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U.S. DEPARTMENT OF STATE
August 1994 US Report to UN on Status of Women 1985-1994
GLOBAL CONFERENCE SECRETARIAT
[Section 3 of 5]
Few statistics about women reveal as much about their place in the
economy as income data. The economic position of women is considerably
lower than that of men, despite unprecedented change. At all age
groups, women have higher poverty rates than men. Two-thirds of the
poor female population in 1989 were either 18 years old, and under (34%)
or 65 years old and over (13%).
In 1992, median family income for families with a female head of
household was $18,587, significantly less than the median family income
for married-couple families ($42,140). Families maintained by a woman
with children under 18 years of age had a poverty rate of 45.7% in 1992
and accounted for nearly half of all poor families with children. In
1992, 31% of female heads of families with children worked but the
family remained poor. Almost 22% of female household heads who worked
full-year, full-time remained poor. A contributing factor to the high
poverty rates of female headed households is the lack of child support
being paid by the noncustodial parent. In 1989, only 51% of women due
child support received the full amount; 24% received partial payment;
25% received nothing. Since the mid-1960's, even with major changes in
the economy over this period, there has been relatively little change in
the poverty rates for families maintained by women.
Not only is the poverty rate of families maintained by women much higher
than for other families, the rate for African American female heads of
households is higher than their white counterparts. Thirty-one percent
of American Indian families, 26% of Eskimo families, and 26% of Aleut
families were maintained by a female head of household for an overall
average of 27% in 1990. Half, 50%, of these families live in poverty.
The largest difference between the poverty rates for females and males
occurred among the oldest segments of the population; the rate for
females 75 years old and over was 17.3% compared with 10.1% for males.
Nearly 1 in 5 older women lived in poverty or near poverty in 1990.
Among elderly women of color, 38% of African Americans and 25% of
Hispanics were poor.
Women comprise 60% of today's 65 plus population. By the year 2000, it
is expected that there will be five women for every two men over the age
of 75. Almost three-quarters of elderly persons living below the
poverty line are women -- in 1990, 2.7 million women age 65 and over had
incomes below the poverty level. Older women tend to be at a
disadvantage with respect to income security for a variety of reasons,
including lower paying jobs, disrupted work patterns due to caregiving
responsibilities, employment that does not provide pension coverage,
higher health costs due to longevity, and relatively more disabilities,
and sex discrimination in insurance and pensions. All of these factors
point towards lower retirement income for women.
The invaluable contributions of women as caregivers for children,
spouses, parents, other relatives and friends often go unrecognized.
Many elderly women face disadvantages in our society due to
discrimination, both because of their age and their sex. Inequities in
employment opportunities that women have to face at every age become
magnified in old age. Women of color are at even greater risk of age
discrimination. Elderly minority women are two to three times more
likely to be poor and in poor health than white women.
According to a recent research report, while the relative economic
status of elderly married couples in the U.S. is better than in any
other country studied, the status of single elderly women is almost the
worst. The difference between the low income rates of single elderly
women and elderly couples is larger in the U.S. than in any other
The HHS Initiative on Older Women will focus on the many contributions
of older women and will develop an action agenda for addressing their
needs in critical areas including income security, health care, domestic
violence/elder abuse prevention, housing, and caregiving.
Despite the tendency for women to delay childbearing, the United States
ranks first among industrialized nations for its rate of teenage
pregnancy. The consequences of living in poverty, for women of all
ages, are great. This is particularly evident among female adolescents.
According to a study done by the Alan Guttmacher Institute, young
African American women and teenagers who are poor or low-income are
especially likely to become pregnant as teens. The Institute study
ascribes this higher rate to variance in the availability of
contraceptives, information and education on sexuality and birth
control, and on birth control practices.
In the U.S., one million adolescent girls, nearly 12%, become pregnant
each year. More than 80% of these pregnancies are unintended --
approximately one-half result in a live birth, while 40% end in
abortion, and 10% in miscarriage. Most adolescent child-bearing occurs
outside of marriage and this has increased markedly during the past two
decades. In 1991, nearly 70% of births to adolescents were out-of-
wedlock, slightly less than 30% were in 1970.
The social and economic costs of premature pregnancy and parenthood are
enormous. Adolescent child-bearing has long been associated with
reduced educational attainment and employment opportunities. Poverty
and economic dependency, which have consequences well into old age, are
more prevalent in families begun by adolescents, particularly those that
are unmarried. The Children's Defense Fund reported, in a 1988 study,
that a teenage mother earns over a lifetime half the earnings of a woman
who has her first child after age 20. Moreover, the children of
adolescent parents are more likely to become adolescent parents
themselves, perpetuating the cycle.
FEDERAL ACTION -- PROGRAM
One important response to adolescent pregnancy is the provision of
contraceptive services. There are several Federal programs that
currently provide such services -- although targeted to low-income
women, they also serve adolescents.
Evaluations of adolescent pregnancy prevention programs indicate that a
combination of interventions works best. Programs that include
abstinence education, sexuality education, social skills training and
practice in applying skills, as well as information about
contraceptives, have demonstrated positive effects in both delaying
sexual initiation and increasing the use of contraceptives among the
sexually active. Lessons from these findings have been incorporated
into two major federal initiatives: welfare reform and health care
Broader Clinton Administration initiatives will seek to change the
circumstances in which high-risk girls and adolescents live and their
self-perceptions. These initiatives will address economic opportunity,
as well as health and education issues.
In the past decade, government has taken steps to reduce the poverty of
women with reform of the welfare system. In 1988, Congress passed the
Family Support Act. The core of the legislation is the Job
Opportunities and Basic Skills (JOBS) training program, which is
designed to educate, train, and employ recipients of Aid to Families
with Dependent Children (AFDC) and thus assist them in becoming self-
sufficient. Administered at the national level by the Department of
Health and Human Services (HHS), the program provides adult welfare
recipients (the vast majority of whom are women) with a broad range of
services and activities, including educational activities, job skills
and job readiness training, job development and placement, and support
services such as child care.
The Clinton Administration has proposed additional welfare reform
legislation, entitled The Work and Responsibility Act of 1994, designed
to provide welfare recipients with more opportunities to support
themselves. A crucial component of the legislation that promotes work
and independence is "making work pay." The $21 billion expansion in
1993 of the Earned Income Tax Credit (EITC), in which low-wage workers
receive tax refunds, was a major step toward making it possible for low-
wage workers to support themselves and their families above poverty.
When fully implemented, it will have the effect of raising the minimum
wage incomes of a parent with two or more children by 40%.
Under the proposed legislation, an expanded and improved JOBS program
would be integrated with mainstream education and training programs. It
will also emphasize transitional support for a person once she is placed
in a job. People who are still unable to find work at the end of two
years will be required to work in a private sector, community service or
public sector job.
In addition, the legislation would strengthen the child support
enforcement program, which would increase the incomes of female headed
households and help poor families to become self-sufficient. Some
elements of the enforcement effort include universal paternity
establishment (preferably in the hospital), central child support
registries in every State to track payments and take prompt action when
support is not paid, a national registry of child support awards and of
new hires, new measures to penalize those who refuse to pay (from
license suspension to government enforcement), and a new program of
required work and training for men who owe child support and fail to
The key missing component for making work pay is affordable, accessible
child care. In order for families, especially single parent families,
to be able to work or prepare themselves for work, they need dependable
care for their children. The welfare reform proposal will increase
child care funding both for families receiving cash assistance and
working families not eligible for cash assistance. In addition, the
proposal focuses on creating a simplified child care system and on
ensuring that children are cared for in safe and healthy environments.
Universal health care, pay equity, and the availability of well-paying
jobs are also essential to making work pay.
FEDERAL ACTION -- PROGRAMS
There are many agencies and programs within the HHS that are working to
meet the unique needs of women. Much of the burden of poverty is
sustained by women who, in many instances, are the heads of their
households -- these women have needs involving children, such as
prenatal, well baby care and child care, in greater proportions than do
men. The three HHS agencies meeting women's "human needs" are: The
Administration for Children and Families (ACF), The Administration on
Aging (AOA), and The Social Security Administration (SSA). HHS provides
direct services or income support to more than one in every five U.S.
WHERE WE ARE
Stable shelter is fundamental to an individual's physical,
psychological, social, and economic well-being. Ensuring a decent home
and a suitable living environment are recurrent themes in all of the
Department of Housing and Urban Development's efforts, and progress
toward those goals contributes to improving the status of women.
HUD efforts to improve the status of women -- HUD cannot legally
discriminate or target programs on the basis of gender, so HUD programs
cannot be designed specifically to benefit women. However, women
predominate in several categories of households that receive assistance
through HUD programs. These include poor households in general, single-
parent households, and elderly households. So, as a matter of practice,
women are disproportionately served by many of the Department's
Public and assisted housing -- The assisted housing programs of the
Department -- public housing, project-based rental assistance, and
Section 8 rental certificates and vouchers -- provide housing
opportunities for 4.5 million lower-income families. These programs are
especially important to meeting the serious affordable housing needs of
households headed by women. According to a recent HUD study, in 1989,
77% of all households living in conventional public housing were female-
headed, and female-headed households with children represented more than
50% of households receiving housing vouchers or certificates.
Furthermore, though females headed 61% of all income-eligible rental
households, about 72% of all HUD-assisted households were female-headed,
indicating that HUD assists a higher proportion of female-headed
households than would be anticipated based on their proportion of the
Certain HUD programs implemented by the Office of Public and Indian
Housing are designed to provide social services, broaden training and
opportunities, and facilitate the transition from welfare-dependency to
paid work. They largely benefit women who are the primary clientele of
public housing. The include
--the Family Self-Sufficiency program, which couples HUD housing
assistance with public and private support services such as child care,
transportation, education, training, substance abuse treatment and
counseling, homemaking and parenting skills, money and household
management training, and homeownership counseling;
--the Foster Child Care program, that helps maintain the integrity of
families by providing housing to families whose lack of adequate
housing, may result in children being place in foster care, or will
prevent the children from being discharged from foster care;
--the Early Childhood Development program, to provide educationally-
oriented child care services for the children of public and Indian
housing residents to enable the parents to seek education, training,
and/or employment; and
--Family Investment Centers, which provide educational and employment
opportunities to help public housing residents make the transition from
welfare-dependency to economic independence.
In addition, efforts to encourage formation of public housing Resident
Management Corporations give public housing residents--the majority of
whom are women--training and leadership opportunities.
One of HUD's priorities for the coming year is to fund the improvement
of severely distressed public housing developments, which are most
likely to have the highest poverty rates. Improving the physical
environment will not only make those housing developments more
comfortable and attractive places to live, it will also generate jobs.
Housing for the elderly -- Because a disproportionate share of the
elderly population is female, and female-headed households are more
likely to be poor, HUD programs for the elderly tend to serve women.
(Prominent among these HUD programs is Section 202--Housing for the
Elderly and Handicapped--of the Housing Act of 1959, which provides
capital advances to nonprofit sponsors for construction and mortgage
financing of housing for elderly and handicapped persons.) Elderly
women occupy about three-quarters of all HUD-assisted, one-person
households; about 30% of all private, project-based, HUD-subsidized
units; and 25% of all public housing units. Three-fourths of all public
and subsidized housing residents over the age of 65 are women. Most of
these female-headed elderly households consist of one woman, over 70,
Current HUD priorities to expand the availability and affordability of
housing opportunities and supportive services to elderly households
-- expanding the availability of reverse mortgages to elderly owner-
occupants of two-to four-unit properties;
-- expanding the use of Service Coordinators to increase access to
needed services; and
-- testing the feasibility of using elder cottage housing (ECHO)--which
relies on relatives or friends to provide some of the needed services--
as an alternative, affordable housing choice for the elderly.
HUD has funded individual projects that are designed to help
participants, many of whom are women, particularly single mothers, to
develop the required skills and opportunities to retain and care for
their homes. For example,
-Walnut Hills Redevelopment Fund, Inc.
This project provides property management, counseling, and training
to selected residents; early intervention and employment training for
female heads of households; fifteen units of new rental housing for low-
income single parents; and on-the-job construction training.
-Women's Research and Development Center
The Women's Research and Development Center (WRDC) develops housing
for low- and moderate-income women and their children. The goal is to
promote the economic independence of women and meet their needs for
affordable, service-rich housing. The WRDC trains women in home repair
skills such as plumbing, carpentry, electric work, and plastering.
Graduates of the Home Repair Training Program apply their skills by
renovating other WRDC-acquired building that will be used for housing.
Other local projects funded by the Department are designed to enable
women to learn skills that will enhance their earning potential and
improve their economic circumstances. The following are illustrative
-Women's Economic Growth (WEG)
Women's Economic Growth (WEG) will assist residents of Siskiyou
County, California to start small businesses, and will work in
partnership with the City of Eureka and the Siskiyou County Economic
Development Council to develop a food processing incubator cooperative.
-The State of Missouri
Missouri received project funds to develop resource directories,
provide technical training, conduct workshops and help communities
develop plans to address four technical assistance problem areas: (a)
improving utilization of minority- and women- owned business
enterprises; (b) increasing technical expertise of housing
rehabilitation program administrators; (c) developing the capacity of
communities to conduct and execute economic development programs; and
(d) better appraise, direct and plan for communities; long range water
-Private Industry Council of Columbus
The Private Industry Council (PIC) received funding assistance to
expand its Minority Female Entrepreneurship Pilot (MFEP) program. The
PIC will work in partnership with the Columbus Area Chamber of Commerce
Minority Business Development Center to provide start-up capital and on-
going management, and technical and financial assistance to assist
minority women in starting or expanding small businesses in the South
-City of Long Beach
Long Beach, California
The City of Long Beach will use funds to provide self-employment
training to residents of targeted neighborhoods and provide access to
capital through the City's microloan program. In partnership with the
American Women's Economic Development Corporation, the city will
implement a comprehensive business training program for its
A 1988 study, Hunger 1993: Uprooted People (Third Annual Report on the
State of World Hunger, Bread for the World) found that 14% of homeless
shelter dwellers were women, by 1992, it was estimated that 20-27% of
the homeless population was women. An estimated 80 percent of homeless
families are headed by single women. Consequently, it may be reasonable
to assume that as the number of homeless females and families increases
so will the number being assisted by HUD's Special Needs Assistance
Programs for the homeless. These assistance programs also include aid
for victims of domestic violence, an estimated 95 percent of whom are
In the Department's Supportive Housing Program, the Transitional and
Permanent Housing Projects serve approximately 7,600+ women at any given
time. ten percent of the Transitional Housing projects are intended to
assist battered women, although men are not excluded. Almost two
percent (1.8%) of the Transitional Housing projects are designed to
serve pregnant women.
Examples of local HUD-funded projects that serve the homeless and/or
battered women include
-Transitional Housing, Inc.
Transitional Housing Inc. (THI), located on the west side of
Cleveland, consists of two sister corporations that provide transitional
housing for homeless women and victims of domestic violence. Residents
range from eighteen to sixty-one years of age.
-Harriet Tubman Women's Shelter
The Harriet Tubman Women's Shelter assists homeless women and
children who are victims of domestic violence. The facility will
provide child care services, education, job training, and other support
-Shelter Services for Women, Inc.
Santa Barbara, California
Supportive services and housing will be provided for homeless
battered women and their children through the purchase of a 16-unit
-Domestic Violence Center of Howard County
The center provides shelter for eight women who have been victims
of domestic violence and their children.
With regard to special difficulties faced by women of color, HUD is
committed to enforcing fully the Fair Housing Act to combatting housing
discrimination in both its obvious and more subtle forms. The issue of
race, in particular, is introduced to highlight the fact that statistics
describing the condition of women in general mask the more commonplace,
difficult, and complex challenges confronted by women of color. By
striving to eliminate discrimination in the home mortgage market and in
access to mortgage and homeowners insurance, HUD will help to make the
dream of homeownership--and the economic advantages it represents--a
reality for many who would otherwise be excluded from the marketplace.
HUD is also committed to expanding access to HUD programs that open
avenues of economic opportunity to women through specific provisions.
For example, the Housing and Community Development Act of 1992,
-- requires that implementation grant applications for the Youthbuild
program (a program to educate and employ economically disadvantaged
youths in rehabilitating or constructing housing for homeless and very-
low income people) contain a description of the special outreach efforts
undertaken to recruit eligible young women,
-- helps women in homebuilding, and
-- directs Government-Sponsored Enterprises (GSEs) to create outreach
programs to ensure equal opportunities for women and minority-owned
business in the solicitation of contracts.
Specific projects funded by HUD -- Individual projects that receive HUD
assistance may be targeted specifically to women. Examples of locally-
directed projects benefitting women that are funded, either directly or
indirectly, by the Department's Community Planning and Development and
Office of Housing Programs are described in the box on the following
page. They are included as examples of projects that not only attempt
to provide shelter, but also to enable homeless, unemployed, generally
unskilled women to enter the economic mainstream providing them with
formal peer support, and other needed services, such as job training,
child care, and education.
Women's Center of Rhode Island
The Rhode Island Women's Center acquires and rehabilitates existing
buildings to provide housing and supportive services to homeless women,
including some women with emotional and physical disabilities.
Women's Housing Coalition
The Baltimore Women's Housing Coalition (WHC) is a non-profit
corporation concerned with the long-term housing and support service
needs of homeless women in Baltimore. WHC operates three transitional
residences--Howell House, Lombard House, and Upton House--that serve
eighteen women for stays of up to one year.
Women's Community Revitalization Project, Inc.
The Women's Community Revitalization Project (WCRP) produces
scattered-site subsidized rental housing units for low-income single
women with children in a rapidly gentrifying low-income neighborhood in
eastern North Philadelphia. This area also suffers from the largest
high school attrition rate in the city and close to half o the
community's families--many of them female-headed--live at or below the
federal poverty line. This women's housing project provides a plethora
of tenant support services, including employment training, leadership
development, counseling, and child care.
My Sister's Place, Inc.
My Sister's Place will acquire, rehabilitate, and manage their second
transitional shelter facility, My Sister's Place II-Transitional
Housing. The facility will serve 22 families with young mothers and
eight mentally ill women.
CURRENT CHALLENGES AND STRATEGIES
Several new or expanded HUD initiatives will help identify and remove
obstacles to advancing the status of women:
First, new regulations, effective November 1992, require HUD to document
and monitor better the impact of its programs on women. To determine
program effectiveness and performance, and to identify what populations
are being aided, future Community Planning and Development program
participants will be required to provide information and data for
racial, ethnic, and gender.
Furthermore, as HUD's Office of Community Planning and Development plans
its programs and prepares regulations to implement its principal
economic development program, it anticipates creating a data category
for women-owned businesses. The Office intends to document the number
of such businesses that HUD programs have helped start or fund.
The Department is undertaking a number of initiatives to implement more
aggressively Title VIII of the Fair Housing Act and other civil rights
laws that prohibit discrimination in housing choice, lending and
insurance on the basis of race, disability, or family composition.
The Department of Veterans Affairs' Loan Guaranty program, though not
targeted to women, is increasingly used by women veterans to finance the
purchase or repair of a home, condominium, or manufactured home. In
1992, over 13,000 women veterans move into greater housing independence
and stability through the loan guaranty program.
WHERE WE ARE
The designation of women's health as a national health priority is an
attempt to rectify the long-standing systemic biases against women as
recipients and providers of health care services and as participants in
Women have a life expectancy that exceeds that of men, and have a lower
risk of dying at every age. The three leading causes of death (heart
disease, cancer and cerebrovascular disease) are the same for men and
women. However, the presentation of these conditions in women as well
as the knowledge that exists about why women develop them and how best
to treat them are not the same as for men.
Women's health issues have been defined by the Department of Health and
Human Services as those health conditions unique to women, more
prevalent or more serious in women, or for which the risk factors or
interventions are different. Insufficient data exist to determine all
the conditions that fall into these categories, much less to determine
optimal care for women afflicted by them.
Conditions unique to women are, not surprisingly, those related to the
major biological difference between men and women, namely the
reproductive tract. Women are seen as outpatients and are hospitalized
and undergo procedures more often than men, due partly to reproductive
tract conditions including normal pregnancy, pregnancy complications,
contraceptive needs, and non-pregnancy related reproductive tract
problems. Some of these conditions may be fatal, such as cancer of the
ovary and uterus, and certain pregnancy complications.
Breast cancer is not unique to women, but is seen only rarely in men.
While men have a greater lifetime chance of dying of cancer than women,
women have a higher rate of cancer death between the ages of 25 and 44,
due largely to breast cancer. In women, it is the most common form of
cancer - 1 in 9 women may expect to develop it. Between 1950 and 1990,
the annual incidence of breast cancer increased by approximately 50%,
while the death rate increased by 4%. In 1991, 43,583 American women
lost their lives to this disease.
Non-reproductive tract conditions are generally not unique to women and
are more prevalent and serious in men. However, notable exceptions
exist. Women are much more likely to suffer from spousal abuse than
men. Women have a higher rate of outpatient visits than men, even when
visits for normal pregnancy are excluded and have higher rates of
hospitalization for endocrine disorders including diabetes, digestive
system disorders (especially gallstones), genitourinary disease, and
musculoskeletal disease. Women have higher rates of endocrine surgery,
digestive system surgery, reduction of hip fractures, and knee and hip
replacement surgery than do men. For some of the conditions which are
more common in men, the rate of increase in prevalence is higher for
women. For years, breast cancer was not only the most common form of
cancer in women, but the most common cause of cancer deaths as well.
Recently, however, the number of breast cancer deaths has been surpassed
by the number of women dying of lung cancer each year. In the past 30
years, the lung cancer rate among women has increased nearly 400%, a
much faster rate than that seen among men. In addition, women are the
group in which HIV infection is increasing at the fastest rate in the
Whether risk factors for disease and indicated interventions differ for
men and women has just begun to be studied and there are few
conclusions. Slightly more progress has been made in the area of
existing (as opposed to needed) differences in interventions. For
example, it has been shown that women with symptoms of heart disease do
not receive the same diagnostic tests or treatments as men, and do not
fare as well. Women have been excluded from research due to the fear of
the complicating effect of pregnancy. As a result, little is known
about risk factors and treatment that works for women, especially child-
bearing and pregnant women, and whether these are different from those
The federal government as well as local governments and non-governmental
organizations have established a number of programs to begin to address
these women's health issues, from the standpoints of policy, service
delivery, and research. What follows is a description of these
programs, the challenges they are designed to meet, and their successes
and failures at meeting them.
A recent national survey by the Commonwealth Fund (1993) revealed
several disturbing trends among American women age 18 and over. For
-- Many women forego needed health care due to lack of adequate health
insurance and vulnerable economic status.
-- Women are more likely than men to change physicians because of
communication problems or physician insensitivity to a stated problem.
-- Depression and low self-esteem are problems for many American women.
-- Women of color are more likely to be poor, uninsured and to lack
needed health care services.
10 Leading Causes of Death Among Women
United States, 1991
Rank Cause of Death Number Rate*
1 Heart Disease 361,048 279.5
2 Cancer 242,277 187.5
3 Cerebrovascular 86,767 67.2
4 Pneumonia/Influenza 41,646 32.2
5 Chronic Obstructive
Pulmonary Disease 40,165 31.2
6 Accidents 29,617 22.9
7 Diabetes Mellitus 27,855 21.6
8 Septicemia 11,081 8.6
Syndrome/Nephrosis 10,942 8.5
10 Atherosclerosis 10,784 8.3
* Rates per 100,000 population.
These findings highlight the importance of psychosocial, cultural and
economic factors as determinants of women's health and quality of life.
For many women, an equal opportunity for optimal well-being remains
unrealized. For example, women who live in poverty and have less than a
high school education -- many of whom are women of color -- have shorter
life spans, higher morbidity and mortality rates, and limited access to
quality health services.
The leading causes of death for women provide compelling reasons for the
heightened attention to women's health issues. As indicated in Table I,
the leading causes of death among women of all ages in the U.S. include:
heart disease, cancer, stroke, lung-related diseases, unintentional
injuries and diabetes. Heart disease, the number one cause of death
among women, accounted for over 30% of all deaths among women in 1991.
Nearly 90,000 women die each year of stroke.
Lung cancer, the leading cause of cancer death among women since 1987,
is almost entirely due to cigarette smoking. In the past 30 years, the
lung cancer rate among women has increased nearly 400%. Presently, it
is estimated that 23 million women in the U.S. smoke cigarettes, a
behavior known to increase the risk of death from heart disease and
reproductive disorders as well as from cancer. The prevalence of breast
cancer has increased significantly in recent decades; estimates now show
that 1 in 9 women will develop this disease in her lifetime.
In 1992, reported AIDS cases increased by a greater percentage among
women than among men. Other sexually transmitted diseases -- including
chlamydia, gonorrhea and syphilis -- affect approximately 6 million
women in the U.S. every year. Women are more likely than men to have
multiple mental health and substance abuse problems, including histories
of physical or sexual abuse.
Beginning with the 1992 survey year, injury and illness profiles of
women and other worker groups were made possible by a major redesign of
the Bureau of Labor Statistics' Survey of Occupational Injuries and
Illnesses in private industry. In that year, there were 764,000
nonfatal work injuries and illnesses to women resulting in days away
from work. This means women accounted for more than one-third of the
2.3 million total of all nonfatal work injuries and illnesses resulting
in days away from work. Women were in the majority in certain
categories of injuries and illnesses, such as cases related to
repetitive motion and assaults and violent acts. Service occupations,
such as nursing aide, food preparation worker, and cleaning worker,
accounted for one-third of all injuries and illnesses to women involving
days away from work. Another half of women's injuries and illnesses
involving days away from work were divided about evenly between
technical, sales, and administrative support jobs (26 percent) and
operators, fabricators and laborers (24 percent).
Both injuries resulting from workplace violence and musculoskeletal
disorders, as well as other occupational injuries and illnesses, are
receiving attention from government, business, labor organizations, and
nonprofit organizations. For example, in September 1993, the National
Institute for Occupational Safety and Health issued an alert on
preventing homicide in the workplace for the purposes of identifying
high-risk occupations and workplaces; informing employers and workers
about their risk; encouraging employers and workers to evaluate risk
factors in their workplaces and implement protective measures; and
encouraging researchers to gather more detailed information about
occupational homicide and to develop and evaluate protective measures.
The Occupational Safety and Health Administration of the U.S. Department
of Labor is in the process of developing a proposed standard to address
FEDERAL ACTION -- PROGRAM
An agency of the Department of Health and Human Services (HHS), the
Public Health Service undertakes activities to promote the health and
well-being of women across the life span; to help them make informed
choices about their health; and to translate policy decisions into
effective women's health programs. The development and implementation
of women's health programs across HHS is based on a set of criteria for
defining women's health issues: health conditions unique to women, more
prevalent or more serious in women, or for which the risk factors or
interventions are different for women.
The Department's new focus on women's health reflects not only an
awareness of the multifaceted nature of women's health issues --
including important biological, psychosocial, cultural and economic
influences -- but also an understanding of the need for effective and
integrated strategies to meet the health needs of women. While
meaningful progress has been made in many areas, including mortality
declines for certain chronic health conditions, women remain at risk for
many other problems, including substance abuse, depression, violence and
HIV/AIDS. Improved health for all women in the U.S. requires a
substantial expansion in the number and scope of women's health
The following key goals provide HHS' framework within which to implement
a comprehensive women's health agenda:
-- To support comprehensive, community-based health promotion/disease
prevention programs for women.
-- To promote access to a full range of gender appropriate and
culturally sensitive health care services for women, especially for low
income, ethnic minority, migrant, incarcerated and homeless populations.
-- To strengthen and sustain research on diseases, disorders, and
conditions affecting women; to strengthen and sustain research on
methods to improve access to and quality and effectiveness of health
services for women.
-- To educate and inform women about relevant health issues and
-- To support health professional training in the recognition and
management of women's health conditions.
-- To promote the appointment of women to Departmental and
international leadership positions which affect women's health and
quality of life.
These goals -- and the policies and programs derived from them -- can
make a worthwhile and enduring impact on optimal health and well-being
for all women in this country.
FEDERAL ACTION -- RESEARCH
Once the statistics on women's health issues through the 1980s were
available, consolidated, and interpreted, HHS realized that insufficient
scientific knowledge existed about the unique problem of women's health
-- knowledge necessary to control and reverse the causes and effects of
--Diseases that affect women disproportionately are less likely to be
--Women are less likely to be included as participants in clinical
--Women are less likely to be principal investigators conducting the
--Significant disparities occur in the use of major diagnostic and
therapeutic interventions for women compared to men.
The Office of Research on Women's Health at the National Institutes of
Health (NIH) was established in 1990 to strengthen and enhance research
related to diseases, disorders, and conditions that affect women and to
ensure that women are appropriately represented in biomedical and bio-
behavioral research studies. In 1991, the Office on Women's Health was
established to advise the Assistant Secretary for Health on women's
health issues and to direct and coordinate women's health activities.
The U.S. Congress has requested a survey of medical school curricula to
determine the extent to which women's health issues are addressed. In
cooperation with the Association of American Medical Colleges and other
relevant groups, NIH will conduct a survey to evaluate the extent to
which women's health issues are addressed in academic and clinical
training curricula. While initial efforts will address curriculum
development in medical education and training, attention will ultimately
be extended throughout the health professions, including dentistry,
nursing and allied health disciplines.
Women Veterans' Health
The Department of Veterans Affairs (VA) contributes to improved health
for this growing segment of the population through emphasis on gender
specific care and research, needs of aging women veterans, service-
connected disabilities, and service-related trauma and stress disorders.
VA is increasing space and services for women's primary care, preventive
screening, and reproductive health needs.
In 1983, VA researchers first included women in a study of aging
veterans; in 1993, VA established a Women's Health Science Division for
national study of Post-Traumatic Stress Disorder. VA centers for
geriatric research and education are investigating osteoporosis,
arthritis, dementia, drug use in the elderly, depression, and long term
care issues, resulting in improved care for aging women veterans. VA is
studying infertility, stillbirths, birth defects, and other reproductive
effects in female Vietnam veterans.
N.B. Women constitute 36% of principal investigators in VA health
research and development projects.
CURRENT CHALLENGES AND STRATEGIES
HEALTH CARE REFORM FOR WOMEN
A principal basis for the Administration's health care reform plan is
the longstanding inequity in health status and health care access
between majority and underserved populations. Access to health care has
been severely limited for the 37 million uninsured individuals in the
U.S. Several million more have insufficient or tenuous access based on
their employment or marital status. Although women comprise over 51% of
the population and 45% of the U.S. workforce, they remain over
represented in low-wage, hourly and part-time positions that do not
provide health insurance coverage or other work-related benefits. As a
result, many basic and long term health services essential to women are
unavailable or available only on a limited basis.
Women who live in poverty or in geographic/social isolation (e.g.,
homeless, incarcerated women), and women who are members of racial and
ethnic minority groups, have less financial and organizational access to
services, lower utilization rates for all types of services, less
preventive care, and poor health status in terms of morbidity and
mortality compared to other social groups of women. For example,
African American and Hispanic women have lower utilization rates for
breast and cervical cancer screening. Women in rural areas are less
likely to receive early prenatal care than women in urban areas. Over
40% of women in state correctional facilities have reported a history of
physical or sexual abuse. Women with children--the fastest growing
group among the homeless--have no regular source of primary health care.
Nor do these women have the necessary support and services to assist
them with any problems associated with breastfeeding. Thus African
American and Hispanic women still have breastfeeding initiation and
duration rates that are lower than the general population.
A cornerstone of the debate over comprehensive health reform is that
access to affordable, comprehensive, quality health care plan is a
fundamental right of all Americans. If health care coverage and health
outcomes are to be improved, the delivery system requires a major
restructuring in the type and process of care. The Administration's
plan refocuses the delivery system on the promotion of good health,
disease prevention and a broad range of public health services, with the
goal of improving health status and quality of life. Health care
priorities are reordered to include six overriding principles: security
of guaranteed, comprehensive benefits; health care costs that are under
control; improved quality of care; increased choices for consumers; less
paperwork and a simpler system; and responsibility from everyone.
Comprehensive health reform represents meaningful change for women's
health by guaranteeing coverage to all women regardless of health
status, marital status, employment status or ability to pay. This
legislation recognizes and responds to the health care needs of women by
providing a comprehensive package of benefits: a full range of clinical
preventive services including physical examinations, mammogram, Pap
smears and other screening tests, immunizations, and counseling
interventions; a full range of reproductive health services, including
family planning and pregnancy-related services;
expanded long term care services including home health care, hospice
care and outpatient rehabilitation; inpatient and outpatient services
including health care provider visits, hospitalizations,
emergency/ambulance services, laboratory/diagnostic services, and
prescription drugs; and, mental health and substance abuse treatment
DEPUTY ASSISTANT SECRETARY FOR WOMEN'S HEALTH
The Clinton Administration has created a new senior level health
position to address inequities in the health treatment of U.S. women.
Special offices of women's health are also being created in many of the
individual Public Health Service agencies.
FEDERAL ACTION -- PROGRAM RESEARCH
Preventing illness and death associated with reproductive occurrences
and promoting healthy reproductive behaviors are the goals of HHS and
its Center for Disease Control (CDC) which provides program consultation
to state and local health departments in the surveillance of family
planning services and reproductive health surveys. A CDC-supported
study is looking at demographic and behavioral differences between women
who choose Norplant and women who choose other methods of contraception.
CDC is currently collaborating with the Arizona State Health Department
in a telephone survey of reproductive health practices of women aged 18-
44 years. In addition, CDC assists other countries interested in
improving their management and operation of reproductive health and
family planning services.
Emory University (with federal funding) is studying determinants of
unintended pregnancy among teens and adult women and contraceptive
decision-making. CDC is also examining the reproductive health effects
on women of various occupations and workplace exposures, including
chemicals and physical and mental job stress.
The NIH's contraceptive research program includes the examination of
motivational factors in birth planning and use of contraceptives.
Studies identify how sexual activity and contraceptive use are
influenced by family characteristics, community norms and access to
contraceptive methods and services. To help provide women with a wider
choice of contraceptives, NIH is supporting development of the female
condom, and is examining the use of RU 486 and other anti-progestins.
REPRODUCTIVE HEALTH-RELATED BARRIERS
o Limited development of intervention projects to reduce adolescent
o Insufficient understanding of the social and economic consequences
of unintended pregnancy, especially among teenagers.
o Insufficient understanding of contraceptive decision-making
o Limited information about risks for chronic diseases among long-term
users of oral contraceptives.
o Lack of information about infertility rates among couples according
to occupation of both partners.
o Insufficient knowledge about the combined effects of workplace
stress, motherhood and homemaker responsibility on fertility rates.
REPRODUCTIVE HEALTH RELATED STRATEGIES
o Support the collection of national and State data on the number of
pregnancies, whether or not pregnancies are intended, number of births,
and number of abortions among sexually active women by race and
o Support research on behavioral models of contraceptive decision-
making and unintended pregnancy in adolescent and adult women.
o Develop effective intervention strategies for preventing unwanted
pregnancy in adolescents.
MATERNAL AND CHILD HEALTH
ADVANCEMENT SINCE 1980
In 1990, the birth rate was 70.9 live births per 1,000 women 15-44
years, 4% higher than in 1980 but 19% lower than in 1970. The increase
was greatest for women 35-44 years (7-8%) and for adolescents 15-17
years (5%). Between 1980 and 1990, the percentage of live births to
unmarried mothers increased steadily to 28%. In 1990, two-thirds of
African American mothers and more than half of Puerto Rican and Native
American mothers were unmarried, compared to 10% of U.S. mothers of
Japanese origin and 17% of white mothers.
In 1990, the number of legal abortions reported was 1,430,000, up from
approximately 1,298,000 in 1980. In 1991, contraception was used by 81%
of sexually active girls age 15-19 years. However, of the
approximately 1.1 million women age 15-19 years who become pregnant each
year, 85% did not intend to do so.
In 1990, the infant mortality rate was a record low -- 9.2 deaths per
1,000 live births. Between 1980 and 1990, infant mortality decreased by
30% for infants of white mothers to 7.6 deaths per 1,000 live births and
by 19% for infants of African American mothers to 18.0 deaths per 1,000
live births. Although the infant mortality rate is at an all time low,
the U.S. continues to rank behind most developed countries. Key factors
during the perinatal period -- poor nutrition, lack of prenatal care,
use of cigarettes, alcohol and other drugs, and adolescent pregnancy --
increase significantly the incidence of low birth weight and infant
mortality. Pregnant women who receive no prenatal care or care only in
the final trimester are nearly three times more likely to die of
pregnancy-related complications such as hemorrhage, embolism,
hypertension and infection. The risk of maternal death remains
consistently higher for African American and other minority women.
MATERNAL-INFANT HEALTH OBSTACLES
o Insufficient knowledge about causes of maternal mortality and
associated risk factors
o Lack of standardized format and procedures for classifying the cause
of maternal deaths
o Insufficient understanding of preventable risk factors associated
with pregnancy-related morbidity
o Lack of understanding of drug and alcohol uses on health of baby
o Misconceptions about the risks of Hepatitis B in pregnant women and
their newborns; inadequate education of health care providers concerning
the need to screen pregnant women for Hepatitis B
o Lack of knowledge about programs available to many low-income women
which address needs of pre-natal care
CURRENT CHALLENGES AND STRATEGIES
Identify maternal deaths, classify causes of death into meaningful
clinical categories and identify preventable risk factors; provide
organizations involved in maternal mortality review with a standardized
format for collecting data and facilitating data entry and analysis.
Support surveillance of ectopic pregnancy and induced abortion to better
understand the epidemiology of pregnancy-related morbidity.
Develop new sources of data to enhance understanding of risk factors and
effective interventions for pregnancy related morbidity.
Support the implementation and evaluation of comprehensive systems of
preventive and treatment services for substance abusing pregnant and
postpartum women and their infants.
Promote the development and validation of screening instruments for
alcohol use prior to conception and during pregnancy; support research
on effective preventive interventions targeting alcohol use during
Enhance data and surveillance systems to accurately document the
incidence of alcohol use during pregnancy and the numbers of children
born with Fetal Alcohol Syndrome.
Promote the passage of State legislation that requires warning signs at
all points of sale of alcoholic beverages about association between
alcohol and birth defects.
Assist States in the development of community-based public/private
partnerships that deliver risk-appropriate prenatal care, maternity and
postpartum care, including breastfeeding support and services to all
women of childbearing age.
Support national, State and local public awareness and health education
campaigns emphasizing the importance of early prenatal care.
Support national, State and local public awareness and health education
campaigns emphasizing the importance of breastfeeding as a health-
Promote interventions, such as outreach and home visiting, to facilitate
timely entry into prenatal care.
Support research on the impact of race/ethnicity, educational
attainment, income and insurance status on prenatal care utilization.
Determine the effectiveness of Medicaid expansions and public/private
sector initiated incentive programs on prenatal care utilization.
Support Hepatitis B screening programs for pregnant women,
immunoprophylaxis of infants born to infected women, and screening and
vaccination of their household contacts; educate women and health care
providers about the need to screen pregnant women for Hepatitis B.
FEDERAL ACTION -- PROGRAM
Within HHS, the Maternal and Child Health Bureau administers the Title V
Maternal and Child Health Services Block Grant, which is designed to
provide comprehensive, coordinated, community-based health care for
mothers and children. Through federal grants, communities with high
infant mortality rates are developing innovative approaches to reduce
the number of deaths among infants. Collaborative community efforts --
including local and state governments, the private sector, schools and
other groups -- are focusing on the needs of pregnant women, mothers,
and infants to assure the delivery of a comprehensive package of
medical, educational, and other social services.
The NIH's National Institute of Child Health and Human Development
supports a multi-disciplinary research program on pregnancy and
perinatology. Research on pregnancy includes: the role of
intergenerational factors in pregnancy; the role of work and physical
activity in pregnancy; maternal nutrition; antecedents and consequences
of caesarean birth; and smoking during pregnancy. NIH also studies risk
factors and complications of pregnancy, including diabetes, intrauterine
growth retardation, anemia, and environmental factors.
CDC provides technical assistance in the epidemiology and surveillance
of pregnancy and its outcomes. CDC has monitored pregnancy-related
mortality since the 1970s and has developed a new National Pregnancy
Mortality Surveillance System to better identify maternal deaths,
classify causes of death into clinical categories, and identify risk
factors for maternal death.
HHS especially supports efforts to improve access to prenatal care and
child health services for low income pregnant women. In 1992,
approximately 30% of U.S. births were paid by Medicaid. The past decade
has seen a significant expansion of Medicaid eligibility and enhancement
of covered prenatal services for this population. State and federal
Medicaid Agencies are collaborating to reduce infant mortality and to
improve maternal-infant health by providing comprehensive coverage for
Nearly 15% of U.S. women and children fall below national standards for
FEDERAL PROGRAM -- NUTRITION
The Department of Agriculture administers a number of food assistance
programs aimed at poverty alleviation and concomitant improvement in
nutritional status. The Food Stamp Program benefits low income
households -- nearly 69% of food stamp households with children are
headed by single women. Each month in FY 1993, an average nine million
women (over age 18) and seven million girls received Food Stamps.
The Special Supplemental Food Program for Women, Infants and Children
(WIC) provides food, nutrition education, and access to health care for
low income pregnant and breastfeeding women and their children. Results
from a number of evaluations have shown that participation of women
during pregnancy improves birth outcomes. More than 40% of all U.S.-
born infants and one of every four pregnant women receive WIC benefits -
- in FY 1993, about 1.4 million women and 4.5 million children
A 1990 report found that women who participated in WIC during pregnancy
had healthier birth outcomes and lower Medicaid costs than low-income
women who did not participate. Participation during pregnancy increased
infant birthweight and lowered the incidence of preterm births. A 1993
report issued by the Government Accounting Office (GAO) showed that
rates of breastfeeding initiation, exclusive breastfeeding, and
continuation of breastfeeding for six months increased significantly
among women in the WIC program, compared to increases in these rates for
all U.S. women, during the period from 1989 to 1992.
WHERE WE ARE
Despite programs in reducing mortality from several cancers, breast
cancer remains a major cause of death, disability, and reduced quality
of life for American women. In 1993, approximately 183,000 women were
newly diagnosed with breast cancer, while some 46,000 died of the
disease. For all American women combined, the incidence of breast
cancer has been increasing while mortality has been relatively constant.
Experience varies, however, with different population groups. For
example, the incidence of breast cancer for women of all ages combined
is higher among whites than African Americans. However, the death rate
from the disease is higher among African Americans. Trends also differ
by both age and race. For example, white women under 65 have
experienced a 7.2% decline in breast cancer mortality from 1973 to 1990,
while mortality among African American women has increased 18.7%.
Deaths from breast cancer among women 65 and above have increased for
both whites and African Americans, although the increase for African
Americans at about 30% has been about twice that of whites, about 14%.
FEDERAL ACTION -- CONFERENCE TO ESTABLISH A NATIONAL ACTION PLAN
Statistics signal a clear need for action -- equally compelling are the
individual experiences of women with breast cancer. On October 18,
1993, President Clinton was presented with petitions signed by 2.6
million Americans asking for "a comprehensive plan to end the breast
cancer epidemic." In accepting the petitions, President Clinton
announced that the Secretary of Health and Human Services Donna E.
Shalala, would convene a conference in mid-December to develop an
approach to a national action plan on breast cancer. About 150
representatives from advocacy groups, consumers, private industry,
academia, scientific research, the media, and the field of education
participated, combining scientific and technical expertise with social
insights and personal and professional experience and commitment. The
Secretary's Conference To Establish a National Action Plan on Breast
Cancer developed a comprehensive plan for research, health care and
policy issues pertaining to the eradication of breast cancer.
The National Action Plan affirms the importance of public-private
collaboration to fight breast cancer and promote breast health.
Implementation of the plan, coordinated by the Office on Women's health,
will involve the participation of consumer, health care professional and
scientific organizations, as well as the Federal government.
HIV AMONG WOMEN
WHERE WE ARE
HIV infection/AIDS is a rapidly growing problem among women in the U.S.
and worldwide. From 1991 through 1992, larger proportionate increases
in reported AIDS cases occurred among women (9.8%) than among men
(2.5%). Approximately 75% of women with AIDS are African American or
Hispanic; from 1991 through 1992, rates were higher for these groups
(31.3 and 14.6 per 100,000 population, respectively) than for non-
Hispanic whites (1.8). While other racial groups have a higher number
of individuals with AIDS, the number of American Indians with AIDS is
rising at a rate proportionately faster than other groups. The
percentage of American Indian and Alaska Native women with AIDS is 13%
of the total number of American Indian and Alaska Native cases, in
contrast to 4% of white women. In 1992, for the first time, the number
of AIDS cases diagnosed among women infected through heterosexual
contact exceeded those infected through intravenous drug use.
BARRIERS TO ADVANCEMENT -- HIV/STD
o Insufficient accurate data on sexual practices, including condom
o Insufficient understanding of correct and consistent condom use
o Need to link HIV/STD risk reduction efforts with concurrent
attention to other health and social service needs of women (e.g.,
family planning, drug prevention/treatment, violence control).
o Lack of risk awareness for HIV/STD infection among low-income
women and low rates of testing and follow-up for women and children who
are at risk.
o Limited information about health care utilization patterns by HIV-
infected and high-risk women.
o Insufficient HIV/STD preventive and treatment services in
facilities where women are frequently seen, including emergency rooms
and family planning clinics, prenatal and obstetric clinics; low index
of suspicion among health care providers about the risk of HIV/STDs in
women (in many high incidence areas, HIV and STD programs are in
separate locations and are separately funded).
o No safe, effective and widely acceptable female-controlled
contraception method to protect women from HIV infection.
o High risk of unintended pregnancy and perinatal transmission among
HIV-infected women; limited studies of perinatal transmission of HIV
o Limited standard protocols for HIV/STD preventive, diagnostic,
treatment and partner notification services.
CURRENT NATIONAL STRATEGIES
Support research on: 1) methods to develop culturally appropriate,
community based HIV/AIDS prevention and care programs; 2) behavioral and
biological determinants of HIV transmission in women; and 3) perinatal
Support the development and implementation of family-centered,
coordinated care models for women, children and families affected by
HIV/AIDS; support the integration of models of care into ongoing systems
Expand efforts to reach HIV-infected women and those at risk of
infection to provide HIV preventive services, including counseling,
testing, referral and partner identification.
Develop, implement, and evaluate clinic-level interventions to prevent
HIV infection in high-risk women of reproductive age and to prevent
unintended pregnancy among HIV-infected women by such initiatives as
encouraging contraceptive use and family planning services use.
Promote access to services by providing reproductive health care in non-
traditional settings (e.g., homeless shelters, drug treatment centers).
Enhance the ability of family planning professionals to deliver
appropriate HIV/AIDS and STD prevention and treatment services to women
through training provided by the 10 Regional Training Centers for Family
Enhance STD preventive health care infrastructure by supporting States
and localities to (1) form strategic alliances among health care
providers, educators, community leaders and patient advocacy groups; (2)
establish access to and utilization of STD preventive services for high
risk women; (3) train health care providers in STD preventive and
treatment techniques; and (4) evaluate the effectiveness of community
Integrate STD education into existing HIV and other disease prevention
curricula targeted to women, particularly adolescents.
Conduct research on the development of effective techniques to modify
community norms regarding risk factors for HIV/STDs (e.g., initiation of
sexual intercourse, partner selection, condom and other barrier
contraception use, and alcohol/drug use).
FEDERAL ACTION -- PROGRAMS AND RESEARCH
CDC monitors the extent of HIV/AIDS through surveys and active AIDS
surveillance; conducts studies on the natural history of HIV infection
in women and the effect of biological factors, such as pregnancy and
hormonal variations, on the course of infection; identifies risk factors
for transmission and develops recommendations to prevent or reduce
behaviors which transmit HIV from men to women, women to men, women to
women, and mother to infant; and supports HIV testing services to help
individuals learn if they are infected with HIV and to improve referral
to appropriate prevention and treatment services. Specifically, CDC
supports nationwide HIV surveys in childbearing women, in women's
clinics, and among women being treated at STD clinics. CDC is also
examining the effect of social factors such as access to health care,
cultural values and attitudes, family structure and social support
systems on the natural history of HIV infection.
CDC provides prevention messages to women through its America Responds
to AIDS campaign, National AIDS Hotline, and National AIDS
Clearinghouse. CDC has a partnership with the American Red Cross to
reach women at increased risk of HIV infection. A similar partnership
with the Hispanic Designers' National AIDS Education Leadership Council
focuses the attention of Hispanic women from multiple disciplines on
local and national programmatic responses and policy development. In
cooperation with the PHS Office of Population Affairs, CDC supports the
training of family planning professionals in HIV prevention. CDC funds
national, regional, State and local community-based organizations that
provide education/risk reduction and public information activities. CDC
also supports HIV/AIDS counseling and testing for women in a variety of
settings, including STD clinics, tuberculosis clinics, prenatal clinics,
family planning clinics and drug treatment centers.
The AIDS Cost and Service Utilization Survey examines the use and costs
of health and social services for persons with HIV/AIDS. Women have
been over-sampled to permit gender-specific analyses related to the
spread of HIV infection. Another study is focused on the caregiving
patterns and needs of minority women with AIDS.
Throughout the Federal government, under a Presidential mandate, all
supervisors and managers receive HIV/AIDS Awareness Training. At least
one agency, the Department of Commerce has inaugurated institutional
changes as a result of this directive. Commerce reports a redefinition
of Personnel Leave Requests expanding the traditional definition of
family member -- spouse, child, grandparent -- to include "any
individual related by blood or affinity whose close association with the
employee is the equivalent of a family relationship."
[End of Section 3 of 5]
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