Working as a registered nurse Essay

Custom Student Mr. Teacher ENG 1001-04 17 September 2016

Working as a registered nurse

I have been working as a registered nurse in Tacoma, WA since 2011 and I have chosen to assess the community health of Pierce County. Tacoma is the county seat of Pierce County and the largest city in the county and third largest city in the state (US Census Bureau, 2014). Pierce County is located south of Seattle and is comprised of 1,679 sq. miles, many of which front the Puget Sound. Northern areas of the county are comprised of islands and peninsulas only accessible by bridges or boats. It also contains one of the nation’s national parks and the state’s tallest peak, Mount Rainier. The Park’s boundaries largely define the eastern border of the County and the White and Nisqually Rivers make up the North and South boundaries respectively. (Snob Hollow Designs, 2014)

Population Economic Status Assessment

Nearly 820,000 people call Pierce County home. It boasts a high population density with 481 people per sq. mile. Urban areas comprise 93 percent of the county. (City-Data, 2014) The median household income in 2013 was estimated to be close to $60,000 and 12 percent of residents are living below the poverty level. (US Census Bureau, 2014) Blacks and African Americans make up the majority of low-income people despite the fact that they comprise only 7 percent of the County population. The majority of residents (76.5 percent) are white, 10 percent are non-black Hispanics and 6 percent are Asians. The median resident age is 35 years and 12 percent of residents are 65 years or older. (University of Wisconsin Population Health Institute, 2014). More than a third of Pierce County children are eligible for free lunch benefits and 8.9 percent of residents are unemployed.

As many as 16 percent of residents are uninsured despite a per capita personal health expenditure of $8,160 annually. Ten percent of those uninsured are children. What’s more, close to 6 percent of residents make less that $10,000/year. It’s estimated that 15 percent of residents are not able to see a health care provider when they need to because they can’t afford it. When they can afford to, primary care providers (PCP) are in short supply and overworked. There are an estimated 1500 patients for every PCP in Pierce County. (University of Wisconsin Population Health Institute, 2014)Medicare is the primary payer of health care expenditures for 10 percent of County residents. (City-Data, 2014)

Pierce County has some of the highest rates of obesity in the nation with a 31 percent obesity rate. This is despite the fact that nearly 80 percent of residents reported exercising in the previous month. (University of Wisconsin Population Health Institute, 2014)The County has numerous parks, hiking trails, walking paths and enjoys a temperate climate with little snow accumulation and mild summer temperatures. Poor nutrition is likely a key contributor with 16 percent of residents classified as food insecure. The County has the lowest access to healthy foods with 8 percent of people living in urban areas where the nearest grocery store is more than a mile from their home. Access to convenience stores is slightly better. (University of Wisconsin Population Health Institute, 2014).

Neighborhood and Community Safety

Any Pierce County resident can testify to smelling the “Aroma of Tacoma” on a regular basis. At various parts of the day, a pungent smell not unlike that of rotten eggs fills the air. The source of the stench is attributed to industries located at the Port of Tacoma, the forest industry, car exhaust, or the tidal changes on the Puget Sound. The extent of air pollution in the area is large. More than three quarters of county residents drive alone to work every day. Just 3 percent take public transportation. The County ranks 16th in counties reporting high carbon monoxide one hour concentration. It is among the dirtiest 10 percent of US counties for its release of water and carcinogens. Chief among these deadly chemicals is methanol and hydrochloric acid. (City-Data, 2014) (Good Guide, 2011)

There are four Superfund Sites in the County that continue to cause contamination of drinking water. One of these sites is Commencement Bay, the hub of the Port of Tacoma, one of the world’s busiest ports. The biggest polluter in the area is the Simpson Tacoma Kraft Company, a forest product company that prides itself on using “every part of the tree except its shadow.” (Simpson, 2014) Another well-known polluter and also a major area employer is the US Military. Superfund Sites exist at both McChord AFB and the US Army Fort Lewis Range. (Good Guide, 2011) Cultural Assessment

For a personal perspective of life inside Pierce County I consulted with a colleague who works as a lactation consultant. She is a 50-year-old college-educated white female who also works as an instructor in a local vocational college. She reports that her cohort’s attitude toward aging is not altogether positive. She is beginning to feel the gradual decline in her body functions and says that she and others like her find it frustrating that their bodies don’t work as well as they did in their youth. That attitude of reluctance tends to affect how readily her peers seek assistance, especially if it means accepting the realities of aging. Some of the physical health problems common in her cohort involve vision, sleep apnea, joint pain, and decreased stamina.

She states that individuals in her cohort tend to be individualistic and prefer their yards, both physically and metaphorically, to be fenced. This perspective crosses over to how children are parented with a high value placed on raising adults that are independent and self-sufficient. Her children have either graduated from college or are currently attending university. She considers financial independence a mark of adulthood. A ritual associated with adulthood is moving out of the family home and their own.

One of the challenges she sees in her cohort is that of obtaining access to mental health care. A colleague recently lost her son to suicide after numerous attempts to help him gain access to care failed and he committed suicide. She feels that only those who are going to hurt others or hurt themselves are recipients of care in a broken system. Because so many are aching for help in the community and a greater awareness of the need, the result has been a reduced stigma associated with mental illness. Acknowledging that mental illness is far from being treated on plane with biological illness, she reports that the awareness of an individual’s lack of control over what is a real disease is growing.

Disaster Assessment and Planning

The incredible amount of physical beauty present in Pierce County is also a source of danger to its residents. The area has been declared as a disaster area 19 times in recorded history. Most of these events were the result of severe storms that caused flooding, landslides, and mudslides. The area is situated on or near several tectonic plates giving it an earthquake risk that is 355 percent greater than the national average. In 2001, a magnitude 6.8 earthquake was centered just 10.8 miles from the city center and caused tens of thousands in damage. An earthquake centered even farther away could affect the county via a subsequent Tsunami. Coastline areas comprise many of the County’s industries, parks, and homes and could be destroyed by a tsunami’s tidal surge. Mt. Rainier frames many of Tacoma’s picturesque views but it is a volcano that could come back to life at any moment. Its last eruption is estimated to have occurred more than 150 years ago but a recent eruption could cause massive downstream flooding in nearly the entire County. (City-Data, 2014)

Disasters caused by flooding precipitated by a tsunami, volcanic eruption, or one of the areas many rainstorms could displace many residents from their homes and block access to urgent and chronic healthcare services. Sewage systems could be affected by the flooding as well as decrease access to clean water. A massive earthquake could destroy many of Tacoma’s older buildings, many of which were built in the early 1900s and well before any seismic construction rules went into effect. Falling objects from an earthquake and resulting fires could result in massive injuries in the short-term and damage to public infrastructure in the long-term. (Pierce County Department of Emergency Management, 2010) Many of the possible disasters that could strike the area do not have the luxury of advance warning. Severe storms may give as little as a day or two notice, tsunamis and flooding just a few hours. Many residents are unlikely to understand the severity of a disaster until they are in its midst.

Because the residents lack the ability to prepare, The Pierce County Department of Emergency Management has five departments to deal with every day emergencies and large-scale disasters. The services include emergency management, enhanced 9-1-1 services, fire prevention, radio communications and an urban search and rescue task force. The Department is working to enroll all residents in an emergency alert system via text. Area hospital employees also have an alert system that sends a text message to employees to report to duty in the event of an emergency. The enhanced 9-1-1 system automatically finds the street address for landline calls. The radio communications team works to ensure that radio remains active in the event cell towers fall during an earthquake or are damaged during severe flooding. Urban Search and Rescue can provide vital services in the event of an earthquake, mudslide, avalanche or abandoned mine collapse. (Pierce County Department of Emergency Management, 2010)

Windshield Survey


The majority of housing options available in Tacoma are single-family detached homes. A housing boom in the 1990s resulted in many newer homes and apartment buildings in both high and poor-income areas. Housing density appears to be highest in high-income neighborhoods. Many homes in both areas have grassed front and back yards. Although the area was heavily wooded when settled in the 1890s, much of the native evergreen trees are gone. Tree replacement appears limited to higher-income areas and is limited to non-native deciduous trees. Housing in lower-income neighborhoods appears to be in fair to moderate repair. Very few homes in these areas have bars over windows or doors. (Patamia, 2015)

Open Space

In Tacoma, there appears to be a moderate amount of open space, especially considering it is an urban area. I saw a large strip of valuable waterfront in the Ruston area dedicated to a walking path and docks used for office space and dining. The jewel in the crown of the Tacoma Metropolitan Park System is Wright Park, a 27-acre parcel spanning more than 10 city blocks in the heart of the city that features an arboretum, lawn bowling, playgrounds, and a pond. In addition, Mt Rainier National Park has more than 235,000 acres of protected forestland and numerous State parks dot the County. All of these spaces are open for public use and park passes are enveloped as part of the residents’ vehicle tax.


The boundaries of the area are largely natural features like rivers and mountains. Neighborhoods begin and end without notification but poorer areas tend to have more chain link fences, fewer shopping areas, and homes that lack fresh paint and ornamental landscaping. Ironically, the most expensive homes in the county have roads that are either gravel or so unkempt that potholes dominate.


People in the county tended to congregate around grocery stores and the strip malls that surround them. I visited an upscale grocery store in the middle of the day and found parking difficult despite an ample lot. Areas surrounding the Port of Tacoma business district tend to always have a large amount of traffic, especially large trucks carrying containers to and from the ships docked in Commencement Bay.


Pierce County, despite the low numbers of residents who use public transportation has numerous options for getting out of your car. Buses travel to every part of the county, even across the Tacoma Narrows Bridge to the Olympic Peninsula town of Gig Harbor. Residents can travel to Seattle using rail or bus. Residents enjoy the capability of attaching their bikes to city buses but since the area is very hilly and frequently rainy, few take advantage of the service. For all of its access capabilities in Tacoma, getting around in surrounding communities is difficult.

Interstate 5 intersects the county, enabling easy access for Port of Tacoma traffic to Canada and the western states. Several state highways run through the community and many are currently undergoing expansive improvement projects. Long-term plans include expanding Seattle’s light rail into Tacoma but recent initiatives to expand inter-county bus services was voted down by residents.

Service Centers

One of the most impressive things about Pierce County is how new and beautiful its schools are. Around these areas, it’s easy to spot social service centers such as YMCAs or Community Healthcare Clinics. Even in the poorest areas of the County, I saw many dentist offices, parks with playground facilities, and sidewalks. I drove by a newer looking middle school several times during my survey and always saw it occupied by students despite heavy rain.


Commercial areas in the county appear to be centered on large chain grocery stores. There are few non-chain, independent dining options and those that are tend to offer high-calorie, high-fat options like hamburgers and milkshakes. I did not see any signs advertising farmers markets but there were more than a few community gardens where residents could grow their own fruits and vegetables. I was also impressed by how few grocery stores there were outside of major shopping areas and how far even the wealthiest had to travel to buy food. In more than one area, there were several grocery stores in close proximity to each other.

People Out and About

I saw several people walking around the County during my survey but all of them appeared to be walking for exercise and leisure, not for transportation. Almost all of these walkers were white and non-obese. A majority of those I saw were wearing Seahawk jerseys and/or colors. It was so persuasive that I felt out of place with an orange sweatshirt. Dogs accompanied many of the walkers and every dog was leashed.

Signs of Community Vibrancy

The Pierce County Community is very diverse but in nearly every area I traveled, I saw signs of vibrancy evidenced by hanging flower baskets, children playing outside, areas of preserved natural beauty, easy access to healthcare, and a lack of abandoned homes, stray animals, or countless homeless people.


Given that nearly three-quarters of Pierce County residents are white, its not surprising to see mostly white people in the County. Surprisingly, there are two major Indian Reservations, the Nisqually and Puyallup, inside Pierce County yet less than 2 percent of residents are Native American. Most of the County looks and feels American with few ethnic grocery stores or signs in a language other than English. Areas where whites live tend to be predominantly white but areas with larger populations of Blacks, Asians, and Hispanics are well integrated. In one strip mall, there was a Mexican taqueria next door to an Asian grocery store.


While only 30 percent of Pierce County residents report being affiliated with a religious congregation, nearly half of them are non-denominational Christian churches. A third of residents report an affiliation with a Roman Catholic Church. I saw many more churches in the less affluent areas of the County than I did in wealthy ones. I also saw one Buddhist temple and Muslim Mosque.


There are 10 hospitals serving Pierce County the largest of which is Tacoma General Hospital that has more than 400 beds and a level II trauma center. A few blocks away with the area’s second level II trauma center and a level III NICU is St Joseph Medical Center with 367 beds.

Signs of homelessness are slightly invisible in Pierce County and tend to be clustered around area shelters or service providers such as the Union Gospel Mission and the YWCA. It’s estimated that 2,000 people including children are homeless on any given night in Tacoma. One of the area hospitals, Western State Hospital, provides services exclusively to the mentally ill but the lack of services to the homeless and mentally ill is striking. There are an estimated 368 mentally ill people for every mental health provider in Pierce County.

Top performing counties have 521 providers per patient. The State ranks 49th in number of available psychiatric beds and several agencies have recently closed their doors or decreased services due to the economic turn down. (League of Women Voters – Pierce County, 2013) (Good Guide, 2011) Forty percent of female tenth-grade children are classified as depressed. The Tacoma Pierce County Health Department lists mental health as its #1 priority in the coming years.


I toured the area in January when the nearest election was months or years away. Cars I viewed had a mix of bumper stickers that indicated the metropolitan area voted for Obama in the previous presidential election, supports the legalization of marijuana, and is a fan of the Seattle Seahawks. Media

No matter the area, evidence of satellite dishes was seen on nearly every home. I did not see any newspaper boxes around area stores. It seems that the primary form of communication medium is through television and the Internet. Television stations accessed by residents are primarily in English but there are two stations that are exclusively in Spanish.

Physical Environment

As mentioned previously, Pierce County is a very beautiful place with views of mountains, water, dense forest, and even a volcano visible from nearly every corner of the County. During my survey, I even viewed a pair of bald eagles playing over the Puget Sound. The areas around the Port of Tacoma and the two Indian reservations tend to be the least attractive areas of the city where billboards for nearby tribal-run casinos predominate the landscape.

Scavenger Hunt

Women, Infants, and Children (WIC)

WIC is a nutrition program that helps ensure that pregnant women, nursing moms and children under five have access to healthy foods. They also provide health education and breastfeeding support including peer counselors. Women who use WIC get money to purchase fresh fruit and vegetables, milk, cheese, whole grain breads and tortillas. They also ensure that children are vaccinated and stay on recommended growth curves. A family of four is eligible for WIC benefits if they have an annual income equal or less than $43,000. Accessing the services requires visiting a WIC location, which are located on major bus routes near hospitals, health clinics, or in tribal offices. There are more than 15 WIC locations in the county and offer services in English, Spanish, Vietnamese, Korean, Russian, Tagalog, and Cambodian. (Tacoma Pierce County Health Department, 2015) YMCA

The YMCA of Pierce and Kitsap Counties offer a variety of services including seven healthy living centers, a summer camp and more than 70 child care sites. Their mission is to offer programs that “build a healthy spirit, mind and body for all.” (YMCA of Pierce and Kitsap Counties, 2014) Monthly fees that are based on household income support membership and financial aid is available. There are steep discounts for members of the military and their families. The variety of services available at the healthy living center is broad. Members of the Tacoma facility take piano lessons, learn how to box, and enjoy an indoor pool.

Family Renewal Shelter

There are 16 different resources for those dealing with domestic violence in Pierce County. Among them is the Family Renewal Shelter. They provide emergency services by way of confidential shelters, self-defense classes, spiritual support, and pet therapy. They also offer help with access to vehicles, educational scholarships, and relocation. Support for the organization comes from private donations from individuals, foundations, businesses, and churches. Access to services is via the organization’s 24-hour crisis line. Information about domestic violence is available on the organization’s website including a button that allows a user to leave the site quickly and eliminate a computer trail. (Family Renewal Shelter, 2014)

National Alliance on Mental Illness – Pierce County

The purpose of NAMI is to support people and those who love them with the challenges of mental illness. Members are people whose lives have been touched by mental illness and can share resources, lessons learned, and empathy with one another. They also advocate for change on local and legislative issues. Support group meeting occur three times a week and are located in a local Episcopal Church. They are free to attend. NAMI Walks occur several times a year and help to reduce the stigma of mental health and expand services, especially in education of mental health issues with police, fire and other first responders. (NAMI – Pierce County, 2015)

Planned Parenthood

A group of community volunteers opened the first Planned Parenthood clinic in Tacoma in 1972 to address concerns about high rates of teen pregnancy and sexually transmitted infections. The organization believes that everyone has the right to choose whether and when to get pregnant and works to prevent unwanted pregnancies. They rely heavily of individual donor support to provide basic low-cost health care, adoption planning, vasectomy services, and fitting for menstrual cups. They also provide abortion services and are frequented by protestors. (PPGNW, 2015)

Tacoma Rescue Mission

There are more than 36 homeless shelters in Tacoma offering everything from emergency shelter, transitional housing, and assisted housing for people dealing with domestic violence, drug addiction, and sexual trafficking. They are a Christian organization funded by the United Way of Pierce County and the cities of Lakewood and Tacoma in addition to funding from Pierce County itself. They report that they provide shelter to more than 400 people nightly and provide food for 26,000 people who have no other access to food. They work to help people overcome drug and alcohol addiction with rehabilitation serves, educational assistance and case management. (Tacoma Rescue Mission, 2015)

Interpretation of Collected Data

Epidemiology examines how health status or health events are distributed across a community and what determines it. The preceding examples give a broad stroke painting of health in Pierce County. Overall, the birth rate (15 per 1000) exceeds the death rate (7.3 per 1000) in Pierce County and the infant mortality rate (6.5 per 100,000) is in line with the national average (6.15 per 1000). (City-Data, 2014)

Pierce County offers many assets that empower the health of its residents. Among these are a large population of college-educated people with 90 percent of adults 25 years and older completing at least high school or obtaining a GED. Although 8 percent of residents are foreign born, more than 80 percent of these report speaking English fluently. The people of Pierce County have access to nature and local foods, including the nation’s largest crop of rhubarb. Strong faith communities with social outreach programs help neighbors in need. The community brims with people who are largely open-minded and access complementary care such as massage, acupuncture, and chiropractic adjustments is common. (Tacoma Pierce County Health Department, 2014)

Community Diagnosis

In my analysis of the data collected, it appears that Pierce County’s top three problems are access to mental health services, high rates of obesity, and access to quality health care.

Access to mental health services

A community that is mentally healthy is productive, enjoys fulfilling relationships with others in the community and is resilient through life’s challenges. Without it, even the healthiest body can fall into disrepair quickly. It’s no wonder then that mental illness is one of the most common causes of disability. The National Institute of Mental Health estimates that as many as one in every 17 people has a seriously debilitating mental illness. The good news is that mental, emotional, and behavioral disorders can be prevented. We know more about how the brain functions than ever before and current research indicates that greatest opportunity to prevent illness is to get people into treatment early and often. (Healthy People 2020, 2015)

With Washington State’s dismal rankings in the availability of psychiatric beds and the high patient load of mental health care providers in the County, there is much work to be done. Healthy People 2020 goals state that 87 percent of primary care facilities should provide mental health treatment onsite or by paid referral. This goal represents a 10 percent improvement over the baseline rate of 79 percent in 2006. (Healthy People 2020, 2015)

High rates of obesity

Pierce County’s high rate of obesity is well above the national average and may be attributed to large number of food deserts, especially in urban areas. People who have healthy weights and access to fresh foods have lower rates of chronic disease and a higher quality of life. Addressing obesity is complex, however, and requires a multi-faceted approach. As with mental health, the most powerful interventions are aimed at prevention.

According to Healthy People 2020, more than 10.4 percent of children ages two to five were considered obese in 2008. The 2020 goal is to reduce that number to 9.4 percent. (Healthy People 2020, 2015)One of the most cost effective ways to achieve that goal is to increase the number of children who are breastfed. A history of breastfeeding, especially exclusive breast milk feeding for the first six months, is associated with an estimated 40 percent reduction in childhood obesity. (AHRQ, 2009) Unfortunately, just 14.1 percent of infants born in 2006 achieved this. Healthy People 2020’s target is 25.5 percent. (Healthy People 2020, 2015) Access to quality healthcare

Optimal health is not a state achieved without support, education and intervention. Ensuring that Pierce County residents get the help they need when they need it is a big part of preventing chronic disease, improving quality of life, and preventing unnecessary death. Some of the reasons people do not see a health care provider are they can’t find one, they can’t afford it, or they don’t have insurance coverage.

The most recent data suggests that as many as 16 percent of County residents do not have health insurance. (Good Guide, 2011) According to Healthy People 2020, the national average is slightly higher at 16.8 percent. The objective is an ambitious one with 100 percent of individuals covered by private insurance or Medicaid/Medicare by 2020. (Healthy People 2020, 2015)

According to Washington State’s Department of Public Health, there are approximately 543 providers in Pierce County including doctors, ARNPs, CNMs, and PAs. A little more than half of them report that they are accepting new Medicaid and Medicare patients. (Washington State Department of Public Health, 2011) Interestingly, Healthy People 2020 has yet to define specific goals for increasing the number of practicing providers in all areas. (Healthy People 2020, 2015)

Primary Prevention Topic

When John Snow, the “father of epidemiology,” was investigating cholera outbreaks in mid-nineteenth century London, the chief cause of unnecessary death was communicable disease. Today, chronic disease that damages the heart, pancreas, and lungs are more likely to kill than bacteria. A large contributor to hypertension, diabetes, and heart failure is obesity. In a society obsessed with weight loss and thinness, obesity rates in adults and even children are growing. Just as John Snow found the source of the disease that was claiming lives in his community, we must also find the source but it is unlikely to be in a solitary water pump in the middle of the city.

Preventing obesity appears to be a life-long task best started at birth. The data demonstrate that increasing breastfeeding rates is a powerful tool in decreasing childhood obesity. Breastfeeding rates for older, educated and more affluent women are already at Healthy People 2020 targets but women who are young, have low levels of education and who are poor are more likely to never breastfeed and are extremely unlikely to continue to do so for six months. (Grummer-Strawn, Scanlon, Darling, & Conrey, 2004)

An organization in the community that helps low-income women establish and maintain breastfeeding is the Women, Infants, and Children Program. A team of peer counselors who have themselves struggled with issues common to low-income breastfeeding women including pumping in the workplace help new moms navigate a difficult terrain and provide their children with the best start in life. Area hospital-based birth centers are working toward or have already achieved certification as a Baby Friendly Hospital. This designation indicates that the facility employs evidence-based practice that lead to dramatic increases in breastfeeding rates. (DiGirolamo, Grummer-Strawn, & Fein, 2008)

Given that the problem of obesity is large in Pierce County, the rewards for reducing it great, and the interventions that are most likely to help are known and inexpensive, I am focusing my primary prevention topic on promoting breastfeeding as a means to reduce obesity in Pierce County.

AHRQ. (2009). Breastfeeding, Maternal & Infant Health Outcomes. Retrieved January 22, 2015, from Agency for Healthcare Research and Quality:

City-Data. (2014). PIerce County, WA. Retrieved January 16, 2014, from

DiGirolamo, A., Grummer-Strawn, L., & Fein, S. (2008). Effect of Maternity-Care Practices on Breastfeeding. Pediatrics , S43-S49.

Family Renewal Shelter. (2014). About the family renewal shelter. Retrieved January 21, 2015, from Family Renewal Shelter:

Good Guide. (2011). Good Guide. Retrieved January 17, 2014, from Score Card – The Pollution Information Site:

Grummer-Strawn, L., Scanlon, K., Darling, N., & Conrey, E. (2004). Racial and Socioeconomic Disparities in Breastfeeding . Atlanta: Centers for Disease Control and Prevention.

Healthy People 2020. (2015). Access to Health Services. Retrieved January 22, 2015, from Healthy

Healthy People 2020. (2015). Maternal, Infant, and Child Health. Retrieved January 22, 2015, from Healthy

Healthy People 2020. (2015). Mental Health and Mental Disorders. Retrieved January 2015, 2015, from

Healthy People 2020. (2015). Nutrition and Weight Status. Retrieved January 22, 2015, from Healthy People 2020:

League of Women Voters – Pierce County. (2013, December 11). Introduction to services for the seriously mentally ill in Pierce County . Retrieved January
18, 2015, from National Alliance for the Mentally Ill – Pierce County:–%205%20pgs.pdf NAMI – Pierce County. (2015). Welcome to the NAMI of Pierce County Web Site. Retrieved January 21, 2015, from NAMI – Pierce County:

Patamia, K. (2015, January 16). Windshield Survey of Pierce County. (K. Patamia, Interviewer)

Pierce County Department of Emergency Management. (2010). Hazard Identification and Risk Assessment. Retrieved January 17, 2015, from Pierce County Emergency Management:

PPGNW. (2015). Who We Are. Retrieved January 21, 2015, from Planned Parenthood of the Great Northwest:

Simpson. (2014). Environment. Retrieved January 17, 2015, from Simpson Company:

Snob Hollow Designs. (2014). County Maps of Washington. Retrieved January 17, 2014, from County Maps of Washington:

Tacoma Pierce County Health Department. (2015). Nutrition Program for Women, Infants and Children. Retrieved January 21, 2015, from Health and Wellness:

Tacoma Pierce County Health Department. (2014, August). Pierce County Community Health Improvement Plan. Retrieved January 15, 2015, from Pierce County Community Health Improvement Plan:

Tacoma Rescue Mission. (2015). Rescue Mission. Retrieved January 21, 2015, from About Us:

University of Wisconsin Population Health Institute. (2014). County Health Rankings and Roadmaps. Retrieved January 17, 2014, from Washington – Pierce County:

US Census Bureau. (2014, December 4). State and County Quick Facts. Retrieved January 16, 2013, from United States Census Bureau:

Washington State Department of Public Health. (2011, July). Primary Care Provider Survey: Pierce County. Retrieved January 22, 2015, from Office of Community Health Systems: YMCA of Pierce and Kitsap Counties. (2014). About Us. Retrieved January 21, 2015, from YMCA of Pierce and Kitsap Counties:

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