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Running head: KUTZTOWN EPIDEMIOLOGICAL STUDY

Kutztown Epidemiological Study

McKenzie Miller and Julianna Brauchle

Cedar Crest College

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KUTZTOWN EPIDEMIOLOGICAL STUDY
Abstract

Epidemiology is the study and analysis of the distribution and determinants of health and disease

conditions in defined populations. An epidemiological study was done on Kutztown,

Pennsylvania in three parts. The first part included a windshield survey, which detailed and

described Kutztown from an outsider perspective. Next, a collection of the specific data

surrounding Kutztown ensued. Using these details, intervention guidelines were able to be

compiled, in which problem areas for residents of Kutztown were determined. The specific

problem area outlined in this paper is poverty among Kutztown residents. This led to the nursing

diagnosis of high incidence of mortality from diseases including heart disease, cancer, stroke,

and chronic lower respiratory disease related to poverty and increased unemployment rate as

evidence by decreased income per capita and decreased median household income. A goal was

then established in order to decrease poverty in the community, along with interventions to put in

place in order to attain this goal. Methods of evaluation were then created.

Keywords: epidemiology, epidemiologic study, interventions, goals, evaluation

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KUTZTOWN EPIDEMIOLOGICAL STUDY
Kutztown Epidemiological Study

Kutztown is a borough located in Pennsylvania that was established in 1815 (Kutztown

Area Historical Society, n.d). The purpose of an epidemiological study is to understand what risk

factors are associated with disease, and how this can be prevented in groups of individuals

(Kintera, 2008). An epidemiologic study was conducted on Kutztown to determine a problem

area, form a nursing diagnosis, establish a goal, propose interventions, and establish a means of

evaluation of the goal.

Problem Identification

In order to identify a problem for the Borough of Kutztown, the data collection was

utilized. According to the data presented, Kutztown’s poverty rates were significant when

compared to Berks County. Data showed that Kutztown’s poverty rate was 23.5%, while Berks

County’s poverty rate was only 13.1% (U.S. Census Bureau, 2016). Furthermore, the per capita

income was over $4,000 lower in Kutztown, being $23,204 compared to the $27,844 of Berks

County, with a median household income of $46,288 compared to Berks County’s median

household income of $57,068 (U.S. Census Bureau, 2016). Because of this, poverty was

identified as a critical area of worry.

Poverty is a major concern for all nurses, including public health nurses. It is imperative

to not only prevent, but intervene when poverty is a dilemma in the community due to the

implications it can have on health. Nurses have helped the poor and impoverished since the

Elizabethan Poor Laws in the seventeenth century (Stanhope & Lancaster, 2016). Additionally,

nurses encounter those who are poor on an everyday basis in homes, schools, clinics, and

hospitals, so it is important nurses can provide effective care and advocate for these individuals

(Stanhope & Lancaster, 2016). These reasons contribute to the need for nurses to understand the
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complexity of poverty, while also understanding the multifaceted challenges that the povertous

face (Patterson & Hulton, 2011).

Poverty is such a concern for nurses due to the fact that it has substantial effects on health

and well being. According to Cohen and McKay (2010), it is argued that nurses have an

obligation to be involved in activities that involve health inequities and social condition that

contribute to development, including poverty. Poverty is included as a social determinant of

health, and in turn, a major Healthy People 2020 objective and target (United States Department

of Health and Human Services, 2014). Because those who are living in poverty may have

decreased access to healthcare due to lack of pay and lack of insurance, overall health is affected

(Stanhope & Lancaster, 2016). For example, according to Stanhope and Lancaster (2016), those

living in poverty can have higher rates of chronic illness, higher infant morbidity and mortality,

shorter life expectancy, more complex health problems, more significant complication and

physical limitation from chronic diseases such as asthma, diabetes, and hypertension,

hospitalization rates greater than those for persons with higher incomes.

This was proven to be true for Berks County, the county in which the Borough of

Kutztown resides. The major causes of death in Berks County included heart disease, with 165.7

deaths per 100,000, cancer with 161.0 deaths per 100,000, stroke at 49.4 deaths per 100,000, and

chronic lower respiratory disease with 38.1 deaths per 100,000 people (Pennsylvania Department

of Health, 2016). Additionally, poverty affects people across their lifespan, including children.

Studies found that children with poverty stricken parents did worse on standardized reading and

math scores, and also had more aggressive and withdrawn behaviors, which often resulted in

completing less schooling, working less, and earning less as adults (Magnuson, 2013). It is also

important to note that those living in low income households have been found to be less likely to
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change their dietary habits, as food prices continue to rise, leading to higher rates of childhood

obesity (Chiverton, 2011).

Given the significance of poverty on health and overall welfare, and the statistical

difference between the Borough of Kutztown and Berks County, poverty was the most

substantial concern and the focus of the epidemiology study due to the influence it has on health

and disease processes.

Nursing Diagnosis

A nursing diagnosis was created in order to clarify the prioritized problem and identify

the various factors that can be contributed to the issue (Stanhope & Lancaster, 2016). The

nursing diagnosis created for this epidemiology was as follows: High incidence of mortality from

diseases including heart disease, cancer, stroke, and chronic lower respiratory disease related to

poverty and increased unemployment rate as evidence by decreased income per capita and

decreased median household income. The nursing diagnosis was then used to create a further

plan of care and establish nursing interventions to decrease poverty in the selected area.

Goal

In order to decrease rates of diseases as well as poverty rates in the Borough of

Kutztown, various goals need to be established. One crucial goal is to decrease the incidence and

minimize the effects of various diseases that can be affected by poverty rates by implementing

various interventions. Another goal is to identify and combat the causes of poverty in Kutztown.

Various causes of poverty included decreased earnings and increased unemployment rate. Other

causes of poverty that could be affecting the Borough of Kutztown include changes in labor

force, increased female headed households, and inadequate antipoverty programs, as explained

by Stanhope and Lancaster (2016). An additional goal is to increase pay equity, increase
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minimum wage, and prevent health disparities, which can be accomplished with aid and

assistance of local and state governments over time. By implementing primary, secondary, and

tertiary nursing interventions, these goals and objectives can be met and change will follow.

Proposed Interventions

Interventions were implemented in order to meet the previously stated objectives in order

to decrease poverty rates in the Borough of Kutztown. Primary, secondary, and tertiary

interventions were used and will be discussed in detail.

Primary Interventions

Primary interventions can be implemented in order to prevent the occurrence of diseases

due to poverty and focused on health education and promotion programs (Stanhope & Lancaster,

2016). The first primary intervention to be implemented is education programs for residents of

all ages. It is imperative to educate the community from the age of small children to older adults

about the importance of preventing diseases before they occur, especially because of the effect

poverty can have on health. Education programs will be tailored to prevention of diseases such as

Human Immunodeficiency Virus (HIV) and Hepatitis C through needle reuse or sharing, as well

as heart disease, stroke, and hypertension in relation to nutrition and exercise.

HIV and Hepatitis C are two diseases that can be spread through needle sharing or needle

stick injuries (Ignatavicius & Workman, 2013). Hepatitis C can cause lifelong debilitating health

problems such as chronic inflammation of the liver, causing complications in the future resulting

in organ transplantation, and HIV can lead to AIDS and ultimately death (Ignatavicius &

Workman, 2013). Those who are facing a poverty stricken lifestyle may be at an increased risk to

develop these two diseases due to the lack of supplies or ability to pay for such supplies like

needles to manage diseases like diabetes (Stanhope & Lancaster, 2016). Because of this, needles
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may be reused or shared. It is important to educate individuals about preventing HIV and

Hepatitis C by disposing of needles after one use as well as not sharing other individual’s needles

(Stanhope & Lancaster, 2016).

Education regarding nutrition is also a critical primary intervention that can be utilized by

people of all age groups, from young to old. Education regarding nutrition can begin in daycare

settings, preschools, elementary through high school levels, and be implemented for adults to the

elderly population. Nutrition can greatly prevent the occurrence of certain diseases, but healthy

choices are often unattainable for those living in poverty because of the lack of funds to purchase

health foods, increasing rates of obesity among impoverished individuals (Levine, 2011). With

unhealthy food choices comes obesity, and obesity-associated chronic illnesses account for about

70% of the United States health care costs (Levine, 2011). Obesity often leads to chronic

conditions such as hypertension, hyperlipidemia, cardiovascular disease, and asthma, a few of

which were the major sources of mortality in Berks County (Levine, 2011; Pennsylvania

Department of Health, 2016).

Because of the unquestionable correlation of poor nutrition to development of diseases,

education must be provided to the community. Overall healthy diet choices can be discussed

with a focus on food choices regarding the prevention of heart failure and heart disease because

it was the number one cause mortality in Berks County with 165.7 deaths per 100,000 people

(Pennsylvania Department of Health, 2016). By collaborating with a dietician, nurses can

educate the community regarding choices for this specific disease process. An important

education point is restricting sodium, which can be implemented to prevent and decrease

exacerbations of heart failure, a tertiary intervention. However, to prevent heart failure,

hypertension, and obesity from occurring initially, it is important to educate individuals and
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families to avoid salty foods when possible and try lemons, spices, and herbs to enhance the taste

of low-salt foods (Ignatavicius & Workman, 2013). The American Heart Association (2015)

suggests fruits and vegetables, whole grains, low-fat dairy products, poultry and fish, nuts, and

vegetable oils, as well as limiting saturated and trans fats, sodium, red meats, and various sweets

and sugar. By doing this, obesity, hypertension, and heart failure can be avoided before it

becomes a problem and causes even more financial stress to individuals and families.

There are also collaborative measures nurses can partake in order to ensure proper

nutrition for individuals who are living in poverty. Working with nutrition department at local

colleges can be a successful intervention that allow nurses and student dietitians to prevent

diseases before they occur and focus on community health. Cedar Crest College has a nutrition

program that could be utilized in order to give those living in poverty the best chance of primary

prevention (Cedar Crest College, n.d.). Additionally, Kutztown has two large grocery stores in

the area that can be a good source of collaboration due to the previously implemented programs

the companies have. For example, both companies have in-house dieticians, attend health fairs,

and also have seminar and cooking demonstrations that can assist residents living in poverty to

cook the healthiest meal they have with the food and products they have (Weis, 2018; Giant,

2018).

In order to prevent diseases, education regarding the importance of exercise is also

imperative for residents. Lack of exercise was attributed to being one of the major causes of

chronic diseases including congestive heart failure, hypertension, type 2 diabetes, and cancer

(Booth, Roberts, & Laye, 2012). By educating the public about the consequences of decreased

physical activity, prevention of heart disease and stroke can be attained, the purpose of primary

prevention (American Heart Association, 2017). The American Heart Association (2017)
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suggests individuals to exercise moderately for 150 minutes per week or 75 minutes per week of

vigorous exercise. A goal to teach the community is thirty minutes a day, five times a week

(American Heart Association, 2017). To lower the risk for heart attack and stroke specifically,

the American Heart Association (2017) suggests 40 minutes of aerobic exercise three to four

times a week. It is evident that by educating individuals in the community, diseases that are

prevalent in Berks County can be prevented.

Another intervention regarding primary prevention includes immunizations for all

residents, especially those at risk such as children who are living in poverty. Increasing

immunizations can assist in decreasing overall healthcare costs in the future for families who

have limited access to begin with. According to the World Health Organization (WHO, 2017),

vaccines have saved millions of lives and prevented “substantial disability” and are one of the

most successful public health interventions of all time. In order to immunize as many people as

possible, collaborating with corporations and groups that have programs in place are imperative.

For example, the Berks Community Health Center offers free or discounted immunizations to

children and adults (Berks Community Health Center, n.d.a). Recommended immunizations

from the Centers for Disease Control and Prevention (CDC, 2016) include Hepatitis A and B,

diphtheria, tetanus, and pertussis (DTaP), Haemophilus influenzae type B (Hib), polio,

pneumococcal, rotavirus, influenza, varicella, measles, mumps, rubella, human papillomavirus

(HPV), meningococcal conjugate vaccine, and zoster vaccine, most of which the Berks

Community Health Center provide for Berks County residents (Berks Community Health Center,

n.d.a). Another program nurses can utilize is the Back-to-School immunization clinic, presented

by the Pennsylvania Department of Health (n.d.). This program allows eligible children and

adults who are uninsured or underinsured to receive immunizations year-round, which can
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prevent diseases before they occur (Pennsylvania Department of Health, n.d.). Immunizations are

an excellent way to prevent and decrease incidence of chronic and debilitating diseases.

Secondary Interventions

Secondary interventions focus on and are designed to increase the probability that

diseases will and can be diagnosed when treatment is possible and will most likely result in a

cure (Stanhope & Lancaster, 2016). Two secondary interventions that can be implemented in

order to manage the diseases attributed to poverty in the early stages include screenings and

implementing a return-to-work program in order to decrease poverty, decrease unemployment

rates, and increase median household income.

Screenings are a vital way to detect various diseases when treatment is still conceivable.

The Berks Community Health Center can be utilized again here as the center provides medical

care as well as screenings for various disease processes including tuberculosis, foot problems,

diabetes, and hypertension (Berks Community Health Center, n.d.b). By establishing a

relationship with this county health center, residents of the Borough of Kutztown can receive

free screenings to prevent the disease processes from getting worse and to save money on

potentially lifesaving medical care through screenings.

Another intervention related to screening is to hold free screenings for blood pressure and

childhood obesity throughout the town. By setting up stands and tables with information and

screening tools at libraries, schools, and grocery stores, nurses can intervene before the disease

process becomes unmanageable. Blood pressure screenings are imperative due to the relationship

between hypertension and the development of chronic diseases such as diabetes and heart disease

that can be further complicated because of poverty. Blood pressure is often known as a silent

killer because there are often no signs and symptoms, a substantial reason the CDC (2018)
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recommends regular screenings. By finding hypertension early, further progression of heart

disease, diabetes, and stroke can be prevented. Education can be done as well at this stage.

Another secondary prevention strategy includes childhood obesity screenings and

prevention programs to inhibit further complications. A simple screening that can be

implemented is height and weight, as long as body mass index (BMI) screening. BMI screening

allows parents to monitor their child’s overall health status and intervene (CDC, 2017). The

United States Preventive Services Task Force (2017) also recommends that clinicians screen

children for obesity starting at the age of six in order to implement various interventions that

were proven to be evidence-based and shown to improve weight. By screening children who are

overweight or obese, public health nurses and school nurses can implement strategies to improve

weight to decrease the likelihood of developing chronic diseases and furthering complications of

poverty.

Another secondary intervention to combat poverty directly is implementing a return-to-

work (RTW) program for individuals who are unemployed in the Borough of Kutztown. The

return-to-work program was created and reviewed by the Institute for Work and Health (2014) in

order to enhance the reentry into the workforce after an injury or illness and was proven to be an

effective secondary intervention as it prevented long-term problems and reduced the impact of

various diseases that have already occurred. By implementing the RTW program, employees can

get back to work more quickly, and in a more efficient manner. This, in turn, will decrease the

unemployment rate of the Borough of Kutztown, increase the overall median household income,

and decrease the rate of poverty. By doing this and having individuals returning to work,

diseases can be prevented, as income is increased and a healthier lifestyle can be more easily

obtained.
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The return-to-work program focuses on modified work for those who are ill or injured,

communication regarding workplace demands, and a commitment to health and safety (Institute

for Work & Health, 2014). The RTW program also prevents those who are already at risk for

injury to be injured again. One of the principles of the RTW program is supervisor training in

work disability prevention, which can further decrease the risk of disability, poverty due to

unemployment, and chronic diseases (Institute for Work & Health, 2014). This program allows

employees to return to work as soon as possible and function in a way that prevents long-term

effects poverty.

Tertiary Interventions

Tertiary prevention encompasses interventions that are aimed at decreasing the resulting

disability from the disease process or problem and rehabilitating in order to prevent further

deterioration (Stanhope & Lancaster, 2016). Two tertiary prevention interventions to be

implemented are identifying and coordinating a network of services, support groups, and

providers that will assist with reduction of poverty and rehabilitation of chronic diseases, as well

as collaborating with case managers and social workers to gather information and resources

regarding tax credits that can be utilized for those living in poverty.

Support groups and rehabilitation services are one of the gold standards of tertiary

preventative interventions. By identifying these support groups and various services, nurses can

prevent worsening of poverty states, and in turn, prevent a worsening of chronic diseases

processes (Stanhope & Lancaster, 2016). Various support groups and services include food

banks, clothing resources and trades, programs in schools and churches, and finding out what the

eligibility requirements are (Stanhope & Lancaster, 2016). Friend, Inc. is a local service based in

Kutztown that was formed in the 1970s because there were no resources in the entire
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northeastern Berks County region (Friend, Inc., 2018). Friend, Inc. is supported by the United

Way and provides multiple benefits including a client-choice food pantry, emergency assistance

through the Salvation Army Service Unit, as well as resource management (Friend Inc., 2018).

Another resource that nurses can arrange for individuals living in poverty are various

support programs such as Women, Infant, and Children (WIC). WIC can assist with combating

poverty as well as decreasing the likelihood of chronic diseases beginning or progressing. A

study completed by Herman, Harrison, Afifi, and Jenks (2008) focused on the Special

Supplemental Nutrition Program that was created by WIC to increase the consumption of fruits

and vegetables because of the protection it can have against chronic diseases that are associated

with poverty and decreased intake. WIC participants in Los Angeles were given a voucher for

$10 to purchase fruits and vegetables at farmers markets and 90% of these vouchers were

utilized by participants (Herman et al., 2008). Researchers found that participants increased their

fruit and vegetable consumption by an average of 1.4 servings, and the program promoted a

healthier lifestyle (Herman et al., 2008). Although those who qualify for WIC are already

stricken by poverty, implementing programs such as the Special Supplemental Nutrition Program

can prevent poverty from becoming an even bigger problem and can prevent chronic diseases

from spiraling out of control.

Other support groups that can combat poverty include income support groups. Magnuson

(2013) from the Institute for Research on Poverty from the University of Wisconsin-Madison

focused research regarding reducing the effects of poverty through early childhood interventions,

one including income support groups. The research concentrated on mothers who were apart of

income support groups, that focused on the fact that income should increase because of

employment, and seeing the effect this had on student achievement (Magnuson, 2013).
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Magnuson (2013) found that children who had mothers in the income support program that

supplemented their earnings had higher levels of student achievement. By implementing more

programs such as the income support group, nurses can intervene early in children’s lives to

decrease the effects poverty can have, including less education, unhealthy habits, and the

development of various chronic diseases.

Collaboration with various providers is vital in order to promote the best success for

patients. Working with case management and social workers is imperative for nurses in order to

gather outside resources that will be beneficial to the client. Working with these groups can

allow families to participate and heighten information regarding various economic interventions,

such as tax credits. Because the family already is living in poverty, tax credits directed toward

increasing income can be beneficial to prevent further deterioration of the impoverished state.

Two tax credits that families may be eligible for include various childhood tax credits and the

Earned Income Tax Credit. The Child Tax Credit was created in the 1990s that provides up to

$1,000 for families per child (Yoshikawa, Lawrence Aber, & Beardslee, 2012). The Child and

Dependent Care Tax Credit is another credit that allows families to receive tax breaks between

20% and 35% of child care expenses that were paid, which may add up to almost $2,000 per year

(Yoshikawa et al., 2012). These tax credits are beneficial for those who are living close to or

below the poverty line, but earn enough money to still qualify paying taxes (Yoshikawa et al.,

2012).

An additional tax credit that can be applied for those living in poverty is the Earned

Income Tax Credit (EITC). The EITC is one of the nation’s largest antipoverty policies, as it

provides refundable income tax for those families who fall just below the threshold of poverty

and is contingent on work effort (Magnuson, 2013; Yoshikawa et al., 2012). Dahl and Lochner
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(2008) found that families that utilized the Earned Income Tax Credit had children who benefited

academically. For every increase of $1,000 acquired through the tax credit, the children affected

had an increase in reading and math standardized test scores (Dahl & Lochner, 2008). Dahl and

Lochner (2008) also found that the effects were larger for the families with lower incomes,

indicating the effects these tax credits can have on families, and children specifically.

Evaluation

Three main goals were previously established in this paper. These goals, in order, are: to

decrease the poverty rate in Kutztown, to identify and combat the causes of poverty, and to

decrease the incidence and effects of diseases in Kutztown. In order to evaluate the effectiveness

of each goal, the goals must be evaluated separately.

When assessing whether or not the poverty rate in Kutztown was decreased, it is essential

to utilize data from the U.S. Census Bureau. The numbers show the rates of poverty in each

community across the United States, and are essential in determining whether the poverty rates

have increased or decreased from year to year. It is essential that poverty rates are decreased, as

poverty has an affect on access to healthcare.

Evaluation of the second goal, identifying and combating the causes of poverty in

Kutztown, would be carried out through utilizing the U.S. Census Bureau statistics as well. In

order to assess whether or not the causes of poverty were combatted and identified, one must

evaluate the rates of poverty and identify whether there was a decrease in poverty rates or not. It

is also helpful to see how many families utilized childhood tax credits and also earned income

tax credit, as this can have an influence on poverty. With these pieces of information, it would be

determined whether the goal was met.

In evaluating the decrease in incidence and effects of diseases in Kutztown there are a
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few different pieces of information. One was to assess this goal would be to look at vaccination

rates over the period of a year. Another way to assess this goal would be to look at the U.S.

Census Bureau statistics on the rate of prevalence and incidence of disease over annual periods.

In the instance that the immunization rates increased and the rate of prevalence and incidence of

disease decreased, it would be known that the goal was reached.

Conclusion

The primary problem area identified within the borough of Kutztown, Pennsylvania was

poverty among residents. This problem led to the nursing diagnosis of high incidence of

mortality related to diseases including heart disease, cancer, stroke, and chronic lower respiratory

disease related to poverty and increased unemployment rate as evidence by decreased income per

capita and decreased median household income. In order to intervene, three main goals were

established. These goals include: decreasing poverty among residents, identifying and combating

causes of poverty among residents, and decreasing the incidence and effects of diseases among

residents. Interventions were then put forth in order to support these goals. Primary interventions

included education and immunizations, while secondary interventions included screenings and a

return to work program. Tertiary interventions included support groups and services along with

tax credit suggestions. When combining all of these resources and interventions, an attempt can

be made to decrease the primary problem area in Kutztown.

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