Tacoma-Pierce County Health Department Technical Report

A Technical Report
on the
Tacoma-Pierce County Health Department
Maternal/Child Health Assessment
Submitted by
Hilary Jauregui, MN, ARNP, PMHNP-BC
Doctorate in Community Health Nursing Student,
Specialty: Cross-Cultural & Global Health
Devon Jennings, BSN, RN
Doctorate in Nurse Midwifery Student
Erin Shapleigh, BSN, RN, CCRN
Master in Occupational & Environmental Health Nursing Student
Anne Turner, BSN, RN
Doctorate in Community Health Nursing Student,
Specialty: Cross-Cultural & Global Health
This technical report was completed on June 11, 2013 as part of a course
offered in the Spring of 2013 at the University of Washington School of Nursing
in the Community Health Nursing program located in Seattle, WA.
Disclaimer: The findings, interpretations and conclusions expressed in the report are entirely
those of the authors, and do not represent the views of the University of Washington School of Nursing or the
Community Health Nursing program.
EXECUTIVE SUMMARY
Children with Dental

Caries
Children aged 6-8 years
old with dental caries in
primary or permanent
teeth
Late Entry to Prenatal
Care
Women beginning
prenatal care after the first
three months of
pregnancy
Pregnant Women Smoking
in the 3rd Trimester
Women smoking in the
last three months of
pregnancy
Perinatal Mortality
Infant death prior to the
7th day after birth or fetal
death at or after 28 weeks
gestation
Children in WIC with
High BMIs
Children aged 2-5 years,
receiving WIC, with a
body mass index at or
above the 85th percentile
Introduction
The purpose of this technical report is to summarize key
findings from interviews with providers and leaders in
maternal-child health in Pierce County. Ten high-needs
indicators were identified by the Tacoma-Pierce County
Health Department (TPCHD) through a Gap Analysis for
the Maternal-Child Health Block Grant application. TPCHD
identified these areas as high need with low community
capacity to meet the need. Of the ten identified indicators,
TPCHD selected a subset of five priority indicators to assess
in the interviews with key informants.
The five high-need areas selected for this analysis:
Children with dental caries
Late entry to prenatal care
Pregnant women smoking in the 3rd trimester
Perinatal Mortality
WIC children with high BMI
Assessment Questions
What are the gaps in services available? How can
those gaps be addressed?
Have there been changes to the high-needs indicators?
What are the future threats to current services?
What is the systems capacity to meet these needs?
Do certain populations have greater disparities in the
high-need areas? Why?
Assessment Approach
A systems framework was used to guide our assessment
approach. Using the systems framework involves gathering
data from service providers as key informant stakeholders, as
opposed to interviewing recipients of services themselves.
This assessment data further supports TPCHDs future
planning to address the high-needs areas.
TPCHD supported this assessment by identifying and
facilitating contact with key informants who have experience
in the high-needs areas.
Assessment Data
The assessment data was developed from interviews of providers and leaders in MaternalChild Health in Pierce County who are involved in care of individuals or populations in the
five high-need areas. The survey questions included four quantitative questions and six
qualitative questions.
Assessment Analysis
Qualitative data was analyzed using latent content analysis and quantitative data was
analyzed using quantitative analysis.
Assessment Findings
The primary issue stakeholders identified was education needs for both clients and
providers. Culturally appropriate, community-based client education on nutrition and
health issues is needed. Provider time and knowledge are major influences on the highneeds areas. In addition, lack of funding and access to healthcare services are major barriers
to meeting the needs of the maternal-child health population.
Assessment Limitations
Due to the small sample size, generalizability of these results may be limited. Due to time
limitations, pilot testing of the interview questions was not possible, but would have been
helpful. Based on the responses from the stakeholders, some of the questions were not a
clear in assessing the intended areas. Additionally, some stakeholders were hesitant to
answer questions because they felt their feedback was not relevant, as they were not
employed in direct client care roles.
Recommendations
Increase education for providers and clients on available resources
Increase provider time with clients to allow adequate time for education
o Increase funding for MCH programs
o Recruit additional MCH providers to Pierce County
o Reduce client load per provider
Continue ongoing assessment with stakeholders to identify new community needs
and gaps in services
Seek additional funding, when possible, to prevent program cuts (e.g. smoking
cessation programs)
Appendices
Appendix A Tacoma-Pierce County Health Assessment Project Brief
Appendix B Assessment Timeline
Appendix C Interview Contact Protocol
Appendix D Scripts for Contacting Potential Interviewees
Appendix E Interview Question Table & List
Appendix F Assessment Data Analysis Guide
Appendix G Content Analysis Coding Table
Appendix H Raw Assessment Data
TABLE OF CONTENTS
Acknowledgements .................................................................................................................. 5
Assessment Process .................................................................................................................. 6
Assessment Questions ................................................................................................................6
Assessment Approach ................................................................................................................6
Framework ................................................................................................................................................................. 6
Lifecourse Approach ................................................................................................................................................ 6
Maternal-Child Health Pyramid of Services .......................................................................................................... 7
Assessment Method .................................................................................................................................................. 8
Assessment Data Collected ........................................................................................................9
Assessment Analysis ..................................................................................................................9
Assessment Findings ................................................................................................................ 10
Stakeholder Experience Working in High-Needs Areas ................................................................................... 10
Stakeholder Frequency of Contact with High-Needs Areas in Current Position ......................................... 10
6-8 Year-Olds with Dental Caries in Primary or Permanent Teeth ................................................................ 11
Pregnant Women Seeking Prenatal Care after the 1st Trimester...................................................................... 12
Pregnant Women Smoking in the 3rd Trimester ................................................................................................. 13
Perinatal Mortality ................................................................................................................................................... 14
Children Age 2-5 Years Old, on WIC with BMIs >85th Percentile ............................................................... 15
Disparities in High-Needs Areas .......................................................................................................................... 15
Additional High-Needs Areas Not Previously Identified ................................................................................. 16
Assessment Limitations............................................................................................................ 17
Recommendations .................................................................................................................. 17
Next Steps ............................................................................................................................... 18
Appendices .............................................................................................................................. 19
Appendix A: Tacoma-Pierce County Health Assessment Project Brief ....................................... 20
Appendix B: Assessment Timeline ........................................................................................... 23
Appendix C: Interview Contact Protocol .................................................................................. 25
Appendix D: Scripts for Recruitment of Potential Interviewees.................................................. 27
Introductory Email ................................................................................................................................................ 28
Follow up Phone Call ........................................................................................................................................... 29
Follow up Email (Attach Original Email To This One) .............................................................................. 30
Appendix E: Interview Question Table & List........................................................................... 31
Appendix F: Assessment Data Analysis Guide ......................................................................... 37
Appendix G: Content Analysis Coding Table ........................................................................... 39
Appendix H: Raw Assessment Data ......................................................................................... 48
References ............................................................................................................................... 70
References Used to Develop Assessment Approach .................................................................. 70
References Used to Analyze Assessment Findings .................................................................... 70
Acknowledgements
We would like to thank Susan Pfeifer and Sandy Bodner of the Tacoma-Pierce County
Health Department for their guidance and collaboration in development of the assessment.
We would also like to thank our key informants for generously contributing their time and
knowledge during the interviews.
Assessment Process
Assessment Questions
What are the gaps in services available? How can those gaps be addressed?
Have there been changes to the high-needs indicators?
What are the future threats to current services?
What is the systems capacity to meet these needs?
Do certain populations have greater disparities in the high-need areas? Why?
Assessment Approach
Framework
A systems framework was used to guide our assessment approach. Using the systems
framework involves gathering data from service providers as key informant stakeholders, as
opposed to interviewing recipients of services themselves. This assessment data further
supports TPCHDs future planning to address the high-needs areas. The systems assessment
framework is informed by the theoretical perspective of the Lifecourse Approach and the
conceptual framework of the Maternal-Child Health (MCH) Pyramid of Services.
Lifecourse Approach
The Maternal and Child Health Bureau has adopted the Lifecourse Approach as a
comprehensive means to conceptualize the health needs of women and children. This
approach is based on research that shows the linkages between population health and the
health of individuals and families at different stages across the lifespan (Fine & Kotelchuk,
2010). Lifecourse Approach research has illuminated connections between an individuals
life trajectory from conception to adulthood with their health outcomes. Health disparities
are tied to differences in exposure and opportunities during the critical development periods
prenatally, in early childhood and adolescence.
In addition to genetic and health behavioral factors, the Lifecourse Approach considers the
social, economic, environmental and cultural contexts that shape an individuals health
status (Lu & Halfon, 2003). Exposures during pregnancy can affect the health trajectory of
the fetus, with effects continuing into early childhood and beyond.
In this project, the Lifecourse Approach frames the populations that were identified within
the high-needs areas. These areas focus on populations at critical developmental stages
ranging from pregnancy to early childhood. Thus, the Lifecourse Approach is an
appropriate framework for assessment of the capacity to serve the Maternal-Child Health
population in Pierce County.
Maternal-Child Health Pyramid of Services

The MCH Pyramid is a conceptual framework utilized by the Health Resources Services
Administration for the Title V MCH Services Block Grant to States Program. The pyramid
identifies the multiple levels at which services are delivered to Maternal-Child Health
populations. The Title V MCH block grant is unique in that it is the only Federal program
that addresses services at all levels. This multi-level, systems approach informs the rationale
for identifying providers delivering diverse services to women and children in Pierce
County. Data gathered from providers at multiple levels of the pyramid allows for a more
comprehensive assessment of capacity to address identified MCH high-needs areas.
Assessment Method
In a report on Promising Practices in MCH Needs Assessment, the Maternal and Child
Health Bureau (MCHB) cites that a comprehensive MCH needs Assessment has two
components: assessment of population needs and an analysis of the capacity of systems to
meet those needs (HRSA, 2004). Population needs, indicated by the priority high-needs
indicators, were assessed by TPCHD and were largely derived from quantitative data.
Community capacity is a broad concept, which encompasses a communitys entire potential
for addressing priority health issues (Goodman et al., 1998). In order to effectively
implement services, organizations must have both an understanding of the communitys real
needs and a thorough assessment of the resources, skills and experience of agencies to meet
those needs (Gandelman, 2006). The inclusion and participation of diverse stakeholders and
leaders in assessing capacity is essential in understanding the multiple dimensions of
community capacity. Therefore, efforts were made to include the voice of critical partners
currently addressing the high-needs indicators in this assessment. Interviewing community
providers provides a lived account of the systems of care that address maternal-child health
needs. This information can then be used to develop a more effective delivery of care to the
maternal-child health population.
Through interviews with maternal-child healthcare providers and leaders, this assessment
focuses on the capacity of systems to meet needs. Through telephone interviews, key
stakeholders offered information about the capacity to address the needs identified in the
TPCHD gap analysis. After review of the assessment brief and gap analysis, a sample of
maternal-child service stakeholders and accompanying rationale for selecting these
informants was generated. TPCHD project partners then provided contact information for
key informants as potential telephone interviewees.
Comprehensive assessment activities that incorporate quantitative and qualitative data can
assist agencies in understanding their capacity to meet health needs and to better target
services towards populations served (Gandelman et al., 2006). Our interview questions
included quantitative data to assess providers areas of practice, experience with the highneeds indicators and frequency of contact with the high-needs areas. Qualitative questions
were aimed at assessing the community capacity to address the identified high needs areas.
Eight providers of MCH services were interviewed. These providers had direct involvement
with the areas identified in the gap analysis, and as a result had the potential to identify
trends or barriers that an outside informant could not. The goal of the interviews was to
capitalize on the knowledge and experience of key informants, as well as to facilitate a more
in-depth understanding of actual MCH needs and the current impact of MCH services in the
county. This data will guide TPCHDs future MCH program planning.
The survey questions were developed based on the stated goals of TPCHD, relevant
literature and prior MCH needs assessment surveys. The MCHB framework, which
recommends assessing MCH capacity along three major dimensions (accessibility,
affordability and quality), was used to categorize survey content.
The MCHB defines each dimension as follows:
Accessibility. Access to services or resources may be assessed using indicators:

(1) the percent of a target population in need who received the appropriate
level of services
(2) the length of waiting lists for needed care
(3) the geographic distribution of available providers or services
(4) the availability of bilingual staff or translators in public education
programs and health care facilities providing services to low-income women,
children and families
Quality. Quality of services may be assessed using both quantitative and

qualitative measures, including those that assess the coordination of care, client
or caregiver satisfaction and cultural competence. The quality of assets can be
assessed by determining the strength of each assets interest in MCH issues and
the assets potential to help build and promote MCH systems of care. If data are
available, the assessment should also include information on how effective the
services are in producing the desired outcomes.
Affordability. For the assessment of direct and enabling services, affordability of

services is a critical dimension to the capacity assessment. This can be measured
using indicators of the ability of the population to pay for the services, such as
non-insurance rates and the adequacy of private insurance coverage for high-risk
persons and those with special needs, such as Children with Special Health Care
Needs (CSHCN). Another measure of affordability is the extent to which public
and private providers provide needed services to the uninsured and underinsured.
These comprehensive categories address potential barriers to, or gaps in, existing MCH
services in Pierce County. Assessment questions from prior MCH needs assessment surveys
were reviewed and matched to one of the three capacity dimensions above. Survey
questions for this assessment were developed to parallel established assessment approaches.
A table showing comparison of prior survey questions and survey questions used in this
assessment can be found in Appendix F.
Assessment Data Collected
Thirty- to sixty-minute phone interviews were conducted with eight key informants.
Interviews consisted of ten questions, both quantitative and qualitative. See Appendix F for
the interview guide.
Assessment Analysis
Content was analyzed using latent content analysis. Interviews were read word for word,
and initial codes were developed from recurrent themes identified in the text. Quotes were
clustered into eight initial sub-themes: client education about nutrition, client awareness of
health issues, culturally appropriate education, community-based education, provider
knowledge, lack of time, lack of funding and access to healthcare. Descriptions were then
established for the sub-themes. From the eight sub-themes, three themes were established:
education needs, budget cuts and access issues.
Assessment Findings
Stakeholder Experience Working in High-Needs Areas
High-Needs
Indicator
Children with
Dental Caries
Late Entry
into Prenatal
Care
Pregnant
Women
Smoking in
3rd Trimester
Perinatal
Mortality
Children on
WIC with
High BMIs
Any Work
Experience in
the Area
50%
100%
100%
63%
75%
Mean Years of
Experience
9.25
16.13
16.75
12.63
9.25
Range of Years
of Experience
0 43 years
5 37 years
6 37 years
0 37 years
0 20 years
Stakeholder Frequency of Contact with High-Needs Areas in Current Position
High-Needs
Indicator
Children with
Dental Caries
Late Entry
into Prenatal
Care
Pregnant
Women
Smoking in
3rd Trimester
Perinatal
Mortality
Children on
WIC with
High BMIs
Frequent
25%
50%
50%
0%
25%
0%
25%
38%
13%
0%
0%
25%
13%
63%
38%
75%
0%
0%
25%
38%
(> 1/week)
Occasional
(< 1/week,
> monthly)
Rare
(< monthly)
None
10
Each indicator will be discussed separately with supporting quotes from stakeholder
interviews.
6-8 Year-Olds with Dental Caries in Primary or Permanent Teeth
The primary issue stakeholders identified is education, for both parents and providers.
Education about proper nutrition and pediatric dental care was emphasized.
Another one would be dietary, learning about what types of things children should
be doing, like should they be on a Sippy cup forever after a bottle because then they
carry it around all the time and bathe their teeth in whatevers in that container. And
also teaching people not to put juice and Kool-Aid and soda and whatever else in
those cups that children carry around all day long and bathe their teeth in sugar, and
even milk is bad and Im teaching them that. And I think theres a gap there in
people understanding that unless they have a child or have seen a child that have had
their teeth pulled before their big ones come in. - OI
One of the things we talk about is nutrition. Making sure they cut down on the
sugar intake and the carbohydrates and the damage it can do to the teeth, as well as
the body. Those are always included in our presentations to any children. It falls into
our ABCD program because its for children through age 5. - MI
One stakeholder discussed how providers in the Tacoma-Pierce County area have worked
hard to establish the dental programs currently in place.
Getting the knowledge out to community providers of what is available and when,
however, remains a challenge. We have wonderful services that we worked hard to
get. Our biggest downfall is making sure our agencies we work with are aware of the
resources out there. - NI
The MCHBs dimensions of accessibility, quality and affordability are clearly identifiable in
the interview data. Quality is reflected in the recognized need for adequately educated
providers and clients. This is a dimension that needs considerable attention to improve all
high-needs indicators. Accessibility and affordability are identified in the interviews, but are
less likely to be altered on the community level at this time. Three out of eight stakeholders
interviewed, expressed optimism about the Affordable Care Act (ACA).
No, I think its going to get even better. With the ACA, children will be cared for. I
see an increase in childrens ability to seek and get services. - NI
I'm sort of hoping with the changes in healthcare that women would know that
they have access. There's so much focus on women's access to reproductive
healthcare that maybe that would improve and people would go earlier. - CF
Pregnant Women Seeking Prenatal Care after the 1st Trimester

Stakeholders identified a lack of time with clients as a primary issue. This lack of time could
be responsible for an increase in women seeking care after the 1st trimester, resulting in
insufficient education in early pregnancy. This increase may result from the inability of
providers to spend quality time with at-risk clients:
So what I would say is that that program is being shrunk so much that our face-toface time with those clients is diminished greatly and it's very, very difficult to feel
like you can be making any kind of impact, how effective you can be given the very
limited amount of time that you'd be able to spend with clients. We get them into our
program but what we can actually accomplish is limited by how often we can see
them. - CF
All eight stakeholders interviewed identified budget cuts as a cause of decreased resources.
Stakeholders indicated that an increase in funding to essential programs could decrease the
incidence of women seeking prenatal care after the 1st trimester:
Well, you could increase funding to the Nurse Family Partnershipyou could
increase the number of nurses out there doing that. I think that might help. - UD
Bus services have been cut, many of them [clients] dont have drivers licenses or
people to take them. Just getting to the appointments are a problem. Most of them
are able to access medical, so they have insurance but its just getting to the
appointments. - GR
A lack of education for clients and providers was the most commonly recorded theme
identified. Stakeholders identified gaps in provider knowledge about issues affecting clients,
as well as resources available to clients. One area specifically identified was with the
prenatal period and lack of dental care to mothers.
Getting them [providers] to realize there is an alternative to having people suffer
[with dental issues] and wait until after they have the baby. We need to rely on the
medical community to help us get that message out. Women listen to their
physicians, all the way. If physicians can convince them they need to get their teeth
fixed, hopefully they can learn that a little faster. - NI
Provider knowledge regarding available prenatal resources and insurances options was
identified as an issue.
But for us at the health department, one of the things is to make sure that the
primary care providers know that our programs exist, like MSS [Maternity Support
Services] that we can see clients in the home and make sure that they're connected
with other services in the community that they are eligible to receive. - CF
12
Some of the younger ones, some of them come through their school nurse or
through the parenting program, if they're in a school that has that. Otherwisethey
go their primary care physician and making sure that they get their medical coupon,
which will allow them to [seek care], because they need insurance coverage to be
able to do that. - CF
Pregnant women were also identified as lacking knowledge about prenatal care resources
and health issues.
If people did not have prenatal care at that point, they would come to us through
WIC or something like that. Its a fairly low percentage of our clients we make
such an effort to get them into prenatal care early. Certainly, if there are other factors
involved, like smoking or drug use or something like that those women do not
necessarily want a nurse coming to their house either, so were not going to
necessarily know about that, which is unfortunate. - GR
I would say mostly the knowledge of the young women not knowing where to go
for resources. I think it is probably our biggest gap because anybody in the area is
eligible for Medicaid services, but they have to know about it and they have to know
where to go to be able to enroll in Medicaid services. - FT
One stakeholder identified a issue for mothers having continued access to health care. Due
to restrictions on when and how they may receive care, they may not know what is
available in the form of prenatal care.
I guess some of it is related to access to healthcare because once some of our clients
have had their babies, that is the end of their access to healthcare, and they probably
live a great portion of their lives not thinking that they can access healthcare. - CF
Pregnant Women Smoking in the 3rd Trimester
Six stakeholders identified a lack of available support for women attempting to quit
smoking. Family and friends who also smoke might be counteracting the support providers
can offer.
A lot of women will cut down on smoking to 2-3 cigarettes per day, which is better
than a pack. Socioeconomic issues play a part as well, people moms hang out with
who are of lower socioeconomic status, who smoke, have a poor diet all effect the
pregnant momEducation is a real problem too, people are addicted to these things,
and its hard to quit. Especially if family, friends, boyfriends who live this lifestyle
would quit too, it would be much easier for the mom. - MI
13
Having consistent support available to clients is vital to support quitting or cutting down on
smoking.
And the other part, a gap in services there is that the Quit Line used to be very
helpful and we had programs in place that could really help those clients and that has
fluctuated, and at this point I'm not sure that the Quit Line has any funding or much
to offer at all. - CF
Adequate training for providers on smoking cessation is important to properly support
womens attempt to quit.
We do get training every so often from some part of the Health Department, though
I think we just lost our tobacco part of the Health Department in this last go around
of the cuts, so maybe that should come under one of the threats. - CF
I think that they need specific skills on how to coach. Those same providers need
education on how to coach people effectively. I think just to say that somebody
stopped smoking doesnt exactly change that behavior. So what are some of the
coaching skills that can be developed or given to people that would enable them to be
more effective? - FT
Perinatal Mortality
Although all eight stakeholders indicated that they had little or no experience with perinatal
mortality, they did offer some insight into the issue. Again, a lack of time to intervene and
lack of funding are affecting provision of services to clients.
The fact that were cutting all of our preventive services is going to hurt us in the
future. Whats going to happen is were going to cost shift, so we dont offer services
to the moms, the babies will be born prematurely, the babies end up in the NICU and
we pay even more money. Again we need the services to take care of the people. FT
In addition to lack of funding for programs, a lack of funding to employ providers able to
identify and intervene with at risk individuals was identified.
we need to have more people on the ground out there identifying at risk
individuals and educating them. - UD
If providers had time and support to identify and intervene with high-risk individuals early
on, they anticipate a decrease in perinatal mortality.
a lot of perinatal mortality is associated with lack of prenatal care or frequent
drug use. So, for example, someone that uses heroin or methadone regularly, or
methamphetamines, are at higher risk for placental abruption So again its trying
to educate the young women about what they have control over. FT
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Children Age 2-5 Years Old, on WIC with BMIs >85th Percentile
Lack of knowledge about healthy nutritional choices was identified as a large contributor to
childhood obesity in Pierce County. Increasing education about nutrition and decreasing
sugary beverage intake is an important element in decreasing childhood obesity, as well as
increasing the initiation and duration of breastfeeding.
Like putting Kool-Aid in baby bottles and things like that, there's lots of ways that
children can start off being overweight and just keep going from there. And definitely
breastfeeding has a lot to do with that as well, and we are trying very hard to increase
the incidence and duration of breastfeeding because breastfeeding itself is more
protective against latent development of obesity, and I think WIC tries to do that.
They're definitely encouraging more breastfeeding and the duration. In some of the
formulas the first product is corn syrup, so what they're starting on is not the best
nutrition, and they're continuing on from there. - CF
I think we need family programs that address the parents on healthy eating and
moving for the whole family, so family-based nutrition and physical activity
programs. - NJ
Providers and clients could benefit from increased education on nutritional choices for
children.
I think there needs to be more breastfeeding education from medical providers,
talking about it, bringing up the conversation, and not just a one time Are you
gonna breastfeed? I believe that weight management isn't addressed very well with
medical providers. - NI
Disparities in High-Needs Areas
The primary disparity stakeholders identified was low socioeconomic status (SES). Pregnant
women with a low SES seem more likely to smoke tobacco and have family and friends
who smoke, as well as have poor diets. Stakeholders thought this may be due to lack of
access to nutritious food sources, low income and lack of knowledge about appropriate food
choices.
"If they're going to try to feed healthful foods to their children in order to prevent
them being obese by the age that you stipulate, they need access to more nutritious
foods and they also need the skills to know how to prepare those foods, because I see
a lot of people that know how to get fast food or add boiling water to top ramen but
they don't really know a lot about food preparation" CF
The lack of basic education was mentioned as a disparity related to an increased prevalence
in smoking.
"The less-educated people tend to smoke more. And by that, I mean maybe they
15
havent completed high school, or are still in high school. It appears that the higher
socioeconomic and higher educated people smoke less." - FT
"There are a lot of obese women in this country, and high smoking rates. A lot of
women will cut down on smoking to 2-3 cigarettes per day, which is better than a
pack. Socioeconomic issues play a part as well, people moms hang out with who are
of lower SES, who smoke, have a poor diet all effect the pregnant mom Education
is a real problem too, people are addicted to these things, and its hard to quit.
Especially if family, friends, boyfriends who live this lifestyle would quit too, it
would be much easier for the mom." - MI
One stakeholder spoke about specific groups of at-risk mothers with health disparities
leading to poor outcomes.
"Well a lot of the time the teens are in denial and they dont know where to go for
support. The Afro-American population, Im not really sure. I dont know if its lack
of knowledge of where to go to get services. And the Native American Indians, were
trying to reach out to them, but thats kind of a challenge in this community. Well,
theyve got uncontrolled high blood pressure, and also a high incidence of diabetes,
so we have more bad outcomes in those patient populations." - FT
In spite of differences among the identified populations, stakeholders indicated a lack of
education on various health-related issues as the root problem. Lack of education on
nutrition, personal health and healthcare access perpetuate the disparities. Despite
educational efforts, barriers remain.
"Again its the Hispanic population and its hard to break through that cultural
barrier. When they believe what their ancestors say versus what a health educator
says, so theyre getting mixed messages from their moms and their grandmas versus
the people that know in healthcare." - OI
Additional High-Needs Areas Not Previously Identified
Stakeholder OI was concerned about the higher prevalence of pregnant women with high
BMIs and Gestational Diabetes. Stakeholder MI identified shifting views of the danger of
marijuana smoking as an important issue. With the recent legalization and media attention,
many pregnant women see marijuana smoking as not very dangerous, compared to tobacco.
There is a noticeable increase in Pot smoking over the last year. We need to do
more focused education that pot smoke is not as harmless as they think. When you
ask if they smoke, they say yes, but when you ask about tobacco, they say oh I dont
smoke tobacco. We really need to be delving in further to clarify, they think this is
smoking. - MI
Stakeholder NI pointed out the age group of adults, 20-64 years old, lack access to dental
care due to Medicaid cuts.
16
[Providers] need to address the inequities, disparities, the fact that they are not
addressing that part of the population that cannot access anything. Its a large group,
an ignored group. As a community, we need to do a better job. Some people have
resources, but resources are dwindling. Theres no reason in the world we should
have a community that has to go to King County for emergency services. I think its
a travesty that were not paying attention to that, and that theres no services for that
community, and its a big one. King County has 14 health departments that can take
care of adults, and they also have a couple of free clinics, and we dont have any. I
tell them to go over to King. Thats really my only thing. -NI
Assessment Limitations
The generalizability of our results may be limited, due to the small sample size of MCH
providers and leaders in Pierce County.
Due to time limitations, pilot testing of the interview questions was not possible, but would
have been helpful. Based on the responses from the stakeholders, some of the questions
were not a clear in assessing the intended areas. Additionally, some stakeholders were
hesitant to answer questions because they felt their feedback was not relevant, as they were
not employed in direct client care roles.
Recommendations
This sample of stakeholders was not able to address all five of the high-needs areas in depth,
interviews with additional stakeholders until saturation of the data is achieved.
The following are recommendations for improvement of services for the maternal-child
health population in Tacoma-Pierce County, as gathered from this assessment data analysis:
Increase education for providers and clients on available resources
Increase provider time with clients to allow adequate time for education
o Increase funding for MCH programs
o Recruit additional MCH providers to Pierce County
o Reduce client load per provider
Continue ongoing assessment with stakeholders to identify new community needs
and gaps in services
Seek additional funding, when possible, to prevent program cuts (e.g. smoking
cessation programs)
17
Next Steps
Stakeholders identified issues stemming from a lack of funding. Unfortunately, there is no
easy or fast solution to funding shortfalls. However, focusing available resources on
educational opportunities should be beneficial. As all eight stakeholders identified, there are
many issues around lack of knowledge, for both providers and clients alike.
One suggestion for improving rates of dental caries and high BMI in children is to offer
culturally appropriate classes in the community on nutritional intake in infancy/childhood.
Additional educational offerings on resources available for pregnant women (e.g. MSS) for
primary care providers and school nurses could aid in improving womens knowledge.
Expanding pregnancy prevention programs targeting youth could be beneficial in addressing
all five of the identified high-needs indicators. In addition, providers should receive
education about evidence-based approaches for support smoking cessation (e.g.
motivational interviewing).
18
Appendices
Appendix A Tacoma-Pierce County Health Assessment Project Brief
Appendix B Assessment Timeline
Appendix C Interview Contact Protocol
Appendix D Scripts for Contacting Potential Interviewees
Appendix E Interview Question Table & List
Appendix F Assessment Data Analysis Guide
Appendix G Content Analysis Coding Table
Appendix H Raw Assessment Data
19
Appendix A: Tacoma-Pierce County Health Assessment Project Brief

Assessment project brief describing Health Assessment project
20
Brief Description: University of Washington School of Nursing graduate students in

community health nursing will conduct key informant interviews with members of the
Pierce County Perinatal Collaborative. This collaborative is comprised of providers,
directors, and key leaders working with women, children and families. Other key
informants may be identified to ensure comprehensive stakeholder input. The purpose of
this assessment assignment is to gather additional data about high need categories.
Seven high need categories were identified through a Gap Analysis conducted for the
Washington State Department Maternal and Child Health Block Grant application process.
Some of the priority high need indicators, for this assignment, are as follows:
1. Post neonatal mortality - infant mortality by leading causes
2. Women smoking in the 3st trimester
3. Late prenatal care (> 1st trimester)
4. Six to eight year old children with dental caries
5. Children on WIC with high BMI
Process: Graduate students will use the five priority high need indicators to determine
which providers or others are important to interview. Graduate students will then develop
the interview survey, record the interviews for targeted transcription, analyze the interview
focused on content analysis, and write a brief technical report. The interview questions will
focus on the community capacity to address the high need areas, gaps providers identify as a
lack of services for high need areas (what should be provided), why are these high need
areas, future threats to provide services to address the high needs areas, and existing
resources to address the high areas in Pierce County.
Students will plan to develop a draft survey in 2-3 weeks for review by the Tacoma-Pierce
County Health Department contact before conducting interviews. Students are also asked to
provide a list of possible interviewees and the rationale for interviewing those key persons to
provide information about the high risk areas. Students are also asked to consider what
might be some unintended consequences of conducting interviews and how to respond to
the unintended consequences. A draft interview guide will be developed by students. The
draft must be reviewed, revised (if appropriate), and approved by the Tacoma-Pierce County
key contact before any interviews are started.
After it is agreed upon who best to interview, the contact at the Tacoma-Pierce County
Public Health Department will facilitate access to key informants. Students can plan for
interviews to last about 45 minutes to 1 hour in duration. Aim to complete 3 interviews each
via telephone or in person, with a student team of two.
21
Access: Go to Meeting can be used for consultation and for presentation. Telephone
conference calls can be used to ask questions about the assessment assignment as well. In
person meetings are acceptable, but there is a desire to use the time to conduct the
assessment versus having multiple in-person meetings.
Deliverable: A draft of the interview questions and a draft of who are appropriate key
informants are needed 2-3 weeks into the quarter. An outline of the technical report is
needed Week 5 of the 10 week quarter. A concise report of key findings in a technical report
format will be completed by the end of the quarter. A presentation of the report is requested.
This presentation can be done using Go-To Meeting, by conference call, or in person.
Contribution to the Pierce County Health Department: The Maternal and Child Health
Content Analysis of High Need Areas will provide additional information to help
understand the gap analysis data and determine how to best address the high need areas.
Final Product Format: A technical report and presentation of the report will be the final
products. The report appendix will include the interview guide, and a high level
transcription of information. The list of references will include citations used to design the
assessment, analyze the data, and conduct the interviews. The information should identify
content themes and identify the area of practice, years of practice of the key informants, and
the key informants frequency of contact with clients who have high need area issues. No
detailed information about who is providing the information is needed or no agency
identifiers are needed. A final presentation will be developed and presented to highlight the
findings of the technical report. Presentation handouts and resources will be developed as
needed. What is not available for the assessment or what was not assessed will be noted in
the final presentations and reports as assessment limitations.
22
Appendix B: Assessment Timeline

Gantt Chart showing timeline for completion of assessment and technical report
23
4/2/13 4/12/13 4/22/13 5/2/13 5/12/13 5/22/13 6/1/13 6/11/13

Read assessment assignment
Scan resources from the course
Best way to contribute to drafts by team members
Review website resources about assessment topic
Read the assessment frameworks
Map relevant stakeholders who & why
Research census data/relevant population data
Meet with key contact for assessment (Susan &
DESIGNING THE ASSESSMENT
Technical Assessment Draft 1
Develop protocol for contact attempts
Use assessment framework
Draft key informant interview questions
DATA ANALYSIS PLANNING
Consider how you will conduct data analysis:
DATA COLLECTION
Conduct key informant interviews
High-level interview transcription
Write up "Assessment Analysis" in Technical
Analyze data using data analysis plan
Write up "Assessment Limitations" in Technical
Write up "Next Steps" in Technical Report
DISSEMINATION OF FINDINGS
Develop presentation
Presentation to site
24
Appendix C: Interview Contact Protocol

Flowchart depicting protocol for contacting key informants identified by TPCHD
25
26
Appendix D: Scripts for Recruitment of Potential Interviewees

Telephone and email scripts for recruitment
27
Introductory Email
Subject: Requesting Interview on Maternal/Child Health Needs in Tacoma-Pierce
County
Good morning,
We are contacting you from the University of Washington School of Nursing Community Health
Nursing graduate program. We are assisting the Tacoma-Pierce County Health Department
(TPCHD) with the Maternal/Child Health Assessment. The health department strongly values your
experience and knowledge, and wants to incorporate it into the assessment.
In order to learn from you, we would like to invite you to complete a brief interview with us to
discuss the 5 priority high need indicators as identified by the TPCHD:
1. Post-neonatal mortality/infant mortality by leading causes
2. Women smoking in the 3rd trimester
3. Late prenatal care (>1st trimester)
4. 6-8 year old children with dental caries
5. Children on WIC with high BMI (>85% on the growth chart)
It will take about 30 minutes and will be conducted over the phone.
As a service provider in Pierce County taking care of the maternal/child population, you have
unique insight into the challenges of addressing the priority needs of the county. We hope to be able
to discuss your insights with you in the next 2 weeks so that Tacoma-Pierce County Health
Department can incorporate that information into future planning decisions.
Thank you for your consideration. If you are interested in participating, please reply all with 2-3
days/times you are available for a phone interview. If you are unable to participate at this time,
please email to let us know.
Sincerely,
Hilary Jauregui, MN, RN
28
Follow up Phone Call

Hello, my name is [insert name here]. I am a nurse and graduate student from the University of
Washington School of Nursing, calling to speak to [insert participant name here] to follow up on an
email from a few days ago.
We are working with the Tacoma-Pierce County Health Department to conduct surveys of maternal
and child healthcare providers in the county to better understand the current healthcare delivery
system and how to improve access and use of services. This information will be used to assist the
TPCHD in improving care to residents, as well as help to determine the best distribution of county
funding.
The health department strongly values your experience and views of the challenges of addressing the
priority health needs in this population. We are hoping to complete a 30-minute interview with you
to gain your insights.
If on the phone: Are you interested in setting up a time to complete an interview?
If y e s: Great! I will be conducting interviews over the next two weeks. What are some days/times
that work for you? [Set up time for interview]. Ok, I will call/see you then! Have a nice day.
If n o : Ok, thank you for your consideration! Have a nice day.
If leaving a message: I would like to schedule a time to complete an interview with you. I will be
conducting interviews on the phone or in person over the next two weeks. If you are interested,
please respond to my original email or call me at [insert number here] with 2-3 days/times that
would work for an interview. If you are unable to complete an interview at this time, please also let
me know via email or phone. Thank you. Have a nice day.
29
Follow up Email (Attach Original Email To This One)

Subject: Follow-Up Interview on Maternal/Child Health Needs in Tacoma-Pierce
County
Hello [insert name here],
We are writing to follow up with you about scheduling an interview about the challenges in
addressing the priority maternal/child health needs in Tacoma-Pierce County. The Health
Department is very interested in gaining insight on this issue, from service providers such as you, to
help guide future planning decisions.
The interview is 30 minutes and will be done over the phone in the next week. We hope you will
take advantage of this opportunity to share your unique perspective.
If you are interested, please send us 2-3 days/times that work for an interview. If you are unable to
complete an interview at this time, please let us know.
Thank you for your consideration.
Sincerely,
Hilary Jauregui, MN, RN
30
Appendix E: Interview Question Table & List

Table summarizing interview questions based on previous MCH surveys and existing literature
31
MCH Assessment Question

Thinking about current
services for [high-need
indicator(s) relevant to the
experience participant
has], what are the future
threats to these services?
Response
Category
Assessment
Category
Openended
Accessibility
Affordability
What are the gaps in

services available to
address [high-need
has]?
Openended
Have you noticed greater

disparities in [high-need
has] within certain
populations? Why do you
think that is happening?
Openended
Thinking about the

current services available
to address [high-need
has], how could those
services be improved to
better address [indicator]?
What are the specific
skills required in the
community of service
providers to address
[relevant high-need
indicator(s)]?
Do you feel your
community posses these
skills?
Accessibility
Affordability
Quality
Accessibility
Affordability
Accessibility
Openended
Affordability
Quality
Openended
Accessibility
Question From Previous

Assessments
Response
Category
Source
What major emerging issues

do you think will have the
most impact upon the health
of families and children in
Virginia in the next 5 years?
Openended
Virginia
State MCH
Needs
Assessment
Of the populations you are

familiar with, what are the
biggest barriers or gaps in
meeting their health needs?
Openended
Virginia
State MCH
Needs
Assessment
Based on your experiences

over the past year, what do
you feel are the most
important unmet needs and
emerging issues impacting
the health of mothers and
children in your jurisdiction?
Openended
Wisconsin
State MCH
Needs
Assessment
Are there specific subgroups

within these populations that
are of the most concern?
Openended
Virginia
State MCH
Needs
Assessment
How could the resources of

the Office of Family Health
Services be best used to
improve the health status of
women and children?
Openended
Virginia
State MCH
Needs
Assessment
Openended
Gandelman
DeSantis &
Rietmeijer
What are the specific skills

required by your agency staff
to carry out the selected
intervention?
Quality
Does your agency staff
possess the above skills?
32
Interview Guide
Part I: Opening
Hi! My name is [insert name] from University of Washington School of Nursing. I am
doing an assessment project collecting data for the Tacoma-Pierce County Public Health
Department.
Thank you so much for agreeing to be interviewed today. Our interview should last about
30 minutes. If it is alright with you, I would like to audio record our interview for later
analysis. I also want to reassure you that your answers and the recorded interview will be
kept confidential -your name and other identifying information will not be connected to
your answers.
Do you have any questions before we begin?
As you know, the Tacoma-Pierce County Health Department wants to better understand
the services available to address the five identified priority health indicators from your
perspective.
That is what our interview will focus on today.
Part II: Participant Background with High-Needs Areas
Question 1. To begin, I would like to get some information about your current work and
the high-needs areas you work with. What is your specific area of practice?
Question 2. Do you have experience working with the following populations?
a) 6-8 year-olds with dental caries in primary or permanent teeth
b) Pregnant women entering prenatal after the 1st trimester
c) Pregnant women smoking in the 3rd trimester
d) Perinatal mortality (fetal death > 28 weeks gestation or within 1 week of birth)
e) 2-5 children on WIC with BMIs > 85th percentile
Question 3. How many years of experience do you have working with [previously
confirmed population(s)]?
33
Question 4. In your current work, how frequently do you come into contact with [previously
confirmed population(s)]?
High-Need Indicator
Scale
6-8 year-olds with dental

caries in primary or
permanent teeth
Frequent weekly or more often

Occasional < weekly, at least monthly
Rare < monthly
None
Pregnant women entering

prenatal care after the 1st
trimester

Rare < monthly
None
Pregnant women smoking

in the 3rd trimester
Perinatal mortality
(fetal death > 28 weeks
gestation or within 1 wk. of
birth)
2-5 children on WIC with

BMIs > 85th percentile

Rare < monthly
None
Rare < monthly
None
Rare < monthly
None
Part III: Services for High-Needs Areas

Question 5: Gaps in Services
A. What are the gaps in services to address [state high-need indicator(s)]? Repeat question for each
indicator indicated by previous answers.
f) 6-8 year-olds with dental caries in primary or permanent teeth
g) Pregnant women entering prenatal after the 1st trimester
h) Pregnant women smoking in the 3rd trimester
i) Perinatal mortality (fetal death > 28 weeks gestation or within 1 week of birth)
j) 2-5 children on WIC with BMIs > 85th percentile
B. If gaps identified, how could services be improved to address those gaps?
Question 6: Change in Indicators
Have you noticed any improvement or worsening of [state high-need indicator]? How would you
describe the change? Repeat question for each indicator indicated by previous answers.
Question 7: Future Threats
Thinking again about current services for [state high-need indicator(s)], what are the future threats
to these services? Repeat question for each indicator indicated by previous answers.
Question 8: Community Capacity
What are the specific skills required in the community of service providers to address [state
indicator]? Do you feel your community possesses these skills? Repeat question for each indicator
indicated by previous answers.
35
Part IV: Disparities in High-Needs Areas

Question 9: Health Disparities
My next question is about the clients you work with, rather than services available. Have you
noticed greater disparities in [state high-need indicator] within certain populations? Why do you
think that is happening? Repeat question for each indicator indicated by previous answers.
f) 6-8 year-olds with dental caries in primary or permanent teeth
g) Pregnant women entering prenatal after the 1st trimester
h) Pregnant women smoking in the 3rd trimester
i) Perinatal mortality (fetal death > 28 weeks gestation or within 1 week of birth)
j) 2-5 children on WIC with BMIs > 85th percentile
Part V: Additional High-Needs Areas
Question 10: Additional High-Needs Areas
Are there any other high-risk areas that havent been identified which need attention?
Part VI: Closing
Those are all the questions I have for you today. Do you have any for me?
Thank you again for taking the time to share your unique insights with me today. Have a
wonderful day!
36
Appendix F: Assessment Data Analysis Guide

Plan for data analysis of quantitative and qualitative responses to interview questions
37
Overall approach: Identify themes and relevant quotes from interview transcriptions. Qualitative
data will be analyzed using latent content analysis and quantitative data will be analyzed using
quantitative analysis.
Method
1.
2.
3.
4.
5.
6.
7.
Read transcripts of eight interviews

Read word for word and highlight key thoughts or concepts
Re-read and take notes to help identify initial code themes
Re-code to group themes into larger categories
Organize groups of codes into meaningful clusters
Develop Tree of clusters, groups and codes
Create definitions for each cluster, group and code
Data Analysis Summary

Questions
Responses
2, 3, 4
Descriptive statistics (frequency counts, mean and averages)
5, 6, 7, 8, 9, 10
Coding of Responses & Content Analysis
All
Analysis of results
Coding Table
Initial Code
Initial Code
with
description
Interpretation
of the initial
code
Sub-theme
Theme
Graneheim & Lundman, 2003
Quantitative Analysis
The analysis of questions 2 and 4 will be presented as percentage of responses. Question 3 analysis
will be presented as the mean and range of responses.
38
Appendix G: Content Analysis Coding Table

Codes with sub-themes and themes
39
Quotes
SubTheme
Description
Theme
"I think that some of it, if I'm seeing new mothers, a lot of them don't cook. And not
only do they not cook or know how to cook, they've never seen their mother cook
either. I don't think all of it is about education. We're trying to encourage behavioral
change. Their levels of exposure to food preparation is very low." CF
"If they're going to try to feed healthful foods to their children in order to prevent them
being obese by the age that you stipulate, they need access to more nutritious foods and
they also need the skills to know how to prepare those foods, because I see a lot of
people that know how to get fast food or add boiling water to top ramen but they don't
really know a lot about food preparation" CF
"The Health Department is trying to address, and is looking for ways where activity can
be part of children's daily lives." CF
"I think that the changes that we've made with the program and the food we give out for
those children are positive changes and they decrease a lot of the juice that children are
getting, and they have added fruits and vegetables, and they can use the farmers market
in the summer. I think the WIC program is definitely trying to make some impact on
that, but obviously what they get from WIC is only a very small portion of what those
children eat." CF
"You know, like putting Kool-Aid in baby bottles and things like that, there's lots of
ways that children can start off being overweight and just keep going from there. And
definitely breastfeeding has a lot to do with that as well, and we are trying very hard to
increase the incidence and duration of breastfeeding because breastfeeding itself is more
protective against latent development of obesity, and I think WIC tries to do that.
They're definitely encouraging more breastfeeding and the duration. In some of the
formulas the first product is corn syrup, so what they're starting on is not the best
nutrition, and they're continuing on from there." CF
"I think we need family programs that address the parents on healthy eating and
moving for the whole family, so family-based nutrition and physical activity programs."
NJ
Client
education
about
nutrition
Nutrition
education is
lacking in
the
community,
clients are
not well
educated on
resources,
appropriate
choices or
food
preparation
techniques
Education
needs
"Another one would be dietary, learning about what types of things children should be
doing, like should they be on a Sippy cup forever after a bottle because then they carry it
around all the time and bathe their teeth in whatevers in that container. And also
teaching people not to put juice and Kool-Aid and soda and whatever else in those cups
that children carry around all day long and bathe their teeth in sugar, and even milk is
bad and Im teaching them that. And I think theres a gap there in people understanding
that unless they have a child or have seen a child that have had their teeth pulled before
their big ones come in." OI
"One of the things we talk about is nutrition. Making sure they cut down on the sugar
intake and the carbohydrates and the damage it can do to the teeth, as well as the body.
Those are always included in our presentations to any children. It falls into our ABCD
program because its for children through age 5." MI
40
Quotes
SubTheme
Description
Theme
Client
awareness
of health
issues
Clients
remain
unaware
of
negative
effects of
health
issues,
and
therefore,
do not
seek care
early on
Education
needs
"One of the things that we see frequently now is obesity. Thats becoming the problem
in that patient population, so the physicians and midwives are very concerned about
it." FT
"The less-educated people tend to smoke more. And by that, I mean maybe they
havent completed high school, or are still in high school. It appears that the higher
socioeconomic and higher educated people smoke less." FT
If people did not have prenatal care at that point, they would come to us through
WIC or something like that. Its a fairly low percentage of our clients we make such
an effort to get them into prenatal care early. Certainly, if there are other factors
involved, like smoking or drug use or something like that those women do not
necessarily want a nurse coming to their house either, so were not going to necessarily
know about that. Which is unfortunate. GR
Oftentimes what we see is that even if they do [quit smoking], theyll pick it back up
again after the baby is born. I think that there are resources, but its the fact that they
dont want to access them. Quitting smoking is one of those things that you really have
to want to do. And a lot of them want to, but its a very addictive substance. GR
And even with all the data that says your baby is more at risk for health problems
we talk about babies born to women who smoke having a very low birth weight. And
they say, Well, that sounds good to me, I dont want to have a big, huge baby. We
say, You need to recognize that globally, your baby is smaller smaller brain, lungs.
Your baby is underdeveloped. Not just like a short person. This is a very serious issue.
They need to be aware that its detrimental, without making people feel guilty. But its
just a very hard thing for them to give up. GR
I think that in Pierce County, we do have lots and lots of women who access Planned
Parenthood, CareNet, some of those services that do offer free pregnancy testing. I
think thats a great doorway to services, because they will refer them to an OB or
whatever resources they want in the community. And so I think that is really helpful
that they can get a free pregnancy test and get introduced to the resources in the
community. Also, once a woman has established she is pregnant, DSHS will refer to
our services at the Health Department, which are home visiting services, and WIC,
which will help encourage them to have a healthy pregnancy, provide them with
information and encourage them to have prenatal care. I think that theres always
room for improvement, we certainly dont get everyone. GR
"Again, its an education issue. I know that the prenatal offices in the WIC program
are all placing a big emphasis on decreasing smoking, but I think the biggest challenge
is trying to convince them. Its education." FT
"Well a lot of the time the teens are in denial and they dont know where to go for
support. The Afro-American population, Im not really sure. I dont know if its lack of
knowledge of where to go to get services. And the Native American Indians, were
trying to reach out to them, but thats kind of a challenge in this community. Well,
theyve got uncontrolled high blood pressure, and also a high incidence of diabetes, so
we have more bad outcomes in those patient populations." FT
"I think its getting better. We dont allow smoking in the hospital, and thats become a
community standard, and I think that thats a good thing. Since they cant smoke as
many places, its not seeming to have the same glamour as it used to. So I think thats
been a good community service." FT
"Were doing a better job of keeping our little babies alive with the micro-preemies. Its
not because of prenatal care necessarily, its because weve improved our nurseries.
About 1 in 10 babies born in the state of Washington is a preemie, but our outcomes
are improving because were giving better care to babies once theyre born." FT
"I think that Pierce county Perinatal collaborative is working on beds for SIDS
prevention and I think that thats something that could be funded. Im also aware of
the Period of Purple crying program that Mary Bridge has that focuses on Shaken Baby
Syndrome, more education possibly for parents." UD
41
Quotes
SubTheme
Description
Theme
Culturally
appropriate
education
Clients
need
education
appropriate
to their
cultural
beliefs,
finding a
middle
ground
between
medicine
and beliefs
Education
needs
"I think that making sure that that health curriculum really does fit with their
lives, I think that would be a way to impact that." FT
"Theyre attempting to use texting, social media, advertising I think that thats
important. Theyre using billboards and using advertising on the buses,
advertising at schools. Theres a program here in the Tacoma school district
called the grads program, the grads program is for young women who are
pregnant or recently delivered with the goal of keeping them in school. So when
theyre going to the high school, the school nurses are trying to reach out to
emphasize the importance of prenatal care. I think all of those are effective ways
of getting that information out, but I think bigger than knowing they need
prenatal care is knowing where to go to get it." FT
"I know that the state has tried to do a lot of education. I think that using Baby
Text is probably a good way to tryanything that we can do to educate about
the early loss that is associated with smoking. I think that that is all helpful
informationweve got to get it down to the Jr. High level. If we can keep them
from starting in the first place then we wont have the struggle of them quitting,
because its so addictive." FT
"Again its the Hispanic population and its hard to break through that cultural
barrier. When they believe what their ancestors say versus what a health educator
says, so theyre getting mixed messages from their moms and their grandmas
versus the people that know in healthcare." OI
42
Quotes
SubTheme
Description
Theme
Provider
knowledge
Providers
lack
knowledge
of current
health
issues and
resources
available,
and skills
necessary
to care for
women.
Education
Needs
"So the thing maybe where more focus could be, would be making sure that if that's
the goal of the program that MSS are more focused on those aspects of it where we
can try to prevent those low birth weights and premature births." CF
"I think that they need specific skills on how to coach. Those same providers need
education on how to coach people effectively. I think just to say that somebody
stopped smoking doesnt exactly change that behavior. So what are some of the
coaching skills that can be developed or given to people that would enable them to
be more effective" FT
"I think theres a lot more education of staff that could be done on that, so that
[patients] get the same message over and over." OI
"Usually this happens with heavy drug users, and they need prenatal care and are
the ones who wont seek it out. Outpatient psychiatric facilities should increase
enrollment to Moms groups in Pierce Co." MI
"These are baby steps to get women, not only women, but caseworkers, counselors,
case managers, people who deal with the population, with WIC people. Getting
them to realize there is an alternative to having people suffer [with dental issues]
and wait until after they have the baby." NI
"We need to rely on the medical community to help us get that message. Women
listen to their physicians, all the way. If physicians can convince them they need to
get their teeth fixed, hopefully they can learn that a little faster." NI
"There is a noticeable increase in Pot smoking over the last year. We need to do
more focused education that pot smoke is not as harmless as they think. When you
ask if they smoke, they say yes, but when you ask about tobacco, they say oh I
dont smoke tobacco. We really need to be delving in further to clarify, they think
this is smoking" MI
43
Quotes
Sub-Theme
Description
Theme
Communitybased
education
High
schools,
middle
schools and
primary
care
providers
need to
increase
their
knowledge
base and
outreach
efforts
around
pregnancy,
lifestyle
choices and
resources
available to
women
Education
needs
"Some of the younger ones, some of them come through their school nurse or
through the parenting program, if they're in a school that has that.
Otherwisethey go their primary care physician and making sure that they get
their medical coupon which will allow them to [seek care], because they need
insurance coverage to be able to do that." CF
"But for us at the health department, one of the things is to make sure that the
primary care providers know that our programs exist, like the MSS [Maternity
Support Sevices] that we can see clients in the home and make sure that they're
connected with other services in the community that they are eligible to
receive." CF
"I think there needs to be more breastfeeding education from medical providers,
talking about it, bringing up the conversation, and not just a one time Are you
gonna breastfeed? I believe that weight management isn't addressed very well
with medical providers. They seem to overlook the weight a lot of times, and
the moms are gaining too much. And I think that nutrition is something too
where we definitely need to be working more with our pregnant women and our
doctors need to emphasize the importance of that." NI
"I have to really think on that one because a lot of perinatal mortality is
associated with lack of prenatal care or frequent drug use. So, for example,
someone that uses heroin or methadone regularly, or methamphetamines, are at
higher risk for placental abruption so they are more at risk for fetal loss from
that. So again its trying to educate the young women about what they have
control over." FT
"I think the fact that were working on trying to get people into prenatal care,
trying to get them not to use drugs. I think one of the things we need to do a
better job of, and Im not sure how to do it, is to figure out how to educate them
about the problems of even taking prescription drugs. Were starting to see a
huge number of women coming in that are addicted to Percocet, Vicodin, things
like that that theyve been given that are legal, but the problem is that theyre
becoming dependent on them. And those types of usage do contribute to
problems with babies." FT
"There are a lot of obese women in this country, and high smoking rates. A lot
of women will cut down on smoking to 2-3 cigarettes per day, which is better
than a pack. Socioeconomic issues play a part as well, people moms hang out
with who are of lower SES, who smoke, have a poor diet all effect the pregnant
mom Education is a real problem too, people are addicted to these things,
and its hard to quit. Especially if family, friends, boyfriends who live this
lifestyle would quit too, it would be much easier for the mom." MI
44
Quotes
SubTheme
Description
Theme
Lack of
time
Providers
lack
sufficient
time to
implement
interventions
with clients
or teach
clients about
health issues
and
resources
Budget
cuts
"So what I would say is that that program [Maternity Support Services & First
Steps] is being shrunk so much that our face to face time with those clients is
diminished greatly and it's very very difficult to feel like you can be making any
kind of impact, you know, how effective you can be given the very limited amount
of time that you'd be able to spend with clients. You know, we get them into our
program but what we can actually accomplish is limited by how often we can see
them." CF
"We just have much, much less time to be with them and to help them develop the
skills to cope with stress in other ways. So I would suggest that having more time
and focus on that, we might be able to have some impact by being able to teach
them other ways to manage stress." CF
Home visiting services are so positive in that there is a trusted person that this
individual can talk to about anything. Ideally, they go to their physician for their
questions, but as hard as these doctors work, they dont have time to sit down and
chit-chat with these girls about every little thing. Thats where we come in and they
are able to have someone that they can, in confidence, privately, one-on-one talk to
someone about these issues. I think its way more successful then just expecting
these girls to be able to do it on their own GR
45
Quotes
SubTheme
Description
Theme
Lack of
funding
Budget cuts
have lead to
cuts to
essential
programs
Budget
cuts
"And the other part, a gap in services there is that the Quit Line used to be very helpful
and we had programs in place that could really help those clients and that has fluctuated,
and at this point I'm not sure that the Quit Line has any funding or much to offer at all."
CF
"So, that was a very active program and the families kept on meeting monthly for an
extended period, and I don't know what has happened to that program. CF
"We have a program where we were able to give out cribs to families where they didn't
have anywhere to put their babies, and that program is no longer operating." CF
My understanding was at the federal level there were going to be some cuts to the WIC
program. I think any cuts to the WIC program would be a threat because they will either
provide services to fewer people or provide fewer services. I'm not quite sure how that
would work, but I think cutting the WIC budget would be a threat." CF
"We do get training every so often from some part of the Health Department, though I
think we just lost our tobacco part of the Health Department in this last go around of the
cuts." CF
"I think that there's not enough free smoking cessation resources for them. I think they're
not getting the information, too, about smoking resources. Here we're very lucky because
we have someone on site. It's the very first job I've had that has somebody on site." NI
"The fact that were cutting all of our preventive services is gonna hurt us in the future.
Whats gonna happen is were going to cost shift, so we dont offer services to the moms,
the babies will be born prematurely, the babies end up in the NICU and we pay even more
money. Again we need the services to take care of the people." FT
"decreased funding and we need to have more people on the ground out there
identifying at risk individuals and educating them." UD
"Well, you could increase funding to the Nurse Family Partnershipyou could increase
the number of nurses out there doing that. I think that might help." UD
"II think that there could be more training in that field for the people that are the first line
people. So that theres a personal contact for learning that information [smoking
cessation]. But again with the dollars, where theyre at, those trainings have gone away.
They used to do them regularly at the state but we dont have them anymore. So its just a
phone call type of thing now and none of the staff is now trained by them on how to make
that happen." OI
"Smoking always has threats; the program gets cut easily. Not sure we have this program
in place right now." MI
"With resources shrinking and the federal government thinking about who theyre going to
care for and who theyre not. The mere fact that women can only seek services for 2
months after theyve delivered to me is a threat." NI
Bus services have been cut, many of them [clients] dont have drivers licenses or people
to take them. Just getting to the appointments are a problem. Most of them are able to
access medical, so they have insurance, but its just getting to the appointments. GR
46
Quotes
SubTheme
Description
Theme
Clients of
low SES,
without
employment
lack access
to healthcare
Access
issues
"I'm sort of hoping with the changes in healthcare that women would know that they
have access. There's so much focus on women's access to reproductive healthcare that
maybe that would improve and people would go earlier. " CF
"I guess some of it is related to access to healthcare because once some of our clients
have had their babies, that is the end of their access to healthcare, and they probably live
a great portion of their lives not thinking that they can access healthcare." CF
"And I'm hopeful that the healthcare reform has included a lot of access for screening
and well-woman checks, that hopefully that might make an improvement in it." CF
"We need NPs, certified nurse midwives, OBGYNs, or maternal-fetal medicine
specialists, and enough of them in the right areas to provide care for these people." FT
"I would say just being low income, lower educated and lack of transportation and
having a lot of children, a lot of times that causes disparity because they dont want to
bring them all in and its a handful to get a babysitter and you have 4-6 kids." OI
"No, I think its going to get even better. With the ACA, children will be cared for. I see
an increase in childrens ability to seek and get services." NI
At the Health Department we have an outreach team which is doing very well in terms
of trying to connect pregnant women with services as early as possible, and I guess some
of that which young women need to know as soon as they find out that they're pregnant,
that that would be the time to start getting those services. CF
Access to
Healthcare
"What are the gaps in services? I would say mostly the knowledge of the young women
not knowing where to go for resources. I think it is probably our biggest gap because
anybody in the area is eligible for Medicaid services, but they have to know about it and
they have to know where to go to be able to enroll in Medicaid services." FT
"Well theyre [drug addicted moms] on drugs, theyre strung out. So they dont do it,
they just dont get it done. Or they dont want to be found out. Or they know drug
screens will be involved or some people that want to keep their child, they dont want to
get caught, they just dont bother to come in. " OI
"Its a stereotypical attitude that I cant get any work [dental work] done in my first
trimester," NI
"We have wonderful services that we worked hard to get. We have services for children
in that age bracket. Our biggest downfall is making sure our agencies we work with are
aware of the resources out there." NI
47
Appendix H: Raw Assessment Data

High-level transcriptions of interviews
48
Question 5: What are the gaps in services to address the high-needs indicators?
Late Entry to Prenatal Care
We have developed a list of dentists who will help these [pregnant] women. Its a stereotypical
attitude that I cant get any work done in my first trimester. Were trying to dispel those myths.
Dont just come in with excruciating pain you can get other work done and its not detrimental
to the baby. Theres a huge effort to get women to understand and seek care.
Given the population I work with, the main problem is transportation. Bus services have been
cut, many of them dont have drivers licenses or people to take them. Just getting to the
appointments [is] a problem. Most of them are able to access medical, so they have insurance,
but its just getting to the appointments.
I really dont know how to get them in, but you dont have control until they enter your
system, you dont know theyre out there pregnant. Just once they arrive and we know that
theyre pregnant then of course theyre getting care, but I dont know where the gap is or
how to get them to come in when they find out theyre pregnant. I think the whole
community has been working on that for a long time, I know a lot of the healthy options
plans in the state now offer incentives for women that come in in the first trimester, so even
they are trying to get patients to come in before they pass that 12 week mark and some
patients claim they dont know theyre pregnant or they havent gotten around to it.
This population has to have DSHS to qualify, a gap could be not having DSHS yet, or if
they dont have their card with them. The doctors can bring them up on the State website
without the card in hand, but many girls dont know this. The doctors can back bill DSHS
for care up to three months back, but many girls dont know this.
So what I would say is that our program is being shrunk so much that our face-to-face time
with those clients is diminished greatly and it's very, very difficult to feel like you can be
making any kind of impact how effective you can be given the very limited amount of
time that you'd be able to spend with clients? We get them into our program but what we
can actually accomplish is limited by how often we can see them? I mean some of them go
and get their pregnancy coverage very early and others don't. And some of them come in
through WIC and so sometimes we get referrals through there. Some of the younger ones,
some of them come through their school nurse or through the parenting program, if they're
in a school that has that. Otherwise, it's how, first of all, they go their primary care
physician and making sure that they get their medical coupon which will allow them to do
that, because they need insurance coverage to be able to do that. So I'm trying to think that
the question is, for some of them, how are you going to motivate them to get started on the
first step towards getting insurance coverage that will let them go and see a medical
provider? I mean for some of them, also, I've seen sometimes they don't quite want to admit
that they're pregnant for a while, especially younger ones. So they may not come very soon
because they're trying not to think about it. I guess some of them have other issues like
substance abuse that may keep them from doing it. Also we're seeing quite a lot of people
who have developmental delays and so even connecting the dots may be something that
may keep them from getting their early care.
49
I would say mostly the knowledge of the young women not knowing where to go for
resources. I think it is probably our biggest gap because anybody in the area is eligible for
Medicaid services, but they have to know about it and they have to know where to go to be
able to enroll in Medicaid services. I think that people are attempting to do it already.
Theyre attempting to use texting, social media, advertising I think that thats important.
Theyre using billboards and using advertising on the buses, advertising at schools. Theres a
program here in the Tacoma School District called the grads program, and the grads
program is a program at Oakland high school for young women who are pregnant or
recently delivered with the goal of keeping them in school. So when theyre going to the
high school, the school nurses are trying to reach out to emphasize the importance of
prenatal care. I think all of those are effective ways of getting that information out, but I
think bigger than knowing they need prenatal care is knowing where to go to get it.
I think there needs to be more breastfeeding education from medical providers talking about
it, bringing up the conversation, and not just a one time Are you gonna breastfeed? I
believe that weight management isn't addressed very well with medical providers. They
seem to overlook the weight a lot of times, and the moms are gaining too much. And I think
that nutrition is something too where we definitely need to be working more with our
pregnant women and our doctors need to emphasize the importance of that.
Children with Dental Caries
We have an oral health program here at the Health Department. I feel like this is a huge
problem. Seeing 3-, 4-, 5-year-olds with massive caries, between bottle rot and high juice
consumption. I think that the community has really started to recognize this is a huge issue with
things like the oral health program. And with things like the last few years, dentists
recommending they have their first dental visit at 1 year. A while ago it was, Dont take the kid
to the dentist until theyre 4. And theres so much information out there now about juice and
stuff like that. But there are segments of the population out there that because of poverty or
whatever, their children are getting lots of processed foods and foods with high sugar content.
Its really, really a problem, I think. As public health nurses doing home visits, often carry
fluoride with us and fluoride kids teeth all the time. At the Health Department, theres the Oral
Health Division, and thats all they do, support oral health. I think that with the new Affordable
Healthcare Act, its really going to make a difference for people being able to access things like
oral health and vision. I think thats the biggest problem, is that people just cant afford it. The
word is out as far as dentists being willing to work with children, thats pretty prevalent. Its just
getting people there, between access and transportation. Thats the issue.
Again, I think its values. Even though they now they should or could or have that available to
them, they just choose not to, I suppose there could be transportation issues, however, Medicaid
does pay for bus passes and transportation for medical appointments, so its just a matter of
getting all of that in a row and its all complicated to do, so patients forgo the dentist. Another
one would be dietary, learning about what types of things children should be doing, like should
they be on a Sippy cup forever after a bottle because then they carry it around all the time and
bathe their teeth in whatevers in that container. And also teaching people not to put juice and
Kool-Aid and soda and whatever else in those cups that children carry around all day long and
bathe their teeth in sugar, and even milk is bad and Im teaching them that. And I think theres a
50
gap there in people understanding that unless they have a child or have seen a child that have
had their teeth pulled before their big ones come in.
Huge effort its pretty good to address children prenatal, all the way up through 19. We have
wonderful services that we worked hard to get. We have services for children in that age bracket.
Our biggest downfall is making sure our agencies we work with are aware of the resources out
there. As a result of that, our nurses go around to the schools to make sure they have updated
information about our resources. I talk to the school nurses, particularly the supervisors. I have
an advisory group with them, to try to keep them up-to-date with whats going on out there.
Children in WIC with High BMIs
Im not sure where the gap is there either because we educate them all the time about that,
but I think maybe if a baby is breastfeeding then WIC shouldnt be giving them formula too.
And I dont know if maybe the patient lies or doesnt tell them the truth that they are doing
both. But I think most people have adequate milk supply without feeding formula too.
These babies they throw up and spit up all the time and then they bring them in to the
doctor for that, and theyre just stuffed, so of course theyre going to throw up.
We have a nutritionist here at the health department who does home visits and she would be
working with that population. When I did work with this population, we could access her as a
resource.
I think that some of it, if I'm seeing new mothers, a lot of them don't cook. And not only do
they not cook or know how to cook, they've never seen their mother cook either. I don't
think all of it is about education. We're trying to encourage behavioral change. Their levels
of exposure to food preparation is very low. I know in some cases they are trying to
encourage that by teaching some of those skills in schools so that they are exposed to being
able to prepare foods. If they're going to try to feed healthful foods to their children in order
to prevent them being obese by the age that you stipulate, they need access to more
nutritious foods and they also need the skills to know how to prepare those foods, because I
see a lot of people that know how to get fast food or add boiling water to top ramen but they
don't really know a lot about food preparation. And there is the nutrition extension, they do
teach food preparation and that, I think, can be helpful when taught in groups so they can
know what are nutritious foods that they can give their children. I think the other thing with
the gaps, which I think the Health Department is trying to address is looking for ways where
activity can be part of children's daily lives. Certainly a lot of the people that I see spend a
lot of their time in houses or apartments, and so I think there's lots of ways to be
approaching that in terms of trying to prevent the childhood obesity which I know is still
increasing rather than decreasing.
I think we need family programs that address the parents on healthy eating and moving for
the whole family, so family-based nutrition and physical activity programs.
51
Women Smoking the 3rd Trimester

If theyre getting prenatal care, certainly through their obstetrician and public health, there are
lots of resources to help them quit. Its whether or not they use them. Thats the issue.
Well, I would say its the same answer because back in the day we would have seen them a
lot more [for support services]. And the other part, a gap in services there is that the Quit
Line used to be very helpful and we had programs in place that could really help those
clients and that has fluctuated, and at this point I'm not sure that the Quit Line has any
funding or much to offer at all. Some years ago we had a program with the Quit Line where
if they were willing to sign up with us they got a $10 gift voucher and they agreed, in return,
to have the Quit Line call them for a series of 10 support interviews. I'm not sure whether,
when they did the pilot study for that, whether they found that that was an effective way of
reaching them, but a lot of the time what we are encouraging them to do is cut down on
smoking and they will often say that they need whatever few cigarettes they've cut down to,
to manage stress. We'd like to offer them other ways to cope with stress instead of using
cigarettes. But I've certainly heard many people say that they can't give up those last 2 or 3
because of the stresses, and a lot of them are living with a very low income, and often in the
social situations that they're in they have a lot of stress. And again, our program, which has
a behavioral health specialist as a part of it, because we have to share the decreased number
of units among the three specialties: the public health nurse, the behavioral health specialist,
and the nutritionist. We just have much, much less time to be with them and to help them
develop the skills to cope with stress in other ways.
I think that there's not enough free smoking cessation resources for them. I think they're not
getting the information, too, about smoking resources. Here we're very lucky because we
have someone on site. It's the very first job I've had that has somebody on site.
Of course we encourage them to quit and of course we give them the resources to quit, but
its sort of impersonal to me because its a 1-800 number and its the state quit line, but its
just a phone call. And so unless people are face-to-face with someone sometimes programs
arent as successful. And it is an addiction so people dont have the desire to call and quit
because theyre addicted and they know it. Its like any addiction, you dont call to get your
help usually, usually someone has to intervene somewhere along the line. And they just
dont see it as necessity or valuable, so they dont. Even though you give them the
information and the resources and agree to help them do it, make the call for them, help
them, its very difficult for them to do that, to want to quit. Continuing to educate and teach
people and try to give a more personal approach to it to help them understand the value of
quitting. Now we have marijuana as well and because its legal, people think they can do it,
but alcohols legal too and we dont encourage that during pregnancy either. So making
them see the value that it all hurts the baby and themselves to have that in their system.
Again, its an education issue. I know that the prenatal offices in the WIC program are all
placing a big emphasis on decreasing smoking, but I think the biggest challenge is trying to
convince them. Its education. I know that the state has tried to do a lot of education. I think
that using Baby Text is probably a good way to tryanything that we can do to educate
about the early loss that is associated with smoking. I think that that is all helpful
information. And we really need to get it, this sounds funny but, weve got to get it down to
52
the Jr. High level. If we can keep them from starting in the first place then we wont have
the struggle of them quitting, because its so addictive.
The biggest issue I see with smoking is when moms dont have enough support to quit or cut
down on smoking. Washington State used to have the quit smoking hotline but with budget
cuts, it was one of the first things to go. Molina healthcare may still provide a quit smoking
program, but Im not sure. Usually if a mom is conscientious about her pregnancy she will
quit on her own.
Perinatal Mortality
I'm not absolutely sure about that. We used to have one of our nurses that worked
specifically that worked with SIDS. I haven't seen any SIDS. So, that was a very active
program and the families kept on meeting monthly for an extended period, and I don't know
what has happened to that program.
I have to really think on that one because a lot of perinatal mortality is associated with lack
of prenatal care or frequent drug use. So, for example, someone that uses heroin or
methadone regularly, or methamphetamines, are at higher risk for placental abruption, and
thats where the placenta shears off from the inside of the uterus, so they are more at risk for
fetal loss from that. So again its trying to educate the young women about what they have
control over. I think the fact that were working on trying to get people into prenatal care,
trying to get them not to use drugs. I think one of the things we need to do a better job of,
and Im not sure how to do it, is to figure out how to educate them about the problems of
even taking prescription drugs. Were starting to see a huge number of women coming in
that are addicted to Percocet, Vicodin, things like that that theyve been given that are legal,
but the problem is that theyre becoming dependent on them. And those types of usage do
contribute to problems with babies.
The few cases that I have had where thats occurred, it does seem like there are few support
groups. Again, access to those. The hospitals, I think, try to help initially. There are certainly
gaps in accessing mental health services in the long term. Many of them will have Maternity
Support Services, but thats just the first 2 months following the birth of their baby. So if theyre
trying to get counseling or something, trying to have the resources for it is an issue sometimes.
I think that Pierce County Perinatal Collaborative is working on beds for SIDS prevention
and I think that thats something that could be funded. Im also aware of the Period of
Purple crying program that Mary Bridge has that focuses on Shaken Baby Syndrome, more
education possibly for parents.
I honestly dont think there are that many gaps, sometimes it just happens. We do, our
group does a really good job with helping pre-diabetics and diabetics. I guess one gap
would be giving them care before theyre pregnant to stabilize their medical problems prior
to getting pregnant and that would be getting their Diabetes in order, their Hypertension in
order before they get pregnant.
Mostly we will see miscarriages here, less than 10-12 weeks, not really fetal deaths beyond
then. Rarely, like 1-2 per year, I will see one. We dont see stillbirths a whole lot either. I do
53
have a coworker who just had an infant die in the past 2 weeks, very sad. Usually this
happens with heavy drug users, and they need prenatal care and are the ones who wont
seek it out.
Question 5b: If gaps identified, how could services be improved to address those gaps?
Transportation. I know in other areas of the country, its not such a big deal. But here, were so
dependent on our cars. And if you dont have one, and cant afford a bus pass And, plus, all
the bus routes have been cut so dramatically in the last few years. I worked a lot out on the Key
Peninsula and Gig Harbor area. I go all the way out to Lakebay, all these little areas out on the
Key Peninsula. There is no bus service out there. So, if you are a 15-year-old living with your
grandmother out on the Key Peninsula, you dont have a way to get into town. Youre counting
on somebody else. The closest bus is in Purdy, a major intersection, and thats a good 20 miles
away. Thats really an issue. They have school busses, but when it comes to transportation to
appointments, that is an issue.
Get women in sooner for care, and referring to Maternity Support Services ASAP.
But for us at the health department, one of the things is to make sure that the primary care
providers know that our programs exist, like MSS, that we can see clients in the home and
make sure that they're connected with other services in the community that they are eligible
to receive.
The importance of prenatal care, because of things like Eclampsia and Gestational Diabetes. A
lot of women just dont know those things are out there. If we can increase their knowledge a
little bit, they can seek out help so those things dont happen to them.
Well, you could increase funding to the Nurse Family Partnership program you could
increase the number of nurses out there doing that. I think that might help.
Trying to advocate for what I hope will be a free clinic here in Pierce County. Pierce County
needs a free clinic. One that people can come to other than filing out their health history form.
They sit down and get care. If they have money to contribute, great. If they dont, we tell them
next time. We dont have a safety net like that in Pierce County. There is a program that the
Dental Society runs, thats a one-on-one program. It is one person at a time attempt to connect
persons who have a great need, with a private dentist who has volunteered their time. Theyre
not going to get their treatment plan like that. Thats what they have. Thats basically what we
have going on here in Pierce County as far as oral health and low-income populations. Were
always striving to do more, but this is what we have.
One of those policies is that we need to have some kind of legislation enacted that demands or
makes mandatory that children have dental screenings, right along with their hearing and vision
screenings at school. Its not mandatory, so its at the whim of the teacher and school, whether
theyre going to check the teeth or not when doing those well child screenings. We need to move
that to another level. The other thing that needs to happen is making sure that in licensed
54
daycare centers, they do some form of oral health intervention during the day. Right now its not
mandatory. If you take a scenario if a child is dropped off at 6am in the morning, theyre given
breakfast, then off to nap time, then they wake them up and play with them a little while. They
give them lunch, play with them a little while, then off to nap. Its an ongoing cycle, then they
get picked up at 6pm by the parent. They try to get them bathed, dressed and fed and off to bed.
So where was the oral health intervention during that day? And unless we make it mandatory
Im not trying to put a huge demand on daycare centers because they have a lot to do. If we can
just get 15 minutes when they brush their teeth after lunch, that would be a good policy. Thats
one of those things thats going to require a WAC change. Its already present in Head Start and
ECAP they know the importance of it. It is mandatory in those programs
Lots of education and again if theyre breastfeeding not giving formula too.
More money would be helpful. We need to make it a priority; Pierce County has a huge
infant mortality rate. Increasing availability of cessation information would be helpful, and
doctors should be addressing quitting more often as well. A lot of moms do quit, they just
need the information on why to quit and how.
I would suggest that having more time and focus on that, we might be able to have some
impact by being able to teach them other ways to manage stress.
Perinatal Mortality
A lot of education.
If we could get people there, women or men, families, would have access to mental health
services. It will just make that so much more accessible. I think that we certainly do see a lot of
prenatal and postpartum depression. Again, access to mental health services beyond Maternity
Support Services, just pregnancy medical. That has traditionally covered pregnancy and just 2
months postpartum. Its just not enough when women are at risk the whole first year for
postpartum depression. Just the whole Affordable Care Act will be instrumental in addressing
some of those issues.
Outpatient psychiatric facilities should increase enrollment to Moms groups in Pierce
County.
Question 6: Have you noticed any improvement or worsening of the high-needs indicators?
How would you describe the change?
One of the things that we see frequently now is obesity. Thats becoming the problem in that
patient population, so the physicians and midwives are very concerned about it.
I don't really see any difference, I don't see any improvement, no.
I dont think this is getting any worse.
55
I dont think I see any change there.

Changing attitudes are not going to happen overnight. These are baby steps to get women, not
only women, but caseworkers, counselors, case managers, people who deal with the population,
with WIC people. Getting them to realize there is an alternative to having people suffer and wait
until after they have the baby. All of these areas, smoking and seeking care during the 1st
trimester, its something we are trying to get to that next level. Its popular now, definitely its
going to take time to get people to turn that around, including the dental community. We need
to rely on the medical community to help us get that message. Women listen to their physicians,
all the way. If physicians can convince them they need to get their teeth fixed, hopefully they can
learn that a little faster.
With accessibility to Medicaid and stuff over the years, that has probably improved. I dont
know any statistics on that. Primarily, if people did not have prenatal care, they would come to
us through WIC or something like that. Its a fairly low percentage of our clients we make such
an effort to get them into prenatal care early. Certainly, if there are other factors involved, like
smoking or drug use or something like that those women are not necessarily want a nurse
coming to their house either, so were not going to necessarily know about that. Which is
unfortunate.
I don't know. I think that would be somebody that kept statistics on a much different level. I
don't know what those specific numbers are. I don't know the answer to that.
Ok, I think that our numbers are actually pretty good in that respect.
I want to say in some populations theres been an improvement, but in others there hasnt.
Again its the Hispanic population and its hard to break through that cultural barrier. When
they believe what their ancestors say versus what a health educator says, so theyre getting
mixed messages from their moms and their grandmas versus the people that know in
healthcare.
We take a Washington State Smile Survey, every 5 years. The last in 2010. We see less children
with decay. Our goal is to cut down the number of children with rampant caries, children who
have had an active experience with decay or fillings in 7 teeth. Our goal is to cut the number
were at 21% in our county our goal is to cut that down by 50% by 2015. We hope to achieve
that with the daily activities through our school program. The last survey that did come out
showed we had an improvement in 6-8 year-olds.

I would say that that problem is not improving. It's probably getting worse. We see more
and more kids that are gaining weight too fast.
I would say yes, with education theres been a slight improvement.
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Everything I know about that is probably increasing. It's not getting better. I don't think
there's any way that that's getting any better. I think it's something we need to be paying a
lot of attention to. I think that the changes that we've made with the program and the food
we give out for those children are positive changes and they decrease a lot of the juice that
children are getting, and they have added fruits and vegetables, and they can use the farmers
market in the summer. I think the WIC program is definitely trying to make some impact on
that, but obviously what they get from WIC is only a very small portion of what those
children eat.
I would probably say here, improvement, because we have the smoking cessation person
here. I think most of our moms do try to cut back or quit.
That just is an ongoing problem. Its funny because we do really track that well screen them in
the first couple of visits and then again at 34-36 weeks. Most of the time, theres this huge
incentive of being pregnant and having a baby, and theyll make an effort to at least cut down.
But its such a difficult thing and most of them are not able to totally quit. Oftentimes what we
see is that even if they do, theyll pick it back up again after the baby is born. I think that there
are resources, but its the fact that they dont want to access them. Quitting smoking is one of
those things that you really have to want to do. And a lot of them want to, but its a very
addictive substance. It is an ongoing battle with the smoking. And we will talk so frankly with
them theres so much data out there to support the affects on your baby. Theres no redeeming
effect for smoking. But, its powerful stuff and a lot of women, especially if there is a poverty
component, you would think that would be a greater incentive to quit because its so expensive.
And yet, its something they hang on to. Smoking is really a problem. And even with all the data
that says your baby is more at risk for health problems we talk about babies born to women
who smoke having a very low birth weight. And they say, Well, that sounds good to me, I
dont want to have a big, huge baby. We say, You need to recognize that globally, your baby
is smaller smaller brain, lungs. Your baby is underdeveloped. Not just like a short person.
This is a very serious issue. They need to be aware that its detrimental, without making people
feel guilty. But its just a very hard thing for them to give up. Smoking is never going to go
away, but its something we need to never give up on. And those of us who are out there in the
field, working in peoples home, really make that a priority.
I know that Pierce County has one of the higher rates of perinatal mortality and it definitely
has to do with socioeconomic status, and the programs that we have in place in the hospital
is what I can tell you that we have, I know that the period of purple crying and SIDS
education are also really important educational pieces.
I'm sure those statistics exist somewhere, but I don't know the answer to that either. I hope
that it's going down.
I think theres been some change in that. Improvement.
I think its getting better. We dont allow smoking in the hospital, and thats become a
community standard, and I think that thats a good thing. Since they cant smoke as many
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places, its not seeming to have the same glamour as it used to. So I think thats been a good
community service.
The smoking rate may even be getting better. Could be because smoking while pregnant is
becoming more socially unacceptable. Unless there is a whole household of smokers, then
she will often quit on her own.
Perinatal Mortality
Were doing a better job of keeping our little babies alive with the micro-preemies. Its not
because of prenatal care necessarily, its because weve improved our nurseries. About 1 in
10 babies born in the state of Washington is a preemie, but our outcomes are improving
because were giving better care to babies once theyre born.
Perinatal mortality seems to be getting better, we have seen fewer preemies lately. The 28-32
week olds seem to do quite well with modern technology.
I would say no. Just kind of the same.
Question 7: What are the future threats to these services?

For us no, if we dont know theyre pregnant and we dont know how to find out theyre
pregnant I think the Health Departments working on they have some outreach workers
that are trying to go out and find pregnant women and bring them into prenatal care.
Its a little more difficult to predict. With resources shrinking and the federal government
thinking about who theyre going to care for and who theyre not. The mere fact that women can
only seek services for 2 months after theyve delivered to me is a threat. Thats one of those
things thats up for discussion all the time. Whenever somethings up for discussion, theres
always a threat it may go away. Im not as comfortable that its here to stay pregnant women
being able to seek services, thats a threat to me.
So much of it depends on Medicaid. And thats up to each individual state. Were all concerned
about whats going to happen with that. The Affordable Care Act is designed to address all those
things. It does specifically address pregnant women. But we just dont know yet what that
coverage is going to be. Weve seen in the last few years that the coverage has just decreased so
rapidly. We hope its going to get better, but its hard to imagine that it will. Insurance coverage
is critical for these women to be able to get prenatal care. If they cant get it, they will not get the
prenatal care. And their children wont be seen by pediatricians either. But were hopeful.
Cuts to Maternity Support Services. Cuts to Nurse-Family Partnership where they do home
visits. Cuts to using translators and interpreter services. So it's making it harder to get these
moms off to a good start.
Decreased funding and we need to have more people on the ground out there identifying at
risk individuals and educating them.
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Not at all, everyone is thinking the new healthcare program will actually help, I guess we
will see.
Financial. Insurance companies cutting services, government cutting services. I think thats
a huge threat.
I'm sort of hoping with the changes in healthcare provision that that would improve, that
women would know that they have access. There's so much focus on women's access to
reproductive healthcare that maybe that would improve and people would go earlier. I don't
know, though. And the threat, I don't know what that would be.
I think the same thing: just education again. Whoever gets cut, then the threat would be
there to lose that education.
No, I think its going to get even better. With the ACA, children will be cared for. I see an
increase in childrens ability to seek and get services.
Well there's really not a whole lot of services offered to them, so I don't really know how to
respond to that one. On WIC, I know that we always hear that there could be cuts to WIC,
but so far they really have done a good job at saving our budget. But as far as the kids, the
services for those kids with high BMIs, there's not many services available to them now
anyway. So as far as the budget being cut, or services suffering, that's a hard one to answer
because there aren't very many. But, I could see that, to cut the budget.
The economic climate with services like WIC and things like that, its questionable. That would
be highly detrimental. Theyre trying so hard to focus on nutrition, but its food access for people
on food stamps and who access WIC. Their access to food is going to be decreasing if things like
WIC get cut and stuff. The economic climate is a huge issue right now. Services have been cut
left and right. Were all just holding our breath to see what happens in the next session.
I dont know that one, I guess just education again. Whoever gets cut, then the threat would
be there to lose that education.
My understanding was at the federal level there were going to be some cuts to the WIC
program. I think any cuts to the WIC program would be a threat because they will either
provide services to fewer people or provide fewer services. I'm not quite sure how that
would work, but I think cutting the WIC budget would be a threat.
I can foresee them cutting the budget and taking them away.
The same, decreased funding.
Smoking always has threats; the program gets cut easily. Not sure we have this program in
place right now.
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Its interesting because for a long time, we would carry patches with us, and will certainly offer
the Tobacco Quit Line. One thing we dealt with was OBs not willing to put their patients on
patches, because they just felt like that was crazy and they should just quit on their own. That
was something that we had tried to work on, in terms of working with the medical community
in recognizing that whatever we can do to help these women stop smoking is worth exploring,
rather than just saying, Well, theyve just got to do it on their own. Thats just not going to
happen. Giving them an avenue for decreasing, or just some help. I think thats improved a little
bit, but not really. I always ask the girls Im working with if their physicians have offered them
patches, and they say, No, that never came up. Improving their access resources like that
would be huge.
The fact that were cutting all of our preventive services is going to hurt us in the future.
Whats going to happen is were going to cost shift, so we dont offer services to the moms,
the babies will be born prematurely, the babies end up in the NICU and we pay even more
money.
Yes, theres always a threat because its a state program.
I'm not sure where the threats would come from for that.
Perinatal Mortality
We have a program where we were able to give out cribs to families where they didn't have
anywhere to put their babies, and that program is no longer operating. I have seen instances
where they don't have anywhere for the baby to sleep, and either they have the baby in the
parental bed at night or during the day they're lying them on the couch and that sort of
thing. So I think that making sure that we're able to prevent some of these behaviors and
encourage and just have the where with all to make sure that families all have a safe place
for their babies to sleep would be one thing.
Again, we need the services to take care of the people. I dont know if you know this, but
the United States is 17th in the world population for bad outcomes for neonates, so theres a
whole lot of countries in Europe that are doing a lot better than we are.
Decreased funding.
Hospitals will always take care of babies, so there will never be a real threat to their survival,
the care can be very expensive but they will always take care of them.
Yes, I would say there is a threat because Maternity Support Services does a lot of the
education on that type of thing with the low-income population and [its] always at risk
because were a state program.
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Question 8: What are the specific skills required in the community of service providers to
address the high-need indicators? Do you feel your community possesses these skills?
The skills are, we want them to know motivational interviewing skills. I think that we need
doctors that are OB experts. We need, possibly, peer counselors or lactations consultants to
talk about breastfeeding, nutritionists, nutrition experts, behavioral health experts to talk
about postpartum mood disorders and depression during pregnancy, helping them to be
stable during pregnancy. We need dental providers to make sure that we have healthy teeth
going on during pregnancy. Parenting and others kids in the families, childcare. We could
use, definitely smoking cessation experts could be used with this population. People with
expertise in counseling in drug and alcohol abuse, community resource person to help make
referrals to different services, getting on insurance, food banks, stuff like that. Definitely we
want to hook them up with WIC if they're eligible, so WIC providers. I think that even it'd
be ideal too to have a fitness expert on the team too, if we're gonna talk about making a
team, someone to talk about physical activity during and after pregnancy. I think that's a
pretty good team there. I think we've got almost all of it. About 95%.
We have an ongoing program. ABCD in other counties is not that widespread. They have
specific target group they work with, they have not necessarily expanded to pregnant women.
But this is a great group to work with because you want to get those children before theyre born.
You want to talk to the parents, talk to the mother, about how to prevent oral disease. What
better way to do that, then start with the women prenatally? Those smart programs have jumped
on that bandwagon. The ones who are still kind of floating around, not quite sure where theyre
going with their program, havent yet. But here in Pierce County, weve addressed that issue.
I think we possess the skills, Im not sure we have the time to, based on financial cuts, the
people in the right place to be able to do that, theres no money for it. I mean it doesnt just
happen, you have to have someone working in that position.
We need NPs, Certified Nurse Midwives, OBGYNs, or Maternal-Fetal Medicine
specialists, and enough of them in the right areas to provide care for these people. We dont
have enough OB providers. Pierce County is short.
I think that in Pierce County, we do have lots and lots of women who access Planned
Parenthood, CareNet, some of those services that do offer free pregnancy testing. I think thats a
great doorway to services, because they will refer them to an OB or whatever resources they
want in the community. And so I think that is really helpful that they can get a free pregnancy
test and get introduced to the resources in the community. Also, once a woman has established
she is pregnant, DSHS will refer to our services at the Health Department, which are home
visiting services, and WIC, which will help encourage them to have a healthy pregnancy,
provide them with information and encourage them to have prenatal care. I think that theres
always room for improvement, we certainly dont get everyone. There are so many women who
dont get the care they need. But I think as a community, there are agencies that are trying to
address that and making it accessible. The first step is: they have got to find out if theyre
pregnant. If they can get free pregnancy testing, that helps a lot. Thats a really positive thing.
The agencies that do that and offer that, are really the first step and do provide a lot of resources.
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They could always improve. I really wish we could do more, and we have talked about as public
health nurses, is pregnancy prevention. Going into the high schools do more on educating
about it. We talk a lot about birth control, but most of our clients are already pregnant. So then
we talk a lot about spreading your pregnancies out, how to prevent the second pregnancy.
Theres always areas that we could definitely improve.
Yes, obviously the earlier that they start prenatal care, the better. But my guess is that if we
had more pregnancies that were intentional, that would be better too because, the most
important time in which some very critical development takes place before a lot of women
know that they're pregnant. So if they're planning pregnancies and starting to take prenatal
vitamins and changing their health behaviors, then that's obviously a good thing. And if
they're not getting any prenatal care until they're into the second trimester, then they've
missed a lot of the critical developmental time periods for many of the organ systems of
their baby. At the Health Department we have an outreach team which is doing very well in
terms of trying to connect pregnant women with services as early as possible, and I guess
some of that which young women need to know as soon as they find out that they're
pregnant, that that would be the time to start getting those services. In terms of how else to
make sure that they do that, I mean I think that doing some sort of outreach through sub
communities is a good idea. We have the Black Infant Health Program that goes to
churches, and we just need to get a lot of awareness, and then whether it comes through
what they're taught in school in their health programs and the classes that they do there (I
think there's a state requirement that all high school students do take health), I think that
making sure that that health curriculum really does fit with their lives, I think that would be
a way to impact that.
I think again, that again could use some education. Not only in my organization bur
everywhere about what causes them and how to encourage families to get their childrens
teeth cleaned, etc.
Our community does, because we have an active school program. It targets all children in
elementary schools. Some of the grants and the efforts on a national basis targets 6-8 year-olds.
Weve made it very clear in our program that it needs to be offered to all elementary children.
Our success is because we feel we need to offer it to all children. They come into the system at
different times. Ideally, you want to place those sealants in that 6-8 year-old periods, but thats
not always possible. As long as that tooth is eligible for a preventative sealant, we go ahead and
address that. We have a great effort in our community just by the mere fact we have our schools
program. We are going to try to increase services by getting other schools to participate. A future
goal is to get more schools in our community to participate to have that available to everyone. It
is available to everyone now, but to allow everyone to take advantage of it. A lot of these
providers have self-contained units, so they do not take up the space in the school. They park
right along side the school and children are escorted out to the vans. So theres no excuse to say
we dont have the space. And they do the case management of the children, send out permission
letters, through the schools. They do the busy work. A lot of schools cant say, Well I dont the
staff to devote to that. It basically requires one staff person to notify the teachers that the van
has arrived and stuff like that.
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As long as we have the ABCD program, WIC is working with us. We have a direct relationship
and partnership with WIC. The services are there, the ABCD program focuses on those kids.
I guess making sure that the families know that even though they are getting the WIC foods
that they know how they can use them. They only get a small amount of fruits and
vegetables and even the non-WIC foods is where they need to be putting their focus. And
then making sure that the mothers of those children know how to shop and how to prepare
the foods once they have them. And I guess making sure that they think it's important
enough that they feed their children nutritious foods and pay attention to their activity and
body composition, that too if they're getting regular check-ups. As far as providers
[possessing those skills], somewhat. There's probably more areas where they can gain skills.
I think theres a lot more education of staff that could be done on that, so that [patients] get
the same message over and over.
So we definitely need doctors to make sure they're healthy. We need behavioral health
counselors/specialists to talk about parenting and talking to kids. And we need nutritionists
to talk about balanced diets, healthy eating. We need people who are skilled in motivational
interviewing. We need to have fitness experts on staff to help with creating a plan for
movement. And I think that sounds good
No, they still need all of those services. [Your community possesses about 95% of the skills
to provide those services, correct?] Yes.
I think that there could be more training in that field for the people that are the first line
people. So that theres a personal contact for learning that information. But again with the
dollars, where theyre at, those trainings have gone away. They used to do them regularly at
the state but we dont have them anymore. So its just a phone call type of thing now and
none of the staff is now trained by them on how to make that happen.
It is certainly something as public health nurses, we are hounding them constantly. Well, we try
not to do that. But just a positive presence. This is something that any time you quit during your
pregnancy, it will be beneficial, so what can I do to help you do that or cut down. Home visiting
services are so positive in that there is a trusted person that this individual can talk to about
anything. Ideally, they go to their physician for their questions, but as hard as these doctors
work, they dont have time to sit down and chit-chat with these girls about every little thing.
Thats where we come in and they are able to have someone that they can, in confidence,
privately, one-on-one talk to someone about these issues. I think its way more successful then
just expecting these girls to be able to do it on their own. I think that support is really a good
thing. Of course, we only get a very small fraction of the pregnancy girls in our community.
Many of them get mixed messages. I think that the fact that theyre in prenatal care, and
someone is saying, Are you smoking? Are you drinking? What are you doing? They get that
health message. There are so many that get missed.
Our substance abuse program has a Moms program. We talk about a lot of things about oral
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health in the Moms program. I go quarterly and meet with this group of women. These are
women who are getting off of substance abuse. We talk about smoking, doing behaviors that are
detrimental to their oral health and their family. I have a relationship with our substance abuse
program and we do utilize our ability to go in and talk with these women about not doing a lot
of things that are detrimental.
I think we have the knowledge and the skills, I guess it's all to do helping those clients make
the right decisions. We do get training every so often from some part of the Health
Department, though I think we just lost our tobacco part of the Health Department in this
last go around of the cuts, so maybe that should come under one of the threats. If our
Health Department is no longer focused on tobacco use and smoking cessation, then that
might not be so good. It's all about trying to encourage behavioral change for smoking, and
you have to substitute other ways to reduce stress. I think there is skill enough, it's just
whether there's opportunity enough to connect. It's all related to having less and less time to
connect with these pregnant women so that we can feel that we're making an impact.
I think that they need specific skills on how to coach. Those same providers need education
on how to coach people effectively. I think just to say that somebody stopped smoking
doesnt exactly change that behavior, so what are some of the coaching skills that can be
developed or given to people that would enable them to be more effective. [Do you think
your community possesses those skills?] No. I dont. I know thereve been some programs
that have been trialed and theyve been trying to get people to do more smoking cessation,
but I think theres more to go.
Perinatal Mortality
Maternity Support Services (MSS) is geared towards trying to prevent prematurity and low
birth weight in infants, and I think one of the things that has been done is the hospitals have
all moved towards not having elective c-sections or delivering babies before 38 weeks, and
they've made quite an impact in that because we recognize that those last couple of weeks
really are very important. Because the Maternity Support Services program looks at the risk
factors related to that, and those risk factors are where we are supposed to concentrate our
efforts with the women that we see in that program. So the thing that maybe where more
focus could be would maybe be making sure that if that's the goal of the program that MSS
are more focused on those aspects of it where we can try to prevent those low birth weights
and premature births. When the delivery nurses say that they're trying to make sure that
babies stay in utero as long as possible that sometimes they've had difficulty in convincing
some of the obstetricians of that, so I'm sure there's always obstacles. But I know that they
have made a lot of advances there. I think that that's made a lot of progress, trying to make
sure that babies stay I utero as long as possible, given that there are instances where it's
important that they do get delivered prematurely, but they're focusing on making sure that
that only happens when it's absolutely necessary.
I think those skills are present.
We need to have the data and understand where we are in the county and what
improvements we need to make. [Do you feel your community possesses those skills?] Yes
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Again, ability to give effective prenatal care and also for them to know the resources,
because when you think about it some of the problems deal with homelessness and lack of
food as well. I think we need more resources. And the thing that were working on with the
health department and through a collaborative that we belong to is to provide cribs to
babies, because there are not enough cribs. So babies are co-sleeping or sleeping on the
floor, so the incidence of SIDS can go up with that population.
Question 9: Have you noticed greater disparities in the high-need indicators within certain
populations? Why do you think that is happening?
I guess some of it is related to access to healthcare because once some of our clients have
had their babies, that is the end of their access to healthcare, and they probably live a great
portion of their lives not thinking that they can access healthcare. So I think that health
disparities have a lot to do with their whole way of thinking about healthcare, and maybe
that's also part of what slows them down in making some initial contact. They don't have a
healthcare system that they're regularly receiving care after they get to a certain age and so
many of them are not covered by any insurance.
Well of course, decreased socioeconomic and homeless population definitely have the
higher incidence. Im not sure [why], it probably has something to do with education level
and stressors.
We are in those WIC programs, trying to make sure all the women that come through there to
try to get them access to all the services before their services run out.
Definitely. Certainly poverty contributes a lot to access, transportation. Smoking rates are way
higher in low-income areas of the county. Lack of education its very prevalent in certain
communities. We have targeted areas in the county that are highest risk for certain things. We
really try to have a concerted effort to reach the people in those communities. Part of it too, is
that the client has to be interested and willing to have the service. That is one thing about
targeted communities is that there is that peer thing, which helps. If somebody is receiving
services, and their friend gets pregnant, theyre more interested in getting services if theyre
referred by a friend. Its better than just getting a cold call from somebody at the health
department, which is a little bit sketchy. We do it, and we try all the time, but it is really helpful
to have those peer relationships. That specific targeting of certain areas, doing community
things. One of our nurses has a very successful group they do nutrition and social time. Its
really great for those girls to meet other girls that are their age, have babies, that whole
socialization. Certainly in those kind of groups, things like health messages, smoking are really
addressed. I think just that little bit of support can make a huge difference.
Yes there is a disparity. I would say the populations we see coming in later would be
Samoan and thats kind of a cultural thing. They just dont feel they need to be seen. Also
some populations of the Russian community. And then we also see it in drug abusers and
users. Well theyre on drugs, theyre strung out. So they dont do it, they just dont get it
done. Or they dont want to be found out. Or they know drug screens will be involved or
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some people that want to keep their child, they dont want to get caught, they just dont
bother to come in.
Oh yes. We notice that with the Afro-American population, the teen population, the Native
American Indian population. Well a lot of the time the teens are in denial and they dont
know where to go for support. The Afro-American population, Im not really sure. I dont
know if its lack of knowledge of where to go to get services. And the Native American
Indians, were trying to reach out to them, but thats kind of a challenge in this community.
I think thats pretty much across the board with low-income. I would say just being lowincome, lower educated and lack of transportation and having a lot of children, a lot of
times that causes disparity because they dont want to bring them all in and its a handful to
get a babysitter and you have 4-6 kids.
One of the greatest things about having a school-based dental program is that children who are
low-income and come from special populations can access dental care at the school, rather than
waiting on a parent, who either may not have a job that will not allow them to take their child
during the week for an appointment. We have parents in high socioeconomics that thing that
baby teeth will just fall out, so lets not worry about that. The ability to go into the school setting
evens the playing field related to health disparities, regardless. If theyre at school, then they
have the ability to utilize the service.
Yes I would say definitely Hispanic population would be higher BMI children. I believe I
touched on that before, they believe they have to feed both breast and bottle.
Again, if they're on WIC, they're low-income and low-income people have a much higher
incidence of obesity. But I don't know how that breaks down. I know in some cultures, a
chubby baby is a healthy baby and there may be more inclination to overfeed because they
think that's healthy, but I don't know what populations specifically, and whether that's won
out statistically or not. I guess other sorts of feeding practices of, maybe early introduction
of solid foods are inappropriate, or certain foods with infants. You know, like putting KoolAid in baby bottles and things like that, there's lots of ways that children can start off being
overweight and just keep going from there. And definitely breastfeeding has a lot to do with
that as well, and we are trying very hard to increase the incidence and duration of
breastfeeding because breastfeeding itself is more protective against latent development of
obesity, and I think WIC tries to do that. They're definitely encouraging more breastfeeding
and the duration. In some of the formulas the first product is corn syrup, so what they're
starting on is not the best nutrition, and they're continuing on from there.
I think that's also low-income people who are certainly more likely to be smoking in the
third trimester than people in higher income brackets that have more access to all of the
things in life. So yes, I think there's definitely disparities in that. Because we don't have
universal healthcare. I think if we had universal healthcare things would be a lot different,
but people don't have access to healthcare unless you have a job with benefits, and the
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population that we're seeing, the high-risk population, we've seen all that with the disparities
that depending on what zip code they live in and their background, that the disparities are
huge. And I'm hopeful that the healthcare reform has included a lot of access for screening
and well-woman checks, that hopefully that might make an improvement in it.
and stressors.
Thats a little bit across everybody. It doesnt seem to be as specific although drug abusers
many times are also smokers. Its kind of the same thing I said for them except for that it
seems to go further than just that population. Its kind of across the board, if youre a
smoker, no matter what population youre in you might have a hard time quitting or not
wanting to. Well theres a lot of studies out there that says the African American population
has a higher rate of prematurity and morbidity and mortality. I would say we do see that as
well. I would say a lot of the groups are at risk of it more than others, just because of their
disbelief that can affect their pregnancy. Like for example diabetes. The disbelief that they
have it or that it would hurt something.
Not really, there are a lot of obese women in this country, and high smoking rates. A lot of
women will cut down on smoking to 2-3 cigarettes per day, which is better than a pack.
Socioeconomic issues play a part as well, people moms hang out with who are of lower
SES, who smoke, have a poor diet all effect the pregnant mom. If they have a diet high in
fast foods, tons of carbs, which are addictive! Carbs lead to an increased insulin level, which
leads to an increased blood sugar level, which leads to increase in fat retention and weight
gain. Education is a real problem too, people are addicted to these things, and its hard to
quit. Especially if family, friends, boyfriends who live this lifestyle would quit too, it would
be much easier for the mom.
The less-educated people tend to smoke more. And by that, I mean maybe they havent
completed high school, or are still in high school. It appears that the higher socioeconomic
and higher educated people smoke less. I think its a culture thing. Within those cultures,
smoking is acceptable.
Perinatal Mortality
I think there's not the numbers there. Well actually, it is known that there is a much higher
rate of prematurity and low birth weight in African Americans, much much higher than in
white populations, so it's a huge disparity in perinatal mortality. Well, that happens even in
some areas where African Americans have good access to healthcare and good social
conditions, they still have a higher rate of perinatal mortality and low birth weight, all things
that go around with perinatality. I don't think anybody knows the answer to that at this
point.
Well yes, with the drug using population for sure. We also have higher incidence with
people who have high blood pressure, and we know that high blood pressure is common in
the Afro-American and Hispanic populations. Well, theyve got uncontrolled high blood
67
pressure, and also a high incidence of diabetes, so we have more bad outcomes in those
patient populations.
and stressors.
Question 10: Are there any other high-risk areas that havent been identified which need
attention
No, not really. I just think that, maybe our teenagers could benefit from some... I think a lot
of the teens are having trouble with antisocial and depressive types of behaviors, it's really
hard to get teenagers to do any form of counseling or group work, so its difficult to get them
to get help.
Well, I mean we just discussed breastfeeding, and I think there is certainly, all the way
down from the national level, there's a lot more backing toward encouraging that, and I
think that's really important in long-term health in many ways. Also, I would say that for
me, I have an interest in vitamin D and we live in an area where we don't get sufficient
sunshine for many months of the year and even when we do, people aren't outside, and I
think if we focused on some of those behaviors that we might be able to be healthier as a
public health measure as well. I believe in that.
There is a noticeable increase in Pot smoking over the last year. We need to do more
focused education that pot smoke is not as harmless as they think. When you ask if they
smoke, they say yes, but when you ask about tobacco, they say oh I dont smoke tobacco.
We really need to be delving in further to clarify, they think this is smoking.
Those are all really valid and I think theyre probably the highest risk, I think those are
really valid populations to look at as far as needs go and where to start. I think there are lots
of high-risk behaviors and high-risk patients out there, but I dont know, Theyve chosen the
correct populations to focus on.
I do think that pregnancy prevention would be an area we could really direct some efforts to.
Whether in high schools or in communities. Certainly the State of Washington provides free
birth control to anybody who wants it, so its not like they cant get it. But access, education,
helping especially young, low-income people identify the consequences of having a child
early. Many of them do beautifully, but it still is a huge challenge. I would like to see some
efforts directed at that. Im not sure where that would start or what that would look like, but
going down that road.
How about High BMI for mothers, pregnant mamas? Thats huge. Right now, were having
women that are pregnant that are 50 BMI and higher and theres a lot of morbidity that goes
along with that as well that people dont realize that they can affect the baby theyre
carrying by being obese themselves. [We are seeing it] more and more frequently. We do a
really good job screening for it, but I think the rates of diabetes are going up and thats
probably related to the obesity rate as well.
68
[Adults, aged 20-64] They need to address the inequities, disparities, the fact that they are not
addressing that part of the population that cannot access anything. Its a large group, an ignored
group. As a community, we need to do a better job. Its the adult population thats just dangling.
I tell everybody: if you have a heart attack on the street, theyd take you to the hospital. If you
wake up in the middle of the night with a toothache, they dont do anything for you. You go to
the emergency room, and that is not a place where people can get treatment. They can get
antibiotics to calm the pain down until it resurfaces, and it will resurface if you dont get it
treated. Some people have resources, but resources are dwindling. Theres no reason in the
world we should have a community that has to go to King County for emergency services. I
think its a travesty that were not paying attention to that, and that theres no services for that
community, and its a big one. King County has 14 health departments that can take care of
adults, and they also have a couple of free clinics, and we dont have any. I tell them to go over
to King. Thats really my only thing.
I think we need to focus more on working cross-divisionally in the department. My issues need
to be issues for the folks in Physical Activity & Nutrition, Communicable Disease, we all need to
look at what we do cross-divisionally and work together to address the issues youre pulling out
children with high BMIs and women who smoke still during their pregnancies. Maybe more
work cross-divisionally with the medical community as well.
69
References
References Used to Develop Assessment Approach
Community Based Action Participatory Research, Chapter 36, Section 2, & Qualitative
Methods to assess community issues, Chapter 3, Section 15
Core MCH pyramid of services (HRSA, Maternal and Child Health Bureau, California, 20112015 Title V Needs Assessment, Background and Methods (Excerpt)
Fine, A. & Kotelchuk, M. (2010) Rethinking MCH: The life course model as an organizing
framework. US Department of Health and Human Services, Health Resources and
Services Administration. Retrieved from: www.hrsa.gov/ourstories/mchb75th/images/rethinkingmch.pdf Stage 1: Conducting a community assessment
http://nnlm.gov/evaluation/guide/stage1.pdf
Gandelman, A., DeSantis, L., & Reitmeijer, C. (2006). Assessing community needs and agency
capacity -- an integral part of implementing effective evidence-based interventions. AIDS
Education & Prevention, 18(4), 32-43.
Goodman, R., Speers, M., McLeroy, K., Fawcett, S., Kegler, M., Parker, E., & ... Wallerstein,
N. (1998). Identifying and defining the dimensions of community capacity to provide a
basis for measurement. Health Education & Behavior, 25(3), 258-278.
Grason, H & Gruyer, B. (1995) Public MCH program functions framework: Essential public
health services to promote maternal and child health in America. Retrieved from:
www.jhsph.edu/...childrens-health.../publications/pubmchfx.pdf
Health Resources and Services Administration (2004) Promising Practices in MCH Needs
Assessment: A Guide Based on a National Study. Retrieved from:
mchb.hrsa.gov/publications/needsassessdec2004.pdf
Lu, M. & Halfon, N. (2003) Racial and ethnic disparities in birth outcomes: A life course
perspective. Maternal and Child Health Journal, 7(1), 12-30.
References Used to Analyze Assessment Findings
Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research:
concepts, procedures and measures to achieve trustworthiness. Nurse education today,
24(2), 105-112.
70

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A Technical Report

Children with Dental

Maternal-Child Health Pyramid of Services

The MCHB defines each dimension as follows:

Accessibility. Access to services or resources may be assessed using indicators:

Quality. Quality of services may be assessed using both quantitative and

Affordability. For the assessment of direct and enabling services, affordability of

Stakeholder Frequency of Contact with High-Needs Areas in Current Position

Pregnant Women Seeking Prenatal Care after the 1st Trimester

Appendix A: Tacoma-Pierce County Health Assessment Project Brief

Brief Description: University of Washington School of Nursing graduate students in

Appendix B: Assessment Timeline

4/2/13 4/12/13 4/22/13 5/2/13 5/12/13 5/22/13 6/1/13 6/11/13

Appendix C: Interview Contact Protocol

Appendix D: Scripts for Recruitment of Potential Interviewees

Follow up Phone Call

Follow up Email (Attach Original Email To This One)

Appendix E: Interview Question Table & List

MCH Assessment Question

What are the gaps in

Have you noticed greater

Thinking about the

Question From Previous

What major emerging issues

Of the populations you are

Based on your experiences

Are there specific subgroups

How could the resources of

What are the specific skills

6-8 year-olds with dental

Frequent weekly or more often

Pregnant women entering

Frequent weekly or more often

Pregnant women smoking

2-5 children on WIC with

Frequent weekly or more often

Part III: Services for High-Needs Areas

Part IV: Disparities in High-Needs Areas

Appendix F: Assessment Data Analysis Guide

Read transcripts of eight interviews

Data Analysis Summary

Descriptive statistics (frequency counts, mean and averages)

Coding of Responses & Content Analysis

Graneheim & Lundman, 2003

Appendix G: Content Analysis Coding Table

Appendix H: Raw Assessment Data

Women Smoking the 3rd Trimester

I dont think I see any change there.

Children in WIC with High BMIs

Question 7: What are the future threats to these services?

Children in WIC with High BMIs

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