Table of Contents

The purpose of my graduate project was to develop a CHSA by: (1) identifying and engaging with stakeholders, (2) collecting and organizing health-related data, (3) identifying needs within the community based on data, and (4) and evaluating the Tobacco Free Empowerment Program (TFEP). More personally, the purpose of my project was for me to enhance data collection and organization, evaluation, professional communication, and collaboration skills. Leaders will observe a clear connection between my project’s outcomes and the Department of Preventive Medicine’s (PM) mission, goals, values, and priorities as one who services communities within the USAG Bavaria footprint.

Specific, measurable, achievable, relevant, and time-bound (SMART) goals were created to aid in the design of the work plan, monitor progress over time, and to illustrate how activities will be met. Objectives were created to ensure stakeholders, Department of Preventive Medicine, and myself have a clear understanding of the internship goals and activities. Goals and objectives clearly identify activities, how I achieved the activities, and the impact it has on the community and/or organization.

This section consists of internship activities, data collected, and deliverables created to fit one of the current needs of Preventive Medicine. The activities and outcomes were based on the goals and objectives listed above. The main aspects of my internship included data collection, data analysis and transcription, and a process evaluation. One will be able to understand how the deliverables are purposeful for the partnering organization. Refer to appendix B for the detailed Agency Report.

I. Activities

Activities throughout the project included obtaining, understanding, and collecting data through CLINOPS and M2 databases, and meetings with stakeholders across USAG Bavaria. Stakeholders consist of, but are not limited to: the garrison commander, director of health promotions, human resources at garrison level, Bavaria’s epidemiologist, public health nurses across the garrison, and other installation organizations. Furthermore, I met with and discussed the TFEP with Ms. Ann Marie Collins, which assisted with the process evaluation deliverable. Other activities included research and analyzation about Army’s Standard of Operations of the TFEP, current and past health programs, and theory and evidence-based practices. Lastly, a logic model was created in conjunction with evaluating the TFEP to enhance future implementation. Refer to appendix A, table 1, for full-detailed logic model.

II. Data Collection

Primary and secondary data were both collected during this project. Primary data such as virtual and in-person meetings, and email traffic are examples of primary data. In addition, secondary data such as statistics within a database were collected. The CHSA identifies priority health issues within communities and overall quality of life. Not only does it outline statistics of health, but perceptions and views of what is important in their community. Therefore, data collection consisted of a combination database, and community and personal meetings. With the guidance from LTC (R) Lois Borsay and CPT Teemer within Preventive Medicine, and Ms. Jamie Brokaw in the Population Health, the databases CLINOPS and M2 were accessed. The databases provided quantitative data such as, but not limited to: total population in MEDDAC footprint, service member population, mammogram and colon cancer, percent of patients with diabetes, obesity, cancer rates, tobacco usage rates, and congestive heart failure and disease.

Other important quantitative data such as housing utilization, covid cases, and high school graduation rates were collected through various avenues. For example, the Vilseck High school was contacted personally for graduation rates, and the number covid cases were pulled from data traced at the department level of preventive medicine. CPT Teemer and LTC (R) Borsay played a huge role in providing point of contacts and resources needed to progress through data collection.

Furthermore, qualitative data such as community resources, community themes, and areas of improvement, were collected through garrison and in-person or virtual meetings at various installations. For example, community strengths and themes were gathered from Ms. Clarissa Lamar, who serves as the Community Ready and Resilient Integrator. I met with her several times and attended the Commander’s Ready and Resilient Council meeting held at the garrison headquarters. This enabled me to gather qualitative data such from various working groups about what they believe are community issues and needs such as, updated suicide prevention measures, uptake in child care centers on-post, overall perceptions of the installation, and health concerns that need to be addressed. In addition, I was able to travel to Hohenfels, Germany to meet with Ms. Petrina Gavrilis, Army Public Health Nurse. The meeting consisted of gaining more data about both Ansbach and Hohenfels communities such as, demographics of both stationary and rotational service members across the garrison.

Data collection also occurred during process evaluation. Ms. Ann Marie Collins in Occupational Health provided the TFEP survey, survey results, and personal accounts about efficiency of program, strengths, and weaknesses. On the other hand, a literature review was performed to support strategies for future implementation of the TFEP. Furthermore, CPT Teemer and other TFEP working group members were able to provide personal and statistical accounts and concerns about the effectiveness and future needs for the TFEP. Emails were sent out to several working group members to gain first-hand accounts about how well the TFEP was implemented, activities implemented, roles of the working group members, number of participants reached, and recruitment procedures.

III. Deliverables

At the conclusion of internship, two deliverables were presented and provided to the Department of Preventive Medicine and MEDDACB: the 2021 Community Health Status Assessment and a Process Evaluation of the Tobacco Free Empowerment Program. Due to page length and number of PowerPoint slides, please refer to the graduate project e-Folio for the CHSA. Each deliverable is unique and benefits the organizations and communities in various ways.

The CHSA provides leaders within the U.S. Army Garrison Ansbach, Stuttgart, and Bavaria a broad understanding of the current health status (STI’s, cancer screenings, etc.), health and wellness programs, and community services offered within each community (religious events, new parent bootcamps, recreational events, shuttle services, etc.). In addition, listing limitations and recommendations for each community assist stakeholders and commanders with understanding the needs for funds and resources. Ultimately, the CHSA will provide a blueprint for communities, in order to drive strategies that will improve overall health across the USAGB footprint.

Based on the community assessment, there were many health concerns, however, tobacco was and has been one of the most significant issues. Despite an effort in 2021 to tackle tobacco rates, evaluation of a current program was needed. Therefore, a process evaluation of the TFEP was performed to enhance future implementation. The purpose of this process evaluation was to define the structure of the program, design a logic model, document program procedures, assess stakeholder’s activity, and analyze the components of process evaluation. PM and stakeholders across USAG benefit from the process evaluation because and it not only assesses the quality of the TEMP, it outlines needed resources and provides evidence-based research to ensure validity, which provides guidelines for future replication. It will further benefit the organization because the evaluation was centered around current needs, accessibilities, and visions of PM and MEDDACB.

An integrative analysis was performed post-internship to understand current health issues and current programs that Public Health Nursing and partnering organizations are implementing to enhance the well-being of the community. The following analysis is based on the MPH foundational competencies, which are used to summarize and align current programs and recommendations.

a. Evidence-based Approaches to Public Health

Applying epidemiological methods, using qualitative or quantitative data collection, using computer or software to analyze data, and interpreting results are all activities which are considered to be performed through evidence-based approaches. In this case, epidemiological methods were not considered based on current programs.

Currently, PM has approached the issue of increased tobacco use among the population head-on. Professionals such as primary care providers, pharmacists, public health nurses, program specialists, the working group, and other professionals within PM, use evidenced-based practices throughout programs. The TFEP is centered around disease prevention through policy change, promoting cessation products like patches, and education. In addition, Army Public Health Nursing uses the MAPP (Mobilizing Action through Planning and Partnerships) Model, which is a tactical tool used to improve overall well-being of a community. It may be compared to many other models used in public health and includes components such as: forming partnerships, collecting data, and pinpointing programs or areas that need refinement (Marion County, n.d.).

Tobacco and other health concerns will continue to be an issue. Therefore, in order for the organization to combat these issues, a grassroots approach is needed. Due to low participation of community programs, community surveys and community town halls will aim to better understand what the members of the community want and need to improve quality of life. For instance, as outlined in the process evaluation, participants are more inclined to participate in a program in which they contribute. If the community members are most interested in a social-based tobacco cessation program, then stakeholders should take their interests into account. In result, this will improve reach and dosage of future programming.

b. Public Health & Health Care Systems

Public health and health care systems differ drastically between the U.S. Army and local county-level departments. Therefore, understanding the structure and organization systems allows professionals to understand the equity challenges within an organization. The lack of healthy food options and easy access to tobacco, fast food, and alcohol, contribute to current health concerns such as obesity, diabetes, and tobacco use in the USAGB communities. In Bavaria, American food options include Burger King, Subway, Pizza Hut and other fast foods. Policy change is needed at the most senior level in order to combat somewhat of a structural bias, which will possibly decrease rates of obesity. Furthermore, gaining partnerships with national science-based corporations such as Centers for Disease and Control and Prevention will provide funding for programs geared towards physical education and tobacco use.

In addition to partnership, ownership of programs through each stage of development is needed to decrease risk for a Type III error. Recently, the TFEP working group was created, but roles were not established among the group. Therefore, in conjunction with the commander’s push to drive the TFEP, responsibilities should be distributed among the group. Such actions will not only enhance communication, but create a sounder system, which will better serve the population. In all, structural and organizational bias seem to be the impediments that should be addressed to better serve soldiers and families, retirees, local nationals, and civilians.

c. Planning & Management to Promote Health

Assessing, planning, and monitoring health and health programs is significant because it greatly impacts community outcomes. In addition, the competency includes applying awareness of values and culture and through programs.

Ways in which the organization is incorporating health-related efforts is through community outreach. Each year, partnering organizations host a health fair on-post that targets current health issues. In addition, the Army Wellness Center provides soldiers and their families, retirees, and civilians with health-related testing. Health assessments include metabolic testing, comprehensive status test, fitness test, and health education courses. Programs and efforts are in place, but need to be promoted appropriately, based on community’s needs. For example, surveys may be distributed during the health fairs to understand physical and nutritional programs that may benefit the community. For instance, the professional who is designing the survey may provide 3-4 examples of future programs that target key health issues in the community; this promotes a grassroots approach for future program implementation.

The U.S. Army takes pride in creating a diverse, respectful, and healthy force. PM is taking matters into their own hands by adapting to cultural values and practices by providing diverse health programs. However, ensuring clinical care is culturally-driven is critical. Due to a multi-cultural military force, nurses and all healthcare staff should be assessed based on cultural competence, quarterly. For example, service members already have required trainings; adding modules focused on skills, attitudes, and awareness of cultural competency is an approach that would foster a better relationship between healthcare staff and patient.

d. Policy in Public Health

Professionals may incorporate policy in public health by simply understanding the decision-making process, or more specifically advocating and evaluating policies that affect the health of the health.

The Standard of Operation (SOP) for the Tobacco Free Living was published in May of 2021. This SOP promotes a tobacco free culture and Tobacco Free Medical Campuses. Meaning, MEDCOM personnel (soldiers, civilians, DoD employees, contractors, and local nationals) will not use tobacco during the duty day or while in duty uniform. In addition, tobacco products are prohibited on or within medical facilities or campuses. To further enhance tobacco promotion, the TFEP was created to educate, increase well-being of community members, and produce a more productive military workforce.

To further enhance advocacy, the working group, PM, and population health department should capitalize on the TFEP. In conjunction with the intervention components, the working group may work with policy makers to determine the best way to decrease tobacco use rates. For example, increasing taxes on tobacco products, the Army Force Exchange Stores (AAFES) promoting nicotine patches and gums, and further promotion around the installation that brings awareness to targeted population.

e. Leadership

Based on competency subtopics, leadership may look very different. For example, it can be seen as providing governance over an organization or activity, or using mediation skills to tackle health issues in the community that need attention.

The organizational structure within non-medical units and medical units differs greatly. Installation organizations and programs such as Morale, Welfare, and Recreation, Equal Opportunity, and the Sexual Harassment and Response Program are programs that the garrison commander oversees. On the other hand, Preventive Medicine, nurses, Population Health, and other MEDDAC B staff serves under the MEDDAC Commander. Therefore, each commander has unique duties and oversees or supports separate initiatives.

Although, in many situations, decision-making may be difficult if both commanders are not abreast about health issues in the community. Thus, leading to misconceptions, miscommunication, lack of partnership, and an overall decrease in community readiness. To further enhance leadership and decision-making approaches, the garrison commander and MEDDAB commander should attend each other’s working groups and meet regularly to disseminate information, understand needs within communities, and discuss future policy change that will target current health issues.

f. Communication

Communication is key across the field of public health. To ensure competency is met when professionals use various ways of disseminating information to their audience, information culturally and ethnically appropriate based on the audience, and making sure that the community understands the intent behind culturally-appropriate content.

Communication strategies such as the CHSA, social media (town halls & Facebook), posters, flyers, and wellness fairs are a few ways that health professionals are communicating with the community across USAGB. These strategies are helpful by informing the community of health hazards, providing monthly updates, increase awareness surrounding current health issues, and providing overall support from health command teams. For example, PM staff creates monthly health observances. February is American Heart Month. The staff develops an eye-catching document that lists ways to stay active, eat healthy, and reduce stress, all which reduces rates of developing heart disease.

Although current strategies are in place, ways in which may further reach communities are radio advertisements though American Forces Network Europe, and PM staff speaking at commanders call to disseminate needed health information. In addition, more health events would be beneficial to reaching families that do not use social media or visit on-post organizations. Monthly, family-friendly, health events would attract the community and would be an avenue to advertise fitness classes and provide family-friendly competitions (i.e., tug-of-war). Ultimately, this will both increase awareness about wellness and promote on-site physical activity for all ages.

g. Interprofessional Practice

Internal teamwork and collaboration is necessary as a public health professional. It is key that professionals are effectively collaborating with various professions by understanding, learning, and combining knowledge.

Many installation organizations work with PM. The Army Wellness Center works with PM regarding the TFEP. Furthermore, the director of the Army Wellness Center is a part of the TFEP working group. Thus, many medical service departments such as the clinics, Family Advocacy Program, and behavioral health, work as a team to ensure wellness across the installation. These interprofessional teams work together to decrease rates of tobacco, STI’s, and other health-related issues. Additional partnerships that may drive implementation and policy change include: garrison, AFFES, fitness centers, and WILD Boar Recreation to capitalize on activities to help reach health goals, encourage health promotion, and provide healthy food options on-post.

Internally, PM has established a working group for the TFEP. Externally, pharmacists, wellness center employees, and other disciplines are usually tasked. I do believe that there should be a community or school board member to expand context input. This expansion of inputs will provide stakeholders with various outlooks and ways to increase quality, participation, and inclusion for health programs. Interprofessional practice is significant throughout program planning, implementation, and evaluations.

h. Systems Thinking

Understanding the system of an organization allows professionals to target specific areas for improvement. This allows professionals to analyze how factors continuously affect programs. In addition, the importance of understanding that various disciplines work both independently and together to solve public health problems plays a key role in problem-solving situations.

The TFEP is a product of a systems thinking approach. Multi-disciplinary groups are involved in the adaption of the program. Different structures and organizations such as population health, PM, Army clinics, and the Wellness Center may work separately, but are viewed as one system to prevent diseases such as Covid-19, disseminate health information, development of health programs such as the TFEP, and provide routine health services. For example, these organizations are working together to promote, implement, and provide tobacco use surveillance across USAGB.

Ways to further improve a systems thinking approach is to broaden partnerships to understand factors that may cause an increase in tobacco use. For example, the Department of Behavioral Health or national organizations may work with the community to reduce stress and help members identify triggers. The utilization of systems thinking approaches will encourage development of health programs, promote policy change, and create a powerhouse of stakeholders.

Health of the Force. (2014). Retrieved from https://api.army.mil/e2/c/downloads/419337.pdf

Marion County. (n.d.). Mobilizing for action through planning and partnerships (MAPP). https://www.co.marion.or.us/HLT/communityassessments/Pages/MAPP.aspx

Public Health Command Europe. (n.d.). Department of preventive medicine. Retrieved from https://rhce.amedd.army.mil/bavaria/DPM/dpm.html

U.S. Army Community Health Status Assessment. (2021). U.S. Army Garrison (USAG) Ansbach, USAG Bavaria, & USAG Stuttgart [Presentation, PowerPoint Slides]

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