Pend Oreille County (pronounced pahn-duh-RAY) has a population of about 12,000 people and covers an area of 1,425 miles of forest, tall mountains and valleys (25,7). The region is rich in natural wildlife and game. There are only 5 relatively small towns with populations of 150-450 people and one city in the county. The largest community within the county is the city of Newport located next to the Idaho border in the SE corner of the county with a population of roughly 2000 people (25). All of the towns sit along the Pend Oreille River and follow the only highway, State Road 20 which travels from Idaho in the SW corner of the county north to the Canadian border.
Three larger towns, Metaline Falls (population 223), Metaline (population 162) and Ione (population 479), are in the northern end of the county and are separated from essentially everywhere else by Colville and Kaniksu National Forests, large mountains long distances to larger cities. It is a minimum of a 90 minute drive to the nearest large town with adequate medical services which would be Newport. The wood pulp, hay and cattle producing communities of Cusick and Usk have a combined population of 212 and share the area with the counties only Indian population, the Kalispel Tribe of Indians who raise buffalo as one of their industries (25). The city of Newport is home to the counties only hospital, the 74 bed Trauma Level IV Newport Community Hospital (27). There is also a 42 bed assisted living complex and a 50 bed skilled nursing facility in the city (27). There are two hospitals, Mount Carmel Hospital (33 bed) and Saint Joseph's Hospital (65 bed) in neighboring Stevens county to the West however they are equally or more distant and require travel over high mountains (15). All three hospitals provide only basic neonatal and prenatal care according to the Washington Department of Health (11).
The county is designated primarily as “small town and isolated rural” per the Washington State Department of Health Dominant RUCA code while the southern one third is designated as “suburban” (1). Pend Oreille is part of the Northeast Tri County Health District which includes Ferry, Stevens and Pend Oreille counties (3). Health data is commonly combined for these three counties which can make it a challenge to separate the nuances to a specific county in some cases. The county has a predominantly Caucasian population (93.5%) with a median age of 41.9 years and a density of 8.4 people per square mile according to the U.S. Census Bureau 2000 survey (2, 7). A total of 16.2% of the population is over 65 years of age which compares to a national average of 12.4%.
Within this county ethnicity does not appear to be an issue, at least as is reflected in the statistical and published information available. The opposite side of the coin could be that ethnic peoples are made so unwelcome that they do not stay but no substantiating or refuting information could be located. No reports of ethnic violence were found. There are very few ethnic minorities within the region with the exception of one local Indian tribe which make up 3% of the population (7). The only native Indian tribe in Pend Oreille is the Kalispel Tribe of Indians on the Kalispel reservation (16). There is a small Indian medical and dental clinic available to the tribe on the reservation 4 days a week for basic services but no emergency services (17). The Kalispel Tribe of Indians gains some of its support from the Northern Quest Resort and Casino outside the city of Spokane. They also have an industries that include the sale of buffalo meat, the manufacture of shotguns and specialty aluminum cases and Petroglyph Printing and Signs (18, 25).
The median household income, at $39,352 is well below the national average and the state average of $55,628 (7). Furthermore 15.9 % of county residents are below the poverty level (7). One striking statistic is that 83.3% of families with a female householder and no husband present are below the poverty level (6). Unemployment is high (#6 highest) and above Washington state and almost all county averages (20). This data suggests that low income and poverty is an issue for many in the county particularly single women with children in the home. Even those who are working are not likely to be able to afford health insurance if it offered and as a result may not seek health care in a timely manner. Image source: http://www.cartoonstock.com/newscartoons/cartoonists/for/lowres/forn371l.jpg
One third of the households have children in the home which make up 21% of the total county population (2, 7). Child abuse in homes is more than two and a half times higher compared to similar counties (8). Childhood Unintentional Injury hospitalizations is 33% higher compared to state levels (10). The U. S. Census Bureau reports that 5% of homes in the county have inadequate or absent kitchen, toileting or heating (4). A total of 81% of adults over 25 finished high school and 19% did not finish (5). Only 12.3% of the population obtained a bachelors degree or higher (5). The combination of very high child abuse statistics and high child injury/ hospitalizations indicate a substantial health and safety risk to the child in every third home. According to the Office on Child Abuse and Neglect, “poverty, lack of social support, social isolation, unemployment and high stress levels” are all factors that increase the risk of child abuse within the home setting (18chp5). Furthermore, child abuse is twice as likely in single parent households, particularly for younger children (18chp5). Poverty and high stress become a truly significant concern that requires addressing within this county when 25% of two parent families and 83% of female parent families with children under 5 years of age living below the poverty line (654 families in 1998) (6).
According to the Washington State Population Survey of 2008, 13.1% of Pend Oreille residents are without health insurance (23). The uninsured statistics can be broken down in various ways and results in some interesting variations. In husband – wife families the uninsured rate is 11.4% whereas in ‘other’ family households the rate was 21%. These numbers mean female head of households have nearly double the uninsured rate of traditional households. This is significant in that research shows that those who are uninsured tend to die sooner, get too little care too late, and get poorer quality care when they do get care (24). Furthermore, these are the same homes where high stress and poverty are causal factors in child abuse.
Smoking and physical activity are a little higher than Washington state and US averages but obesity, fruit/ vegetable consumption, binge drinking, diabetes and mental health are comparable to the rest of the state and US (3). DSHS statistics show that tobacco, alcohol, and crime are not significant issues overall compared to similar counties (8). Teen pregnancy was also low compared to the state and US levels (10). Maternal smoking is nearly 2.5 times the state and US averages (10). Maternal smoking and smoking within the household, especially by the father are issues that clearly affect the health of the coming baby in addition to the health of everyone within the home. The health risks of smoking are well documented. More education and research will be needed to address this health concern.
Access to health care is a little low but fairly close to state and US averages according to the Washington State Department of Social and Health Services (9). There is one 74 bed hospital (Newport Community Hospital) in the south end of the county on the Border of Idaho. Two hospitals, Mount Camel (33 bed) and Saint Joseph’s (65 bed), are in neighboring Stevens county but they too serve the middle and south end of Stevens county (15). All three hospitals (Newport, Mt. Camel, & St. Joseph) provide only basic perinatal and neonatal care (11). Two thirds of the county has a >30 minute drive and three quarters of the county have a >20 minute drive to the nearest acute care hospital (12). Clearly, distance is an issue for a major portion of the county.
All of Pend Oreille County is designated by the Washington Department of Health as ‘Geographic’ which means all county residents have trouble getting health care services (26). Pend Oreille is a federally designated Health Professional Shortage Area (HPSA) for Primary Care, Mental Health and Dental Care (13). Medically Underserved Area (MUA) scores of 15 for Primary Care, 11 for Mental Health Care and 10 for Dental Care are all very low on the 0-100 scale (13, 19). These scores implicate that the county is in need of more health care providers in all three areas due to the geographic limitations of isolation from any major metropolitan areas. The county is designated by the Washington State Department of Health as both a Physician Scarcity Area and a Specialty Scarcity Area by the Washington Department of Health (14). Both of these Scarcity Area types of rural designations implicate that the county has an inadequate number or physicians and specialists to meet the needs of the population.
It appears that the most pressing issues for Pend Oreille that directly affect health and well being include lack of medical providers, unemployment, low incomes, child abuse in the homes and distance to/ lack of quality health care services. Low education levels, remoteness and lack of significant industry are likely contributing factors in the poor incomes within the county. The lack of inward migration of new business and people will also hinder the opportunities for economic growth and improved health opportunities. The shortage of primary, dental and mental health care providers in the area, particularly in the northern half of the county is unlikely to improve without assistance given the lack of growth within the county.
The Positive Parenting Program (Triple P) an evidence-based program funded by the Centers for Disease Control and Prevention (CDC). This is a population based care model that has shown good effectiveness in its results. The goal of Triple P is “to prevent behavioral, emotional and developmental problems in children by enhancing the knowledge, skills and confidence of parents” (28).
The basis for the Triple P program model is the study ‘Population-Based Prevention of Child Maltreatment: The U.S. Triple P System Population Trial’ which was published January 22, 2009 in the journal Prevention Science. This randomized study of 18 counties had a control group of status quo services and a group which received ‘dissemination’. Dissemination consisted of professional training to health care providers in addition to “universal media and communication strategies”. Because “this study is the first to randomize geographical areas and show preventive impact on child maltreatment at a population level using evidence-based parenting interventions” it has the best opportunity to demonstrate valid effectiveness of the interventions.
Poor financial resources limit the expenditure availability within the county. Making use of the limited medical resources already present would combine low resource expenditure with maximal community contact since alternate health care options are not readily available. A reduction in the large rates of abuse and injuries should result in a reduction in costs to the community in the form of unpaid medical bills, reduced law enforcement/ judicial system expenses, reduced mental health service needs, reduced child-out-of-home placements and a healthier long term community. With the well documented trend of abuse perpetuation within abusive homes, the long term benefits have the potential to be substantial and can readily justify the expense of implementing a program. Given the remoteness of the region, parental teaching programs for medical providers could be provided via the Internet, mailed CD materials, webcasts or teleconferencing. In house training could be supplied to large provider groups such as in the hospital and larger clinics.
Image source: Washington State Department of Health.
Pend Oreille County
Pend Oreille County
A Community Health Improvement
Map source: http://pendoreilleco.org/photos/map.gif
Some Background On Pend Oreille
(pronounced pahn-duh-RAY) County
• Population of about 12,000.
• Area of 1,425 miles.
• Rich in natural beauty, wildlife.
• Largest community (Newport)
has population of roughly 2000.
• Only one major highway (State
Road 20) which parallels the
Pend Oreille River.
• All the larger towns follow this
Images copyright of the Kalispel Tribe
Some Statistics of
•Median household income:
(national average: $55,628).
•15.9% of county residents
below poverty level.
•83.3% of families with a
female householder with no
husband are below poverty
•Unemployment 6th highest in
What it means…
Poverty is an issue that
will affect health.
Particularly for women
• Every third household has a child.
• Child abuse is 2.5 X higher than similar
• Childhood unintentional injuries 33%
higher than state levels.
• “Poverty, lack of social support, social
isolation, unemployment and high
stress levels” are all factors that
increase the risk of child abuse within
the home setting per the Office of Child
Abuse & Neglect.
• Poverty and high stress become a truly
significant concern that requires
addressing within this county when
25% of two parent families and 83% of
female parent families with children
under 5 years of age living below the
poverty line (654 families in 1998)
• 13.1% of residents have no
• Female head of households
have nearly double the
uninsured rate (21%) than
Significance: Uninsured tend to
die sooner, get too little care
too late and get poorer
quality care when the do get
The Statistics on
Other Common Health Issues
Statistics as Compared to State & U.S. Averages
Comparable Higher Lower
Obesity Maternal Smoking
(2.5 X State & U.S. levels)
Physical Activity Alcohol
Binge drinking Crime
Access To Healthcare
• Access low
• One 74 bed hospital in SE
corner of the county
• Two smaller hospitals in
neighboring Stevens county
(also serve middle & south end)
• Only basic prenatal & neonatal
• 2/3 of county have >30 minute
drive to nearest acute care
Indicators of Health Care Needs
MUA score of 62.0 or less qualifies for designation as an MUA.
Summary of Health Issues for
Pend Oreille County
• Low income
• Poverty, especially female
head of households with
• Isolation/ distance from
health care services
• Low education
• Child abuse
• Lack of health insurance
• Maternal smoking
• Isolated elderly
• Lack of primary and
specialty care providers
A CDC funded evidence and population based model that
has a successful track record.
Their goal is “to prevent behavioral, emotional and
developmental problems in children by enhancing the
knowledge, skills and confidence of parents”.
Provides professional training to health care providers
and also uses the media to communicate teaching.
Positive Parenting Program (Triple P)
Why Use It?
• Populations used were statistically very similar to Pend Oreille county.
• Program uses existing in-place systems/ services/ providers.
• Had good measurable track-able quantifiers.
• Attempted to rule out any pre-study trends over the five years prior to the
interventions to validate results.
• Large statistically significant outcomes.
• Monitored child injuries in addition to confirmed reports of child abuse.
• Affects key points of intervention opportunities
(hospital, ERs, ambulance workers, schools).
• Uses a variety of methods to disseminate information useful to rural
Why Use This System
for Pend Oreille?
Makes use of existing health care
Low resource expenditure
Maximal community contact
Reduces community costs (unpaid
medical bills, law enforcement/
judicial, mental health)
Healthier long term community
Long term multigenerational
Some Interesting Resources
• Children’s Bureau, U. S. Department of Health and Human Services – Ample information
here from the government.
• Child Welfare League of America – Mission: CWLA will lead the nation in building public
will to ensure safety, permanence, and well-being of children, youth, and their families by
advancing public policy, defining and promoting practice excellence and delivering superior
membership services. Vision: Our vision is that every child will grow up in a safe, loving,
and stable family. Focus: Our focus is children and youth who may have experienced abuse,
neglect, family disruption, or a range of other factors that jeopardize their safety,
permanence, or well-being. CWLA also focuses on the families, caregivers, and the
communities that care for and support these children.
• Circle of Parents – Mission Statement: Prevent child abuse and neglect and strengthen
families through mutual self-help parent support groups.
• Council for Children & Families Washington (also called the Washington Council for
Prevention of Child Abuse and Neglect) – A federally based grant program. Our Mission: To
promote the optimal development of children and families by leading Washington state in
its efforts to prevent child abuse and neglect.
• Friends: National Resource Center for Community-Based Child Abuse Prevention – A good
source of training material. Provides monthly teleconferences, data archives, grant seeking
advice and .
• Healthy Families America – A program that focuses on getting trained staff into homes for
home visits that focus on teaching families parenting skills. Has good success statistics.
• National Alliance of Children’s Trust and Prevention Funds – Mission: Initiate and engage in
national efforts that help State Children’s Trust and Prevention Funds in strengthening
families to prevent child abuse and neglect. Promote and support a system of services,
laws, practices and attitudes that supports families by enabling them to provide their
children with safe, healthy and nurturing childhoods.
• 1) Washington State Department of Health, (2007, July 10). Rural and Urban Commuting
Areas, 2006. Retrieved July 12, 2009, from DOH, Division of Resource Management,
Geographic Information Systems Web site: http://ww4.doh.wa.gov/gis/pdf/ruca_zip_06.pdf
• 2) U. S. Census Bureau; DP-1 Profile of General Demographic Characteristics: 2000
• 3) Washington State Local Public Health Indicators, NE Tri-County Health District,
Prevention and Health Promotion http://www.doh.wa.gov/phip/khi/lphi/lhj/ne-tri/hp.htm
• 4) U.S. Census Bureau; DP-5 Housing Characteristics: 1990
• 5) U.S. Census Bureau; DP-2 Profile of Selected Social Characteristics: 2000
• 6) U.S. Census Bureau; DP-3 Profile of Selected Economic Characteristics: 2000
• 7) U.S. Census Bureau; State & County Quick Facts, Pend Oreille County, Washington
• 8) Risk and Protection Profile for Substance Abuse Prevention in Pend Oreille County
• 9) Washington State Local Public Health Indicators, NE Tri-County Health District, Access to
• 10) Washington State Local Public Health Indicators, NE Tri-County Health District, Maternal and
Child Health http://www.doh.wa.gov/phip/khi/lphi/lhj/ne-tri/mch.htm
• 11) Washington Department of Health, Geographic Information Systems, Access to Hospital-
Based Perinatal and Neonatal Care, 2006 http://ww4.doh.wa.gov/gis/pdf/neon_tt.pdf
• 12) Washington Department of Health, Geographic Information Systems, 30 Min. Drive Times
from Acute Care Hospitals http://ww4.doh.wa.gov/gis/pdf/acute_tt.pdf
• 13) Washington Department of Health, Geographic Information Systems, Mental Health Care
Shortage Areas http://ww4.doh.wa.gov/gis/pdf/primary.pdf,
• 14) Washington Department of Health, Geographic Information Systems, Physician Scarcity
• 15) Washington Department of Health, Geographic Information Systems, Critical Access Hospitals
and Bed Capacity http://ww4.doh.wa.gov/gis/pdf/hosp_list.pdf
• 16) Washington Department of Health, Geographic Information Systems, Local Health
Jurisdictions and Indian Reservations http://ww4.doh.wa.gov/gis/pdf/lhj-ind.pdf
• 17 ) Kalispel Tribe of Indians home page http://www.kalispeltribe.com/camas-center-medical-
• 18) U.S. Department of Health and Human Services, Child Welfare Information
• 19) U.S. Department of Health and Human Services, Find Shortage Areas: HPSA by State &
• 20) U.S. Census Bureau; State & County Quick Facts, Washington by County
• 21) State of Washington Department of Ecology, http://www.ecy.wa.gov/programs/wq/tmdl
• 22) Bench, Dan W. (2002, October 30). PCBS, Mining, And Water Pollution.
• 23) Washington State Population Survey 2008 http://wa-state-ofm.us/SPSOnline/index.cfm
• 24) Care Without Coverage: Too Little, Too
• Institute of Medicine, May 2002.
• 25) Pend Oreille County web page http://pendoreilleco.org/about/
• 26) Washington State Department of Health (2009). Rural Health Programs: health professional
shortage areas and medically underserved areas. Retrieved [July 7,2009]:
• 27) Newport Health and Hospital Services http://www.phd1.org/Services.htm