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Maternal and child health needs assessment (Volume 1982) online

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-119



Native Americans

Preventive Health Services

Analysis of the data for three of the Montana Service Units
shows a ratio of visits for preventive health services to births for
infants at 3.4-3.8 and for children 1-4 years of 1.2-1.4. This is
a reasonable rate for children 1-4 years, but the ratio for infants
falls short of the recommended 6 visits for preventive health ser-
vices during the first yrear. At the Blackfeet Reservation where
there is a pediatrician on staff, 76.7 percent of the infants were
seen for preventive health services in the first month, whereas at
the Fort Belknap and Fort Peck Reservations only 42.9-48.3 per-
cent of the infants were seen during the first month.

Immunizations



During the past three years, considerable energy has been
expended in having children 3-27 months of age appropriately
immunized for their age. As a result, nearly all of the Service
Units have achieved and sustained high immunization levels.

PERCENT OF CHILDREN



APPROPRIATELY IMMUNIZED


FOR
Office


AGE
1978-81

March 31,




3-27 Months ■


■ Billings


Area IHS




Service Unit


Sept


. 30, 1978


1981


Flathead




33%




87%




Blackfeet




47%




92%




Rocky Boy's




62%




100%




Fort Belknap




84%




95%




Fort Peck




58%




91%




Northern Cheyenne




95% *




89%




Crow




73%




93%





*According to the MCH consultant of the Billings area IHS office,
this report was in error. The actual immunization level was closer
to 55%.

Source: Service Unit Reports



- 120 -



Native Americans

Special Health Problems

Over the past three years, developmental assessment clinics
were conducted quarterly on the Fort Peck Reservation in order to
provide a team approach to assessing and planning for those
children with handicapping conditions complicated by social situa-
tions. Attempts were made to establish similar routine clinics on
the Rocky Boy's, Fort Belknap, and Northern Cheyenne Reserva-
tions, where a team approach was also used. A pediatrician on
the Blackfeet Reservation has staffed specialty clinics in cardiology,
facial anomalies and birth defects, including fetal alcohol syndrome.

In addition to these developmental assessment clinics, a special
communications disorders program is operating on each of the
reservations. Each reservation has a specially trained person to
screen for hearing and speech problems. Upon identification,
these children are referred to a three-person team to evaluate the
case and, if necessary, perform surgery. This medical team operates
out of the Billings Area Office.

Each year the individual reservations make a determination of
which health care problems will be focused upon that particular
year. Bringing all children up-to-date on their immunizations,
fetal alcohol syndrome, family violence, accidental deaths, and
child abuse and neglect are examples of areas receiving special
emphasis.

Data Collected by IHS

Demographic data, clinic and hospital workloads, morbidity
and mortality data for a wide variety of conditions are collected by



121



Native Americans

each service unit. The information is then sent to the area office
in Billings where it is compiled and put on computer. (For further
information on any specific data needs contact: Harvey Lich in
Program Planning for information on data concerning direct care
services, and Jerry Zitur for data on contract care services -
phone number: 657-6645.)

"Last Dollar" Policy

According to the Billings Area IHS office, the contract care
system of the Indian Health Service is defined by Congress as a

"residual resource." This definition requires that IHS use all other

1
mechanisms before funding the contracted care service themselves.

Private insurance, Medicaid, the Improved Pregnancy Outcome Pro-
ject, and Handicapped Children's Services program are examples of
funding sources utilized prior to IHS funds.

Needs Assessment Survey

Medical programs provided by the Indian Health Service on
Montana's reservations constitute an additional source of maternal
and child health care in the state. Consequently, the Indian
Health Service on the reservations were included in the group of
providers or coordinators of MCH programs surveyed for the needs
assessment.

During the months of November and December of 1981, three
reservations were randomly selected for personal interview, the



1
Interview with Dr. Dana Copp, Patient Care Coordinator, Billings

Area Indian Service Office.



122 -



Native Americans

remaining four were sent questionnaires to be completed and returned.
Of the seven, five responded to the survey.

Similar questions to those asked of the county health officers
and public health nurses were asked of the Service Unit Directors
of the IHS and/or the public health nurse for IHS.

A caution in reviewing the survey results must be noted.
The following information reflects the opinions of five of the seven
Service Unit Directors on the reservations. Tribal health officers
or directors of the Urban Health Centers were not similarly involved
in the survey and, therefore, assumptions about their opinions on
needed services cannot be made.

The Results

1. MCH-related health service needs encountered the most fre-
quently:

Rank Service Number of Responses

1 Pre and postnatal care 5

2 Family planning 3
Well Child Clinics 3

3 Child protection services 2

2. Are there adequate resources available when you need to refer?

Yes: No: 5

3. Are there adequate resources available for the service demands?

Yes: No: 5



4. What are the most effective ways to inform consumers about
your services?

#1 - Word of mouth
#2 - Local newspaper

Note: Of the several items listed in the survey, these were

the only two which received a response.

- 123 -



Native Americans



What are the areas of greatest need for the women and children
in your service area?



Rank



Service

Nutrition
Family planning
Well Child Clinics
Health education



Number of Responses

3
3
3
2



Others mentioned: parenting, teen pregnancy, middle ear
infections, fetal alcohol syndrome, and crisis intervention.



6. The Service Unit Directors and Public Health Nurses were
asked their opinion on 21 public health services. They were
asked to indicate which services they would like to see started,
expanded, decreased, eliminated, or remain the same. The
following is a summary of the responses.



Service



Start/ Expan d



Decrease/El imiinate Remain the Same



Prenatal Care 3

Nutritional Services 5

WIC program 2

Transportation of clients 4

to health care

Infertility Problems 4

Ob-Gyn Services 3

Birth Control Services 5

Abortion services 3

Child Abuse/neglect 5

counseling

Babysitting services 4

Dental Education 4

Fluoride Rinse 3

Dental Screening 2

Immunization Services 3
Alcohol/drug abuse services 3

Home Visits by nurses 3

24 Hr crisis phone lines 5

VD screen/treatment 4

Special services for 4
pregnant teenagers












1
















2

3
1

1
2

1


1
1
2
3
2
2
2

1
1



- 124 -



Native Americans



Services continued



Servi ce



Start/Expand Decrease/el iminate Same



Follow-up services for

handicapped children
Services for handicapped

parent
Hear ing/vi si on/ speech

screeni ng

Counseling/Education in these areas:

Child Birth Preparation
Child Development
Infant Care
Parent ing Skills
Accident Prevention
First Aid

Specific Chronic illnesses
Care of handicapped children
Care of deve lopmental ly
del ayed chi 1 dren



3
2



5
3
2
it
k
k
3
3




















1

2
2
1



2
1



125 -



CHAPTER VII
REFUGEES

THE INDOCHINESE POPULATION IN MONTANA

Since 1975, nearly 300,000 Indochinese refugees have been
relocated in the United States. Approximately 700 of these refugees
have settled in western Montana, primarily in Missoula and Ravalli
Counties.

The heavy influx of refugees in 1978-79 was initially a shock
to the health and social service systems within those counties.
With the passage of the Refugee Act of 1980, the federal government
alleviated that strain by providing grants to states and localities to
provide settlement services to the refugees. The Act, PL 96-212,
authorized up to 100 percent reimbursement to states and localities
for cash and medical assistance for the refugees for three years
after their arrival in this country. The resettlement programs
centered on provision of education and health services but did
include special grants for job training, interpreters, and transpor-
tation.

Health Problems of the Refugees

The health status of the refugees presented new and complex
problems for health care providers. Intestinal parasites, lack of
immunizations, high rates of anemia, acute malnourishment, and
chronic disorders related to vitamin deficiency were common problems
for the refugees. In addition, higher incidences of typhoid.



- 126



Refugees

tuberculosis, hepatitis B, and malaria were found within the popu-
lation. Some of the health problems could be remedied within a
relatively short period of time by nutritional programs, immunization
clinics, sanitary water supplies, and improved living conditions.
Other problems, however, will require long-term monitoring and
treatment.

The health care providers in the communities receiving refugees
had little advance notice of the type and extent of the health
problems now within their communities. Medical books were reopened
and consultation sought as unfamiliar health problems were encoun-
tered within the new population.

The following is a list of suggested guidelines for physicians
providing care for Indochinese refugees. The guidelines are
reprinted directly from an article by Roy V. Erickson, M.D., and
Giao Ngoc Hoang, M.D., M.P.H., in the American Journal of
Public Health 1980 Vol. 70, No. 9,



-All basic medical exams should include CDC, stool exam for
ova and parasites, TB skin test and/or PA chest x-ray and
HbSAg determination.

-Physicians should expect: hemalotogical disorders, especially
eosinophilia, anemia and microcytosis. As there is significant
prevalence of abnormal hemoglobins among the patient popula-
tion, a hemoglobin electrophorisis is suggested for any patient
with microcytosis and/or anemia.

-Thyroid disease, with euthyroid goiters in particular are
prevalent in the adult population, most likely as a result of
an iodine deficiency.

-Infectious diseases are common, including not only TB and
intestinal parasitism, but skin infections, otitis media, conjunc-
tivitis and malaria.

-Psychiatric problems may become a major health problem.



127



Refugees

Current Problems

Several problems continue in providing health care for the
refugees. One major problem which presents itself is that the
transition for the Indochinese into western medicine is a slow and
belabored process. This problem persists, according to Ethel
Montgomery, Director of Field Nursing for the Missoula County
Health Department, "particularly for the Hmong* population that
had almost no previous exposure to western culture or the English
language." Preventive health care, recognition of symptoms, and
decision-making on when to seek medical care are each areas in
which the refugees are in need of a tremendous amount of education.

Aggravating the health education problem is the persistent
language barrier. A special grant to Missoula County has provided
for an interpreter to work with the county health department
which has subsequently eased this aspect of the health education
problem.

A second problem the health and social services are contend-
ing with, according to Henrietta Brandon, Nursing Supervisor for
Ravalli County Health Department, is the need to help the refugees
"resettle" into a life without dependency on the government programs
that provided for their care during the allowed three-year settlement
period. The transition, according to Brandon, from complete
medical coverage to no coverage has been difficult for the refugees
to adjust to and to understand. Once off the medical assistance



*The Hmong population came to Montana after fleeing their native
Laos when the Communist government began to take over after the
war. In Laos, the Hmong were a special ethnic agricultural-oriented
population.



- 128 -



Refugees

program, the refugees are generally seeking medical care in emer-
gency situations only. Home deliveries are expected to rise dramati-
cally as the refugees attempt to cope with the high rate of unemploy-
ment and their lack of medical assistance. Even in situations
where an employed member of a household has employer-sponsored
insurance coverage, medical care is not being sought. This,
iVIontgomery explains, is often due to the fact that the employed
member of a household is supporting numerous other families and
is, therefore, unable to afford the policy deductibles.

Further complicating the problems of health care for the
refugees is a new federal rule effective April 1, 1982, cutting the
allowed resettlement period from 36 months to 18 months. This is
a particular hardship for the Hmong population, according to
iVIontgomery, because of the great cultural gap that persists and
slows the educational process. With few refugees being able to
find employment and their medical coverage ending, the prospect
for the refugees to obtain and maintain proper health care appear
negligible.

Some of the Indochinese refugees may become eligible for
other assistance programs, primarily AFDC and Medicaid. Others
will be eligible for local general assistance only. The current
federal policy allows for federal reimbursement for costs to the
localities for general assistance payments to the refugees. It also
provides reimbursement for the state's portion of other assistance
programs for the refugees' second 18 months in the country.

To meet what Missoula County is seeing as a burgeoning need
for health care, a Well Child Clinic is being established to serve



- 129



Refugees

the refugee children. During a period of high unemployment,
these and other innovations should ease the transition for the
refugees away from a dependence on the medical assistance program
and yet continue to encourage them to maintain patterns of good
health care.

Other communities are now beginning to experience the problems
in providing health care for the refugees. As the economy worsened
in Missoula County, several Indochinese families recently moved to
Billings with hopes of obtaining employment. The Yellowstone
County Health Department now faces the same problems Missoula
and Ravalli Counties experienced five years ago. Yellowstone
County health care providers must be educated in special refugee
health problems. They will also need assistance in applying for
grants for interpreters and assistance in establishing funding
mechanisms for the provision of medical assistance payments to
eligible refugees. It is expected that as the refugee population
becomes increasingly mobile, more communities will be faced with
similar needs.

BECAUSE OF THE PREPARATION NECESSARY TO ADEQUATELY
MEET THE SPECIAL CARE NEEDS OF THE REFUGEE POPULATION,
IT IS RECOMMENDED THAT SDHES PROVIDE THE COORDINATION
OF SPECIAL TRAINING OPPORTUNITIES FOR HEALTH CARE
PROFESSIONALS WHO WILL BE PROVIDING SERVICES TO THIS
POPULATION. THE INVALUABLE 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.



- 130



Refugees

CUBAN AND HAITIAN ENTRANTS

Although it is a continual on-again/off-again proposal, plans
to house 300-600 Cuban people at the Glasgow Valley Industrial
Park continue to linger. Under the proposed arrangements, the
Immigration and Naturalization Service would administer the refugee
center. A mixture of other federal agencies, including the Office
of Refugee Resettlement and Public Health Service, would bear a
prorated portion of the costs of the center.

Based on a decision made by President Carter in Executive
Order 12251 in November of 1980, Cuban and Haitian entrants will
now be granted the same eligibility for cash and medical assistance
programs as the populations that receive specific granting of
refugee status. By federal definition, Cuban or Haitian persons
entering this country without refugee status under the Immigration
and Naturalization Act are considered "entrants" and were not
initially eligible for resettlement programs. The population originally
planned for the Glasgow Center, however, would be in federal
custody and would eventually be relocated throughout the country
with no anticipated impact on state assistance programs.

Currently, Montana state officials do not foresee the Cuban or
Haitian population being brought to the Glasgow site.



131



CHAPTER VIII
COUNTY PROFILES

This chapter was prepared primarily for use by individuals at
the state and local levels. Information was collected from numerous
sources and incorporated in the tables to present an overview of
maternal and child health related factors for each county. Hopefully
the tables will provide the reader with sufficient information to
make a personal interpretation of the health status of women and
children in each county.

A two-page profile, including maternal and child health related
statistics and an inventory of medical services relating to maternal
and child, is provided for each county. Following the county
profiles, tables of individual indices for the entire state are included.

General Data Considerations

The data provided in this chapter has been collected from
numerous sources. As much as possible, the most current informa-
tion available was used. Due to the limitations inherent in data
collection and reporting, the following considerations should be
kept in mind while reviewing the information contained in this
chapter.

1. The sources, descriptions, and possible restrictions of
all data are listed at the beginning of the individual
county listings.



- 132



2. Some counties with small populations may have a low
incidence of a given characteristic. In these cases, a
single death or instance may give an unrealistic view of
the actual circumstances. Care should be used before
conclusions based on such data are reached.

3. Every effort has been made to include data of known
statistical reliability. In general, this means that the
data are from the decennial census, state department's
information management systems, and statewide surveys.
All of these are subject to reporting and measurement
error and the possibility exists that the accuracy of the
collecting mechanism may vary from year to year.



133 -



EXPLANATION OF HEALTH STATUS INDICATORS USED IN COUNTY PROFILES
(Complete Tables Follow County Profiles)

1980 Population : Advance Counts 1980 U.S. Census. See Table 1.

Population Density : Reflects population per square mile.

Formula: Population/Area.

Number of Women 15-45 : Reflects number of women of childbearing
age. Source: Advance Counts U.S. Census, 1980. See Table 1.

Number of Children Under 21 : Advance Counts U.S. Census,
1980. See Table 1.

AFDC Recipients : Aid to Families of Dependent Children recipients.
Data reflected the monthly averages for state fiscal year 1981.
These figures are not necessarily unduplicated counts. Source:
Statistical Report , State Fiscal Year 1981, Department of Social and
Rehabilitation Services. See Table 2.

AFDC Recipients Under 19 : Aid to Families of Dependent Children
to Women Under 19. Data reflect the current age of the January
1982 caseload. Percent of recipients of ADC under 19 shown in
comparison to entire state caseload for the month. Source: unpub-
lished data from the Bureau of Statistics and Research in the
Department of Social and Rehabilitation Services. See Table 2.

Medicaid Recipients : Data reflect the monthly averages for state
fiscal year 1981. These figures are not necessarily unduplicated
counts. Source: Statistical Report , State Fiscal Year 1981, Depart-
ment of Social and Rehabilitation Services. See Table 3.



General Fertility Rate :

Formula: Number of Montana resident live births in 1980

Number of women 15-45 in 1980
See Table 6.



X 1,000



Infant Deaths : Reflects infant deaths for 1977-80. Rate of infant
death reflected per 1,000 live births for same period. Source:
Bureau of Records and Statistics, Department of Health and Environ-
mental Sciences. See Table 4.

Low Birth Weights : Reflects low birth weights for 1977-80. Rate
of low birth weight reflected per 1,000 live births for same period.
Source: Bureau of Records and Statistics, Department of Health
and Environmental Sciences. See Table 4.

Women Receiving No Prenatal Care : Reflects women receiving no
prenatal care 1977-80 as recorded on birth certificates. Rate of no
prenatal care reflected per 1,000 live births. Source: Bureau of
Records and Statistics, Department of Health and Environmental
Sciences. See Table 5.



134 -



EXPLANATION OF HEALTH STATUS INDICATORS USED IN COUNTY PROFILES (continuec



Women Starting Prenatal Care After First Trimester : Reflects

women starting prenatal care after their first trimester of pregnancy
as recorded on birth certificates. Percent of late prenatal care
reflected per 1,000 live births for 1980. Source: Bureau of
Records and Statistics, Department of Health and Environmental
Sciences. See Table 5.

Induced Abortions : Reflects number of induced abortions for
1980. Rate of induced abortions per 1,000 live births for 1980.
Source: Bureau of Records and Statistics, Department of Health
and Environmental Sciences. See Table 7.

Women in Need of Family Planning Services : Reflects non-reservation
women in 1979 that were determined by a 13-step formula to be in
need of family planning services. The formula takes into account
the following factors: number of women 15-44, number of persons
below 150% of CSA poverty guidelines (which closely parallels 200%
levels for Title X), number of women at or above 150% level, and
estimated number of women not served (assuming 35% of this popula-
tion served by private physician). Rate reflected per 1,000 county
residents, as estimated for 1979 by the Table of Population , Univer-
sity of Montana. Source: Family Planning Program, State Depart-


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