Child health activities in 2018 focused on continued work in the areas of injury prevention, home visiting, oral health, nutrition education, and immunization awareness and education.  Arizona has continued to improve child health outcomes in many areas. Implementation of several evidence-informed and evidence-based strategies targeting Child Health priorities continue to address public health trends and move the needle on improving the health status of Arizona children.  BWCH through alignment and coordination of internal and external partners and resources work to affect system-wide public health change.  2018 child health activities aimed to decrease the incidence of childhood injury and strengthen the ability of families to raise emotionally and physically healthy young children.  Details and highlights about each activity are listed below.

Arizona's Title V program houses the Office of Injury Prevention which serves as a coordinating body for injury prevention within ADHS. The program is responsible for 1) identifying injury problems and the specific needs for injury prevention programs, policies, and services within the state; 2) Keeping abreast of developments within the field of injury prevention and sharing this information with others; 3) Understanding where injury prevention fits into what other agencies are doing (integration) and serving as a coordinating force that brings different players to the table; 4) And building a solid constituency for injury prevention activities within the state.

BWCH through the Emergency Medical Services for Children (EMSC) Program will continue to provide technical assistance to the hospital community to achieve a higher level of preparedness in caring for children. The program goal for 2018 was to have AZ emergency departments verified as ‘Pediatric Prepared.’ These efforts included supporting Emergency Department nurses to acquire specialty certification. In 2018, the Arizona Chapter of the American Academy of Pediatrics engaged 19 Pediatric Prepared Emergency Care (PPEC) facilities to go through the recertification process. In 2018, 6 recertification site visits were coordinated and conducted at four Prepared Advanced Care hospitals, 1 Prepared Plus hospital, and 1 Prepared Care hospital. Additionally, a total of 203 nurses participated in 2 Certified Pediatric Emergency Nurse (CPEN) and 3 Emergency Nursing Pediatric Courses.

Arizona's Child Fatality Review (CFR) has a goal to reduce preventable child fatalities through systematic, multidisciplinary, multi-agency, and multi-modality reviews of child fatalities in Arizona. This is accomplished through interdisciplinary training, community-based prevention education and through data-driven recommendations for legislation and public policy. Collected review data enables the development of prevention strategies and promoting increased public awareness. Arizona will continue analyzing child death data while providing support and training for law enforcement agencies, medical examiners, and first responders. The CFR is more fully discussed in the Child section of this report except for Safe Sleep efforts which are more fully discussed in the perinatal/infant health section.

On November 15, 2018, BWCH released the CFR 25th Annual Report containing updated data for the CY 2017. The number of SUID cases increased 5% from 2016 (n=80) to 2017 (n=84). A large portion of these infants, 50 died while co- sleeping (bed sharing with adults and/or other children). Deaths due to suffocation remained high, and were determined to be the cause of death for 51 infants. It is because of this large proportion that Safe Sleep continues to be a priority in Arizona. One hundred percent of suicides were determined to be preventable, accounting for 6% of all child deaths. Child suicides increased 32% from 2016 (n=38) to 2017 (n=50). Other report highlights identified an increase in both firearm and drowning deaths, which were one-hundred percent preventable. Firearm deaths increased 19% from 2016 (n=36) to 2017 (n=43) and accounted for five percent of all child deaths and drowning deaths increased 30% from 2016 (n=27) to 2017 (n=35) and accounted for 4% of all child deaths. Future actions for prevention include promoting community and family awareness around these deaths.

ADHS created the Healthy @ Home Assessment as part of the Association of State and Territorial Health Officials (ASTHO) and Robert Wood Johnson Foundation (RWJF) quality improvement integration project. The standardized home safety and family wellness assessment integrates environmental health and chronic disease components into the home visiting process. The Healthy @ Home Assessment process recognizes the importance of the child’s home settings has on the child’s health by addressing chronic disease in family members. The assessment process helps identify concerns and provide referrals and education in order to improve the health of everyone in the household. The Healthy @ Home Assessment is also an opportunity to focus on environmental issues in the home such as lead poisoning and asthma triggers. The outcome was for more children and families in Arizona to be screened for health and safety concerns in the home and within the family.  The following materials are made available on the ADHS website:

• Education Materials and Resources
• Home Visit Training
• Healthy @ Home Briefing Sheet

In 2018, home visiting programs continued to work on the objective to increase the number of home visitors using a standardized home safety checklist by 2020. There were 65 home visitors that attended the How to Stay Safe While Conducting Home Visits workshop at the Strong Families AZ Home Visiting Conference. There were 28 home visitors that attended a Home Safety webinar.  The workshop and webinar provided information on safety of home visitors, safety procedures, identification of unsafe home situations, effects of secondhand smoke, and the burden of injury around the home.  The Healthy @ Home website provides a wide array of standardized home safety assessments and checklists for home visitors to use. 

Arizona's home visiting programs continued working to connect all families to preventive and primary care. ADHS administers and/or funds the following evidence-informed home visiting programs: Health Start; High Risk Perinatal/Newborn Intensive Care Program (HRPP/NICP); Healthy Families AZ (HFAz); and Nurse Family Partnership (NFP), Parents as Teachers, and Family Spirit. All of the programs work with families and coordinate/refer with other health and family support providers to improve maternal and child health, decrease family violence including reduction of childhood injuries and maltreatment; Ensure families have access to health care including immunizations; Enhance child development and a child's readiness for school through parent education; and Assist families to improve their economic security.

Health Start was developed in 1992 and utilizes community health workers or "Promotoras" to address the needs of rural, minority pregnant women in Arizona. BWCH has administered the Health Start Program since 1994. Health Start provides education and services to infants from birth to age two including immunization education and immunization records checks and developmental screenings. In 2018, Health Start services were provided to 2,018 unduplicated clients through 13,885 unduplicated home visits to clients and families during (8 months of data). This program is described in more detail in the Woman/Maternal section as its original purpose was to assist pregnant women into prenatal care.

The High Risk Perinatal Program/Newborn Intensive Care Program (HRPP/NICP) is Arizona's oldest home visiting program. The purpose of HRPP/NICP is to reduce maternal and infant mortality and morbidity through a regionalized statewide system of coordinated perinatal care. HRPP/NICP is a primarily state-funded program that leverages Title V funds to increase access and enhance services.  HRPP/NICP continued to provide early identification of women and children at risk of mortality and morbidity, education for health professionals, families and communities on developmental care and medically fragile infants and links pregnant women and infants to the appropriate level of care and establishes standards of care. The components of the program are: an Information and Referral Line; Maternal and Neonatal Transport Services; Hospital and Inpatient Physician Services; Community Nursing Services; and Hospital Developmental Care. As mentioned in Infant/Perinatal section, in 2018, 3929 infants were enrolled in NICP; Community Health Nurses made 7,080 visits to medically fragile infants and their families after they were discharged from the NICU and 831 critically ill pregnant women and 841 critically ill newborns were transported to the appropriate level of care as determined by program contracted physicians.

In 2018, the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV) served 1,941 families completing 27,355 visits. MIECHV continued to support voluntary evidence based home visiting programs in at-risk communities and coordinate services across the early childhood system. ADHS provided funding for Healthy Families (through Arizona Department of Child Safety), Nurse-Family Partnership (through Maricopa County Department of Public Health, Pima County Health Department, and First Things First), and Family Spirit (through White Mountain Apache Tribe). MIECHV also continued to fund Parents as Teachers to three Native American Tribes (Cocopah, Hualapai, and Navajo Nation). In 2018, BWCH re-applied and was awarded the HRSA Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grant for services to be provided in FFY 2019. Arizona requested and was awarded the maximum grant award of $11.4 million for FFY19 Formula funding.  The formula grant proposed to continue home visiting services and supporting Arizona’s home visiting network through CQI and professional development. In addition, MIECHV program proposed to fund Arizona’s Health Start Program as a promising practice. 

MIECHV supported the 2018 Title V state priority needs by implementing various strategies. The strategies and outcomes for 2018 include:

Title V priority need to reduce infant mortality and morbidity and NPM 4: a) percent of infants who are ever breastfeed and b) percent of infants breastfeed exclusively through 6 months: Increase the number of home visitors or community health nurses who are pursuing International Certified Breastfeeding and Lactation Consultants (ICBLC) certification over the next 5 years. Twelve (12) home visitors participated in the support offered to receive IBCLC certification. Participants received monthly webinars to assist in preparing for the exam and were provided study materials. Five candidates have received their certification with seven waiting for test results. 

Title V state priority need to increase early identification and treatment of developmental delays and NPM 6.1: percent of children, ages 10-17 months, receiving a developmental screening using a parent completed screening tool.  ADHS through its Health Start Home Visiting Program completed 5 trainings to 50 home visitors on the ASQ and ASQ SE screening tools. Participants also included MIECHV funded home visitors in 2018.

Title V state priority need to reduce the use of tobacco and other substances across the lifespan and NPM 14: a) percent of women who smoke during pregnancy and b) percent of children who live in households where someone smokes. There were 65 home visitors that attended the How to Stay Safe While Conducting Home Visits workshop at the Strong Families AZ Home Visiting Conference. There were 28 home visitors that attended a Home Safety webinar.  93 home visitors attended an in person and webinar.  The workshop and webinar provided information on safety of home visitors, safety procedures, identification of unsafe home situations, effects of secondhand smoke, and the burden of injury around the home. Information was provided to home visitors on the ASH Line and the Ask, Advice, Refer process. Over 100 home visitors had the opportunity to receive information pertaining to second hand smoke and the impact on children during the Strong Families Arizona Home Visiting Conference in a workshop.

Title V state priority need to strengthen the ability of Arizona families to raise emotionally and physically active children: Provide home visiting with fidelity and identify two CQI strategies that support Title V state priority in home visiting programs by September 2019.  In 2018, MIECHV continued to support voluntary evidence based home visiting programs in at-risk communities and coordinate services across the early childhood system.  MIECHV programs served 1,941 families completing 27,355 visits.  In addition, the CQI strategy focused on increasing timely well-child visits. MIECHV shared report with Arizona Academy of Pediatrics.   MIECHV funded local implementing agencies identified many challenges and causes leading to lower than optimal rates of well child visits. Teams focused on home visitor level PDSAs including home visitor education on what happens at an EPSDT/well child visit, how well child visits are different than immunizations, how to support families to maintain insurance and schedule visits, how to talk with families about well child visits, how to help families prepare for and advocate for their family at well child visits.

In response to the childhood obesity rates, MIECHV continued to fund home visiting programs that address nutrition, obesity prevention and child development. Furthermore, MIECHV partnered with the Bureau of Nutrition and Physical Health to provide training and/or information to home visitors at Strong Families Annual Conference on Empower Home Visiting Guidelines, Nutrition Infant/Toddler Standards.

Evidence-based home visiting continued to be augmented by professional development provided through training and education, online courses, regular informative e-newsletters and an annual Strong Families AZ Home Visiting annual conference. In 2018, 600 home visitors attended the MIECHV funded 7th Annual Strong Families Home Visiting Conference.
 

The Annual Strong Families Arizona Home Visiting Conference included one day that focused on tribal priority topics.  In 2018, both conferences were combined to one, three day conference with the first day being tribal focused. Over 200 participants attended the second year expanding the reach and validating the importance of the tribal focused priorities. The Supervisor’s Institute was held and approximately 100 home visiting supervisors participated in the day-long program.

Additional home visiting activities include the ongoing implementation of a coordinated home visitation data management system.  In 2018,  the data system Efforts-To-Outcomes (ETO) was expanded to include state funded Healthy Families Arizona (HFA) and Nurse Family Partnership (NFP) programs, High Risk Perinatal Health/Newborn Intensive Care Program, and Health Start home visiting programs.  This is an ongoing project and it is anticipated that each of these programs will be fully transitioned into ETO by August 2019. 

BWCH also engaged in a several continued strategies, partnerships and meetings to address child health topics including ACE’s and child welfare. 

BWCH sponsored 11 core ACE’s questions in the 2018 BRFSS. BWCH’s internal and external stakeholders have become dependent on these data to better inform their strategies to mitigate ACEs. These data are also used by BWCH to inform our home visiting programs.   We expect to have a thorough analysis of these measures by FY2019 as FY2018 is a data collection year.  BWCH acknowledges that ACEs can last a lifetime despite the availability of preventive social and public health programming. Early exposure to family violence, abusive treatment, neglect, alcohol and drug abuse, or separated/divorced parents can lead to health and social problems, risk-taking behaviors and a shortened lifespan. Safe, stable and nurturing relationships and communities can break the cycle of abuse and maltreatment. BWCH partners with the ACEs Consortium to share data and support the annual ACEs Summit.

In December 2018, utilizing Title V funds, BWCH supported and participated in the 5th Annual Arizona ACEs Summit:  Becoming a Trauma Informed State - Overcoming Adverse Childhood Experiences to Create a Healthier Arizona. Dr. Bruce Perry delivered the keynote address and was followed by a state-agency leadership panel that discussed working with vulnerable populations in a trauma–informed way.  The day also included breakout sessions focusing on trauma informed implementation in a variety of settings.  The ADHS ACEs online course was completed by 124 home visitors.

BWCH was asked to participate in new initiatives with ASU Morrison Institute.  The Spotlight on Arizona’s Kids project is an initiative undertaken by the Morrison Institute for Public Policy to research and bring together partners to review and discuss the safety and well-being of children whose lives intersect with the child welfare system.  In May of 2018 BWCH participated in the first Morrison Institute Child Welfare Leadership Advisory Board meeting.  The goal of the group is to come together to inform and shape Arizona’s child welfare research aims.  Furthermore, as part of the same initiative, BWCH attended the Spotlight on Arizona Kids Conference held in September 2018 to help state leaders, child advocates and others develop the most-effective child welfare policies.

 
In November 2018, BWCH was invited to attend the Community Conversation on Family First Prevention Services Act. The meeting included a review of the Family First Prevention Services Act and changes. The group engaged in discussion about the impact of the changes for Arizona and how to prepare for successful implementation of FFPSA. 

With the help of Title V funding, Arizona has partnered with The Arizona Partnership for Immunization (TAPI) to promote immunizations statewide. TAPI is a non-profit statewide coalition formed to foster a comprehensive, sustained community program for the immunization of Arizonans against vaccine preventable diseases. TAPI was created in 1993 to improve the immunization levels of children in Arizona and later expanded to include adolescents and adults. Cooperative efforts between the public and private sectors have become a major force in implementing system changes resulting in long-term improvements in immunization service delivery in Arizona. TAPI has over 400 members representing over 200 organizations. TAPI's efforts are reflective of the importance of immunizations over the lifespan, and will impact Arizona and its citizens' quality of life.

Community Education: TAPI distributed over 150,000 educational pieces to schools, child care facilities, private providers, county health departments, community health centers, managed care organizations and WIC sites. Materials are used for new patient packets and parent outreach. The TAPI home web page, www.whyimmunize.org that allows parents, teens and adults to ask medical experts questions about vaccines and immunizations was updated to reflect ACIP recommendations and outbreak information.

TAPI maintained a Facebook page with nearly 700 consistent "likes” and developed a closed Parents Who Protect group to share pro vaccine stories.  Posts to both pages included flu, measles, mumps and Hep A outbreak information; Water safety, flu information, community awareness for general vaccine education, off to college, Vaccinate Before you Graduate, recommendations for young adults, well-baby-visit education, partner links, Tdap in pregnancy, and the importance of adult immunizations.

Each quarter TAPI's tweets on Twitter were viewed 7,000-13,000 times. Content included medical exemptions, parent and doctor relationships, NIIW, CDC updates, back to school information about vaccinations, Tdap, coverage and exemption data, and flu season vaccinations.

TAPI participated in a national social media partnership to keep accurate immunization information trending.  TAPI responded to local media routinely on appropriate referrals for back to school and flu immunizations and in depth stories on vaccine exemptions, school readiness and vaccine education.

TAPI worked with the Arizona American Academy of Pediatrics (AzAAP) to provide background for pediatric spokespeople on childhood/teen immunizations, anti-vaccine stories and outbreaks, and frequently referred reporters to appropriate subject matter experts regarding disease outbreaks and headline events.

Provider Education: TAPI supplied articles for Immunization newsletters and health publications for community health centers, hospitals, public health, AzAAP, AOMA, ArMA and AzNA weekly/monthly emailed updates.

TAPI participated in quarterly calls to discuss HAI and provided support with vaccine education overlap. This group participated in the flu Button Up campaign this year and regularly disseminated immunization education to hospitals and long term care centers.

The HPV oral health work group was established to increase awareness of the HPV vaccine for hygienists and dentists.  The group developed a set of recommendations to be used during oral cancer screening for patients under 26 and parents of teens. Materials and messaging have been disseminated and a training curriculum is in development for oral health professional programs.

TAPI conducts Immunization Best Practices Trainings for provider office vaccine management staff on using patient education materials and resources. In 2018 TAPI hosted 12 state wide trainings with 600 participants aiming to improve vaccine delivery and increase immunization rates.  After the training, practices that have implemented the CDC Standards of Immunization Practice are encouraged to apply for the Outstanding Immunization Practice Award.  As a result of the trainings 81 practices achieved or maintained 90% coverage level for toddler or teen patients in 2018 and were awarded at the annual Big Shots for AZ dinner.

Special Project: In 2018, Arizona's percentage of 19-35 month olds being adequately immunized has remained below our 90% target at 71%. Arizona continues to be challenged by a high exemption rates in some parts of the state. TAPI partnered with AzAAP, Arizona Family Practice Association and state and local health to continue vaccine education through media, clinicians and partners to help educate parents looking for exemptions about vaccine safety.