dallas community assessment and analysis

Community Assessment and Analysis of Dallas Pennsylvania

Community Assessment and Analysis of Dallas Pennsylvania The purpose of a community health assessment and analysis is to identify a community’s assets and issues in regards to its environment, social structure and population (Dreher, Shapiro, & Asselin, 2006). The community assessment utilizes objective data such as vital statistics and demographic data, but also encompasses subjective data that is obtained through a windshield survey and through the conduction of focus groups of community residents. Analysis of this comprehensive data, enables advanced practice nurses to identify the strengths and weaknesses of a community and design interventions to either enhance or help the community. For this community assessment, the Borough of Dallas, Pennsylvania was investigated using the community-as-a-partner approach. History Dallas is a borough in Luzerne County, Pennsylvania. Dallas was created by a charter granted April 21, 1879 from the land entirely within Dallas Township. The township had been formed in 1817 and was named for Alexander J. Dallas, who was the sixth United States Secretary of the Treasury (Epodunk, 2011). The local government describes the borough as the “heart” of the Back Mountain being that is it surrounded by other townships and boroughs. The Back Mountain is, a census-designated place consisting of Dallas, Kingston Township, a party of Wyoming, West Wyoming and Harvey’s Lake (Epodunk, 2011). The latitude of Dallas is 41.336N and the longitude is -75.963W. The size of this borough is relatively small, encompassing 2.4 square mile of which 0.1 is water. The physical boundaries of Dallas are mostly highways. Route 309 runs right through the middle of the Dallas and is otherwise known as the Dallas Memorial Highway. Other highways that border the borough include routes 415 and 118.

Demographics The population was 2,804 at the 2010 census (Pennsylvania State Data Center, 2010). Males attribute for 47.4% of this population whereas females attribute for 52.6%. The population density was 1,116.9 people per square mile. According to PA Department of Health Statistics and Research, Luzerne County had a -2.3% population change compared to Pennsylvania which had a 1.4% change from 2000 to 2008. Table 1 depicts a comparison of Dallas Borough demographic data compared to Luzerne County and Pennsylvania. In the borough the population was spread out with 21.8% under the age of 18, 6.5% from 18-24, 27.4% from 25-44, 26.4% from 45 to 64, and 17.8 % who were 65 years of age or older. The median age was 42 years (Pennsylvania State Data Center, 2010), which is pretty comparative to the county median of 41 and slightly higher than the state median of 38. Dallas Borough is a predominately Caucasian community with whites making up 97.9% of the population. This is comparative to the county level but higher than the state, which may reflect that both the borough and the county are not as ethnically diverse as the state. The predominance of this community being mostly Caucasian, was also reflected during the windshield survey. In the borough there were 1,031 households out of which 29.4% had children under the age of 18 living with them, which is comparable to the county level but significantly lower than the state. Married couples living together account for 58.5% and 8.5% had a female householder. The female with no husband is extremely lower than the state level of 53.70% which can possibly be attributed to either economical burden being that the borough is a wealthy community or possibly the high amount of church going people in this community. There are many new high-income housing developments located within the community as was evident during the windshield survey. The elderly living alone in the community account for 11.2% of the population which is slightly lower than the county level of 16%, but right on with the state percentage. However, when conducting the focus group the home health nurse that was interviewed voiced concern over the amount of elderly living alone in this community so this data may not be as representative as one may think. Quite possibly these elderly may not be physical capable of filling out the census form.
Table 1 Demographic Statistics of Dallas Compared to Luzerne County and PA
| |Dallas |Luzerne |Pennsylvania |
|Population/sq mile |1,116.9 |358 |274 |
| | | | |
|Age | | | |
|18 and younger |21.8% |21% |22% |
|18-24 |6.5% |8.10% |9.36% |
|25-44 |27.4% |27.20% |28.60% |
|45-64 |26.4% |24% |23.10% |
|65 and older |17.8% |19.70% |15.4% |
| | | | |
|Race and Ethnicity | | | |
|White |97.9% |96.63% |85.2% |
|African American |0.47% |1.69% |10.9% |
|Asian |0.78% |0.58% |2.5% |
| | | | |
|Household | | | |
|Children under 18 |29.4% |26.50% |44.60% |
|Married Couple |58.5% |48.80% |42.30% |
|Female, no husband |8.5% |11.50% |53.70% |
|65 and older alone |11.2% |16.0% |11.6% |

Source: Pennsylvania State Data Center 2010 Vital Statistics The five leading cause of death for Dallas Borough in 2008 were heart disease, cancer, cancer of lung/bronchus, diabetes mellitus and cerebrovascular disease (Pennsylvania Department of Health, 2010). Table 2 shows the relationship between males and females affected by all. Table 2.1 depicts the total deaths for Dallas Borough in 2008.
Table 2 5 Leading Causes of Death Dallas Borough 2008
|Disease |Total |Male |Female |
|Heart Disease |23 |9 |14 |
|Cancer |19 |6 |13 |
|Cancer of Lung/bronchus |8 |4 |4 |
|Diabetes Mellitus |5 |4 |1 |
|Cerebrovascular Disease |5 |2 |3 |

Source: PA Dept of Health 2010

Table 2.1 Total Deaths Dallas Borough 2008

|Accidents |3 |
|Accidents MVA |0 |
|Accidents, non-transport |3 |
|Alzheimers Disease |4 |
|Cancer |19 |
|Cancer of breast |3 |
|Cancer of the Bronchus and Lung |8 |
|Cancer of colon and rectum |2 |
|Cancer of Pancreas |1 |
|Prostate Cancer |0 |
|Cerebrovascular Disease |5 |
|Chronic Lower Respiratory Disease |3 |
|Diabetes Mellitus |5 |
|Heart Disease |23 |
|Influenza and Pneumonia |2 |
|Nephritis, nephrotic syndrome |5 |
|and nephrosis | |
|Septicemia |1 |

Source: PA Dept of Health 2010

The above was the only data that was available at the borough level. All of the following data was only available at the county level. Heart disease is the number one cause of death in Luzerne County and occurs at a rate of 254.9 per 100,000 people according to the PA Department of Health’s Bureau of Health Statistic’s Research. This statistic reflects that the leading cause of death in PA is heart disease as well with an occurrence rate of 215.4 per 100,000 people. However Luzerne County has a slightly higher occurrence rate than the state and when compared to the United States (97.62 per 100,000) has a significantly higher occurrence rate. Healthy People 2010 ranks cancer as the second leading cause of death. The rate of occurrence for cancer in Luzerne County is 196.2 per 100,000, which correlates closely with that of Pennsylvania (191.6 per 100,000). Prostate cancer accounts for a large percentage of these deaths and occur at a rate of 130.2 per 100,000 people at the county level and a rate of 159.2 per 100,000 people at the state level. Prostate cancer death rates are significantly higher than that of the United States (6.53 per 100,000). According to Healthy People 2010, the third leading cause of death is stroke. Luzerne county has a slightly lower occurrence rate (39.9 per 100,000) than that of Pennsylvania (45.3 per 100,000). Healthy People 2010 rank chronic lower respiratory diseases as the fourth leading cause of death and accidents as the fifth. Luzerne Country (39.7 per 100,000) has a slightly lower rate of occurrence for chronic lower respiratory diseases than that of Pennsylvania (40.0 per 100,000). Accidental deaths occur at a higher rate at the country level (48.1 per 100,000) than the state (40.9 per 100,000).

Based on all these statistics heart disease, cancer and stroke are the leading causes of death at the borough, county and state level and this has remained constant over the past five years. At the county level the goal set forth by Healthy People 2010 is to achieve a death rate of 166 per 100,000 people for heart disease. Since 2000 the death rate has declined steadily from 247.5 to 200.5 in 2008, but is still far above the goal set forth. Healthy People 2010s goal death rate for cancer is 159.9 per 100,000 people. Cancer death rates have remained relatively stable over the past 10 years in Luzerne County with a rate of 201.6 in 2000 and 194.9 in 2008. This could possibly be attributed to environmental factors which will be discussed further on in this paper. Luzerne County’s rate of death from stroke in 2008 was 40%, this is already below Healthy People 2010s goal of 48%.

According to the PA Department of Health Statistics and Research, the total births for Dallas Borough in 2009 (preliminary data) was 52. Which correlates closely when compared to the last four years. The total number of births for Luzerne County in 2009 was 3,151, which also relates closely to the last four years except for a slight increase in 2007. This shows that families are growing at a constant rate in both the borough and county over the past four years and Table 3 will depict the similarities for the borough, county and state.

Table 3 Number of Births from 2009-2006

| |2009 |2008 |2007 |2006 |
|Dallas Borough |52 |51 |54 |58 |
|Luzerne County |3,151 |3,191 |3,306 |3,188 |
|Pennsylvania |145,472 |148,934 |150,322 |148,706 |

Source: PA Department of Health Statistics and Research

According to the PA Department of Health Statistics and Research, the total number of deaths for Dallas Borough (preliminary data) was 92. This has increased over the past four years. The total number of deaths for Luzerne County in 2009 was 4, 015, which correlates closely when compared to the last four years. The state level fluctuates up and down and does not compare with the borough and county data which will be shown in Table 3.1. The majority of these deaths occurred with residents over the age of 65. The infant mortality rate for Luzerne County in 2008 was 6.9 per 1,000 live births resulting in 22 infant deaths. This correlates closely to Pennsylvania’s rate of 7.3 per 1,000 live births resulting in 1,090 deaths. Table 3.2 will show how closely the data for the borough and county relate when deaths are broken down by age group. This data reflects back on the low percentage of population change over the years.

Table 3.1 Number of Deaths from 2009-2006

| |2009 |2008 |2007 |2006 |
|Dallas Borough |92 |n/a |68 |75 |
|Luzerne County |4,015 |n/a |4,102 |4,058 |
|Pennsylvania |n/a |126,332 |123,967 |124,460 |

Source: PA Department of Health Statistics and Research

Table 3.2 Comparison of Number of Deaths by Age Group for 2008

| |Under 5 years |5-24 years of age |25-44 years of age |45-64 years of age |65 years and older |
|Luzerne County |26 |44 |145 |622 |3,269 |
|Pennsylvania |1,253 |1,511 |4,686 |20,832 |98,040 |

Source: PA Department of Health Statistics and Research

Communicable Diseases Rates

The lowest level of data available regarding communicable disease rates is at the county level. The top five communicable diseases in Luzerne County are as follows: chlamydia, gonorrhea, varicella, salmonellosis and AIDS according to Luzerne County Profile 2010. As per the Pennsylvania Health Profile 2010, the following are the top five infectious diseases for the state: chlamydia, gonorrhea, varicella, lyme disease and salmonellosis. The 2008 rate of chlamydia was 192.3% per 100,000 people in Luzerne County and the state rate was 332.8%. In 2005 the rate of chlamydia was 40.33% per 100, 000 people and in 2001 200% per 100,000 people in Luzerne County. From these statistics one could gather that Luzerne County reached epidemic proportions in 2005 and quite possibly community health nurses took initiative to decrease that rate which is evident by the 2008 data but far from meeting the goal of Healthy People 2010. The high incidence of varicella could be attributed to lack of vaccinations. According to Pennsylvania Department of Health, 48% of Luzerne County adults age 65 and older reported having a flu shot, this was significantly lower compared to PA at 59%. Yet, Luzerne County had an incidence rate of 11.5% which is significantly higher when compared to Pennsylvania at 32.9%, so this data maybe inconclusive.

Behavioral Risk Indicators

One prevalent behavioral risk factor evident in Dallas Borough is obesity, both in the child and adult population. There was no data available at the borough level only at the county and state level. During the windshield survey, the general appearance of the population of Dallas was one of obesity. Many residents voiced concern over the amount of obesity in this community during the focus group interview. The school nurses that were part of the focus group raised the issue of the amount of obesity in children and how they have watched it steadily increase over the years. In 2008, according to the PA Department of Health Statistics and Research 62% of the county’s population was overweight and 63% of the state’s population was as well. This is more than half of the general population and is a key contributor to the leading cause of death being heart disease. The Center for Disease Control and Prevention goes as far as to call obesity an epidemic. One of which that has grown significantly over the years. According to their website, the United States ranks number one in the world for obesity.

Another behavioral risk factor evident during the windshield was smoking. Many people were observed standing outside non-smoking establishments having a cigarette. Offset Paperback which is a factory located in Dallas banned smoking on their property, and many employees were observed standing on the Dallas Memorial Highway smoking. There was no statistical data available on the incidence of smoking on the borough level. According to PA Department of Health Statistics and Research, twenty-five percent of the population of Luzerne County smoked in 2008 compared to twenty-one percent of Pennsylvania’s population. This is below the goal of thirty percent set forth by Healthy people 2010 guidelines.

School Health Statistics

The school health statistics were discussed with school nurses while conducting the focus group. The school nurses identified food allergies as being more prevalent than ever before and they did not know why this was. Possibly children are being tested more frequently or that there is just more allergies due to the amount of pesticides used in foods. They believe that eating more organic foods would reduce the amount of allergies. Also they identify asthma as another big problem in the schools these days, although they say most asthmatics are controlled. One step the schools took to eliminate asthma attacks were to get rid of all the carpets and rugs in the schools since they harbor dust and mold. The biggest concern for the school nurses was that of obesity. The school nurses declared that childhood obesity is out of control. They believe that this is related to a number of factors such as, age of electronics, parents too busy to cook so they eat out a lot, children aren’t allowed to play outside like they used to because of higher crime rates and whatnot, and that this generation of children are just basically lazy. They believe that more education is important, but said that this has been a growing problem over the years and do not know how to fix this. Table 4 shows a breakdown for school health statistics for Luzerne County during the 2007-2008 school year and the high incidence of asthma as mentioned by the school nurses.
Table 4 School Health Statistics
|DISEASES |Number |Percentage |
|Arthritis/Rheumatic Disease |69 |0.15% |
|Asthma |3,124 |6.69% |
|ADD/ADHD |1,611 |3.45% |
|Bleeding Disorder |50 |0.11% |
|Cardiovascular condition |410 |0.88% |
|Cerebral Palsy |97 |0.21% |
|Cystic Fibrosis |18 |0.04% |
|Diabetes Type 1 |143 |0.31% |
|Diabetes Type 2 |26 |0.06% |
|Eating Disorder |55 |0.12% |
|Epilepsy/Seizure Disorders |315 |0.67% |

Source: PA Department of Health Statistics and Research

The Dallas School District is located in Dallas, PA and includes 4 schools that serve 2,781 students in grades KG through 12. The Dallas School District has 17 students for every full-time equivalent teacher, with the PA state average being 14 students per full-time equivalent teacher. The Dallas School District had a grades 9-12 dropout rate of 1% in 2008. The national grades 9-12 dropout rate in 2007 was 4.4%. Under federal law all schools are required to meet all Adequate Yearly Progress Measures. Federal law mandates that all students will be proficient by 2014. Dallas School District met all Adequate Yearly Progress measures, such as graduation (96%) and attendance (94%), academic performance and test participation (89%) during the 2009-2010 school year as found on the Pennsylvania Department of Education website. The district has consistently maintained higher percentages in proficiency in reading and mathematics than the state over the years. Dallas has percentages of proficiency in the mid to high 90’s for the same. Many families move to this area because of the reputation of the school district which is reflected by the population growth. Physical Environment Dallas Borough is unique in that it is rural in character and boasts abundant quality of life amenities such as a quality school district and a variety of outdoor recreation opportunities with its lakes, state parks and trail networks all in very close proximity to significant metropolitan areas. During the windshield survey, newer and high-income homes were found in neighborhoods on small landscaped lots that were well maintained. The more rural areas had homes that were also well-maintained with few signs of disrepair. Many new housing developments are located in Dallas Borough with the name of the development clearly displayed. Neighborhoods consist of open space behind homes, but were also surrounded by houses on all sides. Older homes typically have large front and back yards. Abandoned dilapidated barns were also found on the survey. All areas have modern plumbing. The urban areas have public water, whereas the more rural areas utilize well water. The median house value in Dallas Borough is $170,322 which is higher than the state average of $164, 700. This is reflective of the higher percentage of married couples residing in the community. There were very few signs of decay observed during this windshield survey. The retail business in itself is impressive with only one or two vacant buildings. Barely any litter or trash was noticed, but many of the roads have been adopted by families and agencies as evidenced by adopt a highway signs. The community’s open space is mostly farmland. In the rural area, there are many areas that have land for cattle and other farming purposes. There are also orchards and strawberry picking fields. There are many trees in the urban area but few open spaces due to the vast development of neighborhoods and shopping centers. There are no sidewalks in this area except those in newer housing developments. There are a few parks located within the community with playground equipment and walking trails.

Pollution was also evaluated as part of the inspection of the physical environment. The concerning areas for pollution in Luzerne County were that of air quality and toxins. According to Scorecard.com, Luzerne County ranks in the 90th percentile of the dirtiest counties in the United States related to air quality. The emergence of gas drilling has raised issues and alarms among the environmental community. This was evident during the windshield survery due to the many billboards and signs prohibiting this in Dallas. Many voiced concerns during the focus group regarding the following: polluted water supplies, dirty air, toxic waste, radioactive mud, lowered property values, loss of recreational venues, loss of farmland, loss of tourism, higher crime rates, and damage to our roads and bridges from truck traffic. One can infer that Luzerne County’s pollution rating may change within the next few years if this gas drilling happens.
Health and Social Services Residents of Dallas Borough have access to many levels of health care within a short distance. Both Geisinger South Wilkes-Barre and Geisinger Wyoming Valley which is the trauma center are located within 10 miles of the borough, along with General Hospital. There are several physician and dental offices located in the borough. A lot of family practice is noted along with chiropractic and vision care. The development of an urgent care center is underway. Mercy Center is an assisted living facility for the elderly and the Meadows is a nursing home located in Dallas. The only downfall to health services in this area is the lack of pediatric specialists for these residents need to travel to Danville, Hershey or Philadelphia. Dallas Borough has its own Emergency Medical Services and Fire Department and also has the neighboring towns of the Back Mountain as backup if need be. There are no social services agencies or volunteer organizations located within Dallas, but these are all located within the Wilkes-Barre area which is within 10-15 miles from the borough. Social service agencies include: Bureau of Aging, Child Welfare Service, and various mental health and drug and alcohol treatment centers. Volunteer organizations include: YMCA, CYC, Salvation Army and the American Red Cross.
Economics
According to the US Census Bureau (2000), 51.5% of the residents in Luzerne County sixteen years and older are employed in the civilian labor force. 48.5% are not in the labor force at all, whereas 2.1% are unemployed. The employment rate is slightly lower than that of Pennsylvania’s (61.8%), but the rate of those not in the labor force is slightly higher than that of Pennsylvania’s (38.1%). This could be attributed to the fact that PA has a higher percentage of elderly than Luzerne County. The unemployment rate of PA is 3.5% and slightly higher than Luzerne County. The median family income for Luzerne County was $77, 983 which is significantly higher than that of the state’s which was $69, 412. During the windshield survey, it was evident that Dallas Borough is a wealthy community. Families that were reported living below poverty level in Luzerne County was 4.1% compared to the state of PA at 7.8%. According to the Center for Rural PA (2010), 19.7% of Luzerne County were enrolled in medical assistance, compared to the state total of 17.2%. This could be attributed to the population growth in Luzerne County over the years. As the region continues to achieve low levels of unemployment in an era of fairly strong economic growth, must communities see getting bigger as the main goal of economic development. However, Dallas Borough focuses more on quality than quantity; more about getting prosperous than simply getting bigger. This practice elevates the resident’s quality of life and strengthens the long term sustainability of this community. Thus, the municipality of Dallas is focused on meeting the challenges of the ever changing economy by focusing on innovation, learning and constant adaptation. This is reflective of the amount of people who reside in Dallas their whole life and is evident by the residents who ban together to enhance the place they call home.
Safety
Major crime is not a concern for the borough of Dallas. Dallas is lucky enough to have its own police department, along with each of the neighboring communities in the Back Mountain having their own as well. Many times the police departments cooperate with one another given their close proximity in order to ensure the safety of all the residents located in the Back Mountain area. According to City-Data.com, the majority of crime in the Dallas area has been burglary. The following graph depicts the types of crimes and percentages from 2009-2006 for Dallas Borough.
[pic]
Obviously thefts rank as the highest safety concern for this community. Theft and burglaries are also the top two crimes in the Wilkes-Barre area, which is of note since most of the residents residing in the borough travel here for employment, access to health care and recreation purposes.
Transportation
The primary mode of transportation in the borough is by car. Being that most of the community is rural owning a car is a necessity. A car pool area was noted in a parking lot but was empty when the windshield survey was conducted. There is public means of transportation by bus, but the bus runs on a tight schedule so is not always accessible by all the residents of the community. Not many people were found walking through the borough when the windshield survey was conducted. There are not many sidewalks located in the community except for those in higher income housing developments. Since Dallas is considered the “heart” of the Back Mountain, roughly 40,000 vehicles pass through the borough on a given day. The borough does a good job of maintaining the functional integrity of routes 309 and 415. There was also the recent addition of a new stop light in the center of Dallas due to the high volume of traffic. Residents were not able to cross route 309 during high traffic times and had to travel down out of their way, the installation of this traffic light aided in this problem.
Conclusions
At the conclusion of the community assessment of Dallas Borough, many strengths and weakness of the community were established. One may consider that a major strength in the community is the way the residents and government feel about maintaining and enhancing their environment. A second strength would be the lack of violent crime in this community related to the availability of law enforcement. Many of the weaknesses of this community directly correlate with those of the county and state as the data has shown. Some of these weaknesses include: the high rate of pollution in regards to air quality, the high incidence of prostate cancer among these residents, the high rate of chlamydia and also the overwhelming amount of obesity in both the adult and child population. Cancer is the second leading cause of death across the board and the high incidence of prostate cancer in this community can be related to a variety of reasons. This area has a high population of elderly and advanced age is a risk factor, however this area is mostly Caucasian and prostate cancer is usually more common in African Americans. According to Prostate Cancer Foundation, men who live north of 40 degrees latitude have the highest risk of dying from prostate cancer than any men in the United States. This appears to be related to inadequate sunlight for three months out of the year which diminishes vitamin D levels. Many men do not understand prostate cancer, so an advanced practice would have the opportunity to intervene with both primary and secondary measures. Air pollution is a major concern in this community since it is ranked one of the dirtiest in the country. One can infer that this could relate to the amount of tractor trailers and other high volumes of traffic that travel through Luzerne County on the way to other places. Pollution is a constant concern and interventions for the purpose of this paper are not realistically obtainable. Chlamydia is the most frequently reported sexually transmitted disease in the United States according to the CDC which may be reflective of why it is the most prevalent STD in Luzerene County and Pennsylvania. This prevents an opportunity for an advanced practice nurse to teach the signs or symptoms of chlamydia because it often goes undiagnosed and also to teach health prevention strategies. Health prevention and sexually education could take place in schools. The last concern for Dallas Borough and the one in which this future advanced practice nurse plans to focus on is childhood obesity. Obesity is not only a concern on the community level but also on the state and national level. The United States is ranked number 1 in the world for the rate of obesity as previously stated. The observations made during the windshield survey are supported by this data. Childhood obesity was a major concern for community members during the focus group. Residents describe risk factors attributing to this as lack of parental control, age of electronics, families not having adequate time to prepare healthy meals and the availability of fast food in the Dallas area. The residents have recognized this as a growing health concern over the past five years, but voiced that they are at a loss of what to do to stop the growing epidemic. Through the analysis of both objective and subjective data collected on the community assessment of Dallas, a borough in the county of Luzerne, problem areas were identified. Appropriate health interventions will be implemented in an effort to decrease the rate of childhood obesity in this open-minded community.

References
Center for Disease Control and Prevention. (2008). http://www.cdc.gov/std/chlamydia/STDFact-Chlamydia.htm
Dallas Borough, PA Detailed Profile Information. (n.d). http://www.city-data.com/city/Dallas-Pennsylvania.html
Dreher, M., Shapiro, D., & Asselin, M. (2006). Community Health Assessment. In C. Hall, & J. Palmer (Eds.), Healthy places health people A handbook for culturally competent community nursing practice (pp. 119-195). Indianapolis, IN: Sigma Theta Tau International.
Epodunk. (2011). http://pasdc.hbg.psu.edu/Data/Census2010/tabid/1489/Default.aspx
FBI Uniform Crime Report for Dallas Borough. (2009). http://www.fbi.gov/about-us/cjis/ucr/ucr
Healthy People 2010. (2010). www.healthypeople.gov
Luzerne County Health Profile . (2010). www.portal.state.pa.us/portal/server.pt/document/442663/luzerne_pdf_(6)
PA Department of Education. (2010). http://www.education.state.pa.us/portal/server.pt/community/pennsylvania_department_of_education/7237
Pennsylvania Department of Health. (2010). http://www.portal.health.state.pa.us/portal/server.pt/community/department_of_health_home/17457
Pennsylvania Department of Health. Behavioral Health Risks of PA Adults. (2009). www.dsf.health.state.pa.us/health/site/defalut.asp
Pennsylvania Health Profile. (2010). www.portal.state.pa.us/portal/server.pt?open=18&objID=920141...2
Pennsylvania State Data Center. (2010). http://pasdc.hbg.psu.edu/Data/Census2010/tabid/1489/Default.aspx
Pollution Locator. (n.d). http://scorecard.goodguide.com/env-releases/hap/rank-states.tcl
Prostate Cancer Foundation. (n.d). http://www.pcf.org/site/c.leJRIROrEpH/b.5802027/k.D271/Prostate_Cancer_Risk_Factors.htm
The Center for Rural Pennsylvania. County Profiles. (n.d). http://www.ruralpa2.org/county_profiles.cfm
U.S. Census Bureau. (2010). http://quickfacts.census.gov/qfd/states/42/42079.html