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					                                                           Community Health      1


               Community Health Clinical projects, Ft. Lewis WA

 Mark Doherty, Wendy Magana, Angela Melvard, Ben Quiroz, Heidi Ritting, Ashley

               Roberts, Amber Skipworth, Lisa Wilson, Lacy Volk

                          Pacific Lutheran University
                                                                       Community Health         2


        For our Community Healthcare class, our clinical group was given the

opportunity to work on Ft. Lewis at Classic Madigan with the Army Public Health

Nurses. It has been a unique opportunity for us to learn about community health nursing

as well as learning how Army Public Health takes care of their community. Each of us

had a different experience here at Classic Madigan, but we all learned a lot about public

health nursing.

        Army Public Health’s mission is to ―Provide essential Public Health Nursing

services in field and garrison environments‖ and their vision is to have ―Ready and fit

Soldiers prospering in healthy military communities‖ (Madigan Army Medical Center

Army Public Healthy Nursing Pamphlet).


        Fort Lewis has a unique history of trials, tribulations, and great successes. The

fort was created as a result of World War I. In 1917, the Pierce County Electorate

donated 70,000 acres of land to the Federal Government for use as a military base. This

was the first military installation to be created as the result of a gift of land. The 70,000

acres was named Lewis after the famous Captain Meriwether Lewis from the Lewis and

Clark Expedition. In 90 days, 1,757 buildings and 422 other structures were fully

constructed. After all of the buildings completed construction, the main gate was built. It

still stands today but in a different area due to the construction of Interstate 5.

        During peacetime, Camp Lewis fell into disrepair due to reduced funding and

neglect. The greater Tacoma area, including newspapers, demanded that the government

(War Department) give back the land. However, in March 1926, Congress approved a 10-
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year building plan to revitalize several Army posts, including Camp Lewis. On 30

September 1927 Camp Lewis was redesignated a Fort.

          Between May 1939 and March 1941, the post population exploded from 5,000 to

37,000. To accommodate the growing population, a 2000-acre North Fort Lewis complex

was completed by August 1941. This growth was a result of activity leading up to World

War II.

          The bombing of Pearl Harbor shook the community of Fort Lewis and all along

the west coast. As a result of the bombings the troops of Fort Lewis secured McChord

Field, Camp Murray, and Fort Lewis itself. During the war, the post trained many units

including the 3rd, 33rd, 40th, 41st, 44th and 96th Infantry Divisions. In July 1943, a

camp for enemy prisoners of war (EPW) was established and continued operations for 3


          The boundaries of Fort Lewis were extended even further in 1943 for training

space. This new land became known as Rainier Training Area and it was over 18,000

acres from the Nisqually River. At the end of the war, Fort Lewis became home to the

2nd Infantry Division (I.D.). This division was the first to depart for the Korean War.

          In 1950, the housing situation was strained once again. Two new regimental areas

were built east of the Gray Army Airfield to accommodate the thousands of recalled

reservists, draftees, and many units coming back to Fort Lewis. At the end of the Korean

conflict, Fort Lewis became home to the 4th Division.

          During the Vietnam War the 4th Division deployed to Vietnam in 1966. Fort

Lewis took on the role of training recruits and personnel, and processing soldiers to and

from the Pacific. This resulted in the processing of 2.5 million soldiers and the training
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of over 3000,000 thousand men over a period of six years. By this time Fort Lewis had

also become home to the 9th Infantry Division.

       Fort Lewis was been influenced greatly by war and peace. It continues to grow

and develop through collaborations between government, state, and counties.


       The following are basic demographic data that compare our community, Fort

Lewis, to Pierce County, Washington State, and the United States. The population of the

United States is 281,421,906, the population of Washington State is 5,894,121, the

population of Pierce County is 700,820, and the population of Fort Lewis is 19,089. The

male population of the United States is 138,053,563, the male population of Washington

State is 2,930,661, the male population of Pierce County is 348,452 and the male

population of Fort Lewis is 11,973. The female population of the United States is

143,368,343, the female population of Washington State is 2,963,460, the female

population of Pierce County is 352,368 and the female population of Fort Lewis is 7,116.

The following demographic data relates to ethnicity. In the United States there are

211,460,626 Whites (75.2%), 36,419,434 African Americans (12.9%), 4,119,301

American Indian and Alaska Natives (1.5%), 11,898,828 Asians (4.2%), 874,414

Hawaiian and Pacific Islanders (0.3%), 35,305,818 Hispanics (12.5%) and 18,521,486

people identifying as other (6.5%). In Washington State there are 4,815,072 Whites

(81.7%), 185,052 African Americans (3.1%), 91,299 American Indian and Alaska

Natives (1.5%), 320,979 Asians (5.4%), 217,038 Hawaiian and Pacific Islanders (3.6%),

439,814 Hispanics (7.5%) and 229,131 people identifying as other (3.8%). In Pierce

County there are 548,941 Whites (78.3%), 48,741 African Americans (6.9%), 9,472
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American Indian and Alaska Natives (1.4%), 34,741 Asians (4.9%), 5,075 Hawaiian and

Pacific Islanders (0.7%), 38,577 Hispanics (5.5%) and 14,879 people identifying as other

(2.1%). On Fort Lewis there are 11,537 Whites (60.4%), 3,882 African Americans

(20.3%), 259 American Indian and Alaska Natives (1.3%), 650 Asians (3.4%), 342

Hawaiian and Pacific Islanders (1.8%), 2,507 Hispanics (13.1%) and 1,189 people

identifying as other (6.2%). The following demographic data relate to those who have

attained a high school degree or higher. This data does not reflect the entire population as

a portion of the population is not old enough to have yet completed high school. In the

United States there are 146,496,014 people with a high school degree or higher (52.1%),

in Washington State there are 3,333,171 people with a high school degree or higher

(56.5%), in Pierce County there are 384,540 people with a high school degree or higher

(54.8%) and on Fort Lewis there are 7,289 people with a high school degree or higher

(38.1%). The total number of households in the United States is 105,480,101, the total

number of households in Washington State is 2,272,261, the total number of households

in Pierce County is 260,897, and the total number of households on Fort Lewis is 3,476.

The following demographic data relate to marital status. In the United States there are

120,231,273 people who are married (42.7%), 59,913,370 people who have never been

married (21.3%), 14,674,500 people who are widowed (5.2%) and 21,560,308 people

who are divorced (7.6%). In Washington State there are 2,641,743 people who are

married (44.8%), 1,218,610 people who have never been married (20.6%), 249,461

people who are widowed (4.2%) and 529,708 people who are divorced (0.9%). In Pierce

County there are 309,436 people who are married (44.2%), 136,584 people who have

never been married (19.5%), 28,650 people who are widowed (0.4%) and 67,274 people
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who are divorced (1.1%). On Fort Lewis there are 7,376 people who are married (38.6%),

5,096 people who have never been married (26.7%), 49 people who are widowed (0.3%)

and 573 people who are divorced (3%). The average yearly salary in the United States is

$56,604, the average yearly salary in Washington State is $58,653, the average yearly

salary in Pierce County is $54,972 and the average yearly salary on Fort Lewis is

$37,601. (CDC) See Appendix A for a chart of these demographics.

       In addition Madigan Army Medical Center employs 2,421 civilians to work

alongside of the Army personnel stationed at Madigan.

                                     Systems Theory

       We applied the systems theory to our community of Ft. Lewis to see how the

community functions. It is a cyclic structure that has continuous needs that includes

inputs (resources and things that go into the community), throughputs (activities that the

community does, systems in place in the community), and outputs (results of inputs

which cause the need for more inputs to go into the community).

       We decided that the most significant inputs for this community. These include the

resources from the US Government, Soldiers, housing issues, the age of those in the

community, various education levels, weapons, aircraft, military vehicles, and health care

professionals. We decided that from these inputs, the throughputs or systems in place in

the community are schools/daycare centers, deployments, alcohol, tobacco, fitness,

training, facilities, health care system and education. Some of these throughputs could

also be considered inputs but we decided because of their affect on the community inside

the instillation it would be better to put them here. The outputs from all of these inputs

and throughputs are trained soldiers, mission accomplishment and healthy soldiers and
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families. Based on these outputs we decided that health maintenance, facility

maintenance and new missions feed back into the system and create the need for the

inputs to continue to come into the community and the throughputs to continue to happen

so that the end products can continue to be produced. See Appendix E for a graphic

representation of our system.

                                        Key Informants

       To gain knowledge of the community we would be working in, each group

interviewed a variety of people that we labeled ―Key Informants‖. They were each able to

give us information that helped in the assessment of our community and to tell us what

they thought their communities greatest strengths and weaknesses were.

Community Strengths

      Many facilities for child care

      Close community

      Strong community support- In peace and war the community is there for its


      Security- gates that control the in and out flow of people and things

      Job Security- very hard to be fired from the Army before enlistment is up

      Accessibility of Health Services- all Army personnel and dependants can be

       treated at Madigan Army Medical Center

      Fitness- most of the community is in general good health to comply with the

       Army standards

      Resources for daily living- shopping, health care, churches all on post making Ft.

       Lewis self sustainable
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Community Weaknesses

      Large area- can keep people away from some services dependant on their

       transportation situation

      Lack of knowledge- of resources available and of health care issues due to a lack

       of good advertising

      Drug, Tobacco and Alcohol abuse- related to stress of military lifestyle

      Stress- related to the lifestyle of the Soldier, war, financial issues in the family,

       nations push away from obesity and Army standards for weight.

      Deployment

      Theft and a False Sense of Security- living on a military instillation does not mean

       that it is crime free.

Limitations and Gaps in Overall Assessment

      Not interviewing enough general informants

      Time- not long enough time spent of windshield assessment

      Large area- too much post for each group to see

      Limited access- cant just go exploring without the proper permits

                                    Windshield Survey

General Impressions

       Fort Lewis, Washington is an Army post directly off of the I-5 corridor ranging

from exits 118-125. East of the post, Mt. Rainer glistens in the sunlight on clear days.

Access to the post is restricted to military personnel and their families, and the civilians

who work on the post. To gain access to the post, visitors must apply for a pass and enter
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through one of the many guarded gates. Army military police check car decals and

identification before military personnel and visitors are allowed through. There are built-

in spike strips that can be electronically triggered to rise if an unwanted intruder is trying

to either enter or exit the Army post. Near the gates and hospital there tends to be much

more traffic than anywhere else on post; yet it is worse at commuter times of the day. A

fence surrounds the majority of the post however there are areas for training that allow

rode access without gates or fences.

Scenery, Open Spaces, and Structures

       Fort Lewis is comprised of sections diverse scenery, structures, and open spaces.

It is the home of greenbelt areas, training areas, an airfield, numerous housing units, a

hospital, schools, parks, a lake, a stadium, a football field, a library, many churches and

gyms, a museum, a cemetery, businesses, community centers, and buildings used as

military facilities for training and other services. Many of the buildings are outdated in

style, and lack curb appeal. North Fort Lewis contains a large forested area, American

Lake, a park, gym, training facilities, medical and dental center, a mini- mall, and homes.

The airfield is found right inside the main gate and is home to many helicopters and

hangers. The hospital (Madigan Army Medical Center MAMC) is located not too far

from the Madigan gate off of Exit 122 and is a towering white building with a large

parking lot. South east and west areas of the post have large sections of greenbelts used

for fire ranges and training. Around some of the housing areas there are basketball

courts, soccer fields, playgrounds for children, and open grassy areas. Some of the

businesses on the post are Burger King, Popeye’s, Armed Forces Bank, Credit Unions,

Car Care, Commissary, PX, and many fast-food and small businesses located inside the
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PX. The PX and North Fort Lewis Exchange offer banking services seven days a week.

America’s Credit Union also provides banking services. The overall appearance of Fort

Lewis’s scenery, its structures, and the open spaces varies from different locales on base.


       The housing facilities on post vary greatly. The housing includes barracks which

are in some cases very outdated and rundown, as well as newer apartment style

dormitories. The base also contains family apartment homes, duplex homes, and single

family homes. The enlistee’s housing and the officer’s housing greatly differ. The

enlisted personnel live in smaller, more outdated houses than the officers, who live in

larger nicer homes. The post homes and apartments are arranged into small

neighborhoods. These neighborhoods have open grassy spaces and playgrounds for

recreation. The apartment style homes fluctuate in appearance as well. In some cases the

apartments and multiplexes look older and somewhat run-down, and other areas

apartments appear brand new. The different neighborhoods are distinct in maintenance,

style, and the age of housing.


       Most military personnel and civilians either have their own vehicles, ride bikes, or

walk from place to place on post. There are well maintained sidewalks often used by

runners. We did notice that there are a few cabs (Fort Lewis Taxi Service) driving

throughout the post, and parked in front of the PX (post exchange). Parking is scarce

especially near the PX and MAMC. Early morning, lunchtime, and the early evening is

when traffic is most profound and can make getting from place to place difficult at times.

In concern of safety, Fort Lewis is a very well-patrolled community. There are many
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armed military police, and every gate has armed personnel guarding the entrance and exit

of unwanted people.


       Due to being a community full of many different people from many different

areas of the United States, Ft. Lewis offers religious services to a broad group of

individuals. Some of the different religions that services are provided to are the Catholic,

Protestant, Non-denominational Christian, Jewish, and Muslim to name a few. There are

many chaplains and chaplain services. There are approximately nine which consist of the

Chapel Support Center, Catholic Services, and Protestant Services to name a few; and for

people of Jewish, Buddhist, or Muslim beliefs they can call the Chapel Support Center

for information.

Schools and Helping systems & Social Services

       The base is home of many schools which are all apart of the Clover Park school

district. The three largest are elementary. Some of the schools on Ft. Lewis are:

Clarkmoor Elementary School (Preschool – 268 students), Evergreen Elementary School

(K-5 – 724 students), Greenwood Elementary School (K-5 – 345 students), Hillside

Elementary School (K-5 – 389 students), Beachwood Child Development Center

(Preschool – 12 students), Clarkmoor Child Development Center (Preschool – 12

students), Madigan Child Development Center (Preschool – 12 students), and North Fort

Youth Child Care Center (Preschool – 60 students).

    Caretaker services for children are also offered on base. Child Development Services

provides child care services for children from birth through 12 years old. School Age

Services is an accredited child care delivery system that has before and after school
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programs, as well as full-day programs during school vacations and school closures.

School Age Services also offers a summer camp for children in K-5th grade. For the

older children Youth Services provides Boys and Girls Club of America opportunities for

middle school and teenage youth such as league sports programs, sports clinics and

instructional classes.

   Ft. Lewis, along with the rest of the military, has plenty of resource available to the

soldiers and their families. There are many opportunities for help with finances, child

care, education, jobs, marriage and family counseling, rehabilitation, legal services, and

veteran’s services. Ft. Lewis has something called the Soldier Family Assistance Center

(SFAC), which is a place where you can access all of the above resources. It’s a warm,

and friendly place for families to get all of the things they need in a ―one-stop shop‖.

   Child and Youth Services (CYS) is another resource for families at Ft. Lewis. It’s a

youth center where children can go after school and stay busy with physical activities and

get homework done, with tutoring opportunities if needed.

   Center for Excellence is another ―one-stop shop‖ program that works with families.

Their goal is to help soldiers with families that have had multiple deployments stay

proactive and in the loop. They feature many different resources for helping the families,

including: chaplain, CYS, finances, medical resources, physical fitness, and education.

Recreational Facilities

       There are many different recreational activities one can participate in within the

confines of Ft. Lewis. There are pools, youth centers, fitness centers, gyms, bowling
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center, movie theatre, football fields, soccer fields, and baseball fields. There is an Arts

and Crafts Center where classes are held on different types of crafting. There are

libraries that have more than 143,000 volumes of books, videos, audiotapes, DVD’s and

compact disks. Ft. Lewis also provides access to the Puget Sound, Chambers Lake,

Lewis Lake, Tall Firs picnic area on American Lake, and Miller Hill recreational area.

Fishing and hunting is allowed on post in certain areas as long as fishing and/or hunting

license is purchased. The post also has the Ft. Lewis Golf Course, which is a 27-hole

championship golf course, driving range, practice putting green, lounge, snack bar, pro

shop, and dining area.

Gathering Places

        Many places are available for people to convene, and enjoy the company of

members of the community. The Cascade Community Center is where one can enjoy

good food from the grill or salad bar, watch sports on hi-definition plasma TV’s, have a

cold beverage and hot appetizers, and there are also private rooms for parties and other

functions. Russell Landing Café is another great place for people to enjoy great food and

beverages, while enjoying the scenic view of the shores of American Lake. Club North,

located on North Ft. Lewis, offers different events and themed entertainment like line

dance lessons and karaoke.


        Ft. Lewis not only has employment for military personnel, but for off-post

civilians as well. The Commissary and PX are privately owned businesses that employ

both military and civilian workers. There is worked offered through banks, schools, and

fast-food establishments as well. MAMC employs more than 3,700 medical, dental,
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nursing and administrative personnel, consisting of both military and civilian workers as

well. The majority of the community is employed by the government or is a dependent or

spouse of an employed person.

Health care

         Military families are provided with TriCare for health insurance. This gives

them access to Madigan Army Medical Center, all of the clinics inside of Madigan, and

all of the public health clinics at Classic Madigan. This sets families up with vision,

dental, and medical insurance.
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CYS Teaching Project:


       During our community health clinical we had the opportunity to work at Army

Public Health Nursing (APHN) on Fort Lewis. LTC Baker had three project areas for our

three groups to work on. We had the opportunity to work on a project with Child and

Youth Services (CYS). CYS provides many services, such as childcare, to the children on

Fort Lewis. We were paired with Denise Ruby who works as a community public health

nurse at CYS. As one of our key informants, she identified asthma and allergies as being

a prevalent health issue among the children at CYS facilities as well as the most common

condition reported by parents/guardians during registration. In addition, she identified a

desire by the workers of CYS to be trained on the topic of asthma and allergies because

they see these conditions frequently among the children. Our other key informants

included Patricia Botsford, a registered nurse responsible for special needs children at

one of the CYS facilities, and Norma Abbott, the director of the Beachwood CYS

facility. They both identified asthma and allergies as a prevalent health issue among the

children registered at CYS.


       Asthma is a chronic condition that produces recurring episodes of breathing

problems. People who have asthma have triggers that can initiate the onset of an

asthmatic episode (CDC, 2008). During an episode of asthma the airways swell and the

lining of the airways become narrow and easily irritated. Excess mucous is produced

which clog the airways, and the muscles that surround the outside of each airway tighten

and make airways narrower. The combination of these factors dramatically reduces the
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size of the airways and allows less air to be delivered to the lung tissues. This results in

symptoms such as coughing, wheezing, chest tightness, and shortness of breath (National

Heart, 2008).

       An allergy is a response of your body’s immune system to something that does

not bother other people. This response could be potentially serious. Substances that most

often cause an allergic reaction are food, pollen, dust mites, mold spores, pet dander,

insect stings, and medicines (National Library, 2008). Milk, eggs, peanuts, tree nuts,

fish, shellfish, soy and wheat are the most common foods that cause allergic reactions and

account for over 90% of allergic reactions in affected individuals. An allergic reaction

can be mild and show symptoms including rashes, itchy watery eyes and congestion and

will not spread to other parts of the body. A moderate reaction will spread to other parts

of the body and show symptoms such as itchiness and difficulty breathing. This response

can turn potentially serious when a severe allergic reaction occurs. This reaction is known

as anaphylaxis which is a life threatening emergency. Anaphylaxis occurs suddenly and

affects the entire body. It can begin with itching of the eyes and face and can progress to

swelling of the airways. This swelling makes breathing and swallowing difficult and

causes abdominal pain, cramps, vomiting, diarrhea, and mental confusion or dizziness

(WebMD, 2008).

       The topics of asthma and allergies are closely related. Children with a food

allergy are two to four times more likely to have asthma or other allergic conditions

versus children without a food allergy. 29% of children with food allergy also had

reported asthma compared with 12% of children without food allergy (CDC, 2008)
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Many of the things that can trigger an asthma episode can also cause an allergy in

affected individuals. Both asthma and allergies remain to be interconnected and

potentially life threatening at the same time.

       In the United States approximately 14% of children have been diagnosed with

asthma and approximately 3.9% of children have a food allergy, 30% of children have a

skin allergy and 20% of children have seasonal allergies. We have summarized the

percentage of the population 19 years and under in the United States, Washington state,

Pierce County, and on Fort Lewis in the following table:

United States                                    28.6%

Washington State                                 28.6%

Pierce County                                    30.2%

Fort Lewis                                       38.4%
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         This data illustrates that asthma and allergies are a prominent health issue in

children in the United States so we can assume that these are prominent health issues in

the children on Fort Lewis as well. In addition there are a higher percentage of children

on Fort Lewis versus the United States, Washington State and Pierce County (CDC,


         The prevalence of both asthma and food allergies have been on the rise over the

recent years. The prevalence of asthma is greater in children than it is in adults.

According to the CDC’s analysis of asthma data the prevalence of asthma has increased

in children from 3.5% in 1980 to 7.5% in 1995. Between the years of 2001 to 2004 the

CDC reported the prevalence of asthma in children to be 8.5%. After 2004, the

prevalence of asthma continued to rise while currently 14% of children have are

diagnosed with asthma. Physician office visits related to asthma also reflect the increase
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in prevalence. In 1990 there were 40 visits due to asthma per 1,000 children and in 2004

there were 89 visits due to asthma per 1,000 children. The National Center for Health

Statistics reports that from 1997 to 2007 the number of children with a food allergy

increased by 18%.

The number of hospital discharges in children with any diagnosis related to food allergy

has also increased over the recent years. Between 1998 and 2000 there was an average of

2,615 discharges, between 2001 and 2003 there was an average of 4,135 discharges and

between the years of 2004-2006 there was an average of 9,537 discharges (National

Center, 2008)
                                                                    Community Health 20

       Healthy People 2010 is an initiative designed to address and improve the health of

all people in the United States. The central goals of Healthy People 2010 are to increase

the quality and years of healthy life and to eliminate health disparities (Edelman and

Mandle, 2006). For our project we focused on the goals of Healthy People 2010 that are

related to asthma and allergies in children. Objective 10-4 is to reduce the number of

deaths from anaphylaxis caused by food allergies. Objective 24-1 is to reduce the number

of asthma deaths. This objective states specific target goals for the reduction in numbers

for specific age groups. The 1998 baseline data reported 2.1 deaths per million among

children under age 5 years and the target for 2010 is 1 death per million. The 1998

baseline data also reported 3.3 deaths per million among children ages 5 to 14 years and

the target for 2010 is 1 death per million. Another objective related to asthma is objective
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24-7 which is to increase the proportion of persons with asthma who receive appropriate

asthma care (Healthy People, 2008).


       Based on our assessment data in the Fort Lewis community and the information

that we gathered from interviews with our key informants we generated two nursing


                Risk of a knowledge deficit among CYS staff related to a desire of the

                 staff to have supplemental training on asthma and allergies.

                Risk of inappropriate care of a child experiencing an allergic reaction or

                 asthmatic episode among CYS registered children related to the

                 prevalence of allergies and asthma being reported upon registration with

                 CYS, and the workers report of uncertainty of what to do when a child is

                 experiencing an allergic reaction or asthmatic episode.

       There were several reasons why we chose the issues of a knowledge deficit

among CYS staff and inappropriate child care among CYS registered children. We first

looked at the severity of these issues. Asthma and allergies have the potential to threaten

a child’s life if the reaction is uncontrolled or inappropriately handled. Secondly, we

looked at the prevalence of this issue. Statistics prove that asthma and allergies are

prevalent health issues among children in the United States. Our key informants also

reported that asthma and allergies are the most reported health issues among children

upon their registration to CYS facilities. Thirdly we looked at what the community

wanted to do. The CYS workers expressed a desire to be trained on the topic of asthma
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and allergies. Our key informants, including the director of Beachwood Child

Development Center and a CYS special needs nurse, also expressed a desire for

supplemental teaching on asthma and allergies. Finally, we determined the feasibility and

whether these issues are within the scope of a public health nurse. Since the emphasis

was anticipated to be teaching, we decided this issue was definitely within the scope of a

public health nurse. Feasibility was high because we had access to the appropriate

resources for our teaching project as well approval from the director of CYS.


       Risk of a knowledge deficit among CYS staff and risk for inappropriate care

among CYS registered children will be addressed through teaching a class of CYS staff a

general understanding of asthma and allergies. This class will educate them how on the

early signs of an asthmatic episode and allergic reaction as well as what to do when these

symptoms arise. They will also be taught on action plans, administering inhalers, and

administering EpiPens, standard and the new Twinject. Our plan is teach this class at the

Beachwood CYS location. We had a meeting with Beachwood Child Development

Director, Norma Abbott, in which we selected November 20, 2008 as the date for holding

our classes. Norma suggested that we hold 20-30 minute classes offered throughout the

entire work day so that as many staff could participate as possible. We created a flier to

advertise our class which will be posted at the Beachwood center before our classes. (See

appendix F)

       The core function of our project is assurance. According to Public Health Nursing

Textbook assurance is a role of public health that ensures that essential community-

oriented health services are available (Stanhope and Lancaster, 2008). Assurance
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―provides constituents with services necessary to achieve agreed upon goals, either by

encouraging actions by other entities (public or private sector), by requiring such action

through regulation, or by providing services directly‖ (Schultz, 2008). Through our

teaching project we are assuring that CYS staff have access to a class that offers

appropriate education on the topics of asthma and allergies. We will be providing them

with the necessary information and tools to become educated employees who will be able

to recognize asthmatic episodes or allergic reactions in the children that they care for and

handle the situation effectively.

          The level of prevention of our project is secondary prevention. It would not be

considered primary because the children already have diagnosed asthma and allergies.

The aim of our class is to educate the staff about these already existing conditions in

order to prevent a further or worsening adverse event. A goal of secondary prevention is

treat the early stages of disease to limit the possible disability that disease can cause. We

will be teaching staff to recognize the early signs of an asthmatic episode or allergic

reaction so that these conditions do not progress to be life threatening for any of the

children at CYS.

          We identified short and long term goals for our project that each include

measurable objectives. Our first long term goal was created in collaboration with Mrs.

Ruby because it was originally Army Public Health Nursing’s goal. The following long

term goals are the Healthy People 2010 objectives that are related to our project.

         Short term goal: Provide education to CYS Staff on asthma and allergies
                                                                   Community Health 24

           o       Objective 1: Minimum of one CYS staff member from each module

               will receive a 30 minute class on asthma and allergies on November 20,


           o       Objective 2: Minimum of one CYS staff member from each module

               will demonstrate correct administration of the EpiPen and inhalers on

               November 20, 2008.

           o       Objective 3: The overall mean of the post-test will be greater than the

               mean from the pre-test from the class held on November 20, 2008.

        Long term goal: Provide annual asthma and allergy education to staff at all of

       the Fort Lewis CYS facilities.

           o       Objective 1: APHN will have our resources by November 20, 2008.

           o       Objective 2: APHN will observe our class to generate ideas for future

               classes on November 20, 2008.


         After determining that the class will be held at the Beachwood CYS facility and

setting a date with director Norma Abbott, we began developing our teaching curriculum.

We first developed an outline of all of the topics that we wanted to cover. As we

developed our outline, Mrs. Ruby remained to be a great resource for feedback. She was

very knowledgeable on the topics of asthma and allergies as well aware of available

resources. Our outline included a definition of asthma and allergies, an explanation of

the disease processes, triggers, signs and symptoms, medication administration

information. The medication administration section also included demonstrations of

inhaler use with a spacer and how to use both standard and Twinject EpiPens. After our
                                                                      Community Health 25

outline was developed we then constructed a brief power point presentation (see appendix

G). A pre-test and post-test was written in order to assess the knowledge level of

participants before and after our class. Next, we obtained the supplies to perform our

demonstrations. These supplies consisted of two inhalers, three spacers (adult, toddler,

and infant sizes), EpiPen demonstrators, EpiPen Twinject demonstrators, and straws. All

of the supplies were provided to us through Mrs. Ruby with the exception of straws.

Straws are needed for a demonstration in which the participants will breathe only through

the straw to understand what it might be like during an asthma attack as you cannot get

enough air by simply breathing. After finalizing our PowerPoint and presentation details

we focused on the logistics of how we were going to actually implement our teaching.

Mrs. Ruby agreed to bring a Proxima projector so that we have the tools to show our

PowerPoint presentation. We checked in with the facility periodically beforehand and

were told that they expected 50-60 people to attend our ten classes throughout the day.

We were then able to ensure that we had enough supplies to adequately teach that amount

of people. Finally, we practiced and timed our presentation beforehand to make sure that

it fit within the timeframe. After the completion of all of these steps we were finally

ready to implement our teaching project.


       We evaluated the objectives of our short term goal using both formative and

summative types of evaluation. Formative is described as evaluating during the process

and summative is described as evaluating at the end of the process.

        Short term goal: Provide education to CYS Staff on asthma and allergies
                                                           Community Health 26

o       Objective 1: Minimum of one CYS staff member from each module

    will receive a 20-30 minute class on asthma and allergies on November

    20, 2008.

                   Formative: Check the sign in sheet throughout the day to see

           if workers from all modules were attending a class.

                   Summative: After all of the classes add up the total number

           of staff that attended our class from each module from the sign in


o       Objective 2: Minimum of one CYS staff member from each module

    will demonstrate correct administration of the EpiPen and inhalers on

    November 20, 2008.

                   Formative: Observe demonstrations of correct EpiPen and

           inhaler administration by the staff during each class by all staff

           attending each class.

                   Summative: After all of the classes check the sign in sheet to

           ensure that at least one staff member from each module attended a


o       Objective 3: The overall mean of the post-test will be greater than the

    mean from the pre-test from the class held on November 20, 2008.

                   Formative: Allow staff to ask questions during class to

           clarify any questions they did not know on the pre-test or any other

           questions that they had.
                                                                    Community Health 27

                           Summative: take the average of the test scores from the pre-

                      tests and the post-tests to check if the overall mean of the post-test

                      was greater than that of the pre-test.

        Long term goal: Provide annual asthma and allergy education to staff at all of

       the Fort Lewis CYS facilities.

          o       Objective 1: APHN will have our resources and PowerPoint by

              November 20, 2008.

                           Formative: Provide APHN with resources throughout the

                      project process and receive feedback when creating our


                           Summative: APHN will have our final resources and

                      PowerPoint after our presentation

          o       Objective 2: APHN will observe our class to generate ideas for future

              classes on November 20, 2008.

                           Formative: We will consult with Ms. Ruby throughout the

                      project process for feedback.

                           Summative: Mrs. Ruby will attend our classes and provide

                      us with feedback, and discuss with us changes she is anticipating

                      for future classes.

                                                                     Community Health 28

       Overall, our project was implemented the way we planned and anticipated it

happening. There were slight accommodations that were made the day of the

presentation. For example, we only administered pre-tests and post-tests for half the

sessions because we were running into time constraints within the schedule the facility

had set up for us. There were also slight additions to our teaching plan made within the

first two or three sessions when we, and Mrs. Ruby, wanted certain details included.

Halfway into the day we found it would be helpful to have examples of action plans for

the staff to look at instead of just explaining them. Mrs. Ruby made copies of an asthma

and allergy action plans which were handed out and addressed in the middle of the

presentation. Other than these, the presentation itself went smoothly with very little

changes from the original plan.

       As stated previously, our short term goal was to provide education to CYS staff

on asthma and allergies. Our first objective was that one staff member from each module

would receive a 20-30 minute class presentation on asthma and allergies on November

20, 2008. This goal was completely met. The classes that completed pre-tests and post-

tests received a thirty minute class. During the second half of the day, the classes ranged

from 20-25 minutes. All of the classes still contained the same content and

demonstrations. Each module not only had one staff member present but several. For the

entire day, the total number of staff members present from each module ranged from 3-7

people (See Appendix). Lastly, all of these presentations were conducted on November

20, 2008 just as anticipated.

       The next objective for our short-term goal was that one staff member from each

module would demonstrate correct administration of an EpiPen and inhaler on November
                                                                    Community Health 29

20, 2008. This goal was met since every module was represented as discussed

previously. Every staff member attending our class practiced giving a regular EpiPen as

well as the Twinject on their own leg. Every staff member attending also got a chance to

attach an inhaler to a spacer. The only limitation was that they did not actually practice

administering inhalers. Our original plan was to have them practice inhaler

administration on dolls but we did not have an adequate amount of inhalers or any dolls

in order to do so. Many staff members did verbalize that they have administered inhaler

medication either to themselves and/or to children. We also received feedback from the

staff during the EpiPen demonstration. They asked questions such as where to put their

thumb, location to aim the needle towards, and how much force is necessary. A

noticeable improvement in medication administration confidence and effectiveness was


       Our third and last objective was that the mean score of post-tests would be greater

than the mean score of pre-tests. The mean score for pre-tests was found to be 3.96 out

of 8 questions. The mean score for post-tests was found to be 6.57 out of 8 questions.

This means that there was an increase of 2.61 points reflecting a greater understanding

and knowledge of asthma and allergies among CYS staff members (See Appendix). This

means that there was an increase of 2.61 points, or an increase of scores from 49.5% to

82.1%, reflecting a greater understanding and knowledge of asthma and allergies among

CYS staff members

One limitation we did notice was a slight language and/or education barrier. The staff

members who attended on November 20, 2008 were a very diverse group. Some of the

test answers we corrected seemed to be words that grammatically did not fit within the
                                                                      Community Health 30

sentence given. It made us wonder if the tests administered did not clearly reflect the true

level of understanding all staff members gained. It is possible that some staff members

actually gained an even higher level of understanding that day than what was reflected on

their post test. Either way, there was a noticeable increase in mean scores indicating there

was an increase in knowledge and understanding of asthma and allergies.

          Our long term goal was that APHN will provide annual asthma and allergy

education to staff at all of the Fort Lewis CYS facilities. Our first objective was that

APHN will have our resources and PowerPoint by November 20, 2008. This goal was

met. We were in constant communication with Mrs. Ruby when we were finding and

creating our resources as well as when we were creating our PowerPoint. She was

provided with the final product before our presentation on November 20, 2008.

          Our second objective was that APHN will observe our class to generate ideas

for future classes on November 20, 2008. This goal was also met. Mrs. Ruby attended all

of our classes. She provided us with oral feedback during a break in our class schedule

and also discussed with us some changes that she was anticipating on making. For

example she expressed that the classes should be about 45 minutes to an hour long,

instead of 20-30 minutes.

          We did not have participants evaluate our presentation because we knew there

would not be enough time in our 20-30 minute class. Mrs. Ruby did provide us with oral

feedback on a break between our morning and afternoon classes. She let us know that she

thought we were saying everything that needed to be said and to continue presenting the

way that we were. As mentioned previously we also discussed with her the changes that

she was anticipating on making for future classes.
                                                                    Community Health 31

        One of the things that we did well this semester was time management. We had

heard from a previous class at the beginning of this semester not to procrastinate. Our

group really applied the advice we received because we never felt short of time and when

given time we used it effectively. Every time we met we accomplished something

tangible and verbally communicated goals for the next week. We set a timeline for

completing tasks and remained within that timeframe. Any future group of students that

applies this principle will benefit greatly from it.

        One challenge we did realize was having appropriate time frames for the actual

day of presentations. It took longer than anticipated to set up our PowerPoint and we

began our first class slightly behind. We also underestimated how long it would take

staff members to complete the pre-tests and post-tests. People that came in late

especially altered the time frame because even though they are only one person, we had

to wait so that they completed their pre-test. We reacted to these circumstances flexibly,

but it would be something that we would recommend to future students to consider. In

the future, we recommend actually looking at the room the presentation will be held in

beforehand and to plan for excess time.
                                                                    Community Health 32

Health Promotion Project:

      The Ft. Lewis Army Base and the McChord Air Force Base have a committee

called the Health Education and Promotion Committee (HEPC), a group of healthcare

personnel who manage the monthly health observances. The Monthly Health Observance

for November was diabetes mellitus, which eventually became the subject of our

community health project. While all the other students in our community health clinical

directed their projects toward the Ft. Lewis population, our group directed it towards the

population of McChord. The reason we chose to do this is due to one of our key

informants giving us the opportunity to screen the McChord population for risk factors

for diabetes, at the healthcare center located on McChord Air Force Base. Assessment

was the first step of the nursing process that we used to gather information pertaining to

diabetes mellitus within the McChord and Pierce County area.


      Type 2 diabetes is an epidemic in America. Many people are completely unaware

of the fact that they have this disease. It is estimated that for every two people who know

they have diabetes, there is another individual that doesn’t know he/she has it (Stanhope,

2008, p.647). Diabetes is estimated to affect 23.6 million (8%) of the population in the

United States. From 2005 to 2007 the prevalence of diabetes has increased by 13.5% in

the U.S. (American Diabetes Association year, 2008).

      At the state level, diabetes now affects nearly 1.3 million Washington residents,

which represents 20.3% of the population. Of these affected, 270,000 have been

diagnosed with the disease, more than 100,000 have undiagnosed diabetes, and at least
                                                                   Community Health 33

900,000 have pre-diabetes (Washington State Department of Health, 2005). Since 1990

the prevalence of diabetes has at least doubled in Washington State (Tacoma-Pierce

County Health Department, 2006).

      Diabetes is taking a growing toll on the population of Pierce County, Washington,

including the population of McChord Air Force Base. The population of McChord AFB

is 11,721, in which 7,817 are non-active duty, and 904 are over the age of sixty. Of this

population, there are at least 315 (2.68%) known diabetics according to Ann Ramsey, a

community health nurse on McChord. In Pierce County about 38,000 are currently

estimated to be diagnosed with diabetes (Tacoma-Pierce County Health Department,

2002). About 18,000 individuals of the Pierce County area have type-II diabetes and are

completely unaware of it (Tacoma-Pierce County Health Department, 2006, p.13). In

recent years, there have been about 1000 emergency room visits and about 800

hospitalizations for diabetes in the Pierce County area each year (Tacoma-Health

Department, 2006, p.8). In 2003 about ―800 deaths in Pierce County had diabetes as a

principal or contributing cause. (Tacoma-Pierce County Health Department, 2006, p.8)
                                                                       Community Health 34

                                                        (Tacoma-Pierce County Health
Department, 2006, P.8)

        Type-II diabetes is a highly preventable disease. In the Nurses Health Study, a

large prospective cohort study, about 90% of new cases of diabetes could be attributed to

five modifiable risk factors: body mass index, diet, physical inactivity, smoking, and

alcohol consumption (Tacoma-Pierce County Health Department, 2006, p.13). Another

theory is that stress also plays a part of a risk factor for diabetes. In that hormones that are

designed to deal with short-term danger continue being released throughout the body,

resulting in long-term high blood glucose levels (American Diabetes Association, n.d.).

Of the military population smoking tobacco, consuming alcohol, stress, and an increase

in age among retirees are key risk factors to consider when working with this particular

community. Body mass index (BMI) is also a very important risk factor in assessing

someone for diabetes, and that is what will be explained next. BMI

        ―The single most important modifiable risk factor for diabetes is body mass

index‖ (Tacoma- Pierce County Health Department, 2006, p. 13?). In Pierce County

obesity ―among adults without diagnosed diabetes increased 63% between 1995 and
                                                                   Community Health 35

2005‖ (Tacoma-Pierce County Health Department, 2006, p.13). Body mass index is a

measure of body fat based on the height and weight of a person.

                       At-Risk Weight Chart Body Mass Index
                 Height in ft.& inches   Weight in pounds without
                 without shoes           clothing
                 4'10"                      129
                 4'11"                      133
                 5'0"                       138
                 5'1"                       143
                 5'2"                       147
                 5'3"                       152
                 5'4"                       157
                 5'5"                       162
                 5'6"                       167
                 5'7"                       172
                 5'8"                       177
                 5'9"                       182
                 5'10"                      188
                 5'11"                      193
                 6'0"                       199
                 6'1"                       204                                  If you
                 6'2"                       210
                 6'3"                       216                          weigh the
                 6'4"                       221
               same or more than the amount listed for your height, you may be at risk

               for diabetes. (American Diabetes Association, 2007)

       The increase in the prevalence of type-2 diabetes is closely linked to the upsurge

in obesity. About 90% of type-2 diabetes cases are attributable to excess weight (Hu et
                                                                     Community Health 36

al., 2001). There are a large percentage of people in the Pierce County community who

are obese or have a much higher body mass index than what is within their healthy

normal limits. Of all military personnel in 2002, under the age of 20, 23.8% were

classified as overweight, and 24% of personnel aged 20 or older were defined as

overweight based on Healthy People 2000 guidelines (Bray et al., 2002, p.90). This is a

fairly large number, considering that the active-duty personnel are to remain in shape and

be at or under a certain weight. The data showed a significant increase in overweight

personnel aged twenty or older (19.5% vs. 24.0%). (Bray et al., 2002, p. 90) Stress is

also an important risk factor for diabetes to assess, especially among the military



      Stress is been suspected to play a part in the development of diabetes. Much of the

stressors that afflict the general population of Pierce County are similar to ones many

Americans face today. Along with being at war with multiple countries, the communities

within America have seen the U.S. economy plummet and continue to plummet in large

leaps. People are stressed-out about their financial situation, which in turn can affect the

way they spend accordingly for healthcare prevention and treatment.

      Active-duty soldiers are many times dealing with the same problems of the general

public, but many added stressors related to military life as well. Adjustment from being a

soldier in a war to being a father, husband, wife, mother, daughter, or son when they

return can be extremely challenging. Prolonged deployments and the stress of being in

combat situations are contributing to severe posttraumatic stress disorders (PTSD) for
                                                                     Community Health 37

many soldiers (Tanielian & Jaycox, 2008). PTSD can present in an array of signs and

symptoms, and truly change people’s lives forever. Results from the National Vietnam

Veterans Readjustment Study, for example, show a strong relationship between the

exposure to traumatic stress while serving in a military combat zone and subsequent

occupational instability (Bray et al., 2002, p. 45). The soldiers are not only dealing with

the psychological issues related to serving in war-times, but also face the physiological

changes due to stress’ effects on the human body.

      Indeed ―current theories link the causes of diabetes singly or in combination to

genetic, automimmune, viral, and/or environmental factors (e.g. stress)‖ (Lewis,

Heitkemper, Dirksen, O’Brien, & Bucher, 2007, p.1254). ―Chronic psychosocial stress

is associated with decreased glycemic control among those who do not cope effectively

with their stress‖.(Peyrot & McMurry, 1992) Stress hormones that are designed to deal

with short-term danger continue being released throughout the body, resulting in long-

term high blood glucose levels. (American Diabetes Association, n.d.) Sympathetic

nervous system (stress response) activation stimulates the release of catecholamines and

cortisol from the adrenal cortex and medulla. Catecholamines then decrease glucose

uptake by decreasing insulin release, while cortisol enhances the elevation of blood

glucose promoted by catecholamines and inhibits the glucose uptake by the body’s cells.

―Overall, cortisol’s actions on carbohydrate metabolism results in increased blood

glucose levels‖ (Huether & McCance, 2004, p. 497). Corticosteroids (cortisol) are the

class of steroid hormones that are produced in the adrenal cortex. Synthetic medications

(steroids) can also cause corticosteroid-like effects, and can induce secondary diabetes
                                                                     Community Health 38

because of the effect of cortisol’s function of increasing glucose levels in the blood

(Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007). Prolonged cortisol levels can

also cause the body to release more insulin in an attempt to decrease the high glucose

level. The prolonged increase in insulin can then lead to insulin resistance (American

Medical Association, 2004). An excess of insulin in the blood also encourages the body

to store fat, boosting the risk of obesity (American Medical Association, 2004). The

long-term activation of the stress-response system and the continued overexposure to

cortisol and other stress hormones, can disrupt almost all of the body’s processes. This

puts anyone at an increased risk for numerous health problems including diabetes (Mayo

Clinic, 2008).


      The risk of type 2 diabetes increases as you get older, especially after age 45 (Mayo

Clinic, 2007). Frequently because people tend to get less exercise, lose muscle mass and

also gain weight as they age (Mayo Clinic, 2007). However, the incidence of type 2

diabetes is increasing considerably among children, adolescents and younger adults, to a

predicted epidemic. Since our project focused on the adult population of McChord AFB,

there are no statistics for this population.


      Compared to people who have never smoked, smokers have about twice the risk of

developing diabetes (Houston et al. 2006). ―Sixteen percent of adult’s diagnosed with

diabetes in Pierce County, in 2005, were current smokers.‖(Tacoma-Pierce County

Health Department, 2006, p.9) Historically, the military has had the reputation of being
                                                                     Community Health 39

an environment in which tobacco use is accepted and common. ―Two decades ago, just

over half of military personnel on active duty were smokers.‖(Bray et al., 2002, p. 144)

Smoking has been on the decline since the eighties yet in recent years the military has

seen smoking increase again. The period ―from 1998 to 2002 marks the first time, in the

past 20 years, when cigarette smoking rates showed a significant increase. From 1998 to

2002, there were significant increases in heavy cigarette and alcohol use (Bray et

al.,2002, p.78). Alcohol is also a problem within the military population, and is the risk

factor described next.


      Studies show that drinking moderate amounts of alcohol may lower the risk of

diabetes, the opposite is true for people who drink greater amounts of alcohol. ―Heavy

alcohol use can cause chronic inflammation of the pancreas (pancreatitis), which can

impair its ability to secrete insulin and ultimately lead to diabetes‖ (Mayo Clinic, 2007).

Comparisons of findings between the 1998 and 2002 surveys showed statistically

significant increases in the rates of heavy alcohol use among military personnel (15.4% to

18.1%)(Bray et al.,2002, p.78). The 2002 approximation of binge drinking, ―defined as

five or more drinks of alcoholic beverages at the same time or 3-12 within 2 hours of

each other at least once in the past 30 days, is 41.8% for the military. This compares with

the Healthy People 2010 objective of 6.0% and the civilian benchmark of 16.6%‖(Bray et

al., 2002, p. 86) ―Rates of heavy alcohol use were consistently higher among military

personnel than among civilians.‖(Bray et al., 2002, p. 39) ―In particular, rates of heavy

alcohol use in the past 30 days among military men aged 18 to 25 were nearly twice the

standardized rates for civilian men in the same age group‖ (Bray et al., 2002, p. 40).
                                                                    Community Health 40

Key Informants

      Our first key informant for this project was Kathy Canny a diabetic nurse educator

at Madigan Army Medical Center (MAMC). She indicated that there is a misperception

that because the military community tend to be more active and younger that they have a

lower incidence of diabetes. She indicated that she is seeing more young active soldiers

with diabetes than ever before. K.C. pointed out that these soldiers are returning home

from deployments with a greater incidence of diabetes. She hypothesized that the cause

may be originating in the war zone, or may be from stress, but also revealed that so far

nothing has been relayed to the health care providers.

      We also worked very closely with our key informant Ann Ramsey, a community

health nurse assigned to Army Public Health Nursing service, who’s office is at

McChord’s health clinic. She stated that there is a need for increased health education

marketing and outreach on McChord and Fort Lewis bases. She would not only like to

see marketing for beneficiaries, but also providers, community leaders and clinic staff.

According to Ann Ramsey, screening and marketing for diabetes is important because ―it

is one of the most far reaching, debilitating and PREVENTABLE diseases affecting

everyone today‖. She also pointed out that there is a lack of awareness and screening on

McChord, but not any more significant than anywhere else. She believes that diabetes

awareness needs to ―remain on the radar as people go about their lives.‖ Ann Ramsey

also mentioned that the military bases have many strengths regarding healthcare.

Strengths of McChord Community
                                                                      Community Health 41

      The McChord Airforce Base community has many strengths as far as the

prevention of diabetes is concerned. Within all the military departments physical health

promotion is not only encouraged, it is a requirement. Soldiers are weighed, and are

required to keep their weight at or below a certain number throughout the year. Many

soldiers are also directed to jog for certain lengths, and to build their muscle strength as

well. There are many opportunities for both indoor and outdoor physical activity on both

of the bases. They have parks, lakes, stadiums, fields, indoor and outdoor pools, gyms,

and paved paths for jogging or walking.

      Another obvious strength of the community is being in such close proximity to one

of the best hospitals in the state, in Madigan Army Medical Center (MAMC) located on

the Ft. Lewis Army Base. The government and its health care system and superiors are

vested in keeping the military population healthy and disease free. Healthcare is

accessible to all military personnel. The perception of one of our key informants is ―that

the base community is generally healthy, and [has] lots of resources.‖ The key informant

also mentioned that McChord ―is good with customer service and communication,‖

which are necessary skills when working with the public who may be seeking healthcare.

Barriers in McChord Community

      With strengths, also come barriers for the McChord community. Many of the

soldiers work in extremely dangerous and stress-inducing positions, and also face being

deployed to distant places to fight in the wars around the world. The atmosphere of the

military is extremely intimidating and demanding at times, inducing even more stress.
                                                                      Community Health 42

Some soldiers cope with stress in different ways, and these coping methods can put them

at even further risk for diabetes.


      There are three types of diabetes mellitus, and they are type-1, type-2, and

gestational diabetes. Type-2 diabetes is a disease that is almost entirely preventable, and

for that reason the focus will be more directed towards type-2 diabetes prevention. Type

2 diabetes is thought to develop slowly over years, and has a prolonged asymptomatic

phase during which it is detectable primarily through a screening process. ―Intervention

during the pre-symptomatic phase produces better patient outcomes than later

intervention‖(Tacoma-Pierce County Health Department, 2006).

      Type-2 diabetes in contrast to type-1 diabetes is a highly preventable disorder. As

mentioned previously, ―In the Nurses Health study, a large prospective cohort study,

about 90% of new cases of diabetes could be attributed to 5 modifiable factors: body

mass index, diet, physical activity, smoking, and alcohol consumption‖. (Hu et al., 2001)

The military community has shown to have high rates of smoking, alcohol consumption,

stress, as well as a recently increasing body mass index. All of which can be managed

with a healthy lifestyle. Smoking cessation, weight control, and physical activity are

extremely important for people with diabetes.

      Diabetes-related deaths are on the rise, making it a priority public health.

Nationally, about a third of all people with type-2 diabetes do not know they have the

disease (Tacoma-Pierce County Health Department, 2002). Awareness and screening for

the disease is in great need, as well as the public awareness of possible risk factors for the
                                                                      Community Health 43

disease. ―The high prevalence of undiagnosed diabetes makes screening a strategy of

much current interest.‖ (Tacoma-Pierce County Health Department, 2006)

      Screening tests for diabetes include fasting plasma glucose, oral glucose tolerance,

HbA1c, capillary blood glucose, and risk assessment questionnaires. The risk assessment

questionnaire is aimed to educate the community about their possible risks for diabetes,

and to motivate them to talk to their care providers. The U.S. Task Force on Preventive

Services ―recommends that patient education and support can be effectively provided in

community settings such as churches and libraries as well as health care settings‖.

(Tacoma-Pierce County Health Department, 2006) Prevention and screening of diabetes

is an intervention that may help avert future health problems of the military community,

as well as decrease the burden on the military healthcare system. The prompt detection

and treatment of diabetes will help to prevent possible devastating complications of the


      ―At the time of clinical diagnosis, many new cases of type 2 diabetes already have

preventable microvascular complications.‖ (Tacoma-Pierce County Health

Department,p12 2006). Long-term complications can be disastrous and include blindness,

kidney failure, and lower limb amputation. The screening for diabetes in younger

individuals may have the greatest impact. Younger patients are often more willing to

make the needed lifestyle changes to thwart the progression of the disease. If this current

trend in diabetes is not addressed, the future increases in diabetes will further strain the

American healthcare system, and reduce quality of life as well as the life span for many
                                                                      Community Health 44

people. There are many stakeholders who are working extremely hard to fight the trend

of diabetes in the McChord and Pierce County areas.


      There are many stakeholders that are invested in the welfare of the McChord

community. The military, the government, individual communities, and all U.S. citizens

have a stake in the health of our military personnel. We need healthy soldiers for the

overall welfare of our country. There is a presumption that the U.S. military is younger

and healthier than the average civilian population. This presumption may be true to an

extent, but the military population has many behaviors that still put them at risk for


      According to our key informant Ann Ramsey, a Community Health Nurse from the

McChord Health Clinic, more than half of the McChord Airforce Base population are not

active duty military. This means that much of the McChord military community is not

under the same physical requirements as the active-duty military personnel, which can

put them at a higher risk of diabetes.

Nursing Diagnoses

   1. Risk for undiagnosed and untreated diabetes mellitus among the McChord

       community related to increasing risk factors, overall presumption of ―good

       health‖ among military perpetuating the idea that military have a decreased the

       risk for diabetes, and lack of screening for risk factors of the disease.

   2. Risk for knowledge deficit of the risk factors for type-2 diabetes mellitus among

       the McCord community related to inadequate screening of risk factors, lack of
                                                                     Community Health 45

       resource distribution, inadequate marketing techniques, and use of capital to

       encourage awareness of monthly health observances.


       The plan was to use marketing and screening to promote diabetes awareness

among the military community on McChord AFB. We used a risk assessment screening

tool for diabetes developed by the American Diabetes Association, along with

educational material provided by A.R. A booth was set up as the marketing tool and as a

base for the screening. On November 13, 2008 from 0800 to 1100 student nurses

screened and handed out information about diabetes to the McChord community.

Core Function and level of Prevention

       The plan was to provide the public health core function of assurance by ensuring

that information available, in order to encourage the public to make appropriate health

decisions. The project is designed to employ both primary and secondary prevention.

Primary prevention is established through the use of the booth and the distribution of

educational information about diabetes mellitus to the McChord AFB communtiy.

Secondary prevention was established through the screening of the community for risk

factors of type 2 diabetes.

Short-term goal:

       Our goal was to market diabetes information and screen as many individuals as

possible. This will help increase the knowledge of diabetes mellitus among the military

population, and raise the awareness of the possibility of having diabetes. It will also
                                                                     Community Health 46

highlight the pertinent risk factors and influence the community to seek further

evaluations from their healthcare providers for the disease.


1. 100 members of the McChord community will be screened for diabetes by

    November 13, 2008.

2. 100 members of McChord community will receive education and information about

    diabetes prevention and risk factors by November 13, 2008.

Long term Goal: Through prevention programs, reduce the disease and economic burden

of diabetes, and improve the quality of life for all persons who have or are at risk for

diabetes. (Healthy People, 2010).


1. Prevent diabetes (Healthy People 2010).

2. Increase the proportion of adults with diabetes whose condition has been diagnosed.

    (Healthy People, 2010)


    Meet with LTC Baker to receive Community Health project by October 9, 2008.

    Drive around Ft. Lewis and McChord to do a windshield survey to come up with

       marketing ideas by October 9, 2008.

    Do a windshield survey of Madigan to come up with marketing ideas by October 9,


    Meet with LTC Baker to receive the specific Monthly Health Observance for

       November by October 23, 2008.
                                                                    Community Health 47

    Meet with Kathy Canny, Diabetic Nurse Educator as a key informant and for

       marketing ideas by October 30, 2008.

    Meet with Ann Ramsey as a key informant and for marketing ideas by October 30,


    Meet with Ann Ramsey at the McChord Medical Clinic for rehearsal for the

       execution of the plan. This meeting is to include screening tools and information

       to use, and what we need to bring in order to be prepared by November 13, 2008.

    Provide a list of marketing ideas for health observances to HEPC members by

       November 13, 2008.

    Screen 100 individuals for the risk factors for diabetes by November 13, 2008.

    Provide 100 individuals with educational information about diabetes prevention by

       November 13, 2008.


      We implemented our project with the help of Ann Ramsey, a Community Health

Nurse from the McChord Health Clinic. The assessment of the community came last

instead of first. We spent much of our time doing the research after our screening

because of the uncertainty about what our project would actually be. We managed to

screen 97 individuals from the McChord AFB community. We also provided an

immense amount of information about diabetes to the community.
      The screening tool that we used came from the American Diabetes Association.

The questions asked dealt with gestational diabetes, family history of diabetes, weight,

activity level, and age. The information that we collected from the screenings revealed to
                                                                    Community Health 48

us that the most significant risk factors among the community at the McChord clinic were

age, with 48.5% (47 of the people screened) above the age of 45; and then weight, with

44% (43 of the people screened) above the recommended BMI. The other risk factors

that people had were: 24.7% (24 people screened) admitted to having a family history of

diabetes, 14.4% (14 people screened) confessed to getting little or no exercise, and less

than 1% (1 person screened) revealed to having gestational diabetes.

      We also had observed that there were many people surveyed who had multiple risk

factors. 46.4% (45 people screened) had multiple risk factors, which correlates closely

with the 37.1% of people who are at a high risk for diabetes (thirty-six people). There

were twenty-seven (27.8% of the people) with only one risk factor, which fits closely

with the 29.9% of people (twenty-nine people) surveyed who are at a low risk for

diabetes. 15.5% (fifteen people) of the people had no risk factors, which correlates

closely with the 18.6% of people (eighteen people) who were not at risk for diabetes. The

following graphs describe te characteristics of the 97 people that were screened.
                                                                   Community Health 49

      To evaluate what we have implemented, we need to keep an ongoing relationship

with the community on McChord, the community at the McChord Medical Clinic, and

the Community Health Nurse, Ann Ramsey. This ongoing relationship will allow us see

the movement of diabetes awareness going in the right direction, and also help us keep a

hand in it.

      Formative evaluation: On November 13, 2008, we screened 97 people of the

McChord population, therefore our short term objective has been met.
      Summative evaluation: Because we will not be able to keep up with the long term

objectives due to no longer being a part of PLU’s SoN, we will delegate this portion to a
                                                                   Community Health 50

capable constituent. In order to make sure that we are keeping up with our long term

objectives, we will put Ann Ramsey in charge of checking yearly to see the incidence of

newly diagnosed diabetes cases, and look for an upswing in how many people are

medically screened. We would also investigate whether there was an overall decrease in

the rate of type 2 diabetes mellitus.


      Throughout the project, our group dealt with issues of ambiguity as well as conflict.

The focus of the project changed three times during the semester. We were assigned to

work with the HEPC (Health Education and Promotion) committee, of which the Army

Public Health Nursing Service is chairperson. The committee manages the Monthly

Health Observances. We were assigned to come up with new and inventive ideas for

marketing the monthly health observances. Originally it was our impression that we

would be implementing one of our marketing ideas. The first three weeks were spent on

geographical assessment and devising a webpage for the monthly health observances.

After working on the marketing idea we found out that we were not expected to

implement our ideas, but only submit them to the HEPC members. Our group felt some

disappointment, because of the lack of implementation with this project. We discussed

our disappointment with LTC Baker, APHN, and she helped us with coming up with an

idea that would allow us to implement our project. With help, we narrowed down the

health observances to November’s Diabetes Awareness Month. LTC Baker suggested

that we should use a screening tool for diabetes in the community. There was a sense of

relief once we knew that we would be implementing an intervention. We then decided to

meet with Ann Ramsey RN, MS a Community Health Nurse from the McChord Health
                                                                    Community Health 51

Clinic, who worked on the monthly health observances, for the purpose of acquiring a

key informant interview. We eagerly started our outline for the new project. A week

after we split up our outline, we were told by Ann Ramsey that our project was not going

to be based on diabetes at all, but now we were to educate healthcare providers on how to

use their educational resources. With five clinical days left, panic struck our group. We

did not address our concerns until after the meeting about the new project. After the

meeting, our group had disagreements on how to handle the situation, as well as with our

key informants. Everyone had their own ideas for the project, and for about a week we

discussed how we would go about addressing the fact it had been over a month and we

had been assigned three different projects.

      Finally, we democratically decided on our project, and decided to let our key

informants know our ideas for the project. Taking charge of the project was

counterintuitive to what we were comfortable with doing. Agreeing that there was no

way to implement the different projects; we took one of our ideas from our marketing list

and used it to implement a screening session for diabetes risk factors.

      As a group we think it is important it is for nursing students to speak up as soon as

ambiguity arises. We could have saved time if we would have clarified what was

expected of us. We would also recommend that future nursing students voice their

concerns to each other as soon as possible, trying to be congenial to each other can also

waste precious time. Being direct and clear is much more productive, and can eliminate

                                                                     Community Health 52

Tobacco Cessation Project:


       Tobacco use continues to be a significant problem across America as it continues

to be correlated with cancers and heart disease. One of our key informants stressed that

Fort Lewis has a considerable problem related to smoking and tobacco use. Our main key

informant, Cynthia Hawthorne, gave our group many resources and data about tobacco

use in the Army specifically. Since we had Cynthia Hawthorne as our preceptor our focus

was on tobacco cessation, yet we still had to identify a particular problem. Thus our

group decided to perform a community assessment focused on tobacco use in the Army

to better understand the details about the problem.

       In order to get a better idea of how critical the issue is in the Army we compared

statistics from the nation, state, county, and Fort Lewis. In the United States, 19.8% are

smokers (Center for Disease Control, 2008). In the state of Washington, the percentage of

current smokers is 16.8% (Center for Disease Control, 2008) while the rate in Pierce

County is 20.4% (WA State Department of Health, 2008). From this information, it is

obvious that smoking is still a problem among Washington State and the United States

due to fact that the Healthy People 2010 goal is to reduce the smoking rate to 12%.

       However, it is shocking when one compares the statistics from Washington state

and Pierce County to Fort Lewis. According to the 2005 Department of Defense (DOD)

survey of health related behaviors among active duty Army personnel; cigarette smoking

is a common behavior for more than a third of the Army population. The report reveals

that while the smoking rate has drastically decreased from 1980 (54.3% to 38.2% in

2005) (Bray et al., 2006) the prevalence of smoking in the Army has started to increase at
                                                                    Community Health 53

a steady rate over the past few years. In 2005, 38.2% of Army personnel reported

cigarette use as compared to 31.1% in 1998 (Bray et al., 2006). These statistics are

alarming when one considers that Fort Lewis has a 21% higher prevalence of smoking

than the state and 18% higher prevalence than Pierce County. The following graph shows

the comparison between the nation, state, county, and the Army using the most current

data available. The 2005 DoD data was used for the Army because the DoD release the

results of their study every three years.

       Smoking Prevalence between U.S., Washington, Pierce County and Army

  35                                                             38.2
              19.8                              20.4                             Pierce County
  15                            16.8
                                                                                 U.S. Army
              U.S.         Washington Pierce County           U.S. Army

*U.S. Washington, Pierce County data are from 2008, U.S. Army rate is from 2005—
DoD performs study every 3 yrs.

       Similarly, the report also found that 45% of active duty Army users had limited

knowledge of one or more of the hazards associated with tobacco use. Another article,

Evaluation of an educational intervention for Army tobacco users, found that smokers
                                                                     Community Health 54

tend to be less knowledgeable than civilians regarding the likelihood of contracting

seven-smoking related diseases (Morgan, 2001). This demonstrates a huge knowledge

deficit among the Army community about tobacco use and the need for education.

       Furthermore, from 2001 to 2004 the prevalence of smoking increased 48% among

a representative sample of deployed soldiers in the Army (Smith et al., 2008). Among

those soldiers who have never deployed, smoking increased 44% in this group and

smoking increased 57% in the soldiers who have previously deployed. The research

showed that 31% of deployed soldiers who were previously smokers relapsed back into

smoking compared to the roughly 22% of non-deployed soldiers who relapsed. These

statistics make it clear that the stress of deploying dramatically increases the amount of

personnel that smoke and cause past smokers to start smoking again. From all the data we

have gathered, one can see that smoking in general is a huge health issue but it is even a

greater problem among the Army community.

       Through our main key informant, it was repeatedly suggested that tobacco use in

the Army has always been widely accepted. The report by the DoD (2005) reinforced this

as well by showing that 37.5% of current smokers started smoking after joining the Army

and 50.8% of Army smokers believe cigarettes to be easily available and acceptable

because most of their friends in the Army smoke. Other common reasons that Army

personnel begin to smoke regularly are because it helps them relax or calm down

(26.2%), it helps relieve stress (25.4%), and it relieves boredom (22.2%) (Bray et al.,

2006). The three reasons for smoking among the Army community listed above are

common even among the general population but ways to cope with stress and alternative

behaviors to relieve boredom could be taught. No matter what the reasons for smoking
                                                                     Community Health 55

are among this community their needs to be an intervention because smoking is

becoming a huge issue in the Army.

Key Informant

       As mentioned before, our key informant was Cynthia Hawthorne. She is the

Tobacco Cessation Educator for the Solider Wellness Assessment Pilot Program

(SWAPP). Soldiers who are 120-90 days from deployment or are 90-120 days post-

deployment are screened through this program and referred to her if necessary. She is

responsible for educating and providing resources to help them quit tobacco use. She

also provides them with medications and provides follow-up appointments if needed.

       During our interview Cynthia perceived tobacco use by the military to be a great

issue. She stated that about 37% of Army soldiers use tobacco and it is mainly in the

form of smoking rather than chewing. She also mentioned that 51% of Army smokers

initiate smoking after joining the military.

       She further discussed in detail the many factors that keep soldiers addicted. She

stated that soldiers often are stressed by deployment and the war and do not practice other

forms of stress-relievers. She also explained that it’s not necessarily the physical

addiction that makes it hard for smokers to quit as it is the emotional and psychological

need to smoke. (See Appendix C)


       By analyzing the data, we found smoking in the Army to be higher than county,

state and national levels demonstrating tobacco use to be a problem among the Army

community. The percentage of smokers in the Army was 38.2%, which is higher than the

general United States population (19.8%), Washington state population (16.8%), and
                                                                    Community Health 56

even higher than the Pierce County population (20.4%). This higher than normal smoking

rate lead us to further analyze the problem and address it.

       We discovered that many new recruits begin using tobacco when they join the

Army and according to our key informants and data, there is a lack of awareness about

tobacco-related negative effects. In addition, there is a strong link between Army

stressors, such as deployment, peer pressure, boredom, and increased drinking, with

tobacco use.

       From our assessment we determined that the priority health problem was the lack

of awareness about tobacco use dangers and resources for tobacco cessation. Our

community diagnosis is risk for knowledge deficit about smoking-related dangers among

Fort Lewis community as evidenced by high rate of smokers, high level of Army

stressors, and ineffective coping mechanisms. At the same time, our diagnosis is

supported by the Healthy People 2010 goal of increasing Quality and Years of Healthy

Life because we will attempt to reduce the prevalence of smoking.

       We encountered a few limitations when gathering data.

                      No specific tobacco use statistic for Fort Lewis, however, we

                       hypothesized that the Fort Lewis’ tobacco usage is very similar to

                       the national Army average due to the fact that soldiers from all

                       around the nation come in and out of Fort Lewis.

                      Only the 2005 data from the DoD were available. The DoD

                       releases its data every three years.

                      Do not have the rates of tobacco cessation for the Army or fort

                                                                      Community Health 57

                         Time

                         We will not be able to evaluate our long term goal of reducing the

                          prevalence of smoking until the new DOD statistics are available.


       In detail our plan was to set up and coordinate a table in the Medical Mall at

Madigan Army Medical Center for the Great American Smoke Out. The Great American

Smoke Out is a nation-wide day created by the American Cancer Society that encourages

smokers to quit tobacco use. Our project included marketing the importance of quitting

and preventing tobacco use. We created a brochure covering the costliness of tobacco

use, the benefits of quitting related to healthier body, effects of secondhand smoke and

resources for quitting.

       Our long-term goal is to increase quality and years of healthy life through tobacco

prevention and education (Healthy People 2010).


               -     Reduce tobacco use in adults to 12% (Healthy People 2010)

               -     Reduce the initiation of tobacco use (Healthy People 2010)

       Our short-term goal is to educate the Fort Lewis community on the dangers of

smoking and information on quitting by mandating an educational table.


                   - During the Great American Smoke Out at least 40 smokers will be

                   referred to smoking cessation groups in the community.
                                                                    Community Health 58

               -On 20 Nov 2008, 50 brochures will be distributed to smokers on tobacco

                 cessation, with information about how much tobacco costs yearly, health

                 benefits of not smoking, and secondhand smoke information.

                 -On 20 Nov 2008, 20 smokers will be verbally educated about the

                 harmful effects of smoking and techniques for quitting.

       This project utilized the core function of assurance. According to Stanhope and

Lancaster assurance is the role of the public health nurse in making sure that the

community has resources available to them (Stanhope & Lancaster, 2008). With that in

mind, our groups’ project was to educate smokers about resources available to quit

around Fort Lewis. This core function helped us determine that there is a public health

issue among the Fort Lewis community pertaining to tobacco use. The function of

assurance will be put into action by making sure the public is educated on the dangers of

smoking by providing the necessary resources such as pamphlets, flyers, support groups,

and internet resources. Most of these smoking cessation intervention strategies have been

found to significantly increase cessation and their efficiency is increased even more when

strategies are combined (Ranney, Melvin, Lux, Mclain, & Lohr, 2006). So ultimately we

would be linking people to multiple resources and services around the community.

       The levels of prevention applied to our project are primary and secondary.

Primary prevention will be implemented by developing community awareness and

educating the community about associated tobacco use and negative effects of nicotine on

health to prevent soldiers from ever using tobacco products. Secondary prevention will be

performed by screening for smokers and providing them with information on tobacco
                                                                     Community Health 59

cessation and preventing further damage to health. At the same time we would encourage

current quitters from relapsing.


      Coordinate with Cynthia Hawthorne to develop relevant information for our


      Schedule project at MAMC with Cynthia’s assistance.

      Find and choose handouts, brochures, flyers and make copies.

      Make ―quit‖ kits. Quit kits are re-sealable plastic bags filled with items to help

       tobacco users quit. Some items included are sugar-free chewing gum, toothpicks,

       and hard candy which can be used as alternatives to a cigarette during urges.

      Organize supplies/handouts by themes (quitting, smokeless tobacco, secondhand

       smoking, teens, and pregnancy)

      Come up with interactive activity for table; we used a lung function test which

       calculates the age of a person’s lungs and ―blow bubbles‖ activity, which

       encouraged people to blow bubbles instead of blowing smoke.

      Create brochure specific to our goals and objectives with appeal to Army culture.

      Work with Cynthia to obtain tables.

      Show up on November 20 and set up table.

      Be enthusiastic and engaging people to approach our table.

                                                                    Community Health 60

       The formative evaluation of our short-term goal was by seeing how many people

approached our table, if they took our brochure and their willingness to use the materials

provided. Everyone who approached our table did not refuse a brochure or handouts;

however, not everyone walking through the hallway was willing to stop at our table.

There were some individuals who admitted to being smokers, but were not interested or

ready to quit. Originally, we intended to identify at least 40 smokers and refer them to

tobacco cessation and hand out 50 of our brochures. We evaluated our success by

counting how many brochures we had left over, because each person took a brochure. We

referred 38 smokers or friends/families of smokers to cessation resources through our

brochure and handouts, which was 95% of our short-term objective and we were only 5%

away from reaching our goal.

       As our interactive activity we used a handheld pulmonary function test machine

which calculates ―lung age‖ and warns the user of physical damage caused by smoking.

This handheld device has a mouthpiece which the user covers with their lips and exhales

as forcefully and fast as they can. The machine calculates the age of the lungs by taking

into consideration the height, gender, and ethnicity specific to each user. During our

project about 10 smokers had their lung age calculated and they all were shocked and

taken aback by the results. Some smokers who were only twenty six had lungs of a forty-

five-year-old person. We were able to make an impact on eight individuals, because they

were appalled on what smoking was doing to their lungs. Thus by verbally stating that

they needed to quit and wanted information about quitting we recognized that we were

educating the Fort Lewis community members. This reinforced the fact that our project

was actually working and making an impact on opinions about smoking in the Army.
                                                                   Community Health 61

       The summative evaluation of our long-term goal is to look at the Healthy People

2020 when it comes out in January 2010 to see if the percent of adults smoking is

decreased to the goal of 12%. We could also compare the 2008 Department of Defense

health-related survey to the 2005 Department of Defense survey to see if there is a

decrease in the percentage of Army tobacco users. However, this is beyond the scope of

this project and the summative evaluation will be completed by Cynthia Hawthorne and

Army Public Health Nursing.


       Our community nursing process was very linear and during our preparation of the

project we were well organized. We believe that this was possible because we were

largely guided by our contact person, Cynthia. In fact she had done something similar the

year before and so just picked up where we could. During the development of our project,

we didn’t necessarily come up with manning a table on the Great American Smokeout,

but our preceptor Cynthia suggested that we join her. Yet at the same time, we wanted to

come up with our own interventions for this project. For example, we originally planned

to give away suckers in exchange for cigarettes to encourage people to quit smoking, but

when we met up with Cynthia she had already created ―quit kits‖ which included suckers

amongst other items which could be alternatives to cigarette smoking. Then we came up

with the idea of using bubbles and the campaign ―Blow Bubbles Not Smoke!‖ While we

did have this activity at our table, the strategy wasn’t ever implemented because the lung

function device was more appealing and specifically targeted towards people of all ages.

Whereas the blowing of bubbles seemed to be targeted toward younger generations such

as teenagers, which of there weren’t many teenagers that day because it was a Thursday
                                                                      Community Health 62

during school hours. We learned that although this method was engaging and fun to us, it

wasn’t necessarily what got community members’ attention as much as our other


       In preparing for our project we did not anticipate that it was going to be hard to

get people interested in coming up to our table. We assumed that people would just stop

and get information. However, the location of our table was in a busy, high-traffic area

and this made it difficult for people to stop. We were also hesitant at first, but then

Cynthia urged us to shout out and market our purpose, which was the ―Great American

Smoke Out‖. We were expecting to work side by side with Cynthia at the table which

was how it was discussed, however, after we were set up she had us take over the table

while she observed and supervised. This was actually beneficial to us because we got to

be more involved in the project and actually influence community members.

       One of the challenges we encountered that we didn’t have an effective response

for the individuals who were not interested in quitting their tobacco use. We felt awkward

when people admitted to being smokers but did not want help or just ignored us. The only

response we found to work was telling them that we could provide them with cessation

information so that when they were ready to quit, they could do so with the right

materials and knowledge.

       We realized that our activity of having individuals check the age of their lungs

made a greater impact than the information and brochures we presented. Most people

were open to doing the test, but were shocked by the results. This method generated the

most questioning and interest in smokers about how to quit when they realized what is

happening to their lungs. We would use this method again, because it had more of an
                                                                     Community Health 63

emotional impact on smokers and as we have learned in our leadership class; 90% of

people’s decisions are emotional, making it very probable that they were greatly

influence by the tool we provided. It was a way for them to really, physically see how

their lungs are being affected rather than see picture of other peoples’ lungs.

       Our main short-term objectives were to identify 40 smokers and provide with

resources for tobacco cessation as well as handing out at least 50 of our brochures.

During our project we identified 38 smokers based on the number of handouts we had left

over. Thus we were only 2 short of our first short-term objective and we were 12

brochures short of handing out our brochure. Overall, we believe and feel we were

effective and close enough to our goal.

       A limitation to one of our long-term objectives was that we didn’t anticipate the

cost of producing mass brochures which inhibited us from distributing them to different

places in the community. For our project we were able to make copies in the APHN

office but for mass production we did not want to use their resources and left this option

for them. Due to the cost of making more, we decided to use the left over brochures and

give them to the Army Public Health Nursing office where they can be distributed to

individuals interested in tobacco cessation. We will provide Cynthia with an electronic

version of our brochure so she can use it in the SWAPP program.

       Our recommendation for future tobacco cessation projects would be to develop

more interactive activities that will draw people in such as games or a prize wheel. Our

table also was very cluttered and overwhelming to individuals passing by. Cynthia had a

lot of useful information, but it was overwhelming to the community members and we

weren’t familiar with all the materials. A different location would have been more
                                                                     Community Health 64

effective, because people were going to appointments or having to be somewhere. It was

also difficult to ask employees if they were smokers because they were in there place of

employment and seemed to be a conflict of role identity.

       Overall, the experience was very positive and it was nice knowing that we were

having an effect on the community. We realize that we may not know the exact number

of people that actually quit from our interventions but we know that just by informing

people and letting them know that there is help in the community we made a difference in

a small way for a larger cause.

Application to Practice

       Our Application to Practice

       Through our community nursing process and by executing this particular project,

we have become more confident in approaching smokers and address their need to quit.

We were able to become aware of tobacco cessation resources which we didn’t

necessarily know about before and now have the correct information to link smokers to

appropriate resources.

       Nurses are the largest healthcare workforce and are involved in virtually all levels

of healthcare and across a variety of clinical settings. For this reason nurses have a

greater opportunity of making a big impact on the community of smokers. As

professionals, we have a responsibility and duty to promote tobacco cessation and

smoking prevention. The literature and research is continually trying to improve nursing

interventions for tobacco cessation and we need to continually update ourselves on the

most effective techniques.
                                                           Community Health 65

  Appendix A Chart of Demographics

Demographic       United           Washington       Pierce County Fort Lewis
                  States           State
Total             281,421,906      5,894,121        700,820          19,089
Male              138,053,563      2,930,661        348,452          11,973
Female            143,368,343      2,963,460        352,368          7,116
Average Age       35.3             37.1             35.4             22.4
Ethnicity*        W: 211,460,626   W: 4,815,072     W: 548,941       W: 11,537
                  B: 36,419,434    B:185,052        B: 48,741        B: 3,882
                  A/A: 4,119,301   A/A:91,299       A/A: 9,472       A/A: 259
                  A:11,898,828     A: 320,979       A: 34,671        A: 650
                  H/PI :874,414    H/PI: 217,038    H/PI: 5,075      H/PI: 342
                  H: 35,305,818    H: 439,814       H: 38,577        H: 2,507
                  O: 18,521,486    O: 229,131       O: 14,879        O: 1,189
Education         146,496,014      3,333,171        384,540          7,289
(High School
and higher)
Total             105,480,101      2,272,261        260,897          3,476
Marital           M: 120,231,273   M: 2,641,743     M: 309,436       M: 7,376
Status**          NM:              NM: 1,218,610    NM: 136,584      NM: 5,096
                  59,913,370       W: 249, 461      W: 28,650        W: 49
                  W: 14,674,500    D: 529,708       D: 67,274        D: 573
                  D: 21,560,308
Average           $56,604          $58,653          $54,972          $37,601
Salary (yearly)
     *W=White B=Black A/A= American Indian/Alaska Native A= Asian
      H/PI= Hawaiian/Pacific Islander H=Hispanic O= Other
     ** M= Married NM=Never Married W=Widowed D=Divorced
                                                                      Community Health 66

Appendix B- CYS informants

Key Informant #1

Patricia Botsford, Registered Nurse Child and Youth Services (CYS) Special Needs

How many children do you oversee?

They are working on building demographic data but haven’t quite compiled it yet. We

will have to check other branches. They focus on special needs children which is

probably anywhere between 12,000-15,000 children. Special needs children are not

necessarily the typical special needs children that usually fall under that term. It consists

mostly of asthma, diabetes, seizures, allergies, ADHD, and other behavioral issues.

Other factors we take into consideration include sports requirements/incidents and hourly

care. They also act as a resource for medical issues which includes observing children in

centers, offering suggestions for next care action for child, observing other behavior or

developmental levels, case management, and acting as a representative during the Special

Needs Assessment Process (SNAP) which determines if they will be part of the

Exceptional Family Member Program (EFMP), which determines if soldiers need to be

sent to different areas depending on the health care needs of their families

What is the most prevalent concern or condition within Special Needs?
                                                                      Community Health 67

Asthma and allergies which consist of medication administration, seasonal/food allergies,

and lastly behaviors.

If you are looking at educational needs, who needs teaching and on what information?

The module leaders within CYS would be the ones receiving education. They would

need basic and simple knowledge that consisted of signs/symptoms, what to look for, and

what you would do in that situation. In order to do this you would need to talk to

Training and Curriculum Specialists (TACS). You can also get basic training from

APHN. You want to teach cause relation and include various methods of learning such

as hands on, role play, and pre/post test. Typically adults need to hear things seven times

to learn it and they are very different from each other in their learning styles. The only

skills you would need to teach would be the Epi-twinject and inhaler administration. You

may also want to dispel any myths that people would have prior to receiving education.

Allergy action plan and or maps are also very helpful. You want to keep your clients

attentive so handing out candy while asking questions throughout the presentation can be

very beneficial. Sign in sheets can be very good for the sake of the organization so they

have record of who is attending the class. People who are going to be attending the class

also appreciate as much prior notice as possible. You can do this by flier and remember

to include the date, time, place, objectives, as well as if you are going to have pre/post

test just so they know what is expected of them. They recommend keeping it short,

probably 20-30 minutes so that they get basic information they can retain.

Key Informant #2
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Norma Abbott, Beachwood Child and Youth Services (CYS) Director

What educational needs do you have at this branch?

Whatever education we are giving it is important that it is continuous because we have a

high turnover rate with our employees. So it is hard to keep track of who has had what

training since we always have so many new ones. The other thing to keep in mind is that

we don’t have medical backgrounds so it is very hard for us to administer medications.

We are taking care of numerous children and trying to make sure we are giving the right

medication to right child for the right reason. It is very hard to take care of a lot of

children and try to figure out what to do in an emergency. We offer information in

writing but not everyone read something and gets what they need out of it.

What do you think are some of the most prevalent issues?

Definitely asthma, allergies.

Our idea was to offer education about asthma and allergies.

That would be great, just make sure you are teaching basic information since none of us

here have medical backgrounds and it shouldn’t be too long.

We were thinking 20-30 minutes just covering what to look for and what you would do in

that situation. We would also cover administering Epi-twinject and inhalers.
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Perfect! Would you like to teach each module for 20-30 minutes and we can just rotate

people in and out? Then we could still cover each modules’ children and do it during a

work day.

*We decided to do this education day on either Novemeber 13th or 20th depending on

Denise Ruby’s ability to come on the 20th. Norma Abbott agreed to print fliers if we e-

mailed it to her ( by this upcoming Monday.

Key Informant #3

Katherine Simonson Head Nurse of the Pulmonology Clinic, Madigan Army Medical

Center, Medical Mall

Who do you typically see here at the Pulmonoology clinic?

Here we see adults with asthma, allergies, COPD, bronchitis, pretty much anything that

the ED sends us a referral for we will see. We teach adults in groups of 6-8. We teach

them about their medications, what to do in case of an attack, what to do in an

emergency, numbers of valuable resources in the community and here in the hospital.

Pretty much anything they need, we treat them on an outpatient basis. If the patient is

critical enough to become admitted then we check to make sure we are kept up with the

care and collaborate with the doctors to make sure that when they do go home we can

still manage their health.

Do you typically do anything with children or is it mostly adults you treat?
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We usually only treat adults. If there is a pediatric case in the ER that they would like us

to see we will go down, but we typically only deal with adults here in this clinic.

Is there anything that you think that we need to teach childcare workers about people and

children with asthma and allergies?

Teaching about what to look for in anyone with asthma and allergies is always good.

Making sure they can recognize the individual signs of an attack for each child. Re-

iterating that each child’s symptoms are different and everyone has different triggers.

You can also teach how to use the medications and the emergency meds. Those always

need re-teaching.
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Appendix C- Tobacco Cessation Informant

Cynthia Hawthrone

       One of our key informants was Cynthia Hawthorne. She is the Tobacco Cessation

Educator for the Solider Wellness Assessment Pilot Program (SWAPP). Soldiers who

are 120-90 days from deployment or are 90-120 days post-deployment are screened

through this program and referred to her if necessary. She is responsible for educating

and providing resources to help them quit tobacco use. She also provides them with

medications and provides follow-up appointments if needed. The resources she provides

everyone with regardless of whether they decide to quit or not, are quit lines, websites,

and handouts.

       During our interview Cynthia perceived tobacco use by the military to be a great

issue. She stated that about 51% of Army soldiers use tobacco and it is mainly in the

form of smoking rather than chewing. She also mentioned that 37% of Army smokers

initiate smoking after joining the military.

       She further discussed in detail the many factors that keep soldiers addicted. She

stated that soldiers often are stressed by deployment and the war and do not practice other

forms of stress-relieve. At the same time, the chemicals in tobacco products have become

more and more addicting. She provided us with handouts that she provides to all of her

soldiers. One of her handouts was a newspaper article called ―Nicotine Up Sharply in

Many Cigarettes.‖ This article appeared in the Washington Post and claims that there is

more nicotine in cigarettes than there has been in the past. In fact some brands are more
                                                                       Community Health 72

than 30% stronger. Even so, she specifically pointed out and explained that it’s not

necessarily the physical addiction that makes it hard for smokers to quit as it is the

emotional and psychological need to smoke.

           The biggest barrier she said that there was for tobacco users was their hesitancy to

truly quitting. According to her, the Ft. Lewis community has many resources for both

the SWAPP soldiers, non-SWAPP soldiers, and their families. She gave some examples

such as quit lines, websites, primary care providers, support groups throughout Pierce


Lt. Hill

           After speaking to Cynthia we wanted to interview someone who was not so

involved with a specific issue and we decided to interview PHN Lt. Hill. She too agreed

that tobacco use in the community is an issue, specifically because they have so many

tobacco cessation appointments and referrals in their office. Through our questions we

found that the Army Public Health Nursing Service provides one-on-one appointments

for all Army beneficiaries who walk-in or are referred by TRICARE. She believed that

the nurses provide great support and education to their patients regarding smoking. In

general, she reinforced another key informant’s statements about tobacco use being a

significant community issue.
                                                                      Community Health 73

Appendix D- Health Promotion Informant

Kathy Canny, RN Diabetic Nurse Educator

       Kathy Canny is the Diabetic Nurse Educator at Madigan Army Medical Center

(MAMC). She had a lot of good information in her office including diagrams, food

labels, pamphlets, books, and boxes of information. Her job is to teach new diabetics and

those who are at risk about diabetes and how to keep it under control. She does this by

offering education on healthier food choices and teaching about medication options.

Ft. Lewis is its own special community with a different group of people. Most of the

people that live on post are younger with families and are active duty. We went into the

clinic assuming that diabetes among this community would be lower, but she told us that

our assumption was wrong. The incidence of diabetes among the community at Ft. Lewis

is no lower than the incidence among the community on the outside. Canny has observed

that more frequently than in the past, soldiers are coming home with diabetes. Reasons

for this may be the level of stress that the soldiers and their families are under. The

soldiers go through multiple deployments and are separated from their families for

months and even years at a time. These stress levels can lead to taking on unhealthy

behaviors like smoking and drinking, and hypertension, which are all risk factors for


       We noticed that the collaboration of the health care providers among Ft. Lewis

was pretty good. In our discussion, she gave us plenty of contacts throughout the base.

This leads us to believe that in working together, the soldiers and their families get

thorough care in every way that they need. This means that the Diabetic Nurse Educator
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may collaborate with the Public Health Nurses at ―Classic Madigan‖ and the other clinics

throughout the hospital.
                              Community Health 75

Appendix E

               Ft. Lewis,WA
                                                                    Community Health 76

Appendix F CYS Flier

Asthma and Allergy Awareness Class
          Beachwood Child Development Center
                 November 20, 2008

                   Modules will each attend one 20-30 minute class
                         Classes will be held throughout the day
  Class will consist of brief pretest, interactive learning styles, and a brief post test

                          What is asthma?
                    What allergies are common?
             What to look for in an emergency situation
             How can you prevent emergency situations?
                   Administering the new EpiPen
                       Administering inhalers
               Addressing any questions or concerns

            Contact Norma Abbott at with any questions
                                                           Community Health 77

Appendix G CYS PowerPoint Presentation

                    Asthma & Allergies

                    Ashley Roberts
                    Lisa Wilson
                    Angela Melvard

  What is Asthma?
                             A condition that:
                             •   is chronic

                             •   produces recurring episodes
                                 of breathing problems

                             •   is potentially life-threatening

                             •   can occur at any age

                             •   is not contagious

                             •   cannot be cured, but can be
                                                                             Community Health 78

      What Happens During an Episode
      of Asthma?
 •    The lining of the
      airways become
      narrow and easily
      irritated due to

 •    The airways produce
      a thick mucus

 •    The muscles around
      the airways tighten
      and make airways

     Not all factors affect all people. It’s important to identify what affects a
                             particular student’s asthma.

          • Infections in the
             upper airways, such                 • Exercise
             as colds

             • Changes in                       • Physical expressions
               weather and                        of strong feelings
               temperature                        (crying or laughing
                                                  hard, yelling)
                                                   Community Health 79

Irritants such as:
                               •   Scented
•   Environmental                  products
    tobacco smoke

           • Outdoor air
            pollution          • Strong fumes or

      What are the Symptoms of
                           Early Symptoms:
                           •   Shortness of breath
                           •   Wheezing
                           •   Tightness in the chest
                           •   Coughing
                           Signs of an emergency:
                           •   Symptoms that keep
                               getting worse
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What are Allergies?
An allergy is a
 response of
 your body’s
 system to
 that does not
 bother other

Most common allergy: Food
   Signs
      Tingling   of the Mouth      Wheezing

      Hives                        Trouble  Breathing
      Itching                      Dizziness

      Swelling   of the Lips       Fainting
       or Face

    Children’s food allergies should be posted in
    each module and in the kitchen
                                    Community Health 81

Other Allergies Include…
 Pollen
 Dust Mites
 Mold
 Pet Dander
 Insect Stings
 Medicine

Allergic Reactions
   Mild Reaction

   Moderate Reaction

   Severe Reaction (Anaphylaxis)
                            Community Health 82

   If prescribed,
    give Benadryl

   Call Parents

   Watch Child

   EpiPen

                                        Community Health 83

 Allergy Center
 MedLinePlus Allergies
 National Blood Heart Lung Institute
       Asthma
   Asthma Pamphlet
                                                                   Community Health 84


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