By Jane Gervasoni, U.S. Army Public Health CommandApril 11, 2013
ABERDEEN PROVING GROUND, Md. (April 11, 2013) -- A military installation is a microcosm of the civilian community outside the gates. It is where Soldiers and sometimes even civilian workers and their families live, work, eat, sleep and play. As Army medicine looks at keeping installation populations healthy through the performance triad of physical activity, nutrition and sleep, health promotion experts are looking at how installations influence healthy activities.
Installation and garrison commanders can contribute to the health of people who work and live on their installations. They do this through planning and development of physical environments and selection of services that enhance population health, according to experts at U.S. Army Public Health Command, or USAPHC.
For example, planning for walking paths, bike lanes and on-post eateries that offer healthy foods all enhance the installation population's opportunities for making healthy choices. As well, Army policies and regulations that govern installation environments must support the goal of sustaining and building good population health.
"Our ability to act healthy and eat healthy is outside of ourselves. It is affected by what is constructed around us, and all of that is controlled by policy, regulation and education," said Joanne Hsu, program evaluator in the USAPHC Public Health Assessment Program. "Many people play a key role in making our environment what it is and modifying it to be a healthier place."
A number of leading organizations in health and nutrition, including the World Health Organization, the International Obesity Task Force, the U.S. National Academies of Science's Institute of Medicine, and the Centers for Disease Control and Prevention, "have identified environmental and policy interventions as the most promising strategies for creating population-wide improvements in eating, physical activity and weight status," according to research in technical publications, she said.
Understanding this vision led to the creation of the Creating Active Communities and Healthy Environments, or CACHE, toolkit that will assess the physical environment to see how well it promotes physical activity and nutrition. The CACHE includes modules on both the Military Nutrition Environment Assessment Tool, or m-NEAT, and the Promoting Active Communities tools as well as easy to use implementation materials.
Together these modules in the CACHE provide installation leadership with targeted, actionable information for improving the physical environment.
The m-Neat asks questions about availability, placement and pricing of healthy options in a variety of facilities that prepare and/or sell food.
"The m-NEAT enables DOD communities to measure how well they support and promote a healthy eating environment," said Lt. Col. Sandra Keelin, registered dietitian with the USAPHC Health Promotion and Wellness Portfolio.
"The first step in improving a military community's support of healthy eating is the completion of the m-NEAT assessment. This assessment gathers information about the nutrition environment of a community and assists in the development of a local plan to improve the environment," Keelin explained. "However, this is only a partial solution to problems like obesity and other physical health issues."
The team took this partial solution and built the next piece of the CACHE.
When Lt. Gen. Eric Schoomaker, former Army surgeon general, was briefed on weight-loss efforts in the Army, he asked the USAPHC staff what Army installation environments look like. He wanted to know why he couldn't walk from the medical treatment facility where he worked to his on-post house, and what information was available on promoting a physical environment.
His questions encouraged USAPHC health promotion experts to expand their vision. They began to look for an effective way to make changes in health through changing systems, policy and the environment.
"We took the m-NEAT and added a complementary tool that could assess the physical environment. The tool is called Promoting Active Communities, or PAC," said Amy Cowell, Public Health Associate Program evaluator. "The idea of the PAC was to involve many people on the installation including the master planner, the Morale, Welfare and Recreation Program staff, the Community Health Promotion Council and the installation commander in looking at the big picture.
"Since we work at Aberdeen Proving Ground, Md., it was the first test run of the CACHE," explained Cowell. "It was different than how we would pilot it elsewhere since we were both the developers and the testers. With critical feedback from others involved we were able to reevaluate and quickly make necessary changes."
Working with Robert Melascaglia, Aberdeen Proving Ground, or APG, master planner, Cowell and Hsu looked at the physical environment of the installation. They were looking at bike lanes, sidewalks, exercise and recreational facilities, distances to eating locations and shopping, roads and all environmental aspects.
"I began looking at the post in a whole new way," Melascaglia said. "When you begin to look at how the installation environment affects health, you are adding a new dimension to installation planning in trying to build walkable communities."
"We also looked at recreation facilities and opportunities for free programs and plans for transporting workers," explained Cowell. "This all became part of our toolkit."
The health promotion team quickly realized that there could be a variety of installation environments.
Many of the issues identified from the results of the CACHE on APG are worked as part of the Community Health Promotion Council, said Wendy LaRoche, the APG health promotion officer. So the CACHE is already proving to be a valuable local asset, but it also needed to benefit other installations.
"As we looked at APG we had to change things in the toolkit to fit different situations that would be found at other installations. We had to build the CACHE toolkit so that it could be used to evaluate all installations," Hsu said.
After using APG as a model for the toolkit, the team is planning the next step, piloting the toolkit at a variety of installations.
The team plans additional evaluation and development of the tool, and they hope to create a management database to make it easier for people to access the tool kit and input data that can be evaluated.
"This would give those who are implementing the tool close to real-time feedback on their data; the ability to find out how they scored relative to other sites; and help in developing strength, weaknesses, opportunities and threat analyses," explained Cowell. "This is what we hope to accomplish."
Currently Excel spreadsheets are filled out and sent back to USAPHC.
"This is good, but the rapid feedback to an interactive system would be easier and more convenient," said Cowell.
Laura Mitvalsky, USAPHC's Health Promotion and Wellness Portfolio director, is working closely with the Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy to work towards the end goal of using the CACHE as the baseline tool for the Healthy Base Initiative that will assess installations for all services, with nine Installations to start. This initiative will kick off in 2013. The plan is to have a Web-based tool where installations can submit their CACHE results for an overall score.
As envisioned, the CACHE will provide the ability at a command level to give feedback to military communities using the toolkit. Commanders and their health promotion councils can see how they compare to other installations in building healthy communities.
"In addition, we will be able to compare ourselves to civilian communities and tell how the Army is doing," Cowell said. "And we will also be able to offer evidence-based recommendations to installations who ask for assistance."
Change will not be easy. Regulations and policy govern many aspects of installation planning, and these may have to be reviewed or changed to allow an optimum environment for health.
"The opportunities for affecting health through the CACHE are available," said Keelin. "We hope to encourage leadership to make changes that will contribute to a healthy environment for our military communities."
Mitvalsky says the next step is to develop a module for the CACHE that addresses how to create a tobacco-free environment. The Army surgeon general is spearheading this goal by saying she wants all medical treatment facility campuses tobacco free by April 2013.
Incorporating a tobacco-free module will enhance the ability of the CACHE toolkit to help installation commanders contribute to the health of their workforces and residents by pointing the way to better choices.
"We need to create an environment where healthy change can take place and the healthy choice is the easy choice," Mitvalsky said.
The CACHE will provide the information to show how they are doing in reaching this goal.