Abstract
Notasulga is a rural community located in Macon County, Alabama. The population faces
many challenges including financial burden due to lack of jobs, decline of health status due to
the lack of access to preventative healthcare, and poor nutrition related to the lack of the quality
and quantity of appropriate food sources. This paper discusses the methods that were used to
assess the community including health and population profile data, a windshield survey, and an
interview with a key informant. This paper also includes three key nursing diagnoses that related
to the community assessment, and a discussion of the chosen Healthy People 2020 goal, which
includes how the community compares to the goal and the importance of the goal, followed by a
summary of the findings. While conducting a windshield survey and collaborating with an active
member from the community, it was established that Notasulga will fail to meet the Healthy
People 2020 goal of access to healthcare for all people unless certain measures are taken in
providing education and screening services to the community. The purpose of this paper is to
dissect what factors contribute to the health disparities of Notasulga and provide the community
Notasulga, Alabama is a rural town located in Macon County and is about 30 minutes
from Auburn, Alabama. The students conducted a windshield survey of Notasulga, an interview
with a key informant in the community, and established three nursing diagnoses from the
windshield survey and key informant interview. Based on the results, it was established that the
Notasulga community did not have adequate access to healthcare and do not partake in
preventative measures such as blood pressure checks and dental checks. This paper will discuss
why Notasulga community faces these problems by providing a full community assessment of
Notasulga including what was seen during the windshield survey, information relayed from the
key informant, and the importance of reaching the Healthy People 2020 people goal of access to
healthcare.
Community Assessment
The major problem within the Notasulga community is the lack of health care services.
At the beginning of the assessment of this community, it was noted that there is only one health
care facility located in the town. The Notasulga Healthcare building is located in the middle of
town and consists of only one nurse practitioner as the primary provider (see appendix A).
Problems with this include: long wait time, limited scope of practice, and short visitation time
with the provider. While speaking with the key informant, it was stated that the population does
not value the opportunities of preventable health care (key informant, personal communication,
February 24, 2018). This includes trips to the dentists twice a year, receiving proper eye care and
monitoring blood sugar (see appendix B). A concern that was voiced during the interview was
the problem with the lack of health care services due to the inability to pay for doctor visits and
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the appropriate medicine each individual need. This particular issue is also seen throughout the
country, as described in the article “Perceptions of Health Care and Access to Preventive
Services Among Young Adult” (Luquis & Kensinger, 2017). It is shown through the research
that if a patient seems healthy enough in the patient’s eyes, the patient will pay for food and
housing over health insurance, which in the long run will result in the patient avoiding the doctor
when the patient gets sick (Luquis & Kensinger, 2017, p. 2).
General, but the Dollar General does not have fresh fruits and vegetable to maintain adequate
nutrition. Many residents drive to the Auburn/Opelika area to buy groceries; however, there is a
Carmack’s and a local farmer’s market where residents can buy food (key informant, personal
communication, February 24, 2018). Commuting to the grocery store can pose a problem since
some residents, especially the older adult population does not have transportation to get to the
store (key informant, personal communication, February 24, 2018). The lack of access to healthy
foods is evidenced by high percentage of obesity in Macon county with 40.2% of adults being
The overall life expectancy at birth for residents of Notasulga, AL is 73.2 years, which is
lower than the state average of 75.3 years (“American FactFinder”, 2016). The number of
females with cardiovascular diseases living in Notasulga is 32 and males with cardiovascular
diseases is 38 (“County Health Profiles”, 2009). There are six females and six males living with
diabetes in Macon county (“County Health Profiles”, 2009). The percent of adults that are obese
chronic conditions such as heart disease and diabetes (Hoffman & Sullivan, 2017, p. 1498) .
With already high costs of health care, these added chronic illnesses could further increase the
amount of money people have to pay for care. In Notasulga, 8.6% of the population does not
have any form of health insurance (“American FactFinder”, 2016). Not having insurance means
going to the doctor for preventative care might be too expensive, and thus individuals may not
attend these preventative care appointments (Hoffman & Sullivan, 2017, p. 42-43). From 2004 to
2013, there have been 1,054 incidences of all cancers in Macon County, with 131 incidences of
breast cancer, and 197 incidences of prostate cancer (“Alabama Cancer Facts and Figures”,
2015).
In the Notasulga community, 24.0% of individuals live below poverty and 19.6% of
families live below poverty. Both of these statistics are above Alabama’s state percent of 18.4%
and 14.0%, respectively (“American FactFinder”, 2016). These statistics are relevant because it
shows how nearly a quarter of the community lives below the poverty line. Living below the
poverty line indicates that these people cannot get the adequate healthcare that they need or
afford the nutritional food their bodies need (key informant, personal communication, February
24, 2018). Additionally, 7.1% of the population is unemployed, which is above the state rate of
4.8% (“American FactFinder”, 2016). The majority of the residents work in production,
transportation, and material moving occupations (24.0%), and the median household income is
$40,938, which is below the state rate of $44,758 (“American FactFinder”, 2016). In Notasulga,
100% of the population speaks English only, 65% of residents are White, and the median age of
residents is 41.9 years (“American FactFinder”, 2016). There are 272 family households and 158
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non-family households (“American FactFinder”, 2016). Of the homes in this community, 76.6%
were built between 1950 and 2014 with the median value of the homes at $96,700 (“American
FactFinder”, 2016).
Windshield Survey
The community of Notasulga is a small rural community in Macon County, Alabama that
is about 30 minutes away from Auburn, Alabama. Notasulga is accessible from Auburn via
Highway 14. Upon arriving in the town of Notasulga, the students entered into the town center
where there are one or two stores and restaurants that are running businesses. There are many
houses in Notasulga ranging from over thirty years old to about five years old. There were not
any established neighborhoods, the houses were along the roads in the town. A green space was
located by one of the churches in town, and a baseball field and football field were behind the
high school. Driving through Notasulga, the people tended to congregate toward the churches to
have meetings and spend time with each other. Also, the people in town went to the restaurant in
the downtown area to enjoy a meal. The people in the town drove their cars to get to and from
places because there were not many sidewalks in the community. Highway 14 runs through the
town and provides transportation to Auburn, Alabama. As for service centers, there was not a
central recreation center but the school had fields behind it. The town had one healthcare clinic
in the downtown area and a volunteer fire station. For shopping, the people would have to drive
to the Dollar General or Carmack’s to get some groceries, however there is not a central grocery
store like Publix or Kroger in the town. The people in the town were sitting on their porches, but
they were not out walking because there are not really any sidewalks throughout the town. When
driving through Notasulga, the people seen were African American but some Caucasians were
CAP PAPER 7
present as well. The town has two churches: Methodist and Baptist. A health clinic was in the
middle of town, but if the community wanted to go to a hospital, they would have to travel to
Opelika or Tallassee. Throughout the town, signs were up showing a candidate running for state
representative, but a predominant party affiliation was not identified. Notasulga did not have a
local newspaper, and many houses showed no sign of antennas or satellites. In Notasulga, the
high school, middle school, and elementary school are all located in the same spot and the
Key Informant
The key informant of Notasulga grew up in the community and currently lives in the
community. When asked what the role of the key informant was in the community, the key
informant said that they were a town council member of district 2. The key informant stated that
some of the strengths of Notasulga included proximity to interstate 85 and state roads 14 and 81,
proximity to Auburn and Montgomery, railroads that run through the town, potential for Macon
County to get Leonardo T-100 Trainer to build trainer jets, which would produce 750 jobs and
the ability for the town to make money, new home construction has increased, and senior citizen
center on Highway 12 that provides occasional health checkups. When asked are there areas of
improvement in the community, the key informant responded that Notasulga needed better cable
services, cell phone service, its own water source, more recreation opportunities, and better
education. The key informant said that the major concerns of community members included
access to health care, the failing school system, issues related to the aging population (key
The key informant was asked if they believe there is adequate access to healthcare and
they responded with the answer, no. The key informant elaborated stating that there is a lack of
preventative health care due to financial issues, and the population does not value preventative
health care including trips to the dentist, eye care, and blood sugar checks. The key informant
also stated that the population does not go to the doctor in a timely manner and the older
population lacks transportation to go see a healthcare provider. When asked if there are any
special concerns related to health among the residents in their community, the key informant
responded that transportation, lack of IT service, nutrition/diet, preventative care, ability to pay
for medications and doctor visits, aging populations, and support systems. We asked the key
informant about the community barriers and facilitators to reaching the Healthy People 2020
goals of living longer, healthy lives, and the key informant responded with the lack of IT
infrastructure, low income of resident, and less interest in preventative care would prevent the
community from reaching their goals. Finally, the key informant was asked if they would like to
add anything else, and she responded with the major issue is the community’s lack of interest in
preventative health care. For more information on the key informant’s answers, direct attention
One of the nursing diagnosis for the community of Notasulga, AL includes a risk for
resources and 19.6% of the population living below the poverty line, as evidenced by the
interview with the key informant and the high rates of preventable, chronic diseases such as
diabetes (52.7%) and hypertension (39.5%) (“American FactFinder”, 2016). The second nursing
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diagnosis is a risk for ineffective health maintenance in the adult population of Notasulga, AL
related to a neglect for preventative health care and rural location of the community as evidenced
by information from the key informant that states, “the people in this community don’t get their
blood sugars checked regularly, and don’t go to the doctor until they are deathly ill” (key
risk for a nutritional deficit in adults in Notasulga, AL as related to the percent of families living
below the poverty line (19.6%) and a lack of grocery stores in the proximity that carry fresh
produce, as evidenced by the percent of obese males (39.9%) and females (53.9%) (“American
FactFinder”, 2016) (see Appendix C for complete nursing diagnoses). Of these diagnoses, the
risk for ineffective health maintenance in the adult population is the most important because it
directly relates to the Healthy People 2020 goal of access to healthcare for all. Without access to
healthcare, the community is at greater risk for improperly managing chronic and acute diseases.
An objective that applies to Healthy People 2020 in the Notasulga community is access to
health services because it is a rural area. There are three main aspects of the access to health
services objective. The first is access to coverage, which is associated with preventative health
care, and lack of health insurance. With chronic diseases deficient access results in increased
pain, worsening of the condition and increased risk of additional health problems. To solve this
patients need prescription medication access and compliance, which is most of the time only
possible with reliable coverage. The second aspect is providing services like yearly health
promotion screenings, and health promotion teaching on overall health such as exercise, and diet
to prevent cardiovascular diseases. This can be done through community programs organized by
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health departments in colleges and universities. Also, programs that teach pediatric population
about hygiene and how to avoid injury and accidents such as burns, motor vehicle accidents, and
contact sports injuries are important to preventative care. The third aspect consists of working
with the health care system in providing timely care to patients, which is made possible by
increasing the number of health professionals in the community, and building more community
health centers equipped with health resources and equipments (“Access to Health Services”,
2014).
An article by Bolin et al., (2015) discusses a survey that was conducted regarding what
rural residents considered as the most important aspects of health care. With 17% of the U.S.
population living in rural areas and only 9% of doctors practicing in these communities, it is no
surprise that the overwhelming majority of survey participants selected access to healthcare as
their most important factor of healthcare (Bolin et al., 2015, p. 326). Bolin’s article emphasizes
how the the community of Notasulga, AL does not meet the Healthy People 2020 goal of
ensuring all people have access to adequate healthcare. As a rural community with one small
health clinic, Notasulga residents are geographically disadvantaged. If a resident were to seek
either preventative care or emergency services, the resident would have to drive to the
Auburn/Opelika area or call an ambulance -both of which are costly. The key informant further
reinforced the struggle that community members face with the lack of nearby healthcare services
by discussing how residents often lack transportation, and have to pay others to take them to
doctors’ appointments, which prevents people from attending preventative care appointments
(personal communication, February, 24, 2018). Notasulga residents are also economically
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disadvantaged; with an unemployment rate of 7.1% and 19.6% of families living below the
(“American FactFinder”, 2016). According to our key informant, the Notasulga community
members struggle with valuing preventative health care and nutrition; combine this with the high
cost of these services, and preventative care gets placed on the backburner (personal
communication, February, 24, 2018). The geographic location plus economic disadvantage
further prohibits Notasulga from reaching the Healthy People 2020 goal of access to adequate
People who do not have health insurance often delay preventative care; for example,
women may lack health insurance, and as a result do not have access to screenings such as Pap
smear tests to detect cervical cancer at early stage (Okoro, Guixiang, Fox, Eke, Greenland,
Town, 2017.) According to the article by Shepherd, Locke, Zhang, and Maihafer (2014), lack of
preventative care can delay detection of chronic diseases, which may lead to increased pain,
worsening of the condition, and increased risk of additional health problems. To solve this,
patients need access to affordable preventative care and medications, which is often only
available to those who are insured (Shepherd, Locke, Zhang, and Maihafer, 2014). Shepherd, et.
al., (2014) says that community health centers have been a success in linking health care
providers to the underserved population; this in turn provides quality health care to the
community. For example, community health centers in Washington, Montana, and West Virginia
medications (Shepherd, Locke, Zhang, and Maihafer, 2013). Notasulga has only one health clinic
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that services the town. Increasing the access of community centers in Notasulga that can provide
preventative care will grant timely screening to the underserved population and help the
population reach the Healthy People 2020 goal (key informant, personal communication,
Summary
The community of Notasulga, AL is located in a rural area with limited access to grocery
stores and healthcare, which places the community at a disadvantage for meeting the Healthy
People 2020 Goal of access to healthcare for all people. According to information gathered from
the windshield survey, key informant interview, and health and population profile worksheets,
Notasulga has a high poverty rate, high rates of preventable diseases such as hypertension and
diabetes, and does not value preventative care. The Healthy People 2020 goal of adequate access
rates of chronic diseases and improve outcomes for treatment of current diseases in this
community. The students hope that by increasing access to preventative care in the community,
Notasulga can take another step towards reaching the Healthy People 2020 goal of access to
healthcare.
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References
https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services
Alabama Cancer Facts and Figures. (2015). Alabama Department of Public Health. Retrieved
from: http://www.alabamapublichealth.gov/ascr/assets/FactsFigures2015.pdf
American FactFinder: Poverty Status in the Past 12 Months. (2016). Retrieved from:
https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF
https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF
Bolin, J.N., Bellamy, G.R., Ferdinand, A.O., Vuong, A.M., Kash, B.A., Schulze, A., & Helduser,
J.W. (2015). Rural Healthy People 2020: New Decade, Same Challenges. The Journal of
County Health Profiles. (2009). Alabama Department of Public Health Statistics. Retrieved from:
http://www.adph.org/healthstats/assets/chp09.pdf
Gamble, S., Mawokomatanda, T., Xu, F., Chowdhury, P. P., Pierannunzi, C., Flegel, D., & Town,
M. (2017). Surveillance for Certain Health Behaviors and Conditions Among States and
Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2013
and 2014. Morbidity And Mortality Weekly Report. Surveillance Summaries, 66(16),
1-144. doi:10.15585/mmwr.ss6616a1
Hoffman, J.J., Sullivan, N.J. (2017). Ethical Concepts. Medical-Surgical Nursing (p.42-43).
Hoffman, J.J., Sullivan, N.J. (2017). Managing Care for the Adult Patient with Obesity.
Luquis, R. R., & Kensinger, W. S. (2017). Perceptions of Health Care and Access to Preventive
Okoro, C. A., Guixiang, Z., Fox, J. B., Eke, P. I., Greenlund, K. J., & Town, M. (2017).
Surveillance for Health Care Access and Health Services Use, Adults Aged 18-64 Years
-- Behavioral Risk Factor Surveillance System, United States, 2014. MMWR Surveillance
Shepherd, J., Locke, E., Zhang, Q., & Maihafer, G. (2014). Health Services Use and
Appendix A
Appendix B
Are there any special concerns related to Transportation, lack of IT service, lack of concern
health among residents in your about nutrition/diet, preventative care, low ability
community? to pay for medications and doctor visits, aging
population and support system
Appendix C
Signs and Symptoms of the 53.9% of females are obese and 39.9%
people living below the poverty line and a lack of grocery stores in the area as
hospital/doctors/pharmacies, cost of
hypertension (39.5%)
A risk for non-compliance in the young and older adults in Notasulga, AL, as
related to a lack of a local major hospital and pharmacy, the cost of transportation
families below the poverty line (19.6%) as evidenced by our interview with our key
informant, and high rates of chronic, preventable diseases such as heart disease and
diabetes.
community.
sugars”
as related to a neglect for preventative health care and the rural location of the
“people in the community don’t get their blood sugars checked regularly, and