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North Coast Breast Health Community Assessment: Needs, Assets and Opportunities

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This is a community breast health needs assessment of Oregon's North Coast.

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North Coast Breast Health Community Assessment: Needs, Assets and Opportunities

  1. 1.       OHSU Knight Cancer Institute North Coast Breast Health Community Assessment:  Needs, Assets and Opportunities  September 30, 2011  Revised December 21, 2011        Developed by:  Lisa Domenico and Dolly England   Funded by NCI grant 3P30CA069533‐13S19 
  2. 2. Acknowledgements We would like to thank the following people for their contributions to this report.  American Cancer Society: Gretchen Renggli; Hillary Orr  Area Health Education Center (AHEC): Karen Bondley; Monica Di Pietrantonio  Columbia County Health District: Lori Peterson  Columbia County Women’s Resource Center: Rachael Barry-Dame  Columbia Memorial Hospital: Nancy Magathan  Clatsop County Health Department: Belinda Kruger, Margo Lalich, Steven Blakesley  Lincoln County Breast Health Coalition  Lincoln County Health and Human Services: Joell Archibald; Rebecca McBee-Wilson; Liz Young  North Lincoln Hospital: Johneen Benham  OHSU Center for Women’s Health: Michelle Berlin  OHSU Let’s Get Healthy Program: Lisa Marriott; Adam Lipus; Stephano Cetola  Oregon Breast and Cervical Cancer Program: Kathy Mix  Oregon Office of Rural Health: Emerson Ong  Samaritan Health Systems: Emily McNulty  Susan G. Komen for the Cure, Oregon and SW Washington affiliate: Gail Brownmiller  Samaritan Pacific Health Services: Rebecca Fransham-Mercer; Ursula Marinelli; Lorie Williams  The Rinehart Clinic: Suzie Whalen  Tillamook County Breast Health Coalition  Tillamook General Hospital: Ginny Gabel  Tuality Health Care: Mary Mulholland  Women’s Cancer Coalition of Linn, Lincoln and Benton Counties: Cindy McConnell Use of the contents of this report is permitted without prior approval with attribution to:Domenico, Lisa J, England, D (2011). Oregon North Coast Breast Health Community Assessment:Needs, Assets and Opportunities. Knight Cancer Institute at Oregon Health & Science University.For more information about this report, please contact Dolly England at englandd@ohsu.edu or 503-494-3389 or Lisa Domenico at domenico@ohsu.edu or 503-418-5332.   OHSU Knight Cancer Institute                                          September 30, 2011  2 
  3. 3.  List of Appendices Appendix A Breast Cancer Incidence and Mortality- Oregon State Cancer Registry (OSCaR) and Mammography Screening Rates-Behavioral Risk Factor Surveillance Survey (BRFSS)Appendix B Oregon Office of Rural Health (ORH): Demographics: Population of Rural Women by AgeAppendix C Oregon Office of Rural Health (ORH): Poverty Levels/Minority PopulationsAppendix D Breast Health Network Appendix E Key Informant Interview Questions   OHSU Knight Cancer Institute                                          September 30, 2011  3 
  4. 4. North Coast Community Assessment:                Needs, Assets and Opportunities This breast health resource and needs assessment was conducted by our Community Health Educator (CHE)in 2011, specifically targeting Oregon’s North Coast counties of Columbia, Clatsop, Tillamook and Lincoln. Weused the following community assessment, constructed by county, to drive the development of a 4-yearoutreach plan. Our intent is to impact the cancer health disparities, beginning with breast cancer, using aninnovative and interactive intervention called “Let’s Get Healthy!” (LGH!) and involving our CHE to affectchange in these communities using data and relationships built through this process. Our scope is the cancerrisk reduction and screening practices of Hispanics and lower socioeconomic populations of theaforementioned counties but to also share our learning’s with others engaged in improving the burden of breastcancer in their communities.Data sources for Needs Assessment The development of our needs assessment is built upon a foundation of prior statewide data collection andanalysis and adds an in-depth examination of specific rural communities. We focus on four rural counties –Columbia, Clatsop, Tillamook and Lincoln – obtaining data from a myriad of sources to develop a richerunderstanding of the breast health/cancer issues and assets of these communities. The specifics of our datacollection process are noted below.General background information was collected for each county from multiple sources including OregonBluebook1 for county history information, major employers listed on local government web pages, economicdevelopment alliances and community events from the Oregon Festivals & Events Association. The OregonOffice of Rural Health (ORH)2 was a significant source of data. ORH defines rural as “a geographic area ten ormore miles from a population center of 30,000 or more.” They provided 2010 county demographics, such asthe number of age-appropriate rural women for mammography screening, the largest rural communities,poverty data, federal designations (e.g. medically underserved), as well as income, race and ethnicity data.From the Oregon State Cancer Registry (OSCaR), we acquired county-level average annual breast cancerincidence and mortality counts3, and late stage diagnoses data.4 OSCaR identified any statistically significantfigures. The Behavioral Risk Factor Surveillance Survey (BRFSS) provided the percentage of women reportinghaving received a mammogram in the past two years5 (See Appendix A). Driving times to mammography siteswas obtained from a statewide mammography capacity survey and analysis conducted by the t Knight CancerInstitute’s Regional Cancer Control Strategies (RCCS) team in 2009. We derived driving time to the eachmammography site using zip codes. (These county-specific maps are included in the individual countyprofiles.)We utilized Catholic Healthcare West’s Community Need Index (CNI) maps6, developed in partnership withThomson Reuters. Using a four-point scale to identify severity of need, the CNI maps pinpoint neighborhoods(by zip code) with significant barriers to health care for each county in our target area (These county-specificmaps are included in the individual county profiles.) Rather than relying solely on public health data, the CNIaccounts for the underlying social and economic barriers that affect overall health. Using a combination ofresearch, literature, and experiential evidence, Catholic Healthcare West identified the following five prominentsocio-economic barriers to quantify health care access in communities.OHSU Knight Cancer Institute                                          September 30, 2011  4 
  5. 5. 1. Income – percent of elderly, children, and single parents living in poverty. 2. Cultural/Language – percent of adults over the age of 25 with limited English proficiency 3. Educational – percent without high school diploma 4. Insurance – percent uninsured and unemployed 5. Housing – percent renting housesIn addition we looked at the population of rural women by age, socioeconomic status and race/ethnicity; alldata provided by the Office of Rural Health and the 2010 Census. (See Appendix B & C).Finally, we compiled a “breast health network.” We collected breast health/cancer medical services (e.g.hospitals, Federally Qualified Health Centers, mammography sites, Health Departments). Also included areproviders of the Oregon Breast and Cervical Cancer Program (OBCCP) that help low-income, uninsured, andmedically underserved women gain access to lifesaving screening programs for early detection of breast andcervical cancers (See Appendix D). The OBCCP served 7,840 women statewide through approximately 120enrolling providers. A significant and important component of our CHE’s effort was conducting key informantinterviews to learn of specific programs/activities and successes/concerns at the local level. A list of contactswas developed from current relationships, Komen grantees and by asking for names of additional key players.We developed a question set (see Appendix E) but also allowed the conversation to be driven by communitymembers. Already this process has begun to build relationships and engage more directly with those interestedin addressing the breast health needs in their communities.Summary Findings Overall, the North Coast has great need but also tremendous potential. With the exception of one county,mammography sites are housed within hospitals. There are strong connections between the hospitals, clinicsthat provide primary care to low income or under-screened women, and the community organizations whoseek to drive women to those services. Much of the breast health outreach and education has been supportedby community grants from the local affiliate of Susan G. Komen for the Cure. In these rural communities, thework has been largely done by staff of hospitals or clinics, some only to their patients, others to the broadercommunity. A few have been able to incorporate their grant-funded program into operational budgets, whileothers risk losing their programs if not funded by Komen. Many of the programs are repeated each year, oftenduring Breast Cancer Awareness month in October. A number of key informants recognize the need to reachthe low income and Hispanic residents in their communities. A few have connected with food banks, domesticviolence shelters or laundry mats to provide resources and information; however, there has not been greatsuccess reaching Hispanic populations. Many have asked for additional resources, particularly materials thatare free/low cost, written for low literacy levels or in Spanish.   OHSU Knight Cancer Institute                                          September 30, 2011  5 
  6. 6. Columbia County   Summary Columbia County, named for its location along the ColumbiaRiver, was created in 1854. It encompasses almost 700 squaremiles, with 62 of those miles being Columbia riverfront. TheChinook and Clatskanie Native Americans inhabited this regionfor centuries prior to the arrival of Robert Gray, captain of theship Columbia Rediviva, in 1792. (There are no designated triballands in the county today.) The Lewis and Clark Expeditiontraveled and camped along the Columbia River shore in the area later known as Columbia County in late 1805and on their return journey in early 1806. 7Columbia County has a strong economic heritage centered on forest products, shipbuilding, mining andagriculture industries. The extensive stands of old growth timber, which had attracted many of the early settlersto the area, were completely logged by the 1950s. Second growth timber provides the raw material for locallumber and paper mills. The Trojan Nuclear Plant, located near Rainier, was in operation from 1975 to 1993.8 The Columbia River is a major route for ocean-going vessels and is a popular playground for fishing, boating,camping and windsurfing. The rural lifestyle and scenic beauty of Columbia County, coupled with its proximityto Portland, have drawn many new residents to the area. 9 Today, the majority of the population lives in threerural cities – Clatskanie, St. Helens and Vernonia. All are designated Health Professional Shortage Areas(HPSA) for Geography and Population. Vernonia is a Medically Underserved Area/Population area andClatskanie has an Oregon Office of Rural Health (ORH) designation of unmet need.10  Based upon access tohealthcare, the town of St. Helens has the greatest need.Breast cancer resources are limited in Columbia County including a high provider turnover rate (as commentedby a key informant), a singular mammography screening site, lack of a community hospital (often the hub ofoutreach activity), no dedicated resource to coordinate services to low income women through the OregonBreast and Cervical Cancer Program (OBCCP), and limited inventory of printed educational materials.However, this county also has access to the only mobile mammography van in the state. Our contacts at theHealth Department and Women’s Resource Center (WRC) would be willing to distribute any breast healthmaterials, but do not have current resources to actively conduct any outreach. In addition, Public Health iscurrently undergoing some organizational changes which may limit their ability to contribute to any outreachefforts.Geography and Demographics There are three major rural population centers in the county - Clatskanie, St. Helens and Vernonia. The total rural population of the county is just under 50,000 people. The percentage of women of mammography screening age is comparable to the state averages as noted below in Table 1. A small Hispanic population resides in this county. However, the percentage of households living below 200% of the FPL ranges from 22-28% in the largest towns of Clatskanie, St. Helens and Vernonia (Table 2). All have a Health Professional Shortage Area (HPSA) designation for Geography and Population. Vernonia has a Medically Underserved Area/Population areas designation, and Clatskanie has an Office of Rural Health (ORH) designation of unmet need.11   OHSU Knight Cancer Institute                                          September 30, 2011  6 
  7. 7. Table 1 Population of Rural Women by Age Ages 45-64 Ages 65-74 Ages 75+City # % # % # %Clatskanie 2,035 30.8% 565 8.5% 417 6.3%St. Helens 5,047 29.5% 1,290 7.5% 975 5.7%Vernonia 509 27.3% 137 7.3% 83 4.4%Oregon 27.6% 7.8% 7.7%(Appendix B)  Table 2 Poverty Levels/Minority Populations  % Below 200% % for Largest % for % in ORCity FPL* County Minority CountyClatskanie 27.2% 23.5% Hispanic 2.9% 11.75%St. Helens 22.1% Hispanic 4.5%Vernonia 27.9% Hispanic 2.4%Rural 33.3%Oregon 29.6%*Federal Poverty Level(Appendix C) OHSU Knight Cancer Institute                                          September 30, 2011  7 
  8. 8. The Community Need Index (CNI) map, which indicates neighborhoods with significant healthcare barriers,has pinpointed the greatest need in the northeast portion of the county, especially in St. Helens (zip code97051).  Breast Heath Network There are no hospitals located in this county. The local health department is undergoing a transition to a non-profit organizations and it is unclear whether they will continue to offer the current breadth of services(Communicable Diseases, Emergency Preparedness, Environmental Health, Immunizations, School-BasedHealth Centers, Sexually Transmitted Disease Program, Tobacco Prevention Education, Women, Infants,Children (WIC) program). There is a primary care clinic, associated with a health system, located in St. Helenswhich provides the county’s only mammography facility (Table 3).OHSU Knight Cancer Institute                                          September 30, 2011  8 
  9. 9. Table 3 Name of Organization Location Type Columbia County Health District St. Helens Public Health Department Legacy Imaging Services at St. Helens St. Helens Mammography Site Oregon Health & Science University-Family Scappoose Primary Care Clinic Medicine ClinicMammography and Breast Cancer The county’s one mammography site is within a 30 minute drive if a woman lives along the I-5 corridor.However, there are sections within this county that are less densely populated that would require drivinggreater than 30 minutes each way. Columbia County has two OBCCP providers and a very limited number ofOBCCP allocations. Locally, most clients who utilize the program receive an annual exam and are referred tonearby mammography site in Multnomah County. Map created by:  Domenico, Lisa J. (2009), Knight Cancer Institute at Oregon Health & Science University   OHSU Knight Cancer Institute                                          September 30, 2011  9 
  10. 10. In this county, neither the incidence not mortality rates are statistically higher than the state average. Basedupon a five-year average, 34 women are diagnosed with breast cancer and 6 die annually.12 (See Table 4)Table 4 Mammography Female Incidence Female Mortality Women MMG Cases Per 100,000 % Late Cases Per 100,000 40+ Screening per (age Stage per Year (age Rate Year adjusted) Diagnosis adjusted) Columbia 12,338 74% 34 134.3 27% 6 23.0 Oregon 913,828 73.3% 2,707 131.9 27%* 511 23.9 Population estim ates: US Census Bureau, Am erican Com munity Survey (ACS) 2006-2008; ++ US Census Bureau, Population Estim ates 2008 data set Screening Data: BRFSS 2004-2007 Age Adjusted data Incidence & Mortality data: SEER 2002-2006 data, State Cancer Profiles Late stage diagnosis: OSCaR 1996-2006 ^ Rate/trend is not calculated due to instability of small num bers *Statistically Significant County (H=High, L=Low) + % Based upon lesds than 50 respondents, may not accurately reflect county  (Appendix A)Community Resources While there is recognition of need by our community contacts, there are no current resources to activelyengage in outreach. When the situation changes, there are a number of community events and worksites thatcould be targeted as noted below.Community Events of Interest  July: Columbia County Fair and Rodeo (St. Helens) July: Clatskanie Blues Festival (Clatskanie) September: Scappoose Sauerkraut Festival (Scappoose) October: Halloween Town (St. Helens) December: Christmas Ships Parade & Tree Lighting (St. Helens)Major Employers (100 + Employees) 13  Manufacturing (2,230) Government (2,175) Retail trade (1,908) Health care and social assistance (1,489) Accommodation and food services (1,166) Other services except public administration (1,092) Real Estate, Rentals, Leasing (1015) Construction (916) Transportation and warehousing (722) Administrative and waste services (717)      OHSU Knight Cancer Institute                                          September 30, 2011  10 
  11. 11. Key Informant Interviews Our key informant interviews were conducted in May 2011 by our Community Health Educator. Sheinterviewed staff of the Health Department, a women’s domestic violence resource center and the mobilemammography van who provides services in this county.1. Columbia County Health District - St. Helens, OR Lori Peterson: Office Manager, Family Planning/Prenatal Billing May 26, 2011Columbia County Health District (CCHD) is Columbia County’s only safety net clinic providing valuableresources for underinsured and uninsured residents. Their program is currently under transition as thedepartment changes from a publicly funded Health Department into a privately funded non-profit. CCHD is anOBCCP provider. They provide mammography screening to approximately five women per quarter, which fallsshort of the need. As with any county, they can request additional resources from the State. They utilize anurse practitioner two times per week to perform all the women’s health exams. As noted earlier, the onlymammography site is located at Legacy Imaging Services in St. Helens, so women are referred to that site orto Portland, a 28 mile drive, for their imaging.Strengths They are the health care resource to low-income/vulnerable populations within their community.Challenges Transportation: o The County’s transportation system “CC Rider” has limited services often requiring women to make multiple transfers before getting to their final destination. Therefore, a one hour medical appointment could take significantly longer via public transit. Limited healthcare resources: o No OBGYN in Columbia County o Legacy clinic only accepts insured clients. o Our informant feels there is a high provider turnover rate in all specialties.Outreach Activities Educational Trainings Outreach/Education- Most is done in clinic at the Health Department.Partnerships Provider for the Oregon Breast and Cervical Cancer Program (OBCCP)         OHSU Knight Cancer Institute                                          September 30, 2011  11 
  12. 12. 2. Tuality Health Care, Vernonia, OR Mary Mulholland, Mobile Mammography Coordinator May 24, 2011Tuality operates the only mobile mammography van in Oregon.Staffed by one technologist and one nurse, they performscreening exams only, no diagnostics. Currently the van isequipped with analog technology, but there are near term plansto convert to digital imaging.The mobile van targets mainly insured or private-pay patients. Few, if any, are uninsured women. The van isstationed most days in the parking lot of Tuality Health Care in Forest Grove (Washington County), providinggreater convenience to its patients than a hospital appointment. However, it does travel monthly tocommunities within an approximately 25 mile radius of Tuality Health. The mobile van staff partners withclinics, businesses, senior centers and others to provide mammography services for health fairs or othergatherings. Appointments are pre-scheduled and organizations must recruit ten or more patients for eachevent. They have current screening event partnerships with Nike, Intel and Fred Meyer and Coffee CreekCorrectional Facility. Most of the marketing for an employer screening event involves encouraging the businessor organization to put information about the mobile mammography screening event on their website, send outinformation via an all staff email or place posters on employee bulletin boards. In partnership with theProvidence Health System, the Tuality van goes to once per month to their clinic in Vernonia, which has on-sitemammography capabilities. While this is an added local resource, it is not available to women in other parts ofthe state.Tuality Health is an OBCCP provider and serves a diverse group of women -- 25% of clients are non-Englishspeaking, most are Hispanic and Spanish speaking, as well as Asian/Pacific Islander and Russian/Slavicwomen. No interpreter services are provided. One of the commonly visited workplaces is Intel, where many ofthe non-English speaking women screened are the wives of employees originally from India. Strengths  They developed an approach for doing outreach to insured women  Have the State’s only mobile mammography van. Challenges  Feel providers need more education around “when to screen”      Outreach Activities Partnerships  Provider for the Oregon Breast and Cervical Cancer Program (OBCCP)  Mobile van to workplaces: Nike, Intel, and Fred Meyer  Coffee Creek Correctional FacilityOHSU Knight Cancer Institute                                          September 30, 2011  12 
  13. 13.  3. Columbia County Women’s Resource Center, St. Helens, OR Rachael Barry-Dame, Director May 26, 2011The Columbia County Women’s Resource Center (WRC) is an organization dedicated to endingfamily violence and sexual assault. Their program includes The Starting Place, which is a 22-bed shelter forwomen and children who have experienced domestic and sexual abuse. The shelter is a safe haven wherewomen can begin to put their lives back together following traumatizing relationships. Their trained team ofadvocates provides 24-hour services to victims and their families. They are there to listen and offerwhatever information and support they can.Normas Place Thrift Shop supports the Resource Center by providing funding for programs and services,giving job training to those in need, and offering low-cost items for sale to the community. The ColumbiaCounty Women’s Resource Center provides NO direct clinical services. Rachael feels the Women’sResource Center doesn’t have the capacity to do breast health outreach, but would stock and distributeresources to her cliental. She would be interested in doing some kind of partnership with us on anawareness event. Some data she offered:  Large faith communities in Rainer and Clatskanie  22,000 people living in unincorporated area of the county  70% commute outside of the county everyday to work  People travel outside the county for health services o Rainer or Clatskanie residents are likely to go to Cowlitz County, WA o Vernonia residents seek services in Washington County o St. Helens/Scappoose residents seek services in Multnomah County o Rainer is a hot place for Bingo! Proceeds benefit WRCStrengths  WRC has a good sense of the people within the community and how they seek out social services.  Open to discussing education outreach collaboration.Challenges  No capacity for breast health outreach.  Cliental may not feel breast health is a current priority.Outreach Activities Events  13 Nights on the River- Live music and market every Thursday during the summer.Partnerships  They offer job training via Norma’s Place with Oregon Department of Health Services (DHS).  Community Action Team (CAT) is a local resource for housing and energy assistance. They provide services to veterans and operate head start and other early childhood learning programs.  Family Violence Council is a group that is made up of local social services organizations as well as the commission on families, DHS and the District Attorney’s office.OHSU Knight Cancer Institute                              September 30, 2011    13 
  14. 14.  Clatsop County  Summary  Located in the most northwestern corner of the state,Clatsop County encompasses just over 1,000 squaremiles bordered by the Pacific Ocean to the west andColumbia River to the north. The county gets its namefrom the Clatsop tribe of Native Americans, who livedalong the coast of the Pacific Ocean prior to Europeansettlement. The Lewis and Clark Expedition stayed forthe winter of 1805-6. Astoria, Oregons oldest city wasestablished as a fur trading post in 1811 and namedafter John Jacob Astor. The first U.S. Post Office west of the Rocky Mountains was established in Astoria in1847. The summer resort of Seaside was founded by Ben Holladay in the early 1870’s after he constructedthe Seaside House, a famous luxury hotel for which the city was named. 14A popular point of interest is the Astoria Column, a tower 125 feet. It sits in a wooded area 600 feet abovesea level on Coxcomb Hill, Astoria’ s highest point. The column was built by the Astor family in 1926 tocommemorate the regions early history. 15 The forested coast range bisects the county creating travelobstacles during the winter months. Forest products, retail and tourism and are the major industries.The majority of the rural population lives in two cities along the western coastline. Both Astoria and Seasideare designated Medically Underserved Area/Population areas.16 The greatest needs to access healthcareare in the north and mid-section of the county, particularly Warrenton and near Astoria, and to a lesserdegree towards the south portion of the county.Due to our inability to connect with Providence Seaside, all of our key informant interviews were conducted inAstoria. Columbia Memorial Hospital in Astoria conducts a number of breast cancer outreach activities,funded for multiple years through Komen community grants, which are now part of the hospital’s programs.They understand the needs of their community but have limited resources. However, they are an eagercommunity partner for piloting our “Let’s Get Healthy!” intervention.Geography & Demographics  The largest rural communities in Clatsop County are all along waterways - Astoria, Cannon Beach, Gearhart, Seaside, Warrenton – with approximately 37,000 residents over 1,085 square miles. 17 As noted on the tables below (Table 1), the percent of women over 45, appropriate for mammography screening, is slightly higher than the state. Approximately a third of residents in Astoria and Seaside are below 200% of the Federal Poverty line (FPL), which is slightly higher than the state average. The greatest concentration of Hispanics is in Seaside at 9% of the population. (Table 2)OHSU Knight Cancer Institute                              September 30, 2011    14 
  15. 15.  Table 1 Population of Rural Women by Age City Ages 45-64 Ages 65-74 Ages 75+ # % # % # % Astoria 3,602 28.8% 1,127 9% 1,131 9% Seaside 1,985 31.2% 693 10.9% 728 11.4% Oregon 27.6% 7.8% 7.7%(Appendix B)  Table 2 Poverty Levels/Minority Populations  % Below 200% % for Largest % for % in City FPL* County Minority County OR Astoria 31.5% 31.9% Hispanic 5.9% 11.75% Seaside 31.9% Hispanic 9% Rural 33.3% Oregon 29.6%*Federal Poverty Level(Appendix C)                 OHSU Knight Cancer Institute                              September 30, 2011    15 
  16. 16.  To indentify the greatest need in the county, the Community Need Index maps indicate a needed focus in thenorth and mid-section of the county, particularly Warrenton (zip code 97121 and 97146) and near Astoria (zipcode 97103), and to a lesser degree to the south (zip code 97138).    Breast Health Network There are two major health systems in this county, both along the coast, that provide the cancer screeningand treatment services for the county -- Columbia Memorial Hospital in Astoria to the north and ProvidenceHospital in Seaside to the south. There is a strong collaboration between Columbia Memorial Hospital andOHSU Knight Cancer Institute for oncology services. These hospitals are the mammography screening sitesin the county. Astoria has the only low-income health clinic and three of the four OBCCP providers in thecounty. (See Table 3)  OHSU Knight Cancer Institute                              September 30, 2011    16 
  17. 17.  Table 3 Name of Organization Location TypeColumbia Memorial Hospital Astoria Hospital Komen Grantee Mammography SiteClatsop County Health Department Astoria Public Health DepartmentCoastal Family Health Astoria Federally Qualified Health CenterProvidence Seaside Hospital Seaside Hospital Komen Grantee Mammography SiteMammography and Breast Cancer As noted above, there are two places a woman can obtain a mammogram – in Astoria and Seaside. As themap below depicts, if a woman lives in the northwest corner of this county, her one-way drive is within 30minutes of a mammography site. However there are sections within this county that are less denselypopulated that would require a drive greater than 30 minutes each way, mainly the southern portion of thecounty.     Map created by:  Domenico, Lisa J. (2009), Knight Cancer Institute at Oregon Health & Science University      Legend: 61 to 180 minutes 31 to 60 minutes 0 to 30 minutes OHSU Knight Cancer Institute                              September 30, 2011    17 
  18. 18.  Oregon consistently ranks in the top 10 states for incidence and mid-range for mortality, so while neither theincidence nor mortality is statistically higher compared to that state average, there is significant burden ofbreast cancer in this county. (See Table 4)Table 4 Mammography Female Incidence Female Mortality Women MMG Cases Per 100,000 % Late Cases Per 100,000 40+ Screening per Year (age adjusted) Stage per Year (age adjusted) Rate Diagnosis Clatsop 10,021 64.0% 32 132.5 30% 7 28.0 Oregon 913,828 73.3% 2,707 131.9 27%* 511 23.9Population es tim ates : US Cens us Bureau, Am erican Com m unity Survey (ACS) 2006-2008; ++ US Cens us Bureau, Population Es tim ates 2008 data s etScreening Data: BRFSS 2004-2007 Age Adjus ted dataIncidence & Mortality data: SEER 2002-2006 data, State Cancer ProfilesLate s tage diagnos is : OSCaR 1996-2006^ Rate/trend is not calculated due to ins tability of s m all num bers*Statis tically Significant County (H=High, L=Low)+ % Bas ed upon les ds than 50 res pondents , m ay not accurately reflect county  (Appendix A)Community Resources Much of the cancer awareness/outreach in the county is associated with the American Cancer Society (ACS)Relay for Life event and the outreach efforts of Columbia Memorial Hospital, both in Astoria. While SeasideProvidence Hospital is a large health system and presumably has their own outreach programs, to this pointwe have been unable to make direct connections with them to include their activities in our report. The majorcommunity events are in the summer months in the coastal communities of Astoria and Seaside. There arenumerous worksites that employ a large number of people which could provide outreach opportunities.Community Events of Interest  April: Astoria/Warrenton Crab, Seafood and Wine Festival June: Astoria Music Festival June: Seaside Beach Soccer Tournament July: All coastal towns have an event for the 4th July: 2011 Relay For life of Clatsop County (Astoria) August: Annual Seaside Beach Volleyball Tournament (30 years!) September: Seaside Wheels & WavesMajor Employers (100 + Employees) 18  Georgia-Pacific (1,038)  Costco (100) State Agencies (430)  Seaside School District (187) Clatsop County (224)  Safeway (two locations) (180) Pig N Pancake (80 up to 130 Seasonal)  Steve Martin Management (24) U.S. Coast Guard (391) Astoria School District (249) Columbia Memorial Hospital (240) Fred Meyer (220) Safeway (two locations) (180) Weyerhaeuser Co. (155) Clatsop Community College (145) Pacific Coast Seafood Co. (125)OHSU Knight Cancer Institute                              September 30, 2011    18 
  19. 19.  Key Informant Interviews Our Community Health Educator was able to personally speak with breast health resources in Astoria only. Wewill continue to build this section more is learned.1. Columbia Memorial Hospital, Astoria, OR Nancy Magathan, RN; Breast Health & Cancer Resource Coordinator March 4, 2011Clatsop County has a champion for breast health outreach and education -- Nancy Magathan. She has built arobust breast cancer education program, first with Komen grant funding and now supported by the hospital.Her programs could be models for other hospitals looking to develop similar programs. According to Nancy, notall Clatsop residents seek care in the county, and instead travel to Pacific, Wahkiakum or Cowlitz counties inWashington State. Cancer treatment services are also sometimes sought at St. John Medical Center inLongview, WA (Cowlitz Co.), even though Columbia Memorial is closer.Strengths Successful in using print media for outreach. Placing ads in the local newspaper, “The Daily Astorian,” is a popular outreach method. Usually receive referral calls from local women within 48 hours of ad placement. Initially started with a Komen grant, the Breast Health education program is now financially supported by the hospital. They have added a Patient Navigator to their breast health program with funding from Susan G. Komen for the Cure, Oregon and SW Washington affiliate. The purpose of the grant is to assist women in the screening and treatment process.Challenges Columbia Memorial only has one outreach person so they are limited in the amount of outreach they can do. Hospital business practice requires a woman get a referral from her medical provider to obtain a screening mammogram. Some people living in Clatsop County seek services in Washington State. To inform women that they can access those same mammography and cancer treatment services in Clatsop County, Nancy uses newspaper ads and articles to reach women outside her area of direct contact. There is confusion about recent U.S. Preventive Services Task Force (USPSTF) mammography recommendations. Nancy stated that “most insurance companies follow recommendations of USPSTF so while a woman can get a mammogram at age 40, insurance may not cover the cost of the mammogram until she is 50.” She has heard this from women who see healthcare providers in Seaside. Outreach Activities  Direct Care Services Educational Trainings Assisting women to access screening services  Breast/Colorectal health (Quarterly) at hospital Health Fairs & Tabling EventsAwareness Events  County Employee Health Fair (Annually) Project Homeless Connect- (Annually)  Relay for Life (Annually)  County Fair (Annually)  CostcoOHSU Knight Cancer Institute                              September 30, 2011    19 
  20. 20.  Partnerships Provider for State of Oregon Breast and Cervical Cancer Program (OBCCP) Philanthropic Educational Organization Clatsop Community College Job Corps Women’s Resource Center Churches BusinessIndirect Newspapers: Daily Astorian (reaches 74% of Clatsop County including: Astoria, Warrenton, Gearhart, Seaside, Cannon Beach, Manzanita, Rockaway Beach; WA- Ilwaco, Sea view, Long Beach, Ocean Park Nahcotta and Oysterville.) Social Media/websites: http://www.y-me.org/ Hand Out’s: Patient reminder post card, breast health brochures etc.2. Clatsop County Health Department, Astoria, ORSteven Blakesley, Health Promotion SpecialistNovember, 2011Clatsop County Public Health is not currently involved with Oregon Breast and Cervical Cancer Program(OBCCP). The clinic does not do any breast cancer outreach or education as it is focused on family planning,STD/HIV testing, and immunizations. The public health program that is most aligned with the OBCCP is theHealth Promotion and Chronic Disease Prevention program. The focus is primarily on reducing chronic diseaseprevalence by promoting changes to policy and environments that support increased physical activity andhealthier food choices. The health promotion coordinator partners with both hospitals on various initiatives.Together with the Oregon Health Authority a colorectal cancer screening campaign was successfully piloted inClatsop County in 2010.Strengths  Facilitate broad base of partnerships throughout the north and south region of the county, e.g. ongoing partnerships with both Seaside Providence and Columbia Memorial hospitals  Worked in partnership to pilot Colorectal Cancer Screening Campaign in 2010  Strong network of community partners including local rep for American Cancer SocietyChallenges  OBCCP not supported through current grant funding   OHSU Knight Cancer Institute                              September 30, 2011    20 
  21. 21.  Tillamook County  Summary Tillamook County is the land of trees, cheese and ocean breeze! Thecounty was named after the Tillamook Indians who lived in the areassurrounding the Tillamook and Nehalem Bays. Tillamook is a NativeAmerican word meaning "Land of Many Waters." The major physicalfeatures of Tillamook County are a rocky and irregular coastline,stretches of coastal lowlands, and heavily timbered mountains of theCoast Range. With seventy-five miles of coastline, four bays, and ninerivers, recreational and tourist opportunities are numerous.19 Theforested Coastal Range divides the county east to west, where snowis common resulting in travel obstacles during the winter months.When early settlers saw these green valley’s in 1851, they recognizedthat Tillamook’s mild climate, abundant water, and year aroundpastures were perfect for raising dairy cattle. Dairy farming and timberare the countys most significant employment sectors; there are 150 family dairy farms and 93% of the countyis classified as forest land.The major rural communities are Medically Underserved Area/Population areas and have higher than stateaverage poverty levels. Its residents are generally older than those living in other parts of the state, andHispanics are the largest minority population.The county is served by one hospital, one mammography site and four, Federally Qualified Health Centers(FQHC). The FQHC in Wheeler conducts much of the community breast cancer outreach in this county fundedby Komen grants. There is a local breast health coalition made up mostly by hospital staff and other safety netclinics. Most of this groups activities are centered around October Breast Cancer Awareness Month, althoughthis group did collaborated with the Knight’s Regional Cancer Control Strategies team in 2009 to address acommunity concern surrounding confusion around the change in mammography screening guidelines.Statistically significant low mammography screening rates have been the issue the community has sought toaddress and therefore, may be an ideal community partner.     Geography & Demographics  Tillamook County encompasses just over 1,133 sq miles. The population of its rural communities is 25,250 with the majority living in three rural cities along the western coastline – Tillamook, Cloverdale, and Nehalem. All three are designated Medically Underserved Area/Population areas.20 The towns of Tillamook and Nehalem have a higher percentage of households living below 200% of the FPL at 38% and 37%, respectfully, than the state at 29.6%. (Table 1) As noted below (Table 2), the percentage of 65+ year old women is twice the state average and Hispanics represent the largest minority population and are concentrated in the town of Tillamook.OHSU Knight Cancer Institute                              September 30, 2011    21 
  22. 22.  Table 1 Poverty Levels/Minority populations  % Below 200% % for Largest % for % in City FPL* County Minority County OR Cloverdale 27.7% 35.6% Hispanic 5.2% 11.75% Nehalem 38.0% Hispanic 5.0% Tillamook 35.6% Hispanic 10.3% Rural 33.3% Oregon 29.6%*Federal Poverty Level(Appendix C)  Table 2 Population of Rural Women by Age Ages 45-64 Ages 65-74 Ages 75+ City # % # % # %Cloverdale 798 33.2% 275 11.4% 258 10.7%Nehalem 555 32.9% 256 15.2% 242 14.3%Tillamook 2,463 28.2% 907 10.3% 884 10.1%Oregon 27.6% 7.8% 7.7%(Appendix D) OHSU Knight Cancer Institute                              September 30, 2011    22 
  23. 23.  To target the greatest access need in the county, the Community Needs Index map identifies the communitiesof Wheeler (zip code 97136), Cape Meares (zip code 97141) and Bay City (zip code 97107).    OHSU Knight Cancer Institute                              September 30, 2011    23 
  24. 24.  Breast Health Network  There are four Federally Qualified Health Centers (FQHC) located in Cloverdale, Rockaway Beach andTillamook. Tillamook County General Hospital (in Tillamook) is the only hospital and mammography site in thecounty. There are only two OBCCP providers for the county to serve low income women. Name of Organization Location TypeTillamook County Cloverdale Clinic Cloverdale Federally Qualified Health CenterRockaway Beach Clinic Rockaway Beach Federally Qualified Health CenterTillamook County Health Department Tillamook Federally Qualified Health CenterTillamook County General Hospital Tillamook Hospital Mammography SiteRinehart Clinic Wheeler Federally Qualified Health Center Komen Grantee Mammography and Breast Cancer While there is one mammography site in Tillamook County located in the town of Tillamook, many residentscan drive to the mammography site in less than 30 minutes. Those in the northern portion of the county have a30-60 minute drive one way to Tillamook, but also have the option of driving north to Seaside into ClatsopCounty.     Map created by:  Domenico, Lisa J. (2009), Knight Cancer Institute at Oregon Health & Science University       OHSU Knight Cancer Institute                              September 30, 2011    24 
  25. 25.  While the county level incidence and mortality rates are numerically higher than the state average, they are notstatistically different. Based upon a five-year average, in this county just over 25 women are diagnosed withbreast cancer and 5 die annually.21 Until recently, Tillamook County had a statistically significantly lowermammography rate (55%) than the state average. That has improved based upon the most recent BRFSSdata (61%). However, there is a recognized community need to continue to address awareness and access tomammography for its residents, especially given its older female population. (Table 3)Table 3 Mammography Female Incidence Female Mortality Women MMG Cases Per 100,000 % Late Cases Per 100,000 40+ Screening per (age Stage per Year (age Rate Year adjusted) Diagnosis adjusted)Tillamook 7,198 61% 25 134.5 26% 5 25.0Oregon 913,828 73.3% 2,707 131.9 27% 511 23.9Population estim ates: US Census Bureau, American Com munity Survey (ACS) 2006-2008; ++ US Census Bureau, Population Estim ates 2008 data setScreening Data: BRFSS 2004-2007 Age Adjusted dataIncidence & Mortality data: SEER 2002-2006 data, State Cancer ProfilesLate stage diagnosis: OSCaR 1996-2006^ Rate/trend is not calculated due to instability of sm all num bers*Statistically Significant County (H=High, L=Low)+ % Based upon lesds than 50 respondents, may not accurately reflect county  (Appendix A)Community Resources Local efforts over the past 3-5 years have been focused on improving the mammography screening ratesthrough transportation assistance and awareness campaigns. Much of that outreach in the county isassociated with the Rinehart Clinic, an FQHC and a Komen grantee, located in Wheeler, as well as the BreastCancer Coalition located in Tillamook. While the latter group is small, they have been effective in localawareness raising and fundraising efforts to support breast cancer screening in their community. There are anumber of community events and workplaces that, along with the energy of the breast health coalition, mightbe suitable venues for our “Let’s Get Healthy!” intervention.Community Events of Interest  March: Great Oregon Spring Beach Cleanup (Entire Oregon Coast) May: Kite Festival (Rockaway Beach) June: Dairy Parade “Tillamook County, Butter than the rest!” (Tillamook) June: Tillamook County Rodeo (Tillamook) July: American Cancer Society 2011 Relay For life (Tillamook) th July: All coastal towns have an event for the 4 August: Tillamook County Fair (Tillamook)Major Employers (# of employees)  Dairy Manufacturing (474) Timber/Saw Mills (341) Meat Processing (275) Fresh and Frozen Seafood Processing (66)OHSU Knight Cancer Institute                              September 30, 2011    25 
  26. 26.  Key Informant Interviews  Our Community Health Educator was able to interview all the players for breast health/cancer outreach in thecounty. They include the FQHC, the hospital and the breast health coalition. In 2009, the Knight worked withthese same players to address a need they identified in their community – discussing the changes in themammography screening guidelines.1.  The Rinehart Clinic - Wheeler, OR Suzie Whalen: Breast Health Coordinator June 15, 2011Tillamook County has a champion for breast health outreach and education in Suzie Whalen at the RinehartClinic. She is knowledgeable about the screening issues in her community and is actively working to addressthem. She connects women with local, state and national resources and administers a transportationassistance program, made possible by a grant from Susan G. Komen, ACS and local fundraising efforts. Thisprogram provides a woman under 250% of the Federal Poverty Level (FPL) a $25 gas card to help to coverexpenses for a well woman exam, mammogram or follow up breast health procedures. In addition, they canprovide a gas card to any patient that requests help or has significant barriers, regardless of income level, toobtain her mammography screening or breast cancer treatment. This is significant as the average drivebetween Tillamook and Wheeler is 25 miles each way. In addition, the Rinehart Clinic organizes severalcommunity awareness events in October for Breast Cancer Awareness Month including a bra fashion show, artexhibit and fundraiser. Unlike many counties, Tillamook has an excess of OBCCP slots, potentially anindication of the lack of readiness of some the county’s low income women to obtain a mammogram.Tillamook General Hospital has a breast health educator one day per week via a partnership with the RinehartClinic that allows employee wellness events such as receiving their mammogram while “on the clock”. Womenalso receive a 15 minute neck and shoulder massage in addition to educational materials and other “pink”giveaways. Finally, the American Cancer Society holds an annual “Relay for Life” event to raise funds andincrease cancer awareness in the community.Strengths Started outreach with clinic patients. They had 17% compliance on screening rate and were able to increase it to 59%. Has successfully organized multiple fundraising/awareness events including a bra fashion show which is now being hosted by the local museum. Successfully implemented two Spa Days. Currently working on the third “Latina Spa Day” Rinehart clinic has a solid relationship with the local hospital Tillamook General Hospital including providing office space for the Rinehart Clinic breast health educator. They have a system for follow up with clients. Suzie works evenings 2 weeks per quarter to call Rinehart Clinic patients who are due for MMG. 1 day per month is spent following up with patients who have had an abnormal finding and require further diagnostics.Challenges Distance to mammography services (general transportation) Resources for men with breast cancer. (Currently there are three men with breast cancer in the county) Large deductible’s make receiving preventative screenings difficult for some women Suzie felt unsure about whether outreach information was getting to the patients via the providers and clinic staff (county-wide)OHSU Knight Cancer Institute                              September 30, 2011    26 
  27. 27.   Susie feels that people in this county will only seek care if they are sick, won’t go to the doctor for preventative care. She feels more patient education is needed. Lack of ability to fill all the OBCCP vouchers available. It seems they started with 12 OBCCP slots then increased to 35 slots. In 2010 they entered into a partnership with OHSU and their OBCCP slots increased again to 65. It seems they now have more slots than they can fill with their current outreach strategies. Lack of Spanish speaking staff. Poor attendance of a Latina Spa day (only four of the 35 slots were filled).Outreach Activities Direct Care Services Assisting women in setting mammography appointments Patient Navigator is available one day per week at Tillamook General Hospital to provide support services to women receiving breast cancer treatment at the hospital.Events October Breast Cancer Awareness Month Events including: bra fashion show and exhibit Spa DayEducational Trainings Provider and clinic staff education happens via an early morning breakfast that takes place in the clinics. This method of outreach seems to work well for giving providers and clinic staff updates to the breast health program locally.Health Fairs & Tabling Events They participate in a health fair that is part of the local County Fair. Approximately 500 women received educational materials last year.Partnerships Tillamook Creamery Tillamook General Hospital Churches Senator Betsy Johnson OHSU- Dr. Elizabeth Steiner School District Women’s Resource CenterIndirect News Paper: Tillamook Headlight Harold a free local newspaper- usually gets a few referrals from the advertisements. Flyers & PostersOHSU Knight Cancer Institute                              September 30, 2011    27 
  28. 28.  2. Tillamook General Hospital, Tillamook, OR Ginny Gabel: Community Health Education & Community Health Improvement Partnership (CHIP) Director June 15, 2011Ginny Gabel is a nurse and health educator at Tillamook General Hospital. She provides health education onvarious topics to patients and interested community members. Topics range from nutrition, to managingchronic illnesses, to breast cancer education. She also organizes various support groups including theWomen’s Cancer support group.Ginny conducts outreach throughout the county, although infrequently in South County. She has identifiedPacific City, located in south Tillamook County, as a tourist population. She is trying to reach residents and notthe transient tourist population. She thinks locals living near Pacific City may be seeking screening servicessouth in Lincoln City; or “over the hill” in Portland. In addition, Ginny feels that many people in TillamookCounty have a “What I don’t know won’t hurt me” mentality, especially when it comes to preventative cancerscreenings. People are VERY private, being a small community that they may be reluctant to allow others toknow what’s happening in their lives.Strengths  Ginny and the staff at Tillamook General know their community and the concerns they have around confidentiality. She understands their general health and mammography screening issues.Challenges  Not enough printed materials and other educational resources that talk about cancer and lifestyle/diet changes  Low Literacy rates  Low Health Literacy ratesOutreach Activities  Direct  American Cancer Society: Look Good Feel Better Program  Provides support to the Women’s Cancer Support GroupEducational Trainings  Quarterly Breast Cancer EducationPartnerships  Rinehart Clinic  American Cancer Society  Tillamook County Breast Health CoalitionIndirect/Trusted Resources  Book: “The Cancer Project” by Neal D. Barnard and Jennifer K. ReillyOHSU Knight Cancer Institute                              September 30, 2011    28 
  29. 29.  3. Tillamook County Breast Health Coalition, Tillamook, OR June 15, 2011Our Community Health Educator was invited by Suzie Whalen to participate in the Tillamook County BreastHealth Coalition meeting which took place at Tillamook General Hospital. It was a small group that met, butrepresentatives from Tillamook General Hospital, The Rinehart Clinic, Area Health Education Center (AHEC)and American Cancer Society (ACS) were present. We learned about the groups collaborations with ACS,Tillamook General Hospital and the Rinehart clinic. They are in the process of planning a Latina Spa Day andwere looking for advice on how to outreach to the Latina community.In addition they were excited to share that the ACS program “Look Good...Feel Better” is now happening inTillamook County. “Look Good…Feel Better” provides a free two-hour workshop for women undergoing cancertreatment. This program helps improve the self-image, appearance, and quality of life of patients by teachingbeauty techniques to help cope with the temporary appearance-related side effects of cancer treatment.Overall this group is trying to work together to address the Breast Cancer issues within Tillamook County.While they may have limited participants, they have been effective in mobilizing the people, resources andpartnerships they do have.Strengths  Effective in mobilizing people, resources and partnerships within their communityChallenges  Small group of peopleOutreach Activities Events  Latina Spa Day (Tillamook)Partnerships  Tillamook General Hospital  Rinehart Clinic  American Cancer Society  Area Health Education Center  OHSU Knight Cancer Institute  North Lincoln Women’s Cancer Coalition   OHSU Knight Cancer Institute                              September 30, 2011    29 
  30. 30.  Lincoln County  Summary With miles of beach and coastline, Lincoln County is one of the most popularvisitor destinations on the Oregon Coast.22 Lincoln County encompassesalmost 1,000 square miles bordered by the Pacific Ocean. Named for AbrahamLincoln, 16th president of the United States, Lincoln County was created by theOregon Legislature in 1893. For the first decades of its existence, LincolnCounty was isolated from the rest of the state. The construction of U.S.Highway 101 (completed in 1925), and the Salmon River Highway (completedin 1930) created easy access to the more populated Willamette Valley. In 1936,as one of many federally funded construction projects, bridges wereconstructed across the bays at Waldport, Newport, and Siletz, eliminating theferries needed to cross these bays.Principal industries of the county are tourism, trade, health services and construction. Paper manufacturingand fishing are still important sectors, although they contribute proportionally less to the countys employmentthan in the past. Newport is one of the two major fishing ports of Oregon (along with Astoria) and ranks in thetop twenty of fishing ports in the U.S. The cities of Blodgett-Eddyville, Lincoln City, Toledo and Yachats aredesignated Medically Underserved Area/Population areas.23 Both Newport and Yachats have almost 40% ofhouseholds living below 200% of the FPL. The percentage of women 65+ years old is twice the state averagein Lincoln City, Waldport and Yachats. (Table 1)Lincoln County is served by the Samaritan Health System that operates two of its five hospitals in this county.There are Federally Qualified Health Centers, a health department and school-based health centers that servelow income women and their families. However, the breast cancer statistics reflect statistically significantly highrates for both of mortality in women 40 to 64 and late stage diagnoses in women over 65 years. There aremany outreach efforts across this county to raise money for screening services. It seems many things happenin the northern part of the county as well as the southern portion, however there seems to be little happening inthe middle section of the county. Geography and Demographics  The majority of the population, accounting for 46,000 residents, lives along the western coastline in one of seven cities. The female population in Lincoln City, Waldport and Yachats is proportionately older with 12-14% and 11-12% of the population of women 65-74 years and 75+, respectively, compared to approximately 7% statewide (Table 2). Hispanics are the largest minority population in many Lincoln County communities, but Newport has the highest concentration at almost 13%. The northern part of Lincoln County includes the Siletz Reservation, created by treaty in 1855. The reservation was open to non-Indian settlement between 1895 and 1925. The Siletzs tribal status was terminated by the federal government in 1954, but became the first Oregon tribe to have their tribal status reinstated in 1977. As a result, there is a significant Native American community, 16% of the county’s population, in Siletz. The current reservation encompasses 3,666 acres (15 km).24OHSU Knight Cancer Institute                              September 30, 2011    30 
  31. 31.  Table 1 Poverty Level/Minority populations  % Below % for % for City 200% FPL* County Largest Minority County % in OR Blodgett-Eddyville 36.0% 36.1% Hispanic 3.4% 11.75% Lincoln City 36.4% Hispanic 8.6% Newport 39.7% Hispanic 12.9% Waldport 34.5% Hispanic 3.7% Yachats 39.5% Hispanic 4.9% Siletz 31.1% Native American 15.9% 1.4% Toledo 30.7% Native American 3.5% Rural 33.3% Oregon 29.6%*Federal Poverty Level(Appendix C)Table 2 Population of Rural Women by Age25  City Ages 45-64 Ages 65-74 Ages 75+ # % # % # %Blodgett-Eddyville 211 27.6% 53 7.8% 48 7.6%Lincoln City 2,936 32.6% 1,092 12.1% 1,089 12.1%Newport 1,815 29.7% 632 10.3% 683 11.1%Siletz 342 29.8% 90 7.8% 70 6.1%Toledo 777 29.6% 189 7.2% 166 6.3%Waldport 1,226 34.4% 501 14.4% 391 11.3%Yachats 309 38.0% 116 14.2% 97 11.9%Oregon 27.6% 7.8% 7.7%(Appendix B)  OHSU Knight Cancer Institute                              September 30, 2011    31 
  32. 32.  Pinpointing need based upon access to healthcare, the Community Index map indicates highest need inNewport (zip code 97367), followed closely by Toledo (zip code 97391), Logsden (zip code 97357) and Neotsu(zip code 97364).    OHSU Knight Cancer Institute                              September 30, 2011    32 
  33. 33.  Breast Health Network  There are two hospitals from one health system in this community; Samaritan North Lincoln Hospital in thenorth and Samaritan Pacific Communities Hospital in the south. There are four low-income health clinics in thiscounty – three in Newport and one in South Beach – as well as multiple school based health centers (SeeTable 3).Table 3 Name of Organization Location Type Samaritan North Lincoln Hospital Lincoln City Hospital Mammography Site North Lincoln Women’s Cancer Coalition Lincoln City Cancer Coalition Samaritan Pacific Communities Hospital Newport Hospital Mammography Site Lincoln County Health and Human Services Newport Federally Qualified Health Center Newport Primary Care Clinic Newport Federally Qualified Health Center Centro De Ayudo Newport Federally Qualified Health Center Women’s Cancer Coalition of Linn, Lincoln Newport Cancer Coalition and Benton Counties South Beach Behavioral Health Clinic South Beach Federally Qualified Health CenterMammography and Breast Cancer There are two mammography sites in Lincoln County located in Lincoln City in the north and Newport in thesouth. For women who live in the cities and towns along the coastline, access to mammography is generallyless than 30 minutes one way. For those living in the hills or to the south, drive times increase to an hour ormore each way. The Coast Range which bisects the county north to south creates a travel obstacle during thewinter months with many on the east side traveling into Benton, Linn and Polk counties for services.    Map created by:  Domenico, Lisa J. (2009), Knight Cancer Institute at Oregon Health & Science University   OHSU Knight Cancer Institute                              September 30, 2011    33 
  34. 34.  Lincoln County has statistically significant high mortality rates, as well as late stage diagnoses. While thescreening rate is only 66% versus the state at 73%, this is not considered a significant difference. Based upona five year average for this county, 45 women are diagnosed with breast cancer and 11 die annually.26 Thepercentage of women over 45, appropriate for mammography screening, is slightly higher than the state. (SeeTable 4)Table 4 Mammography Female Incidence Female Mortality Women MMG Cases Per 100,000 % Late Cases Per 100,000 40+ Screening per (age Stage per Year (age Rate Year adjusted) Diagnosis adjusted)County 14,241 66% 45 130.8 31%* 11 31.0*Oregon 913,828 73.3% 2,707 131.9 27%* 511 23.9Population estimates: US Census Bureau, American Community Survey (ACS) 2006-2008; ++ US Census Bureau, Population Estimates 2008 data setScreening Data: BRFSS 2004-2007 Age Adjusted dataIncidence & Mortality data: SEER 2002-2006 data, State Cancer ProfilesLate stage diagnosis: OSCaR 1996-2006^ Rate/trend is not calculated due to instability of small numbers*Statistically Significant County (H=High, L=Low)+ % Based upon lesds than 50 respondents, may not accurately reflect county  (Appendix A)Community Resources Much of the cancer awareness outreach activities in the county are incorporated into fundraisers for localscreening programs. An annual Fashion Show put on by Pacific Communities Hospital Foundation raisesmoney for the screening services at Samaritan Pacific Communities Hospital. They have also been successfulin implementing a Surviving to Thrive program for survivors in their community. In North Lincoln County, AreaHealth Education Center (AHEC) and North Lincoln Hospital partner with a group of local business women whoput on a similar fundraiser. American Cancer Society programs are also visible here with Relay for Life being asuccessful event in this community. The Women’s Cancer Coalition of Linn, Lincoln and Benton Counties are atri-county partnership to address women’s cancers within their community. This group has implemented ascreening event in Benton County called “Mammathon” which successfully screened 100 women in one daylast year. They hope to bring this program to Lincoln County. There is also an active Community HealthImprovement Program (CHIP) that addresses many local health issues including breast health/cancer. Thereare year-around community events and large employers that could be leveraged for our outreach efforts.Community Events of Interest  January: Crab Krack (Newport) April: Wooden Boat Show & Crab feed (Depoe Bay) May :Waldport Great Garage Sale (Waldport) May: Fashion Show Fundraiser for local mammography screening and patient care services (Newport) June: Lincoln City Summer Kite Festival (Lincoln City) July: Newport Clambake and Seafood BBQ: (Newport) July: Lincoln County Fair (Newport) August: Relay for Life (Newport) August: Nesika Illahee Pow-Wow (Siletz) August: Garage sale fundraiser for mammography screenings.( Newport) th September: 56 Annual Indian-Style Salmon Bake (Depoe Bay) October: Lincoln City Fall Kite Festival (Lincoln City) October: Health Fair at Chinook Winds Casino (Lincoln City)OHSU Knight Cancer Institute                              September 30, 2011    34 
  35. 35.   November: Siletz Tribal Restoration Pow-Wow (Siletz) November: Chowder Cook Off (Lincoln City) December: Fashion Show Fundraiser for local mammography screenings (Lincoln City) December: Festival of Trees (Newport)Major Employers (100 + employees)  Confederated Tribes of Siletz Indians (1,127) Samaritan Health Services (800) Lincoln County School District (500) Lincoln County (425) Georgia Pacific Toledo (420) OSU Hatfield Marine Science Center (401) Pacific Seafood (200) Fred Meyer (200) City of Lincoln City (160) Wal-Mart (157) Central Lincoln PUD (136) Salishan Lodge (130) City of Newport (125) Trident Seafood (seasonal) (120) Shilo Inns (100)  Inn at Spanish Head (100)    OHSU Knight Cancer Institute                              September 30, 2011    35 
  36. 36.  Key Informant Interviews  1. Lincoln County Health and Human Services (HHS) - Newport, OR Joell Archibald, RN, BSN, MBA; (Director) Rebecca McBee-Wilson: (Primary Care Division Director) Liz Young, BSN, RNC (Clinic Coordinator for Primary Care) June 16, 2011 Linn, Lincoln and Benton counties have a partnership with Samaritan called the “Coast to Cascade Wellness Network.” Prompted by grant requirements, HHS recently completed the Robert Wood Johnson Foundation (RWJF) health rankings; the Public Health Department just completed a health assessment utilizing the CDC’s CHANGE tool as a requirement of their Healthy Communities Grant. The county tobacco use is 3rd highest in the state with 26.9%.27 Our informant describes the socioeconomic climate as mixed -- high and low income earners with various levels of education. There are large numbers of retired people, tourists and those who work in the tourist industry, in often lower wage jobs. Those individuals who have health insurance may seek services “in the valley” (Corvallis & Salem) as opposed to locally. Low wage earners, often without insurance or unable to leave their jobs without losing pay, are less likely to seek services until they are sick. In her clinical experience, many never receive preventative health services like dental or vision screenings. Low income residents, particularly Hispanics, are served through school base health centers that have been successful in building trust within these vulnerable populations. The other two clinics run by the county are shared in a cooperative with Veterans Affairs (VA) one day per week. This clinic brings a VA doctor to the community including specialty doctors. This is the first clinic of its kind in the nation. It has been very successful and people appreciate having this resource in the community. The downside to sharing space is that the county-run clinics cannot operate when the VA runs their clinics. They are currently operating at maximum capacity but are looking to expand.Strengths  Public Health really understands their community and the challenges some community members face.  They have a community needs assessment and evaluation tools needed to track progress.Challenges  Women within the community do not know where to go for information  They feel there are communication issues with the two Samaritan hospitals that make creating a cohesive county-wide program difficult.  North Lincoln- concerned that there is no outreach person to engage with community  More women want to be screened through the OBCCP than is currently allocated to the county   OHSU Knight Cancer Institute                              September 30, 2011    36 
  37. 37.  Outreach Activities  Direct Care Services  4 school based health centers  2 county FQHCsEvents  Lincoln County Fair (Senior Day)- AnnuallyEducational Trainings  Limited- by invitationHealth Fairs & Tabling Events  Senior Health Fair (2,500 attended in past years) at Casino- AnnuallyPartnerships  Dental Group  Obesity Group  Early Childhood Committee- Weekly  Veterans Affairs (VA)Indirect  The local radio station allows interviews and other advertisements. Public Health has been on before talking about healthOHSU Knight Cancer Institute                              September 30, 2011    37 
  38. 38.  2. Women’s Cancer Coalition of Linn, Lincoln and Benton Counties Cindy McConnell, RN June 16, 2011The Women’s Cancer Coalition is a group of women who formed a coalition to address the unmet breasthealth screening needs within their community. This group meets quarterly and is made up of volunteers: BethEvans (Samaritan), Jane Glassman and Joann Stutzman (Corvallis Clinic), Sarah Blanton (ProjectHER/Corvallis Clinic) and Cindy McConnell (Community Cancer Survivor). It is a small but effective group. Thisgroup began as the Benton Breast and Cervical Coalition, but has since expanded to all three counties.Most of their work is around fundraising for one of their annual screening events, Mammathon which iscollaboration with local clinics and generous funders to screen up to 100 women in one day. In previous yearsthey have been able to enroll 50 women onto the OBCCP program and have detected as many as threecervical and two breast cancers. Many more women received biopsies and colposcopies from the screeningsthey received at this event. Mammathon has been so successful that they have added information packets,transportation child care and snacks. They hope to expand this event in upcoming years to Lincoln County.This event is possible because of successful fundraising throughout the year, as well as local clinicians whovolunteer their time to staff the screening event.When talking about educational resources Cindy mentioned a few resources that were not currently availablewithin her community, and that she wishes was available. She explained the need for simple materials that arevisually pleasing, nothing “too bulky.” In addition, the materials need to be available for different age levelsincluding young people and the elderly. This was important to her because so much of their outreach is donevia information sharing.Strengths  They learned how to effectively run a large scale screening event with limited financial resources and great partnerships.  As a coalition, they are small in numbers but highly effective in getting work done.  There group has managed to survive and thrive even through structural changes.  They have gained community support for their screening event.Challenges  There are some difficult business relationships between the Corvallis Clinic and Samaritan Hospital.  Newport is lacking resources.  Feeling that there is misinformation by providers about available services.  Lacking a good tracking system for documenting the mammography screening events and other outreach.  Problems printing NCI materials. Limited funding to print resources, and need to be in Spanish and Asian languages.   OHSU Knight Cancer Institute                              September 30, 2011    38 
  39. 39.  Outreach Activities  Events  Pink Ribbon Tea  Homeless ConnectPartnerships  Samaritan Health System  Corvallis Clinic in Benton County  Luna BarsIndirect  Flyers  Newspaper ads (2 weeks prior to event)  Word of mouth  RadioTrusted Cancer Resources  NCI websiteOHSU Knight Cancer Institute                              September 30, 2011    39 
  40. 40.   3. Samaritan Pacific Health Services, Newport, OR Rebecca Fransham (Social Worker), Ursula Marinelli (Pacific Communities Health District Foundation Director), Lorie Williams (RN, CWCN) June 16, 2011 Samaritan Women’s Clinic is based out of Samaritan Pacific Hospital in Newport, OR (south Lincoln County). They see a mix of unemployed, uninsured or underinsured women. Many women are diagnosed with breast cancer at late stages. Pacific Community Hospital Foundation organizes a few fundraisers for Samaritan Pacific Hospital, including a fashion show which provides prescription assistance, mammography screening and gas card vouchers. The American Cancer Society (ACS) program “Relay for Life” event occurs annually at Newport High School. Samaritan Pacific works primarily with women in treatment services, but is interested in getting more involved with preventive breast health. Strengths  Work well with local community groups to organize fundraising events to support their screening program and support services for women in treatment.  Have patient education information for patients going through treatment within their hospital. Challenges  Transportation to appointments or screenings is a challenge for some women.  No programs for undocumented clients who have an abnormal finding and require follow up services or treatment.  Samaritan requires a doctor’s referral to get a mammogram; a woman cannot self-refer. This is an issue for women who can’t afford the office visit. However, once established with a provider, the reminder letter can be used to schedule future screenings.  Women, clinicians and clinic staff need to be educated that there is no longer a deductible or co-pay for mammography screening.  Education and literacy levels are low in some populations.  Need patient education materials on pain management. Outreach Activities   Events Partnerships  Fashion shows raise money and patient  American Cancer Society support for women’s cancer program (May)  Janet Sutherland: volunteer esthetician, lives in south county (Waldport) Educational Trainings  Educational opportunities for patients going Indirect through treatment  Resources- NCI, American Cancer Society  Created patient education packets and DVDOHSU Knight Cancer Institute                              September 30, 2011    40 
  41. 41.   4. Area Health Education Center Lincoln City, OR Karen Bondley (Program Manager) Monica Di Pietrantonio (Admin Assistant) June 16, 2011 The Area Health Education Center (AHEC) implements health education to many different age groups in Lincoln County, but especially K-12. AHEC understand the needs of the local clinics, have worked with community based organizations and local Parish Nurses on a variety of health topics. The Parish Nurses promote OBCCP on an ongoing basis. Much of AHEC’s local breast health activities are centered on their leadership in the Lincoln County Breast Cancer Coalition which meet quarterly at North Lincoln Hospital. As a result, they are particularly familiar with the players in North County. They have a partnership with the Snowflake Foundation, a sub-committee of the North Lincoln Hospital Foundation, which is made up of local business women who raise funds to support local mammography screening and follow-up services. They have also been involved in breast health education via the OBCCP Program and act as an educational resource for women interested in getting screened. In the past, AHEC been instrumental in getting 165 women screened through the OBCCP over a 60 day period through community partnerships, including the OHSU Knight Cancer Institute, and other outreach activities. It is their experience that working with private clinics is easier than working within hospital systems. Strengths  Lincoln County Breast Cancer Coalition  Lincoln Co is supportive of women’s health issues  AHEC is good at delivering health education to small populations within the community, especially youth.  Organizing educational screening events for nurses and providers.  Understand North Lincoln County and the dynamics of the clinics and hospital systems in the surrounding area.  They have worked with OHSU in the past and completed a community breast health needs assessment and program implementation in 2009 (provider education on mammography screening guidelines). Challenges  Lack of insurance  Lack of understanding that there is no a co-pay for mammograms.  Fear of mammogram and that it will be painful.  Many “Hispanic Healers” in the community. Some Latino women seek their services instead of a western medical provider.  Not reaching the Latino /Undocumented communities  Social issues around breast health  Middle aged women working in tourist industry are not being reached.  Low literacy levels  29% high school dropout rate  Young women lack info on breast health   OHSU Knight Cancer Institute                              September 30, 2011    41 
  42. 42.  Outreach Activities  Education  Youth EducationEvents  Snowflake Foundation Fashion Show- run by local business womenPartnerships  Lincoln County Breast Cancer Coalition  Partnerships with 4 clinics (2 in Newport 2 in Lincoln City)  Snowflake FoundationIndirect Outreach Activities  Newspaper  102.7 radio station offers free ads for non-profits  Informational posters in dressing rooms, laundry mats, etc.Trusted Cancer Resources  National Library of Medicine  Medline Plus  Mayo clinic  Susan G. Komen for the CureOHSU Knight Cancer Institute                              September 30, 2011    42 
  43. 43.  5. North Lincoln Hospital; Lincoln City, OR Johneen Benham July 19, 2011Johneen Benham is a Mammography Technologist at North Lincoln Hospital in Lincoln City, OR. Johneenprovided similar information as AHEC and the Lincoln County Breast Cancer Coalition as she is an activeparticipant and collaborator.As a Mammography Technologist, Johneen’s perspective is on how women access mammography screeningservices locally. Samaritan North Lincoln Hospital screens approximately 2,000 women per year. SamaritanNorth Lincoln Foundation has funding to assist any women interested in a screening mammogram. If thewoman has an abnormal result however, she would be responsible for any follow up costs. If cost is an issue,the hospital will work out payment plan options. When needed, Samaritan North Lincoln refers patients toother Samaritan Health System hospitals in Corvallis or Albany where they provide the newest treatments inchemotherapy and radiation therapy in Lincoln City and Corvallis, respectively.North Lincoln Hospital and staff, like Johneen, understand the needs and challenges within their communityand collaborate with local partners to address those issues. North Lincoln Hospital actively partners with AHECand the Lincoln County Breast Health Coalition for breast cancer screening, education and outreachopportunities in North Lincoln County.Strengths  Educating women about mammography during screening visit.Challenges  Not enough providers are aware of the OBCCP program.  TransportationOutreach Activities Partnerships  Lincoln County Breast Cancer Coalition  AHECOHSU Knight Cancer Institute                              September 30, 2011    43 

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