Running head: COMMUNITY HEALTH PROMOTION PAPER: FORT LEAVENWORTH
Community Health Promotion Paper
Fort Leavenworth
Jennifer Gray, Tiffany Lemanski, Mary MacQuarrie, and Anita Isbell-Graham
University of Kansas School of Nursing, Graduate Studies
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Community Health Promotion Paper: Fort Leavenworth
Part 1a: Introduction
The Community of Interest (COI) chosen by our team was Fort Leavenworth, an Army
post located north and west of Kansas City. We interviewed two key people at Fort
Leavenworth who are responsible for health care on the post: Colonel (COL) David Bitterman
and Major (MAJ) Julie E. Lee.
Driving onto Fort Leavenworth can be an intimidating experience with armed guards
and random car searches at each entry point. "It's the ultimate gated community" says COL
David Bitterman, the Commander of the Post hospital-Munson Army Health
Center. With his title comes the responsibility of health care for the entire
post which consists of an approximated 3500 soldiers and an additional 7,000
Colonel David Bitterman
civilian family members and post employees (Bitterman, 2012). In layman's
terms, COL Bitterman is Fort Leavenworth’s' Director of Health Services. He earned dual
Master's Degrees: one in Health Administration from Baylor University and another Master's
Degree in Strategic Studies from the Army War College. Fort Leavenworth (Post) presents a
unique health care challenge due to its diverse demographic population. Fort Leavenworth is
home to two prisons, including the Army's only maximum security prison (Bitterman, 2012).
The Post also houses the Command and General Staff School which brings many foreign officers
and their families to Fort Leavenworth (Bitterman, 2012). Finally, it is home to the largest
population of military police and their families on any one Army post (Bitterman, 2012).
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While COL Bitterman is charged with making all health care decisions and organizing
every health activity on the Post, he doesn't have to do it alone. He has a large staff of talented
military experts who assist in advising him when faced with a health concern. One of those
staff members is MAJ Julie Lee, a master's prepared nurse. She serves as the Colonel's Chief of
Preventative Medicine. Her duties include executing any interventions in preventative
medicine or public health that the Colonel has identified as necessary for the overall health of
the community (Lee, 2012).
Part 1b: Community Assessment
There are several ways that the Fort Leavenworth health care management team
identifies health promotion needs for their community and many different organizations are
involved. Community assessments are conducted based upon several sources: mandates from
the Public Health Command (PHC), suggestions and ideas made at Town Hall Meetings, and
information retrieved from the Army’s online databases (Bitterman, 2012).
Fort Leavenworth has been using electronic medical records, known as the Composite
Health Care System (CHCS) since 1994 (Bitterman, 2012). This provides healthcare
professionals with information that enables risk stratification of various issues faced by military
personnel. According to Bitterman (2012), this allows the Post’s healthcare team to proactively
target patients and populations that are at risk. For example, based on the data, the preventive
health team routinely sends out letters to people who are due for health screenings.
Additionally, trends in healthcare are more easily tracked, which allows for improved direct
health care as well as the development of future preventative healthcare programs. COL
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Bitterman also described another computer database called (AHLTA), a windows-based
program with advanced capabilities to track risk factors like: age, weight, lifestyle, laboratory
tests, and chronic disease. When at risk individuals are identified the health care team
proactively intervenes to prevent future problems.
In addition to the above resources used for community assessment, MAJ Lee identified
several other methods. Her team developed a web-based community needs assessment that
allows individuals to input data into a website to be analyzed by the Preventative Medicine
team. MAJ Lee is also a member of the Community Health Promotion Council. This council
consists of key leaders from different organizations on Fort Leavenworth who share
information and ideas about improving health throughout the Post (Lee, 2012). One objective
for the council was to determine how to reduce suicides on Post (Lee, 2012).
Part 1c: Identification and Prioritization of Problem Areas
The Army uses a systematic approach when prioritizing health promotion and
preventive care. Frequency and severity of an issue is one of the considerations. There is also a
point system utilized that assists in identifying priority problems that need to be addressed
(Canham-Chervak, et al, 2010). Each factor is weighted and assigned a point (1-3), indicating
the relative importance of the program. Factors considered in prioritization include:
Issues/problems that have goals that meet the mission of the agency; importance of the
problem to health and readiness; preventability of the problem; feasibility of the program or
policy; timeliness, and benefits of the program overweigh the costs and risks (Canham-Chervak,
2010).
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Prioritizing health care needs at Fort Leavenworth is unique and is dictated by either the
Post’s Commanding General or the Army's Public Health Command (PHC), located in Aberdeen,
MD (Bitterman, 2012). The Army PHC is able to track health data Army-wide. This information
is then forwarded to individual posts. Each post implements interventions as problems are
identified. COL Bitterman points out one recent initiative from the PHC, the Rabies Outreach
Program. Rabies is epidemic in Iran and Afghanistan due to a large feral dog population in
these countries. This can be problematic for soldiers deployed to these areas. Many of the
soldiers serving in high stress regions seek the company of animals for psychological comfort
(Bitterman, 2012). However, the solider may be endangering his or her life in the process.
Army medical teams discovered that several soldiers had come into contact with rabid dogs
while deployed. Some contracted rabies and one soldier died (Lee, 2012). COL Bitterman
explained that soldiers are a vulnerable population especially when deployed, since they are
faced with host nation diseases that are not prevalent in the United States. The Army-wide
Rabies Outreach Program generated a list of soldiers who might have contracted rabies, and
passed this information on to individual posts. At Fort Leavenworth, COL Bitterman and MAJ
Lee were charged with finding these soldiers and initiating rabies assessment and treatment.
All of the soldiers tested negative or received treatment on Post. However, there was a plan in
place in case the illness surpassed the Post's health care resources. COL Bitterman explained
that they have a very close relationship with the local hospitals and medical experts. A soldier
with rabies needing these services would be referred to a local community doctor.
Part 1d: Plans for Health Promotion/Preventive Care
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Although an Army post has many resources to plan and carry out health promotion
programs and intervene for preventive care, there is also collaboration between Army
Headquarters, other posts and the community where the post is located. Limitations at the
Fort Leavenworth post include the lack of medical specialists (such as transplant facilities,
cardiothoracic surgeons, specialized oncologists, etc.) and no on-site emergency department
(Bitterman, 2012). Due to these factors, Fort Leavenworth relies heavily on local facilities for
assistance. Tri-Care, the insurance program that covers health care expenses for military
personal and their families, allows for referrals to outside facilities as needed. Fort
Leavenworth works closely with area hospitals, medical providers and health departments to
ensure patron’s needs are being fully met.
Internal and external factors can influence any program or intervention. The PHC
provides influence and direction with emphasis on the required time line for executing an
initiative. For example, an emergent initiative such as the rabies program leaves little room for
manipulation or change. Ground rules and expectations are outlined at central administration,
and the order is carried out at the local level. However, in other initiatives recommended by
PHC, such as reduction in tobacco use on a military base, the Commander and his team have
more latitude to implement the program. In these cases, the program can be tailored to the
community at hand according to a prescribed time frame (Bitterman, 2012).
Other factors, such as funding or staffing, are less an issue in the military community
than the general population. The Commander is able to seek assistance with funding from the
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regional Headquarters in Seattle if needed (Bitterman, 2012). Assistance from trained personal
located outside the Post is also possible.
Part 1e: Evaluation
Health promotion programs on the Post are tailored to meet the healthcare needs of
the individuals. However, like any system, there needs to be a process to retrieve feedback
from the community. At this time, there are multiple sources of feedback for specific
interventions, public programs, and the health care delivery system on Post. The Interactive
Customer Evaluation (ICE) is a web-based technique to reach out and gain feedback from
customers (Bitterman, 2012). This allows for more instant access to real time data. This tool is
an effective indicator of key problems in the way a program is managed or the way healthcare
is delivered. Another evaluation method is a patient satisfaction tool: the Army Provider Levels
Satisfaction Survey (APLSS) (Bitterman, 2012). Patients receive a mailed survey after their
healthcare experience. Responses received regarding their care is measured using a holistic
approach. Everything from the parking to the final stop at the outpatient pharmacy is
evaluated. This allows for an all-inclusive look at how healthcare is delivered. Positive survey
results in additional money allocated to the healthcare operating budget (Bitterman, 2012).
However, negative results may result in the loss of funding for a particular department
(Bitterman, 2012). These survey tools can be individualized to fit a particular intervention or fit
a specific population. Also, these tools can be very effective in finding trends in both positive
and negative survey results.
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Although military health care is unique to each Army Post , Fort Leavenworth follows
many of the same guidelines as its civilian counterparts. The Post Hospital is accredited by Joint
Commission, follows Center for Disease Control recommendations, and relies on government
funding for programs. The decision-making strategies used by COL Bitterman and his team are
based on evidence, theory, and a holistic understanding of the health promotion process.
Caring for military and their families is a challenge, however trained military experts like COL
Bitterman and MAJ Lee ensure that their community has every available resource to function as
a healthy American Community.
Part 2
Smoking cessation within the military is the health issue our team has chosen to
address. In a study conducted by Gierisch, et al. (2012) military service and combat exposure
are risk factors for smoking. The study goes on to state that although evidence suggests that
veterans are interested in tobacco use cessation, little is known about their reasons for quitting,
treatment preference, or perceived barriers to effective tobacco cessation treatment (Gierisch
et al., 2012).
Part 2a: Discussion of Health Promotion Theory
Pender’s revised Health Promotion Model (2011) is relevant to smoking cessation.
Health promoting behavior, which in our program is smoking cessation with a target group of
military personnel, is the end point in the Health Promotion Model directed toward attaining
positive health outcomes for the client (Pender, 2011). Smoking has been part of the military
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culture since WWI, when cigarettes became widely available (Gierisch et al., 2012). Service
members were issued cigarettes with their rations to help them escape the tedium of war,
boost morale, and offer pleasure, comfort, currency and a feeling of camaraderie. Gierisch et
al. (2012) Research shows that smoking is still perceived as endemic in military service by the
newest veterans. Veterans felt smoking was encouraged and was a normal part of life during
deployment (Gierisch et al., 2012). Deployed troops have a higher rate of smoking initiation
and smoking relapse compared with non-deployed troops (Gierisch et al., 2012).
Part 2b: Concepts of the Theory
According to Pender (2011) the Revised Health Promotion Model has three major
concepts to consider: Individual characteristics and experiences, behavior-specific cognitions
and affect, and behavioral outcomes (Pender, 2011).
Individual Characteristics and Experiences
According to Pender (2011) each person has unique perspectives and experiences that
effect their actions. Pender (2011) goes on to explain that this includes prior related behaviors
and personal factors. Pender indicates that prior related behaviors are proposed to be the best
indicator of future behavior. The nurse helps the patient form a positive behavioral history for
the future by focusing on the positive benefits of behavior change, educating the patient on
overcoming obstacles to the behavior change, and fostering a high level of self-efficacy through
positive feedback with each successful behavior performed (Pender, 2011). Personal factors
are categorized as biological, psychological and socio-cultural according to Pender (2011).
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Pender (2011) states that biological factors include age, gender, BMI, physical maturity,
strength, agility and balance and psychological factors include self-esteem, motivation,
competence, perceived health status and their personal definition of health. Socio-cultural
factors include race, culture, ethnicity, education and socioeconomic status (Pender, 2011).
Behavior-Specific Cognitions and Affect
Pender (2011) indicates there are six variables of this concept that are considered major
motivators for intervention and that these variables can be modified with health promotion
education. Pender’s first variable is the perceived benefit of action in anticipating that positive
outcomes will occur from health behavior. The second is that perceived barriers to action are
expected, imagined or real obstacles and personal costs of learning a health promoting
behavior. The third variable is that perceived self-efficacy is a self-judgment of the patient
regarding their ability to effectively learn and execute the health promoting behavior. Pender’s
fourth variable is that activity related affect is the patient’s positive or negative feelings that
occur before, during and after the behavior itself. According to Pender these influence the selfefficacy cycle, which means the more positive the subjective feeling, the greater the feeling of
self-efficacy. Increased feelings of self-efficacy can generate further positive affect. The fifth
variable according to Pender (2011) is that interpersonal influences include family, peers and
healthcare providers. Beliefs, behaviors, or attitudes of others influence the “norm”. Pender
states that modeling is also an influence on behavior. Pender’s sixth variable states situational
influences are personal perceptions of any situation that can encourage or discourage a
behavior. These may have a direct or indirect influence on behavior (Pender, 2011).
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Behavioral outcomes
This concept involves the patient committing to a plan of action according to Pender
(2011). She states that it is the intention and identification of a planned strategy leading to
initiating a health behavior (Pender, 2011). Competing demands are alternative behaviors due
to environmental factors like work or family care obligations (Pender 2011). Competing
preferences are behaviors that the patient has relatively high control over like going to a place
where smoking is allowed when one is trying to quit smoking. Health promoting behaviors are
actions that promote positive health outcomes such as optimal well-being, personal fulfillment,
and productive living (Pender, 2011).
The health promotion model is ideal for smoking cessation for military personnel. A
large number of smokers in the military want to and plan to quit (American Lung Association,
2012). In the 2005 Department of Defense Survey, 23.1 percent of current smokers in the
military indicated that they were planning on quitting in the next 30 days (ALA, 2012). Forty
percent intended to quit in the next six months (ALA, 2012). Unfortunately, many of these
personnel were not able to quit successfully. Previously in 2004, 52.8 percent of current
smokers surveyed attempted to quit but were unsuccessful (ALA, 2012).
Some have argued that smokeless tobacco use can serve as a less harmful alternative to
smoking; however, evidence from recent surveys suggests that smokeless tobacco use is
complementary to smoking (Department of Defense, 2008). Restrictions on smoking in public
may induce smokers to obtain nicotine for a source that does not produce secondhand smoke
while at work but to go back to smoking at other times (DoD, 2008). Evidence suggests that
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smokeless tobacco use is doing very little, if anything to reduce smoking in the military (DoD,
2008).
Part 2c: Measurement of Targeted Outcomes
Effective program evaluation is a systematic way to determine the effectiveness of a
health promotion program and make improvements as necessary (CDC, 2011). First, we would
want to assess the number of people who attended the smoking cessation program, how many
people started and how many completed all sessions. This would allow an administrator to
determine what percentage of the client panel took advantage of the program as well as to
evaluate the cost-effectiveness of program. It would also provide the denominator in
determining the number of people who succeeded in making the behavior change.
The goal of the program is to promote healthy behavior by quitting smoking. To assess
whether the client maintained smoking cessation, we would conduct a survey of those patients
who participated. A questionnaire would be administered upon completion of the program,
and again at 6 months and 12 months following the completion of the formal smoking cessation
program to determine the number of people who are not smoking.
Part 2d: Dissemination of Findings
It will be important to communicate the findings and recommendations to the providers
and staff at the clinic to reinforce their actions in promoting smoking cessation. This could be
accomplished through a written summary of the data on a quarterly basis, or at the annual
review meeting. Knowing which smoking cessation options worked for people may help the
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provider in discussions with other clients. If the clinic has a newsletter, results of the findings
could be disseminated to clients as a way to motivate others. The mandate for electronic
health records (EHR) has a provision that requires a system of communication between
physician and their patients. Many offices have now set up portals through the EHR that
provides this contact. This may be another method to disseminate program findings and
recommendations.
For our COI, the army, there is a specific reporting mechanism in place. The
Commander of the post Hospital would receive a copy of the findings and recommendations.
These would also be submitted to the PHC, which develops policies and procedures for the local
instillations. Findings could also be disseminated to the soldiers on the base via a newsletter or
personal mail.
Conclusion
Community health leaders impact lives at the individual and community level.
Development of prevention programs or health promotion activities takes the work of many
departments. Effective coordination and development are best done when an established
theoretical model is followed. Implementation of program interventions is best accomplished
with attainable goals, measurable outcomes and coordination with appropriate support staff to
ensure optimal results.
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