Section III.E.2.c State Action Plan Narrative by Domain

MCH Population Domain: Child Health

National Performance Priority Area: Physical Activity

North Dakota Priority: Reduce Overweight and Obesity in North Dakota Children – 2018 Annual Report Narrative (October 1, 2017 – September 30, 2018):

According to the 2017 Youth Risk Behavior Survey (YRBS), 30% of North Dakota students in grades 9 through 12 had a body mass index (BMI) of 85% or greater (overweight and obese). This number has increased over time: 23.4% in 2007, 24.4% in 2009, 25.5% in 2011, 28.6% in 2013 and 28.7% in 2015.

The YRBS also indicated in 2017 that 26.1% of North Dakota students in grades 9 through 12 were physically active for a total of at least 60 minutes per day the past seven days. Although low, this does represent an increase from the 2007 level of 21.8%. The amount of time students required to spend in a physical education (PE) course varies. In North Dakota, elementary grades one through six must offer a minimum of 90 minutes of physical education (PE) each week. Students in grades 9 through 12 must have at least one credit of PE, of which half can be health education.

According to the National Survey of Children’s Health, 2016-2017 (combination of two years) 66.7% of North Dakota children ages 6-11 are physically active at least 60 minutes a day 4-7 days a week. The national average is 56.1%. North Dakota children ages 12-17 are physically active 54.4% 60 minutes a day 4-7 days a week, while the national average is 47.2%.

A balanced diet and regular physical activity benefit the health of children and adults. Poor diet and physical inactivity contribute to many serious and costly health conditions, including obesity, heart disease, diabetes, some types of cancer, unhealthy cholesterol and high blood pressure. Title V recognizes that a multi-pronged approach is needed to make a meaningful change.

One approach taken to reduce overweight and obesity in children is through the work of three Maternal and Child Health (MCH) grantees (Fargo Cass Public Health, North Dakota State University (NDSU) Extension Services and the South East Education Cooperative). The Evidence-Based or Informed Strategy Measure (ESM) for reducing overweight and obesity in children is defined as the numbers of schools MCH grantees worked in to reduce overweight and obesity in North Dakota children. Monitoring this ESM provided a basis for monitoring the reach of program efforts. From April 2016 through May 2017, the three grantees reach 88 out of 200 individual school buildings within their service areas. The grantees have continued this work in the 88 schools and added 24 additional schools in their service area (113/200). The Title V Director, MCH Nutritionist and the School Health Specialist continued to work in coordination with these grantees by providing technical assistance and assuring consistent communication among grantees. Funding for these grantees started in April 2016 and will continue through September 2021. To evaluate the effectiveness of the strategies being implemented by the MCH grantees, the North Dakota Department of Health (NDDoH) contracted with staff from NDSU, Master of Public Health Program. They have conducted site visits to each grantee; reviewed grantee work plans and developed a theory of change for each grantee. 

The School Health Specialist worked with the North Dakota Department of Public Instruction (NDDPI) and the North Dakota School Board Association on recommendations to a new wellness policy that schools can adapt. This new wellness policy identified what schools should be working toward quality improvement regarding policy, nutrition, promotion, physical activity, school sponsored activities, nutrition standards, hydration standards, marketing, qualifications and training. The new policy was scheduled to be released in January 2019.

Establishing healthy behaviors at an early age has been supported by research in the New England Journal of Medicine noting “excess weight gained before age five increased the chances of obesity at age 12 by four times the rate as compared to normal weight children.” According to the 2017 Child Care Profile-Child Care Aware of North Dakota, 70.9% of children ages 0 to 5 had both parents in the labor force. With the large percentage of children in North Dakota spending time in care outside of their home, the early care and education setting is one of the best places to reach young children with obesity prevention efforts. Through funding from the Pediatric Obesity Collaborative Improvement and Innovation Network (CoIIN), the MCH Nutritionist led a collaboration with Child Care Aware of North Dakota, the North Dakota Department of Human Services, NDDPI, and the Head Start Collaboration Office, to coordinate a Train-the-Trainer event on March 18, 2018, related to nutrition and physical activity best practices for early care and education providers. The training was adapted from, curriculum for the ChildCareAlive! Shaping the First Five Nutrition & Active Play programming offered since 2014 through ChildcareAlive!. Further information on the training can be found at: http://www.childcarealive.org/. Five professionals were trained to offer the programming and to encourage sustainability, Child Care Aware ensures the program is approved through the North Dakota’s workforce training registration for child care providers and coordinates training locations, dates and times with the trainers. 

Title V staff partner with the Women, Infants and Children (WIC) Program and their work to reduce obesity and increase physical activity. WIC is an important partner in addressing healthy weight among the MCH population. Local WIC staff conduct nutrition risk assessments (including collecting body mass index information), provide personalized nutrition education, promote and support breastfeeding, provide tailored food packages that include fresh fruits and vegetables, whole grains, and low-fat dairy products, and make referrals to other community and health services. In 2018, data from LegeNDS (North Dakota WIC MIS) indicates that 13% of children were assigned the at risk of overweight or overweight children risk code and 9% were assigned the obese children risk code at certification. In North Dakota, childhood overweight/obesity is of concern among American Indian children who historically are more likely be obese then non-Native child participants.

Title V staff also followed and supported a number of promising initiatives within local communities that impacted childhood obesity such as the Child Care Physical Activity ordinance in Cass County (being implemented by MCH grantee Fargo Cass Public Health) and Go!Bismarck-Mandan (MCH grantee NDSU Extension is an active member of this committee). While these are not statewide initiatives, these models can be replicated in other communities/counties.

When it comes to obesity prevention, breastfeeding has been proven to help reduce obesity. Breastfeeding promotion and support are also an integral component to work of the MCH Nutritionist. Information regarding breastfeeding strategies and activities are discussed in the Perinatal/Infant Health domain, breastfeeding priority.

Challenges remain in schools. North Dakota is a local controlled state, which means each district can ultimately determine what they will and won’t do when coming to policy. The end of the Diabetes, Heart Disease, Obesity and School Health (DHDOSH-1305) funding and not receiving any further money to enhance school health makes it much more challenging to the improvement of a healthy school environment.

Critical Partners:

• North Dakota Department of Public Instruction
• NDSU University Extension
• Fargo Cass Public Health
• South East Education Cooperative
• NDSU, Master of Public Health Program
• North Dakota School Board Association
• Regional Education Associations
• Dakota Medical Foundation

MCH Population Domain: Child Health

National Performance Priority Area: Preventive Dental Visit

North Dakota Priority: Increase Preventive Dental Services to Children – 2018 Annual Report Narrative (October 1, 2017 – September 30, 2018):

The burden of oral disease is not uniformly distributed throughout North Dakota. Access to oral health services is an ongoing concern and challenge. Vulnerable and underserved populations face a variety of barriers to oral health care, including transportation issues, lack of insurance or ability to pay for care, inability to take time off work to go to the dentist or transport their children, limited availability of providers accepting Medicaid and lack of understanding of the importance of good oral health and its impact on overall health. The limited oral public health infrastructure, particularly in rural counties and lower economically impacted state regions, has provided limited options for families in need. The existing oral health safety-net facilities are overburdened and cannot take on more patients without expanding their infrastructure.

Disparities in oral health exist among specific population and age groups in North Dakota. A significantly higher proportion of minority children have decay, experience untreated tooth decay, and have urgent dental needs. According to the 2017-2018 Oral Health Basic Screening Survey (BSS), one in five (23%) third-grade students ages 8-11 assessed has untreated caries. American Indian (AI) children in third grade experienced more dental caries (tooth decay) than white children (93% vs. 63%); had more untreated dental decay (43% vs. 17%); and had lower rates of sealants than White children (46% vs. 50%).

Third-grade children at schools with more than 50% of students eligible for the National School Lunch Program (NSLP) had higher rates of tooth decay (81%) compared to schools with less than 25% of children enrolled in NSLP (64%). These children also had higher rates of untreated decay (31% compared to 16%). 

North Dakota adolescents are also at risk for dental caries. According to the 2017 Youth Risk Behavior Survey (YRBS), 17.8% of students in in grades 9-12 reported to have three or more cavities in their permanent teeth, and approximately one in four middle school students (28%) and high school students (1.4%) reported not having had a dental visit within the previous 12 months.

The State Oral Health Program (OHP) has conducted an Oral Health Basic Screening Survey (BSS) every other year. The BSS is a non-invasive, open-mouth survey developed by the Association of State and Territorial Dental Directors (ASTDD) to assess and monitor the oral health status of key populations such as third graders, kindergarteners, Head Start and/or older adults. A third grade BSS was conducted in the 2017-2018 school year on third graders per ASTDD guidance and due to the need for more trend data among third grade students. 

Established in 2008, Seal!ND continued to increase access to preventive dental care to underserved populations. The program continued to employ two public health hygienists that provided services in schools. Services offered with this program included: oral health screenings, oral health education, dental sealants, fluoride varnish and referral to a dental home if needed. Fluoride varnish and sealants are best practice strategies in reducing dental decay in children. The collaboration and partnership with Valley Community Health Center, Family Healthcare Center, Northland Community Health Center, the Ronald McDonald Care Mobile and Bridging the Dental Gap (safety net clinics) and eleven private practice dentists has enabled the OHP to expand preventive oral health services, showing the program exceeded their expectations of the original three to five private practice dentists to implement the school-based dental sealant program. Additional partnerships are anticipated to expand the program.

While Maternal and Child Health (MCH) Block Grant funds provided support to the OHP, funding for Seal!ND that was provided through the Health Resources and Services Administration (HRSA) Oral Health Workforce Grant ended on August 31, 2017 and the Centers for Disease Control and Prevention Oral Health Grant (CDC) ended on August 31, 2018. Two new grants were awarded to North Dakota on September 1, 2018 from HRSA and CDC, which focused on building and strengthening connections for medical/dental collaborations to occur and enhanced the oral public health infrastructure and capacity for placement of a public health hygienist into a medical facility to provide oral health screenings, fluoride varnish, education, referrals and care coordination to the low-income and uninsured population. Also, Otto Bremer and Delta Dental grants were received to maintain and expand the Seal!ND program for the upcoming year.

The MCH Block Grant also funded the North Dakota Dental Foundation (NDDF) to implement a telehealth pilot project. Funding enabled the NDDF to purchase equipment necessary to carry out teledentistry. The equipment was used in various dental practices and provided oral health services at the first Mission of Mercy event which served 916 North Dakota citizens in need of oral health care. However, due to change in personnel at the NDDF, this project did not move forward as anticipated. The new executive director of the NDDF and OHP continued to collaborate on how to move this forward and engaged new and existing state and national partners.

The Evidence-Based or Informed Strategy Measure (ESM) for increasing preventive dental services to children has been defined as the number of children that received dental sealants per school year. In the 2017-2018 school year, the OHP public health hygienists provided services in 29 schools, while private practice dentists and Federally Qualified Health Centers (FQHC’s) provided services to 20 schools. These 49 schools all met the criteria of 45% or greater of free and reduced fee lunch program. In these schools, 899 children received dental screenings, and of these, 331 students received a dental sealant. A barrier to accurate data collection was due to inconsistent reporting from some private practices and FQHC’s, therefore the numbers of children served in 2017-2018 are lower.

In late 2016, the North Dakota Oral Health Coalition (NDOHC) was integrated into the NDDF. The NDDF assists with helping individuals in North Dakota who do not have access to dental care through education and workforce initiatives. The alignment in priorities and activities between the NDOHC and the NDDF allowed for a smooth transition to better serve North Dakota’s oral healthcare needs. The OHP Director participated in quarterly ND Oral Health Coalition meetings.

In 2011, the North Dakota Department of Health (NDDoH) and the NDOHC developed the Burden of Oral Disease and the Oral Health State Plan for the Future years 2012-2017. This publication is comprised of two reports addressing oral health in ND, Burden of Oral Disease and the State Plan for the Future. The Burden of Oral Disease reports provides a comprehensive overview of demographic, socioeconomic and health status inequalities through the state. The State Plan for the Future outline’s key actions and quality improvement strategies to prevent oral health disparities and provide access to dental care, thereby preventing and reducing oral diseases and improving the overall health of North Dakota citizens. This document was not updated due insufficient time, changes in personnel, and the fact that the CDC did not require a burden document in the last five-year grant cycle. The OHP continued to collaborate with the chronic disease programs on the Chronic Disease State Report which included oral health.    

The OHP continued to promote the Smiles for Life curriculum for interested stakeholders such as in medical schools and in physician assistant, nurse practitioner and nursing programs. Unfortunately, there was no interest due to lack of capacity within their current curriculum. A public health hygienist provided in-person trainings at ten long-term facilities utilizing the Smiles for Life curriculum. The OHP contacted clinics, local public health and Head Start to determine interest in trainings and/or re-trainings for fluoride varnish application, but due to lack of interest, no entities were trained.

North Dakota has strong community water fluoridation programs; 97% of North Dakota’s population receives optimally fluoridated water through community water systems, which are monitored on a monthly bases utilizing the Water Fluoridation Reporting System. The OHP has continued to work collaboratively with the North Dakota Department of Health’s Community Water Fluoridation (CWF) program to sustain the community water fluoridation efforts and promote fluoridation as new water systems development. Continued trainings were provided quarterly for local water operator’s and systems were accessed for replacement equipment by the CWF program.

While efforts of this priority and work plan focused on children, the OHP continued work throughout the lifespan. The OHP focused efforts on the older adult population through support of a DentaQuest 2020 Grant. This grant focus is due to change in 2018-19 and North Dakota many no longer apply for this funding. Hence, an anticipated challenge will be how to stay engaged with this population.