RCHC Community Project Abstracts

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Integrating Education on Postpartum Issues into Existing Birthing Classes for Pregnant Women
Date of project: 10/12/2009

Although the prevalence of postpartum depression (PPD) amongst mothers on the Warm Springs Reservation is unknown, many of the risk factors for PPD are epidemic issues amongst this population. Risk factors include previous depression and social factors such as little support available from family or friends, difficult or stressful marriage or relationship, and stressful events occurring during pregnancy or after childbirth. Unfortunately, many of the prenatal patients seen at Warm Springs Wellness clinic have social stresses such as an unplanned pregnancy while they are young and single, past or current domestic violence, issues with alcohol abuse or family members and partners who abuse alcohol. These stressful and unstable social factors can become risk factors for the development of PPD. The Warm Springs Wellness clinic has many effective no-cost programs for parents including educational birthing classes, WIC, lactation consulting, home nurse visits after birth, free child car seats and parenting classes to help address many of the issues that affect mothers and their babies. Discussion and education around postpartum issues including PPD was one aspect that was missing from the great programs already established. As part of my project, I developed a presentation for expecting parents regarding postpartum issues and presented these topics to parents at prenatal clinic and birthing classes. I also created an educational pamphlet about the baby blues and postpartum depression for the Warm Springs Wellness Clinic to be displayed in patient rooms and provide more information on the issues and warning signs.

Warm Springs Fire and Safety - EMS Funding and Training Challenges
Date of project: 9/7/2009

Rural EMS agencies are under similar strains as every other aspect of health care. They struggle to recruit, train, and retain providers. The funding for these agencies, especially in a struggling economy, is at a bare minimum. Many of these agencies in the past have been able to provide continuing education and equipment upgrades with the help of grant funds. The Warm Springs Fire and Safety service is no exception. I tried to identify additional funding or resources that were not being utilized. After a local and regional search I was not able to find any financial sources that had not been evaluated, but I was able to offer some strategies to try to maximize the resources that are available. I also provided 5 hours of training to 2/3 of the staff at this department.

Exploring the decrease in the percentage of women receiving pap tests at the Warm Springs Health and Wellness Center--reasons why and strategies for improvement
Date of project: 8/3/2009

According to the Government Performance Results Act (GPRA) report, the percentage of women age 21-64 receiving pap smears at the Warm Springs clinic has steadily decreased from 74.1% at baseline in 2000 to 58.3% in the past year. The current goal for the clinic is 90%, and the goal of this project is to determine what has contributed to the decrease in pap test rates and what can be done to increase the percentage of women receiving these exams. First a survey was distributed to the health care providers at the clinic to explore reasons for the decrease in pap tests and to gauge community awareness. Based on the responses given, an educational pamphlet was put together for patients including information about pap tests, HPV, and how to prevent cervical cancer.

Depression in Warm Springs
Date of project: 10/13/2008

Depression is a serious condition that affects the mind and body, associated with a host of co-morbidities and potentially resulting in suicide. Factors associated with increased prevalence of depression that are certainly found in Native American communities include poverty, displacement, and relative lack of jobs. However, there are some barriers that prevent the people of the Warm Springs reservation from getting counseling help for depression, such as cultural factors, lack of knowledge about the local Counseling Center and its services, and misconceptions of poor patient confidentiality and costly services. To address the issue of depression in the Warm Springs community, I designed a pamphlet for the Counseling Center that would help in getting the word out to the community about the Counseling Center and the services they offer, appeal cross-culturally, aid in screening for depression, provide resources to help intervene, and dispel misconceptions.

Screening for urinary Incontinence in Women > 50 years of age in Warm Springs, OR: An underdiagnosed issue
Date of project: 9/8/2008

Urinary incontinence (UI) is a significant health issue with substantial social impact. However, this issue is often unaddressed by health care providers in one of its major populations, older women. The goal of this study is to illustrated the degree to which urinary incontinence in woman ages 50 and up is underdiagnosed in Warm Springs, OR. Warm Springs Health and Wellness Center is an Indian Health Services clinic and the only clinic on the reservation. A sample population of women ages 50 and up coming to the Warm Springs Health and Wellness Center medical offices between September 23 and October 6, 2008, were screened for UI using the previously validated MESA questionnaire for urinary incontinence. Surveys were scored and UI prevalence according to the MESA questionnaire was compared to prevalence according to IHS ICD-9 codes for UI. According to a VGEN search of EHR (electronic health record), Warm Springs Health and Wellness Center only had a 13.0% prevalence of UI women in aforementioned sample population. However, according to the MESA questionnaire at least 58.7% this sample population had some form of UI. Not only is UI unaddressed in this community, but patient knowledge and educational information is lacking. Therefore, the final product of this project is an educational pamphlet on UI. Social gatherings and community is a very important part of this population, hopefully addressing undiagnosed and untreated UI may be improve the quality of some of these women, allowing them to actively participated in community functions and gatherings without fear or embarrassments associated with UI.

Improving Screening Rates for Colorectal Cancer on the Warm Springs Indian Reservation: Using Radio and Internet Video to get the message across
Date of project: 10/15/2007

On the Warm Springs Reservation in Central Oregon, the Indian Health Services (IHS) is responsible for providing health care to the members of the Confederated Tribes of Warm Springs. The IHS has a set amount of resources; therefore, preventative medicine is an important component of the healthcare system. One preventative measure, screening for diseases, can help lower costs and reduce incidence of diseases. The Warm Springs Health & Wellness Center (WSHWC) has a chronic care initiative that is exploring new ways of improving the screening rate and treatment of disease. One of the diseases being studied is colorectal cancer. As a part of the chronic care initiative, this community project created two new ways of encouraging tribal members to get screened for colorectal cancer. One is a radio ad campaign educating people on the need to be screened was implemented. The second is an animated video that demonstrates how to complete the screening test.

Caregiver Perspectives on Childhood Obesity in the Warm Springs Community
Date of project: 9/10/2007

Background: Much like other Native Americans across the United States, the Native Americans of Warm Springs, OR have high rates of obesity, regardless of sex or age. Caregivers have the opportunity to exert significant influence over the factors that contribute to obesity among their children. Methods: The BMI profiles of 600 Native American children in Warm Springs from age 5 through 14 were determined from electronic medical records. A survey tool was then developed and used to survey 19 caregiver-child pairs in the community. The survey recorded the height and weight of the child, and asked qualitative questions of the caregiver regarding the child’s weight, factors contributing to weight and general health. Results: Electronic medical records showed that 56.8% of children ages 5 through 14 were either at risk or overweight. On the caregiver survey, only 50% of caregivers of children who were at risk or overweight actually believed that their child was either “slightly overweight” or “very overweight.” For children who were at risk or overweight, 30% of caregivers agreed with the statement: “Some people are born to be fat and some thin; there is not much you can do to change this.” While the vast majority of caregivers believed that what a child eats (95%) and how much a child exercises (95%) are “very important” to their present and future health, only about two thirds of all caregivers believed that how much time a child spends in front of a TV (69%) and how much a child weighs (63%) are “very important” to their present and future health. About a third (37%) of all caregivers were “not at all concerned” that their child would get heart disease in the future.

Access to Health Care Services on Warm Springs Reservation: A Needs Assessment for a Mobile Health Unit
Date of project: 9/11/2006

A mobile clinic offers the ability to provide primary medical services to individuals and families living in remote rural areas. While a mobile clinic may not offer the most efficient means for health care delivery, many communities may find that its value—measured by health services provided to people with few other resources—is worth the effort. Mobile medical health programs offer the possibility of reaching populations who otherwise may not access traditional health care services. Poverty and lack of mobility are examples of life circumstances that can create insurmountable barriers to obtaining these services. This project was the first step in determining the need for a Mobile Health Clinic on Warm Springs Reservation. I compiled quantitative patient database information on community access to the Warm Springs Clinic. I developed and held a Focus Group, as well as employed a written survey tool, to gather qualitative input from community members. The next step of this project will be to obtain funding through a grant, which is a project I would like to continue to work on with a future student placed at this site.

Patients and Providers’ Perceptions of Motivations for Cessation of Methamphetamine Use on the Warm Springs Reservation
Date of project: 8/7/2006

Methamphetamine abuse continues to be a scourge on the health and welfare of rural communities throughout Oregon. While treatment programs exist, screening for use and facilitating users’ willingness to enter such programs are significant problems. This project examined the motivations of methamphetamine users to quit while concurrently probing the ways in which providers at the clinic on the Warm Springs Reservation screen for and encourage cessation of methamphetamines. The assessment of both groups was done via standardized interview. The results of this study show that the perceived motivations for cessation of use between users and providers were similar in some respects and dissimilar in others. Specifically, a fear of losing custody of children was a common perceived motivation by both groups although there was little implementation of this motivation in patient care. Also, abusive relationships were found to be a perceived barrier for former users while this went largely unrecognized among providers.

A Chart Review of Domestic Violence and Specific Co-morbidities on the Warm Springs Reservation
Date of project: 3/20/2006

There is a higher rate of domestic violence (DV) in Native American communities, and in turn certain medical problems (DMII, cholelithiasis and cholecystitis, ect) also occur disproportionately in native populations. While it is known that there are a number of co-morbid conditions and problems that victims of DV experience, this has not been examined at length in Native Americans. The clinic staff on the Warm Springs Reservation have been concerned with the problem of DV for some time, and have led in the initiative to make screening for DV a GRPA requirement. As an extension of their efforts to identify victims of DV and increase outreach to this segment of the patient population, they had earlier examined the medical records of a random selection of 100 female patients and found that 58% of these women were identified as victims of some sort of DV. This information has proved useful in discussing the severity of DV on the Warm Springs Reservation, and has been employed as part of educational and grant writing activities. The attempt herein is to look at a select number of medical problems in the same patient sample, in order to gauge what variations in medical problems exist between those with a history of DV and those who have not been victims of DV. The hope is that this information can also be used in expanding educational efforts regarding DV and its comorbidities.

Alcohol and Methamphetamine Related Hospitalizations: A Chart Review of 100 Warm Springs Patients Admitted to Mountain View Hospital
Date of project: 10/17/2005

After noticing that a large number of Warm Springs patients were being admitted to the hospital as a result of alcohol or methamphetamine abuse, I decided to choose this as my project topic. I completed a chart review of 100 consecutive admissions to Mountain View Hospital in Madras, OR. All patients were older than 10 years of age. Emergency Department visits were not included. I found that 22 patients were admitted with either a positive urine drug screen (UDS) or a blood alcohol level above 0.08. Six patients had a positive UDS: 4 for methamphetamine and 2 for cannabinoids. A total of 30 patients were admitted for alcohol-related reasons, including intoxication, withdrawal or other conditions. This amounts to a 30% alcohol-related hospitalization rate, which jumps to 36% when admissions for obstetrical conditions are excluded. This is a high number of costly hospital stays, some of which could have been avoided if the patient had another place to stay while he or she became sober. The tribe may want to consider establishing such a place and investing the recuperated money into substance-abuse prevention programs.

Warm Springs Health and Wellness Center Mortality Review of 2002-2003
Date of project: 9/12/2005

Mortality studies are an important and valid tool for evaluating the healthcare issues that affect a community. This project is a mortality review, recording the causes of death of patients of Warm Springs Health and Wellness Center in 2002 and 2003. Patient information was recorded by age at death, sex, immediate cause of death, manner of death, and associated co-morbidities such as alcohol, smoking, and seat belt use. Results from this study were compared to US mortality statistics in 2002 and 2003, and to previous Warm Springs mortality data for 1991-2000. The current study included the deceased from a population of 6464 active patients who received their care at Warm Springs Health and Wellness Center. The average age of death in Warm Springs over the two-year period (Jan. 2002 - Dec. 2003) was 45.5 years. This is lower than the average age of death during 1991-2000 of 46.7 years, and the average US life expectancy of 77.5 years in 2002 and 2003. This mortality review found that an average of 72% of deaths in Warm Springs were from natural causes, 20.5% from accidents, 4.3% from suicides, and 2.6% were from homicides.

Skateboarding Safety: A project in Warms Springs, Oregon
Date of project: 8/8/2005

Skateboarding has become a fast growing trend in the United States. It is projected that by the end of 2005 there will be 15 million participants in this sport7. Unfortunately, accompanying this increasing popularity is an increasing numbers of injuries. In 2002, a study done by the Consumer Product and Safety Commission demonstrated that skateboarding had the highest injury rate compared to other wheeled sports including bicycling, in-line skating and scooters7. According to American Academy of Orthopedic Surgeons, each year in the US skateboarding injuries cause about 50,000 visits to emergency departments. In addition, more than 1500 children need to be hospitalized for head injuries or disabilities that frequently result in loss of vision, hearing or speech, as well as changes in thinking and behavior. Furthermore, in most fatal cases the rider was not wearing a helmet3. The community of Warm Springs, located on the Warm Springs reservation in central Oregon, has a population of nearly 4000. Approximately one year ago, the community built a skate park for their youth; it is unknown exactly how many injuries have occurred at this park since its construction, but according to health care provider reports it is estimated to be significant. This study was designed to determine the underlying rationale of the children of the Warm Springs community for not wearing protective equipment, including helmets and pads, while skateboarding. A survey was developed to assess the motives of the children under the ages of 18 utilizing the skate park. In addition, an informative brochure was developed with educational activities as well as information for parents on the importance of wearing helmets while doing all wheeled sports. Twenty-one children were surveyed. The answers from the children paralleled responses from children across the nation. The most frequent response regarding not wearing a helmet was “I don’t get hurt and so I don’t need to”. Other popular answers included “I don’t know”, “It’s uncomfortable” and “I don’t like the way it looks”. Four children said they would wear them if it were required while others said they still would not. Eight children owned helmets. In addition, it was observed that many other wheeled vehicles were being used at the skate park including bicycles and scooters, again without helmets or other safety equipment. The information collected in this study will be used for further educational opportunities for the children as well as possible legislation.

Availability of Health Care in Warm Springs, With a Focus on the Elderly
Date of project: 10/18/2004

Warm Springs is a small Native American community in central Oregon, located on the 640,000 acre reservation. The reservation is populated by The Confederated Tribes of Warm Springs, which consists of the Wasco, Warm Springs, and Paiute tribes. The tribe built a comprehensive Health and Wellness center that is utilized by the Indian Health Service for direct medical and dental care. Currently, the clinic serves an annual patient population of 5,750 through an array of specialty clinics, classes, and social services. One of the specialty clinics is a senior clinic that was recently implemented to accommodate specific health problems and concerns of the tribal elderly. Many of the native elderly population are chronically ill and mortality in the elderly is high, despite free and high quality health care. When HIS explored obstacles for seniors to receive health care, they revealed that seniors were consistently missing their appointments for reasons that could be remedied. The specialty clinic was designed to reduce total senior clinic appointments, aid in senior transportation, and coordinate the senior’s specific health care plan. Investigation into improvement in disease prevalence or improvement in health, since implementation of the senior clinic, has not yet been done. However, it is impressive to note that now more than 90% of seniors attend their Senior Clinic appointments. As the senior clinic continues to be used, it will be interesting to note possible changes in the health of the seniors as well as in the attitudes of elderly, ideally taking accountability and control over their health.

Warm Springs Use of Native Healers
Date of project: 8/9/2004

Even though the Indian Health Service at Warm Springs provides extensive care for the Native population through its Clinic, no information is known as to the extent of Native Healer presence on the Reservation. Native Healers are otherwise known as Medicine Men, or Women. Thus this study was conducted with the goals of assessing the presence of native medical practices within the population at the IHS clinic. There have been one study done on this topic, but there a couple of case reports and focused articles in the literature available. The one published study is by C. Kim and Y.S. Kwok looking at the Navajo population in the early 90s. They have concluded that 62% of Navajo Native Americans have used native healers in their lifetime, and that 39% have used one the past year. They found that the concerns that were brought to native healers were mostly arthritis, pain, depression and anxiety and chest pain. Majority of the study focused on epidemiology of native healer use in the realm of socioeconomic status within the reservation. Very few differences were found between the users and non-users.

Sleep Apnea in a Central Oregon Community
Date of project: 9/29/2003

Sleep apnea is increasingly being recognized as a disease associated with significant morbidity and mortality. Recognizing the relevance of this topic, the community oriented primary care project sought to investigate sleep apnea in a Central Oregon community. Data were collected from patient records at the local Health and Wellness Center to determine the extent of the problem within the active patient population. The prevalence and distribution of sleep apnea in the community were evaluated. In addition, co-morbid conditions and their particular significance to the community were considered. Findings indicate that the active patient population within this Central Oregon community with a diagnosis of sleep apnea mirrors the characteristics of those with sleep apnea in larger studies. Patients with sleep apnea in this Central Oregon community are more likely to be male, middle-aged, obese, and have significant co-morbidity. Co-morbidities most commonly included psychiatric conditions, dyslipidemia, type 2 diabetes mellitus, and hypertension. Strategies to improve identification of patients with sleep apnea and to prevent future morbidity from sleep apnea within the community were developed.

Determining Efficacy of the Seatbelt Coalition: Finding other areas of outreach
Date of project: 11/10/2003

Deaths due to unintentional injuries ranks first among the people aged 1-44 years old living on the Warm Springs Reservation. Compared to U.S. accidental death reates (which ranks as the fifth leading cause of death among the same age group). Before the passage of a tribal seatbelt law, the safety officer at the warm springs health & wellness center began to collect survey data on the use of seat belts in Warm Springs, OR. Dating back as far as 1992, the data has shown a slow and consistent rise in the use rate of 88% (as of 2002) This project was designed to invesigate what the Seatbelt Coalition's goals and activities, provide an assessment of data collected on seatbelt use, and develop a set of educational materials for the Warm Springs Health & Wellness Center and its patient population. Results revealed a average seat belt use of around 56% in drivers and 42% in passengers in 2003. A set of ten slides were created that attempted to reach out to the younger at-risk population to help them gain insight into the reasons for using seat belts. Further efforts by the seatbelt coalition are needed to continue the fight to get more community memebers to use seat belts. This will ultimatley reduce the number of fatalities due to MVA that can be saved by simply using a seat gelt.

Age Trend of First-Time Mothers and the Implications for a Central Oregon Community Clinic
Date of project: 8/18/2003

Young motherhood carries with it not only risk factors for the mother and the child, but it also serves as a proxy for a number of social, economic, and behavioral risk factors contained within the community. This has implications for the mothers and their children, as well as places demands on the healthcare system and community resources. While the national trend is that women are becoming mothers at an older age1, an investigation into the trend for a Central Oregon community clinic had never been done. By examining prenatal visit records, I found that though the number of young mothers has not increased over the past decade, it has not significantly decreased. The number of very young and late teen mothers has declined, however the number of 17-18 year olds who become pregnant has increased over the past decade. Furthermore, because the entire youth population is increasing out of proportion to older age cohorts, the average age of motherhood is decreasing. In addition, I verified the presumption that women who first become pregnant at a young age do tend to have more children than women who become pregnant when older. These findings suggest that the factors that are influencing women to delay motherhood on the national level are not acting on a local level. This study does not investigate the intent of pregnancy and young motherhood among this community, nor the many potential socioeconomic and behavioral factors that have been associated with young motherhood. Hopefully, this project will serve as an entrance into an issue that deserves further attention.

Warm Springs Health and Wellness Center Preliminary Mortality Review 2001
Date of project: 3/24/2003

Mortality studies are an important tool to understand healthcare issues pertinent to a community. The present project is a mortality review of patients at the Warm Springs Health and Wellness Center, in Oregon, who died in 2001. Information recorded included: immediate cause of death, age of death, sex, if restrained in MVA and associated co-morbidities including alcohol, smoking, Hepatitis C and HIV. Results were compared with US, IHS, Oregon and previous Warm Springs’ mortality data. The average age of death, 52.3 years, was comparable to Warm Springs’ 1991-2000 data, 46.7 (40.6-53.2), and was predictably lower than the US life expectancy in 2000, 76.9. The top 4 categories of death were 1) cancer, 2) chronic liver disease, 3) diseases of the heart and 4) accidents. While dramatic shifts can be seen in yearly mortality reviews, the data suggests that the local healthcare system is making an impact on certain diseases, such as diabetes.

Herbal and Complementary Medicine Use in a Native American Community
Date of project: 9/23/2002

BACKGROUND: Although the use of complementary medicine is known to be extensive in the general American population, the role of alternative treatment in this Native American community has not been described. OBJECTIVE: To determine the prevalence of use of complementary medicine, reason for use, how the patient first learned of the complementary treatments, sources of reliable information on alternative therapies used by the patient, and whether or not they had previously been asked about unconventional treatment by clinic personnel. METHOD: Cross-sectional interview of 21 patients seen in an Indian Health Service ambulatory care clinic. Herbal and alternative treatments were compared to prescription medications obtained by chart review to identify any interactions. RESULTS: Fifty-seven percent of individuals interviewed had used herbal medications or alternative treatment modalities at least once in their lifetime. Patients were likely to continue using herbal and alternative treatments if their initial treatment was felt to be effective, even if later treatments proved to be ineffectual. Herbal and complementary medicine ws used most often for health promotion, family and tribal tradition, and religious practice, as well as chronic conditions such as low back pain, migraine headaches, diabetes mellitus, and depression. Family and tribal traditions was found to be the most common source for first-time patient exposure to herbal and alternative therapies, followed by internet, friends, media advertising, and employers. Nearly half (48%) of all patients would look first to their family physician for reliable information on herbal and complementary treatments. While over half of clinic patients interviewed reported using herbal or alternative treatments sometime in their lifetime, only 5% had ever previously been asked about herbal and complementary medicine use by personnel in the clinic. CONCLUSION: Use of unconventional treatments is common among patients in this Native American community. Patients demonstrate a willingness to discuss use of herbal and complementary therapy and have an expectation that their medical providers will be knowledgeable about these treatment options. Unconventional treatment use is not related to patient dissatisfaction with conventional medicine and patients perceive no conflict between these different health system beliefs.

Ranking of IHS Community Health Objectives and Community Health Issues Identified by Warm Springs Residents.
Date of project: 11/5/2001

Each year, the Clinic Directors of the Portland Area Indian Health Service formulate a "Clinical Objectives for Fiscal Year - SES Workplan" (see pages 2-4). It is a list of important topics of focus for improving the health of the communities served by the IHS clinics. This project was an attempt not to determine the extent to which these objectives are being met, as that is done regularly through chart review by IHS employees, but rather to ask the question of residents of Warm Springs: What do you feel are the Community Health Issues most affecting you and those around you? To that end, a survey (or, more accurately, two surveys, as the original was revised following review of responses) was presented to patients and staff at the Warm Springs Health and Wellness Center. Respondents were asked both to rank the objectives identified by the Area clinical directors and to add others which were not listed.

Creating Culturally Appropriate Materials To Encourage Drinking Water On The Warm Springs Reservation.
Date of project: 9/24/2001

The potency of providing health care in a manner that is consistent with people's cultural traditions is becoming evident to many. Those in attendance at the Barbados III conference held in Rio de Janeiro in 1993 go beyond deeming such practice powerful; they declare that people have a right to receive such care and to have their own health care practices disseminated: "Indigenous people have an undeniable right to their history and cultural heritage. The medical establishment should... collaborate in a more decisive and committed way in the formulation and application of preventative health policies, including the legitimation of ethno-medicine as a fundamental contribution of ethnic culture for all humanity. I am not yet knowledgeable enough about allopathic medicine to legitimize ethno-medicine with any authority. However, I certainly agree that "(i)ndigenous people have an undeniable right to their history and cultural heritage" and am aware that scientists who have investigated indigenous medical practices have discovered that they often make sense from a scientific cultural perspective. Thus, when the nutritionist at Warm Springs asked me to design posters that would encourage water drinking, I was excited about attempting to do so in a way that honored the cultures of the three nations on the reservation. In this paper I will first give a demographic, historical and philosophical context to my project and then will discuss the project itself.

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