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Summary Paper: Chester County

Summary Paper-Chester County

Rachel Neale

IPC 501: Health Promotion and Disease Prevention in a Diverse Society

Dr. Ruth-Sahd

November 5th, 2023

A community is a complicated conglomeration of populations, cultures, practices,

resources, settings, and more. All of these different puzzle pieces work together to make up the

community, but sometimes it also might place certain residents at risk for various health issues. It

is the role of public health officials to determine what health issues to address, how to address

them, and how to evaluate those interventions. This paper will take a close look at Chester

County (CC), Pennsylvania: its demographics, its resources, and its health issues. Then one

health issue in particular, Sexually Transmitted Infections (STIs) will have a proposed

intervention in the form of individual behavioral interventions such as a Safer Sex Skills

Building (SSSB) course.

Community Overview

CC is the 7th mot populated county in Pennsylvania, with the latest total population being

545,823 residents (U.S. Census Bureau, 2022). The racial demographics are as follows: 83.9%

Caucasian alone, 6% African American alone, 7.2% Asian alone, and 7.7% identify as

Hispanic/Latinx (U.S. Census Bureau, 2022). Of the total population around 9.5% are foreign

born persons (U.S. Census Bureau, 2022). The landscape of CC is a combination of rural and

urban areas, with around 1,700 farms in the county taking up around 1/3 of the entire acreage of

CC (Chester County, 2018). That being said, the county is considered more urban (U.S. Census

Bureau, n.d.). CC is a more affluent county, with median household income at $109.969, and

only 6.6% of the population living in poverty (U.S. Census Bureau, 2022).

The main vulnerable population in CC is the migrant population, with 12% of the

residents speaking a language other than English at home (U.S. Census Bureau, 2022). The
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Summary Paper: Chester County
migrant worker population is significant in CC, particularly those hired by the mushroom farms

in the county (Benshoff, 2017).

The county is not a very walkable area, so many residents will require a car for

transportation; around 72% drive alone to work, and 44% of the population has a commute

longer than 30 minutes (County Health Rankings, 2023). Fortunately there are bus routes

available including Chesco Connect, which allows discounted rides for seniors or disabled

residents (Chesco, n.d.).

Chester County does struggle with healthcare access in the the hospital bed per 1,000

residents is 1.6, compared with 2.3 bed statewide (Health, n.d.). This means that there are less

beds available for the county’s residents compared with state averages (and national averages).

Furthermore, of the several hospitals that reside in CC, most do not provide access to high

specialty areas such as Neonatal Intensive Care Units (NICUs) or trauma centers (Pennsylvania

Trauma Systems Foundation, n.d.).

Problem

Overview of Health Issues

Chester County, though it scores consistently healthier in most areas compared with state

and national averages, still has areas of improvement with regards to the health of its residents.

Two areas in which CC scores worse than state is in excessive drinking rates and rates of

pertussis. According to County Health Rankings (2023), 23% of the population of CC report

excessive drinking compared with 21% statewide. And Chesco (2023), reports pertussis rates of

3.8 per 100,000 compared with 1.9 per state. In addition, CC still has an alarmingly high obesity

rate of 30%, even if lower than state percentage of 32% (County Health Rankings, 2023).
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Summary Paper: Chester County
Finally, a health issue that is on the rise is STI rates, with CC at 195.6 per 100,000 residents

(County Health Rankings, 2023).

STI Rates

STI rates are comparatively low in CC compared with state and national averages (408.3

and 481.3 respectively) (County Health Rankings, 2023). But the fact that it is a preventable and

treatable health issue that is on the rise is of significant concern. Public health officials often

target this health issue because it is a preventable illness and residents can prevent it with the

right information and access to healthcare.

Etiology

An etiology is a cause of a problem, and STI rates that are on the rise have several

potential etiologies. The HealthyPeople 2020 Determinants of Health Framework can be utilized

to formulate possible risk associated with STIs.

Policy Making

A current risk for increasing STI transmission rates is the lack of specific policies in

Pennsylvania regarding sex education in public schools. There is a law stating that HIV

prevention must be taught and abstinence along with it, but no requirements on STI prevention or

safe sex (CDC, 2017).

Health Services

A continued concern within CC is the lack of access to healthcare, particularly bilingual

providers. The hospital bed to resident ratio is below the state’s average, and residents often rely

on transportation to get them to a facility. Thus these barriers pose a risk to STI rates because

those at risk of infection may have a hard time getting tested for STIs or getting access to

condoms if they cannot afford them.

According Harvey & Henderson (2006), the Latinx male population are less likely to

utilize condoms during intercourse. This could be for a variety of reasons including lack of

information, but it also could be a cultural attitude toward condoms that impacts an individual’s

decision whether or not to practice safe sex.

Biology and Genetics

Within the HP 2020 framework of biology/genetics, a concern is the increased risk that

adolescents have in contracting STIs. According to NCSL (2020), approximately half of all new

cases per year are adolescents. This could be a social factor in that younger people may be more

concerned about the perceived negative reaction from their sexual partners, but it is also

biological in that it directly correlates with age (Harvey & Henderson, 2006). Another risk factor

to consider in this Determinant of Health is that STIs can often be asymptomatic and transmitted

unknowingly (Mayo Clinic, 2022).

Social Factors

As just mentioned, a significant social factor can be the fear of the sexual partner’s

response to safe sex practices (Harvey & Henderson, 2006). There is a generalized stigma around

using condoms during intercourse, and it may be difficult to know how to speak up for that

protection to prevent STIs. A physical factor within this framework is the language barrier that

many migrant families face; this makes it more challenging to understand sex education classes

in schools and have healthcare providers that give them proper education on safe sex in their

preferred language.

Recommendations
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Summary Paper: Chester County
Low health literacy in the latinx population is one of the biggest risk factors for STIs

rates because of its impact on all of the other risk factors. According to the Health belief Model,

if a person were to truly be informed of their risks and susceptibility to disease, they would

change their behavior (Riegelman & Kirkwood, 2019). But because non-English speakers are at

a higher risk for low health literacy and are less likely to have a healthcare provider speak their

native language, they are at risk for not understanding the possibility of STIs with unprotected

sex, or the possible consequences that come to a pregnancy/newborn with untreated syphilis.

With this risk factor in mind, an evidence-based recommendation would be to offer a

Safer Sex Skills Building (SSSB) course in Spanish to the latinx community in CC (Burlew et

al., 2023). According to a meta-analysis by Gause et al., (2018), behavioral HIV prevention

interventions demonstrated increased condom use and increased partner discussions about safe

sex.Gause et al. (2018), stated “supporting long-term behavioral change often involves

promoting the development of skills that may be practiced outside of the intervention setting”,

meaning that the goal of interventions like SSSB is to equip residents with the ability to advocate

for safer sex in their daily lives. SSSB would be an applicable behavioral STI prevention

intervention to help teach residents in the community about how to have these hard conversations

with their partners and how to advocate for safe sex practices. But in order to reach the hispanic

community in CC this intervention needs to be adjusted to uniquely meet the cultural needs of

hispanic residents and, at the minimum, be translated and presented in Spanish. This is where the

evidence is lacking to support this intervention. Burlew et al. (2023), performed a SSSB course

that was adjusted to match the culture of Black women using substances in the U.S. Results of

this intervention correlated with higher condom use (Burlew et al., 2023). Therefore a culturally-
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specific SSSB course for the hispanic/latinx community may have a positive impact on condom

use and safe sex practices to prevent STI transmission.

SSSB as an intervention is considered a downstream factor. According to Reigelman

&Kirkwood (2019), “downstream factors are those that directly involve an individual and can

potentially be altered by individual interventions”, and SSSB as a public health intervention

attempts to change individual behavior, not that of a group or a population in one given action.

Mainstream and upstream factors are more related to larger groups of people and, though

important towards preventing STI transmission rates, are not related to this intervention.

Purnell Domains for Cultural Considerations

Public health officials must take hispanic cultural considerations into account to ensure

this intervention is effective. Within the Family Roles and Organization domain, family is

considered to be more important than the individual, with the priority being on the wellness of

the collective whole (Cartwright & Shingles, 2010; Purnell, 2002). Knowing this, the persuasive

argument will be on the benefits of the course (and by extension safe sex practices) on the

community as a whole. In addition, fathers tend to be the more dominant partner, which may

make safe sex practices difficult, so the intervention must be tailored to teach how to have those

conversations well within that context (Cartwright & Shingles, 2010).

A second domain, Pregnancy, is also quite applicable to STI transmission rates, as some

untreated infection have critical impact on a pregnancy or a newborn, including congenital

syphilis. In the Latinx community, babies and pregnancy are considered a gift and therefore

anything that might jeopardize either of those things would be considered negative and worth

preventing (Cartwright & Shingles, 2010). A person who identifies as hispanic might be more

likely to participate in the SSSB intervention if they understand that an STI infection can
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Summary Paper: Chester County
endanger a pregnancy via a miscarriage or cause lifelong defects in a newborn exposed to an

STI. A third and final Purnell domain, High Risk Behaviors, gives insight into cultural

considerations for the intervention (Purnell, 2002). The hispanic/latinx population are less likely

in CC to perform preventative screenings including mammograms and flu vaccines (County

Health Rankings, 2023). Knowing that their community is less likely to go for preventative care

may be an area of focus for the SSSB class.

Implementation

As mentioned earlier, a theory of behavioral change that applies well for this health issue

and intervention is called the “Health Belief Model” (Riegelman & Kirkwood, 2019). The idea is

that “personal beliefs influence health behavior” and that “people will be more likely to take

action if they believe they are susceptible to the condition” (Riegelman & Kirkwood, 2019).

Public health initiatives therefore should be addressed to educate the community on their risk of

STI transmission and the potential consequences of unprotected sex. According to this theory,

educating residents is one of the more effective ways to influence behavior.

Objectives

One objective for this health issue is as follows: “80% of sexually active adults with more

than one partner in CC will report consistent condom use”. This would be addressing primary

level of prevention, so as to prevent disease from actually occurring. A second objective is this:

“90% of those surveyed in the hispanic population in CC will be able to verbalize where to

access free STI testing in CC”. This objective is more secondary level of prevention, as it hoping

to catch disease early to prevent long-term effects.

Barriers
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Summary Paper: Chester County
There are two main barriers to achieving these goals and addressing the issue of STI rates

in CC. One of these is the language barrier, that 12% of residents speak a language other than

English in the home (U.S. Census Bureau, 2022). These residents are at risk of poor

communication with their providers who might not speak their native language, and therefore

low health literacy. According to Shamsi et al. (2020), language barriers correlate with poorer

health outcomes. The second barrier is healthcare access. As mentioned previously there is a

shortage of hospital beds in the area, shortage of high speciality hospitals, and a need for a car

for transportation to most areas in the county. All of these factors make it more difficult for

residents to know about STI transmission, let alone STI testing and treatment.

Partners

One of the biggest partners for this project would be an organization that breaks through

both of these barriers, La Comunidad Hispana (LCH). This is a nonprofit organization that brings

healthcare to anyone regardless of their ability to pay, and all of their providers are bilingual,

helping Spanish-speaking residents to get quality care in their own language (La Comunidad

Hispana, n.d.). This organization has multiple offices which means increased access to the

hispanic community and ability to disseminate information about the SSSB course and to

campaign for it.

Another group of partners to consider would be the mushroom farms where many

migrant workers are employed. The employers could place in their break-rooms or businesses

pamphlets or posters advertising the intervention for those who might not have needed LCH for

medical care. This is a symbiotic relationship too; the employers benefit if their workers are not

getting infections that put them out of work.

have unique access to uninsured patients who may not have a primary care provider to give

preventative education. An Emergency Department might often get patients who have non-urgent

issues like STI infections, and could work with the Public Health Department to bring awareness

to STI rates and offer the SSSB course as an option.

Media Campaign

Though a billboard or a TV advertisement might be effective, a better way of making sure

the information can get to a large number of people in a variety of setting is a pamphlet. This is

even more important as a pamphlet can be quickly hidden, as a course on safer sex skills may

bring embarrassment to the intended party. The pamphlet would be in Spanish to reach the

correct population group, and would be placed in the majority of mushroom farms as well as be

available at LCH facilities. LCH could also recommend known Spanish businesses like

landscaping businesses or restaurants.

Evaluation

The evaluation period would likely be long, at least a year or two after the intervention, if

not longer. I will take months for the information about the SSSB course to be disseminated to

the majority of households in the area, let alone more time for people to read the pamphlets and

process whether or not to attend a course. Then it will take time for residents to attend available

courses and decide what behavioral changes to make from it. From there a surveyor might be

able to come in and ask questions in the community to see if the mentioned objectives above

were met or not. The data for evaluation would be collected in a variety of methods, including

data from the CDC (as certain sexually transmitted infections are reportable) and anonymous

surveys sent around to households in the county via text, email or postal mail. Another possible
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Summary Paper: Chester County
way to evaluate effectiveness would be to partner with local family practices to see if their rates

of STI diagnoses has decreased, or they could ask questions based on the objectives to see if they

have been met or not.

Partners and Evaluation

The partners listed above would be important in the evaluation process. Their role would

be to continue to disseminate the information and share informational pamphlets with their

patients/employees, particularly ones that are demonstrating high-risk behaviors or are at a

higher risk for STIs, including sexually active adolescents and drug users. The partners could

also report back to public health officials any feedback received about the campaign and/or

intervention such as: is the language culturally appropriate? Are residents changing their

opinions about STIs after the SSSB course?

RE-AIM Approach

The RE-AIM approach is beneficial in the evaluation process because it asks a lot of the

questions necessary to examine all aspects of an intervention and its effectiveness (Riegelman &

Kirkwood, 2019). RE stands for Reach and Effectiveness, and the look at the ability of the

intervention to reach the intended population (Riegelman & Kirkwood, 2019). AIM stands for

Adoption, Implementation and Maintenance, and these three evaluate how well the intervention

is accepted (Reigelman & Kirkwood, 2019). Knowing that the “R” stands for “Reach” allows

public health officials to ask, “is this intervention helping out the intended individuals, or has it

impacted a different population group?” (Riegelman & Kirkwood, 2019). With regards to the

SSSB intervention, RE-AIM can ensure that it targets the vulnerable population of the latinx

population in CC, evaluate if it is making an impact, how well the intervention is being received

by the hispanic community, and how might it continue to be effective long-term? All of these are
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Summary Paper: Chester County
important aspects to consider as public health officials with regards to interventions and

campaigns.

Conclusion

A perceived health issue is not near so simple as to have a quick fix. Most of the time

there are many factors that play into why the health issue exists and cultural considerations that

make it persist in the community. In the case of Sexually Transmitted Infections in Chester

County, language barriers and poor healthcare access play a large role. In addition, the large

migrant population in the county makes health literacy more difficult and therefore safe sex is

less widely known and accepted. A Safer Sex Skill Building course that is offered in Spanish

would help give the tools the Hispanic/Latinx community may need to have discussions with

their partners on safe sex and hopefully begin to decrease the transmission rate of STIs and

therefore the complications that come from it. But all of this would be useless without

community partners like LCH or local employers; they are a direct influence on the community

and can have a long-term influence on their health and wellness in the years to come.
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Summary Paper: Chester County
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