ZOIE CLIFT

Sometimes getting an F on a report card is a very good thing.

If, rather than discouraging the student, that F translates into a renewed focus on improvement, it’s arguably a great catalyst for change. Such is the case with Arkansas’ women’s health services.

Last fall, Arkansas received a failing mark in a national women’s health study showcasing many of the challenging health issues affecting women in the state. Now, the medical community is taking an honest look at those challenges and what can be done to improve that grade in the future.

The report, released by the National Women’s Law Center along with Oregon Health & Science University, looked at 27 measures of women’s health, ranging from the rates of routine screening tests for breast and colon cancer to obesity and access to healthcare.

It was the first-ever report card to assess the overall health of women at the national and state levels. The benchmarks were based on the U.S. Department of Health and Human Services’ Healthy People 2010 initiative. While women’s health status varied greatly by state, overall the nation’s grade was “unsatisfactory” and no state received a passing grade.

Twelve states failed outright, including Arkansas, which ranked low in health insurance, healthcare access (especially rural women) and failed down the lines in terms of screening and preventive measures.

The report spurred discussions statewide about the root of these challenges the medical community faces and what physicians, hospitals and healthcare professionals can do to improve Arkansas women’s health services.

A Chronic Challenge
A strong challenge is chronic diseases.
“Many more women die of chronic illness than any other cause,” said Dr. Richard R. Nugent, chief of the Family Health Branch, Center for Health Advancement, Arkansas Department of Health. “Heart disease, cancer and stroke top the list, as for men.”

According to Nugent, all these chronic diseases as causes of death, have identifiable health risk factors that can be addressed preventively. The list includes obesity, tobacco use, diabetes, and hypertension. Arthritis, while it is not so strongly associated with death, nevertheless leads to severe disabilities and institutional care.

Dr. Martha Phillips, an assistant professor in the UAMS Colleges of Medicine (Department of Psychiatry) and Public Health (Department of Epidemiology) said women also present different symptoms for heart disease than men.

“There isn’t the ‘crushing heart pain’ that most might associate with it, but more pain in the back, neck, shoulders, flu-like symptoms,” she said, “which are notorious for being perhaps easy to excuse. When women complain about these symptoms in general, sometimes it is attributed to stress or hormones versus going through the battery of tests that men do.”

Nugent said a path forward is to invest in women’s health since women frequently are the caregivers for the family and are the first role model for good health behaviors for their children.

“We need to help women develop their health literacy and skills, so they can obtain the information they need and apply it to their lives,” he said. As an example, Nugent suggested teaching women to ask three questions of their healthcare providers: What is the diagnosis?; What is the treatment?; and how to apply the information learned.

He stressed the importance of physicians becoming familiar with data on women’s health and emphasizing prevention. Highly effective but basic efforts primary care providers can make include addressing obesity through improving nutrition and increasing physical activity; enhancing screening for breast, cervical and colorectal cancer, diabetes and osteoporosis; and recognizing and treating arthritis because it causes important disabilities.

“It’s always good to remember that the primary motivator for healthcare behavior is a doctor telling you (that) you need to do it,” said Phillips. “We need to pay more attention to keeping healthy people healthy. Part of the solution is to prevent disease and then ensure people have high quality care once they get sick.”

Covering the Rural and Uninsured
Funding for, and access to healthcare are also ongoing issues in the state.
“Despite most people’s understanding, the majority of young women in Arkansas do not have adequate healthcare coverage,” said Dr. Curtis Lowery, chairman of the Department of Obstetrics and Gynecology at UAMS. “During pregnancy, 63 percent of all deliveries are covered by Medicaid. Within the first six weeks after delivery, this universal healthcare is revoked, leaving the majority of women older than 18 without private insurance coverage uncovered.”

Lowery said an example of this problem is seen in colposcopies. Medicaid covers women for family planning, allowing them consultations and to receive yearly pap smears; however, there exists no mechanism in this program to deal with patients with abnormal pap smears.

Another problem, he said, is the shortage of obstetrical and gynecological providers in rural areas. This is particularly acute with healthcare coverage for obstetrical patients because of increased fears of litigation.

According to Lowery, fewer hospitals and rural healthcare providers are providing obstetrical care to patients around the state. While the public health department has stepped up to cover prenatal visits in many of these places, delivery support is lacking in many of the counties of the state and some obstetrical facilities are actually closing within Arkansas, as seen in DeQueen.
“While the needs for these services are great, it is also costly and complicated for small, rural hospitals to deliver obstetrical services,” Lowery said.
“Arkansas is blanketed in rurality. Therefore, the healthcare shortage is felt as an even greater challenge in these rural areas where subspecialty care is scarce to non-existent.”

Nugent said access to healthcare can be enhanced by extending physicians’ capacities via nurse practitioners and physicians’ assistants. Also, health literacy and skills development can be provided by other helpers like nurses, social workers and health educators who can help a woman assess her health risks and plan preventive life-style changes, and can recognize the need for and make referrals to their healthcare providers.

A Community Solution
“Nationally, there is a great deal of conversation about the notions of care coordination (family planning and maternity) leading to more widespread application of preconception and inter-pregnancy health counseling,” Nugent said. “School nurses and teachers can add to healthcare and literacy for children in schools.”

Another factor to hone in on is social determinates of health across the state.
“It is important to be aware of the huge dichotomy in health outcomes in women, particularly among minority patients around our state, the Delta, and the South,” said Lowery. “These healthcare disparities are huge, resulting in significant differences in mortality and morbidity in these patients.

“While we have taken an aggressive approach to healthcare delivery in Arkansas’ children, we have not invested as much time and resources in providing preventative healthcare maintenance and other healthcare to women who are not currently pregnant…Our focus should steer attention to preventative healthcare in women, doing everything we can to keep individuals healthy throughout their lives, young or old,” said Lowery.

According to Nugent, the role of the community is critical in enhancing public awareness and spreading health literacy among its residents. Health insurance coverage for all women would both enhance access to care and better distribute the costs. Looking at the healthcare system itself can lead to better access, improved quality, and reduced costs.

He added that women experience great disparities in health status among racial, ethnic and economic subgroups, and that addressing these differences requires cultural competence in the provision of healthcare and health education.



May 2008