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									                                                                       Community Health 1


                    Community Health Clinical Project, Ft. Lewis, WA

 Bethany Carlson, Zele Desta, Maxi Gould, Emily Haydu, Kate Huff, Kailee Pederson, LaNora

                        Siggelkow, Laura Vetter, and Amy Whitney

                                Pacific Lutheran University
                                                                                Community Health 2


       During the fall of 2009, our community health clinical group had the opportunity to

experience and work with the Army Public Health Nurses at Classic Madigan. During the

semester we learned about the Fort Lewis community and the resources that the Army Public

Health Nurses provide and oversee. We had the experience of being on one of the largest army

forts as well as seeing and being a part of public health nursing. We learned that public health

nursing collaborates with the community to identify and prevent many different health issues and

concerns. Each of us had the opportunity to see different aspects in community health at Fort

Lewis such as environmental health, occupational health, child youth and school services, the TB

clinic, flu shot clinics and the special adult clinic. Our goal during this semester was to assess

and identify a community health problem and to work with the community in improving this

concern. With the help of the APHN we were able to accomplish our goal and implement

interventions to help improve this community problem.



       When the U.S. Army decided to place a new post in Washington State, the Army‘s

original interest was to build the post in the Spokane Valley. Tacoma businessmen attempted to

encourage the U.S. Army to establish a military post in the American Lake or Tacoma area. The

Tacoma News and Tribune publisher, Frank S. Baker, was a leader in the idea of having an

Army post near Tacoma. No one person is given credit for the idea but it took multiple leaders

to accomplish the location for the post. ―There is no finer Army post site anywhere in the United

States. In this area there is every physical condition desirable for Army training and
                                                                               Community Health 3

maneuvers,‖ exclaimed Major General Arthur Murray during a 1912 visit to the Nisqually


          In 1916, the Major General J. Franklin Bell of the Western Department of the U.S. army

sent out personnel to inspect possible sites for a new post in the Pacific Northwest. Captain

Richard Park was sent and did not have the Nisqually Plain on his original agenda, but it soon

appeared through a Tacoma businessman‘s committee asking the Captain to visit the area. Upon

his visit to the area, he found it not only acceptable but was impressed and stated ―…the most

magnificent field I have ever seen for military maneuvers.‖ The Army was not the first to find

this location favorable for training. In 1915, Washington state troopers used what is now the

Fort Lewis area for training.

          In August of 1916, Major General Bell met with the Tacoma businessmen group to

discuss how to attain the land. Later that year the Tacoma businessmen representing the Pierce

County Citizens went to Washington D.C. and spoke with the Secretary of War Newton D.

Baker, offering to donate the 140 square miles for the military base. On November 15, 1919, the

land no longer belonged to Pierce County or Washington State, but it was officially Federal

property of the United States of America. It was named Lewis after Captain Meriwether Lewis

of the Lewis and Clark expedition. Today some of the originally donated land is home to the

parade field and Gray Army Airfield.

          Construction began quickly on July 5, 1917, with the first building being built within

three days. In the 90 days following the start of construction, Camp Lewis saw 1,757 buildings

and 422 other structures built and all were fully lit, plumbed, and heated. The main gate was

built upon the completion of the buildings. The original main gate still stands today, as a ruin of
                                                                                Community Health 4

what it once was, near today‘s main Fort Lewis gate. In December of 1917, with approximately

37,000 men, Camp Lewis quickly became the largest military post in the United States.

       During the construction period, the Army trained and distributed soldiers to fight in

World War I. The 91st Infantry Division trained and shipped out to France in June of 1918.

After that, the army trained the 13th Infantry Division in trench warfare, and before deployment,

the Armistice was signed on November 11, 1918. This ended World War I.

       With the end to World War I, Camp Lewis experienced dramatic change. Once being

one of the most active military camps, post WWI, Camp Lewis came to a standstill. The Camp

Lewis Commander Major General Henry Greened was reassigned, and the Camp was left to

Brigadier General James A. Irons. From 1919-1927, the camp began to crumble before the eyes

of the soldiers living there. The make shift barracks started to fall apart, other buildings fell to

decay. This lack of upkeep disgusted the greater Tacoma area whose citizens had donated the

land to the U. S. government. They demanded the U.S. War Department give the land back; this

was supported by local businessmen, and newspapers. The agreement between the county and

government stated the post will remain in government hands as long as it is used for the

purposes—one in particular, a training area.

       In 1925, rumors spread saying Camp Lewis was being closed and was back to civilian

ownership. During this year, some civic groups began to reclaim thousands of acres of land by

tearing down and selling building parts for scraps. All of a sudden, very suspiciously, a fire

struck. No one was ever caught in the starting of the fire, nor did anyone or any group claim


       In March of 1926, the Secretary of War, Dwight F. Davis, asked Congress to approve a

building plan to rebuild and upkeep three army posts over the next ten years. Camp Lewis was
                                                                              Community Health 5

one of the three selected. On September 30, 1927, the Army re-designated Camp Lewis a Fort,

as it is called today- Fort Lewis.

       Through the years, the population on Fort Lewis decreased to 5,000 by 1939. But in-

between March 1939 and March 1941, the population grew to 37,000. In order to accommodate

the huge influx, Fort Lewis built a complex on what is now North Fort Lewis, a 2,000 acre area.

The new complex was completed in August of 1941. All of the growth at Fort Lewis is directly

related to the activity leading up to the American involvement in World War II.

       When word of the bombing at Pearl Harbor reached Fort Lewis, it shook the community.

Quickly, after word of the bombing, Fort Lewis soldiers secured Camp Murray, McChord Field,

and Fort Lewis. During this time of war, Fort Lewis was the training home to many Infantry

divisions. A camp for Enemy Prisoners of War (EPW) was established during July of 1943; the

camp remained in operation for three years.

       Also, in 1943, Fort Lewis grew by land, adding some 18,000 acres from the Nisqually

River. At the end of World War II, the 2nd Infantry Division was stationed at Fort Lewis; this

division was the first to deploy to fight in the Korean War. At the end of World War II, the

Fourth Infantry Division also was stationed at Fort Lewis. The 4th Infantry Division was

deployed to fight in the Vietnam War in 1966. Fort Lewis again became the main training post

and began sending soldiers across the Pacific, as well as in processing them when returning back

to the states. In just over six years, Fort Lewis processed over 2.5 million troops and trained

over 300,000 men.

       Over the course of nearly 100 years, Fort Lewis has become what we know it today.

Currently, Fort Lewis continues to grow and is currently home to approximately 35,000 soldiers.

                                                                              Community Health 6

       Fort Lewis has a total population of 19,089 as reported in the 2000 census compared to

that of Pierce County, which has a total of 774,144. Fort Lewis is 62.7 percent male and 37.3

female. Pierce County is 49.7 percent male and 50.3 percent female. The median age for Fort

Lewis is 22.4 years and for Pierce County the average is 35.6 years. On Fort Lewis, the highest

percent of the population is between 25 and 34 years of age, which is 27.1 percent. Fort Lewis is

60 percent White, 20 percent African American, 1.3 percent American Indian and Alaska Native

and 3.4 percent Asian. The rest of Fort Lewis is reported as people with more than one race. In

Pierce County it is reported that 77.6 percent White, 6.7 percent African American and 1.3

percent American Indian and Alaska Native. It is interesting that Fort Lewis does follow Pierce

Country trends considering so many people come and go from the base.

       The average household size for Pierce County is 2.57 with an average family size of 3.1.

Fort Lewis has an average household size of 3.75 and the average family size of 3.78. About 57

percent of people in Pierce County over 15 have never been married. Fort Lewis only has about

38 percent of people over 15 as never married. This is a finding that would be expected to be

lower compared to Pierce County rates because of the benefits that come along with the military

life. In Pierce County of the population that is 25 years and older, 30.2 percent have their high

school degree. 10 percent have associate degrees, 15 percent have bachelor‘s degrees and 8

percent have graduate or professional degree. Fort Lewis has 22.2 percent with their high school

diploma of those 25 years and older. Only about 24 percent of people have their bachelors or

associate degree. Only about 5 percent have their graduate or professional degree. It is interesting

that the rates are so low because of all the educational opportunities that the Army gives to their

troops. The mean household income for Pierce County is almost 58,000 where as Fort Lewis is
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32,000. Only 1.9 percent of people on Fort Lewis are unemployed compared to 6.3 percent in

Pierce County.

       Total STD rates for Pierce County were 576.3 per 100,000 in 2005. For Washington State

the rate was 600 per 100, 000. These rates do not include HIV/AIDS. In 2005, Chlamydia had

the highest incidence rate of 453.5 per 100,000 and for Washington state it was 297.6 per

100,000, which was also the highest for the state. In Pierce County, the average age of infection

of Chlamydia is 15 to 25. For the year of 2006, the rate of Chlamydia for the United States was

344.3 per 100,000. In Washington State it was 278.6, while the rate was highest in Pierce County

at 391.9. In Fort Lewis alone for the year of 2006, there were 474 cases of Chlamydia (a rate of

about 13.5 per 1,000 people). The rate and the number of Chlamydia cases nearly doubled by

2008, with a total of 1066 cases (a rate of about 30.5 per 1,000 people). See Appendix A for

graphs and tables with rates of Chlamydia and other STI's for the U.S., Washington, Pierce

County, and Fort Lewis.

Systems Theory

       The systems theory is an interdisciplinary theory and framework used to show how

systems of nature, society, and science work together to produce results and explain productivity.

A systems theory is also continuous in its inputs, throughputs, and outputs which is why it can

be compared to a cycle. A systems theory can be applied to a community as well. Inputs such as

resources go into the community, resources are modified by the community in some way

(throughput), then these original resources are changed and produce an output. This activity is

cyclical in nature- as it outputs it has a need for more and new inputs, thus causing a

continuation. The Fort Lewis community as a system is comparable to a closed system in that it
                                                                               Community Health 8

is very self-contained. However, it can also be open since it interacts with outside forces and

relies on external factors for the importation of food.

       Systems theory is a basic, logical approach to understanding a complex system. It is also

a good way to show how the community of Fort Lewis functions. Within the community of Fort

Lewis, the priorities inputs of soldiers are physically and mentally trained and tested to carry out

Army missions and objectives. This training and educating by the Army to the soldiers is the

throughput of the systems theory. The output of the Fort Lewis community in this example is

trained soldiers which will go on to accomplish military tasks and goals. In the cyclical structure

of the systems theory, the output of soldiers will lead to a need for an input of soldiers. The

trained soldiers functioning as the output will then go on to train new soldiers thus continuing the

feedback nature of the systems theory and the community of Fort Lewis.

       The Fort Lewis community also functions in a sustainable sense in its health care and

health maintenance system. Fort Lewis has a hospital, clinics, and community programs. These

services are inputs into the greater Fort Lewis systems theory. The throughput of these services

includes the application of health care, ―the prevention, treatment, and management of illness

and the preservation of mental and physical well-being through services offered by the medical

and allied health professions‖ through the act of caring for the health of individuals, families, and

communities. The outcome in this scenario is healthy soldiers, families, and the overall Fort

Lewis community. Fort Lewis has many resources that address the community holistically such

as services for mental health (counseling), spiritual outlets, and many physical health centers.

Many fitness and recreational services are available to increase health promotion and prevention

of disease. The need for this continuous cycle of health care at Fort Lewis is significant due to

the nature and propensity of human beings to encounter physical and mental problems. This
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cycle is then constant as the throughput attempts to care for, cure, and maintain the people of the

Fort Lewis community.

        Fort Lewis offers continuous community knowledge and learning services through its

libraries and Army Continuing education services. The Army offers abundant tuition and

scholarship support in education for its members. As the Fort Lewis community individuals input

into the systems theory, education and knowledge offered by Fort Lewis functions as the

throughput. Education and knowledge act to enhance the individual and hopefully produce a

more intelligent, capable, and effective community as the output of the system.

        Money, as a resource inputting into the Fort Lewis system, enables the development and

maintenance of new and old structures at Fort Lewis. Roads and transportation are also

maintained. The output of these inputs and throughputs include facilities the community can use

to carry out their activities.

Key Informants

        As part of our assessment process, we interviewed key informants from the Fort Lewis

community. We interviewed several interdisciplinary workers involved in the health care system

at Classic Madigan. Our key informants consisted of an Army Public Health Nurse, the Chief of

Preventive Medicine, a Physician‘s Assistant, and a religious leader in the Fort Lewis

community. It was important to get a variety of perspectives on sexually transmitted infections

in the Fort Lewis area. As we were doing our research, we discovered that Madigan Army

Medical Center invests a considerable amount of resources to the prevention and management of

STIs. Furthermore, they are involved in collaborating information with the Tacoma Pierce

County Health Department and Centers for Disease Control (MAMC memorandum 40-28).

                                           Mr. Johnson
                                                                            Community Health 10

       During the interview process, getting cooperation and attention from our key informants

was not an issue. They were incredibly helpful and willing to assist us in our project. Prior to

the interview process, we had established a working relationship with our key informants which

made the interview process seamless. Mr. Johnson is the primary care provider at the special

adult clinic (SAC). He sees the prevalence of STIs at Fort Lewis first hand in his office during

his physical examinations and teachings. He stated the problem with teens and the need for

education. “High Schools need to reinforce some moral issues—having sex could be dangerous

and a risk to health.” He also mentioned the importance of parental obligation in encouraging

safe behavior, such as abstinence. He recommended a number of possible solutions to the

prevalence of Chlamydia, Herpes and Genital Warts at Fort Lewis. When asking him what he

would like to see changed at Fort Lewis, he mentioned increasing awareness of his clinic by

posting flyers and handouts at Waller Hall and the barracks. (See appendix)

                                           Captain Hill

      When interviewing the Army Public Health Nurse, (Captain Hill), she suggested a few

solutions to the problem at Fort Lewis. Largely, she talked about the lack of education at the

SAC clinic. She pointed out the importance of adding a Bachelor level nurse in the SAC clinic.

As a Public Health Nurse, her role is limited in working with STI patients because there is no

position currently available for a registered nurse in the SAC clinic. “We need to implement an

RN in the SAC clinic to provide the education and holistic care that patients need.” When we

told her about our plan to post flyers throughout the army base to raise awareness, she thought it

was a great idea. However, she added a valid point regarding our flyer. She stressed the

importance of reassuring the service members that their confidentiality will be respected. She

stated “I recommend that you mention on the flyer that the chain of command will not be
                                                                            Community Health 11

involved whatever the outcomes are and that information is on a need to know basis”. Captain

Hill also suggests another excellent proposal to increasing compliance and behavior

modification. “I think that the idea to put condoms and flyers/pamphlets in the examination

room is a great idea”. By implementing this small measure, it will minimize

barriers/stereotypes a patient may experience in the waiting room when taking a pamphlet from

the ‗STI educational wall‘ or taking a condom from the ‗candy jar‘ placed next to the secretary‘s

desk. (see appendix)

                                            LTC Baker

       The Chief of Preventive Medicine, LTC Baker, has been working in community health

for a number of years. She showed us the amount of educational material printed for members of

Fort Lewis. In fact, there was a walk in closet full of flyers, posters, and pamphlets on STI

prevention, awareness, and treatment options. There was information on at least ten different

types of STIs, ranging from Bacterial Vaginosis to Genital Warts. As we were looking through

the massive pile of pamphlets, we discovered that there were no flyers promoting the SAC clinic.

Our group decided to do a walkthrough of the barracks and Waller Hall, which is the in and out

processing center on post. We were looking to see if there were any signs posted concerning STI

awareness, or the SAC clinic. We did not find a single flyer raising awareness of STIs, or the

SAC clinic during our walk through. We brought this fact to LTC Bakers attention and proposed

that we do something about this by posting informative flyers around the barracks and Waller

Hall. She thought it was a good idea because of the benefits it has by increasing the awareness

of the SAC clinic. However, she added a few suggestions. “I think the quality of care offered at

the SAC clinic can be improved if the staffing is increased. Additionally, the hours of operation

can be increased to give soldiers more options”. She brought up a great point, because the hours
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of the SAC clinic are only from 0730-1030 M-F. This can be a barrier to access of care due to

the limited options it gives service members and their family members. (See appendix)

       After carefully analyzing the interview data, STIs are attributed to many possible reasons.

There are several theories to this problem in our society. We spoke to a religious leader in the

Fort Lewis community, and he mentioned an interesting comment about the prevalence of STIs.

We also researched some important facts from Planned Parenthood, which supports our key

informant‘s comments. He stated that, “Our generation is drifting from abstinence. Respecting

the union between husband and wife is a driving factor from a Christian’s perspective. We are

living in a sexual society where it is taken lightly; this can be a contributing factor to our

problem”. This religious leader had an interesting point which can be applied to the STI

prevalence in Fort Lewis. This should be considered when assessing the contributing factors to

STIs at Fort Lewis. In addition, Planned Parenthood encourages abstinence as a form of birth

control and STI prevention. ―Used continuously, abstinence is 100 percent effective in

preventing pregnancy. It also prevents STIs” (www.planned The fact is that

people practice abstinence for many reasons. Some may practice it for personal, moral, or

religious beliefs and others want to prevent pregnancies and STIs. After looking at abstinence

from a religious aspect along with Planned Parenthood, there are many benefits to practicing safe

sex. Regardless of the reasoning or motives, abstinence can be a safe and effective choice for the

Fort Lewis community to practice. (See appendix)

Windshield Survey

                                        General Impressions

       Fort Lewis is a multi-dimensional community; a community sewn together through years

of structure, determination, support and tradition. Fort Lewis is located in the beautiful, green
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Pacific Northwest. There are many gates in which to access this military community. The main

Liberty gate lies off of I-5, exit 120. This is where all civilian and visiting members of Fort

Lewis must come first. In order to get into the community, you have to have a badge or a pass

that is given by the Liberty main gate welcome center. There are 10 gates total that gain access to

Fort Lewis. When you do get onto to Fort Lewis, the community can appear overwhelming at

first glance, especially to someone unfamiliar with the area. First impressions of Fort Lewis

might include: structured, green, well protected, and uniform (add others from group members).

As you begin to look deeper into Fort Lewis, the friendlier community based lifestyle comes to



        Though we did not travel all 691 miles of roads, it was evident that Fort Lewis is very

diverse in how the vast space is utilized. There are wide-open areas for training, and a large

airfield with hangers. Businesses are centrally clustered together, and buildings used for various

purposes are scattered throughout. There are neighborhoods full of homes that vary in style and

age. Ft. Lewis consists of many large areas of woodlands, parks, and prairies. Though

landscaping may not be aesthetically pleasing throughout all areas of the base, Mt. Rainier‘s

picturesque beauty lies to the east and is a breath taking sight on crystal clear days.


        Fort Lewis offers their enlisted members and their families a wide variety of housing

opportunities. Neighborhoods consisted of duplexes and single-family homes. The fronts of the

homes were well kept and the name of the enlisted solider is posted outside. There are parks

with playgrounds and community centers located near the neighborhoods. Officer‘s homes

differed in size and style. Some housing is much newer and appeared in better shape than the
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older homes. There are barracks available for soldiers and apartment housing is also available

for shorter stays.

        Recreational facilities for soldiers and their families are located all around Fort Lewis.

There are activities for individuals of all ages to participate in. Physical fitness is an important

aspect of military life and there is a large fitness center on base. Individuals and families can go

bowling, see a movie at the theatre, or check books out of the library. Individuals can attend

other community activities such as arts and crafts or Latin sensation dancing at the Madigan


        Within the gated boundaries of Fort Lewis, the community has many businesses available

to meet their needs. Clustered around the main fort for easy access, there is a PX for one stop

shopping and a mini mall. Some of the businesses are Popeye‘s, Burger King, Credit Unions,

24-hour shoppette, laundry and dry cleaning, equipment and rental shop. There are also many

automotive services including a car rental service, auto parts store, vehicle repair garage, and

four gas stations. The Fort Lewis Commissary is a large super store that offers a large grocery,

meat and produce department.

                                  Social Services/Helping Systems

        Fort Lewis offers its community members a wide range of religious services and

education. The following religious services are held at many chapels located throughout Ft.

Lewis: Catholic, Jewish, Liturgical Protestant, Protestant, Contemporary Protestant, and Gospel.

Religious education and bible studies are also offered for community members to utilize.

Fort Lewis provides Child Youth and School services to members of the army community. This

service provides soldiers opportunities to meet army requirements as well raising their family in

a healthy structured environment. These programs are designed to encompass all aspects of a
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child‘s development, including physical, intellectual and emotional. Child development services

are also provided and include day care for families.

       At Classic Madigan, Fort Lewis has a cluster of public health offices that offer a variety

of amenities available for soldiers and their families. The goal of army public health nursing is

to enhance health outcomes of the individual and the community.

       There are many other resources available to help Fort Lewis‘s soldiers and their families.

Madigan Army Medical Center is a large hospital that provides care to all of Fort Lewis‘ soldiers

and their families. The hospital‘s Medical Mall offers many outpatient services including

Pediatric oncology/hematology, OBGYN, pediatric clinic and more. The Soldier and Family

Assistance Center is a place to get a multitude of services that are unique to the needs of

individual soldiers and their families. There are also many clinics and programs offered for

soldiers to enhance their wellness and readiness.


The majority of work in Fort Lewis comes from the active duty military personnel. Soldiers go to

work every day to train and prepare for the skills needed to protect our country. Fort Lewis

provides many job opportunities for families of soldiers and civilians. Some opportunities

include store businesses, construction projects, fast food chains, health care employment at

Madigan army hospital and landscaping work. The ACAP also provides job fairs and

opportunities for civilians to become employed. The Civilian Personnel Advisory Center is a

center which has a web resource that is set up for civilians on Fort Lewis to help aid in job


                                                                            Community Health 16

       Safety is a major concern on Fort Lewis and is evident by the 100% identification checks

at the gates prior to entering the post. Fort Lewis has a Hazard Awareness and Emergency

Preparedness Program to prepare for all kinds of emergencies. There is also strict enforcement

of ―no talking on the cell phone while driving‖; hands free devices must be used. The military

police patrol the area to help ensure safety of its community.

       All vehicles must be registered at the Visitor‘s center or at Waller Hall. There are a wide

variety of vehicles driving around on post, including army vehicles, civilian vehicles, personal

vehicles, and school buses. There is a lot of traffic in the morning, around lunchtime, and in the

late afternoon. Parking is scarce, especially around Madigan Army Medical Center. People are

seen running and riding bikes. Though there were many areas lacking sidewalks, the sidewalks

we observed were well maintained.

Healthy People 2010

       One of the goals of Healthy People 2010 is to reduce the incidence of STIs. Specifically,

according to focus area 25, their goal is to ―promote responsible sexual behaviors, strengthen

community capacity, and increase access to quality services to prevent sexually transmitted

diseases (STDs) and their complications‖ (HP2010). STDs are not only a burden to their carriers,

but have significant consequences for reproductive health and fetal wellbeing and are also linked

to several cancers. They are costly and cause many complications, yet they are preventable! The

main strategy to fight the spread of these infections is primary prevention, mainly through

education of the public. HP2010 points out that this significant health problem remains ―largely

unrecognized by the public, policymakers, and public health and health care professionals‖

(HP2010). STDs need to be brought into focus in order for any change to occur.
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          As part of their effort toward achieving this goal, HP2010 has identified several factors

in the spread of STIs. There are biological factors to take into account, including the

asymptomatic nature of STIs, the lag time between infection and complications, and gender and

age (HP2010). STIs result from unprotected sex and because their carrier may not realize they

are infected, protection may not be used. Many infections have no signs or symptoms or have

very mild signs and symptoms, causing people to disregard them. As a result, people do not seek

medical treatment at times when they really should (HP2010). Along the same lines,

asymptomatic STIs can have a long time period between infection and complications. Due to the

fact that it may take up to years for a complication to arise, (such as cervical cancer caused by

HPV) ―people frequently do not perceive a connection between the original sexually acquired

infection and the resulting health problem‖ (HP2010). If more people were made aware of the

connection between significant health complications and STIs, perhaps they would be more

vigilant about protecting themselves.

          Several social and behavioral factors also contribute to the spread of STIs, including

poverty and marginalization, substance abuse, and access to health care. STIs are more common

in areas of poverty and high-risk sexual behavior such as sex workers, adolescents, and migrant

workers (HP2010). These people often do not have access to health care to get treatment or

education about prevention. The need for publicly supported STI services is greatly needed in

these areas. Access to care is ―essential for early detection, treatment, and behavior-change

counseling for STDs‖ (HP2010). Secrecy is also an important factor contributing to the spread

of STIs. Sexuality is a very private part of someone‘s life and is not openly discussed in the U.S.

According to the Institute of Medicine (IOM), this secrecy about sex ―impedes sexuality

education programs for adolescents, open discussion between parents and their children and
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between sex partners…, education and counseling activities of health care professionals , and

community activism regarding STDs‖ (HP2010). All of these factors reiterate the point that

education and available treatment are essential to the population.

          In order to develop an effective ―national system of STD prevention‖ in the United

States, HP2010 acknowledges that sexual behaviors and norms need to change (HP2010).

Openness of sexual topics needs to become the norm to ensure that sexual relationships are

consensual and honest. Openness of this matter would allow parents to talk frankly to their

children, as well as teachers and counselors to students, about responsible behavior and avoiding

sexual risks. Health care providers would also be able to form a comfortable environment with

their young clients to educate about sex and risk avoidance and to regularly screen them for

STDs as needed (HP2010).

          HP2010 came up with three STD transmission dynamics: the rate at which uninfected

individuals have sex with infected individuals, the probability that an exposed person will

become infected, and the time period during which an infected person remains infectious and

able to spread disease (HP2010). These factors interact and affect the rate of STD infection. To

prevent this, interventions aimed at altering the ―natural course of these factors‖ need to be

implemented through education in schools and in the community (HP2010).

          Under this overarching goal, Healthy People 2010 goes into specific objectives about

STDs they are working to prevent. Objective 25.1 is to ―reduce the proportion of adolescents and

young adults with Chlamydia trachomatis infections‖ (HP2010). Specifically, they want to

reduce the percentage of females age 15-24 years old (who attend STD clinics) who are infected

from 12.2% (1997) to 3.0% (by 2010), and reduce the percentage of males from the same age

category and diagnosis from 15.7% (1997) to 3.0% (by 2010) (HP2010).
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          Reducing Gonorrhea is also an aim as stated under objective 25.2 (HP201o). The

baseline in 1997 was 123 new cases of gonorrhea per 100,000 and the target for 2010 is 19 new

cases per 100,000 (HP2010). These sub-goals are being worked toward by making the changes

mentioned earlier and implementing educational programs in communities.

        Effective communication is the key to educating the public about STD concerns. For this

reason, focus area 11 of Healthy People 2010, Health Communication, is important to consider.

Their goal is to ―use communication strategically to improve health‖ (HP2010 11, 2000). Using

effective communication aids in disease prevention and health promotion by making others

aware of health risks, available treatments, resources, and support systems. Health

communication is particularly important in the community where it ―can be used to influence the

public agenda, advocate for policies and programs, promote positive changes in the

socioeconomic and physical environments, improve the delivery of public health and health care

services, and encourage social norms that benefit health and quality of life‖ (HP2010 11, 2000).

In order to successfully combat STDs, communication and resources to reach the public need to

be utilized.

Army Regulations

        Army regulation 40-5 discusses preventative medicine and the establishment of

preventative services and programs. It also discusses the responsibility of improving and

sustaining health throughout the army (1-1). 1-7a2 refers to DA Pam 40-11, chapter 2 for further

information about disease prevention and control programs and services.

Chapter 2, section 2-8 of the DA Pamphlet goes into detail about the prevention and control of

STIs. According to this section, ―successful prevention and control of sexually transmitted

diseases (STDs) requires the following: (DA Pa 40-11 p 5)
                                                                             Community Health 20

   1. Accurate diagnosis and appropriate treatment of infected persons and their sexual


   2. Personal interviews and epidemiological contact investigation.

   3. Active surveillance at the installation level.

   4. Health education directed at all sectors of the military community.

   5. Reporting of STDs through the RMES as soon as possible after diagnosis.‖

     Effective control and prevention of STDs also requires ―appropriate therapy and follow-up,

disease intervention, identification of locations where a high level of STD transmission may

occur and community and unit health education‖ (2-8c). A community health nurse plays an

important role in the education and follow-up of civilians and soldiers at Fort Lewis. They can

play a part in STD case interviews, counseling, treatment, and contact investigations.

In terms of what these programs should include, section 2-8e says that ―Army STD control

programs will adhere to guidance published by the CDC on screening procedures, treatment,

follow-up and prevention strategies.‖ Guidance provided by TSG on the recommended treatment

for uncomplicated gonorrhea and other STDs takes precedence over CDC guidelines.

Assessment of MAMC, Classic Madigan.

       ―Classic‖ or ―old‖ Madigan is the original Fort Lewis Army Hospital. It was originally

founded by Colonel Patrick S. Madigan, who was known as "The Father of Army

Neuropsychiatry.‖ When Colonel Madigan passed away in 1944, the hospital was named in his

honor. It consists of multiple single story buildings. The buildings are structured with brick and

white panel siding, with grey roofing. The buildings are very large and spread out with long

hallways. Old Madigan is currently undergoing remodeling and has many trailers set up on the

property that serve as temporary housing for many army services. It is surrounded by green trees
                                                                              Community Health 21

and some housing for soldiers and families. Old Madigan houses many services that are in clinic

settings. Some of these services include: Army Blood Bank, Family Assistance for Maintaining

Excellence (FAME), military and family life consultant program, army community services

(ACS), confidential alcohol treatment and education program (CATEP), and behavioral health

services. Fort Lewis did a great job preserving a historical building and utilizing it to serve

soldiers and their families all in one convenient location.

             Assessment of Preventative Medicine and Army Public Health Nursing

       Preventative medicine is a series of care measures taken to prevent or inhibit disease. It

focuses on stopping the spread rather than looking for a cure. Fort Lewis has their very own

department of preventative medicine. It works to protect its soldiers and their families in order to

keep them healthy and active. The mission statement for their preventative medicine department

is, ―We are committed to serving our community by promoting public health and workplace

safety and will respond to the needs expressed by our community.‖ The goal is to educate

soldiers and their families and to have everyone become an expert on health prevention.

Becoming an expert will not only benefit families, it will also benefit the community as a whole.

This can stop disease before it starts and stop the spread of disease which leads to a decrease in

medical cost. Families will not be spending thousands of dollars on disease tests and treatments

if the disease process never occurs. Funding can be spent on continuous prevention. The Army

Public Health Nursing Department (APHN) falls under preventative medicine. They offer many

services to meet the mission and vision of preventative medicine. There are about six nurses who

run the APHN clinic. These nurses oversee and work with the occupational health, STD or SAC

clinic, and environmental health clinic. Within the APHN clinic they focus on tobacco cessation,
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TB, and child services. However, these nurses also participate in environmental inspections

related to the child and youth services centers.

        The tobacco cessation program is a voluntary ―stop smoking‖ program. It is set up to

educate and support soldiers and family members in making the choice to stop smoking and

improve their health. Out of the six nurses there is one head nurse who oversees the program but

all the nurses trade off working for the program. Staff members are non-judgmental and

individualize care for different clients. The program provides resources and medical support in

order to stop smoking. Our group found this program to be quite successful and many referrals

were made. The head nurse of this program was great with patients and was very knowledgeable

about the subject.

        The PPPT is a program that works with pregnant and postpartum women to support them

to continue physical training. It is a mortified PT program to help keep the women in shape so

when they come back from giving birth they do not have as much work to be able to meet their

tests. They stay in the program for three months after giving birth to be able to gain their

strength and wellness before going back to regular PT. They gain education and skills that will

help them stay healthy through their pregnancy. Captain Hill gave our group an excellent

briefing on the program and what it entails.

        The TB clinic is located within the APHN office and also has one nurse as the lead with

the rest participating in care. The clinic involves testing, consults for positive test, referrals and

follow-ups with patients who have had a positive TB test or treatment. Our group found that the

nurses are very supportive and spend a large amount of time with their patients and do a huge

amount of education. It seemed that the patients left feeling relieved and really knew what they
                                                                              Community Health 23

need to do to be well. The nurses are very much advocates for the patients and would try to get

them what they needed.

       CYSS is the child and youth school services on Fort Lewis. This program involves many

different facilities that provide after school care and daytime care so soldiers can do their duties

and meet the needs of their units. The nurses for this program inspect the facilities and make sure

that things are running properly. They will also do the training for these facilities and in our

group we were able to teach some of these classes on asthmas, emergency medications, SIDS

and communicable diseases. The nurses also will evaluate children to see if they will be

acceptable to be at the after school facilities. If the children have too many medical issues, they

cannot attend the after school programs. Once again, the nurses really work hard and do a great

job at ensuring their clients are taken care of.

       The occupational and environmental health clinics work outside the office of the APHN

but still falls under their department. The occupational health clinic works with all the civilian

workers for Fort Lewis. The workers come there to get medical work ups to make sure they are

fit to be hired and if they have an on-the-job injury they will come to get care. The nurses are

also in charge of around two hundred people who they have to insure they get their yearly

physicals and tests. The environmental health clinic inspects all the food facilities on base to

insure sanitation and proper food preparation. The dining facilities will be graded by the

inspectors and available for people to look up. Another priority is to test for West Nile virus in

mosquitoes. Medical waste supervision is also under the environmental health department. They

insure that waste is being disposed of properly. The workers in environmental health love their

jobs and work very hard. One inspector told us he loved coming to work and was never bored.
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They really save Fort Lewis and the army a lot of money by preventing illness, but as stated by

the Colonel of the department, it is hard to put a number on how much they save.

                         Assessment of Special Adult Clinic (SAC clinic)

       Multiple members of our group spent two to three hours observing, participating, and

evaluating the clinic. We observed the interview process, treatment process, and doctor

consultations. We saw a variety of clients and STIs, with Chlamydia, gonorrhea and genital

warts being the most prevalent in the Fort Lewis community. We found the staff to be well

informed and educated on STIs. The staff was also very sensitive and non-judgmental to all

clients in the clinic. Some staff were not as thorough as others in the interview process, but

needed information was obtained. We found that it was the men speaking with male clients who

were more direct and to the point, compared with the women who talked longer and with more

detail. The temporary facility can be considered restrictive to patient care due to size. There

were adequate resources/condoms in the lobby, but our assessment found no resources/condoms

readily available for patients in the rooms or other private areas. We feel that more clients would

be willing to utilize such resources if they were in a more private area. The interview tool was

well designed with the exception of an STI education assessment. The clinic is placed in a

private location and is well disguised (yet not well marked). This is probably to protect the

client‘s privacy.

       Our assessment of the surrounding area of Fort Lewis found a lack of SAC clinic

information. Upon assessing the barracks for informational flyers, we found none. The same

lack of flyers creating awareness was found in the PX, commissary, and Waller Hall. We also

noticed there was no information about the SAC clinic in the Fort Lewis Welcome Packet, which

is received by soldiers & families upon coming to Fort Lewis. There is also no specific flyer
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representing the SAC clinic. Because there is such a high prevalence of STD‘s in this community

the SAC clinic is a good resource for soldiers and families to utilize, which is why we feel the

SAC clinic should be advertised more.


       After gathering all of our assessment information, we came up with two nursing

diagnosis that relate to the identified community problem. The nursing diagnoses are as follows:

      Risk of sexually transmitted infections among members of the Fort Lewis community

       related to the high incidence of STI‘s, risky behaviors, lack of preventative education,

       STI knowledge deficit, lack of awareness of SAC clinic, and missed opportunity for

       behavior modification at the SAC clinic per key informant.

(Diagnoses support healthy people 2010)



Core Functions

       The core function used in our project is assurance. ―Assurance refers to the role of public

health in ensuring that essential community-orientated health services are available, which may

include providing essential personal health services for those who would otherwise not receive

them‖ (Stanhope 2008). As public health representatives, we identified the problem of STD

prevalence in the Fort Lewis community and provided educational resources to implement

throughout the community. These resources include: an educational poster to be put up in the

barracks and in Waller Hall, adding an educational piece into the SAC clinic interview screening

tool, making resources available in patient rooms within the SAC clinic, and placing a SAC

clinic informational flyer into the orientation packet. By providing these resources to the
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community, we are assuring that critical preventative health information is being provided for

members of the community to help decrease rates and prevent STDs.

Short Term Goals

      Increase awareness of STD prevalence

      Increase education on STI prevention

      To increase the number of Fort Lewis community members utilizing the SAC clinic for

       education, screenings, and early treatment.

Objectives for short term goals

      Soldiers and their families will receive an informational flyer about SAC clinic services

       in their welcome packet upon coming to Fort Lewis by January 2010.

      SAC clinic awareness posters will be placed in the barracks, Waller hall, PX, and

       commissary by January 2010.

Long Term Goals

      Increase knowledge and access to quality services to promote responsible sexual behavior

       and prevent sexually transmitted infections.

      To decrease the prevalence of STIs within the Fort Lewis community

Objectives to meet long term goal

      SAC clinic will provide educational resources within patient rooms and restrooms within

       a year.

      Integrate and utilize a ―current knowledge STI education assessment‖ to the SAC clinic

       interview screening by December 2010.

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       To implement the plan we have devised strategies or ―interventions‖ to meet our goals.

Our interventions each address a level of prevention. These levels are primary, secondary and

tertiary. A primary intervention is ―prevention of the initial occurrence of disease or injury‖ (ATI

pg 7). A secondary level of prevention is the ―early detection of disease and treatment with the

goal of limiting severity and adverse effects‖ (ATI pg. 7). A tertiary level of prevention is the

―maximization of recovery after an injury or illness‖ (ATI pg 7). As public health representatives

the following interventions focus largely on increasing the use of the SAC clinic and the

resources utilized there.

Interventions for short term goal

      Assess for current information promoting the SAC clinic within the barracks, Waller

       Hall, and Fort Lewis welcome packets- Primary prevention

      Place SAC and STD awareness posters in Waller Hall- Primary prevention

      Place informational flyer about the SAC clinic in the orientation packet- primary


      Placing an educational STD poster in the barracks- primary prevention

      Placing SAC clinic flyers in the PX and commissary- primary prevention

      Increase hours of operation of the SAC clinic from 0730 to 1830- secondary prevention

      Student presentation of proposed interventions to Army Public Health Nursing- tertiary


   Interventions for long term objectives:

      Assess SAC clinic for adequacy and use of educational tools for prevention of STIs –

       primary prevention
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      Gather resources to place in patient rooms and bathrooms within the SAC clinic-primary

       and secondary prevention

      Put in place condoms and resources into the patient rooms and patient bathrooms within

       the SAC clinic- primary and secondary prevention

      Create the ―current knowledge STI education assessment‖ to add into the interview

       screening tool at the SAC clinic- primary prevention

      Suggest a public health registered nurse and a nurse practitioner be hired to improve

       holistic teaching at the clinic- primary prevention

      Student presentation of proposed interventions to Army Public Health Nursing- tertiary



       Evaluation consists of two parts; formative and summative. Formative evaluation is a

continuous evaluation process that is conducted throughout the entire project. It is a prospective

look at the progress being made. It allows for evaluation at multiple points throughout the project

to detect deficits and gaps within the knowledge base to be changed or improved upon.

Summative evaluation is retrospective analysis of how the entire project turned out which is

conducted at the end of the project. If the project has no dedicated ending point, time periods can

be developed in large intervals in which to evaluate progress.

       Our project, we hope, will be continuous; therefore formative evaluations will be done

frequently. For completion of our portion of the project, we will do one summative evaluation of

the reaction and acceptance of the proposed project to the Army Public Health Department. For

formative evaluation, staff will interview clients on how they heard about the SAC clinic. Also,
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for one month the SAC clinic will survey clients on the effectiveness and helpfulness of the

resources provided in the patient rooms, how readily available the SAC clinic is to clients, and if

adequate education was given. For summative evaluation, the army public health nurses will

compare and contrast STI rates from year to year to assess if changes have occurred from the

interventions implemented. Further evaluations of the utilization of the SAC clinic with the goal

that clientele will increase from year to year. The Army Public Health Department will reassess

findings that were initially found. For example, a deficit in knowledge in the clientele about the

location of the SAC clinic will be evaluated for improvement.



       During the entire semester, our group had a great experience at Fort Lewis. We not only

had the opportunity to observe and participate in activities with the Army Public Health Nurses

but had the experience to help to inform about a change in education and awareness involving

the Special Adult Clinic (SAC).

                                                                            Community Health 30



Captain Hill- Army Public Health Nurse
   1. Do you think that STI’s are a problem at Fort Lewis?

   Yes, it is big enough to cause a public health concern. There is an STD problem in our
   nation; there is a problem in state of Washington, Pierce County, and Fort Lewis. Fort Lewis
   has a big population we have about 35,000 soldiers on this post. It is our responsibility to
   educate the public.
   2. What STI’s are most commonly seen here?

   Chlamydia runs ramped in Fort Lewis and this can be preventable. I think the education
   should start at the middle school level. I think the public health nurse should be the one to go
   around and educate the adolescents on post. More responsibility needs to be put on the
   parents to educate their children. Currently, our department does not go to the middle school
   on fort Lewis to give classes on STIs.
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   3. How do you follow up on patients (to make sure they understand, are getting treatment, are
      changing their ways, etc)?

   The units have annual STI briefings but its up to the discretion of the commander. These
   classes are given upon request and they are provided by the army public health nurses. The
   Army is experiencing rapid deployments to Iraq and Afghanistan, STI briefings have not
   been a priority for units. They are just way to busy in their training and preparations for
   deployments for STI briefings.

   4. What educational resources are available at Fort Lewis? How do you provide education or utilize
      these resources for patients?

   Education is the number one way to prevent sexual transmitted disease. The issue is
   targeting the behavior of our soldiers; I see constant reckless and dangerous behavior from
   our soldiers. The educational deficit in the young soldiers has contributed to the increased
   rates of Chlamydia. When I was a Fort Gordon, the public health was responsible for the
   schools and the SAC clinic. Here at fort Lewis our roles are limited.

   5. How should STIs be dealt with differently (What would you like to see change, How would you
      make a change at Fort Lewis that you think would be beneficial to soldiers)?

   I think that the idea to put condoms and flyers in the examination room is a great idea. I also
   think adding the educational teaching to the screening form will increase the quality of
   education. Nurses need to be involved in the SAC clinic. Our roles are limited in working
   with STI patients. We need to implement an RN in the STI clinic to provide the education
   and holistic care.
   I think your proposed interventions are great and terrific. The Flyers will raise awareness of
   the STD clinic and assures the soldiers that their confidentiality is respected. I recommend
   that you mention on the flyer that the chain of command will not be involved whatever the
   outcomes are and that information is on a need to know bases.


LTC Baker- Chief of Preventive Medicine, Madigan Army Medical Center
   1. Do you think that STIs are a problem at Fort Lewis?

       Yes, STIs are a huge issue here at Fort Lewis, the statistics show it, and the infection rates are
       rising every day. If you want specific rates for STDs go and see Mr. Johnson at the special adult

   2. What STIs are most commonly seen here?
                                                                              Community Health 32

   Mostly Chlamydia is seen the most here and Herpes has been a trend lately.

   3. How do you follow up on patients (to make sure they understand, are getting treatment, are
      changing their ways, etc)?

   Contact screenings are done here at Fort Lewis to map out the chain of infection. This is an
   important role for the army public health nurse. In addition some STI‘s must be reported to
   the CDC and the department of health. During this process the PHN investigates the contact
   history of the individual and conducts an epidemiological history.
   4. What educational resources are available at Fort Lewis? How do you provide education or utilize
      these resources for patients?

   We have brochures, pamphlets and other resources available to our service members. There
   is a clinic here dedicated to STIs called the special adult clinic. The SAC clinic is a walk in
   self referred clinic open to soldiers and civilians. The hours of operation are 0730-1000 M-F
   and there is a physician‘s assistant and LPN working there.

   5. How should STIs be dealt with differently (What would you like to see change, How would you
      make a change at Fort Lewis that you think would be beneficial to soldiers)?

   I think the education process can be improved at the SAC clinic. They have an LPN (Mrs.
   Penny) and a PA (Mr. Johnson) along with a secretary and a medic. I think the quality of
   care offered at the SAC clinic can be improved if the staffing is increase. Additionally the
   hours of operation can be increased to give soldiers more options. It could be
   counterproductive for production of work if the hours of operation are only from 0730-1030.
   I think there is a missed opportunity for behavior modification among Fort Lewis soldiers.
   We need to do a better job of getting people screened before they are at risk. We need to do
   a better job counseling our military on behavior modification.


Mr. Johnson- Physician Assistant at the Special Adult Clinic

Do you think that STIs are a problem at Fort Lewis?
Yes I do, we need look at our population to stop the spread of infection. Teen education—he
thinks education is a great thing, but is primarily the parents‘ job. Need for education-High
Schools need to reinforce some moral issues—having sex could be dangerous and risk to health.
STI are a problem everywhere, they are also a problem in the military. The increase in STIs may
be to the generation, young people today have very different life styles
What STIs are most commonly seen here?

Three most common STI seen on Ft. Lewis


                                                                             Community Health 33

       Genital Warts

How do you follow up on patients (to make sure they understand, are getting treatment, are
changing their ways, etc)?

Try to educate about the need for safe sex, condoms all the time, but that still is not 100 % safe.
There is a limited amount of information a person will retain on a visit.

What educational resources are available at Fort Lewis? How do you provide education or
utilize these resources for patients?

There are programs at unit level training available upon request. Also Soldiers are given a class
during basic training.

How should STIs be dealt with differently (What would you like to see change, How would you
make a change at Fort Lewis that you think would be beneficial to soldiers)?

Plan-make soldiers more aware of SAC to come for screenings—via hand outs, posters in Waller
Hall—―Had Sex?‖ (Got Milk?)

Contract tracing could significantly decrease the STI rates, epidemiological investigation These
are social issues related directly to public health

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