Rural Women's Health Conference Summary Report Summary Report   (PDF File, 1.82 Mb) August 13 -15, 2007 Omni Shoreham Hotel, Washington DC

Workshops, Part II

Identifying and Addressing Depression During and After Pregnancy Among Rural Georgia Women

This presentation summarized the findings of a study on depression in expecting and new mothers. Sandra Pittman, Ph.D., Director of the Prenatal Center at the Medical College of Georgia, began by noting that the study was conducted through the Enterprise Community Healthy Start program in rural Georgia. The learning objectives included:

• Understand process components of identifying depression during and after pregnancy
• Consider the incidence of positive depression scores pre- and post-natally among a population of rural women
• Describe other considerations necessary when women screen positive for depression
• List implications and strategies for practice in addressing prenatal depression
• List implications and strategies for community education in addressing prenatal depression
• Discuss implications for research in addressing prenatal depression

Dr. Pittman explained that the program uses the Beck Depression Index and the Edinburgh Postnatal Depression Scale for depression screening. In many cases, they cannot contact women by phone but can mail a letter with information on the program and prenatal depression. She noted that face-to-face screening is more effective because the tool can be scored right away and discussed with the client. With mail screening, there are always concerns about literacy level.

Dr. Pittman also noted that with scoring face-to-face, one issue is how to follow-up with the client. She said they look for all types of intervention possibilities. She noted that oftentimes, the client does not want to go into care or into counseling, but sometimes, a support group is okay. She said they have numerous spaces arranged for counseling to help with the issue of stigma.

Dr. Pittman reported that the results of screening included enrolling 397 clients between 2004 and 2006. There were 111 clients in the program 3 months postpartum who had a positive depression screen pre-natally. She said of those clients, 18 women accepted the intervention, and 66.7 percent became negative for depression. She noted that what you see is what you expect—the earlier you identify depression and the earlier the woman accepts services, the greater the number that will move from a positive to a negative depression score.

Dr. Pittman described how Enterprise Community Healthy Start has learned several lessons from this study. She reported that one important fact is that depression screening helps identify women who have severe mental illness. Another conclusion is that group and individual strategies may be helpful in meeting the needs of women resistant to appointment keeping. In addition, enlisting other community agencies will broaden community awareness. She concluded by stating that additional strategies for overcoming barriers to access to mental health services must be sought and evaluated.

Using Videoconferencing Technology to Effectively Train Remotely Located Community Health Promotion Staff

This presentation highlighted a health training program that is conducted via videoconferencing. Litia Garrison, B.S., Health Educator for the WISEWOMAN and WISE At Every Size programs at the Southeast Alaska Regional Health Consortium (SEARHC), began by explaining that SEARHC is a health organization governed by representatives from 18 communities. She reported that the clinics serve 12,500 Native people and another 6,000 non-Natives in rural areas with minimal access to health services. She said the service communities are spread throughout the southeastern Alaska panhandle over a distance of approximately 350 miles from the north to the south end. She noted that most communities are not connected by roads. Instead, transportation is mostly by boats and planes.

Ms. Garrison explained that SEARHC uses videoconferencing for business meetings, telemedicine, telepharmacy, telebehavioral encounters, continuing education credits, staff training, lab procedure training, and family visits. She also noted that when people in tightly knit communities come to Sitka for a hospital stay, videoconferencing allows them to connect with their families.

Ms. Garrison went on to explain that in order to enhance their usage of the media, SEARHC sponsored a 4-day videoconferencing training session. She said staff learned numerous things during the training, including the benefits of using a document camera to share information right on the screen that they typically would have had to send in some other way to the remote sites. Like with theater, Ms. Garrison explained, creating an optimum set is a key to success. Good eye contact, clear sight lines, good lighting, access to tools and materials, good backdrops, and the presenter's appearance all need to be considered.

Ms. Garrison said the group also learned about differences between live videoconferencing and traditional classrooms. Live videoconferencing is similar to live TV and very different from classroom instruction. Coordinating the teaching of those onsite and at remote locations takes practice and planning. She said they learned about the importance of developing involvement objectives, like knowing how often you will include your learners, how you will do that, when you will do it, and how many times they will interact. The minimum standard to strive for is 30 percent interaction time during a live videoconferencing event. Even better, you should strive to engage learners among remote sites, not just from the near side to the far side.

Ms. Garrison concluded by noting that while there are limitations, videoconferencing allows for a near hands-on experience and helps connect people across great distances. She said in Sitka, they could not plan a training session on any single day and expect that people from all of the State's remote communities would be able to make it on that day. However, videoconferencing enables them to schedule regular trainings and connect with people on a consistent basis.

Improving Migrant Women's Access to Early Detection Services Through Effective Partnerships in a Frontier State

This presentation highlighted a program that uses partnerships to improve the health of rural and migrant women, including increasing early detection for breast cancer. It was presented by Carol Peterson, M.S., RN, National Rural/Frontier Women's Health Coordinating Center Director and Health Promotion/Disease Prevention Specialist, Wyoming Health Council; Cathy Florian, Director, Wyoming Migrant Health Program; and Mandy Hobbs, RN, Women's Wellness Coordinator, Wyoming Migrant Health Program.

Ms. Peterson opened the session by describing how providing health services in a large, rural State like Wyoming presents multiple challenges. With 515,000 residents, Wyoming is very sparsely populated. Seventeen (17) of the State's 23 counties are classified as frontier. It is also fairly homogeneous—91 percent of the population is white.

Ms. Peterson, Ms. Florian, and Ms. Hobbs explained that the Wyoming Health Council (WHC) works to address the health-related needs of low-income residents. Formed in 1990, WHC is the coordinating agency for the State's Title X Family Planning Program. Partnering with other organizations is a critical part of providing services in rural areas because it can reduce duplication of services. They went on to explain that since WHC is a nonprofit organization, as opposed to a public entity, it is not weighed down by bureaucratic issues. This allows for more rapid implementation of programs and the ability to respond quickly to changing priorities. Another important aspect of partnering is that programs can pool resources and complement strengths and weaknesses.

The presenters described how the Wyoming Migrant Health Program (WMHP) serves the Big Horn Basin area, which includes four counties—Park, Big Horn, Washakie, and Fremont. They stated that the goal of the program is to improve the health status of migrant and seasonal farm workers and their families through the assurance of high-quality primary and preventive care. WMHP also administers the Women's Wellness program. This program provides navigation for wellness services for women who are uninsured or cannot afford to pay for annual breast and cervical cancer screening. The program also provides education on self breast exams, either on an individual or a group basis.

The presenters explained how the program grew significantly during the first 2 years in terms of both staff and clients. A secretary was added to take care of paperwork, schedule appointments, make reminder calls, and communicate with the State Health Department. An outreach worker was also hired. They concluded by noting that in year 2, the program conducted 559 educational encounters and 264 clinical breast exams, of which 18 were abnormal. They also provided 199 mammograms, of which 14 were abnormal.

A Survey of Rural Women's Health Literacy and Sources of Health Information

This workshop offered strategies for improving community health literacy. Barbara Disckind, Senior Writer at the U.S. Department of Health and Human Services Office on Women's Health, began the session with a definition of health literacy—the ability to obtain, process, and understand health and medical information. She noted that it is different from regular literacy. Many highly literate people have low health literacy. Health literacy is affected by culture, knowledge, and the clarity with which health information is communicated.

Ms. Disckind went on to note the importance of health literacy, which can directly effect people's medical treatment. Many underserved people (e.g., elderly, poor, low education, minority, and limited English speakers) may have their health care suffer in quality due to health literacy issues. In 2003, the National Assessment of Adult Health Literacy found that 90 million Americans had either basic or below-basic levels of health literacy.

Ms. Disckind then offered several strategies for improving health literacy, including the use of plain language and the teach-back method. She explained that the teachback method is a non-judgmental way of having patients repeat instructions to make sure they understand the health information given to them. She explained that plain language is a tool to remove jargon from health information. It is not "dumbing down"the information or an insult to patients, but a helpful tool in improving health literacy.

Next, Jennifer Peters, Coordinator for Community Health Promotion at the University of Arizona, Mel and Enid Zuckerman College of Public Health, Rural Health Office, outlined four practical strategies to improve health literacy. First, improve the usability of health information, making sure the contents are appropriate and easily understood. Second, improve the usability of health services like forms and instructions. Third, improve the accessibility of healthcare environments through clear signs and directions. Lastly, improve accessibility to quality health information and educators.

Ms. Peters went on to explain how health literacy issues lead to low social empowerment, low self-efficacy, poor health outcomes, and an increase in money spent. She said health literacy should be viewed as a learned behavior. Improving health literacy in a community involves improving the environment and resources to assist community members in supporting and helping each other.

Ms. Peters outlined four types of literacy—fundamental, scientific, civic, and cultural. She explained that civic literacy is the ability to recognize, process, and understand media sources and quality; where to access media; and how to advocate for causes. The media often sends mixed health messages. A person with low civic literacy would have trouble interpreting the data, which leads to low health literacy. She concluded by stating that because of the high prevalence of TV as a health information source, we need to increase people's ability to discern quality information.

Gender-Specific, Culturally Competent Recovery Services for Rural Women

This presentation highlighted an innovative program that offers gender-appropriate services for substance abuse treatment and recovery. Niki Miller, M.S., CPS, Executive Director of the New Hampshire Taskforce on Women & Recovery and Adjunct Faculty at the Springfield College School of Human Services, began by noting that 92 percent of women in need of alcohol or drug treatment do not receive it. Ms. Miller said that you cannot send someone away for 30 days and then expect them to come back and be cured. For example, you would not send someone with diabetes away for 30 days and expect them to be healed. She explained that women heal within the context of relationships, communities, and families.

Ms. Miller then described the New Hampshire Taskforce on Women & Recovery, which is a small, nonprofit organization dedicated to improving the lives of at risk and recovering women, families, and girls through collaboration, education, empowerment, and advocacy. It was formed by a group who conducted a statewide needs assessment and made a report to policymakers. She noted that instead of just walking away from the report, the group formed an advocacy taskforce.

Ms. Miller discussed some of the findings from the needs assessment. One finding was that women who had experienced more than five treatments were told they were treatment resistant. She explained that the treatment system is failing women and that there is also an incredibly high rate of trauma among women in treatment. She noted one alarming study by Feletti and Anda, which found that 78 percent of female IV drug users experienced 4 or more types of childhood trauma, whereas only 0.5 percent of non-traumatized women use IV drugs. Ms. Miller explained there is a clear cycle of sexual and violent victimization and addiction.

Ms. Miller stated that the New Hampshire Taskforce on Women & Recovery developed five types of services:

1. Corrections services—workers go into the prison system and deliver interventions. Ms. Miller noted there is a skyrocketing rate of incarceration of women that is driven by substance abuse.
2. Telephone "warmline"and linkage services—both providers and women can call for help and information. Ms. Miller noted that the majority of these services are provided by volunteers.
3. Professional and public education
4. Women's Leadership Training Initiative (WLTI)—an initiative that spans mental health, substance abuse, and domestic violence. Ms. Miller noted WLTI is funded by the Substance Abuse and Mental Health Services Administration's Center for Mental Health Services and Center for Substance Abuse Treatment.
5. Ensuring the voice of recovering women and families is at every table

In closing, Ms. Miller noted that through this effort, the New Hampshire taskforce has learned several things that they did not know 5 years ago. In the past, women have been labeled treatment resistant, but the reality is that the treatment was woman resistant. She explained that the treatment did not address child care, history of trauma, and other important issues. No system is capable of healing every recovering woman, but every recovering woman has a role in healing the system.

Substance Abuse Treatment for Women in Rural Indiana: A Costly Gender Gap

This presentation summarized the findings of a study on the gender gap between substance abuse treatment services for men versus services for women in rural Indiana. Ruth Case, B.S., Performance Improvement Coordinator at the Affiliated Service Providers of Indiana (ASPIN), began by providing an overview of ASPIN, which is located in Indiana. ASPIN is a network of 13 community mental health centers and addiction providers that deliver services to 74 of Indiana's 92 counties. Ms. Case noted that there are 45 federally designated rural counties in Indiana, and many other counties are very rural, although they have not officially received that designation.

Ms. Case explained that ASPIN conducted a needs assessment and identified that women in need of addiction treatment were a significantly underserved population. She said one of the first things ASPIN did was look at the data and analyze the differences between women and men in substance abuse treatment. They found that women represented only 35 percent of those served, despite data indicating that addiction is an equal opportunity disease. Yet, the total cost of serving women was 47 percent of the total overall cost for substance abuse services. They also found that women in treatment have a lower average annual household income than men in treatment, yet women have a higher average number of dependents in their households. Of individuals desiring employment, the unemployment rate for women was much higher. Ms. Case explained that this information means that women who need treatment typically need more services at higher costs, yet they have less money to pay for them.

Ms. Case then discussed the numerous barriers to treatment for women. She noted that the financial barrier is tremendous. If you only have enough money to buy groceries for your children, you are going to spend the money on that, not on a weekly treatment session. Transportation and child care are also significant barriers. She went on to explain that there are also barriers to treatment in the legal system. In many cases, women are more likely to be sent to jail than to be referred to a court ordered treatment diversion program.

Ms. Case concluded the session by outlining several strategies ASPIN identified to effect change. She said the first key is to reduce barriers to treatment. A number of providers who work directly with the courts showed them that the number of referrals were higher for men than for women. Ms. Case noted that this information was an eye-opener to the courts. Ms. Case then described additional strategies that included securing funding for childcare, developing women-only treatment groups, offering combined treatment, and providing supplemental educational programs. She said securing financial support is also a key strategy. One solution is to look at how current funding can be adjusted to target women. Ms. Case said ASPIN also did a lot of work with the court system to talk about the cost of incarcerating women versus putting them in a treatment program. She explained that another way to consider the financial burden involved is to look at costs now versus hidden costs down the road that will be incurred if women do not receive treatment. She went on to explain the hidden costs of not providing treatment—which include judicial costs, incarceration, child welfare, and child treatment costs. For example, each child afflicted with Fetal Alcohol Syndrome will cost $1.4 million over his or her lifetime in institutional and medical costs.

Taking Control: Women and Their Options in Treating Premenstrual Syndrome and Menopause

This presentation offered a summary of options for dealing with menopause. Carol Roberts, M.D., President and Medical Director of Wellness Works, began by noting that menopause occurs in stages. In their 40s, most women experience perimenopause, during which ovulation is intermittent. Dr. Roberts explained that menopause occurs when menses cease, which for most women is in their 50s. As women enter their 60s, the process continues with a decline in the production of all hormones. There are a range of symptoms associated with the various stages of menopause, many of which overlap. These include insomnia, mood swings, poor concentration, and memory loss. In particular, during menopause a rise in cholesterol, weight gain, and bone loss can occur. She noted the greatest bone loss occurs in the first 5 years of menopause.

Dr. Roberts questioned, if menopause is a natural process, why is it necessary to treat it? She said over the centuries, there have been various approaches to addressing the symptoms of menopause. These have included committing women to insane asylums, divorce, and herbal treatments. She said in 1950, Premarin, the first form of estrogen replacement therapy (ERT), also known as hormone replacement therapy (HRT), was introduced.

Dr. Roberts noted that following the introduction of ERT, the incidence of endometrial, uterine, and breast cancer increased significantly. In the 1970s, progestins were invented and used to prevent uterine cancer, when combined with Premarin. She said in 2002, questions were raised about the safety of HRT (progestins and Premarin). However, it was also reported that HRT can prevent heart disease. Currently, many women are unsure of what is the best approach for treatment of the symptoms of menopause.

Dr. Roberts concluded by noting that bioidentical hormones are an alternative to HRT for the treatment of menopausal symptoms. In addition, she noted that they are available over-thecounter, which is an indication of their safety.

Women's Bone Health: Issues Through the Lifespan

This workshop included presentations on three topics:

1. Secondary osteoporosis
2. The female athlete triad
3. Fracture care.

Secondary Osteoporosis

Kimberly Templeton, M.D., Associate Professor of Orthopaedic Surgery and Health Policy and Management at the University of Kansas Medical Center, began her presentation on the first topic by noting that peak bone mass occurs in females between 11 and 14 years of age. She said bone mass is relatively constant until mid-life, after which, women undergo two phases of involutional bone loss. Dr. Templeton explained that while bone density is used to define osteoporosis, bone quality is also an issue. In fact, she said, there are multiple issues involved in bone health. These include genetic influences, exposure to hormones, and lifestyle (e.g., diet, exercise, smoking, and alcohol consumption). Dr. Templeton went on to explain that there are also various medical conditions and medications that can increase the risk of osteoporosis. Medical conditions include insulin-dependent diabetes, malabsorption syndromes, hyperparathyroidism, hypogonadism, rheumatoid arthritis, and inflammatory bowel disease. Various medications associated with reduced bone mass in adults include anticonvulsants, cytotoxic drugs, glucocorticoids and adrenocorticotropin, gonadotropin, and immunosuppressants.

Dr. Templeton noted that oral contraceptives have also been associated with loss of bone mass. However, there is conflicting data and many variables including differing strength. She explained that there have been many studies done relating to this topic. While the findings are mixed, it is most likely that use of oral contraceptives has an impact on bone mass. She said breast cancer also is a proposed risk factor for osteoporosis, which can be related to premature ovarian failure, direct effects of chemotherapeutic agents, direct effects of breast cancer, or the effect of anti-estrogen hormonal agents.

Dr. Templeton concluded the first part of the presentation by noting that there are many additional factors that affect bone health. These include lifestyle and other conditions and/or their treatment. She said these conditions effect bones either through impact on sex hormones or other mechanisms.

The Female Athlete Triad

Sharon Hame, M.D., Associate Clinical Professor at the University of California, Los Angeles, Department of Orthopaedic Surgery, began by explaining that the Female Athlete Triad (FAT) is made up of three conditions: (1) disordered eating, (2) amenorrhea, and (3) osteoporosis. She said these three components do not need to occur simultaneously. She went on to explain that while the prevalence of FAT is unknown, major variables are age, sport, and ethnicity. She also noted important factors include striving for low body weight and participation in an activity where appearance is judged.

Dr. Hame explained that eating disorders are a wide spectrum of harmful and often ineffective eating behaviors used in attempts to lose weight or achieve a lean appearance. Behaviors associated with disordered eating include binging, purging, caloric restriction, excessive exercise, and use of diuretics, laxatives, and diet pills. Dr. Hame reported that an estimated 3 percent of young women suffer from disordered eating—10 to 62 percent of females athletes suffer from it. With female athletes, the risk factors include the perception that thinness can improve performance, as well as pressure from coaches, parents, and judges.

Dr. Hame went on to explain that inadequate nutrition accompanied by excessive exercise can result in the ovaries decreasing production of estrogen, leading to amenorrhea, which can lead to bone loss. Amenorrhea is defined as the lack of menses for 3 or more consecutive months after menarche begins. Dr. Hame reported that amenorrhea occurs in 2 to 5 percent of the general female population and in 15 to 66 percent of female athletes.

Dr. Hame concluded the second part of the presentation by stating that FAT is treatable. Key aspects of treatment include athletic participation, positive energy balance, healthy weight goals, frequent visits with health care professionals, and written contracts. She emphasized that in order to treat disordered eating, a multidisciplinary team approach is often used including a physician, psychologist, nutritionist, athletic trainer, coaches, and parents.

Breaking Tradition: A New Look at Fracture Care

Laura Tosi, M.D., from the Division of Pediatric Orthopaedic Surgery at the Children's National Medical Center in Washington, DC, began the third part of the presentation by asserting that too much focus and public attention has been directed toward osteoporosis. She explained that while osteoporosis is a serious condition, fracture risk is a much more comprehensive way of assessing an individual's bone health and determining the likelihood of future fractures.

Dr. Tosi reported that each year in the United States there are 1.5 million fractures. Fractures can have significant consequences. For patients with hip fractures, 6.3 percent die while in the hospital. Of the 93.7 percent that survive, up to one-third dies within a year. Of those who live beyond a year, half of those returning home need help with daily activities. She noted that the estimated annual cost of treating fragility fractures is $12-$18 billion.

Dr. Tosi stated that traditionally, calculations on fracture risk have been based on the World Health Organization's (WHO) definition of osteoporosis. However, this has been revised and the new approach considers age, previous history of fracture over age 45, bone mass density (BMD), low body mass index (BMI), family history of hip fracture, current cigarette smoking, high alcohol intake, and previous steroid exposure. This new approach is based on evidence that prior fractures are a risk factor for future fractures—the risk increases 1.5-9.5-fold following the initial fracture. She noted that a history of fragility fracture is more predictive of future fracture than bone density.

Dr. Tosi concluded by stating that other important considerations with fracture risk are the rapidly expanding population of individuals with secondary osteoporosis and the fact that the majority of Americans are not receiving adequate levels of Vitamin D, which plays a critical role in calcium absorption. According to the Third National Health and Nutrition Survey, over 70 percent of women ages 51-70 were estimated to not be meeting adequate intake guidelines for Vitamin D based on daily intake from diet and supplements.

New Leaf Choices for Healthy Living

This workshop highlighted a weight loss and healthy living behavior change program for rural women in Alabama. Jessica Hardy, M.P.H., B.S.N., Director of the Alabama Office of Women's Health and Emergency Preparedness and Nurse Coordinator at the Alabama Department of Public Health, began by reporting that Alabama ranks second-highest in the United States for obesity, with 26- 30 percent of the population defined as obese. Ms. Hardy explained that when her office started project planning in 2004, the Alabama Department of Public Health found that 57 percent of women in Alabama were overweight or obese, including 66 percent of women ages 45-54, 73 percent of black women, and over half of white women. She noted, however, that this was self-reported data, and in 2006, some of these data shifted.

Ms. Hardy explained that New Leaf is a lifestyle initiative with a structured nutrition and physical activity program and two assessment components developed by the University of North Carolina (UNC) at Chapel Hill. The initiative focuses on chronic disease risk reduction through weight reduction with an emphasis on cardiovascular health.

She went on to explain that in an effort to conduct community outreach cost-effectively, the Alabama Office of Women's Health used a pre-existing network of community health advisors from the University of Alabama that do outreach for breast cancer survivors. They trained these advisors in the New Leaf curriculum to conduct weight loss and healthy behavior change programs in women ages 40-65.

Ms. Hardy stated that the program was implemented at five sites in three counties, with one alternate county. Based on meetings and focus groups, the curriculum was modified to fit community health advisors' schedules and training from the UNC nutritionist. Ms. Hardy noted that they found the program needed to be long enough to bring about change, but not too long to burden volunteers. The result was a 6-month program. Each participant received a manual and participated in 14, one-hour sessions. They also met weekly for the first 8 weeks to get people into a pattern of desired behavior changes. After that, they met biweekly for 2 months and then met monthly for the last 2 months.

In closing, Ms. Hardy noted that one of the biggest lessons learned is that communities are very eager for participatory programs. She said if we can find ways to help them take part in program planning from the beginning, they are more open to the programs and will try to find ways to sustain them.

Utilizing Community Health Workers to Engage Colonial Residents to Improve Health Through Resident-Led Community Partnerships

This workshop highlighted an innovative community program for increasing access to care and improving health outcomes for rural people in South Texas. Julie St. John, M.A., M.P.H., South Texas Regional Director at the Center for Community Health Development, began by explaining that community health development is a process by which a community identifies its needs, develops goals, and plans and implements activities. She went on to explain that the Center for Community Health Development focuses on broader determinants of health, social, psychological, physical, and emotional well-being. Its work is population-focused, not individual-based. The center pools resources as much as possible to improve community health status.

Ms. St. John stated that the center received funding from HRSA and the Robert Wood Johnson Foundation to create an Integrated Health Outreach System (IHOS). The goal of the project was to create a model to improve health status and access to care in two clusters of colonias in Hidalgo County, Texas. The population of 655,202 in Hidalgo County is 90 percent Hispanic. There is a 13.4 percent unemployment rate, and 36 percent of residents live below the Federal poverty level. Sixty (60) percent are uninsured and more than 20 percent, or 150,000-200,000, live in colonias. Colonias are unregulated residential areas lacking basic services like water, electricity, mail, and trash pick up.

Ms. St. John explained that the idea behind the project was to get health providers to come together to serve residents. The area had a network of agencies, including Planned Parenthood, a Federal clinic, and a university program that provided transportation. They also had promotoras and community health workers—lay people from the community who live in colonias and have some training. In addition, HRSA funded a federally qualified health center to open two satellite clinics with full-time doctors, covering about 80,000 of the residents.

Ms. St. John noted that the project centered on a partnership approach. Project planners assessed needs and conducted several key informant interviews and focus groups led by the promotoras. From this work, they identified a range of issues to address. Promotoras then led the residents in prioritizing these issues, so they could start seeing an impact as soon as possible. Residents decided to form three task groups to focus on environmental issues, health, and transportation.

In closing, Ms. St. John stated that there were numerous successes. Her team held health fairs and walkathons; developed a bilingual resource directory of services; created a network of health providers called the Colonia Health Improvement Network (CHIN); established trash collection once a week in each area; and revised the IHOS transportation service to be more user-friendly. In the last 3 months, they have made close to 1,000 transports to appointments.

Conducting a Community-Based Needs Assessment

This workshop highlighted the findings from an assessment of the needs of a rural New Hampshire community. Karen Horsch, M.A., Evaluation Consultant, and Martha Hill, M.A., Director of the North Country Health Consortium (NCHC), New Hampshire National Rural/Frontier Women's Health Coordinating Center, began by explaining that the assessment was a partnership between the RFCC and the NCHC. The presenters noted that it was a big step for the RFCC to determine the needs of the community, because up to that point, little to no data had been collected and organized about the area. Through the assessment, the RFCC planned to learn about the concerns of women and identify the services in the North Country, help the services meet the needs of women, and identify the role of the RFCC in meeting the needs of women and care providers.

Ms. Hill noted that the project team developed a threepronged strategy to collect data. They used focus groups of women, interviews with providers, and an anonymous survey distributed at women's health fairs.

Ms. Horsch reported that the fi ndings from the focus groups and survey revealed that the lack of specialists, lack of providers, transportation barriers, and lack of parenting programs for new moms were perceived as the biggest challenges facing women in receiving health care. Many women lamented the "dehumanization"of health care, especially older women. Ms. Horsch reported that women also found it hard to form relationships with doctors because the doctors often left the area within one or two years. She said women also did not seek out Nurse Practitioners and almost exclusively wanted to see their doctors. Also, the focus groups found that women expected a prescription at the end of the visit, because they equated a prescription with a solution.

The presenters noted that the providers interviewed believed that health resources are inadequate for everyone, not just women. The lack of training on women's health was seen as a problem exacerbated by lack of funding and the expense and time it takes to travel to training courses. The providers also cited the diffi culty in recruiting and maintaining staff, mirroring the frustration the women expressed. The interviews suggested that the RFCC could help with training, community education, and connecting resources for service work.

Current as of October 17, 2008