Sheryl Motl.

Maternal and child health needs assessment (Volume 1982) online

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267 -









APPENDICES

APPENDIX A Questionnaire used for telephone survey of Montana

Women

APPENDIX B Questionnaire used for survey of Public Health

Providers

APPENDIX C County Public Health Providers

APPENDIX D Health Care Standards for Women and Children

APPENDIX E List of Persons Interviewed

APPENDIX F Gallatin County High-Risk Registry Scoring System

and Questionnaire

BIBLIOGRAPHY



APPENDIX A



COUNTY



STUDY //8J-3
TOWN



MONTANA S I K

902 3rd Avenue South

Creat falls, MT 59405

Hello, I'm with Montana Surveys. We're conducting a survey for the

Montana State Department of Health. May I speak with a female that resides in your
household that would be in the age range of 15-44 years of age?

1. May I ask your age? ^^^^^ ^^ LINE ^

SAY:

These next few questions are for statistical purposes only.

2. Which of the following amounts best represents your total
household income for the past year?

KE;AD list - CIRCLE ANSWER NUMBER)

Under $7,500

7,500-10,000

10,000-15,000



1
2
3



$15,000-20,000
20,000 or over



4
5



CHECK gUOTA FOR INCOME)



ENTER NUMBER CIRCLED ON LIN



^-P



3. How many persons are currently residing in your household?

ENTER ON LINE f



4. How many children in the following age groups are currently
residing in your household?

READ LIST)

1. under 5 years 3. 10-14 years

2. 5-9 years



4. 15-18 years _

5. Is the male head of the household currently employed?

CIRCLE NUMBER



Is the female head of the household currently employed?
B) Are You



CIRCLE NUMBER



■^
-►




SAY:

These next questions have to do with health care.

6. Which of the following are you currently usjng for financing
of your health care?



CIRCLE NUMBER-



Private Medical Insurance

Indian Health Service

Medicade

Medicare

No Insurance - Cash Only



one/two adults
only skip to q. 5



3
4



Yes 1

No male 3

Yes 1
Refused J

1

2

3

4



No 2
Refused

No 2



1
2
3
4
5



A-1



APPENDIX A



7. Does your county have a public health department?^



B) Is a nurse provided by your county to serve your area?.
(CIRCLE NUMBER BOTH PLACES

8. Which of the following, if any, would or have kept you rrom — v

seeking health care from a county public hpalth dpoartmpnt'?

fl%-Al> \xst)
^Lack of transportation 1 Lack of babysitter 4

2 Attitude, of Dept. 5
personnel ^ ^

3 Location of Service 6



^Clinic hours
Cost of services

(ASK IF #6 LOCATION IS MENTIONED)



*A) In what way would or has the location of the service
been a problem?

[ASK B) ^ *Too great a distance-

Inconvenient location

*B)ttrbout what distance would you have to travel to get to
the location of service?

ENTER AMOUNT

(ASK IF" #5 .ATTITUDE MENTIONED)
O
**Please explain in what way the attitude of public health

department personnel would or have kept you from seeking
health care from their department?

=ROBE



Which of the following, if any, would or have kept you from
seeking health care from a private physician? CRc«. 1 i.jt)

Lack of transportation

Clinic hours

Cost of services



Lack of babysitter



1
2
3
4



Attitude of personnel 5
Attitude of physician 6
Other than mentioned 7



None of the previously
mentioned



Yes


1


D.K.


3


Yes


1


D.K.


3



1

2
3



1
2



1 5

2 6

3 7
4



8



4
5
6



(2)



lU. Have you personaly received health care from a doctor or
nurse during the past two years?



-*



(IF NO SKIP TO q. 11)



Was this for an:



Illness

Check up

Accident/Emergency



B) Did you receive this health care from a public or private
health care service?

Public

Private

Both

(IF NO CHILDREN SKIP TO 12)

11. Have any children, 18 years or under, currently residing in
your household been seen by a doctor or nurse during the
past two years? (IF NO SKIP TO q. 12)



APPENDIX A

Yes 1

1
2
3



1
2
3



B) What is the age of the child/children that saw a doctor
or nurse during the past two years?



f



(FOR EACH CHILD MENTIONED)



C) Was this for an:



Illness

Check up

Accident/Emergency

D) Did this/these children receive this health care from
a public or private health care service?

Public

Private

Both

12. Has a public health nurse ever made a visit in your home?



13. Which of the following best describes how often you visit a
dentist?



(READ LIST)



(IF NO CHILDREN SKIP TO q. 15)



Once a year or more
Less than once a year
Emergency only



No



Yes 1 No 2

(ENTER YOUNGEST FIRST)

1st

2nd



3rd



oldest



1st 2nd 3rd oldest



1
2
3

Yes 1
O.K. 3



No 2



(3)



A- 3



APPENDIX A



1^. How frequently do the children, 18 years and under, currently
residing in your household visit a dentist? (READ LIST)

Once a year or more

Less than once a year

Emergency only

15. In your opinion, does fluoride in a municipal water supply
help in the prevention of tooth decay?



DO NOT READ LIST)



17.



Yes

No

It's suppose to, think
so, but not sure.

D.K.



The following is a list of medical services that may or may not
be provided by a public health department.



1
2
3



1
2

3

4



As I read each item, indicate if you see a need for each particular service
to either be started, remain the same, be expanded, decreased or eliminated
in v our area. ^ Do you see a need for SAY ITEM to be started, remain the
ame, be expanded, decreased or eliminated?

START AT** FOR EACH ITEM)



a. Care during pregnancy

b. nutrtional services, i.e, menu ,
planning

c. counseling for chjld abuse parents 1

d. Venereal disease service 1

e. transportation to health care center 1

1



Started
1



f. Family planning counseling

g. dental education

h. care of a physically handicapped
child.

i. alcohol/drug abuse counseling

j. abortion counseling

k. home visits by nurse

1. counseling services for pregnant
teenagers
childrens imrr.unization service



m.
n.



24 hour crisis telephone lines, i.e
a place to call for a personal or
family crisis i.e, rape, child/spouse
abuse ect. 1

adequate information on sex
education 1



Same
2



2
2
2
2
2



2
2
2

2
2



2
2



Expand
3



2
3
3
3
3



3
3
3

3
3



3
3



Decrease
4



4
4
4

4
4



4
4
4



4
4



4
4



Eliminated
5



(4)



A-4



APPENDIX A



Started

|). iittn i)( (I <li!vr;l(jpfTi(;riL.'jl ly of

(ribfitally disabled child 1

q. counseling for parents of developmentally
or mentally disabled children 1



Same



2
2



Expand



3
3



Decrease



Lliminatcd



4
4



r. the W I C program 1

DOES NOT KNOW WHAT THE W 1 C PROGRAM IS...1

EXPLAIN: A nutrition program offered to low income women, infants and children
who are at a nutritional risk. This program provides foods that supplement the
diets of these persons, plus provides nutritional education.

(AFTER READING, ASK q. r AGAIN)

18. Which of the following do you feel are the TWO most effective
ways to inform you of services provided by health agencies
in your area? (READ LIST)

(RECORD IN ORDER OF lst/2nd MENTIONED)_



5
5



1. Television

2. Word of mouth

3. Radio

4. Educational talks



5. Pamphlet

6. Local Newspaper

7. School

8. Other



19. Are any members of your household presently pregnant?



A) Which month are you/she in?



ENTER MONTH



B) How often have or will you/she see your doctor in the
first three months?

ENTER NUMBER OF TIMES J^

20. Were any members of your household pregnant at any time during
the past 24 months?



A) Which person or persons in your household was pregnant
during the past 24 months?



1 Mother



2 Daughter 3 Other



21. In this pregnancy, how many times during your first three
months did you see your doctor?

Less than once a month



More than once a month
Once a month



U*-



2^.



Yes i

No 2

(no skip to q. 20]



Yes 1

No 2

(no skip to end)

1
2
3



(5)



A-5



APPENDIX A



22. If you delivered in the past two years did you see your doctor

for a 4-6 week check up? Yes 1 No 2

A) Did you child, born within the past two years, have a

4-6 week check up? Yes 1 No 2



Thank you for sharing your opinion with us on this survey. In case my supervisor
wants to verify my work, may I please ask you name and telephone number?

Name Telephone

City County Interviewer



Is your residence in: 1 City limits

2 suburban area, within 3 miles of town limit

3 Rural Town limits

4 Rural
Any notes Interviewers wish to add:



A-6



11/81
APPENDIX B



MCH NEEDS ASSESSMENT QUESTIONNAIRE FOR LOCAL HEALTH OFFICERS/PUBLIC HEALTH NURSES



1. In what city or town are you located?



2. In what county or counties do you provide services?



3. For county without an organized health department:

Approximately what percent of your time is spent on MCH related program??

For county with an organized health department:

Approximately what percent of your department budget is spent on MCH related

programs? _j %

4. What kinds of health service needs do you encounter the most frequently in
MCH related programs?



5. Do you feel there are adequate resources within your department/county to deal
with those service needs?

6. Do you feel there are adequate resources available when you need to refer?



7. What factors if any, do you feel would keep people from seeking help from a
local health department or from private medical care?



EM^ LOCAL HEALTH DEPARTMENT

Lack of transportation ' .

Clinic/department hours

Cost of services

Location of services



PRIVATE MEDICAL CARE



Client unawareness of service
Physician/personnel attitudes_

Client's personal reasons

Other ( please specify)



B-1



APPENDIX B



8. What are the two most effective ways to infom consumers about services
provided in your county ? "

Television Pamphlet



Word of mouth Local Newspaper

Radio Other ( please specify)

Educational talk



9. In what ways does your department/ county inform the public about its services?



10. Approximately what percent and amount of resources is allocated by your
department/county for educational/informational purposes?
Amount ^Percent

11. What percentage of women and children in the county need MCH services, but
are not receiving them? %

12. What do you think are the greatest priorities for women and children

in your county?



13. Do you have any suggestions as to how the state could better provide for the
health care needs of the women and children in your county?



B-2



APPENDIX B



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B-4



APPENDIX B
LIST OF MCH RELATED SERVICES IN YOUR COUNTY



This is a list of MCH related services that I believe are available in your county.
Please check the list for errors and/or make the necessary additions. In
addition, please indicate either the percentage of your time (or the local health
department's) that is spent in each of the area OR the number of persons served
in each area. If I have indicated that I will be meeting with you personally,
please hold this list until our meeting. If you have received a questionnaire
please return this corrected list with the questionnaire.

SERVICES PERCENTAGE OF YOUR TIME SPENT IN EACH AREA OR

NUMBER OF PERSONS SERVED IN EACH AREA



Prenatal classes
Well Child Clinics



Pre-School Screening
WIC services



Nutritional services
Dental Education



Fluoride rinse program

Dental Screening

Child Immunizations _
Diabetes Screening



Blood Pressure Screening _

VD Screening

Family planning counseling

Family Planning Clinic

Parenting Classes

Home Health Visits

Alchohol-drug abuse
or treatment

Developmental ly disabled
follow-up services



Handicapped children
follow-up services

Mental Health counseling

Genetic Risk Evaulation

Adoption services

Abortion services



B-5



APPENDIX B



Services for pregnant
teenagers



Child abuse/neglect

Transportation to
health care



Other? Please specify



B-6



APPENDIX C



COUNTY PUBLIC HEALTH PROVIDERS

Counties without a local health officer:
Carter

Counties without a county public health nurse:

Carter

Deer Lodge - has school nurse, job corps nurse, and home

health nurse
Liberty
Madison
Meagher

Powell - has school nurse
Sweet Grass - has school nurse
Treasure - nurse available by referral only

The following counties are part of the Central Montana Health
District, sharing a health officer and receiving nursing services
from Fergus County as requested by the county commissioners:

Judith Basin - has school nurse

Golden Valley

Musselshell - has school nurse

Petroleum

Wheatland



Each of the remaining counties not listed have both a health officer
and public health nurse.



C-1



APPENDIX D



STANDARDS FOR MEDICAL SERVICE FOR WOMEN OF
CHILD-BEARING AGE AND CHILDREN AGES 0-21

Part I: Health Services for Women of Reproductive Age, With a Special
Focus on Services Relevant to Reproduction

Health Services for Infants in the First Year of Life

Health Services for Children From One Year to Early
Adolescence

Health Services for Adolescents

Health Services for Children With Special Needs



Part


II:


Part


III


Part


IV:


PART


V:



Included within are lists of needed services developed by the complilation of
standards from the following resources:

Better Health for Our Children: A National Strategy , The Report of the Select
Panel for Promotion of Child Health, Department of Health and Human Services

Standards for Child Health Care , American Academy of Pediatrics

Standards for Obstetric-Gynecologic Services , American College of Obstetricians and
Gynecologists



These standards were prepared for the assessment of the health care needs of


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Online LibrarySheryl MotlMaternal and child health needs assessment (Volume 1982) → online text (page 19 of 21)