RCHC Community Project Abstracts

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Childhood Obesity: A review of literature to support development of a community intervention
Date of project: 10/12/2009

besity is one of the leading health concerns in the developed world. Being overweight and obese as an adult has consequences of type II diabetes, cardiovascular disease, hyperlipidemia, and exacerbates other health conditions such as arthritis. Obesity is growing not only in the adult population but also the pediatric population. More than 16% of children are obese or overweight currently, a 4-fold increase in the last 30 years. These numbers are larger in underserved and minority populations. The Community Health Improvement Partnership (CHIP) in Madras, OR has initiated a number of programs in the schools and community to fight obesity. There is interest in focusing on pregnant women and parents of young children to change behavior before it becomes habit. Background research was needed to identify which groups to target and how to have to most meaningful impact at a reasonable cost for the community. A review of the literature showed 1) the early in life the intervention, the more successful, 2) Interventions should aim at decreasing sedentary activity and unhealthy food choices 3) Anticipatory guidance and reinforcement of breast feeding, delaying introduction of solids and parental nutrition knowledge building are effective tools in preventing obesity.

H1N1 Influenza: Patient Education and Preparation in Jefferson County
Date of project: 8/3/2009

With the most current novel influenza virus pandemic sweeping our planet, no locale however small seems immune. Although Jefferson County has yet to confirm a case of H1N1 this year, its residents are still worried and questioning what this coming flu season will bring. After attending the H1N1 Influenza Preparedness Summit in Salem as well as meeting with local representatives from the health department and surrounding clinics, I have learned that patient education with a consistent message will be the key to preventing a widespread outbreak in this community as well as abating much of the fear surrounding this pandemic. My goal in this project was to create materials for the Madras Medical Group (MMG) clinic to use this coming season to educate its specific patient population about H1N1 in order to encourage early preventative measures and limit spread among the community. Through a presentation to the MMG on the current H1N1 status in our state, my goal was also to provide clear and accurate information on treatment and prevention to the medical staff so that they might pass this information along to their patients, families and friends.

Preparing a Rural Community for Emergency and Outbreak
Date of project: 4/27/2009

When faced with a large scale Emergency or an Infectious disease outbreak a small community is still held to the same standards of preparedness as compared to a more urban medical community but must do so with some unique challenges. The recent global outbreak of H1N1 influenza has proved a catalyst to ensure hospitals are up to par with regards to Emergency and Outbreak response plans and Madras Mountain View Hospital is no exception. This community project has three primary endpoints including: 1) To Conduct interviews with hospital personnel to educate myself with regards to rural hospital preparedness for emergencies and infection disease 2) To identify strengths and weaknesses inherent to the response plans 3) To develop information fliers for medical staff education, outlining levels of the response plans including medical staff responsibilities.

Connecting At Risk Infants with Community Resources: Reducing abuse, neglect, and crime
Date of project: 3/16/2009

Child abuse is a tragic, costly, and persistent problem; the primacy of infancy implies that these events will follow a child through the rest of his/her life. In the current economy the local population of Jefferson County has been hit hard, particularly with unemployment as major industries have closed their doors. At times like these the risk to children climbs and the need for child abuse prevention is more acute. A local program, the Ellsbury-Read Project, is trying to effect this change through new parent education on brain development in addition to promoting character development through the rest of childhood. The intention of my project is to add materials to the project to allow teaming with medical professionals. I had four main end points: 1) A simple refresher card (Spanish, and English) for new parents based a on brain development DVD the program has to show parents before discharge that will be dispensed at WCC, 2) A review of the most recent literature regarding the complications of abuse/neglect on the developing mind, particularly the hyper-sensitization of the HPA axis, 3) a complete succinct list of community resources for at-risk infants 0-2y.o. explaining services and restrictions, 4) an addendum with risk factors and programs specific info, to either add or attach to current WCC forms, was the final end point. All final products were given to the project and clinic for use as desired.

Planning for Obstetric Emergencies
Date of project: 2/9/2009

Obstetric emergencies can be extremely tense situations especially when the health of a newborn infant or mother may be compromised. Planning for these particular emergencies can help provide efficiency and strategy in implementing the best care for the mother and the newborn. It was found at the Madras Medical Group and Mountain View Hospital in Madras, Oregon that that a basic plan for obstetric emergencies had not been established. For my community project, I helped establish an obstetric emergency medication kit that would be stocked and easily accessible in the OB unit for obstetric emergencies. Having a protocol in place and necessary medications in one easily accessible place can reduce the amount of stress and anxiety that often accompanies such obstetric emergencies.

Keeping Kids Physically Active in Madras, Oregon
Date of project: 12/29/2008

Childhood obesity has become a major health problem throughout the United States over the last several decades. When battling this epidemic, there is often a two-pronged approach involving nutrition and physical activity. In Jefferson County, only half of youth met the recommendations for physical activity suggested by the Center for Disease Control. In addition, Jefferson County does not have the resources for a parks and recreation division to help organize and publicize available youth sports programs. This project focused on the opportunities for children to participate in organized physical activities in Madras, Oregon. The aim of this project was to provide a resource for patients that provides information about guidelines for physical activity for children and the youth sports programs that are available in the community of Madras.

Community Diabetes Education: Development of a patient handout for Madras's Diabetic Workshop
Date of project: 9/8/2008

Diabetes has become an epidemic in the United States with over 7.8% of the population affected. Jefferson County is not immune to this phenomenon and Madras Medical Group (MMG) has a large population of diabetic patients. Although no cure to diabetes is currently available, much can be done to prevent complications, improve quality of life and manage the disease through patient education and vigilant care. This project will provide educational information on how diabetes is managed in the primary care setting and what patients can do to minimize complications of diabetes. This information will be presented in the form of an informational pamphlet and a power point presentation to the Madras community at a local diabetes workshop. The content of the pamphlet was a representation of most frequently asked information in the primary care setting based on observations of patient-physician interaction in the office. Information was gathered from clinic staff and online diabetes resources in order to create the educational materials to represent MMG at the workshop. The workshop was set up to introduce diabetic resources to the community and provide information to diabetic and pre-diabetic patients, their families, and those with risk factors for diabetes about the disease.

Juniper Junction Relief Nursery: Child Abuse Prevention in Jefferson County
Date of project: 8/4/2008

Juniper Junction Relief nursery is a new organization developing in Madras, Oregon, to address the serious matter of child abuse in Jefferson County. According to the county website, in 2006, Jefferson County’s rate of child abuse was 10.5 per 1000 compared to 6.9 per 1000 in the state, and approximately half of the victims were under six years of age. Further outlined is the epidemic of alcohol and drug abuse in the county, the high rates of poverty and the effect these have on children and their health. Juniper Junction Relief Nursery’s main goal is to assist families with multiple risk factors for child abuse by providing therapeutic classrooms for children 0-5 years old, home visits from teachers, and parent education classes. The organization hopes to follow the Eugene relief nursery’s lead in also offering basic needs support, drug and alcohol support groups, respite care, mental health services and Latino outreach. All of the classes and support revolve around the family and keeping families together in a healthy, safe environment. After learning of Juniper Junction Relief Nursery, I attended a council meeting and interviewed different members to find out what needs they had and what I could do to help address them. After these interviews, a tour of the facility, review of the classes to be offered, and research of the original program out of Eugene, it was decided that pediatric health brochures based off of a class that will be offered, called, “What to do when your child gets sick” was the way I could best help advance the development of the nursery. I created 10 brochures in English and 10 brochures in Spanish that address basic healthcare concerns many parents, especially first time parents, seem to have. I also translated a Tylenol dosing chart into Spanish, that the clinic and the relief nursery both felt was needed. The main goal of the brochures is to help educate parents on the health problems their children may face and provide a source for the relief nursery to reach out to both the English and Spanish speaking population in the county. Ideally, these brochures and the knowledge provided to parents prevents unneeded emergency room visits and clinic visits for children.

Recommended Techniques for Safe and Environmentally-conscious Disposal of Un-needed prescriptions in Madras, Oregon
Date of project: 4/28/2008

The proper disposal of expired or unused prescription medications continues to be an ongoing problem in the United States with no standardized disposal technique in place at a federal level or, in Oregon, even a state level. This study was designed to examine the current disposal technique Madras residents utilize to dispose of unused or expired outpatient medications as well as to provide a comparison as to what happens in an inpatient setting at the pharmacy and home health/hospice associated with the MountainView Hospital. The design was an informal survey of patients in clinic regarding their disposal habits as well as querying the MountainView pharmacists and hospice nurses as to their current protocol for medication disposal. Further phone calls were made to the Oregon Board of Pharmacy and the DEQ in regards to their recommendations for proper disposal techniques. Previously, there was no information available to patients for proper techniques to purge unneeded medications; therefore the final product of this project was the development of a patient handout to inform Madras residents of the most appropriate and environmentally friendly mechanisms of pharmaceutical disposal. Furthermore, as there is no organized collection system for outdated or unused medications anywhere in Oregon, an additional component of the project was to create a proposal for the Madras Medical Group to use as a long term community solution for the problem of proper medication disposal

Raising Awareness of HPV and HPV Vaccination Among Eligible Females in Jefferson County
Date of project: 3/17/2008

The Human Papilomavirus (HPV) is the most common sexually transmitted infection worldwide and is second only to HIV in the cost burden to the United States health care system. Eighty percent of sexually active men and women will acquire HPV infection at some point in their lifetime . The Quadrivalent HPV vaccine was approved by the FDA in 2006 for use in 9 to 26 year old females. Trials of the HPV vaccine have shown 98 to 100 percent efficacy in preventing type specific HPV infection and 90 to 100 percent efficacy in preventing CIN 2/3. By informal interviews with health care providers and information from two local clinics, it is estimated that the HPV vaccine is being underutilized in Jefferson County. Based on information from two local clinics, approximately 10% of 15 to 24 year old females in Jefferson County were vaccinated for HPV in 2007. The goal of this community project was to increase HPV vaccination rates by raising awareness of HPV and HPV vaccination among eligible females in Jefferson County. To accomplish this goal a lesson plan was created using information from the CDC Department of Health and Human Services that targeted 10th grade students and met Oregon and National Health Standards. The lesson plan was well received by the head of the health department at Madras High School and will be integrated into the 10th grade Health 1 curriculum beginning this year.

Development of the Jefferson County School Wellness Policy
Date of project: 12/31/2007

During the past 20 years, there has been a dramatic increase in the prevalence of obesity in the United States, with more and more children becoming overweight and/or obese. It is thought that as much as 14% of 2 - 5 year old children and 19% of 6 - 11 year old children in the U.S. are overweight. This is becoming a growing health concern as there is a clear increase in morbidity and mortality associated with being overweight and obese due to increased risks of coronary heart disease and type 2 diabetes. Although obesity-associated morbidities occur most frequently in adults, overweight children and adolescents are more likely to become overweight or obese adults. Conversely, health-conscious and active children are more likely to maintain these habits into adulthood. The Jefferson County school district has received federal funding for a Community Health Improvement Project (CHIP) aimed at reversing the growing trend of childhood obesity in Central Oregon. To complete the first objective of the CHIP, a Wellness Policy was developed to be presented to the 509J school district for approval. This Wellness Policy is aimed to motivate and assist students aged kindergarten through twelfth grade to maintain and improve their health and prevent disease by shaping the children’s attitudes toward physical fitness, nutrition, and health. It focuses on improving district-wide school policy in four main areas: health and nutrition education, physical activity and physical education, nutritional standards, and policy review.

“Healthy Futures: Nurturing Children’s Development.”
Date of project: 10/15/2007

A child’s early experiences profoundly influence his brain development and how he will interact with the world throughout his life.1 Increasingly, instruction and support in providing the nurturing and stimulation that children require for proper brain development is imparted to inexperienced parents by community resources. 2 One such resource, the Maternal Case Management program at the Jefferson County Health Department in Oregon, has just been eliminated due to low utilization. The Healthy Start program in Jefferson County is facing the same fate, also due to low utilization. The fact that both the teen pregnancy and child abuse rates in Jefferson County are higher than the Oregon state average suggests that lack of need of these social services is not the reason for their low utilization.3,4 Rather, lack of awareness of these social services is to blame for their low utilization, according to the local Community Health Improvement Partnership (CHIP) in Jefferson County. To increase awareness, and thus increase utilization, of social services available to infants and children in Jefferson County, I created a comprehensive list of these resources and made it available at the nurse’s station at the Labor and Delivery Department of Mountain View Hospital, the major hospital in the county. To encourage new parents to access this list of resources, I also created a video that explains the neurodevelopment that results from adults’ early interactions with infants, and the importance of enlisting social services when necessary to ensure that these interactions are positive and promote a child’s healthy development. This video is available in both English and Spanish, and will be required viewing for patients who deliver at Mountain View Hospital, prior to their discharge.

Pattern of Emergency Department Use at Mountain View Hospital in Madras, Oregon
Date of project: 9/10/2007

The emergency department use in the United States has reached an unprecedented level. The overcrowding and runaway costs that have resulted are an impetus to investigate ways to redirect nonemergent patrons from the emergency department to the primary care clinic. Despite the common opinion that patients who do not have a primary care physician or health insurance account for the majority of misuse, this is not well supported by published evidence. In single urban center research studies and a nationwide survey have found instead that lack of a regular primary care physician or insurance do not correlate with decrease emergency department use. Studies of single urban centers in particular may not be representative of rural healthcare entities. The issue of ED misuse has not been addressed in the specific setting of a rural ED. In this community-oriented primary care project, it was hypothesized that discernible groups among a small community may disproportionately use the emergency department for nonemergent care and thus provide a suitable target for interventions to decrease this misuse. To this end, emergency department visitors with various local primary care providers were documented for a one-week period and categorized as emergent or nonemergent. Although the numbers in the study were low, they suggest that patients from certain primary care clinics do have disproportionately high levels of emergency department use for nonemergencies. Reasons for this may include deficient patient education measures at these clinics and low weekly business hours.

Barriers to Accessing Dental Care and Use of Medical System for Oral Health Problems by Low-income Residents in Jefferson County, Oregon.
Date of project: 4/30/2007

Despite the preventable nature of most oral disease, Oregonians have high rates of caries and periodontal disease. Low-income populations are disproportionately affected by dental problems and may be influenced by lack of access to dental care. Barriers to accessing dental care and use of emergency department (ED) services for dental needs were studied using interviews and ICD9 code analysis for a local hospital in rural Oregon. Barriers to accessing dental care include transportation and appointment availability for Oregon Health Plan (OHP) patients and cost and appointment availability for underinsured or uninsured low-income patients. Dental appointments and free preventive services are available for Native American patients suggesting other barriers to good oral health. Uninsured patients and Medicaid patients followed by Native American patients represented the largest percentage of patients seen in the ED for dental problems. Preventive resources and education about oral health in the community are limited. These results indicated that lack of access is only one barrier to poor oral health. Increasing preventive services, educational resources and community awareness about oral health may be more beneficial in improving oral health outcomes.

Access to Care and the Impact on Emergency Department Utilization in Madras, Oregon
Date of project: 3/19/2007

Access to health care is an important issue nationwide and is particularly salient in Oregon right now with multiple health care reform measures headed for the legislature. Utilization of emergency services can be used as a proxy to measure access to primary care. Key informant interviews were administered in tape-recorded sessions with health care providers and administrators in a rural Oregon community. The key informants were providers and administrators from Mt. View Hospital (MVH) in Madras, Oregon and from the four clinics that serve MVH. The interview sought to explore primary care providers' perceptions and experience with access to care issues in their communities, including questions about what affects access, trends in access and utilization, perceived needs to improve access and delivery of care, Emergency Department use, and strengths and challenges of primary care. Interviewees indicated that access to care is affected by health insurance, cultural and educational barriers, and common (misperceptions. Trends include a changing population that brings changing health care demands and narrowing financial margin. ED is thought to be overused for non-urgent/non-emergent care, in particular by those who feel no financial consequence. In the opinions of providers as well as administrators, access needs to be improved by legislation that changes the structure of health care programs.

Risk reduction strategies for prevention of STDs and teen pregnancy in Madras, Oregon
Date of project: 2/12/2007

Sexually transmitted diseases (STDs) and teen pregnancy remain major public health challenges for young people in the United States and rural Oregon is no exception. STDs in rural Oregon follow national trends: The top two STDs are HPC and Chlamydia, and about half of new infections diagnosed each year are young people 15 to 24 years of age. The service area of Madras Medical Group also has staggering teen birth rates (women age 15 to 19). 2004 estimates of teen births in the service area are 158 per 1,000 live births, almost four times the national average (CPU site information, CDC). The objective of this project was to find clinical evidence of effective risk-reduction interventions in preventing STDs and/or teen pregnancy. Literature search revealed risk-reduction counseling interventions that were effective in reducing STDs and increasing safe sex behavior, notably most effective in younger patients. Studied interventions were based on interactive counseling and the AIDS Risk Reduction Model which focuses on three stages of behavior change: labeling high risk behavior as problematic, making a commitment to change high risk behavior, and seeking and implementing solutions directed at reducing high risk activity. Similar counseling techniques were found to be effective in programs aimed at reducing teen pregnancy. From this data, a proposal for a brief, one-on-one, low cost intervention to reduce the risk of STDs and teen pregnancy was developed for Madras Medical Group. Though not yet fully implemented, the intervention has received positive feedback in informal interviews from both the target population and the clinicians.

Contraception and Family Planning Education in Madras, Oregon
Date of project: 1/1/2007

Jefferson County Oregon has the highest teen pregnancy rates in the state, however, it has doctors that are working to decrease that rate. To help them in the pursuit of this I developed a comprehensive patient handout explaining 17 different contraception options available. The handout is designed to allow patients to make the decisions about which contraceptive methods works best for their lifestyle. I attempted to increase contraception education giving a talk to and getting the handouts to be apart of the materials offered at the county birthing and parenting class. The result was a one page double sided handout that was well received by physicians, nurses, and staff at Madras Medical Group. This handout will help Madras health care professionals guide their patients in making contraception decisions.

Gay, Lesbian, Bisexual, and Transgender Health Resources in Madras, Oregon
Date of project: 10/16/2006

Several studies have estimated between 3 and 10% of the U.S. population are gay, lesbian or bisexual. Small towns often have very few organizations or agencies to support this minority. This project looks for resources for gay, lesbian, bisexual and transgender (GLBT) individuals in the town of Madras, Oregon. Local health providers and administrators were interviewed to identify steps that have already been taken to support health needs of GLBT patients. In addition, using several national health resources, suggestions were gathered for improving the clinical atmosphere and health care for GLBT patients at one local clinic and hospital in Madras. The findings and suggestions collected during this process were presented to and discussed by a group of family practice physicians in the community.

Utilization of the ER in Madras: Implications for health care availability and health care costs.
Date of project: 9/11/2006

Between 1992 and 1999, the amount of ER utilization increased by 14% from 89.8 million to 102.8 million visits annually. This increase continues. US health care spending has also increased steadily, with rates of increase now in the double digits. Over-utilization of the ER has translated to increased health care spending, as well as inadequate long-term care for the patient. By analyzing the characteristics of patients admitted to Mountain View Hospital ER in Madras, we may gain some insights into the determining factors involved in patients' decisions to go to the ER instead of a primary care clinic. Madras is a rural community in central Oregon with unique health care issues related to its need for greater clinic accessibility, its shortage of primary care providers in the face of a growing population, and its housing of a larger subset of uninsured patients than Oregon as a whole. Mis-utilization of Mountain View Hospital's ER is a problem and solutions are discussed.

Rural vs. University Medicine: A comparative review of data
Date of project: 8/7/2006

Rural communities in Oregon face many obstacles to adequate health care relative to their urban counterparts, especially those with direct access to a teaching hospital. Among the more serious of these are: a lack of specialty care, a smaller selection of primary care, greater numbers of "working poor," and fewer clinical options for low income patients. Most medical students at OHSU are not exposed to non-university medicine until their third year of school, and even then, a miniscule percent of their overall education is dedicated to these pursuits. This project attempts to create a framework by which OHSU students can begin to understand the differences between rural and university health care settings before their clinical years.

Contraceptives: A Survey of Jefferson County Teenagers
Date of project: 5/1/2006

Jefferson County has the highest rate of teen pregnancy in Oregon. Research shows that programs that combine emphasis on delayed initiation of sexual activity as well as sexual and contraceptive education helps reduce teen pregnancy rates. In order to reduce teen pregnancy in Jefferson County, sexual and contraceptive education will need to be taught in a comprehensive way. The goal of this project was to evaluate the knowledge regarding contraceptives of teenagers in Jefferson County, where they obtain their information, who they trust regarding contraceptive information, and what myths exist surrounding contraceptives among teens in this county. Surveys were administered to four health classes to a total of 79 high school students and discussions were held following the administration of the survey. Results showed teens get most of their information from school, friends, and health care professionals. They trust doctors, nurses, and parents to provide accurate information. There is good understanding that abstinence prevents pregnancy. Knowledge of comparative efficacy of specific contraceptive methods was not good. Knowledge of new contraceptive methods such as the NuvaRing and Mirena were low. Many students did not know the window of opportunity to take emergency contraception. Myths regarding side effects of contraceptives include breast cancer risk, infertility, birth defects and weight gain. Health care professionals are trusted by teens in this county generally feel safe speaking with their health care providers. Significant room for improvement exists in the education of teens in Jefferson County regarding contraceptive methods.

Oral Anticoagulation Management at Madras Medical Group in Madras, Oregon
Date of project: 3/20/2006

Maintaining anticoagulated patients within an INR of 2.0-3.0 has been shown to reduce bleeding events without increasing rates of the thromboembolic events for which anticoagulation was being administered. Madras Medical Group of Madras, Oregon recently changed their warfarin administration system to that outlined in Ebell (2005). This project examined the charts of all 103 patients receiving anticoagulation services for a six-month period before and a six-month period after the change. The mean number of INR checks per patient during both six-month periods was 3.9 Before the change 44.3% of INRs were within the therapeutic range, while 48.4% were within range after the change. The number of bleeding events was the same before and after the change. Three thromboembolic events occured after the change. Use of a new flow sheet would provide easy access to important information for the group. Use of a point of care meter could make INR testing more accessible to patients and could result in more frequent testing and a greater time in therapeutic range.

Are We Still a Fast Food…County? – A Look into Dining Options and Overconsumption in Madras, Oregon
Date of project: 2/13/2006

Obesity continues to be a major public health concern and has become a prime target for health promotion and disease prevention efforts over the years. Previously, a rural health community research project was conducted to investigate the prevalence of obesity and metabolic syndrome in Madras, Or with results indicating rates comparable to, if not higher than those of Jefferson County and the country. I based my research off these findings and qualitatively studied how the lack of healthful dining options and societal barriers contribute to poor dietary choices and overconsumption in people in Madras. Methods for this study included utilizing the Jefferson County surveillance data with emphasis on ethnic and socioeconomic disparities to establish a background understanding of the population. Various fast food and dining locations were then visited, and managers and working staff interviewed to obtain subjective perspective on the dietary preferences of members in the community. Findings from this research included consumer interests in heartier portions, meatier options with condiments, special value meals, and cheaper, highly advertised items, regardless of their nutritional value. Furthermore, literature reviews demonstrated correlations between culture and socioeconomic status with rates of obesity, specifically a higher percentage of Hispanics and lower income households with poorer dietary habits. Based on these findings, a brochure on weight loss and management was designed in both English and Spanish to increase community awareness in a culturally sensitive and population-specific manner. Emphasis was placed on preventive measures, proper diet, exercise and healthy lifestyle choices to minimize risk factors for obesity and its related comorbidities.

Obesity and the metabolic syndrome in Madras, OR
Date of project: 1/2/2006

Although attempts at weight reduction are common in the United States, the prevalence of obesity has increased at an alarming rate since the 1980s. In this study an attempt was made to calculate the prevalence of obesity as well as comorbid conditions contributing to the metabolic syndrome in a Madras, Oregon family practice clinic. All patients over the age of 35 who entered during the course of a week were weighed and measured and had BMIs calculated. Their charts were reviewed for comorbid conditions including known cardiovascular disease, diabetes, hypertension, and dyslipidemia.. Patients were categorized as healthy weight (BMI = 18.5-24.9), overweight (BMI = 25-29.9), or obese (BMI > 30). Of 62 patients, 17.7% were of healthy weight, 33.9% were overweight, and 48.4% were obese. Additionally, 21% of patients evaluated met criteria for the metabolic syndrome, a cluster of clinical and biochemical abnormalities associated with the onset and progression of atherosclerotic cardiovascular disease.

Reach Out and Read: the first steps toward establishing a local program.
Date of project: 10/17/2005

Discussions with Kindergarten teachers and reading coaches at several schools in Jefferson County, supported by the DIBELS* standardized literacy test scores for this year, revealed a high percentage of children who are at risk for not meeting benchmark goals in literacy without significant intervention. A growing body of evidence suggests that physicians can play a role in promoting literacy by adopting the strategies presented through a Reach Out and Read program (ROR). Providers give a brand new book to children between the ages of 6 months – 5 years at their well child exam, accompanied by age-appropriate advice to parents on how to effectively read aloud to their children. Retrospective and prospective studies report increased attitudes and frequency of reading to children, as well as higher scores on standardized literacy assessment tests when compared with children not exposed to ROR. The initial steps of establishing an ROR program in Madras were undertaken during this project: gathering local and demographic information to evaluate the need for this program, estimating an annual budget, and presenting the idea to Madras Medical Group, with the goal of attaining a group consensus to continue the steps toward completion of this project. Future steps include identifying and applying for long term funding, generating community support, outlining a plan for creating a “literacy-rich” environment in the office, and finally, submitting the online application to the national ROR center. *DIBELS: Dynamic Indicators of Basic Early Literacy Skills

Pediatric Follow-Up for Infants of Uninsured Hispanic Women in Madras, Oregon
Date of project: 9/12/2005

Pressure from restraints of the current health care system, as well as recent advancements in methods to prevent and treat disease have put preventative health care in the forefront of the minds of primary care physicians and public health professionals. Unfortunately, in the area of pediatrics, recommendations for preventative services have not always been supported with well studied and documented evidence. This is true of the current standard system for well-child visits to general pediatricians. Although routine immunization has been strongly supported with clinical trials, very few of the current accepted practices of behavioral counseling and routine screening during well child visits are supported by solid evidence. Despite the lack of evidence, the American Academy of Pediatrics' Guidelines for Preventative Pediatric Health Care have become the standard of care and are expected by pediatricians and parents alike. This study looks at a population of children born to uninsured Hispanic mothers in Madras, Oregon and attempts to answer two questions. First, chart review and a database of national health statistics were used to determine whether this particular population of young infants is receiving preventative health care at a rate equivalent to national levels. Second, two subsets of the population were compared in an attempt to assess the efficacy of well-child care in preventing disease and its usefulness in contributing to the full vaccination of this subset of children. Results show that the study population is receiving preventative healthcare services that meet the current community standards. They also suggest that children that receive higher levels of those services are more likely to be healthy, immunized and free of disease.

Assessing Occupational Asthma at Bright Wood Corp in Jefferson County.
Date of project: 8/8/2005

Bright Wood Corporation is the largest employer in Jefferson County. Bright Wood, privately owned by the Stovall Family, is a group of secondary wood processing facilities that have many occupational hazards that contribute to the morbidity and mortality of the Central Oregon community. Bright Wood has done a respectable job lowering the acute injury rates, but many long-term morbidities have not been studied. Prior studies in occupational medicine highlight occupational asthma as a potentially unappreciated morbidity associated with wood dust. The objective of this study was to evaluate asthma rates within the community and comparing them to asthma rates within the Bright Wood employees seen at Madras Medical Group.

Lets Talk About Sex: A look into the Attitudes and Behaviors of Jefferson County
Date of project: 4/25/2005

Teenage pregnancy is a problem throughout the United States. In Oregon, Jefferson County has the second highest teenage pregnancy rate when compared to other counties. This leads to increased health risks for teens and children, and an increasing amount of financial stress on Madras, OR, the heart of the medical and educational services in the county. This study connected the researcher with Jefferson County High School teens via one-hour focus groups in a effort to generate ideas that will be helpful in decreasing the teenage pregnancy rate in Jefferson County. The focus group design and the sample population were chosen because teenagers may have insight into solutions that adults are less able to provide. The information gathered from students was compared with literature recommendations for effective community strategies for decreasing teen pregnancy. The result is a list of recommendations or suggestions for the community of Madras in addressing the important problem of teenage pregnancy.

Evaluation of Cervical Cytology Screening in Madras, Oregon: clinical considerations in the context of changing standards of care
Date of project: 3/21/2005

The incidence of cervical cancer worldwide has declined sharply since the advent of cervical cancer screening. Current focus on decreasing morbidity and mortality related to cervical cancer rests on improvement of screening methods, development of screening guidelines, and establishment of effective follow-up systems. In the context of continually evolving screening methods and guidelines, clinicians are faced with the task of complying with current standards of care. This is made more difficult by subtle lack of consensus between the leading organizations on when and how to screen. The intent of this project was to evaluate Madras Medical Group’s current screening program and to identify areas for future improvement. By examining Pap data from March 2004- March 2005, creating a spread sheet, and reviewing charts, several trends were identified. Madras Medical Group appears to be over-screening women with history of hysterectomy and women who are older than 70. The intervals between Paps may also be more frequent than necessary, especially in patient who are getting ThinPrep exams. By developing a system to identify women who do not need yearly cervical cytology screening, Madras Medical Group may be able to improve their compliance with current standards of care.

Barriers to Enrollment in the Oregon Medical Marijuana Program in Madras, Oregon
Date of project: 2/7/2005

Since its approval by voters in 1998, the Oregon Medical Marijuana Program has provided legal protection for enrolled patients to grow and use marijuana for symptomatic treatment of cancer, glaucoma, HIV/AIDS, agitation due to Alzheimer’s Disease, and any medical condition that produced cachexia, severe pain, severe nausea, seizures, or persistent muscle spasms. Initial estimates predicted growth of 500 members per year, but by July 1, 2004, OMMP membership cards had been issued to 10,196 people. Despite the popularity and rapid growth of the OMMP, many barriers exist in enrolling patients with qualifying medical problems. Through interviews with physicians, a physician’s assistant, home health & hospice nurses, patients, as well as chart reviews, barriers to enrollment in the OMMP were identified, some of which are unique to the rural community in Madras and others that apply to patients statewide. Information regarding the OMMP, Madras Medical Group’s enrollment in the program, and barriers to enrollment were presented in a lecture to the clinic’s providers with the goal of increasing provider understanding of medical marijuana in Oregon.

Assessment and Treatment of Acute Psychiatric Disturbances in Madras, Oregon
Date of project: 1/3/2005

A review of medical records in the Madras Mountain View Hospital over the past year reveals that physicians in Madras, Oregon are not managing psychiatric emergencies up to the standards that they are capable of meeting. For instance, physicians in the Madras Medical Group are placing acutely psychotic patients in restraints or seclusion 61% of the time. This is significantly more than the 20% of time that experts find these measures appropriate. This difference is not likely a reflection of a threefold increased number of psychiatric patients in Madras compared to the rest of the country. Rather, it more likely reflects the fact that the psychiatrically ill population of Madras is not being appropriately cared for in emergent settings. In fact, experts would consider 60% of “holds” in Madras inappropriate. Fifty percent of patients placed in the Madras holding room did not even have a physician-documented psychiatric evaluation in their chart. The primary reasons for these problems are the limitations of a rural setting, increased level of complexity involved in emergent behavioral care, and rural physician discomfort with their acting role as psychiatrist. Madras does not have even a single community psychiatrist. These factors indicate that the Madras Medical Group would benefit from a review of appropriate delivery of acute psychiatric care. Specifically, an approach that better balances the rights of patients with considerations of safety and good standard of care is presented here and contrasted with the current level of care in Madras. Recommendations for improved assessment, charting, and intervention are offered. Furthermore, an outline of appropriate pharmacological treatments is provided.

Westside Elementary School Asthma Education Project in Madras, Oregon
Date of project: 10/18/2004

Asthma accounts for 14.6 million lost school days, 12 million bed rest days, and 24 million restricted activity days per year. It is the leading cause of school absences among children with chronic conditions. In Oregon, there are 74,000 children with asthma. Elementary school asthma education can assist schools in organizing a community to the needs of children, including disadvantaged and minority children whose asthma often goes undetected. A group of six previously identified Westside Elementary School children in Madras, Oregon completed an asthma education program, which consisted of five, 50-minute group lessons held during the school day. It taught the kids how to detect the warning signs of asthma, including triggers that can cause an attack, and how to respond appropriately. The program has been proven to reduce the number of asthma attacks, improve student academic performance, develop student's confidence in managing their own asthma and assist in teaching parents about better asthma management decisions.

Health Care Services Available to Undocumented Immigrants in Madras, OR
Date of project: 9/13/2004

Policy changes within the past ten years have limited undocumented immigrants access to insurance and health care. Undocumented Hispanic immigrants, many of whom are farm workers, suffer serious health problems because of the conditions in which they live and work. Due to fear of deportation most do not seeking medical care or preventive services for themselves or their U.S. born children. Studies have shown migrant farm workers to be among the most vulnerable populations with poor health outcomes and limited access to care. Madras has a large Hispanic farm worker population many of which are undocumented. These individuals face barriers in accessing health care due to lack of insurance, poverty, and language and cultural barriers. This study attempted to ascertain what health care resources are available to undocumented immigrants in Madras. The project design consisted of gathering information through interviews at area health facilities and observing patient care visits at a prenatal clinic targeting this particular population.

Prevalence of Methamphetamine Use In Jefferson County, Oregon
Date of project: 8/9/2004

Methamphetamines use has major health and societal impacts in rural communities across the United States. A previous community project in Madras, Oregon, sought to educate high school students regarding the ill effects of methamphetamine use. That investigator acknowledged the prevalence of methamphetamine use in the area, but did not attempt to quantify the prevalence. The aim of this project was to try and provide some numbers and demographics of methamphetamine use in Jefferson County, Oregon. Because there is no single source where such information is stored and tracked, a number of different sources were queried.

Emergency Contraception: Provider Attitudes and Prescribing in Jefferson County, OR
Date of project: 5/10/2004

Emergency contraception is a safe, easy to use and relatively inexpensive method for preventing unwanted pregnancy. In spite of this, it continues to be underutilized for reasons that are not fully understood. This study was an attempt to examine the prescribing habits and attitudes of rural primary care practitioners regarding emergency contraception in the Madras, Oregon area. The design was a written survey of local primary care practitioners and emergency physicians. The overall response to the survey implied that primary care practitioners in the Madras area are open to the use of emergency contraception but most do not make it part of routine family planning discussions. The majority desire an informational handout to use as a tool for discussion of EC with patients.

Hepatitis C in Madras, OR: Development of a Patient Information Handout
Date of project: 3/29/2004

The hepatitis C virus (HCV) is an enormous public health problem in the United States. In 1997, the cost associated with HCV was approximately $5.46 billion. Though they were not aware of the exact number of patients in their practice with HCV, the physicians at the Madras Medical Group in Madras, OR all felt that HCV was a big problem in Jefferson County. Despite this, it was noted that they had no written information on Hepatitis C to give to patients. Because they are the primary care providers for a number of patients with chronic HCV, and because there are important lifestyle modifications patients can make to optimize their health and the health of their liver as well as prevent transmitting the virus to others, the physicians and I agreed that a comprehensive patient handout would be very useful in their practice. I conducted an extensive internet search for information on HCV designed for patients and created a one page, double sided handout to be distributed to appropriate patients at the clinic as well as the county health office.

The Utility of Written Information for the Rural Family Practice Patient
Date of project: 1/5/2004

As health technology becomes increasingly complicated and patient appointment times become shorter, written information for patients in the form of handouts and brochures has become more popular. This study sought to determine how many patients received this type of education, whether it was useful, what they liked or disliked about it, and how many used the Internet as a resource. A questionnaire was designed and distributed to all patients with appointments at the Scappoose Family Health Clinic for a three-week period. Compilation and analysis of the results revealed that approximately 80% of patients have received written information, all of which read at least some of it. Nearly all found the information at least somewhat useful, half kept the handout for future reference, and approximately 75% said they would like to receive written information in the future. Finally, approximately half of patients used the Internet as a resource for health information and would like to receive Internet sites from their health care providers. The results of this study are similar to those found in recent literature. Written handouts are helpful for patients, and most would like to receive information in this format in the future. Reasons centered around taking control of one’s own health, making informed decisions, and wanting to know accurate, updated information about their health.

The Fight Against STDs in Madras, OR
Date of project: 9/29/2003

It is estimated the 15 million sexually transmitted diseases are contracted in America every year. Chlamydia and gonorrhea are the 1st and 2nd most reported infectious diseases in the United States. My project examines the incidence of reportable STDs in Jefferson County, Oregon, namely, chlamydia, gonorrhea, HIV/AIDS, and syphilis. This data is compared to more urban counties in the state. Prevention strategies among the adolescent population of Madras, Oregon were also examined, and providers at Madras Medical Group were surveyed to assess how they practice STD prevention and screening. While no new cases of HIV/AIDS or syphilis have been reported in Jefferson County for several years, the incidence of Chlamydia infection is higher than the state average and also higher than several more populous counties (Lane, Benton, Marion). Incidence of gonorrhea is lower than that of chlamydia reflecting a statewide pattern, but incidence is still higher in Jefferson County than in Lane or Benton Counties. Prevention strategies for adolescents consist of an abstinence-based program for 8th graders and an abstinence-plus program for high school students including information about birth control and condom use. While the public health officer for STD prevention would like to have more comprehensive programming at younger ages, she worries that providing students with material that some parents find inappropriate may result in the schools canceling the public health programs. She is also limited by funding constraints, thus does not present as much programming as she feels is needed by the teens. The providers at Madras Medical Group are united in most of their practices and beliefs, including willingness to provide patients of any age with condoms and instructions on use as well as the belief that educational programming on STDs in schools is inadequate. Finally, updated treatment guidelines were developed from the 2002 CDC recommendations and placed at the nurses’ station for quick reference.

Assessing Reaction Time: A Screening Tool for the Rural Clinic
Date of project: 8/18/2003

Recent headline news around the nation has indicated that the elderly population is not safe behind the wheel. The recent increase in automobile deaths involving elderly divers has prompted the insurance companies to demand their elderly patients be objectively evaluated by their physicians. Many of these forms require evaluation of the patient’s vision, eye sight, seizure disorder, chronic illness, reaction time, etc. All of these being relatively quick and easily objectively evaluated in the small rural clinic, except for reaction time. An inexpensive reliable measure of a patient’s reaction time doesn’t currently exists. My study was designed to study the effectiveness and reliability of a 30 cm ruler drop with the determination of the population mean and standard deviation for reaction time. Statistical analysis of 75 patients reaction time suggested that the 30 cm ruler drop when compared with an 8000 subject study using a computerized test considered the “gold standard”, was reproducible and a sensitive method for determining a subjects reaction time. The suggested use of the 30 cm ruler drop is to use it to determine patients reaction time and report this number on insurance forms. It is also suggested that it be used as a screening tool only, and should not be used as grounds removal of automobile licensure. A person scoring 2 standard deviation outside the population mean should be referred to a testing facility for more extensive evaluation.

Methamphetamine abuse: a growing problem in Central Oregon.
Date of project: 3/24/2003

Methamphetamine abuse is a serious and growing problem throughout the United States, especially in rural communities. The prevalence of methamphetamine abuse is increasing in Madras, Oregon and the ill consequences of the problem are becoming obvious to the community at large. This project acknowledges the problem and identifies a high school population as needing education for primary prevention of methamphetamine use. The design of the project was giving a thirty-minute presentation with a question and answer period to the health classes at Madras High School. Given that the average age of first methamphetamine use is in the mid-late teens, it was felt that the high school population needed to be informed of the problem, risks, and consequences of methamphetamine use. Also, handouts were given to the students written by the National Institute of Drug Abuse. The findings of this project were that the high school students had never been given information on methamphetamine use. They gained knowledge of this serious and growing problem in their community and the consequences of methamphetamine use.

The adolescent years: A window of opportunity to influence lifelong bone health influence lifelong bone health
Date of project: 12/30/2002

An estimated 25 million Americans suffer from osteoporosis and about 1.25 million skeletal fractures occur annually in the U.S. as a result of osteoporosis. Weight-bearing activity, avoidance of excessive use of alcohol and decreasing exposure to cigarette smoke are also important factors promoting bone health. Individuals living in northerly latitudes, who are dark-skinned, or who do not drink milk must be vigilant about getting adequate Vitamin D. The study’s results yield a somewhat mixed picture regarding bone health. Students’ calcium intake based on Calcium Score Survey indicates that the vast majority (>90%) are meeting at least the minimally recommended calcium requirements of 1300 mg and that only 12 % are meeting the National Institute’s of Health recommendation of 1500mg daily. However, the Bone Health Survey revealed that forty-five percent of students report not always getting their “4 a day” (approximately 1300 mg) requirement. The BHS also showed that half of students reported inadequate vitamin D levels. Students were two times more likely to report inadequacies in calcium and Vitamin D than in exercise and calorie consumption as factors adversely affecting bone health. Excessive use of alcohol use, on an intermittent or regular basis, and smoking were reported less frequently (10-20 percent of students). Moreover, according to the total scores on the BHS, 91 percent of students are no living adequately bone-healthy lifestyles to prevent future risk to their health. Quantification of risk is not possible because of the multi-factorial nature of osteoporosis and because the greater role of genetics in determining actual risk. Primary prevention of osteoporosis in adolescence is one of the very most potent ways to prevent this debilitating disease. Limiting intake of calcium in schools and milk-flavored vending machines have been successful endeavors in promoting calcium intake in several schools, including Sisters and Bend, and is also recommended for Madras High School. Furthermore, because of its northerly latitude and high number of dark-skinned, and presumably lactose-intolerant, students, a basic multivitamin is recommended to prevent osteoporosis secondary to a Vitamin-D deficiency.

Meningitis in Madras: Epidemiology, Prevention and Public Education in the Setting of a Local Fatality
Date of project: 11/4/2002

Meningitis is an uncommon disease with serious morbidity and mortality. Cases often occur in outbreaks. This study was prompted by a fatal case of meningococcal meningitis occurring during my rural rotation in Madras, Oregon. The tragedy led to grief, confusion, fear and a great demand for information in the local community. Objective: The goals of this study were to 1) research the pathophysiology and epidemiology of meningitis specific to Jefferson County, 2) aid in public education and prevention of meningitis and meningococcal disease through the development of an educational handout. Methods: The study design included discussion with local doctors, interviews with the public health nursing staff, and literature review focused on epidemiology and pathophysiology of meningitis with a focus on trends on Oregon and Jefferson County. Conclusions: Meningitis can be caused by viruses, bacteria or fungi. Bacterial causes tend to be more severe. N. Meningitidis and S. pneumoniae are the most common causes of bacterial meningitis. They are contagious. Symptoms are similar to those causing many common illnesses. Disease rates in Oregon are higher than the rest of the country. Immediate chemoprophylaxis is essential in controlling outbreaks. Only close contacts should take antibiotics to prevent infection. Vaccines are available, however, most cases of meningococcal disease in Oregon are caused by serogroup B, a group that is not covered by the vaccine. Results: The final result of this project was a patient handout written in both English and Spanish focusing on education, epidemiology, prevention and available resources for community residents. The handout addresses questions such as: What is meningitis? Is it contagious? How is it spread? Who needs prophylactic treatment? Are there vaccines available? It is my hope that this information will help dispel disease myths and aid in public education and prevention.

Yuck Mouth: Pediatric Dental Health in Jefferson County
Date of project: 7/1/2002

Tooth Decay is the most common chronic disease of childhood. Despite the significant consequences for childhood health and wellbeing, many children go untreated. Dental care has recently been cited as the most prevalent unmet health need in U.S. children, particularly amongst minorities and those living in poverty. These disparities and the prevalence of unmet need often goes unrecognized by physicians, in part due to the traditional separation of medicine and dentistry. Primary care physicians, however, play an important role in child and family development at precisely the time where dental guidance is needed. In an effort to increase parental education about dental disease prevention, a pamphlet was constructed for the Highlakes Clinic and the surrounding area. The pamphlet was constructed utilizing reviews of journal and internet sources as well as interviews of community members. The role of primary care physicians in oral health and disease prevention was then explored. It was found that by incorporating education about preventative oral health physicians could compliment existing dental services and help better meet the health care needs of area children, particularly the underserved.

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