Comm Assess Paper Final Revision Copy

Community Assessment 1

Running head: COMMUNITY ASSESSMENT PAPER

Community Assessment Paper

Maureen A. Hammond, Sarah McNair, Andrea Montgomery, and Alice Rhodes

Ferris State University

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Abstract

Young children exposed to second hand smoke often present with chronic serious otitis media

(CSOM), necessitating the placement of ear tubes. For the purpose of this study we chose to look

at children ages one to five that were undergoing surgery for ear tube placement secondary to

CSOM at Spectrum Health Butterworth Hospital. Our findings indicate that parents with no

college education and lower incomes tended to smoke more, although all of the parents studied

seemed concerned with their child’s well-being. Also, the rate of smoking was higher in our

study than in the general population. Because studies show smoking is strongly linked with

middle ear disease, we believe smoking cessation campaigns should be a top priority for nurses

and all medical health professionals, most especially those caring for the pediatric population.

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Community Assessment Paper

Community Concept and Terms

Maurer and Smith (2005, p. 341) define a community as “an open social system

that is characterized by people in a place over time, who have common goals.” “A community is

a group of people with a common identity or perspective, occupying space during a given period

of time and functioning through a social system to meet its needs within a larger social

environment” (Maurer & Smith, 2005, p. 342). Our choice of community is that of young

children, ages one through age five, who experience exposure to second hand smoke (SHS), and

are affected by recurrent chronic serous otitis media (CSOM). In this paper we will define SHS

(also known as environmental tobacco smoke) as the mixture of gases and particles from the tip

of a cigarette, cigar, or pipe, as well as the exhaled smoke from the smoker (CDC, 2006).

Chronic serous otitis media is to be defined as three or more episodes of serous otitis media and

is associated with the potential for hearing loss and speech impairments (Kerstein, 2008).

Aggregate and Criteria for Community

Our chosen community of children fit the criteria for community based on their

comparable ages, their home environment, exposure to SHS, and other common characteristics,

such as dependency and vulnerability. This group shares a similar health problem, which is

recurrent inner ear infections necessitating treatment with rounds of antibiotics and placement of

ear tubes. We acknowledge that this group is immature and very dependent on others for their

well-being. Because of their immaturity they are not able to function at a very high level within

their social system. Their lack of cognitive functioning prevents them from identifying their

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commonalities and negates their ability to recognize a universal perspective. Nonetheless this

group does fit our rudimentary criteria of a community.

Major health Issues of Aggregate

According to the Centers for Disease Control (CDC), the leading causes of death for

children birth through age four are: unintentional accidents which usually occur in the home,

deaths due to congenital malformations, deformations, and chromosomal abnormalities, and

lastly, deaths due to assaults and homicides. Our text (Maurer & Smith, 2005) reinforces this

data regarding accidents, noting most injuries that occur within the home are preventable. Proper

assessment by a home health nurse could identify home health hazards and avert such incidents.

Low birth weight is another major health issue for this group. Low birth weight can be attributed

to many causes, including lack of prenatal care and intrauterine exposure to illicit drugs and

alcohol. In turn, children born with a low birth weight are more susceptible to increased risk for

developmental disabilities, including attention deficit disorder and attention deficit hyperactivity

disorder. Other issues related to low birth weight include mental retardation, autism, seizure

disorders, increased risk for sudden infant death syndrome, and other developmental problems.

Low socioeconomic status with its subsequent limited access to health care has a profound effect

on this aggregate’s health. Children who are living in households with poor income often receive

care in response to crisis rather preventatively (Maurer & Smith, 2005). Poverty also influences

access to health care due to other barriers, such as lack of transportation, cost, possible language

barriers, and inability to navigate through the system’s “red tape.” Our aggregate is vulnerable to

the socioeconomic status, health knowledge, and lifestyle choices made by their caretakers. This

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community assessment will focus on children, age’s birth through five, who are exposed to SHS

in the home and are affected with chronic serous otitis media.

Methodology

The objective of this study was to determine the association between parent education,

socio-economic status, SHS and CSOM in pre-school children who required a surgical procedure

called tympanostomy with ventilation tube placement. The community assessed included pre-

school children ages one through five who were scheduled for this surgery. The methodology

used in this research project was a descriptive interview that collected data on an existing

variable. The data was used to justify and assess a current health issue. The tool used to obtain

the data was a pre-surgical face to face interview with the surgical patient’s caregivers. The

interview included closed-ended questions regarding smoking and caregiver’s education and

current employment, from which socioeconomic status was inferred.

The study took place in the outpatient surgical center at a city hospital in Grand Rapids,

Michigan. Children’s surgeries at this center include tonsillectomies, adenoidectomies,

myringotomies with ventilation tube placement, hernia repairs, circumcisions, bowel surgeries,

plastic surgeries and open heart surgeries, along with many others. This hospital serves the

Grand Rapids area and surrounding communities.

The methodology used to study relationships among theses factors was a face to face

interview done by a pre-surgical registered nurse (RN). This method was chosen because it

allowed easy access and quick identification of the desired information as part of routine pre-

operative health history taking. The nursing profile questions used in this study are listed below.

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Questions used from the Pediatric Nursing Profile for this study.

Demographic History: Name, age, sex, birth date, address, who child lives with, whether house or apartment, ethnicity.

History and Physical: Height/weight, reason for admission, birth history, past medical and surgical history including cognitive, neurovascular, cardiovascular, respiratory, gastrointestinal, and urinary systems.

Psycho-Social History: child’s level of education, school name, parent’s marital status, who child lives with, siblings, religious beliefs, recent stressors, parental concerns regarding child’s development, child’s favorite hobbies/ activities, hand preference, food preferences, pain tolerance, parents employment, safety factors; exposure to smoke, use of bike helmets, safe environment.

Most Important Concern: for the child or parent.

The face-to-face nature of the interview also allowed the interviewer to gain additional

information including verbal tones, expressions and answer response time. Over the course of

three weeks, children were studied who presented for a surgical procedure called myringotomy

or tympanostomy, with pressure equalizer tube placement. Additional information was gathered

as part of the routine history, but is not presented here: child’s medications, last oral intake of

food or fluids, and a general review of pertinent information. All information was obtained in a

private place, either in the child’s semi-private room or in an area that is conducive to the

family’s privacy. Sometimes the families choose to forgo the privacy and discuss the information

in the playroom, to allow the child distraction. The specific information gathered for this study,

including child age, race, surgical procedure, and caregiver smoking status. In addition, college

education was determined based on the caregivers’ employment. Professionals were assumed to

have a college education. Also, socioeconomic status of low, middle or high was assumed based

on the patient’s insurance status and the caregivers’ employment. All of this data was noted,

recorded from pre-surgery assessments and later put into tables

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Permission to collect data for this study was given by the manager of the department.

Consent from the parent or legal guardian and approval from the hospital’s internal review board

was not necessary because the research was for a school project with no intention of publication.

This was approved by the manager of the department and the instructor of this course.

Community Description

The community studied was one to five year old children who presented for ear tube

surgery at a city hospital in Grand Rapids, Michigan. Most children who come in for this surgery

have had a history of four to six ear infections and several uses of antibiotics. Other health

issues, such as craniofacial anomalies, sensor- neural hearing loss, or a syndrome relating to a

hearing deficit could also warrant surgery, although the community studied was only children

with chronic ear infections, not congenital anomalies. This study did not collect data on children

with anomalies, syndromes, or cranio-facial deformities.

The population in this group was mostly poor to middle class. Most of the patients having

this surgery did have some form of insurance, children’s special aid, or Medicaid for payment.

The majority of the community was native-born citizens of the United State and was white and

Christian. Most families had both parents at home although some were single parent homes or

living with extended families while separated from their spouse. In the community, smoking is

relatively common, although the negative health effects seem to be well known.

According to the Helen DeVos Children’s Hospital literature, approximately two million

ear tube surgeries are performed in the United States per year. According to the Michigan

Department of Community Health, Michigan Behavior Risk Factor Survey (2005), 21.9% of

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adults smoke in this state. According to the Grand Rapids City Statistics we had 16,335 children

less than 5 years of age in the city of Grand Rapids (Grand Rapids Statistics).

Community’s Perception of Health

Our community’s perception of health is difficult to ascertain due to their limited ability

to adequately communicate their needs. Their primary concern was whether or not they were

going to get a ‘shot.’ For this section, we defer to their caregivers. The caregivers’ perception of

health was primarily positive. Caregivers generally sought to maintain the child’s well being.

Overall, parents were caring and concerned with the child’s health and wanted to improve the

child’s well-being. This was displayed by the many attempts of antibiotic treatments, doctor

visits, and now a surgical procedure to help the child maintain health. The general feeling was

that of respect for the medical profession and parents often stated they hoped this surgery would

take care of the problem. The caregiver’s respect for the medical profession was either

verbalized to the nurse or displayed by the families’ attention to the child. It was also evident by

the attentive and respectful attitude toward the nurse doing the interview. When asked questions

regarding the child’s safety, most parents were confident and quick to respond. There did not

seem to be any issues when asking about using proper car seats, providing a safe home, and

using bike helmets, but when it came to the smoking questions, many hesitated and were

reluctant to answer. Three of the families seemed reluctant to answer and denied smoking, but

the odor of smoke was on their clothing. As we have learned, “People are known to respond to

questions in a way that makes a favorable impression, this response style is known as social

desirability.” (Nursing Research, 2002, p. 303). Generally, a researcher has no way to tell if a

responder is telling the truth, but in this case the odor of smoke was so prevalent on the family

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and the child that odor was the deciding factor. Overall, it was thought that most caregivers were

honest in the study. For the purpose of this study, the three caregivers who did not admit to

smoking in the assessment probably do or live with someone who does, which would bring the

total to nineteen children exposed to smoke who needed this surgery. Therefore, the data shows

a little over half of the children needing surgery were exposed to a smoking environment. Most

caregivers seemed to want the best treatment and care for their child but were not interested in

any information about the risks of smoking. If the parents or caregivers said that they were

smokers, the RN would offer smoking cessation material. Ninety percent usually declined.

Comments made included: “I already know what it says”, “I know it is something I need to do”,

or “Not today.” Bringing a child in for a surgical procedure can be very stressful to a parent, and

it can be difficult for the nurse to educate the parent about the risks of smoking at this time.

Results and Statistics

In the United States, myringotomy and tube placement have become a mainstay of

treatment for recurrent otitis media in children. According to the Helen DeVos Children’s

Hospital literature, approximately two million ear tube surgeries are performed in the United

States per year. In this observational study, thirty-six children presenting for myringotomy and

tube placement at a city hospital in Grand Rapids, Michigan were studied (Table 1). Ages were

between one and five. The majority of the patients were white (83%) and there were more boys

(69%) than girls (31%). All of the children had at least four past ear infections and 9 of the

children (25%) had a similar type of surgery before. More than half (53%) of children had at

least one caregiver who smoked. Based on caregiver’s profession, it was assumed that 83% of

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the caregivers did not have a college degree. Most of the patients came from families with low

(69.4%) or middle class (22.2%).

By comparing the rate of smoking in this population (53%), to the rate of smoking in the

general Michigan population (21%), it seems that smoking is especially common among

caregiver’s of children who had surgical treatment for recurrent otitis media. Caregivers with a

profession that required a college education were less likely to be smokers (only 2 of 6 were

smokers). Also, caregivers of low socioeconomic status tended to be smokers (60%) more than

caregivers of middle socioeconomic status (44%). Out of the thirty six families, it seemed that

the caregiver’s educational level and socioeconomic status did have a relationship to the use of

tobacco. Parents or caregivers with no college education were more likely to smoke, and families

with less income also tended to use tobacco more.

In the United States, myringotomy and tube placement have become a mainstay of

treatment for recurrent otitis media in children. There are several lifestyle issues related to high

rates of middle ear disease. Studies have shown one of the most serious is parental smoking.

One study on the effects of passive smoking on children’s health estimated that 165,000 of the

myringotomies performed each year on American children are related to the use of tobacco in the

household (Encyclopedia of Surgery).

The results of this study showed that 53% of the children who needed ear surgery were

exposed to second hand smoke in their homes. The conclusion of this study shows a strong

correlation between smoking and the need for ear surgery, although it does not prove that

smoking was the cause of CSOM and subsequent ear surgery. It can be said that SHS is an

important risk factor for CSOM in pre-school age children and the avoidance of daily exposure

to domestic tobacco smoke could have a positive public health impact.

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Table 1. Information about children observed.

Supplementary Data Table (Smoking status, 0= no smoker, 1=one parent smoker, 2=two parents smokers, 1*= suspected smoker)

Age   Count Percent  1 2 5.6%  2 5 13.9%  3 11 30.6%  4 7 19.4%  5 11 30.6%

Sex      Male 25 69.4%  Female 11 30.6%

Race      White 30 83.3%  Black 3 8.3%  Hispanic 3 8.3%

Past infections      4 7 19.4%  5 15 41.7%  6 14 38.9%

Repeat Surgery?      No 27 75.0%  Yes 9 25.0%

Smoking Exposure      No 17 47.2%  Yes 19 52.8%

College Graduate      No 30 83.3%  Yes 6 16.7%

Socioeconomic Status    

  Low 25 69.4%  Middle      9 25.0%  High 2 5.5%

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Community Strengths

When we first looked at the idea of community strengths within this population we had

difficulty discerning what some of their strong points or assets might be. At face value this

community appears vulnerable and quite dependent. However, if generally healthy, this

community is very resilient. Children of this group develop coping mechanisms which help them

deal with many physical and/or psychological events that occur in this early part of their lives. In

response to physical injury, many a caregiver, nurse, or physician can tell you stories of how

quickly children heal and bounce back. Children are often revered in this country as “our future,”

and have benefited from federal legislation that established such programs such as Medicaid,

Temporary Assistance to Needy Families, Women’s Infants and Children Program, State

Children’s Health Insurance Program, as well as many other locally funded and run programs.

Socio-Political Influences

According to Jarvie and Malone (2008), 40% of children under the age of five live with

someone who smokes, with 68% of those children living in homes with an annual income of less

than 10,000. Smoking is more common for single mothers with education less than a high school

diploma and who are consequently of a lower economic status (Sheahan & Free, 2005). These

statistics reflect the data from our study, which revealed 53% our community living with at least

one caregiver who smokes, almost 70% of the children living in families with lower incomes,

and 83% of the caregivers having no college degree. Professor Lorraine Klerman (2004) reports

that this population of children exposed to SHS receive the least amount of public and

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professional attention. There has been a lack of adequate funding for pediatric home health care,

which in turn has led to a shortage of adequately trained clinicians and ancillary personnel

(American Academy of Pediatrics, 2006). Medicaid, which is the major payer for pediatric home

health care at 77%, does not provide sufficient funds for beneficiaries to utilize home care.

Physicians and nurse practitioners are currently not reimbursed for time spent educating or

counseling family members of young children on the importance and impact of smoking

cessation. Even though a 2003 national survey of parents identified the belief among smoking

parents that pediatricians should address smoking cessation, only half were actually counseled to

do so (Winickoff et al., 2003).

Significance of Data

For the purposes of this community assessment, one of our group mates conducted a

qualitative study utilizing face to face interviews. Our objective was to establish whether or not

there is a link between SHS and CSOM in pre-school children ages one through five. A

convenience sample of 36 patients was used. Confounders, including children with cranio-facial

abnormalities, and those with genetic anomalies and syndromes which predispose them to

CSOM were not included. Through interviews by the RN, it was determined that 19 of the

children lived in homes where they were exposed to SHS. When offered information on smoking

cessation, 90% refused. Conclusive data from this study showed that 53% of the children having

ear tubes placed for CSOM were exposed to SHS. We believe that this supports a strong

correlation between CSOM and SHS.

Three Health/Social Issues

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The three issues we have identified as relating to our choice of community are: a

potential link between exposure of this pediatric population to SHS and the development of

CSOM, secondly, a lack of college education for our community’s caregivers, and thirdly, most

of the children lived in families with a lower socio-economic status. These three health/social

issues and their etiology/correlation were formerly discussed in socio-political issues above (pp.

11&12). As a group we chose to focus on the relationship between SHS and CSOM as our

primary focus for our nursing plan.

Link between SHS and CSOM

According to Murphy (2006, p.904), “Cigarette smoke decreases mucociliary clearance

by respiratory epithelium, potentially facilitating bacterial colonization. There is also increased

adherence of bacteria to respiratory epithelial cells of smokers and inflammation from tobacco

smoke may result in epithelial injury, predisposing to bacterial colonization.” Bacteria including

streptococcus pneumoniae and haemophilus influenzae, which are responsible for middle ear

infections, have been colonized from the parent or caregiver as well as the child. SHS as a risk

factor for CSOM dates back to 1978, with data taken from cross-sectional and case-control

studies (Neto, Hemb, & Brunelli e Silva, 2006). Neto, Hemb, & Brunelli e Silva (2006)

concluded from a literature review that increased CSOM due to SHS was about 66%. They cite

two meta-analysis which estimate the relative risk of 1.66, with one parent smoking. This

relative risk increases with the number of cigarettes smoked as well as the presence of another

smoker in the house.

Consequences of SHS for this Population

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Exposure of children to SHS has been linked to low birth weight, sudden infant death

syndrome, an increase in upper respiratory infections, asthma, and otitis media (Winickoff et al.,

2003). In the United States approximately 43% of all children are exposed to SHS. Otitis

media alone accounts for 3 billion in health care spending and 25 million office visits (Kerstein,

2008). The CDC (Centers for Disease Control [CDC], 2006) notes that developing

children are more susceptible to the affects of SHS. Babies born to mothers who smoked

during pregnancy are more likely to have weaker pulmonary function and are in danger of

developing other respiratory problems such as upper respiratory infections, frequent asthma

attacks, bronchitis, and pneumonia. Children are exposed to more SHS more than non-smokers

because they come in contact with it in their homes or in the family car (CDC).

Need for Education, Prevention, and Intervention

In addition to retrieving articles about SHS and its possible links to CSOM,

discussions took place with four of the ENT surgeons at Spectrum Health Butterworth, as well as

a large inner-city pediatric practice. When asked about counseling parents of children with

middle ear disease and the consequences and affects of parent’s smoking on children. The

pediatrician’s office reported that counseling to quit smoking occurred on an individual basis,

depending on the family and child’s situation. Two of the surgeons relied on counseling to come

from the primary care provider or the pediatrician’s office. The other two believed that they

would have no influence on the parent(s) to quit smoking. This information was rather

disheartening to hear. As mentioned previously, surveys of parents, including those that smoked,

believe that their child’s pediatrician should address cessation of smoking (Winickoff et al.,

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2003). Kerstein advises that prevention rather than prescription should be the gold standard for

management of CSOM (2008). Unfortunately, most physicians and other clinicians lack training

in tobacco counseling (Klerman, 2004), and many physicians surveyed believed that counseling

parents to quit smoking was not one of their responsibilities. Other factors affecting the number

of parents and caregivers that are counseled to quit smoking include a lack of time and a lack of

reimbursement by insurance for counseling (Klerman, 2004).

Recommended Nursing Plan

In prioritizing three health issues, we feel intervention, prevention, and education would

be the most important. In order to address the consequences of SHS, our population’s caregivers

will need to be informed about the link between SHS and chronic otitis media. Sheahan and Free

(2005) have reported that smoking was more prevalent among parents with lower incomes and

less education. Resources are available in the community to teach caregivers about the hazards of

second hand smoke, however, healthcare providers also need to be educated on how to best

utilize this information to teach the importance of smoking cessation. Therefore, we believe

addressing the caregiver’s knowledge deficit in regards to second hand smoke should be given

the highest priority.

Nursing Diagnosis

The nurse’s ultimate goal is to lower the number of children suffering from otitis media

related to SHS. Parent’s awareness of the risks of SHS must be evaluated and their willingness

to reduce their child’s exposure needs to be evaluated. A nursing diagnosis we believe

complements this goal is knowledge deficit: potential for enhancement related to SHS, as

evidenced by recurrent otitis media in children.

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Expected Outcomes

Our main expected outcome would be to see a decrease in the number of children

needing ear tubes as a result of exposure to SHS. While we obviously can’t force caregivers to

quit smoking, we can certainly educate them of its negative affects on themselves and their

children. At well-child visits, all smoking parents should be counseled to quit smoking, and those

unwilling to quit should be able to name at least two ways to decrease the amount of SHS their

child is exposed to.

Interventions and Evaluations

One of the biggest problems facing the education of this population is helping the health

care provider to feel comfortable asking about smoking in the home. As reported by Klerman

(2004), a study conducted by the National Ambulatory Medical Care Survey found only 1.5% of

all 33,823 ambulatory care visits by children included tobacco counseling, and of the well-child

visits that included counseling, information about the link between otitis media and smoking was

only give 0.3% of the time. This is in stark contrast with a 2003 report by Winickoff et. al.,

which stated “Surveys have demonstrated that 79% to 93% of parental smokers agree that their

child’s pediatrician should provide smoking cession advice, and 48 % to 56% believe it is part of

the pediatrician’s job to advice parents to quit smoking” (p.1147).

Physicians and other health care providers will need to be educated on how to approach

the topic of second hand smoke and it’s affect on children. Pediatricians should be encouraged to

get involved with organizations such as the American Academy of Pediatrics to increase

awareness and knowledge of the best way to teach parents about the hazards of second hand

smoke. The American Academy of Pediatrics is up to date with the latest anti-smoking policies

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and has an abundance of resources. They are very passionate in regards to patient’s exposure to

second hand smoke and could serve as an excellent resource for physicians who may feel

uncomfortable or unsure of how to approach the subject.

Physicians are not the only ones who may feel uncomfortable bringing up the subject of

smoking cessation. Hospital departments, pediatrician’s offices, and other work environments

could provide brief training sessions for nurses on how to best approach the subject with family

members. Depending on the setting, diagrams, videotapes, or internet links could be provided so

that the nurse can best accommodate each caregiver’s unique learning style (Ackley & Ladwig,

2004). Handouts highlighting the effects of second hand smoke should be given to caregivers at

each well child visit. The Center for Disease Control has many handouts available that are easy

to read and understand, they would be easy to obtain and print. During the child’s assessment,

the nurse caring for the child could highlight some of the key points of the pamphlet and

encourage the parent to read it over. Of course, barriers to learning should also be assessed, so

that the teaching is built to accommodate the parents’ level of understanding. Community nurses

can provide information to families who are involved in government assisted programs such as

Women Infant and Children (WIC). Because the population being served by the community

health nurse may not be as consistent as those bringing in a child for an annual wellness visit, the

information presented needs to be upfront and to the point. The most important material should

be presented first, so that it “sticks with” the caregiver; additional information can be given once

the caregiver understands the basic concepts of the information being presented (Ackley &

Ladwig, 2004). In the hospital setting, nurses could initiate automatic consults when a family

responds that there is a smoker in the home. At Spectrum Health, when a child is admitted there

is a task on the admission profile that asks if there is anyone who smokes in the home. When the

Community Assessment 19

response is “yes” social work is automatically contacted so this issue can be addressed. The

number of consults could be inventoried and then the number of families who utilized the

information could be analyzed. Community resources such as Keeping Infants Safe from Smoke

could also be consulted to give the family more long-term counseling and information on how to

effectively decrease the amount of SHS present in their child’s environment.

Conclusion

In conclusion, we believe nurses and other medical health professionals should strongly

encourage the caregivers of young children to either quit smoking or minimize second hand

smoke exposure of their children. Young children are very dependent on others for their well-

being and it is one of our responsibilities as healthcare providers to advocate on their behalf.

Because of the strong link between SHS exposure and the necessity of ear tubes, we believe

teaching smoking cessation would be one of the most effective ways to decrease the number of

children needing the surgical placement of ear tubes.

References

Ackley, B.J. & Ladwig, G. B. (2004). Nursing Diagnosis Handbook: A Guide to Planning Care

(6th ed.). St. Louis, Mo.: Mosby

American Academy of Pediatrics. (2006). Financing of pediatric home health care. American

Academy of Pediatrics, 118, 834-838. doi: 10.1542/peds.2006-1489

American Academy of Pediatrics. Pediatricians can help parents quit smoking. (2009). Retrieved

March 20, 2009, from http://www.aap.org/advocacy/release/mar09smoking.htm

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Campaign for Tobacco-Free Kids. (n.d). Health harms from second hand smoke. Retrieved

March 15, 2009, from http://tobaccofreekids.org/research/factsheets/pdf/0103.pdf

Centers for Disease Control. (2004). Deaths: leading causes for 2002. Retrieved March 22,

2009, from http://www.cdc.gov/nchs/data/nvsr/nvsr53

Centers for Disease Control. (2006). Smoking and Tobacco Use [Fact Sheet]. Retrieved March

20, 2009, from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_

smoke

Encyclopedia of Surgery: A Guide for Patients and caregivers. Retrieved March 15, 2009, from

http://www.surgeryencyclopedia.com/La-Pa/Myringotomy-and-Ear-Tubes.html.

Grand Rapids Area Population and Demographics: Area Connect. Retrieved March 15, 2009,

from http://grandrapids.areaconnect.com/statistics.htm.retrieved03/15/2009

Jarvie, J. A., & Malone, R. E. (2008). Children's secondhand smoke exposure in private homes

and cars: an ethical analysis. American Journal of Public Health, 98, 2140-2144.

doi:10.2105/AJPH.2007.130856

Helen DeVos Children’s Hospital: Health Library. Retrieved March 17, 2009, from

http://www.devoschildrens.org/?s=8&hospID=36d00930453745378a180ce81b.03/15/2009.

Kerstein, R. (2008). Otitis media: prevention instead of prescription. British Journal of General

Practice, 58(549), 364-365. Retrieved from

http://www.pubmedcentral.nih.gov/tocrender.fcgi?journal=261

Klerman, L. V. (2004). Protecting children: reducing their environmental tobacco smoke

exposure. Nicotine & Tobacco Research, 6, S239-S252. doi:10.10801146222

410001669213

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Maurer, F. A., & Smith, C. M. (2005). Community Public Health Nursing Practice: Health for

Families and Populations (3 ed.). St. Louis, Mo.: Elsevier Saunders.

Murphy, T. F. (2006). Otitis media, bacterial colonization and the smoking parent. Clinical

Infectious Diseases, 42(7), 904-906. Retrieved from

http://www.journal.uchicago.edu/doi/pdf/10.1086.500942

Neto, J. F., Hemb, L., & Brunelli e Silva, D. (2006). Systematic literature review of modifiable

risk factors for recurrent acute otitis media in childhood. Jornal de Pediatria, 82(2), 87-

96. doi:10.2223/JPED.1453

Sheahan, S. L., & Free, T. A. (2005). Counseling parents to quit smoking. Pediatric Nursing,

31(2), 98-108. Retrieved from http://0-find.galegroup.com.libcat/ferrsiedu/itx/retrieve

Winickoff, J. P., McMillen, R. C., Carroll, B. C., Klein, J. D., Rigotti, N. A., & Tanski, S. E.

(2003). Addressing parental smoking in pediatrics and family practice: a national survey.

Pediatrics, 112(5), 1146-1150. Retrieved from

http://pediatrics.aapublications.org/cgi/search

Wood, G.L., & Haber, J. (2005). Nursing Research: Methods, Critical Appraisal,

and Utilization (5th ed.).St. Louis, MO: Mosby.

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Table 2. Demographics of SamplePatient Number Age Sex Race

Past infections

Repeat Surgery?

Smoking Status

College Graduate

Socioeconomic Status

1 2 M White 5 No 1 No Low2 5 M White 6 No 2 No Low3 3 F White 4 No 0 No Low4 1 F White 6 Yes 1 No Low5 4 F Black 4 No 0 No Low6 5 M White 5 No 1 No Low7 3 F White 6 Yes 2 No Low8 5 F White 6 No 0 No Low9 3 M White 5 No 1* No Low10 3 M White 5 No 0 Yes Upper11 4 F White 5 Yes 0 No Low12 5 M White 4 Yes 1 No Low13 2 M White 5 No 2 No Low14 4 M White 6 No 0 No Middle15 4 F White 6 Yes 1 No Low16 3 M White 5 No 0 Yes Middle17 3 F Black 5 No 0 No Low18 2 F White 4 No 1 No Low19 2 M White 5 No 0 No Low20 5 M Hispanic 5 No 1 Yes Middle21 5 F White 6 No 2 Yes Middle22 1 M White 5 No 0 No Middle23 5 M White 6 No 0 No Low24 2 F White 5 No 1 No Middle25 3 M White 4 Yes 0 Yes Upper26 4 M Black 4 No 1 No Middle27 2 M Hispanic 4 Yes 0 No Middle28 3 M White 6 No 1* No Low29 3 M White 6 No 1 No Low30 2 M White 6 Yes 1* No Low31 3 M White 5 No 0 No Low32 2 M White 6 No 0 Yes Middle33 2 M White 5 No 2 No Low34 4 M Hispanic 6 No 0 No Low35 2 M White 5 No 1 No Low36 4 M White 6 Yes 0 No Low