Priority Needs

Strengthen emotional, physical, and social services to achieve an equitable and optimal development for children.

National Performance Measures

NPM 6 - Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year. NPM 7.1 - Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9. NPM 13.2 - Percent of children, ages 1 through 17, who had a preventive dental visit in the past year. NPM 15 - Percent of children, ages 0 through 17, who are continuously and adequately insured.

 

In 2023, the Arizona Title V Program priorities for children continued to focus on decreasing the rate of injuries, both intentional and unintentional, for children aged 0-19 years and improving access to quality preventive health services, specifically developmental screening. All activities under each priority have been categorized using Levels of Public Participation (Inform, Consult, Involve, Collaborate, Empower) and can be found in Appendix K. Levels of Public Participation under the Children’s Health section. The Children’s Health population domain continued their work in Health Equity activities. The Health Equity activities are identified in italics throughout this section of the report and information about Family Engagement can be found interwoven through the annual report and in the Family Partnership narrative.

Injury prevention programs supported NPM 7.1 and 7.2: Injury Hospitalization (rate of hospitalization for non-fatal injury per 100,000 children, ages 0-9 and 10-19). The strategies to decrease the incidence of childhood injury continued to analyze child death data to support and train law enforcement agencies, medical examiners, and first responders on death scene investigation and primary prevention efforts in the recognition of unsafe sleeping environments. Technical assistance for emergency departments and support of local Safe Kids coalitions strategies were implemented. BWCH home visiting programs continued to implement a variety of home visiting models to support NPM 6: Development Screening (percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year). Access to care programs supported improving access to care including NPM 13.2 - Percent of children, ages 1 through 17, who had a preventive dental visit in the past year.

The ADHS Bureau of Women’s and Children’s Health (BWCH) programs continued to recover from the impacts of COVID-19. Stakeholders continued to work together to shift strategies, establish revised processes, and implement remote/virtual resources to continue supporting children. The Children’s Health Annual Report will include program updates addressing key activities and results from CY 2023 (January 1, 2023 - December 31, 2023), health equity and family & youth engagement strategies, challenges, and emerging issues; including any continued COVID-19 impact and the strategies implemented to sustain the programs/services. Cross-cutting strategies for children’s health domain will be addressed. The following sections detail the 2023 implemented strategies and activities.

Arizona's Child Fatality Review (CFR) Program contracts with and funds 10 local review teams to conduct an in-depth analysis of all child fatalities occurring within the state. CFR reviews are conducted by a multi-disciplinary group of dedicated professionals including medical professionals, law enforcement, public health professionals, child safety specialists, behavioral specialists, and representatives from Arizona's tribal nations. Each year the team reviews around 850 child deaths in the state. Teams have been instrumental in the identification of preventable child deaths occurring throughout the state. The ADHS used the review data collected to develop prevention strategies, increase public awareness of high-risk behaviors, and promote child safety. The Annual Child Fatality Review Report on 2022 Arizona Deaths, published in November 2023, provided statewide partners with key insights, data, and recommendations concerning child fatalities in Arizona. In addition, regional CFR infographics provide communities with localized data summaries.

As a result of the pandemic, the CFR program adopted virtual review meetings, which has increased participation and proved beneficial. Virtual and in-person reviews are now being conducted and the method of attendance is decided by the local review teams.

The ADHS continued to administer and/or fund a variety of evidence-based and -informed home visiting programs including Health Start, High-Risk Perinatal Program (HRPP), Healthy Families AZ (HFAz), Nurse-Family Partnership (NFP), Parents as Teachers, Family Spirit, SafeCare Augmented, and the Maternal and Early Childhood Sustained Home-Visiting (MECSH) models, that are intended to connect families to preventive and primary care. All of the programs work with families and coordinate their referral to 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 and essential health services, including immunizations; enhance child development and a child's school readiness through parent education; and assist families in improving their economic security. Collectively, the home visitation programs completed 40,032 home visits serving 6,573 clients in Arizona in 2023.

Figure 28. Summary of ADHS Home Visiting Programs

Programs	Funding Sources	Households Served in 2023	Implementation Partners
Healthy Families**	MIECHV	1,538	State Agencies, County Health Departments, Community-Based Agencies, Tribal Nations
Nurse-Family Partnership**
Family Spirit**
Parents as Teachers**
Safe Care Augmented**
Maternal and Early Childhood Sustained Home-visiting
Health Start*	State Lottery, MIECHV, MHIP	1,461	County Health Departments, Community-Based Agencies, Tribal Nations
HRPP	State General, Proposition 207 and Title V	3,574	County Health Departments, Community-Based Agencies

**Evidence-based model
*Promising approach

To address the Title V priority need to reduce infant mortality and morbidity and NPM 4: Breastfeeding, ADHS home visiting programs worked collaboratively with the Bureau of Nutrition and Physical Activity breastfeeding team to increase the number of home visitors or community health nurses who are pursuing their certification as an International Board Certified Lactation Consultant (IBCLC) over the next 5 years. In 2023, there were five (5) individuals that became certified.

To address the Title V priority need to increase early identification and treatment of developmental delays and NPM 6: Developmental Screening, ADHS home visiting programs implemented revised measures to monitor new home visitor Ages and Stages Questionnaire (ASQ) training and document the percent of children enrolled in home visiting programs that receive at least one ASQ within one year of enrollment. New home visitors hired during the federal reporting period of October 1, 2022-September 30, 2023 all received ASQ training to be able to provide the screening to families. Seventy-five percent (75.4%) of families enrolled in MIECHV-funded home visiting services received a timely ASQ screening. Forty-eight percent (48%) of HRPP-enrolled participants received a timely ASQ screening and forty-two percent (42%) of non-MIECHV-funded Health Start participants received a timely ASQ screening. The completed screening percentage ranges between 42-81% across programs.

In 2023, the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) in Arizona funded the following evidence-based home visiting programs: Healthy Families (through the Arizona Department of Child Safety contracted to local non-profit organizations), Nurse-Family Partnership (through the Maricopa County Department of Public Health, Pima County Health Department and non-profit organizations), Family Spirit (through Coconino County and San Carlos Apache Tribe), Parents as Teachers (provided by two Native American Tribes: Cocopah and Navajo Nation), SafeCare Augmented (provided by a non-profit organization), and the Maternal and Early Childhood Sustained Home-visiting program (provided by the Pima County Health Department and a non-profit organization). In addition, the AZ MIECHV grant continues to be approved to fund Arizona’s Health Start Program, as a promising approach. Through the home visiting programs listed above, MIECHV served 1,577 adults and 1,446 children or 1,538 families in at-risk communities through 18,743 visits, coordinating services across Arizona’s early childhood system.

Evidence-based home visiting continued to be augmented by professional development provided through training and education, online courses, regular informative e-newsletters, a podcast, and an annual conference.

In 2023, the 3-day Strong Families AZ Conference returned in-person and included two days of a state-wide agenda in which the topics are relevant to all home visitors and then a one-day, concurrent agenda of priority population focus which included a serving tribal communities agenda and working with High-Risk Perinatal families agenda. This provides an opportunity for those serving these priority populations to receive professional development targeted to their role and the services that they provide to families. There were a total of 535 unique attendees across the 3-day conference with 420 attendees for the state-wide agenda, 138 attendees for the Tribal Agenda, and 257 attendees for the HRPP agenda. Ninety-three percent (93%) of attendees who completed the evaluation indicated that the conference was excellent with intentions of applying what they learned in their work. Attendees represented all 15 counties and all 22 federally recognized tribes in Arizona.

In addition to maintaining the large conference, the “Learning Festival,” a once-a-month professional development opportunity for home visitors, also continued. It was originally designed to take the place of conference breakout groups when the conference switched to the online platform due to COVID-19. It was very successful in 2020 which prompted the continuation of that format from 2020-2023. Some of these topics included building strong co-parenting relationships; understanding the impacts of cannabis use during pregnancy; the importance of early vision screening; early development screenings; reflective listening; and understanding the use of technology on developing brains. There were 12 Learning Festival sessions in 2023 with a total of 856 attendees across all sessions. Attendees for each session range from 35 to 100. (Appendix L)

Home Visitors have also received additional professional development on the topic of Congenital Syphilis. A webinar was provided that included education and information on Congenital Syphilis, the importance of treatment, the challenges and barriers to treatment, and how to support families in completing treatment. Additionally, social media posts about the importance of screenings and completing treatment have been shared across the Strong Families AZ, Arizona’s Home Visiting Alliance platforms. Home visitors also provide information to enrolled participants on the importance of prenatal appointments, STI testing, and treatment, and support the coordination of transportation to treatment if and when necessary.

Strong Families AZ, Arizona’s Home Visiting Alliance, also produces The Parenting Brief, a podcast for parents featuring tips from fellow parents and the latest insights from childhood experts hosted by Jessica Stewart-Gonzalez, Office Chief for Office of Children’s Health at the ADHS. The episodes focus on public health topics. The podcast provides an opportunity for caregivers to access accurate public health information in a format that is quick, aligns with how they access other information, validates experiences, and provides resources. In 2023, there were 12 podcast episodes produced on topics including sensory screening, car seat safety, early identification of developmental delays and autism, baby/child product recalls, gestational diabetes, navigating the medical system, safe cribs, health plans for kids, nutrition, potty training, toy safety, and safe haven laws. During 2023 there were 5,759 downloads of the podcast overall with the majority of listeners accessing it directly from a podcast application on a smartphone. Most individuals who downloaded at least one episode found the podcast through a Google search with the keyword phrases of “support for parents” and “parenting tips”. The click-through rate is 7.62%, an increase from 6% in 2022, and remains significantly above the industry standard of 2%. The Parenting Brief Podcast continues to reach its target audience of parents between the ages of 19-44 with 86.9% of listeners identifying in that demographic.

In 2023, MIECHV-funded sites focused their continued quality improvement (CQI) efforts on how to use the 2022 data collected through the MIECHV benchmarks to improve developmental screens and referrals. In 2022, 70.6% of enrolled participants received a timely developmental screening. In 2023, that increased to 75.4% of enrolled participants received a timely developmental screening. During the annual Strong Families AZ Home Visiting Conference, each MIECHV-funded site had a poster designed with the intention of engaging conference participants in learning about CQI. The posters were displayed throughout the conference exhibitor space and the sites were excited to share the work with the conference attendees.

Figure 29. Strong Families AZ Home Visiting Conference Poster

Additional home visiting activities included the ongoing implementation of a coordinated home visitation data management system. In 2023, all programs included in the Efforts-to-Outcomes (ETO) continued their participation in the Data Management Workgroup. During the 2023 Interagency Leadership Team (IALT) Retreat the state system reports were utilized to inform the 2024 priorities. This was a significant milestone in the coordinated home visitation data management system. The IALT members were able to review and analyze the data to determine high-risk, underserved communities to develop strategies for improving coordination.

The Arizona Health Start Program is an evidence-informed, promising approach home visiting program for at-risk pregnant and/or postpartum people with children under the age of 2 that was funded through the state lottery (as part of the Title V match), the Maternal Health Innovation Program and the Maternal Infant Early Childhood Home Visiting Program during this reporting year. In 2023, the Health Start Program provided services to 1,627 children and their caregivers - providing prenatal, postpartum, and child visits.

The High-Risk Perinatal Program (HRPP) 2023 updates and activities can be found in the Perinatal/Infant Health 2023 Annual Report.

In 2023, the BWCH Home Visiting Workgroup sustained its collaborative efforts to enhance program implementation. The workgroup continued efforts to coordinate goals and actions to be congruent with the ADHS Strategic Plan, Arizona Health Improvement Plan (AzHIP) strategies, Title V MCH Block Grant priorities, and home visitation program requirements. In 2023, the consolidation of home visiting programs within the ADHS, previously divided between the Office of Women’s Health and the Office of Children’s Health, now under the umbrella of the Office of Children’s Health has proved instrumental. This organizational realignment significantly bolstered program implementation and fostered stronger internal collaboration. As a result of the restructure, the internal workgroup has sunsetted and each of the program leads will convene under the direction of the Chief, Office of Children’s Health.

The Office of Injury and Violence Prevention (OIVP) is housed in the Bureau of Chronic Disease and Health Promotion. In 2023, Arizona’s Title V Program continued to provide funding to and collaborate closely with the Office of Injury and Violence Prevention on initiatives to reduce injury and death among infants and children (e.g., Safe Sleep, traffic injuries, etc.).

The Office of Injury and Violence Prevention provides support to the five local Safe Kids coalitions that are located around the state; additionally, the Office serves as the liaison between Safe Kids Worldwide and the local coalitions. Each coalition works to help families and communities keep kids safe from unintentional injuries, including but not limited to reducing traffic injuries, drownings, falls, burns, poisoning, and more. As the Safe Kids Arizona coordinator, ADHS held quarterly meetings to update the local coalitions on what was happening at the national level and to ensure that the local coalitions were aware of any grant opportunities that Safe Kids Worldwide was providing. Currently, there are two local health departments that are the lead agencies for Safe Kids coalitions—Coconino and Yuma Counties—however, the OIVP also collaborates with Apache, Cochise, Gila, La Paz, Mohave, Navajo, Pinal, Pima, Santa Cruz, and Yavapai counties.

The Office of Injury and Violence Prevention promotes car seat accessibility and child passenger safety (CPS) education to reduce traffic injuries and fatalities among infants and children. 

The Office of Injury and Violence Prevention provides the national Child Passenger Certification training around the state to certify individuals to become car seat technicians, with a focus on rural and tribal communities which are our most vulnerable. The OIVP was able to collaborate with the Coconino County Health District, the AK-Chin Indian Community, and the Salt River Pima Maricopa Indian Community in 2023. Three (3) training courses were held and as a result, a total of 58 students were certified, 3 participants became instructors, and 1 became an Instructor Candidate.

With Title V funding, the Office of Injury and Violence Prevention along with the Safe Kids coalitions held a one-day Continued Education Unit (CEU) conference for technicians in the fall of 2023. With the participation of six (6) national car seat manufacturers, this conference gives technicians from around the state who are not able to attend national conferences the opportunity to have one-on-one time with car seat manufacturers to ask them questions and get answers straight from the source regarding their product. There were a total of 129 participants that attended and we received great feedback and suggestions. Partners continue to provide education virtually as well as in person. 

Arizona’s Title V Program, through the Office of Injury Prevention and the MCH HAF IGA, Arizona’s home visiting programs, and Arizona’s CFR Program all continue to collaborate closely on Safe Sleep education and sudden unexpected infant death (SUID) prevention. More information on these efforts can be found in the Perinatal/Infant Health 2023 Annual Report.

In 2023, Title V funds were allocated to fourteen (14) out of the fifteen (15) County Health Departments through the Maternal & Child Health Healthy Arizona Families (MCH HAF) Intergovernmental Agreement (IGA). The county health department can utilize the funds to address children’s health initiatives, such as household safety, teen safety driving programs, physical activity, preventive dental visits, bullying prevention education, and collaborating on leveraging the state-level Safe Sleep Child Passenger Safety Interventions. Figure 30 provides a list of the Counties, the population-specific National Performance Measures they are working to address, along with the associated strategies. Apache, Coconino, and Pima County have focused on providing their communities with car seat education. The counties provide classes to the community on car seat education from car seat certified technicians. The certified technicians provide education and tips on the type of car seat families and caregivers should buy (rear-facing, forward-facing, and booster seat) based on the child's weight, height, and age. The technicians are certified to teach families how to install the car seats properly, ensure there is proper harness and belt placement, and when parents should move their children from a rear-facing car seat to a forward-facing car seat to a booster seat. Coconino and Pima County are a part of the Safe Kids Coalition whose mission is to reduce unintentional injuries to children 0-14. The Safe Kids Coalitions host checkup events and inspections to ensure that car seats are properly installed within the community.

Figure 30.  MCH HAF IGA Counties and associated National Performance Measures

County	NPM	Strategies
Apache	NPM 7.1	Car Seat education and installation
Coconino	NPM 7.1	Car Seat education and installation as well as the proper installation for transportation of children with special health care needs
Gila	NPM 13.2	Promote preventive dental visits for children
Maricopa	NPM 6	Quality Improvement to strengthen the developmental screening process
Navajo	NPM 7.1	Promote and educate the community on car seat safety as well as home, playground, and outdoor Safety courses
Pima	NPM 7.1	Child Fatality Review
Yavapai	NPM 6	Implement and train on communication tools for youth and adults with special healthcare needs

 

The Adverse Childhood Experiences (ACEs) workgroup comprises the Bureau of Assessment and Evaluation and other agencies within ADHS. The workgroup established new ACEs action plans with funding support of $300,000 allocated in October 2021 through the Smart and Safe Arizona Act (Proposition 207). The three plans are as follows:

1. Enhance surveillance and data visualization on ACEs/PCEs.
2. Enhance provider awareness of ACEs and PCEs.
3. Make ADHS a trauma-informed care agency.

For the first plan, the ACEs workgroup identified all sources of data (i.e., the National Survey of Children’s Health, Youth Risk Behavior Survey, Behavior Risk Factor Surveillance System, and Electronic Surveillance System for the Early Notification of Community-based Epidemics [ESSENCE]) pertaining to the 34 ACEs and 10 PCEs in Arizona and met with cross-agency experts to determine the role of public health in that metric, ease of data capture, import of metric, and overall health impacts. Currently, the ACEs and PCEs dashboards are available on the public-facing ACEs website (azdhs.gov/ACEs) using the BRFSS and NSCH data, and additional ACEs root cause dashboards were developed using various data sources such as free and reduced lunch rates to examine factors associated with ACEs. The root cause dashboards also summarize the most recent findings on root causes identified in the literature through a literature review. The detailed surveillance guide on ACEs and PCEs, listing the Arizona-specific data sources, variables, and considerations for data analysis, has also been documented and is available on the website.

The ACEs workgroup has created a provider-based video from AZ providers to AZ providers about an evidence-based and trauma-informed approach to ACEs and patient care. Additionally, the ACEs workgroup developed content geared toward providers, focused on awareness of the prevalence of ACEs in Arizona, and evidence-based recommendations for practice, which is in development.

For the third action plan, the ACEs workgroup conducted a nationwide search for frameworks on trauma-informed organizational change for large-scale agencies, branded the approach, and found champions within the department. Currently, the workgroup is at the pre-implementation stage, seeking to make changes within key development areas based on the (SAMHSA) domains of consideration for organizational change structures. The model includes organizational development components aimed at transforming both employee environments and interactions as well as public environments and interactions:

1. Leading and communicating
2. Hiring and orientation practices
3. Establishing a safe environment
4. Collaborating with others
5. Reviewing policies and procedures

Furthermore, the workgroup collaborated with the Arizona State University Morrison Institute to conduct policy analysis with experts in ACEs in Arizona to explore policy initiatives to mitigate the effects of ACEs and inform future policies. The workgroup also had 10+ presentations in the past year to disseminate recent findings on ACEs, and PCEs, and their impact on Arizona youth mental health at various channels of communication, including the State Board of Education meeting, county superintendents’ meetings, KJZZ, ADHS’ Director's blog, and state and national conferences. In addition, one infographic on ACEs and PCEs, using the 2021 Arizona Youth Risk Behavior Survey data, has been published along with three infographics on youth mental health, electronic vape product use, and disordered eating–all of which highlight their relationship with ACEs. Lastly, a research article titled “Supportive Relationships Mitigate the Effect of Cumulative Exposure to Adverse Childhood Experiences on Depression, Anxiety, Stress, and Suicide Considerations—The Arizona Youth Risk Behavior Survey” was published in Children in 2024. The results of this article were presented as an individual paper at the 2023 American Public Health Association meeting. 

ADHS implements the Empower Program to support Arizona’s early care and education (ECE) facilities in their endeavors to encourage young children to grow up strong and healthy. By enrolling in the Empower Program, licensed child care facilities, both family child care group homes, and centers, voluntarily agree to implement all standards and develop a written policy for each standard that meets the needs of all children served. In turn, the childcare facility is provided a fifty percent (50%) reduction in licensing fees, partially funded through Title V Block Grant. The fee discount was temporarily suspended for a three-year period (July 1, 2021-June 30, 2024), and licensing fees were reduced to $1 per year. This is a temporary benefit provided by the Child Care and Development Fund COVID-19 Relief dollars to assist financially struggling providers due to the pandemic. Additionally, ECE programs contracted with the Arizona Department of Economic Security (DES) are required to enroll and participate in Empower, as are all Quality First (QRIS) participants. The Empower Program requires providers to adopt ten (10) health standards, two (2) of which impact children's oral health: 'Fruit Juice' and 'Oral Health'. These efforts are welcomed by oral health stakeholders who recognize the link between fruit juice and the oral health of young children. In 2023, the Office of Oral Health (OOH) continued support of online e-learning courses on implementing tooth-brushing programs in child care and serving fruit juice. These training resources are available to all childcare staff in Arizona at no cost. AZ ECE Workforce Registry credit is also available, free of charge, to those who enroll. In 2023, ‘Empower Training: Fruit Juice in Child Care Settings’ had 168 users, and ‘Empower Training: Tooth Brushing in Child Care Settings’ had 110 users. Enrollment in these training courses continues to approach pre-pandemic levels but the early childhood landscape in Arizona is still stabilizing post-pandemic. In 2020, a work group of the Empower Advisory Committee (EAC) began a thorough review of all the standards, including Standard 7: Oral Health and Standard 5: Fruit Juice. Workgroups comprised of EAC members and ECE providers have reviewed existing standards and components, comparing them to child care licensing rules and best practices such as Caring for our Children, National Association for the Education of Young Children (NAEYC), and Go NAPSACC. The work groups finalized changes to the updated Empower standards, including implementing a new standard on social-emotional well-being in early childhood education. The revised standards were rolled out in July 2023, with training scheduled to be updated in the workforce registry in 2024.

Building on the work of Arizona’s participation in the Nemours grant, ‘Better Together’ from 2019-2022, Go NAPSACC is currently being embedded into the statewide early care and education system. Three state agencies, ADHS, DES, and FTF, have agreed to split the subscription cost of $30,000 per year for a three-year period to establish the use of the system. Of the seven (7) modules addressed in Go NAPSACC, there is a module specific to Oral Health. Go NAPSACC system includes tools to complete full improvement cycles in each topic, including self-assessments, goal setting, action planning, and reassessment, as well as numerous tips, materials, and online training.

With the help of Title V funding, ADHS 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, including most of the primary care providers in AZ. 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: In 2023, TAPI distributed over 125,000 educational pieces to schools, childcare 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 and for COVID-19 vaccine information. The TAPI webpage (whyimmunize.org) allows parents, teens, and adults to ask medical experts questions about vaccines and immunizations and was updated to reflect Advisory Committee on Immunization Practices (ACIP) recommendations and COVID-19 outbreak information.

Social Media and Other Public Health Communication: TAPI maintained a Facebook page with consistent "likes” and maintained a closed “Parents Who Protect” group to share pro-vaccine stories. Posts to both pages included flu, measles, mumps, Hep A and COVID-19 outbreak information; water safety; flu information; community awareness for general vaccine education; off to college, Vaccinate Before You Graduate, and other 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 15,000-20,000 times. Content included medical exemptions, parent and doctor relationships, National Infant Immunization Week, CDC updates, back-to-school information about vaccinations, Tdap, coverage and exemption data, catch-up vaccines, and flu/COVID-19 vaccinations. TAPI participated in national social media partnerships to keep accurate immunization information trending across all immunization coalitions, using the COVID-19 outbreak to educate about the importance of all immunizations.

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 vaccine education, the development of the COVID-19 vaccine by age, and catch-up vaccines disrupted by COVID-19. TAPI worked with pro-immunization 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 information and health publications for community health centers, hospitals, public health, and professional associations through weekly/monthly emailed updates. Professional associations participated in the flu & COVID-19 Button Up campaigns this year and regularly disseminated immunization education to clinicians. Partnerships with the Pediatric and March of Dimes chapters developed campaigns for catchup doses that kids have fallen behind on, new immunizations protecting from RSV, and vaccines during pregnancy. 

TAPI conducted Immunization Best Practices Training for provider office vaccine management staff on using patient education materials and resources. Aiming to improve vaccine delivery and increase immunization rates, in 2023, TAPI hosted 15 statewide training sessions for routine and COVID-19 vaccines (reaching over 850 participants). 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 training, 83 practices achieved or maintained a 90% coverage level for toddler or teen patients in 2023 and were awarded at the annual Big Shots for AZ dinner. Continuing best practices maintained high coverage levels despite disruption from COVID-19.

Special Projects: In 2023, Arizona's percentage of children aged 19-35 months being adequately immunized has remained below our 90% target at 63%. Arizona continues to be challenged by high exemption rates in some parts of the state. TAPI partnered with the Arizona Department of Education to increase vaccine education through school health offices, to help educate parents looking for exemptions about vaccine safety. TAPI used previous survey results to develop resources needed in health offices to open conversations with parents. Materials and training were developed and posted to a school nurse webpage for a one-stop resource catalog.

TAPI continued to provide train-the-trainer programs on 10 Things Parents Need to Know about Immunizations. These quarterly trainings are attended by Community Health Workers, Social Workers, Educators, and Social Services staff that may have a trusted relationship with the community. The training provides community influencers with tips and tools to combat vaccine misinformation and answer parents' questions about vaccines.

Though the focus of health agencies was primarily on COVID-19 response, Arizona partners continue to promote immunization coverage in high-risk areas and have been able to continue to protect children from vaccine-preventable diseases.

To support families, children, and parents with newborns, BWCH and BNPA maintain the Title V Toll-free MCH Helplines. The dedicated service includes three helplines: 1. Breastfeeding; 2. Children Information Center; and 3. Women's, Infant, and Children (WIC) Program. Information is provided in English, Spanish, and Telecommunications Device for the Deaf (TDD). Additional information about Children’s Information Helpline can be found in the Perinatal-Infant Health 2023 Annual Report.

The ADHS Sensory Screening Program, funded through Title V, addresses the Arizona Legislature’s mandates for hearing and vision screening for preschool- through high-school-aged children. The program loans hearing and vision equipment to stakeholders to complete screenings. The hearing screening reports from schools are due annually. Vision screening report submission was voluntary for the 2022-2023 school year. The program received 1,703 hearing screening and 823 vision screening reports for the 2022-2023 school year. These reports detail that 549,010 children and adolescents received hearing screenings including 93,752 CYSHCN, and 231,109 children and adolescents received vision screenings including 36,746 CYSHCN.

Vision screening reports have historically been lower than hearing screening and remained so for this school year as well. Submission of vision screening reports is currently voluntary. The requirement for schools to complete vision screening was added to Arizona Revised Statutes (ARS §36-899.10) in 2019. During 2023, the Sensory Screening Program finalized the draft of the administrative rules that will guide these screenings and require the submission of annual reports.

Throughout 2023, the Sensory Screening Program began working with the identified statewide contractor, Arizona American Academy of Pediatrics, to provide hearing screening training to schools at no cost to the participants. The hearing screening curriculum was revised and updated, a hybrid training option was developed, and the development of an online self-paced training course for hearing screening was begun. Vision screening training was temporarily suspended in anticipation of the pending vision rule adoption. When the Vision Rules are finalized, schools will be required to have screeners certified through an ADHS training program to perform vision screenings.

The ADHS Sensory Screening Program has also developed an online reporting database to maintain the trainer/screener certifications, training rosters, and training evaluation through Qualtrics, a research software. The online database allows the program to enter training rosters after completing the training and it generates an email to the trainees with a link to download the certificates along with a training satisfaction survey. The feedback from the training satisfaction survey assists with modifying the training sessions as needed and helps improve the quality of training. In 2023, the ADHS Sensory Screening Program processed 977 certificates through the Qualtrics system. Of the 977 certificates, 842 were hearing certificates and 135 were vision certificates.

The ADHS Sensory Screening Program has automated the hearing and vision loan equipment program through Checkfront, an online booking and reservation system designed to make it easier for stakeholders to reserve hearing and vision screening equipment. The online system allows stakeholders to reserve sensory equipment from locations in Phoenix, Flagstaff, Yuma, and Tucson. In 2023, the program received 394 reservation requests to reserve 838 pieces of hearing and vision equipment for screening/training.

In 2019, the Emergency Medical Services for Children (EMSC) Program was transferred from the Division of Prevention, Bureau of Women’s and Children’s Health, to the Division of Preparedness, Bureau of Emergency Medical Services. In 2023, the EMS for Children Program Manager and Arizona Family Advisor Network (FAN) Representative were actively engaged in several projects while collaborating with key partners such as the CYSHCN Program Director and Family Advisor, Coyote Crisis Collaborative, the Western Regional Alliance for Pediatric Emergency Medicine (WRAP-EM), the Arizona Chapter of the American Academy of Pediatrics, and Phoenix Children’s Hospital. Some examples of ongoing projects are the development of a statewide prehospital pediatric-specific EMS recognition program, participation in pediatric disaster activities, such as mass casualties and family reunification, pediatric emergency care coordinator (PECC) recruitment and PECC education, connecting first-responders with schools for pediatric disaster preparedness, and preparing for a national launch of an inaugural prehospital pediatric readiness assessment following the EMS survey. These projects provide support to the Arizona Prehospital Agencies and Emergency Department personnel statewide while adhering to the EMSC national performance measures.

At the heart of the Arizona EMS for Children (EMSC) Program is the Pediatric Advisory Council for Emergency Services (PACES) which convenes quarterly on a virtual platform. PACES includes standing representation from each of the four EMS regions throughout the state, which represent both urban and rural areas, standing representation for a tribal representative to represent Arizona’s tribal community, and family representation through the EMSC FAN as well as the Arizona Title V with the CYSHCN Program Director and Family Advisor. Their perspectives enhance PACES’ understanding of health disparities and inequities across the state as the EMSC develops and implements strategies to improve pediatric health outcomes through education, training, and resources. In 2023, educational programs such as the Neonatal Resuscitation Program (NRP), Pediatric Seizure training, and Pediatric Airway training were discussed following an analysis of the National EMSC Data Center (EDC) Emergency Medical Services (EMS) survey and approved through the PACES committee in 2023 to provide to urban and rural EMS agencies. EMSC educational resources are shared on the ADHS website.

The Arizona Title V Program continues to provide funding to the Arizona Chapter of the American Academy of Pediatrics (AzAAP) to promote Pediatric Prepared Emergency Care (PPEC). AzAAP provides technical assistance to hospitals in Arizona, including Critical Access Hospitals (CAHs) in rural and remote areas of the state, to achieve a higher level of preparedness in caring for children. These efforts include supporting Emergency Department nurses to acquire specialty certification and increasing the number of Arizona Emergency Departments certified as ‘Pediatric Prepared’.

In 2023, a total of 41 member hospitals across Arizona were certified as ‘Pediatric Prepared’ hospitals (Appendix M). Certification is available for three levels of care: Pediatric Prepared Emergency Care (32 hospitals), Pediatric Prepared Plus Care (2 hospitals), and Pediatric Prepared Advanced Care (7 hospitals). The first level of certification, Pediatric Prepared Emergency Care, provides services for pediatric care as part of a general Emergency Department. The hospital refers critically ill or injured children to other facilities and may or may not have pediatric inpatient services available. The second level, Pediatric Prepared Care Plus, provides services for most pediatric emergency care. The hospital has a focus on pediatrics, but ICU services for children are not available. The highest level of certification, Pediatric Prepared Advanced Care, provides services for all levels of pediatric emergency care, includes a pediatric intensive care unit, and has a specific focus on pediatric services. AzAAP continued to conduct site visits in 2023 with five (5) out of six (6) being completed.

To complete the program’s annual nurse training, a Certified Emergency Nurse (CEN) exam preparation course took place on April 25th and 26th with forty-five (45) attendees. In addition, an Emergency Nurse Pediatric Course (ENPC) took place on August 24th and 25th with ten (10) nurses attending the training. On September 13th and 14th AzAAP hosted a Certified Pediatric Emergency Nurse (CPEN) course with twenty-eight (28) nurses in attendance. AzAAP has created a learning management system, AzAAP PedsLMS, and Continuing Medical Education (CME) applications are being completed to host two separate webinars for pediatric emergency physicians. The first will focus on the medical surge during pediatric disasters and the other will discuss Naloxone use in the emergency departments.

The AzAAP CEO has a seat on the Arizona Pediatric Advisory Council for Emergency Services (PACES) and actively participates in quarterly meetings to continue to build relationships benefitting the PPEC program. AzAAP continues to work with a Doctor of Nursing Practice (DNP) student on a project to understand how PPEC can best partner with freestanding emergency departments to include them in the program and prepare them for pediatric patients. This plan includes gathering baseline data on the pediatric preparedness of freestanding emergency departments, conducting an applied project, and offering future recommendations based on the results. The student has completed the project and presented the results to the PPEC Steering Committee.

During 2023, hospitals have been experiencing ongoing staff changes and shortages. The changes have led to facilities recertifying later than anticipated because of the new contacts and needing additional time to learn about the program and its requirements. AzAAP continues to work with hospitals that are experiencing significant hardship due to the lasting impacts of the COVID-19 pandemic. AzAAP continues to work with hospitals to become certified and recertified as they are able and are actively discussing ways to better support PPEC facilities.

In response to the COVID-19 pandemic, the AzAAP has established the Arizona Pediatric COVID-19 Training Center to provide high-quality education and training around the diagnosis and treatment of pediatric COVID-19. This work was originally funded in 2021 through a one-time, one (1) year special funding from the Title V Maternal and Child Health Services Block Grant, but has continued to be funded at least through September 30, 2024. The Arizona Pediatric COVID-19 Training Center was created in direct response to the urgent public health crisis to support AzAAP members (pediatric providers) by providing timely information and resources as they navigate the pandemic and provide care to patients and families. The Training Center is the home for a broad range of COVID-19-related resources, webinars, and toolkits; hosts a podcast and a blog; and serves as a resource to help members address concerns and safely provide care to patients. The objective of this work is to promote understanding of and adherence to Centers for Disease Control (CDC) and national-level American Academy of Pediatrics (AAP) guidelines and policy recommendations on infectious disease, immunizations, and infection disease control methods, particularly concerning pediatric populations and COVID-19, to improve patient outcomes.

With the COVID-19 pandemic moving to an endemic stage, AzAAP rebranded to the Arizona Pediatric Infectious Disease Training Center and Podcast allowing the expansion of the training center and podcast to provide education in infectious disease. This includes addressing the decline in preventative well-child visits and the decrease in childhood vaccination rates. The Training Center provides high-quality education and training around infectious disease prevention, diagnosis, and treatment, and to meet the emerging needs of providers and families.

Through the Arizona Pediatric Infectious Disease Training Center, AzAAP hosts a podcast, ID Talk: Answers from an Infectious Disease Specialist, which is hosted by Pediatric Infectious Disease Specialist Dr. Sean Elliott. Each podcast episode is about 20 minutes long which answers questions and offers real-time support/mentoring to pediatric healthcare professionals as they care for their patients. The podcast features the most up-to-date, evidence-based, Arizona-specific information on a range of childhood infectious disease topics including clinical guidelines, treatment recommendations, diagnostics, and more. The podcast is available through the AzAAP website and YouTube channel, as well as on Spotify, Pandora, and Apple Podcasts. There have been over 10,581 total downloads since the inception of the podcast with 3,101 downloads between January and December 2023.

AzAAP produced 22 podcast episodes in 2023, covering topics like updated COVID-19 guidance, and the Omicron variant XBB.1.5, long COVID-19, variants, test kits, booster shots, and COVID-19 prevention nasal sprays. In addition, the podcast has covered various topics like the malaria outbreak, foodborne illness, the rise in syphilis cases in Arizona, respiratory syncytial virus (RSV), the triple-demic of COVID-19, RSV and the Flu, and immunization schedules among many others.

AzAAP also offered free continuing medical education (CME), in collaboration with the national AAP and the CDC, Project Firstline, on “Infection Prevention and Control” with increased attention on system-level changes. AzAAP posted over 54 unique Project Firstline posts on Facebook, Twitter, and LinkedIn to promote resources that have been developed.

AzAAP has formed the Arizona Unified Health and Wellness Council to expand services and support that is provided to schools by opening a broader scope of infectious disease management efforts, such as maintaining a safe and healthy environment, containing coughs and sneezes, implementing frequent hand hygiene and other mitigation strategies that schools struggle to implement or sustain. The council members serve as the advisory group for projects that address infectious disease management in schools. The council will work on establishing a long-term partnership to tackle school infectious disease management with a special focus on equity, diversity, inclusion, and the unique cultural and environmental challenges that underserved populations and communities face. During a council meeting, an action plan was identified to address school attendance including when a child is too sick to attend school. The first project was creating a one-pager for schools to utilize guiding when students should stay home to prevent the spread of infectious diseases. The one-pager will be shared with school health professionals and parents.

AzAAP hosted its Annual Conference & Exhibition in June of 2023. The conference was a three-day post-graduate course that combined lectures, case presentations, questions and answer sessions, and workshops with time for informal interaction with the guest faculty and peers. The conference has been designed to develop, maintain, and increase the knowledge, skills, and professional performance of pediatric healthcare professionals (including general pediatricians, pediatrics subspecialists, residents/fellows, nurses, and physician assistants) by providing them with the highest quality, most relevant and accessible educational experiences possible.

AzAAP has continued the Vaccine Preventable Disease (VPD) Committee to strategize on the most pressing issues facing infants, children, and adolescents in the state. The committee is responsible for developing and submitting proposed infectious disease prevention and immunization goals and developing an annual plan to achieve the approved goals for improving infectious disease prevention and immunization within Arizona. The VPD Committee currently includes fourteen (14) provider members from across the state and with diverse backgrounds, including two residents and two medical students who meet quarterly. The committee’s goals include: increasing the statewide percentage of COVID-19 vaccinations in eligible pediatric populations by 10 percentage points by 2024 and increasing the statewide percentage of routine childhood immunizations by 5 percentage points by 2024.

With the constant influx of new guidance and immunization recommendations, it can be challenging for healthcare professionals to stay up to date. With the respiratory virus season along with the triple-demic of flu, RSV, and COVID-19, it becomes even more crucial that healthcare professionals have access to the latest information. COVID-19, in particular, is an ever-evolving disease with new strains of the virus emerging, subsequent updates to vaccines, and updated guidance on prevention and control measures.

As AzAAP creates and shares positive evidence-based messaging with caregivers on the best ways to protect their children and families from vaccine-preventable diseases, they have been met with strong anti-vaccination sentiment. AzAAP has been navigating misinformation about infectious disease and immunizations online which has been a challenge that has been amplified by the misinformation during and after the COVID-19 pandemic. The influx of misinformation has heightened distrust in vaccines and healthcare professionals. AzAAP has been researching and following techniques on how to navigate negativity around vaccines. AzAAP staff have been attending social media strategy sessions offered by AAP to equip the Chapter with effective techniques to counter misinformation online and have been shared with AzAAP’s network of pediatric healthcare professionals. By staying informed and adopting these social media strategies, AZAAP aims to enhance public trust in vaccines and combat misinformation online.

The Engaging Families and Young Adults Program (EFYAP) continued to implement and work with family and/or young adult advisors throughout each Bureau’s office and among the population health domains. The Office of Children’s Health has worked with one family advisor for the past eight years and another family advisor for the past two years through the CYSHCN program. More information can be found in the CYSHCN 2023 Annual Report.

Alongside the Children’s Health activities and work headed by the OCH team and collaborators, the Office of Oral Health (OOH) and Primary Care Office (PCO) continued in their cross-cutting activities relating to Children’s Health.

The Office of Oral Health, housed within BWCH, implements several oral health programs and initiatives to improve the oral health of Arizona's children, pregnant women, and other high-risk populations aimed at addressing NPM 13.2 - Percent of children, ages 1 through 17, who had a preventive dental visit in the past year. Key programs and initiatives for children’s health include the school-based Dental Sealant Program, Silver Diamine Fluoride (SDF) Program, Fluoride Varnish Programs, and the Healthy Smiles Healthy Bodies Survey. Each of these programs receives partial funding from Title V. During 2023, all of these programs continued to experience disruption to services due to the continued effects of the pandemic.

Arizona has continued and enhanced several strategies to improve the oral health of Arizona's MCH populations. The Bureau of Women’s and Children’s Health (BWCH), Office of Oral Health (OOH), initiated the Arizona School-based Sealant Program in 1987, with a grant received from the Flinn Foundation. This evidence-based program is designed to reach high-risk, underserved school-aged children on their school campus using portable dental equipment. Additional funding that same year from the Ronald McDonald Children's Charities allowed OOH to continue the program. In July of 1989, the Sealant Program was incorporated into the OOH State Budget, and Maternal and Child Health Block Grant dollars were used for supplies, equipment, and contracting personnel for the Arizona School-based Sealant Program. Since then, legislative changes have enabled the program to become sustainable through the establishment of the Oral Health Fund and the ability to receive Medicaid reimbursement for oral health services.

The Arizona School-based Sealant Program (SBSP) is implemented to reach underserved and high-risk populations in an effort to decrease tooth decay in susceptible teeth where topical fluorides are less effective. To expand the reach of the program, OOH has been involved in collaborative efforts with other state health agencies and organizations to promote the use of dental sealants and to provide technical and educational assistance in the development of additional resources for dental disease prevention.

The program has been very effective at reaching Arizona’s most vulnerable children by targeting high-risk schools. Both public and charter schools with 50% or higher free and reduced school meal program participation may apply and are eligible to participate in the program. Dental screenings and sealants are provided to children in 2nd and 6th grade with parental consent. Sealants are provided to uninsured children, Medicaid and State Children's Health Insurance Program (SCHIP) beneficiaries, and those covered by Indian Health Service. These two age groups are targeted because they have newly erupted permanent first or second molars that benefit from the placement of dental sealants. The sealant program provides services to children in 5 of the 15 Arizona counties. Services are provided by trained and calibrated dental providers. OOH provides technical assistance and trains local providers to ensure successful sealant placement and retention and makes every effort to connect participating children with a dental home in or near their community.

School-based dental sealants are one of only two evidence-based methods for the prevention of tooth decay and are crucial to reducing decay in children. Untreated tooth decay can cause pain and infection and can affect overall health. Dental screenings help identify serious oral health issues and dental sealants prevent the development of future health-related issues that can require more invasive treatments.

School-based dental care is a crucial way to reach low-income children who may otherwise have little to no access to care. Nationally, children in low-income families are at higher risk of caries and are less likely to receive sealants than children in higher-income families, at 39% and 46%, respectively. (Griffin et al., 2016) A 2020 report, cited in this CDC Commentary on Oral Health and COVID-19: Increasing the Need for Prevention and Access, asserts that: “The oral health care safety net is expected to cover . . . one-third of the US population, notably those who are low-income, uninsured, and/or members of racial/ethnic minority, immigrant, rural, and other underserved groups.” (Northridge, Kumar, Kaur, 2020).

At the start of the pandemic, OOH revised the SBSP policies and procedures so providers were adequately prepared to deliver services safely. The Arizona School-Based Sealant Program Provisional Policies and Procedures Manual aligns with the most current guidelines and recommendations from the Centers for Disease Control and Prevention (CDC), Organization for Safety Asepsis and Prevention (OSAP), Environmental Protection Agency (EPA), Arizona Department of Education (ADE), and Arizona Department of Health Services (ADHS). OOH continues to update this guidance on an ongoing basis.

During the 2022-2023 school year, the Arizona SBSP reached 183 schools and provided oral health screenings and referrals for 5,308 children. Of the 5,308 students who received screenings, 3,810 received dental sealants. This was a 115% increase from the 2021-2022 school year when 1,770 children received dental sealants. This increase was attributed to the easing of COVID-19 protocols in schools in addition to increasing eligible 3rd-grade children who previously missed the opportunity to participate due to school closures. Additionally, of the children who participated in the program, approximately 906 children (17%) were identified as children with special health care or needs.

Despite the increase in the number of children served, counties encountered challenges, including the inability to provide services due to staff losses and difficulty in securing programmatic personnel. Ongoing shortages posed obstacles in hiring new providers, which directly affected service delivery, particularly in rural areas. 

The Arizona SBSP bills Medicaid for eligible children and uses Title V funds for services to the uninsured. Partnerships with federally qualified health centers (FQHCs) and county cooperative extensions have provided outreach to additional counties. OOH is committed to expanding the reach of school-based sealant programs and serving more individuals in rural communities. Currently, efforts are underway to secure the services of a Statewide Standing Order Dentist to further support this goal.

The purpose of the Health Resources and Services Administration (HRSA) grant is to increase oral health workforce activities in underserved areas as well as participation in school-based prevention programs. Targeted activities include implementing an online curriculum for dental providers to have access to training on how to implement school-based dental sealant programs as well as provide high-quality dental sealants. In addition, an oral health curriculum designed to meet Arizona educational standards will be provided to participating schools to increase oral health literacy among targeted age groups. The incorporation of educational standards from the Arizona Department of Education into learning materials not only enhances learning but also serves as a compelling justification for schools, potentially increasing participation rates by demonstrating clear alignment with established educational benchmarks for Arizona language and health standards.

In addition, the OOH partnered with the Oral Health Resource Center (OHRC) to develop the national training modules for dental providers and worked on developing an Arizona-specific training module which will be housed on the OHRC website with an opportunity to earn continuing education credits once completed. All sealant program providers will complete the training which offers 12 hours of training per provider.

OOH preventive programs also include the Kindergarten Fluoride Varnish Program as part of the same eligibility and infrastructure as the AzSBSP. During the 2022-2023 school year, the number of schools that participated was 40. The Fluoride Varnish program screened 620 children and 507 children received at least one fluoride varnish, a 61% increase from the 2021-2022 school year where 315 children received fluoride varnish.

The OOH implements a Preschool Fluoride Varnish Program for children ages birth through five. This is in partnership with Arizona’s early childhood agency, First Things First (FTF), through the Arizona Early Childhood Development and Health Board. The Arizona Fluoride Varnish Program began as a pilot with OOH and First Things First, an Arizona voter initiative that supports early childhood education and health. The program is offered at Women Infants and Children (WIC) Program offices, immunization clinics, and child care centers. The application of fluoride varnish, an extremely effective cavity-prevention agent, in combination with dental screenings, referrals, and other educational services, is the core of the primary prevention program. The role of OOH is to provide professional development and a sustainable billing system with local partner agencies. During the 2023 state fiscal year (July 1, 2022–June 30, 2023), the Fluoride Varnish Program served 15,426 children, ages birth through five, in five counties including screenings, fluoride varnish, oral health education, referrals, and case management. As part of this strategy, OOH provides technical assistance to partners instrumental in providing preventive oral health services. This included the administration of monthly Community of Practice meetings, education on anticipatory guidance, and motivational interviewing. During the 2022-2023 school year, 52 providers participated in over 68 hours of professional development.

A key addition to the Preschool Fluoride Varnish Program is to reach underserved and high-risk pregnant women. OOH’s role is to provide the local partner agencies with professional development on anticipatory guidance and motivational interviewing for pregnant women. During the 2022-2023 school year, OOH provided eight hours of professional development for 38 providers.

Another key strategy of OOH is to reach high-risk children and families to increase oral health literacy. During the 2022-2023 school year, OOH provided a total of 168.5 hours of oral health education in 183 elementary schools. This education reached 18,325 children and distributed oral health supplies, including toothpaste, toothbrushes, and floss.

The Office of Oral Health began implementing the Healthy Smiles Healthy Bodies (HSHB) Survey during the 2019-2020 school year. This survey is conducted by OOH every five years and is tied directly to the Title V MCH Needs Assessment. The goal of the HSHB Survey is to collect oral health and body mass index (BMI) status of population groups (kindergarten and 3rd grade) in Arizona. This surveillance data informs public health programs, monitors progress toward reaching state/national benchmarks, including Healthy People 2030 objectives, and contributes to the CDC National Oral Health Surveillance System. The survey continued during the 2022-2023 school year with an additional 44 schools participating. This concluded the data collection phase with the final report to be published in June 2024 and data shared with the CDC National Oral Health Surveillance System.

The COVID-19 pandemic has had a significant negative effect on securing dental providers for OOH programs. The February 2021 Journal of Dental Hygiene reported the results of a 30-question web-based survey completed by licensed dental hygienists. One in twelve had dropped out of the workforce citing concerns about being exposed to the novel coronavirus and the infection control measures being taken at dental practices that led them to leave the profession. OOH prevention programs have experienced the most severe shortage in the availability of dental providers ever in the history of the program. Maricopa, the largest County contractor, has reported a severe shortage of dental hygienists and dental assistants. Some left the profession and the County has not been able to hire since the start of the pandemic. Additionally, other contracted partners have reported issues with retaining and hiring dental providers. OOH currently has no dental providers to cover Santa Cruz, Cochise, and Yuma Counties and has been actively recruiting for the past 12 months. Community health clinics also have reported shortages because dental providers have been reassigned to COVID-19-related activities.

The Office of Oral Health continued working in partnership with the Arizona Health Care Cost Containment System (AHCCCS; Arizona's Medicaid program) by collaborating on reimbursement of oral health services for AHCCCS-enrolled children. Reimbursement of program services has built sustainability in the program and increased AHCCCS' preventive services initiatives. One major achievement and outcome of this collaboration was the institution of a policy within the AHCCCS Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements for health plans to participate with the Cavity Free AZ prevention programs. Collaboration between the two state agencies also included referrals and identifying opportunities to link Medicaid-eligible children to dental homes.

During 2023, OOH worked with a broad array of national, state, and local public and private partners to educate decision-makers on dental public health issues and concerns of state oral health programs that impact and reach children. One such partnership included statewide and regional oral health coalitions that were instrumental in addressing access to care issues for our most vulnerable populations. In 2021, Arizona worked on providing technical assistance to partners regarding the recently signed Dental Therapy bill, which created a new class of dental care providers in Arizona who will be able to provide primary dental care for children and underserved individuals. Rules for dental therapists were established in 2022 and partners are eager to move forward with implementation.

The Primary Care Office (PCO) within BWCH leads statewide efforts to improve access to care to all health services in Arizona’s rural and underserved communities through the State Loan Repayment Program (SLRP), the National Health Service Corps Loan Repayment Program (NHSC), and the Conrad 30 J-1 Visa Waiver Program. Focused on dental provider shortages areas, NHSC also supported an additional 54 dentists, and 19 registered dental hygienists in Arizona while the State Loan Repayment Program supported 11 dentists.

Additional information about the Primary Care Office and Access to Care activities can be found in the Women/Maternal Health and Perinatal/Infant Health 2023 Annual Report.