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care providers;

2. The refugee population is now becoming more mobile. Com-
munities outside of Missoula and Ravalli Counties are experi-
encing difficulties in serving the needs of the refugees;

Therefore, it is recommended that SDHES:

PROVIDE THE COORDINATION OF SPECIAL TRAINING OPPOR-
TUNITIES FOR HEALTH CARE PROFESSIONALS WHO WILL BE
PROVIDING SERVICES TO THIS POPULATION. THE INVALU-
ABLE RESOURCE OF THE HEALTH CARE PROFESSIONALS IN
MISSOULA AND RAVALLI COUNTIES SHOULD BE UTILIZED
IN TRAINING OTHER COMMUNITIES TO MEET THE SPECIAL
NEEDS OF THESE NEW MONTANANS.
Chapter VII, Refugees



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CHAPTER II
BARRIERS TO HEALTH CARE

Any assessment of health care needs cannot be complete
without addressing factors that limit the availability and accessibility
of needed health care services. Despite a growing recognition of
the importance of health promotion and disease prevention, many
financial, informational, and organizational barriers continue to
exist in limiting provision of such services. Lack of transportation,
location of services, hours of the clinics, attitudes of the personnel,
lack of awareness of service, cost of services, lack of a babysitter,
and cultural differences were all factors considered as barriers (at
least to some extent) to women seeking health services in this
needs assessment. Two of these factors, costs of services and
lack of awareness, were most prevalent in the needs assessment
and will be discussed further.

Financial Barriers

In both the survey of Montana women and the survey of the
public health providers, cost of services was listed overwhelmingly
as the greatest barrier to health care services. There is a wide-
spread but erroneous assumption that Medicaid has guaranteed
access to health care for the poor. Actually, Medicaid in Montana
covers only approximately 23 percent of the persons below the
federal poverty level. According to a study completed in 1976 by
HEW, there were 86,000 persons of the state population of 745,000



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Barriers

who were below the federal poverty level in Montana. This repre-
sents 11.5 percent of the entire population of the state. In 1981,
the average Medicaid caseload was 19,709 per month. With that
average caseload, only 23 percent of the low income population is
being served by Medicaid or 2.4 percent of the entire state popu-
lation.

Complicating the problem of access to health care is that,
according to survey of Montana women, 30 percent of the low
income women had neither public nor private insurance coverage.
In comparison, 14 percent of the women in the survey of all income
levels had no form of insurance. (Complete survey results are
discussed in Chapter IV.)

Further complicating the financial barrier is that private
insurance coverage is inadequate in many cases:



■Less than 30 percent of American children are covered through
private insurance for out-of-hospital physician visits;

•Employment-based insurance plans often shortchange coverage
for children's needs. Only 15 percent cover children's eye-
glasses, 9 percent preventive care, and 32 percent children's
dental care;

-More than half of the private insurance plans fail to cover
prenatal care, 45 percent exclude postnatal care, 90 percent
exclude family planning, and about 50 percent leave majoc
gaps in covering newborns during their first days of life.



1
Table 25 Survey of Income and Education Demographic Social and

Economic Profile of States, Spring 1976. Bureau of Census,
Depart-
ment of Health, Education, and Welfare.
Source: Montana Department of Commerce.

2
Better Health for Our Children: A National Strategy . A report

of the select panel for the promotion of child health. U.S. De-
partment of Health and Human Services, PHS, DHHS Publication
#79-55071, p. 44.

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Barriers

Financial problems, either from the lack of good insurance
coverage or no public or private insurance at all, present a major
barrier in the accessibility of the health care system to low income
people. Without the ability to pay for the necessary health services,
preventive or acute care is either not sought or people are forced
to use emergency rooms of local hospitals.

BECAUSE OF THE INADEQUACIES IN SOME CASES OF PUBLIC
AND PRIVATE HEALTH INSURANCE IN PROVIDING COVERAGE
FOR MATERNAL AND CHILD HEALTH SERVICES, IT IS RECOM-
MENDED THAT SDHES SERVE AS AN ADVOCATE AND LOBBYIST
TO EFFECT CHANGE IN THIS AREA. With continued emphasis on
self care, wellness, and prevention, it can be argued that the
broadening of insurance coverage could not only be cost-effective,
but could result in no cost increases as well. The issue of adequate
insurance coverage for maternal and child health services must be
brought into the public arena for debate. SDHES could serve as
the catalyst for that need.

The public health providers should be acutely aware of the
major role they must play in providing health care to the people
being affected most dramatically in times of fiscal stress. Local
health departments are the primary providers of public health
services and, consequently, are presently feeling, or will soon be
feeling, the pressing needs for increased services at a time of
dwindling resources.

Hard questions for hard times need to be addressed. Should
public health departments struggle to resist the budget cuts or
struggle to minimize their negative effects? Should they adjust
their budget by deep gouges or in small decrements? Should they

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Barriers

spread the pain of budget reductions over their entire service
population or target where the cuts will be? Should they retain
their most efficient and cost effective program at the risk of
limiting equitable access to their services?

To begin to answer these questions, a commitment must be
made to provide decision-makers with the management skills and
expertise to cope with the changes facing their communities. Some
communities have already identified alternative resources to assist
them in the provision of services. The donations of the people of
Custer County enable every diabetic child within their county to
attend a special summer camp for diabetic children. Granite County
has a committed group of volunteers that assists the public health
nurse in notifying people of upcoming special clinics and new
programs. Civic groups in Wheatland County operate immunization
clinics for their county.

Not all public health needs can be met by volunteers or local
resources. Yet, both seem to have been underestimated for the
valuable services they can provide within their community. Churches
have traditionally been a source of service to their communities
and may be underutilized. Statewide and national organizations,
such as the United Way or Shriners' Hospitals for Children, provide
a tremendous service in their communities. Presentation to these
private service groups by state or local leaders could yield an
additional resource for the provision of health care needs at local
levels.

In the meantime, public health departments, particularly those
staffed with the lone public health nurse, may need assistance in
managing their programs as the demands on them are increased.

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Barriers

THEREFORE, IT IS RECOMMENDED THAT THE SDHES PROVIDE
TRAINING OPPORTUNITIES FOR THE LOCAL HEALTH DEPART-
MENTS IN IDENTIFYING ALTERNATIVE RESOURCES WITHIN
THEIR COMMUNITIES AND DEVELOPING A MANAGEMENT SYSTEM
THAT ALLOWS THEM TO SET PRIORITIES FOR USE OF THEIR
EXISTING RESOURCES.

Information Barriers

The most elaborate slate of public health services would serve
no purpose if people are unaware of their existence or unfamiliar
with how to use them. The current groundswell of health promotion
activities are addressing these issues. Availability of services,
proper use of medical providers, recognition of symptoms, and
alternative resources for medical care are some of the subjects
covered in "self-care," "wellness," parenting, and general health
education classes.

Yet, there still remains a group of people who are unaware of
the public health services in their communities. In the survey of
Montana women, n percent of the respondents did not know if
there was a public health department in their county. Thirty-one
percent did not know if their county provided a public health
nurse to serve their area. This lack of awareness of public health
services also differed substantially throughout the regions of the
state. Persons in far eastern Montana were much more likely to be
aware of public health services than those in south-central or
western Montana. (Complete results of the survey and details of
this question are included in Chapter IV.)



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Barriers

Within the low income population in the survey, 21 percent of
the women were not aware of the public health services in their
area. This compared with the total survey population responses of
11 percent is almost doubled. Slightly more of the low income
persons were aware of a public health nurse in their community -
71.5 percent compared to 69 percent of the total population. Only
9.7 percent of the total population had ever had a public health
nurse visit in their homes.

Of particular significance in these numbers is the fact that
21 percent of the low income population in the survey were unaware
of the public health services in their area. Generally, it is these
low income people who are the targets for many public health
programs. These people must be made aware of the public health
services in their area, or perhaps will end up foregoing any form
of health care. In the survey of public health providers, the
number one factor listed as a barrier for persons in seeking health
care at a public health department was the client's unawareness of
service. This supports the concern that more people need to be
informed of available services.

A question was asked in both surveys of the most effective
way to inform people of the services provided by the health agencies
in their area. The number one response in the survey of Montana
women was "television" followed by "local newspaper." In compari-
son, television as a means of providing information on services was
ranked last of the six possible options by the public health pro-
viders. "Word of mouth" followed by "local newspaper" were listed
as the most effective means by the providers.

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Barriers

When asked how the public health departments did inform
people about their services, "newspapers" and "word of mouth"
were the top two means utilized, with "television" receiving only
three responses.

The divergence of opinion on the use of television can, of
course, be explained by the lack of most communities in having a
local television station in their area. This serves to limit the
public health department's access to public service announcement
options. Missoula County, being one of the counties with a local
television station, makes significant use of television in making
people aware of their services and in promoting good health practices.
Not only is Missoula County involved in talk show formats and
news releases but, in addition, they are running a series of profes-
sionally designed "advertisements."

As mentioned, only a few communities have access to television
for the promotion of their programs and departments. THEREFORE,
IT IS RECOMMENDED THAT THE SDHES ASSIST THE LOCAL
HEALTH DEPARTMENTS IN MAKING PEOPLE AWARE OF THE
LOCAL HEALTH DEPARTMENTS AND THE SERVICES THEY PRO-
VIDE BY WORKING WITH ALL LOCAL TELEVISION STATIONS IN
GENERAL PROMOTION SPOTS STATEWIDE.

In addition to making people aware of their departments and
programs, the public health departments also need to help people
become aware of the variety of other resources within their com-
munities. The network of the referral system within the communities
is crucial in meeting the diverse needs of the people. Mental
health agencies, child protection services, home health agencies,



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Barriers

and welfare services are each programs which could supplement the
services provided to persons through the health department. In
addition, public health providers should also be prepared with
information on alternative sources of health care within their
community - including licensed nurse-midwives, nurse practitioners,
and women's centers. A particular need for licensed nurse-midwives
is growing as increasing numbers of women cannot afford adequate
prenatal care from private physicians and, as several counties
reported, are not receiving any prenatal care.



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CHAPTER III
THE WORLD OF WOMEN AND CHILDREN

MOTHERS AND INFANTS - PRENATAL CARE

Nearly all American women experience one or more pregnancies.
Yet, despite public and professional agreement that women should
begin prenatal care early in pregnancy, only 74 percent of all
babies born nationwide in 1977 were born to women who made their
first visit for prenatal care during the first trimester of pregnancy;
1.4 percent received no prenatal care at all. The situation has
been improving; however, as five years earlier the comparable
figure was 69 percent.

The situation in Montana presents a brighter picture. Accord-
ing to information recorded on birth certificates, 80 percent of all
babies born in the state in 1980 were born to women who started
prenatal care during their first trimester. Less than 1 percent
(.77) of all babies born in 1977-80 were born to women making no
prenatal visits.

The number of women seeking early prenatal care is signifi-
cantly different for the Native American population on Montana
reservations. According to data from the Area Indian Health
Service (IHS) in Billings, only 57.6 percent of the pregnant women
receiving services from IHS started prenatal care in their first
trimester. This figure, however, represents an 8.5 percent increase
from 1974.



1
Better Health For Our Children: A National Strategy . A report

of the select panel for the promotion of Child Health, U.S. Depart-
ment of Health and Human Services, Public Health Service, DHHS
Publication #79-55071.

- 18 -



Prenatal Care

Perception of Need

In the survey of Montana women, 53 percent of those pregnant
within the past two years would like an increase in pregnancy-related
public health services; 45 percent of these women would like the
services to remain the same. Two percent of the women would like
the services eliminated in the public health sector.

For all women in the survey, regardless of pregnancy status,
52 percent would like the services increased; 47 percent would like
them to remain the same; and 1 percent would like them decreased.

In the survey of public health providers, prenatal care was
ranked the number one priority for women and children in their
counties. It ranked second in a list of health service needs that
they, as providers, encounter most frequently. Sixty percent of
the providers would like the service increased and 40 percent
would like the services to remain the same. For a complete ranking
of the services by both the Montana women and the public health
providers, see Chapters IV and V.

Existing Services

State Programs

Supplementing the local prenatal programs are two projects
currently funded with federal monies and administered by the State
Department of Health and Environmental Sciences. The Improved
Pregnancy Outcome Project (IPO) provides funding for the transport
of high risk mothers and infants in distress to medical centers
with the capabilities to care for their special problems. In addition,
funding is provided for procedures and laboratory tests to evaluate



19



Prenatal Care

the status of high risk pregnancies for genetic and medical problems.
Public education and continuing education for health professionals
associated with pregnancy are also sponsored by the program.
The transport and testing services of the Improved Pregnancy
Outcome Project are available statewide to low income families on a
sliding financial eligibility scale basis.

In 1981 the IPO Project paid for the transport of 94 infants at
a cost of $106,899 and 33 maternal transports at a cost of $9,828.
In addition, 86 tests were conducted for high risk pregnancies at
a cost of $8,954. Continuing education opportunities were provided
for 531 health professionals.

A second federally funded program for pregnant women is the
Special Supplemental Food Program for Women, Infants, and Children
(WIC). The main objective of this program is to provide nutrition
education, counseling, and supplemental nutritious food to low
income pregnant and lactating women, infants, and children up to
age five. To be eligible for the program, the women and children
must be both below 185 percent of the federal poverty level and
who, because of poor health or inadequate nutrition or both, are
at nutritional risk. Pregnant women must also be receiving pre-
natal care to be eligible for the program.

In addition to the provision of the supplementary foods, local
WIC programs are required to see that health services are available
to WIC participants, thereby influencing the levels of participation
in prenatal and child health services for low income women.

Numerous studies document the benefits of the WIC program
for high risk pregnant women. In addition to its improvement of



20 -



Prenatal Care

the client's nutritional status and associated health problems, the
program is also estimated to save three to four dollars in medical
costs for every dollar invested in the program. These factors
have led to wide acceptance and support for the program.

WIC is available in 37 Montana counties and each of the 7
Indian reservations. The program serves approximately 13,000
persons each month. This represents approximately 40 percent of
those persons income eligible (not necessarily nutritionally eligible),
who are receiving services from the program. This 40 percent
figure is the second highest in the nation of states with WIC
programs. Only Vermont serves a higher percentage. Nationally
the average is 20 percent. Indian reservations serve 57 percent
of their income eligible population.

Currently, insufficient funds prevent serving more of the
eligible population and from expanding the WIC program into counties
currently unserved.

Nutritional consultants from the state office provide an addi-
tional indirect service for pregnant women. Consultation is pro-
vided to family planning programs, local WIC programs, and health
professionals in the nutritional needs of the pregnant and post-
partum woman.

Perception of Need

In the survey of Montana women, 54 percent of the respon-
dents would like the WIC program expanded and ranked it ninth on
a list of 18 possible services. Forty-two percent of the women
would like the service to remain the same, while four percent
would like it eliminated.

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Prenatal Care

In the survey of public health providers, 40 percent would
like the service expanded and ranked it 11th out of 21 services;
55 percent would like the service to remain the same; and 5 percent
would like it eliminated or decreased.

County Programs

Within the public sector, county health departments possess
the greatest opportunity to influence the extent and type of prenatal
care for women within their counties. To insure that as many
pregnant women as possible receive early medical and nursing
supervision, it is necessary to set some procedure to identify them
as early as possible. A highly desirable goal is that of notification
by the private physician to the health department of each obstetrical
high risk client. Part of the problem, of course, is already solved
if the woman is under medical supervision. However, even here,
the health department may render services through public health
nursing and education, including follow-up of women who miss
appointments or plan no regular medical prenatal care.

While listed as the greatest priority for women and children in
the county, prenatal classes are available in only 24 counties.
Within these counties, the range of prenatal services varies from
medical and preventive services within the Maternal and Infant
Project in Yellowstone County to individual counseling as requested
in other counties. Some counties refer women to existing prenatal
classes within area hospitals or to an on-going Lamaze program.
Missoula County has a high-risk program that monitors the adequacy



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Prenatal Care

of prenatal care in women identified as being high risk. Follow-up
of these women continues for up to one year after the birth of
their infants.

Generally, the prenatal programs within the counties are
available to all county residents regardless of income. Some of the
programs offered through the private sector charge a fee for their
classes. The Maternal and Infant Project is the only provider for
medical services to those women who are income eligible.

Indian Health Service

The Indian Health Service provides complete prenatal care for
Indian women. Prenatal classes are offered by the Community
Health Nurses. As described later in Chapter VI, all Indian
women, regardless of income, are eligible for IHS medical services.

At the present time, prenatal services are also available to
urban Native Amercan women through Urban Indian Health Clinics
in four Montana cities. These clinics are open to all Native Americans
regardless of income or tribal affiliation. Helena, Billings, Missoula,
and Great Falls have Urban Health Clinics.

The Urban Health Clinics are currently faced with a proposed
elimination of all federal funding. For most of the urban clinics,
federal funding accounts for over 70 percent of their funding.

Special Projects

Currently, the Maternal and Infant Project in Yellowstone

County provides complete prenatal care for high risk women. In

addition to providing medical care to income eligible women, the



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Prenatal Care

project offers classes in prenatal care, infant care and parenting
skills, family planning education, dental evaluations, support
counseling, labor and delivery classes, well-child clinics and
immunizations, nutritional guidance, referrals, and health care
maintenance plans for all women.

Federallly mandated funds for the Maternal and Infant Project
will be terminated June 30, 1982. Yellowstone County has the
option of continuing these services through use of the federal
block grant monies if they view this as a priority.

Concerns

From this review of services, five issues are presented as
needs in the area of prenatal care for women. First, all women
are not equally aware of the need for early and consistent prenatal
care. This is evidenced by the 20 percent of Montana women who
gave birth in 1980 with no prenatal care in their first trimester.
IT IS THEREFORE RECOMMENDED THAT THE STATE DEPARTMENT
OF HEALTH AND ENVIRONMENTAL SCIENCES MAKE A CONCERTED
EFFORT IN CONJUNCTION WITH OTHER STATE AGENCIES TO
INFORM ALL WOMEN OF THE NEED FOR EARLY PRENATAL CARE.
Public service announcements on radio, television, and newspapers,
messages on milk cartons, egg cartons, and grocery bags can each
provide a short informational message encouraging women to learn
more about good prenatal care and to seek the services of a private
physician early in their pregnancies.

A second concern is that prenatal classes are not equally
available around the state. As mentioned, prenatal classes are



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Prenatal Care

available in only 24 counties. Because of the lack of resources in
some counties and/or the rurainess of others, prenatal classes are
not offered in every county. Some counties may have alternative
resources such as Lamaze classes and hospital sponsored programs
that can meet the needs for the service. Other counties have
placed their priorities elsewhere.

The importance of prenatal education in addition to medical
prenatal care should not be underestimated. If the data from the
National Ambulatory Care Survey are any indication of the amount
of time a women spends with a physician during pregnancy, the
total is low. An average visit for prenatal care is 10.7 minutes of
direct contact with the physician according to the study. The
American College of Obstetricians and Gynecologists recommends
that a women have ten prenatal visits during her pregnancy. If
this recommendation is met, that means the physician spends only
107 minutes with the patient over the term of the pregnancy. In
addition, the study found that there was some diet counseling in
14 percent of the visits and medical counseling during 25 percent
of the visits. Prenatal education offered by a local health depart-


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