distributed in the area? Are they spread throughout? The shops are located in clusters of 2-3 in close proximity with spaces of parking lots or houses in between. Are there ethnic stores, ones that display other than English language? There are no ethnic stores, or stores that display languages other than English. Do signs advertise tobacco, alcohol? Yes, the convenience store displayed advertisements for both alcohol and tobacco.

E. Schools Are there schools in the neighborhood? Are they public or private? There are many schools in the area for all ages, both public and private Are there play areas, sports fields connected to the schools?

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There are play areas at the elementary schools and sports fields/areas at the middle and high schools. Is graffiti evident in the schools? I did not see any graffiti on any of the schools. Do the school grounds appear to be well-kept?

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Yes, the whole area looks as though it is being built up so besides the construction areas it is a maintained area. Are there school bus stops or crossing guards? There were not specific bus stops. There were some stops on corners of the streets and then some buses stopped in front of houses. There were crossing guards and uniformed police officers directing traffic in front of some of the schools, mainly the public schools. Police officers directing traffic in front of some of the schools, mainly the public schools. Schools in the area: Tidewater park elementary school PK-5 Ruffner Middle School 6-8 Richard Bowling Elementary School PK-5 Noahs Ark Christian Preschool pK Mcdonald Montessori PK-3 Lindenwood Elementary School PK-5 Jacox Elementary School PK-5 Hunton YMCA Day Care Center PK Hearld of His Coming Child Care PK Grandy Village head Start Center PK GOP Busy Bee Child Care Center PK Faith Academy School Of Excellence PK K-8 Dreamkeepers Academy at J.J. Roberts Elementary School PK-5 Chesterfield Academy Elementary School PK-5 Calvert Square head Start PK

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B.T. Washington high School 9-12 Virginia Virtual Academy K-8

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F. Religion What churches to do you see? Who uses the churches? There are ten churches in a two mile radius from the Barretts House. This is very ideal for the women in the house because they can walk to a church of their choosing, if they decided to attend any of these churches. The people in the community use these churches. The denomination of these churches ranges from Baptist, Lutheran and Episcopal. Do you see evidence of their use for other than purely religious purposes? No, from what I can gather the churches are used purely for religious purposes.

G. Human Services Where are hospitals and health services located in relation to the neighborhood?

Sentara Norfolk General Hospital 600 Gresham Drive, Norfolk, VA - 3.3 miles CHKD 601 Childrens Lane, Norfolk, Va - 3.3 miles Sentara Leigh Hospital 830 Kempsville Road, Norfolk, VA - 4 miles Bon Secours Depaul Medical Center 150 Kingsley Lane Norfolk, Va 23505 - 4 miles

Are there physician offices, health clinics or centers, dentist offices? Yes Physician offices/health clinics/centers:

Sentara Health Systems 1151 Azalea Garden Rd, Norfolk, VA 23502 (757) 857-8100 - 2 miles Carroll Hospital Center 500 E Main St, Norfolk, VA 23510 (757) 823-7826 - 3 miles Fresenius Medical Care (Dialysis) 1902 Omohundro Ave, Norfolk, VA 23517 (866) 4342597 - 3 miles Norfolk Health Department 606 W 29th St, Norfolk, VA (757) 683-9230 - 4 miles Planned parenthood (family planning) 425 W 20th St, #6, Norfolk, VA (757) 624-9224 3.5 miles James L Watson DDS Jr 703 E Virginia Beach Blvd, Norfolk, VA 23504 (757) 6223391 - 2 miles

Dentists:

Are there alternative medicine centers (acupuncture, massage, etc.)? I didnt see any that were located around the house or in the local neighborhood.

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Are spiritualists advertised? I didnt see that they were clearly advertised. Memorial Spiritualist Church 307 W 37th St, Norfolk, VA 23508 (757) 622-5070 Are social agencies (welfare, WIC, social services) available? Human Services 741 Monticello Ave. Norfolk, VA 23510 Ph: 757-664-6000 (welfare and social services) Norfolk City Wic office 830 Goff St, Norfolk, VA (757) 683-9280 Are there senior centers and child care facilities? Senior centers: Norfolk Senior Center 924 W 21st St, Norfolk, VA 23517 (757) 625-5857 4miles **not really walking distance Child Care facilities: Kingdom Kidz 1228 Lead St, Norfolk, VA 23504 (757) 313-0329 New Hope Day Care 1401 Tidewater Dr, Norfolk, VA 23504 (757) 961-6643

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H. Transportation How do people get in and out of the neighborhood (car, bus, train, bike, walk)? Barrett house is located in Vincent Avenue of Norfolk Virginia (VA) off E Princess Anne Rd and Ballentine Boulevard. People get in and out of Vincent Avenue Norfolk, VA through cars, buses, train, bikes and by walking. Are the streets and roads conducive to good transportation and to community life? The streets and roads around Vincent Avenue are conducive to good transportation and community life. Are the streets in good condition? Are they paved? Gravel? Brick? Dirt? Most of the streets are in good condition, they are paved with limited sign of dirt and road damages. Are formal bus stops or public transportation signs visible? Bus stops and public transportation signs are visible on the street. Is public transportation available? If so, how frequently? The mean of public transportation to the area are both HRT buses and light rail. Two buses (bus 18 and 23) travel between Ballentine Boulevard and Princess Anne road. There are three bus stations nearby Vincent Avenue all within few yards of Barrett House. The frequency of the bus ride are 17 times/day

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with an interval of 1 hours between each stop. A light rail station with a park and ride lot is also located on Ballentine Boulevard. The light rail usually makes about 43 stops daily at this station with an average of 15 minutes between each stop. Detail information about the bus and the light rail route can be found on the link below. http://www.gohrt.com/routes/route-18.pdf http://www.gohrt.com/routes/lightrail-schedule.pdf Is this a high-traffic area? Are speed limit signs or speed zones posted? Vincent Avenue is a high traffic area, because it is located off two major roads which are Ballentine Boulevard and E Princess Anne Rd. The area is also located close to Norfolk State University. Speed limit signs are posted on the street. Is there a major highway near the neighborhood? Whom does it serve? I- 264 W and 264 E is a major highway around this area. I- 264 W serve commuters from Virginia Beach to other Hampton roads area and I-264 E serve commuter from Norfolk to Virginia Beach area.

I. Protective Services What evidence do you see of police, fire, and emergency services? The Norfolk Police Department is about a mile away from Barrett house on Virginia Beach Blvd. The closest fire department is about a mile and a half away from Barrett house on Virginia Beach Blvd. The closest hospital is Norfolk General Hospital, which is about 3-5 miles from Barrett house, about a 10-15 minute drive. There does not seem to be a Patient First or anything similar in the area. Are there fire station houses, fire hydrants? Yes, there is a fire station about 2 miles away on Virginia Beach Blvd. There are many fire hydrants throughout the area; there seems to be at least 1 per street. Do houses have security systems? About 1/4 of the houses in the area have some sort of sign displayed in their yard advertising a security system. Is there evidence of Neighborhood Watch programs? There is no evidence of these types of programs visible or apparent to the public. Are there emergency shelters for neighborhood use (e.g., tornado shelters)? There are multiple schools in close proximity that can be utilized in times of emergency such as Ballentine Elementary and Richard Bowling Elementary school, each less than a mile away from Barrett

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house.

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J. Neighborhood Life Whom do you see on the streets (women, men, mothers with children, teenagers, elderly)? Most of the people on the streets are African American adult men who appear to be between the ages of 20-60. In daylight hours, there are some women and children in their front yards, but they do not seem to be outside after dark. What ethnic groups are part of the neighborhood? Bilingual signs? The neighborhood consists mostly of African Americans and a few Caucasians. There are no bilingual signs. Are there informal gathering places/hangouts? What are they? For whom (teens, men, etc.)? African American men between 20- 40 gather on porches in front of their houses. The groups consist of three to four members. Members of the community also gather at the local market up the street. Are there social clubs or cultural organizations? The area around the Barrett house does not seem to have any social clubs or cultural organizations. Is there evidence of interaction among neighbors? Yes. Neighbors occasionally speak with each other in passing and when gathered in groups. Is there evidence of homelessness? There is not any sign of homelessness around the Barrett House. What animals do you see (stray dogs, watch dogs)? There are stray cats roaming the neighborhood. I did not see any other animals. Are there parks or other recreational facilities in the neighborhood? Public or private? There is a park in the neighborhood. It does not have any signs posted that it is a private area.

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Honor Code

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The Honor Pledge: "I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of the academic community, it is my responsibility to turn in all suspected violators of the Honor Code. I will report to hearing if summoned."

Signature: Seun Aransiola, Amanda Coffin, Joseph Crossman, Sid Eugene, Natalie Eyer, Jessica Fluharty, Vanessa Gonzales, Emily Plemmons, Kayla Vadney, and Jenifer Wessling

Date: 12/10/13