Renée Bouvion, M.P.H.
2201 Sixth Avenue, M/S RX-29
Seattle, WA 98121
Region X consists of:
Region X overview
Region X contains 23 percent of the land area and 30 percent of the total inland waters in the United States. Approximately 60 percent of this land, which contains several major mountain ranges, is owned by the federal government. (Nationally, the federal government owns only about 34 percent of the land). The region is largely rural, with a relatively small, scattered population and few urban areas. These geographical features present unique challenges for health care service delivery.
Though Region X currently is home to only 11,236,405 persons or about 4 percent of the U.S. population, its growth rate is higher than the U.S. average. Population density in Region X remains significantly lower than the U.S. density at approximately 35.2 persons per square mile. An estimated 12.8 percent of people in Region X live in medically underserved areas compared to 11.8 percent for the U.S ( Making the Grade: A National and State-by-State Report Card, National Women's Law Center, 2004).
The population of Region X is largely white (82.2 percent). The percentage of Native American/Alaska Native (4.9 percent) and Asian/Pacific Islander (3/7 percent) populations are higher than the U.S. as a whole. Racial and ethnic diversity varies from state to state in Region X. Alaska and Washington have the highest percentage of African Americans with 3.5 percent and 3.2 percent respectively. With the exception of Alaska, Hispanics represent the largest minority population in Region X states, making up 8.0 percent of the population in Oregon, 7.9 percent in Idaho, and 7.5 percent in Washington. Percentages of Asian and Pacific Islander populations are highest in Washington (5.9 percent) and Alaska (4.5 percent). Between 2000 and 2004, the fastest growing racial/ethnic groups in Region X were Hispanic and Asian, with increases of 22.6 percent and 16.1 percent respectively. The Hispanic population increased the most in Oregon and Alaska. Washington and Oregon saw the largest increases in the Asian population.
- While white females comprise 84 percent of the region's female population, nationally they comprise 75 percent. The differential representation is not uniform:
- Black women comprise only 2.2 percent of the region's female population while they make up close to 13 percent of the nation's female population;
- American Indian females account for 2.3 percent of the regional population as compared with less than 1 percent of the national population;
- Asian/Pacific Islander females are 4.7 percent of the regional population and less than 4 percent of the national population;
- Hispanic women make up just under 7 percent of the women in the region while they comprise 12 percent of the women in the nation.
There is also a lower percent of foreign-born population in the region (8.9 percent versus 11.1 percent nationally) with Washington being the only state approaching the US average. Additionally, of those foreign-born households in the region, a lower percentage appear to experience linguistic isolation, which could represent a barrier to health care access, with Washington again being the only state. The percent of female population below the poverty level is slightly lower in the region than the nation (11.9 percent versus 13.5 percent). As is the case nationally, the percent of female population below the poverty level is greater than for the male population. The percent of female-headed households is also lower in the region, but the percent of females divorced is higher than the national.
While the percent of the population living in urban areas is essentially the same as the national average, the population density is much lower than the national average. Washington is the only state above the national average and the population density in Alaska is the lowest in the nation.
Alaska is the largest state in the U.S. with over 586,412 square miles of land area. The total population is estimated at 626,932 (2000 census) for a population density of only 1.06 persons per square mile. It is more than twice the size of the state of Texas and it claims the most northern, western, and eastern points of land in the U.S., more miles of coastline than all of the lower 48 states combined, over 5,000 glaciers, over 3 million fresh water lakes, and 3,000 rivers. Within Alaska's borders are the nation's 2 largest national forests. It has numerous mountain ranges and contains the highest peak in North America, Mt. McKinley. Unique climatic conditions affect service delivery in Alaska, with temperatures ranging from 100 degrees to minus 80 degrees Fahrenheit, and permafrost adversely affects road construction so that many communities are accessible only by air. Many other communities, particularly in the Southeast part of the state are accessible only by air or water routes known as Alaska's Marine Highway.
There are no counties in Alaska. Instead, it is divided into 26 census areas and 12 native health corporation areas. Most pubic health services are provided by federally subsidized native health corporations (for eligible beneficiaries), private non-profit agencies, or directly by state-employed staff. There are 2 independent health departments in Alaska.
In 2000, the distribution of racial/ethnic groups in Alaska was as follows: 74 percent white (non-Hispanic), 4.3 percent African-American, 19 percent Alaska Native/Native American, and 5.2 percent Asian/Pacific Islander. These figures represent some individuals reporting more than one race. Hispanic origin was reported for 4.1 percent (all races). These figures reflect a stable population for every group except Alaska Native/Native American population, which continues to grow at a greater rate than the state average. The percentage of Native Americans residing in Alaska is higher than any other state in the U.S. Over half of all Alaska Natives are Eskimos, another third are American Indian, and smaller percentages are Aleuts. There are language barriers since the Eskimo group includes 2 different languages, Inupiat (in north and northwest Alaska), and Yupik (in south and southwest Alaska). Alaska Native populations are distributed widely throughout Alaska, with 71 percent living in over 200 small communities or tiny "native villages". All other racial/ethnic groups are concentrated in just 6 census areas with the highest population density: Anchorage, Fairbanks, Juneau, Kenai, Ketchikan, and the Matanuska-Susitna.
The crude birth rate in Alaska (15.9 per 1,000 population in 2000) continues to be one of the highest in the nation, although it has steadily declined from a high of 23.6 in 1980. Alaska Natives have the highest birth rate of all racial groups in Alaska (23.4 per 1,000 in 1999) — almost half that of whites and about 1.5 times that of African Americans and Asian/Pacific Islanders. One fourth of infants born annually in Alaska are Alaska Native.
Since 1991, the national birth rate among teenagers ages 15-17 years and 18-19 years has been declining and in 2000, reached record lows of 27.4 and 79.2 births per 1,000, respectively. Alaska has consistently exceeded the nation in the rate of decline of teen births among 15-17 years-olds; but in spite of significant declines among older teens, the birth rate for 18-19 year-olds has remained higher than the national rate. A significant racial disparity persists for the birth rates of Alaska Native teens and white teens. While both have shown declining rates over the last decade (29 percent and 41 percent decline) the Alaska Native teen birth rate was still 2.5 times that of white teens.
Cancer screening and incidence rates also vary by racial group. Overall in Alaska, the average annual breast cancer incidence rate for women was 141.3 per 100,000 — slightly higher than the U.S. rate of 132.9 in 2000. Mortality from breast cancer has been relatively stable for Alaskan women but has been higher for Native and African American women than for whites. Significant effort has gone into improving breast and cervical cancer screening rates for Native and un- or under-insured women and good progress has been made. Alaska has achieved the Healthy People 2010 goal of increasing the proportion of women 40 and older that has received a mammogram in the previous 2 years as well as the HP2010 goal for the proportion of women 18 and older that has ever received a Pap test. The tate-managed Breast & Cervical Health Check program has grown enormously since its inception and will serve nearly 10,000 in 2005.
In contrast, Alaska has not made progress toward achieving the HP2010 goals for early or adequate prenatal care — both of these measures remain well below the 90 percent target. While the national scores are low (84.1 percent for early care; 74.6 percent for adequate care), prenatal care in the first trimester was even lower among Alaskan women (80.1 percent) and adequate care was significantly lower for Alaskans (58.3 percent). Analysis of Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) data indicated that 1 in 5 Alaskan women did not get prenatal care as early in their pregnancies as they wanted. Among these women, nearly 30 percent did not know they were pregnant or were unable to get an appointment earlier. Another common reason was lack of funds or insurance.
Sexually transmitted diseases (STD) are the most frequently reported infectious diseases and constitute a significant health problem in Alaska. Although the rate for gonorrhea in Alaskan women is slightly lower than the national rate, at 109 per 100,000 it is 5.7 times the HP2010 goal of 19. Alaska's reported chlamydia rate for women in 2003 was the highest in the nation at 858 per 100,000. For all STDs, women are disproportionately affected. The availability of a rapid HIV test and of urine-based combined chlamydia-gonorrhea tests has made testing possible in such nontraditional settings as popular "hang outs" of youth and target groups, detention centers and even bars that sponsor risk reduction and testing nights.
The State of Alaska Division of Public Health (DPH) supports a Women's Health Unit in the Section of Women's, Children's and Family Health. More information is available at http://www.hss.state.ak.us/dph/wcfh/. Priority activities in 2005-2006 include the creation of an abortion/pregnancy/contraception information website, maintaining the Title X Family Planning Program in geographic areas with proven high incidence of unintended pregnancy, and improving coordination of women's health activities occurring throughout the department and/or division to reduce duplication of efforts.
Less than 50 miles wide in the northern panhandle and more than 300 miles wide in the southern end of the state, Idaho is as diverse as its width. The total area of the state of Idaho is 82,751 square miles with a population density of16.5 per square mile based on 2003 estimates. The state is divided into 44 counties. Idaho has numerous mountains, canyons, and gorges, including Hell's Canyon; the deepest in North America. Great distances that incorporate mountain ranges, high deserts, 2,000 lakes, countless rivers and streams, and the largest wilderness area in the lower 48 states separate the urban areas. There are 4 major Indian Reservations in Idaho: Coeur d'Alene, Nez Perce, Shoshone-Bannock, and the Duck Valley Indian Reservation. The primary providers of public health services are the 7 public health districts. They cover multiple counties and are governed by local boards appointed by the county commissioners within each district. The health districts work in close cooperation with the Department of Health and Welfare to provide an array of health services and programs to the residents of Idaho. There are between 4 and 8 counties in each health district.
The 2003 U.S. Bureau of the Census population estimate for Idaho is 1,366,332, which includes 681,517 females (49.9 percent). Idaho's growth rate of 5.6 percent since 2000 is the fourth highest growth rates in the nation. The vast majority (96.4 percent) of the population is White. The racial/ethnic distribution of the population of color is: 8.7 percent Hispanic, 0.7 percent African American, 1.6 percent American Indian/Alaska Native, and 1.3 percent Asian/Pacific Islander. Idaho has the highest percentage of persons of Hispanic origins in Region X although Washington state has the largest number of Hispanic persons. There are several concentrations of Hispanic population in Idaho, especially in the southern counties.
The number of Idaho resident live births increased 3.9 percent from 20,973 in 2002 to 21,794 in 2003. Following decades of consistently higher birth rates, Idaho's birth rate fell considerably in the 1980s to converge with the U.S. rates in 1988 for the first time. After 3 years below the U.S. rate, Idaho's birth rate rose above the U.S. birth rate again from 1992 through 2003. In 2003, the birth rate for Idaho was 16.0, a 2.6 percent increase from 15.6 in 2002. Although teen pregnancy rates in Idaho are declining (from 51.2 per 1,000 teen women aged 15-19 in 1999 to 48.1 in 2001and 45.8 per 1,000 teen women aged 15-19 in 2003), adolescent pregnancy remains a problem. Of the pregnant teens who utilized Idaho Family Planning Clinics in 2004, 81.2 percent indicated the pregnancies were unplanned, mistimed and/or unwanted compared with 65.3 percent of pregnant women aged 20 and older who were seen at public clinics. The state is concerned about the consequent negative effects on Idaho families and the health of the mothers and their children. There were 138 infant deaths for an Idaho infant mortality rate of 6.3 per 1,000 live births in 2003, which is down 12.5 percent from a rate of 7.2 per 1,000 live births in 1998.
Breast and cervical cancer are also health concerns in Idaho. One hundred and seventy-two women died from breast cancer in 2003 for a crude mortality rate of 25.2 per 100,000 women. The 3 year average number of breast cancer deaths for 1998-2000 and 2001-2003 was 172 and 159 respectively, for 3 year average annual rates of 27.4 and 23.8 per 100,000 women. In 2003, 14 women died of cervical cancer for a crude rate of 2.1 per 100,000 women. The 3 year average annual rate for cervical cancer was 2.1 per 100,000 women in 1998-2000 and 2.5 per 100,000 women in 2001-2003.
Sexually transmitted infections continue to be closely monitored in Idaho. Chlamydia continues to be the most frequently reported infection in Idaho for both males and females. In 2004, 2,784 cases of chlamydia were reported. Women presented over 75 percent of these cases. Much of the difference between reported cases in females and males can be explained by chlamydia screening practices. In order to prevent complications leading to infertility, the Public Health Service Task Force (PFSTF) recommends universal screening for chlamydia in sexually active females aged 15-24 years of age. Older females and males are screened based upon self-reported sexual behavior, epidemiologic linkages to positive cases and/or symptomology. Idaho participates in the Region X Infertility Prevention Project, including district health department STD and Family Planning clinics, which follow PFSTF recommendations.
Since 2001, Idaho has experienced a significant increase in the number of reported syphilis cases (11 cases in 2001 vs. 77 cases in 2004). These cases have been reported primarily from the Southwestern region of the state and have been equally represented by males and females. Persons 15-29 years of age represent 75 percent percent of the reported cases through 2004. Consequently, women of child-bearing age have been a particularly vulnerable population. During 2003-04, 7 congenital cases of syphilis were reported. The STD/AIDS Program and Office of Epidemiology and Food Protection continue to monitor all reported cases of sexually transmitted infections and link individuals to quality care services in Idaho.
Other women's health issues include access to care for rural women, domestic violence, increasing awareness of preventive care needs of women, especially for older women and access to appropriate prenatal care. The Idaho State Department of Health and Welfare, Division of Health has a variety of public health programs addressing the needs of Idaho women. These efforts include family planning, sexually transmitted diseases and HIV, breast and cervical health, diabetes, physical activity and nutrition, maternal and child health (MCH), Women, Infant and Children Nutrition Program, injury prevention, and general health promotion.
The Idaho Department of Health and Welfare, Division of Health is currently funding 2 special projects through the use of MCH funds specifically directed at women's health issues. The first project, Oral Health for Pregnant Women, has 3 objectives:
- To educate health providers and consumers about the potential link between periodontal health and pregnancy outcomes;
- To increase access to dental care by having medical providers - MDs, PAs, NPs, RNs - do oral health screening, education, and referral to community dentists;
- To improve pregnancy outcomes by identifying women with periodontal problems and helping them get needed dental care.
The second project focuses on lay midwives in Idaho and involves a couple of phases. The first phase, which has been underway for the past year, is centered on data gathering. It was determined by the Idaho Perinatal Project that there was a need to establish a method for documentation that would accurately reflect birth outcomes of home births that come to the local hospital for care. It was believed these births often began under the care of a lay midwife. Idaho does not currently have certification or licensure requirements for lay midwives. The Idaho Perinatal Project is also working with the major medical insurance carriers to look at the number of hospitals that have prohibited VBAC's (vaginal birth after cesarean) in their facilities. The statewide medical associations and other health care providers will attempt to address the continuum of care for women who wish for a VBAC even if it is not offered in their community. An effort is also being made to educate the general public on the difference between a lay midwife and a certified nurse midwife and how to make a good consumer decision regarding this choice. The second phase of this project will begin in the next year. In addition, certification requirements and hospital policy will be explored.
Oregon has a population of 3,582,600 almost evenly divided between females (50.4 percent) and males (49.6 percent), according to estimates of the Population Research Center published in March 2005. On average, there are 35.6 persons per square mile, but the population is distributed unevenly across the state. More than 2/3 of the population live in the Willamette Valley, the coastal region, and the mountainous areas of Southern Oregon. The Cascade Range divides the state between the Willamette Valley and the most sparsely populated eastern part of the state, which includes large areas of desert.
Oregon has 36 counties that are served by local county health departments for public health services. Multomah County, which includes Portland, is both the smallest county in size and the largest county in population.
Oregon is much less racially and culturally diverse than the United States as a whole; 86.6 percent are White (reported as primary race) compared to 75.1 percent for the whole country (according to the 2000 U. S. Census Bureau). The Hispanic population (at 8 percent, counted as Hispanics of any race) is the largest racial/ethnic group, followed by Asians (3 percent), African Americans (1.6 percent), Native Americans (1.3 percent), and Native Hawaiians and other Pacific Islanders (0.2 percent). Native Americans represent a larger proportion of Oregon population than it does for the U. S. population and widely distributed in Oregon but have tended to move from rural tribal areas and reservations into cities in the past decades. The Hispanic population, represented mainly by Mexicans at 78 percent, increases substantially during the summer months when migrant farm workers are needed. 4.1 percent of Oregon's women live in linguistic isolation (person in a household in which no person 14 years or over speaks only English, and no person 14 years or over who speaks a language other than English speaks English "very well.") 1 Each year, 1,700 new refugees enter Oregon's borders making it the 11th largest refugee resettlement state in America.
Oregon has significant geographic disparities. Many Oregonians live in rural or frontier areas and have limited access to health care. 23.5 percent of Oregon's population live in rural areas and 3.3 percent live in frontier areas. Of Oregon's 36 counties, 26 are designated frontier and 97.2 percent of Oregon's counties are designated as Health Professional Shortage Areas, compared to 82.2 percent of counties nationally.
The age distribution of Oregon women is similar to that of all women in the United States. The majority of women are of childbearing age, 15 — 44 years old (41.7 percent). Young females under 15 represent 19.7 percent of the population. Women age 45 — 65 represent 23.8 percent of Oregon's female population. Older women, age 65 and over represent 14.6 percent of the female population. However, as in the United States as a whole, the ratio of older women is growing. As a result programs and resources that limit their focus to services needed in the reproductive years of women are insufficient.
It is well recognized that "Most of the health care burden in the United States stems from chronic illness, more than half of which may be related to lifestyle and behavioral factors." As in many other states, the leading causes of death for women in Oregon are: heart disease, cancer and stroke. Many of these illnesses can be attributed to specific, correctible health behaviors as well as to a lack of early screening and care. Recent Oregon data show that:
- 19 percent of women report that they smoke
- 33 percent of women report that they have been diagnosed with high cholesterol
- 20 percent of women report that they engage in no physical activity
- 21 percent of women report that they are obese
- 15 percent of women report that they have no healthcare coverage
- More than 20 percent of eligible Oregon women don't get routine mammograms
- 12 percent of women have never had a Pap test
As to health status generally, racial and ethnic health disparities in Oregon reflect nationwide statistics. Recent Oregon Behavioral Risk Factor Surveillance System and Pregnancy Risk Assessment and Monitoring Survey data report that in comparison to white women, women of color are significantly:
- Less likely to have health insurance
- Less likely to report exercise or physical activity in the past 30 days
- More likely to ever have been diagnosed with diabetes
- More likely to be current smokers
- More likely to report having experienced physical violence in the past year
- Less likely to get prenatal care in the first trimester
Health care access in oregon
The uninsured population in Oregon is approximately 11 percent overall, but 16 percent of Oregon women are uninsured. Many of the uninsured represent the "working poor", those who make too much money to be eligible for Medicaid benefits but do not have employer provided insurance or enough expendable income to afford insurance.
Medical insurance in Oregon has been available to all resident families with incomes to 100 percent of federal poverty level (FPL). Pregnant women with incomes to 185 percent FPL are eligible for Medicaid benefits through the Oregon Health Plan (OHP). In addition, through the Family Planning Expansion Project, all Oregonians of reproductive age with incomes to 185 percent FPL have access to comprehensive family planning services.
The Oregon Health Plan (1115 Medicaid Waiver) was designed to serve a greater number of people than traditional Medicaid by limiting health care services considered non-essential, ineffective or experimental. Eleven percent of Oregon women are currently insured through the Oregon Health Plan. However, due to declining state revenues, the Oregon Health Plan recently added premiums and co-payments to all beneficiaries except pregnant women, children and the disabled. In a 6 month period in 2003, OHP coverage was cancelled for nearly 40,000 enrollees because they could not or did not pay their premiums. Oregon's governor has stated he will ensure that pregnant women continue to receive benefits. The same has not been guaranteed for women who are not pregnant. While it is important to insure care to pregnant women; forgoing preconception and interconception care, and care for women's health in general, can negatively impact the health status of women.
For the 16 percent of Oregon women living in poverty, reduced insurance benefits may significantly alter their health status. This negative impact may affect others, as most informal caregivers are women, many sandwiched between caring for an ailing relative and caring for their children. More than 40 percent of the Oregon population living in poverty are single females with children.
Even eligibility for OHP does not guarantee access to care. Women on OHP report that they are provided with reduced medical services or no services at all due to the low reimbursement rate. In eastern and coastal Oregon a woman seeking preventive services may not have access to women's health practitioners or public clinics. Training in comprehensive women's health services is limited or non-existent for providers serving rural areas and many preventive or intervention opportunities are missed. Especially missing from rural areas are resources for screening, treating or referring women for behavioral, emotional or chronic disease care.
In April 2003, the Oregon Women's Health Program conducted 6 focus groups on "Health Care Services for Women" to better understand the health needs of Oregon women that may not be captured in qualitative data. These focus groups took place throughout the state with women from various economic, age and ethnic groups participating. Those attending revealed many needs related to changing the negative health behaviors listed above. Some findings from the focus groups included:
- Participants described difficulty in getting adequate care in a timely manner, especially when presenting with an illness.
- Many women said they do not seek preventive services because they are unaware of the importance or availability of such care.
- Women of color noted that men are given more attention than women when it comes to preventing heart attacks or stroke.
- Refugee women, who may face linguistic and cultural isolation when seeking health care, reported not being familiar with preventive care as they only sought care in their home countries when sick.
- Women living in rural towns reported privacy concerns when seeking health care at a local facility.
- Women expressed a desire to exercise but lack the motivation or time to do so. Many expressed interest in programs offering information and activities related to weight loss, nutrition and exercise.
- Participants in the focus groups expressed a desire to learn stress-management techniques instead of being prescribed a medication for stress.
- In general, there was a concern that mental health medications are over-prescribed and recommended with no regards for side effects, and without accompanied counseling.
Finally, the women participating indicated they are very interested in health care issues. However, they find that reliable information about health care has not been widely available. National studies have indicated that women may not be as satisfied with the information they receive from their health care providers as are men or with the level of communication with their provider. Women in the Oregon focus groups emphasized that they are interested in preventing physical and mental disease and want more information on this subject. They expressed a need for culturally sensitive campaigns that advertise free screening services.
Current system of care for women
The fragmentation described in the background section of this narrative is most pronounced for those women who do not have health insurance or who live in communities without access to primary care providers. Overall, the care network available to uninsured and underinsured women in Oregon includes county health departments, Community, Migrant and Rural Health Centers, the Oregon Health & Science University, non-profit family planning clinics, and tribal clinics. There are approximately 100 such agencies with as many as 200 clinic sites operating at any one time throughout the state of Oregon.
Unless women seeking services are eligible for the Oregon Health Plan (Medicaid) or otherwise insured, women, and the safety net clinics that serve them, are dependent upon subsidies from multiple funding streams to get the care they need, such as Title X, Oregon Health Plan, Family Planning Expansion Project, categorical federal or private grants and patient fees. Rarely do these funding streams support provision of comprehensive women's health services — either preventive or primary. A woman entering a clinic is usually given care only for her presenting condition, without adequate time to address other health or prevention concerns. For the most part, available public funding is limited to urgent primary care or specifically limited preventive services such as family planning, prenatal care, STD testing and treatment, and/or breast and cervical cancer screening. Clients who are eligible for one program may not be eligible for the others based on differing income requirements, age limitations, and even definitions of the scope of care to be made available.
Family planning clinics make every effort to provide a more comprehensive scope of services for their clients — by stretching the use of categorical service dollars to include the widest array of possible services, by charging fees on a sliding scale or on a donation basis. In addition, these clinics develop and use extensive referral networks to other providers. For example, a client may seek services of a family planning clinic and have a variety of needs outside contraception. Clinicians believe that other medical issues often get in the way of assuring that family planning decisions are effectively reached and therefore attempt to empower the client to address pressing medical needs. However, clinics and clients constantly struggle with significant gaps in service availability because of differences in eligibility standards and care coverage between categorical programs. Referral to other providers does not assure that clients get the services they need because providers are off-site and there is no mechanism for follow-up to referrals. Primary care slots may be filled to capacity or a client's need may not be urgent enough to get immediate attention. Unless clients are eligible for the Oregon Health Plan or have other coverage, clinics may be referring clients with no hope of being able to finance the services they need.
Public resources have specific and substantive program requirements, including standards of care and protocols for education and counseling. Clinicians, health educators, and counselors find themselves constantly challenged to present consistent health messages that operate for the benefit of the whole client. Conflicting care standards and priorities between programs — even those operated within the same agency or clinic setting — can result in conflicting messages to clients and fluctuating priorities for care among clinic providers. Conflicting standards and priorities do not support integrated, comprehensive care.
Public health resources for women
The Office of Family Health, Oregon Department of Human Services, is the Title V Agency for the state. The Office of Family Health (OFH) houses the following sections: Perinatal Health, Child Health, Adolescent Health, WIC, Immunization, and Women's and Reproductive Health and Oral Health as well as programs in genetics and integrated data systems. OFH sections and programs work collaboratively at the state-level on program and policy development affecting the same population groups. A primary function is to provide consultation, technical assistance, financial support, and research support to county health departments and other organizations and agencies. The Office of Family Health is the lead agency in Oregon responsible for funding and monitoring key MCH programs and services that in turn are implemented by local health authorities.
Programs providing direct care services to women and currently supported by Office of Family Health are generally targeted to meeting reproductive health needs.
- The Women's and Reproductive Health Section provides funding and technical assistance to a network of Local Family Planning Clinics who deliver:
- Health Services; including physical exams, cervical and breast cancer screening, pregnancy testing, STD testing and treatment, dispensing of birth control methods and more.
- Health education and counseling about reproductive and preventive health concerns including: breast/testicular self-examination, birth control, STD/HIV risks, infertility, pregnancy counseling, and domestic violence.
Each year the Women's and Reproductive Health Section supports over 250,000 clinical visits.
- The Perinatal Health Section ensures the provision of an array of services to pregnant women:
- Clinical prenatal care to the uninsured and underinsured
- Genetic screening services
- Maternity Case Management
- Smoking-Cessation services for pregnant women
- Ongoing assistance in addressing socio-economic and health factors related to pregnancy
- Public Health Nurse Home Visitation
The Perinatal Health Section serves 8,000 women annually.
- The Adolescent Health Section provides health care services for youth through School Based Health Centers (SBHC). Over 13,000 young women receive services at SBHC's each year.
- Other services to women provided through the Office of Family health are: WIC nutrition services for pregnant, lactating and post-partum women, immunizations for young women and adults, oral health screening for pregnant women and parenting and child development information through early childhood services.
SafeNet Toll-Free Line: A component of the current system of care
Safenet is a vital link for Oregonians to have access to health information and services. Through its regularly updated information and referral database, SafeNet assists callers with simple request and complex health concerns. SafeNet improves accessibility to medical care; advocates for callers with special health needs and acts as a guide through public and private health systems. Currently, SafeNet serves over 30,000 callers per year.
Other public health programs
Programs in Oregon's Office of Disease Prevention and Epidemiology (ODPE -Acute and Communicable Disease Prevention; Environmental and Occupational Epidemiology; Health Promotion and Chronic Disease Prevention; HIV/STD/TB Program and Injury Prevention and Epidemiology) serve the population as a whole through research, data collection, epidemiological investigation and policy recommendations. They provide information and understanding around health issues relevant to women, which is often directed to the adult population at large, without specific focus.
ODPE manages the State's Breast and Cervical Cancer program, which networks with public and private providers to fund screening services for a targeted population; utilizing some, but not all of the same providers as make up the MCH network in local communities. The Breast and Cervical Cancer program serves 6,000 women annually.
In addition, DHS Health Systems Planning assists local communities and clinics to improve access to needed health services through the health care safety net. Health care safety net clinics are community-based providers who offer health services to low-income people, including those without insurance. Most safety net patients are Oregon Health Plan enrollees, the uninsured, and other vulnerable Oregonians who pay a sliding discounted fee for primary care services. Primary care services provided by the safety net include, but are not limited to: urgent care, acute and chronic disease treatment, services based on local community need (mental health, dental, and vision), preventive care, well childcare and enabling services (translation/interpretation, case management, transportation and outreach). The Migrant Health Program assists 7 safety net clinics serve the health care needs of Oregon's migrant and seasonal farm worker population. The annual population of Oregon's migrant and seasonal farm workers and their families is estimated to be 175,000. Annually, safety net clinics support over 600,000 clinical visits.
Other DHS Health Services include: Office of Medical Assistance Programs (Medicaid agency), Office of Mental Health and Addiction Services, Office of Public Health Systems (Environmental Health) and the Public Health Laboratory. Partnerships with other public health programs are numerous but not necessarily coordinated throughout. Examples of joint ventures include; Medicaid and public health family planning initiatives, tobacco prevention programs and preventive dental care. But it has been identified repeatedly that there is a need for gender analysis in research, program planning and development and educational approaches across public health, mental health, and Medicaid programs. Many of these programs incorporate analysis of and address disparities in special populations but omit gender analysis.
The Office of Family Health looks forward to increased collaboration with Oregon Health and Science University (OHSU) so that more Oregonian women can receive comprehensive health care. OHSU's Center for Women's Health, a Center of Excellence in Women's Health, is creating a new model of health care for women based on the values of wellness, interdisciplinary care, cutting-edge research and empowering patient education. The center supports complementary modes of care, including; high-tech, high-touch, traditional, alternative, wellness, mental health and nutrition.
OHSU comprehensive services are only available to women who seek care at their campus-based clinic. Unfortunately, the physical location of OHSU's Center for Women's Health limits availability for women living outside of the Portland metro area.
The Oregon, Office of Family Health is also the recipient of a grant to expand the 800-SafeNet information and referral line to also cover resources for women across their lifespan.
- National Women's Law Center - Making the Grade on Women's Health 2000
- Immigrant and Refugee Community Organization. Portland, Oregon. 2003
- From Rural to Remote America: Family Health Care in Alaska, Idaho, Oregon and Washington. Association of Maternal and Child Health Programs. March 2004
- Addressing Health Care Shortage Areas in Oregon. Oregon DHS Public Health, Health Systems Planning. 2003
- US Census Bureau 2000
- HHS Office on Women's Health "Women's Health Issues: An Overview" 2001
- Oregon Selected Women's Health Issues 2004 (Unpublished). Data Sources: Oregon Vital Statistics, 2001-2002, HIV/AIDS & STD 2002 program reports, Oregon Women's Health & Safety Survey, 2004, Oregon Behavioral Risk Factor Survey, 2002, Hospital Discharge Database, 2002
- Gustafson A. Oregon Health Plan is in critical condition. Statesmen Journal Salem, Oregon, Oct. 12, 2003
- The Status of Women in Oregon. 1998. Published by Institute for Women's Policy Research.
- Sola A. Health Care Services for Women, A Report on Six Focus Group Discussions. 2003 (Unpublished)
- HHS Office on Women's Health "Women's Health Issues: An Overview" 2001
- Sola A. Health Care Services for Women, A Report on Six Focus Group Discussions. 2003 (Unpublished)
- Moreno A. Migrant Health Fact Sheet. Oregon DHS Migrant Health Office. 2003
- Oregon Health & Science University, Center for Women's Health
To access the Oregon women's health program website, visit http://www.oregon.gov/DHS/ph/wh/index.shtml.
The state of Washington covers 66,663 square miles, and is bordered by British Columbia on the north, Idaho on the east, Oregon on the south, and the Pacific Ocean on the west. The state has 39 counties. Twelve of the counties border on Puget Sound, and adjacent waters of the Pacific Ocean which extend from Canada south more than 160 miles. The inland waters of the Pacific Ocean surround 2 of the counties. The state's capitol is Olympia, the largest city in Thurston County, which sits at the southernmost tip of Puget Sound. The Cascade Mountains, which run from north to south through the heart of the state, form a natural barrier between western and eastern Washington. There are 36 Native American tribes in Washington state, some occupying reservations, which vary greatly in geography, resources and population. There are 35 local public health jurisdictions covering the state. Many counties are considered "underserved" in terms of having qualified health providers. There are 38 counties with some level of primary care shortage designation, 31 counties with some level of dental shortage designation and 27 counties with some level of mental health shortage designation.
In 2003, there were an estimated 6.1 million, Washington state residents. Washington state remains predominantly White, with Whites accounting for 85.5 percent of the population. However, increases occurred for most minority groups in the period between 1990 and 2003. In 2003, Asian/Pacific Islanders accounted for 6.0 percent of the Washington state population, Blacks accounted for 3.6 percent, persons reporting multiple races accounted for 2.9 percent, American Indian/Alaska Natives accounted for 1.6 percent, and Native Hawaiians/Pacific Islanders for 0.4 percent. Hispanics represented about 8 percent of the Washington state population in 2003. Washington has the highest percentage of Asian/Pacific Islanders in Region X. The Hispanic percentage of the population in eastern counties still increases substantially during the summer months during the fruit and vegetable harvest season. Despite the fact that the state is no longer receiving the large in migrations of Asians and persons of Hispanic origin it received in the 1980's, the percentage of the population that is non-white is expected to continue to increase.
Washington birth risk factors tend to be similar to or better than the national average. In 2002, an estimated 83.4 percent of Washington state pregnant women entered prenatal care during the first trimester of pregnancy, compared to the national figure of 83.7 percent. Tobacco smoking during pregnancy among women with a live birth in Washington state decreased significantly from 20.1 percent in 1990 to 10.9 percent in 2003. Nationally in 2003, 11.0 percent of women with a live birth smoked during pregnancy. In 2003, the Washington low birth weight (LBW) rate for singletons was 4.6 percent, representing 3,702 births in Washington state. The overall Washington LBW (which includes multiple births) was 6.1 percent. In 2003, the national singleton LBW rate was 6.1 percent and overall LBW rate was 7.9 percent. In 2003, 447 Washington state infants died in their first year of life. The Washington state infant mortality rate (IMR) for 2003 was 5.6 per 1,000 births, compared to a preliminary 2003 national rate of 7.0 per 1,000 live births.
In April 2005, 47.6 percent of Medicaid clients are enrolled in Healthy Options, a Medicaid-managed care plan. The First Steps program provides Medicaid coverage to pregnant women and infants less than 1 year of age with family incomes at or below 185 percent of the federal poverty level. Eligible women receive Medicaid-paid maternity care and maternity support services throughout pregnancy up to 2 months postpartum. Infants with specific needs or risks are eligible for case management during their first year of life.
The latest available research data (2002) on (1) all women and (2) teen women in need of publicly supported contraceptive services to prevent unintended pregnancies are from the Alan Guttmacher Institute, Inc. (AGI). While the Washington state Title X Family Planning program is serving a greater percentage of these women than the national averages, AGI data show that 51 percent of women ages 13-44; and 34 percent of all teen women (ages 13-19) in Washington state do not have the access through state and federally funded family planning programs.
Based on available information, among the federally funded family planning providers, only the Title X program slides fees to zero while also paying for education, clinic, laboratory services and supplies for poverty level income clients. Title X in Washington state covers women in need of contraceptive services for women whose family income is less than or equal to 250 percent federal poverty level.
To further increase access to family planning services for low-income women and men not otherwise Medicaid eligible, a Medicaid waiver for family planning coverage was implemented in July 2001. The 5 year research and demonstration project called TAKE CHARGE provides Medicaid-paid family planning services to men and women with family incomes up to and including 200 percent of the federal poverty level. In the first 3 years, more than 230,000 men and women enrolled in the program. More than 2/3, or 68.3 percent, of these women were between the ages of 18 and 29; the same age group accounted for 73 percent of all Medicaid-paid births in 2003.
The Washington state pregnancy rate for women 15 to 44 years old (per 1,000) has continued to decline. In 1990 the pregnancy rate was 96.0 per 1,000 women 15 to 44 years old, in 2000, the rate was 83.2, and it continued to decrease to 81.7 in 2003. The teen pregnancy rate for 15 -17 year olds has also decreased from 57.9 (1990) to 36.3 (2000), and 28.8 in 2003. Teen pregnancy continues to be a concern in Washington state. The birth rate for 15-17 year olds has decreased from 25.3 in 1997 to 20.4 in 2000, and 15.3 in 2003.
Washington state has seen numerous efforts to increase access to emergency contraceptive pills (ECP) through collaborative agreements in pharmacies and increased awareness among providers and residents. The potential impact on unintended pregnancy has not been determined yet, however, over 1,000 ECP prescriptions are now dispensed per month under the collaborative agreements.
In looking at chronic diseases that affect women, Washington has the highest rate of occurrence of breast cancer in the country, although death rates are slightly below the national average. There is also a "stroke buckle or belt" in the Pacific Northwest for stroke. The state has the eighth highest stroke rate in the country with more women dying from stroke than men in absolute numbers although this is not reflected in death rates. Heart disease remains the leading cause of death for both men and women, as is true across the country. Asthma is another chronic condition that affects women disproportionately starting in their teen years and throughout adulthood. The state has recently completed state plans for Heart Disease and Stroke Prevention and Management, Asthma Control, Diabetes Prevention and Control, Comprehensive Cancer Control, and updating of the Tobacco State Plan. Most of these plans are available on the Department of Health website.
Washington is fortunate to have almost $30 million a year for the Tobacco Prevention and Control Program. Since the program started 3 years ago, teen smoking rates have decreased significantly. In addition, more tobacco users are successfully quitting tobacco use through access to a telephone-based counseling service and physician-office centered interventions.
Since 1996, data on domestic violence offenses reported to the police have been compiled and reported by the Washington Association of Sheriffs and Police Chiefs (WASPC). There have not been consistent changes in the rates of reports to police of domestic violence between 1996 and 2004. In 2004, there were 52,035 domestic violence offenses reported to the police, equivalent to 8.4 per 1,000 population. In 1998, the Washington Behavioral Risk Factor Survey, a household survey of non-institutionalized Washington adults, found that about 1 in 5 women reported experiencing physical violence from an intimate partner in their lifetimes.
In 2004, chlamydia continues to be the most common sexually transmitted disease in Washington state with 17,635 reported and an incidence rate of 285.9 per 100,000 population. Since 1988 Washington state has participated in screening and prevalence monitoring activities through the Infertility Prevention Project (IPP). Though the number and rate of chlamydia infection has increased over the last 6 years, Washington's incidence rate is favorable compared to the 2003 national rate of 304.3 per 100,000 (CDC 2004). More sensitive laboratory techniques, increased funding for screening for asymptomatic infection (as opposed to symptomatic treatment), improved surveillance and reporting are a few factors that may have contributed to the increase. There are peak age-specific rates in 15-19 year old females (and 20-24 year old males). Gonorrhea cases increased to 2,810 from an all-time low of 1,949 cases in 1998, yielding a statewide incidence rate of 45.6per 100,000 population. Incidence is highest in the 20-24 age group for males and the 15-19 age group for females. Primary, secondary (P&S) and early latent cases of syphilis totaled 201 in 2004. In 1996, King County reported only a single case of P&S syphilis. In 2004, of the state's 150 primary and secondary cases, 123 (82 percent) were reported from King County, driven by an outbreak among men who have sex with men, men associated with anonymous multiple partners in bathhouse venues and illicit drug use, especially methamphetamines. However 6 female cases of early syphilis were reported in 2004, suggesting that the infection may become resurgent in heterosexuals. The statewide incidence rate for primary and secondary syphilis increased significantly to 2.4 per 100,000 compared to 1.2 observed in 2003. There were 2,152 cases of initial (primary) genital herpes and one case of neonatal herpes reported. HIV/AIDS data as of June 30, 2005 reflect that the proportion of AIDS cases among women in Washington state has risen dramatically since 1990 when only 6 percent of diagnosed cases were in women. The percentage of female diagnosed cases rose to 17 percent in the year 2004, and was 14 percent cumulatively (between 1998-2004). The proportion of cases among people of color increased in and outside King County through the late 1990's. For example, people of color constituted 20 percent of Washington's cases diagnosed in 1993 and 35 percent of cases diagnosed in 2000. The number of diagnosed cases of AIDS appears to be dropping due to new antiretroviral therapy, which retards progression of HIV to AIDS. As a result of these effective treatments, the number of persons living with HIV or AIDS continues to increase by an average of 10 percent per year.
Vaccination is one of the most successful disease prevention strategies in public health. Continued emphasis is needed to improve childhood and adult immunization rates and ensure the best disease prevention. The recommended immunization schedules have had many additions in the last few years — updated information and resources are available at www.doh.wa.gov/cfh/immunize.
The state's proximity to the Pacific Ocean, Puget Sound, and numerous lakes and rivers brings the issue of methylmercury and other contaminants such as PCBs and PBDEs in fish to the forefront. The Washington State Department of Health has released recommendations about the safe consumption of fish for women of childbearing age, women who are breastfeeding, and children on their website: http://www.doh.wa.gov/fish/. These recommendations expand upon advice recently released by the EPA and FDA which are available at http://www.cfsan.fda.gov/~dms/admehg3.html.
The Washington State Department of Health has organized a Women's Health Resource Network, which has been a forum for division and department wide input and response into current and emerging women's health issues and projects. Their goal is to assist the Department of Health in building state and local capacity to address the needs of women and their health concerns across the lifespan.
For more information on the Washington women's health program, visit http://www.doh.wa.gov/cfh/women/.
Content last updated August 8, 2008.
A federal government website managed by the Office on Women's Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services.
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