NPM #6 Developmental Screening – Support adequate early childhood development and education.

 

Developmental screening is a short test to tell if a child is learning basic skills when he or she should, or if there are delays. Early identification of developmental delays is critical to the provision of timely interventions so that the adverse impact of such developmental delays is mitigated over the life course spectrum for the child. Since 2006, the American Academy of Pediatrics (AAP) has recommended that assessment for developmental problems among young children be incorporated into every preventive health visit and that formal screening occur at regular intervals, including the 9-, 18-, and either 24- or 30-month well-child visits.

 

According to data from the 2018-2019 National Survey of Children’s Health (NSCH), 30.6%* of Missouri parents reported they completed a standardized developmental screening tool during a health care visit, compared to 36.4% nationally. Nationally, children with special health care needs (CSHCN) (45.9%) were more likely to receive a standardized developmental screening than children who did not have a special health care need (32.3%). Two-parent married households in Missouri had a higher percentage that had a developmental screening (37.5%)* than their national counterparts (36.9%). In Missouri, 40.1% of those with private insurance received a developmental screening compared with 38.5% nationally. Fewer Males in Missouri (27.4%)* received a developmental screening than females (37.5%)*.

 

Comprehensive developmental screening can improve lives and outcomes for children and families. Since those who work with infants and young children can play a key role in the early identification of developmental delays, partnerships with public health providers, early childhood professionals, and home visitors are key to implementing developmental screening tools. The Missouri Department of Health and Senior Services (DHSS) collaborated with multiple stakeholders to make sure resources were available to educate families about key milestones.

 

Public Health Providers

The Missouri Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides developmental monitoring and referrals for developmental screening through the WIC Developmental Milestones Program. In FY19, 80 local agencies were participating in the program. Data from FY20 is unavailable due to challenges with implementing the program in local agencies during the COVID-19 pandemic. A survey to assess current local agency participation is planned for FY21-22. WIC continues to provide referrals for developmental screening to primary care physicians and programs including, but not limited to, ParentLink, Home Visiting, and IDEA diagnostics programs (i.e., First Steps or Early Childhood Special Education). Children with developmental delays identified through screening can then be referred for intervention.

In FY20, the WIC Developmental Milestones program used Title V grant funds to add the new CDC’s developmental checklist for five year olds, Your Child at 5 Years, in English and Spanish, to the list of available materials. Additional copies of Your Baby at 6 Months checklist were also printed for distribution to local agencies. In addition, funds were used to purchase the Baby’s Busy Day: Being One Is So Much Fun! book, a CDC LTSAE resource offered to promote brain and language development based on the public health campaign “Talking is Teaching: Talk, Read, and Sing”. A new ordering form was created to provide an updated listing of all available resources and improve the efficiency of ordering materials for the local agency.

The CDC developed a mobile application for parents to track a child’s milestones from ages 2 months to 5 years called the CDC’s Milestone Tracker App. Title V grant funds were utilized to add the CDC’s Milestone Tracker App icon to the WIC Shopper’s App, a mobile application tool utilized by WIC caregivers to manage and verify WIC benefits. Presence of the icon on the WIC Shopper’s App allows easy access and promotion of developmental monitoring. The mobile application provides outreach on the importance of developmental screening and public awareness to WIC families. WIC Shopper App data showed 12,812 clicks on the CDC’s icon from May through September of FY20.

Grant funds were also used to support planning for subsequent year projects. Missouri WIC began working in partnership with the Association of State Public Health Nutritionists (ASPHN) in implementing online educational modules and promotional materials for all states promoting CDC’s LTSAE initiative. The online modules will be available through WIC-ed.com, WICSmart, and WIChealth.org. The WIC local agencies in Missouri will promote the education modules to participants via WIChealth.org. Collaboration with internal partners at WIC also began in FY20 to implement tracking of developmental screening referrals to health care providers and ParentLink through the Missouri WIC MIS system. Completion of the referral tracking project is set for FY21.

 

The Maternal Child Health (MCH) Services Program surveyed the Local Public Health Agencies (LPHAs) regarding the type of infant and early childhood developmental screening being provided and the screening methods and tools being utilized. Fifty-four LPHAs reported providing infant developmental screening and referral for suspected/identified delay, although no consistent screening tool was reported as being utilized, and 99 reported referring infants for developmental screening. Cape Girardeau County Public Health Center reported using the Denver Developmental Screening Tool at the health department’s rural health clinic. The WIC departments of Barry, Carter, Hickory, Polk, and Texas county health departments, along with several other LPHAs, were part of a pilot phase in the implementation of Developmental Milestones, a screening and educational program developed by DHSS in partnership with the University of Missouri based on CDC’s LTSAE public health campaign. Columbia-Boone, Kansas City, Phelps/Maries, Randolph and St. Louis county health departments reported using the Ages and Stages Questionnaire-3® (ASQ3). A total of100LPHAs reported working with community partners to provide infant developmental screening and/or referral. Not all of the LPHAs were aware what screening tool(s) were being utilized by outside referral agencies. However, Butler County Health Department reported the Ages and Stages Questionnaire®: Social-Emotional (ASQ®:SE) and ASQ3 were utilized by the Early Head Start Home Based Program, Lincoln County Health Department reported the Parents as Teachers (PAT) Program used the ASQ and DIAL-4, Springfield-Greene and Taney county public health agencies reported PAT used DIAL-4, and Vernon County Health Department reported the PAT and Early Head Start programs use the ASQ3.

 

Missouri continued participation in the Maternal Child Environmental Health (MCEH) Collaborative Improvement & Innovation Network (CoIIN) to support and improve coordinated systems of care to address the needs of maternal, infant, and child populations that are at risk for, or experience exposure to lead. Since 2018, activities included: forming a state team, participating in planning and evaluation webinars, implementing outreach and education campaigns in targeted areas of the state, and presenting at Learning Sessions. This project began the development of a strong partnership between Missouri’s Title V Program and CLPPP. Plans are to continue COIIN project activities and partnerships to more effectively improve lead poisoning prevention efforts. Each year, new areas of high risk will be identified and targeted for outreach and education.

 

Early Childhood Professionals

In FFY2020, the Child Care Health Consultation Program offered 16.25 hours of continuing education trainings for child care providers, 4.5 hours of specialized consultation, and 6 technical consultations regarding developmental screening service referrals and well-child care. The purpose of offering this service is for more families to be educated about the importance of, and be referred to a direct source for developmental screening and well-child care so that children receive additional support if needed.

 

Staff with the Section for Child Care Regulation (SCCR) referred child care providers to the Inclusion Specialists when there were concerns regarding the development of a child in care. SCCR staff provide the contact information for the Inclusion Specialists and the information is also located on the SCCR website. Child Care providers are able to seek assistance from the Inclusion Specialists to implement strategies and make environmental changes to accommodate the needs of a child in care while maintaining compliance with rules and regulations. The recommendations may include changing the room arrangement, providing training to the staff, assisting with scheduling, guiding providers to adapt programming, or providing resources. The Child Care Inclusion Specialists assisted families to locate and coordinate services to meet the developmental needs of the children they serve. Inclusion specialists assess the needs of the child in relation to proper child care placement. Through child observation and consultation with the family, they are able to ascertain what services the child is currently receiving, identify what might be available, and assist with the coordination of services moving forward.

 

In St. Louis, Vision for Children at Risk (VCR) implemented LEAP (Learning Everything at Pace) Ahead St. Louis. VCR uses the Brooks Publishing Ages and Stages Questionnaire Enterprise system to track developmental and social/emotional screenings completed by VCR and their 15 partner sites. The Boone County Early Childhood Coalition continued promoting an online screening hub for parents and providers to complete screenings using the Survey of Wellbeing of Young Children (SWYC) and track children with the goal of increasing the number of children being screened in Boone County.

 

The Missouri Milestones Matter (MMM) program team recruited 19 child care facilities to begin piloting in the fall of 2019. The pilot ended in May 2020. In the spring of 2020 the MMM program was chosen to be published as a cutting-edge practice in AMCHP Innovation Station. The Missouri Department of Elementary and Secondary Education was the recipient of the Preschool Development Grant: Birth to Five (PDG: B-5) in 2020 and have funded training along with an implementation guide. Training participants have included child care facilities along with home visiting programs. Through PDG: B-5 the LTSAE campaign materials are now a part of the overall early childhood system in Missouri and are promoted to parents and service providers.

 

Home Visiting

In FY20, 92.2% (392/425) of enrolled children ages 9, 18, and 30 months received a developmental screening using ASQ-3, a validated screening tool through Maternal, Infant and Early Childhood Home Visiting (MIECHV), Building Blocks (BB), and Healthy Families Missouri Home Visiting (HFMoHV) programs. ASQ-3 developmental screening tool consists of 21 questionnaires. It is used to screen children ages 2 months to 60 months; each questionnaire contains 30 developmental items including communication, gross motor, fine motor, problem-solving, and personal/social development subscales. Parents or caregivers try activities with the child and check the box that best describes what the child can do (yes, sometimes, or not yet).

 

Additional resources shared with all GHC contracted home visiting staff through the Missouri Home Visiting Gateway Weekly Update included:

• 1/24/20 – Link – Strengthening the Developmental Screening Process
• 4/10/20 – Link – WIC Developmental Milestones Program
• 8/28/20 – Link - How Co-Created Goals Support Social Emotional Development
• 10/25/19 – Link - Five Ways Pediatrics Can Support Social Emotional Development
• 10/4/18 - Boston Basics are five evidence-based parenting and caregiving principles that encompass much of what experts find is important for children from birth to age three.
• 3/1/19 - First Steps is Missouri's Early Intervention system that provides services to families with children from birth to three years of age with disabilities or developmental delays. Resources:
  • Missouri First Steps Program Brochure
  • General Information
  • Eligibility Criteria
  • Regional Contact Sheet

• 6/28/19 -The Devereux Center for Resilient Children (DCRC) is committed to promoting partnerships between the most important adults in a child's life - parents, family members, as well as early care and education professionals. Resources:
  • Infant/Toddler Activities
  • Preschool Activities

 

In addition to the efforts listed above, additional resources are available to educate families on the importance of developmental screening. The Newborn Health program distributed the Pregnancy and Beyond book, which outlines developmental milestones to correspond with each well-child check and encourages parents to discuss these with their doctor if their child is not reaching these milestones. These booklets are handed out at hospitals and doctors’ offices and cover pregnancy, infancy, and childhood up to age 5. Public awareness materials focused on the importance of developmental screening were available at health fairs and conferences throughout the year. The public awareness materials included a new growth chart that has developmental milestones for children from birth to age six. The growth charts have been very popular, being ordered by schools, clinicians, and early childhood programs.

 

* Interpret with caution due to sample size limitations.

 

NPM #7 Injury Hospitalization – Reduce intentional and unintentional injuries among children.

 

Injuries (intentional and unintentional) are the leading cause of mortality and morbidity in Missouri children. Missouri’s rate of non-fatal injury related hospitalizations among children ages 0 through 9, decreased increased by almost 14% from 120.4 per 100,000 persons in 2018 to 137.2 per 100,000 persons in 2019.  Unintentional injury deaths continue to be the leading cause of death among MO children 1-9 years old, and in 2018, the main causes were motor vehicle accidents (13) and Exposure to Smoke / Fire / Flames (14), followed by drowning (10). Almost all of these tragedies are preventable, which is why Missouri implemented strategies to collaborate, raise awareness, and provide resources to address this issue.

 

Certain strategies in Missouri for NPM #7 impact both the child and adolescent populations. However, to avoid duplicative narrative, strategies were only listed in one or the other population domain. Activities that had a larger focus on the child population are listed below, but it should be noted that some may address a wider age group.

 

Local Public Health Agencies (LPHAs)

A strong local public health network is needed to promote health and protect the public from public health risks. LPHAs addressed injury prevention in their communities through their MCH work plans. The MCH Services Program assisted their efforts as listed below.

 

Promote General/Traffic Safety

A total of 89 LPHAs reported providing general safety education; 95 LPHAs reported providing car seat education, installation, and inspection; 83reported providing education on proper seat belt usage; and 93 reported providing child passenger safety education. Traffic safety highlights included:

• Dunklin, Harrison, Laclede, Miller, Putnam, Gasconade, and Texas county health departments among many others continued to have at least one Certified Passenger Safety Technician on staff and provided child passenger safety seat inspections, education, installations, and free child passenger seats as needed for children that did not have a child passenger seat or were in unsafe seats due to size, weight, and/or expired/damaged seats.
• Many LPHAs utilized existing partnerships to provide car seat and seat belt safety education to area child care facility staff and discussed referral options available to share with parents (i.e. car seat inspection/installation, etc.).
• Webster County Health Department partnered with their local Division of Motor Vehicle (DMV) office to provide educational materials/resources to new drivers at the time of licensing.  This included a teen/parent driving agreement as well as resources for new driver courses (MU’s First Impact via Zoom).
• Caldwell County Health Department was able to distribute child passenger seat and seatbelt education to childcare providers as well as the DMV for dissemination.
• Some LPHAs are taking the opportunity of when a parent/teen comes into the health department to obtain a birth certificate for the purpose of a driving test/licensing to give out safe driving materials/opportunities for education (MU First Impact Zoom class schedule, etc.).

 

Prevent Unintentional Injury

A total of 87 LPHAs reported addressing home and school safety, 65 reported addressing bicycle safety, 21 reported addressing farm safety, 24 reported addressing all-terrain vehicle (ATV) safety, and 58 reported addressing fire safety. Examples of LPHA activities included:

• Callaway County Health Department provided “I Can Bike” in collaboration with a community member for the handicap population to teach them how to ride a bike and the safety precautions to implement.
• Harrison County Health Department, in partnership with other community partners, hosted an annual Fall safety event titled Scare on the Square to promote children’s safety during Halloween.  
• Moniteau County Health Department created an Unintentional Injury pamphlet that is being used as an additional component in CPR trainings offered to child care providers. The health department also provided bicycle safety education to the Pre-K class in California, teaching pre-K students about the importance of wearing a helmet while riding their bicycles.  

 

Suicide/Violence/Substance Abuse Prevention

Multiple LPHAs targeted their efforts to address suicide, violence, and/or substance abuse prevention in their MCH Work Plans. Additionally, a total of 98 reported addressing child abuse and neglect, 56 reported addressing domestic violence, and 54 reported providing bullying prevention information and training. Highlights of this work included:

• Butler, Iron, Linn, St. Francois, Vernon, and Webster county health departments conducted anti-bullying education for children in child care settings.
• Many LPHAs collaborated with community partners to successfully pass community ordinances for Prescription Drug Monitoring Programs (PDMP); other LPHAs provided training to community members and first responders on proper Narcan usage and distributed Narcan to area first responders and law enforcement.
• Laclede County Health Department provided Stewards of Children trainings to childcare providers and faculty at local school districts in Laclede County.  The purpose of the Stewards of Children training is to teach others to recognize signs of sexual abuse and how to intervene and react responsibly.  The health department also used the Developing Nurturing Skills curriculum with childcare providers and school faculty.
• Camden County Health Department partnered with the Council for Drug Free Youth to provide TEAM to 7th and 8th grade students at Camdenton Middle School to target alcohol, marijuana, prescription drugs, heroin, and meth.  This program encourages trust, understanding and acceptance among peers through communication with strong substance-abuse prevention message. The health department also shared vaping and substance use education for their Family Night event at Camdenton Schools.Osage County Health Department used the HALO (Healthy Alternatives for Little Ones) curriculum to teach preschool and Kindergarten aged children about both healthy and harmful choices, including drug prevention, stress management, family communication and feelings.

Water Safety

A total of 65 LPHAs reported addressing water safety, with several reporting using the Josh the Otter educational curriculum. Camden County Health Department (CCHD) continued their Water Safety efforts, partnered with the Missouri State Water Patrol and Make a Wish Boat Ride Program, and supported the Life Jacket Loaner Boxes in two locations. The boxes were stocked with life jackets for all ages to use as a loaner and return after use. CCHD also continued to provide stencils to grow the number of locations in the area that have “Life Jacket Zone” painted in an eye-catching bright orange to remind boaters of all ages to don life jackets as they approach boat ramps, docks, and water access areas.

 

Child Care Providers

In FFY2020, the Child Care Health Consultation (CCHC) Program offered 881 hours of continuing education trainings for child care providers, 214.5 hours of health promotions for children in child care, 89.5 hours of specialized consultation, and 44 technical consultations related to child safety and injury prevention topics. This included information about bullying, fire, guns, poisoning, alcohol, drug, motor vehicle, TBI, playground, child abuse, sun, lead poisoning, CPR/First Aid, suicide, and water. By offering these services, the CCHC Program increased knowledge of child care providers resulting in safer child care environments. Health promotions also increase the knowledge of the children.

 

Injury Prevention

The Injury Prevention Program serves as the state lead for Safe Kids Worldwide and provided funding for ten Safe Kids coalitions covering 59 counties in Missouri. Too many families don’t have access to the information and resources they need to keep their kids safe from tragedies such as drownings, car crashes, fires, and falls. These coalitions are a grassroots network that work closely with community partners to fill that gap and prevent unintentional childhood injuries. Program areas addressed by the coalitions included child passenger safety, bicycle safety, fire safety, firearm safety, safe sleep, water safety, poison control, heatstroke prevention, and other areas based on community needs. The coalitions offered a broad array of activities to achieve the performance goal, which included providing car seats and education to parents of young children, conducting car seat checks, working with water patrol to provide water safety education, hosting educational events, and conducting media campaigns with prevention messages. In FFY20 these coalitions provided services to over 54,000 children and parents through over 400 educational events. At these events over 1,700 child safety seats were distributed and over 2,000 car seat checks were conducted. To increase workforce development, the Safe Kids Missouri Leadership Workshop was conducted in September to educate coalition leaders and other partners about a wide range of topics including information from the University Extension on ATV safety, Water Patrol on water safety, Safe Kids Worldwide, Missouri Foundation for Health, and COVID19.

 

The Injury Prevention Program coordinated the Missouri Injury and Violence Prevention Advisory Committee (MIVPAC), which serves to provide advice, expertise, and guidance to the Missouri Injury Prevention Program and to establish injury prevention as a state priority. The Committee consists of representative members from state agencies, local and regional government agencies, non-government bodies, and consumers. Its goal is to reduce the morbidity and mortality of children aged 0 -19 years due to injuries and violence. MIVPAC continued to focus on work addressed in the MIVPAC Strategic Plan, review data to determine critical target areas for injury prevention, and identify evidence-based interventions to address the priorities established by the Strategic Plan.

 

NPM #14 Smoking – Reduce childhood exposure to secondhand smoke.

 

The home is the place where children are most exposed to secondhand smoke. According to NCSH 2018-2019, 20.2% of Missouri children live in households where someone smokes compared with 14.4% nationally. Nationally, children from high school graduate households were most likely (26.0%) to be living with smokers, followed by households with some college (19.7%) and less than high school (18.6%), and college graduate (7.7%) households. The proportions of children exposed to secondhand smoke in Missouri were higher than the national figures for high school graduate households (37.5%), some college (28.2%), and college graduate households (11.5%). In addition, Medicaid insured children were more likely to be exposed to secondhand smoke in the home (22.2%) than their privately insured (10.5%) and uninsured (15.2%) counterparts nationally. Missouri children who were privately insured (15.6%) or on Medicaid (34.2%) also had higher percentages of secondhand smoke exposure than their national counterparts. In Missouri, 21.7% of non-CSHCN children lived in households where someone smoked compared to 22.4% of CSHCN. Unmarried two-parent households had the highest proportion of smoking in Missouri (37.7%)*. This was greater than single parent households (28.6%) and more than double the proportion for two-parent married households (17.5%). Children age 12-17 years had the highest percentage in Missouri (23.3%), compared with (16.2%) nationally. Compared with their national counterparts (16.3%), a greater percentage of non-Hispanic White children were exposed to smoking in Missouri (23.4%).

 

Missouri has made progress in increasing the number of communities that have ordinances to prevent secondhand smoke exposure in public places. As of 2019, there are 37 communities with comprehensive smoke-free ordinances, which is more than double the number of communities (15) in 2010. Teaching youth about the dangers of tobacco use and increasing smoke-free laws and policies such as smoke-free homes and vehicles can have a positive impact on the MCH population.

 

In FFY2020, the Child Care Health Consultation (CCHC) Program provided three hours of continuing education trainings for child care providers regarding the dangers of secondhand smoke, and one health promotion for children in child care regarding smoking prevention. The purpose for offering these services was to decrease the number of children exposed to secondhand smoke by increasing child care provider knowledge about the dangers of secondhand smoke to children’s health.

 

The MCH Services Program supported LPHA efforts to eliminate exposure to secondhand smoke and identify and eliminate tobacco-related disparities among population groups. Of the 114 LPHAs, 37 reported providing classroom tobacco-avoidance education, 97 reported having tobacco-free policies and/or ordinances in place for public buildings/spaces, 30 reported participating in secondhand smoke prevention campaigns, 44 reported participating in electronic cigarette prevention campaigns, and 107 reported providing maternal tobacco assessment, cessation, and education, as well as referral to the Missouri Tobacco QuitLine.

 

Highlights of the LPHA efforts included:

• Clay County Health Department developed a prenatal/postpartum smoking cessation program “Tobacco Free….Let It Be,” targeting WIC participants who report active or recent smoking and providing them with the resources for successful cessation.
• Cole County Health Department collaborated with HUD (Housing and Urban Development) to pass a NO SMOKING ordinance in rental homes.
• Dent County Health Center provided high school students with Taking Down Tobacco training; the students returned to their high school as peer educators.
• Harrison County Health Department worked with faith based organizations to implement formal tobacco free policies and provide signage to serve as a consistent message.
• Scott County Health Department provided lung screenings using Forced Vital Capacity testing to evaluate lung function, which may indicate the need for referral and follow-up with a medical provider.
• St. Genevieve County Health Department checked birth records of new mothers who were reported as smoking tobacco and made contact to provide cessation education and referral resources.
• Many LPHAs, including Jackson, Laclede, and Osage counties, provided vaping education on risks, dangers and cessation to students in their local schools.
• Many LPHAs worked with community partners to ensure current tobacco-free ordinances and policies were updated to include the use of vaping products.

 

* Interpret with caution due to sample size limitations.

 

NPM #15 Adequate Insurance – Ensure adequate health insurance coverage and improve health care access for MCH populations.

 

According to NSCH 2018-2019 data, 60.9% of Missouri children were adequately insured compared with 66.8% nationally. The percentage of adequately insured children differed by age groups and CSHCN status. Children in Missouri ages 12-17 (60.5) had the lowest rates of adequate insurance coverage, followed by 6-11 year olds (67.0%) and 0-5 year olds (73.8%). Children with special healthcare needs (64.6%) were less adequately insured than non-CSHCN (67.9%). Missouri high school graduate households had the highest percentage of children who were adequately insured (72.5%) compared to households with some college education (69.6%) and college graduate households (63.7%). However, the percentage of college education households that were adequately insured in Missouri was lower than national averages (67.1%). Those in Missouri with private insurance (62.6%) were less adequately insured than those on Medicaid (87.0%). Medicaid recipients in Missouri were also more adequately insured than their national counterparts (81.9%). Two-parent unmarried households (67.1%)* were more adequately insured than two-parent married households (66.9%) and single parent households (65.7%) in Missouri, but less than their national counterparts (70.8%). Nationally, non-Hispanic Blacks (71.3%) were more adequately insured than non-Hispanic Whites (67.0%) and Hispanics (66.0%). This was mirrored in Missouri, as non-Hispanic Blacks (74.3%)* were also more adequately insured than non-Hispanic Whites (66.7%) and Hispanics (62.2%)*.

 

In FY19, 80% (558 out of 702) of Missouri primary caregivers enrolled in Department of Health and Senior Services’ (DHSS) funded home visiting programs had continuity of health insurance coverage for 6 months in the previous year’s enrollment. Since Missouri did not participate in Medicaid expansion, many low-income adults, the population targeted for home visiting services, did not have sustainable insurance coverage following the closure of MO HealthNet for pregnant women coverage 56 days after the birth of the baby. The Missouri home visiting team, in collaboration with the Department of Social Services (DSS), improved and expedited the Medicaid enrollment process for home visiting clients by developing and continuing to update a Q & A document, which home visitors use to educate clients on navigating the Medicaid enrollment/eligibility process for pregnant women. Additionally, DSS provided a point of contact for home visitors to reach if issues arose with getting eligible clients enrolled in a timely fashion. Getting pregnant primary caregivers enrolled in Medicaid more quickly has enabled clients to initiate prenatal care earlier in their pregnancies.

 

Access to adequate health insurance continues to rank as a high priority for Missouri’s MCH populations, particularly for Medicaid populations. There are many barriers to accessing healthcare, and rural areas in general experience large gaps in access to preventive, primary, and dental care. This is a prominent issue in Missouri where 99 of its 115 counties are classified as rural. Of the 126 licensed general acute care hospitals in Missouri, 59 are located in rural areas, with 25 of these classified as Critical Access Hospitals, which offer a limited range of services. A total of 84 of the 106 Primary Medical Care Health Professional Shortage Areas (HPSAs) in Missouri are in rural areas.

 

In 2017, 78 of Missouri’s rural counties had poverty rates above the state average. As of 2017, the poverty rate for rural residents (16.2%) was 35.0% higher than the urban poverty rate (12.0%). Lack of access to care can have serious consequences for vulnerable populations, particularly pregnant women. Deficiencies of rural healthcare result in a higher burden of illness among rural women compared to their urban counterparts. The lack of physicians, limited technology, and transportation issues, compounded with the economic state of many rural Missouri residents, is cause for concern in the area of women’s health.

 

Due to these access issues, rural Missourians tend to have less access to postpartum healthcare, and experience a delay in prenatal care initiation due to an inability to get an appointment with a healthcare provider. In general, rural Missourians have higher emergency department (ED) utilization rates for all diagnoses than urban residents. Females in rural areas have higher ED utilization rates than males. This can be interpreted as an indication that primary care is lacking in rural communities, and that this deficiency impacts females more than males.

 

Health care resources in rural Missouri are limited, even for those who have health insurance, have no financial difficulty, and have access to transportation. Receiving adequate health care for those who are low-income, uninsured, and geographically isolated is even more challenging. By working with health care providers and communities, access to care can be improved for the underserved. Title V worked to both ensure adequate health insurance coverage and improve health care access for MCH populations through education, referrals, and by providing resources and technical assistance.

 

In FFY20, over 21,000 Pregnancy and Beyond booklets were distributed to health care providers and other providers throughout the state. The Pregnancy and Beyond booklet is a tool for a pregnant woman and her health care provider to track the progress of her pregnancy. The book allows women to record their health information. Taking the book to prenatal visits can help women remember questions and write down special instructions from their health care provider. The book discusses the importance of prenatal care and shares the phone number for TEL-LINK, if a woman does not know where to go for prenatal care. TEL-LINK is the Missouri DHSS’ confidential, toll-free telephone line for maternal and child health care. The purpose of TEL-LINK is to provide information and referrals to Missouri residents concerning a wide range of health services. Callers requesting referrals are transferred to the appropriate agency. In FFY20, TEL-LINK referred 227 callers to Medicaid/MO HealthNet services. Another resource, Text4baby, allows women to enroll in the program to receive three text messages each week. The program delivers customized messages within the first few weeks of pregnancy about free or low-cost healthcare. During week 12 of pregnancy, participants receive a text that reads “Need help paying for prenatal care visits? Medicaid pays for pregnancy check-ups & delivery. Info at 800-835-5465 or finder.healthcare.gov”. Another text is sent in week 15 that states “Even if you feel great, a pregnant woman needs check-ups with a Dr. /midwife (CNM/CM). For help with costs, call 800-835-6465 or finder.healthcare.gov”. Accumulative data since July 1, 2016 showed that 8% of enrollees in the Text4baby program did not have insurance at the time of enrollment, and 66% of those enrollees applied for Medicaid.

 

The Bureau of Genetics and Healthy Childhood (GHC) served 966 families through four evidence-based home visiting models. During FY19, home visitors from these models assessed all home visiting clients for insurance status at initial enrollment and periodically throughout enrollment. As needs for health care coverage were identified, home visitors assisted clients/families in the Medicaid enrollment process and through referrals to the Affordable Care Act (ACA) marketplace. Clients were referred to their nearest federally qualified health center to speak with a trained navigator in order to obtain eligibility and enrollment assistance. Data from FY19 indicated that 96% of children and 80% of primary caregivers enrolled in home visiting had insurance coverage through Medicaid, private, or other insurance at some point during the preceding year. From November 1st to December 13th of 2019, weekly reminders of Open Enrollment on the Health Insurance Marketplace were shared with all home visitors through the Missouri Home Visiting Gateway Weekly Update.

 

The majority of LPHAs worked to ensure adequate health insurance coverage and improve health care access for the MCH population, and of the 114 LPHAs:

• 107 reported screening clients for MO HealthNet or other insurance coverage;
• 103 reported screening for an identified primary care provider;
• 106 reported performing pregnancy testing, prenatal education, and OB/GYN referrals;
• 64 reported providing prenatal case management and/or referral for pregnant women; and
• 75 reported assisting pregnant women with Medicaid enrollment eligibility.

 

LPHAs strive to provide services to cover the gaps in service areas that result in improved health care access for the MCH population. Some highlights of these service areas for the local agencies include:

• Camden County Health Department refers pregnant women to the Federally Qualified Health Center (FQHC), Central Ozarks, which has a patient navigator who assists with temporary Medicaid enrollment. This navigator is also available to help all others who are in need of insurance coverage. The FQHC also offers a sliding scale fee for services.
• Cole County Health Department provides referrals to Aspen Dental, which provides free dental exams to uninsured children.
• Livingston County Health Center’s Certified Diabetic Counselor provided one-on-one consultation and education for individuals with diabetes and their family members regardless of an individual’s insurance status.
• Multiple LPHAs are offering reduced-price laboratory testing with a doctor’s order to all regardless of insurance coverage status.
• Grundy County Health Department offered free newborn home visits to mothers regardless of insurance status, in which a nurse provided support and education on infant care, postpartum care, and breastfeeding.
• Multiple LPHAs offered temporary Medicaid enrollment services to pregnant women and offered assistance in the coordination of WIC services and scheduling of the initial prenatal appointment with a local OB/GYN provider.
• Phelps/Maries County Health Department refers those who are under or uninsured to Your Community Health Center, a FQHC that provides medical and dental care. Refer to Prevention Consultant for Teen Outreach Program.

 

LPHAs reported an increased health equity focus and increased staff education on providing resources and services to ensure equitable access to health care and reduce health disparities. Adair County Health Department provided special immunization and communicable disease services to a large Congolese population, and several LPHAs provided special services to Amish and Mennonite populations, including special mass immunization clinics and after-hours private clinic visits. Callaway County serves a large deaf population. The Callaway County Health Department has a nurse on staff that is fluent in American Sign Language (ASL) and is able to use that to communicate and provide services.

 

In FFY2020, the Child Care Health Consultation (CCHC) Program offered 2 technical consultations regarding health care access, 14 technical consultations regarding WIC referral, and 4 technical consultations regarding MO HealthNet service referrals. Consultations are provided to child care providers and/or the children and families they serve to assist in meeting a particular need. Consultations regarding referrals provide connections to local resources to help fulfill a child’s need, specifically access to care, insurance, and WIC. By offering these services, more families receive education and are referred to a direct source for insurance and/or WIC enrollment so that more children are adequately insured and have access to needed health care and proper nutrition. As a result, child care providers are aware of services within the community and are knowledgeable to make referrals to families when needed in the future.

 

The School Health Program (SHP) continued to engage partners in local communities and statewide to support school nurses in their efforts to connect students and families with health care resources and health services. As a member of the advisory council for the Show Me School Based Health Alliance, SHP encouraged schools and communities to partner with local providers and FQHCs to support primary care and health services near where students learn. Presently, school-based and school-linked health services are present in 79 of the 115 counties in Missouri through local community partnerships, with sites planned to expand access to services in three additional counties and adding programs in many other counties. These programs enhance access to care for children and families in mental/behavioral health, primary care/physical health, oral health and vision care services.

 

SHP provided educational opportunities for school health services staff through the Nurse Education Webinar Series (NEWS), a set of live presentations that are also recorded and archived in a learning library for later viewing. This programming focused on the latest information relating to managing children with health issues and special health care needs in the school setting, as well as professional development in school nursing practice. An ongoing effort for SHP is to support school nurses to better understand the processes for Medicaid/MO HealthNet enrollment and the options in managed care plans under the state plan system. The annual NEWS programming included a well-attended session on 11/20/2019, with the Legal Aid Societies covering Missouri, titled Access to Care: Partners in the Community. The presenters explained the Medicaid system and the services their organizations offer to assist families with applications and eligibility issues. As a collaborating partner with Cover Missouri Coalition and the Medicaid Advisory Group, the SHP is actively engaged in promoting access to health insurance with community agencies to connect uninsured families to Medicaid programs and other health insurance options available in their region and understanding areas of need across the state. SHP continued to promote the School Nurse Link (www.schoolnurselink.com) as a resource available to all school nurses as they work to support families to access services and utilize their healthcare and insurance plan benefits, as well as help to find health insurance resources.

SHP has worked with 19 participating schools to implement the TEAMS project (Enhancing School Health Services through Training, Education, Assistance, Mentorship, and Support), which supported school health policy improvement for 131,626 students in Missouri. The project began in 2017 and wrapped up with the final Local Education Agencies (LEAs) completing their modules in January 2020.

With the start of the school year each fall, the SHP continues to use the School Health Online Reporting System (SHORS) to collect student enrollment, student health information, and health office staffing reports. Despite participation for SHORS reporting being voluntary, we continue to have over 80% of the 518 public school districts in Missouri reporting, and reporting from the Charter systems and many of the private and parochial schools. The Special Health Care Needs survey allows the SHP to monitor key chronic health conditions through aggregate reporting, along with district reporting on the number of students with health insurance. The SHP encourages school nurses to use this health insurance information to target students and families in need of health care resources and assist them to enroll in health plans and establish medical and health care homes. School nurses understand that students with chronic health conditions are especially in need of a medical home to coordinate care and manage conditions. In the 2019-20 school year, the SHORS reporting represented 84% of MO public school students and 34% of these districts reported collecting health insurance information.

 

The SHP has ongoing efforts to improve the number of LEAs reporting as well as to grow the number of districts assessing student health insurance status. In February 2020, SHP distributed a survey to 432 lead school nurses to assess practices for asking about student health insurance status, and providing assistance and referral to community resources. With a 50% response rate, 85% report they regularly ask if students have health insurance; 70% report reaching out to community partners to assist families in need. Reported experiences included:

• “We have assisted families in navigating the application process, provided assistance with online information and sending necessary information for the application online or by fax. We often refer students without a medical home to the local health department or the local Access clinic/FQHC for assisting in applying for Medicaid.”
• “Largest number of uninsured are those without documentation. We refer to FQHC but there is a huge trust/fear issue related to deportation. We utilize our district translators to build trust within this community.”
• “Parents are oftentimes unsure of the status. Even with encouragement to be proactive, it is difficult to get them to reach out and/or check status. Filing for or renewing is always intimidating to parents. We offer help to check but usually meet resistance as they don't want the school in their business. If child needs medical or dental, we always go with our FQHC. It's frustrating when you think the child can at least qualify for presumptive Medicaid but instead the FQHC gives them a sliding scale amount and parent can't afford that. Parent walks away and we start from scratch. Oftentimes, it feels the school nurse is trying harder than the FQHC to get the parent help and it feels like the school nurse is trying harder than the parent and the child is the one suffering.”

 

The Office of Dental Health (ODH) works closely with the Coalition for Oral Health (MCOH), Missouri Primary Care Association (MPCA), and Missouri Dental Association (MDA), all of which address access to quality dental care in Missouri. These organizations are well positioned to effectively communicate about oral health topics with legislators, the Governor, and other high-level decision makers in Missouri. The ODH consulted with MO HealthNet to successfully continue the adult dental benefits for participants.

 

Access to primary care dentists is severely limited throughout most of rural Missouri. A total of 79 of the 95 Dental Health HPSAs in Missouri are in rural areas and 11 counties lack a dentist. Teledentistry increases access to dental care in areas of the state where dental specialists are not available. It reduces the time and cost burdens of traveling outside of one’s community. Patients can instead go to a nearby clinic in their area and then a dentist, working remotely, can screen and diagnose that patient through a videoconference. The off-site dentist can review records and make decisions about needed dental treatment, which a local dental hygienist may be able to provide. Since 2017, MO HealthNet has included two codes for teledentistry on the list of covered dental codes. This provides opportunity for a virtual dental home that works beyond the limitations of geography. ODH had four teledentistry contracts available through two grants received on September 1, 2018, providing those in underserved communities access to dental care and allowed the dentist to receive MO HealthNet reimbursement, which will provide the dentist sustainability to the program after the completion of the contract with ODH.

 

ODH is a recipient of the Health Resources and Services Administration (HRSA) Oral Health Workforce grant. Through this grant, the goal is to build Missouri’s Teledentistry workforce by contracting with a hygienist and dentist to perform teledentistry in nursing home and school settings, provide an educational opportunity at the Missouri Primary Care Association conference, and increase the number of educational workshops and technical assistance for Teledentistry. Through these efforts, the aim is to increase teledentistry options in Missouri and reduce the number of people who lack access to dental care. The technical assistance contract has been awarded and assistance provided. The teledentistry workshop was hosted by the Coalition for Oral Health and held online in September, 202020. Also through the HRSA grant, ODH contracted with LPHAs to provide fluoride varnish to WIC participants and other high risk children who visit their LPHA. This is a Medicaid reimbursable expense, so the goal is for the program to become self-sustainable. It also provided limited preventive care to high risk children who may not have access to that service due to a shortage of dental providers. As of September 30, 2020, ODH has contracted with eight LPHAs to provide fluoride varnish to their WIC participants, as well as any child who comes to their health department for services. However in 2020, all in-person visits to WIC clinics ceased due to the COVID-19 pandemic. This prevented the LPHA WIC contractors to apply fluoride varnish, however, they are poised to start again as soon as permission has been granted to hold in-person clinics. Since its inception, 745 children have received this important service, along with oral health education.

 

ODH is also the recipient of the CDC State Actions to Improve Oral Health Outcomes grant, which contracts with a dental program to provide dental sealants onsite at schools. Since September, 2019, ODH has contracted with Lincoln County Health Department (LCHD) to provide and promote dental sealants in schools in both Lincoln and Shelby Counties. Since December, 2019, ODH has contracted with Jefferson County to provide and promote dental sealants in Jefferson County schools. Through this contract, both LPHAs bill Medicaid, for those eligible, in order to utilize this often under-utilized benefit and thus improve the oral health of children in those high-risk areas.

 

* Interpret with caution due to sample size limitations.

 

SPM #3 Oral Health – Percent of children, ages 1 to 17 years, who had a preventive dental visit in the last year.

 

According to NSCH 2018-2019 data, nationally 79.6% of children ages 1-17 years old had a preventive dental visit in the last year. This was a greater percentage than in Missouri (74.2%). A lower percentage of Missouri children age 1-5 years old (43.7%) had a preventive dental visit than their national counterparts (59.7%). This age group also had a lower percentage than Missouri children age 6-11 years old (83.4%) and 12-17 years old (81.0%). The children in Missouri who most frequently had a preventive dental visit in the last year were in college educated households (79.4%) followed by some college (72.7%), and high school graduate (58.2%)* households. Privately insured Missouri households (77.7%) more frequently had a preventive dental visit than Medicaid (62.5%) and uninsured (49.6)* households. In Missouri, children in two-parent married households (74.4%) reported more commonly having had a preventive dental visit in the last year than single parent (69.5%) households and two-parent unmarried households (42.2%)*.

 

Learning good oral health care and establishing regular (at least annual) dental visits at an early age is important. Tooth decay is the most common childhood disease, but it is preventable. During regular dental visits or as part of public health programs like the Preventive Services Program (PSP) or dental sealant programs, children can receive fluoride varnish or dental sealants, which are each important for the prevention of tooth decay. Infants and toddlers can suffer from “baby bottle tooth decay,” which is caused by frequent, prolonged exposure to drinks that contain sugar. This often occurs when children are allowed to drink sugary drinks from bottles or sippy cups, especially when they are put to bed with a bottle. Only breast milk, formula, or water should be put in bottles to avoid this problem.

 

Among older children, tooth decay can lead to problems eating, speaking, and learning. Poor oral hygiene can lead to poor self-esteem. Later in life, poor oral health can lead to pregnancy complications, trouble controlling diabetes, and increased risk of heart disease. Links between poor oral health and other chronic diseases such as stroke, pneumonia, and dementia are also being studied. The Office of Dental Health (ODH) is committed to improving the oral health of all Missourians through education, prevention, partnership and leadership.

 

The importance of dental visits among children was reinforced in literature, namely through the “A Healthy Smile for Your Young Child” brochure from the National Maternal and Child Oral Health Resource Center distributed by WIC and the “Healthy Smiles from the Start” booklet developed by the ODH and the Missouri Dental Association (MDA). This booklet gives tips to parents on their young child’s oral care, when to see a dentist, and teething. The importance of regular dental care was also stated within the context of the ODH’s promotion of the use of dental sealants. Referrals and care coordination components of the PSP, described more below, also encourage regular dental visits for children, particularly those who have been identified as having evidence of a dental need. The education provided by all home visitors to women enrolled in home visiting programs included education about activities to support good oral health for their children.

Genetics and Healthy Childhood (GHC) supported Home Visitors were provided with ordering information for oral health resources from ODH during the annual March 2020 Home Visiting Summit.

 

The School Health Program (SHP) collaborated with the State Dental Director and the Office of Oral Health to support school nurses in updates in oral health practices and identifying local resources for students and families. The annual Nurse Education Webinar Series (NEWS) for the 2019-20 school year included a spring session presented by Missouri’s Dental Director, Oral Health Updates (4/11/20). As with all of the presentations in the NEWS series, this session was archived and made available for viewing at any time. SHP promoted the importance of oral health care with school nurses as a significant part of successful student learning.

 

As part of the SHP annual Health Office Orientation workshop (August 2020), the Oral Health Program provided a presentation on the Preventative Services Program (PSP) and oral health care resources in communities. This workshop was reorganized in 2020 to accommodate COVID-19 restrictions, changing from an in-person program to a series of online modules and virtual meetings with subject matter experts. The change in format enabled the SHP to record modules and make them available in a learning library for new school nurses to reference throughout the year.

 

The ODH was well on its way to seeing a record number of children PSP, which is an evidence-based fluoride varnish and oral health education program, until the COVID-19 pandemic closed the schools in March. PSP served 76,529 children during the 2019-2020 School Year. Each child received an oral health screening by a dental professional, two doses of fluoride varnish, oral health literature and supplies, and oral health education. The oral health education was either provided by school staff or the dental professionals that volunteer to operate PSP. Educational materials were provided by ODH (for each grade, K-12), but some schools chose to use materials included in their health education curriculum or collaborate with non-profit entities like Delta Dental’s Land of Smiles Program.

 

Due to COVID-19, ODH needed to alter the way PSP was carried out, so PSP Plan B was created. Plan B would give schools options in how they would carry out PSP. ODH worked with the school nurse program and gained their thoughts on how to bring PSP Plan B to the schools in the midst of a pandemic for the 2020-2021 School Year since visitors were limited or not allowed in schools. Oral Health educational videos were created by dental hygienists in ODH to be a substitute for the in-person training that an oral health professional would normally do. The videos were narrated and converted to YouTube so teachers or school nurses could use those in their health curriculum.

 

Communication to the schools and students were also adapted to give parents instructions on how to apply fluoride varnish at home and what nurses needed to look for if their students were having dental health issues.

 

Missouri has been singled out in recent years for its poor status in terms of dental sealants. In response, ODH promoted the use of dental sealants as an effective means to prevent decay on newly erupted molars. This promotion occurred as part of the PSP. Dental sealant literature, produced with MCH Block Grant funding, was distributed to dental clinics, FQHCs, LPHAs, and other partners. In 2019, using CDC funds, ODH contracted with the Lincoln and Jefferson County Health Departments to apply sealants to students in their counties and nearby counties. Before the schools closed due to COVID-19, both counties coordinated these events with PSP and provided sealants, screenings and the MCH Block Grant funded fluoride varnish and dental health literature. Between both counties, they sealed the teeth of 407 students for a total of 1605 sealants

 

In FFY2020, the Child Care Health Consultation (CCHC) Program offered 8 hours of continuing education trainings, 34.5 hours of specialized consultation, and 4 technical consultations for child care providers, and 106.25 hours of health promotions for children in child care, regarding children’s oral health. Components of these services stress the importance of good oral hygiene and routine dentist visits, while also promoting oral hygiene policy development among child care facilities. The CCHC Program’s goal through offering these services is to promote oral health practices in child care and increase the number of children receiving dental care. As a result, child care providers and children become aware of oral health issues and the importance of regular oral health care.

 

Through screening, referral, and participation in the provision of preventive dental services, the LPHAs worked to increase the number of children, ages 1 to 17 years, who had a preventive dental visit in the last year. Of the 114 LPHAs, 95 reported screening clients for an identified dental care provider and providing dental referrals, 96 reported having community partners who provided oral health screening and referral, and 41 reported providing dental screenings and/or services. More specifically,

 

• Vernon County Health Department has a nurse on staff that helped provide fluoride treatment to uninsured children in the Miles for Smiles mobile dental unit.
• Caldwell and Harrison county health departments offered the PSP fluoride rinse, screening, referral, and education program.
• Laclede County Health Department conducted dental screenings in the WIC program and referred to the local FQHC as needed. The FQHC offers dental services on a sliding scale fee to under- and un-insured children and adolescents.
• Pulaski County Health Department provided toothbrushes, toothpaste, and floss to community members, including children, and referred to the local FQHC as needed.
• Since April 2005, the Lincoln County Health Department (LCHD) dental clinic has been serving children and adolescents with Medicaid, Medicare, and those who are under- or un-insured by providing services on-site and in schools. The LCHD dental program received a $46,000 grant through DHSS to expand their Teledentistry program and will be partnering with the Shelby County Health Department (SCHD) to facilitate dental services in Shelby County schools and assist SCHD in determining the feasibility of their own Teledentistry program.
• Dallas County Health Department has a Bright Smiles Program in which MCH contract funds were utilized to pay a part-time coordinator to conduct regular brushing and oral health education to students in kindergarten through second grade at a local elementary school.
• Clay County Public Health Center’s school-based dental program provided free dental screenings, oral health education, dental sealants, and fluoride varnish applications to Clay County students.
• Joplin City Health Department partnered with a local dental school in which dental students provided education on oral care once a week to WIC participants.
• St. Louis County Department of Health provided oral health education with toothbrushes and toothpaste and reported providing dental services at three health department clinic sites.

 

Lastly, multiple LPHAs collaborated with community partners to host mobile dental vans at the health department, school(s), and other community sites.

 

* Interpret with caution due to sample size limitations.

 

SPM #7 Physical Activity – Percent of children ages 6 through 11 who are physically active at least 60 minutes per day.

 

According to the 2018-2019 NSCH data, 32.8% of Missouri children ages 6-11 years old were physically active for at least 60 minutes a day, compared with their national counterparts at 28.3%. Boys in Missouri (38.9%)* more commonly met this benchmark for physical activity than girls (36.1%)*. Compared with their national counterparts (26.2%), a higher percentage of those who lived in Missouri suburbs (37.8%)* had at least an hour of activity a day. In Missouri children from college graduate households less frequently (22.1%) reported having 60 minutes of physical activity per day than those from some college (44.5%)* and high school graduate (46.6%)* households. Medicaid recipients in Missouri (52.6%) were more frequently physically active for an hour daily than their national counterparts (29.1%). Obesity is complex, and environmental and behavioral factors play a critical role. Healthy eating and regular physical activity are critical to achieving and maintaining good health. Missouri works to implement best practices to ensure all Missourians live in communities that support these healthy habits.

 

Recent research by the Robert Wood Johnson Foundation (RWJF) forecasted Missouri would spend $12 billion a year on obesity-related health care in 2030 as a result of alarming increases in childhood obesity. RWJF ranked Missouri 17th in the nation for adult obesity. The Behavioral Risk Factor Surveillance System (BRFSS) reports that three out of four Missouri adults have at least one chronic disease, and more than two of every three adults are overweight (35.4%) or obese (32.5%). Today’s children are tomorrow’s parents, a major influencer of children’s diet and physical activity habits. Poor dietary habits and sedentary behaviors formed in childhood persist into adulthood making it critical to support healthy habits early. Through the Department of Elementary and Secondary Education (DESE)/Department of Health and Senior Services (DHSS) data system collaborative, Missouri school districts reported an increasing number of school-age youth are living with complex chronic conditions such as asthma (10%) and diabetes (0.34%), with many depending on schools for support. Obesity and chronic condition prevalence rates are significantly higher among African American and Hispanic communities, which compounds the gap in health equity and educational attainment for children from these minority groups.

 

Certain strategies in Missouri for SPM #4 impact both the child and adolescent populations. However, to avoid duplicative narrative, strategies were only listed in one or the other population domain. Activities that had a larger focus on the child population are listed below, but it should be noted that some may address a wider age range.

 

Obesity is a complex issue with many solutions, requiring collaboration from multiple organizations. One way Missouri brings these partners together is through the Missouri Council for Activity and Nutrition (MOCAN), the statewide obesity prevention council facilitated by University of Missouri Extension (UME). MOCAN’s member organizations are structured into workgroups specific to settings or topics: schools & child care, physical activity, worksites, food systems, messaging, and policy. DHSS staff supported through MCH funding participate in MOCAN workgroups to support statewide improvements in physical activity.

 

The Bureau of Community Health and Wellness (CHW) and the MOCAN Physical Activity Workgroup continued their efforts to build and expand the Missouri Livable Streets Advisory Committee. The advisory committee is a collaborative network of statewide stakeholders who serve to channel information and provide guidance for moving Missouri communities towards inclusive, mobile, and healthy places. The Advisory Committee has four work groups: education, funding, partnership and advocacy. Work group members continued to provide guidance to DHSS in shaping future Livable Streets activities. The advisory committee’s work focused on: building a collaborative network of stakeholders from across the state, providing information through the Livable Streets website and Facebook page, encouraging inclusive designs and programs, and reaching communities throughout Missouri. In FY20 the Advisory Committee supported the active living strategy of the Centers for Disease Control and Prevention (CDC) (1807) grant that targeted adoption of Livable Streets policies and plans in 10 rural and six urban communities.

 

In FY20, the updated Missouri MOve Smart Child Care Physical Activity Recognition program guidelines and supporting materials including the online training were promoted by DHSS and MOCAN Child Care work group partners. Six new child care providers received MOve Smart recognition in FY20.

 

In FY19 CHW concluded a pilot project with Columbia/Boone County Public Health and Human Services to use 12345 Fit-Tastic! MAPPS for Change with child care providers. The five key elements of the MAPPS for Change are: consistent use of message, consistent assessment of weight status and lifestyle behaviors, healthy lifestyle plan for all, policies and practices to create environments that enable healthy eating and active living, and statistics and storytelling to track and promote success.

 

Ongoing 12345 Fit-Tastic! initiatives included:

• The Child Care Health Consultation Program offered 12.5 continuing education trainings and 9.5 hours of health promotions for children using 12345 Fit-Tastic!
• Through a collaborative agreement with the Children’s Mercy Kansas City Weighing In Program, the MCH Services Program provided support to LPHAs and their partners on the 12345 Fit-Tastic! Healthy Lifestyle Initiative and 11 LPHAs continued to implement the 12345 Fit-Tastic! framework as part of their three-year FFY 2019 – 2021 contract work plans in local healthy lifestyle initiatives for children.

 

DHSS partnered with the DESE Director of Missouri Healthy Schools on a CDC grant to provide professional development and technical assistance to schools on wellness infrastructure, nutrition, comprehensive physical activity programs, and managing students with chronic disease in the school setting. The five-year cooperative agreement started in June 2018. The cross-department leadership team is working with seven priority local education agencies (LEAs) and also providing professional development opportunities to reach additional LEAs.              

 

CHW also continued contracts with eight LPHAs to facilitate a self-assessment and planning process for 11 school sites using the CDC’s School Health Index (SHI) Self-Assessment and Planning Guide. Schools identified strengths and weaknesses in their policies and programs that promote health and safety and developed action plans for improving student health. School sites made health and wellness improvements that included:

• One school site worked on improving health and wellness of its faculty and staff through health screenings.
• Five school sites worked on improving their school wellness efforts through the addition of health education to the curriculum, adding water bottle filling stations, enhancing the membership and function of their School Health Advisory Council, changing to non-food rewards, offering healthy food during fundraisers and concessions, establishing alternative discipline instead of taking away recess, updating health and wellness policies, providing education to children and families with chronic conditions, and promoting the wellness policy on the school website.
• Seven school sites worked on improving their physical education program and physical activity opportunities through adding updated physical education equipment, establishing before and after school walking clubs, updating the PE curriculum, enhancing professional development opportunities for teachers, adding a bike rack, initiating a community wellness event, and incorporating classroom brain breaks.

 

As a partners on the CDC 1801 grant, School Health Program (SHP) is working with DESE and the MO Healthy Schools program, along with a cohort of LEAs to implement tools and best practices addressing nutrition and physical activity in the school setting. In the seven participating schools, the grant project team is implementing assessment and intervention tools to improve the school wellness environment (17,072 students).

 

Integrating physical activity into young children’s lives is essential to creating a foundation of movement and activity that they will carry throughout their lives. Physically active children learn habits in early childhood that greatly increase their chances of remaining physically active through their young adult and teenage years and into adulthood. In FY20 CHW continued to leverage support from CDC’s 1807 grant and UME to implement the Go Nutrition and Physical Activity Self- Assessment for Child Care (NAP SACC) Program to assess child care providers’ current practices in both physical activity and nutrition. Trained LPHA Child Care Health Consultants, Child Care Aware of Missouri consultants and UME Nutrition and Health Specialists serve as Go NAP SACC Technical Assistance (TA) Consultants to provide training and technical assistance to child care providers in adopting healthy nutrition and physical activity practices and policies. By September 30, 2020, 72 child care providers had registered with a TA Consultant to participate in the Go NAP SACC project, effecting 2,406 children. Of the72 child care providers, 41 completed a pre-self-assessment in Physical Activity, 25 in Outdoor Play and Learning, 21 in Screen Time, 47 in Child Nutrition, 19 in Breastfeeding and Infant Feeding, 16 in Farm to Early Child Care, and 13 in Oral Health. After completing the pre-self-assessment, the TA Consultants guided the child care providers in creating and completing goals. The top physical activity goals selected by the providers included reduction of sedentary time for infants, toddlers, and preschoolers; increased teacher participation and interaction during physical activities with children and infants; and increased outdoor and indoor physical activity for children). Other goals included professional development, enhanced policies, and family education on infant and children physical activity, outdoor play, and screen time reduction, among others.

 

In FFY2020, the Child Care Health Consultation (CCHC) Program offered 34 continuing education trainings for child care providers, 128.75 hours of health promotions for children in child care, 41 hours of specialized consultation, and 10 technical consultations regarding the importance of physical activity and nutrition. Through offering these services, the CCHC Program works to promote physical activity and nutrition in child care and increase the number of children engaging in activity and healthier eating. As a result, child care providers and children become aware of the many benefits of physical activity and proper nutrition. An example of a children’s nutrition health promotion is the use of the research-based curriculum, Learning About Nutrition Through Activities (LANA) health promotion kit, which provides hands-on learning to promote increasing fruit and vegetable consumption. An example of a children’s physical activity health promotion includes the use of a stethoscope and jump rope. Prior to and immediately after jump roping, the children use the stethoscope to listen to their heart rate and have a discussion about why their heart rate changes, what’s happening in their body, and why physical activity is important. When possible, the importance of combining regular physical activity with proper nutrition is incorporated in physical activity and nutrition related health promotions.

 

The MCH Services Program supported LPHA efforts to increase the percent of children who are physically active for at least 60 minutes per day, prevent and reduce childhood obesity, and identify and eliminate obesity-related disparities among children 6-11 years of age. Of the 114 LPHAs:

• 90 reported providing child care and school-based programs to prevent obesity 61 LPHAs reported providing worksite wellness campaigns to encourage physical activity.
• 72 LPHAs promoted healthy lifestyle initiatives-16 participated in park improvements, 16 participated in sidewalk and safe street enhancements, and 19 partnered with their community to install and/or enhance walking trails and environmental facilities.
• 44 LPHAs provided cooking, food preservation, and gardening classes, 23 maintained farmer’s markets with SNAP and/or EBT benefits, and 30provided community gardening.
• Numerous LPHAs facilitated MOve Smart, 12345 Fit-Tastic!, Girls on the Run, and a variety of other physical activity campaigns.

 

MCH Services Program staff participated in the LPHA Healthy Lifestyle Learning Collaborative and served on the MOCAN School Health Work Group and other regional and state collaborative groups to promote healthy lifestyles and weight for children. Numerous LPHAs participated in local community coalitions to promote healthy lifestyle choices. The MCH Services Program contracted with 19 LPHAs to increase the percent of children/adolescents ages 6 through 17 who are physically active at least 60 minutes per day. Specific LPHA activities and accomplishments included:

• Hickory County Health Department (HCHD) opened the HCHD Fitness Center available for use to all community members. HCHD encouraged and facilitated local farmers and ranchers working with local schools to promote the ever-growing farm-to-school movement.
• Warren County Health Department continued to manage the Warren County Community Fitness Center, offering a variety of physical activity classes/activities for children and youth including homeschoolers, individuals with disabilities, and participants in emergency need programs.
• Randolph County Health Department hosted the virtual walking event “Randolph County Summer Marathon”. Participants were encouraged to complete 26.2 miles of physical activity throughout the summer months. 41 community members (including women and children) participated. The health department collaborated with local businesses as “Mile Marker Sponsors” and each had an incentive to encourage increased physical activity (for example: YMCA day pass, water bottle, jump rope, fruit infused water, etc.).
• Pulaski County Health Department has been successful in implementing ACTIVE (Adolescents Committed to Improvement via Exercise) programs in 3 school districts. This program has been implemented with the after-school program and provides kids with an opportunity to be active (train for 5K, etc.) as well as break down the word CHAMPION into lessons on Courage, Hardiness, Adaptability, Motivation, Integrity, Optimistic and Never Give Up. The health department also hosted the summer campaign “Summer Staycation.” This encouraged families (including women and children) to stay active during the summer (amongst COVID-19) and share how they were exercising and making healthy choices; participants were entered to win a FREE dinner/night away from home at the Fort Wood Hotel.
• Columbia-Boone Public Health Center continued to provide 12345 Fit-Tastic! phone interventions to WIC participants. For those who reached their goals, they were rewarded with vouchers for fresh fruits/vegetables. The health department was also able to record their Take 5 Yoga and provide a link on social media as well as the health department webpage so that women and children in the community could take part from home (due to COVID-19 restrictions of gathering). They also hosted Lunch in the Park events which provided healthy lunches to low-income children during the summer months. 12345 Fit-Tastic! messaging were incorporated in the events, and over 70 children attended.
• Several LPHAs worked with local school food service programs during COVID-19 school closures. Many schools continued to provide breakfast and lunch meals to children by either pick-up or drop-off method. Many LPHAs took this as an additional opportunity to incorporate 12345 Fit-Tastic! messaging materials, including links to FREE at home workouts (GoNOODLE) and additional resources.

 

* Interpret with caution due to sample size limitations.