Child Health – Annual Report

Guam’s Title V Needs Assessment identified many priority needs in the domain of child health. These included reducing obesity, reducing unintentional injuries, immunizations, and increasing rates of developmental screening. However, after completing a systematic prioritization process, reducing injury rose as a top priority. For the Child Health domain, Guam selected NPM # 7.1 – Rate of hospitalizations for non-fatal injury per 100,000 children aged 0 through 9 years.

Each year, millions of children are injured and live with the consequences of those injuries. For some children, injury causes temporary pain and functional limitations; for others, injury can lead to permanent disability, depression, chronic pain, traumatic stress, and a decreased ability to perform age-appropriate activities. In addition, family members must often care for the injured child, which can cause stress, time away from work, and lost income.

In 2018, injury was responsible for 15 child/young adult deaths on Guam. Twenty-seven percent (27.2%) of hospitalizations and 86.4% of the emergency room visits for children/young adults aged 0 to 24 years were due to injuries. As in the case nationally, the types of injuries vary by age group and have been broken into groups of injuries to those less than one year, one to nine years old, ten to nineteen years, and twenty to twenty-four years of age.

For those one through nine years of age, the leading causes for Emergency Room (ER) visits and hospitalizations were because of injuries by falls and trauma (unintentionally struck by object(s)); for age group ten to nineteen years, the leading cause of ER visits or hospitalizations were trauma and unintentional motor vehicle accidents (occupant or driver); for the age group twenty to twenty four, the leading causes were unintentional motor vehicle accident (occupant or driver) and drowning.  

The Bureau of Family Health and Nursing Services (BFHNS) and the Guam Title V program provide support to the Guam Council on Child Death Review and Prevention (GCCDRP). This multi-disciplinary team reviews the deaths of infants, children, and young adults up to the age of 24 years. The GCCDRP works to provide accurate data and information detailing how and why Guam children are dying. The GCCDRP also makes recommendations to assist in reducing the number of preventable infant, child, and young adult deaths.

In 2018, 62 infants, children, and young adults died on Guam. This was 4.9% higher than 2017 and 33.5% lower than 2016. During 2018, 51.6% of the deaths occurred to infants less than one year of age; 9.6% to children aged one to four years old; 3.2% to children aged five to nine years; 4.8% to children aged fifteen to seventeen years; 8% to young adults aged eighteen to twenty years; and 22.5% to young adults aged twenty one to twenty four years. There were no deaths within the age group ten to fourteen years old. Of the 62 deaths in 2018, 22.5% were deemed preventable; this was a decrease from 2017, where 33.8% of the deaths were deemed preventable.

In 2018, there were disparities in the percentage of child deaths represented by each racial/ethnic group compared to the percent of child population. Even though they represent7% of the population, Chuukese children made up 27% of the child deaths, while Filipinos make up 27.3% of the population and 19.3% of the child deaths. Chamorros make up 37.2% of the population and 33.8% of the deaths.

The mission of the Guam Department of Public Health and Social Services (DPHSS) is to protect the lives of those that call Guam their home. Motor vehicle injuries continue to be a leading cause of death and injury to children and young adults. The current method of child passenger safety intervention through education, enforcement, and policy change has worked to increase child safety seat use and is an evidence-based approach listed in the Centers for Disease Control and Prevention Guide to Community Prevention Services.

The Guam Department of Public Works-Office of Highway Safety (DPW-OHS), along with the Guam Police Department – Highway Patrol (GPD-HP) and other partners such as Title V, continue to promote and implement high visibility and educational outreach as an essential part of Guam’s successful seat belt laws.

In 2018, DPW-OHS conducted 4 community outreaches and 19 school presentations on the importance of using seat belts and child safety restraints as well as pedestrian and bicycle safety. In addition, GPD-HP conducted two operation “Buckle Down” interventions. Operation Buckle Down is an educational and enforcement program that DPW-OHS and GPD-HS conducts together. Parents are observed while driving into school grounds to see if they were compliant with Guam seat belt laws and had their children restrained. Parents who were non-complaint were issued seatbelt and/or car seat citations.

The Annual Observational Seat Belt survey conducted in 2017 showed Guam’s seatbelt usage for all passengers at 90.9%. This was the fifth year using the National Highway Traffic Safety Administration procedures. In 2018, the Annual Observational Seat Belt survey showed Guam’s seat belt usage at 92.2%, which was an increase of 1.4% from 2017 data.

In July 2018, the Child Passenger Safety Technician (CPST) lead instructor and CPST instructor conducted a Child Passenger Safety Renewal course and Child Passenger Safety Technician Standardization Training that re-certified 7 CPSTs and 12 new CPSTs.

The number of auto-pedestrian fatalities more than tripled between 2017 and 2018. In 2017, there were 14 pedestrian deaths compared to four in 2017. 

The Pedestrian and Bicycle Safety programs primary goals are to increase the awareness of pedestrian and bicycle safety. DPW-OHS conducted presentations at elementary, middle, and high schools on the importance of walking on sidewalks, utilizing crosswalks, and wearing reflective gear while riding a bicycle and/or operating a motorcycle.

 In 2016, there were two cyclists killed on Guam roads, a vehicle driven by a distracted driver struck and killed a 53-year old male, and a 5-year old was hit and killed by a vehicle while riding her bicycle.

The Guam Cycling Federation, I-Bike Guam, and the Non-Communicable Disease Consortium Obesity/Physical Activity team have brought awareness of automobiles and cyclists sharing the roadways on Guam by placing “sharrows” on the roadways. Sharrows (Shared Roadway Bicycle Markings) are intended to help bicycle riders position themselves away from parked cars, to avoid being struck by suddenly opened car doors, and to alert other road users to expect bicyclists to occupy travel lanes. The efforts of the Guam Cycling Federation, I-Bike Guam, and the Non-Communicable Disease Consortium Obesity/Physical Activity team have yielded more than 200 sharrow markings on the roadways. In additions to the sharrows, signs marking “bike route” and “share the roadways” have been erected along popular routes

Child abuse and neglect is one of the Nation’s most serious concerns. Approximately 3 million cases of child abuse and neglect involving almost 5.5 million children are reported each year. The majority of cases reported to Guam’s Child Protective Services (CPS) involve neglect, followed by physical and sexual abuse. There is considerable overlap among children who are abused, with many suffering a combination of physical abuse, sexual abuse, and/or neglect.

Physical abuse occurs when a child’s body is injured because of hitting, kicking, shaking, burning, or other show of force. One study suggests that about 1 in 20 children have been physically abused in their lifetime. Sexual abuse is any sexual activity that a child cannot understand or consent to. It includes acts such as fondling, oral-genital contact, and genital and anal intercourse. It also includes exhibitionism, voyeurism, and exposure to pornography. Studies have suggested that up to one in four girls and one in eight boys will be sexually abused before they are eighteen years old.

Most child abuse occurs within the family. Risk factors include parental depression or other mental health issues, a parental history of childhood abuse, and domestic violence. Child neglect and other forms of maltreatment are also more common in families living in poverty and among parents who are teenagers or who abuse drugs or alcohol.

In most cases, children who are abused or neglected suffer greater mental health than physical health damage. Emotional and psychological abuse and neglect deny the child the tools needed to cope with stress, and to learn new skills to become resilient, strong, and successful. A child who is maltreated or neglected may have a wide range of reactions and may even become depressed or develop suicidal, withdrawn, or violent behavior. Not all children who are abused have severe reactions. Usually the younger the child, the longer the abuse continues, and the closer the child’s relationship with the abuser, the more serious the mental health effects will be.

The Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) provides voluntary, evidence-based home visiting services to at-risk pregnant women and parents with young children until kindergarten entry. The MIECHV Program builds upon decades of scientific research. MIECHV home visiting services seek to educate parents on child development and progress on developmental milestones and help families connect to necessary services, such as health care or community resources. Under the MIECHV program, Guam is accountable for meeting benchmarks in six areas: (1) improved maternal and newborn health; (2) prevention of child injuries, child abuse, neglect or maltreatment, and reduction of emergency department visits; (3) improvement in school readiness; (4) reduction in crime or domestic violence; (5) improvements in family economic security; and (6) improved coordination and referrals for other community resources and support.

Home visitors prevent child injuries by providing information on hazards in the home environment, coaching caregivers in positive parenting practices and providing guidance on when to seek out further medical care. Home visitors complete a Home Safety Checklist (HSC) with the caregiver to identify safety concerns in the home that may put the infant or toddler at risk for an unintentional injury. Home visiting programs in Guam screen mothers and pregnant women for domestic violence using validated screening tools, and make appropriate referrals to domestic violence services. In addition to screening women for domestic violence, home visitors offer support and education regarding healthy relationships, and assist in the completion of safety plans for domestic violence, to help the mother strategize how to keep her and her children safe. On Guam, 80% of moms were screened for maternal depressive symptoms within 6 months postpartum; 100% of families were provided intimate partner violence referrals; and 91.7% of families were provided information or training around prevention of child injuries (which included car seat safety and safe sleep education) throughout the project period.

Other Child Health Concerns

Immunization

Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Vaccines stimulate the body’s own immune system to protect the person against subsequent infection or disease.

Guam Public Law 32-73 was passed in 2013 and requires all health care providers performing immunizations on children and adults to submit immunization reports into the Guam Immunization Registry (Guam WebIZ). The information collected allows the Immunization Program to assess the immunization status of children to ensure immunizations are current.

Immunization is a proven tool for controlling and eliminating life-threatening infectious disease and is estimated to prevent between 2 and 3 million deaths each year. It is one of the most cost-effective health investments, with proven strategies that make it accessible to even the most hard-to-reach and vulnerable populations. It has clearly defined target groups; it can be delivered effectively through outreach activities; and vaccination does not require any major lifestyle change.

MCH staff works closely with the Immunization Program to ensure that children receive their vaccinations on a timely basis to protect them from childhood diseases. The Immunization Program provides the vaccines and the staff to process the patients and MCH provides the staff to administer the vaccines. Walk-in clinics are offered twice a week at Central Public Health. Immunizations are also available at the Child Health Clinics. The Immunization Program conducts immunization outreaches at low income housing areas, mayors’ offices, shopping malls, and at schools, so that as many children as can be immunized are. A month before the opening of the new school year, immunizations are offered daily at Central Public Health to meet the demands to get children ready for school. Due to federal mandates, immunizations are only available to children who are underinsured, uninsured, on MIP, or on Medicaid

As depicted by the graph above, Guam falls well under the US percentage of children aged 19 through 35 months who have completed the combined 7-vaccine series. The 7-vaccine series consists of 4 or more doses of DTaP, 3 or more doses Polio, 1 or more doses of MMR, the Hib full series, 3 or more doses of HepB, 1 or more doses of Varicella, and 4 or more doses PCV.

State and local jurisdictions require children to be vaccinated before starting school to maintain high vaccination coverage and protect schoolchildren from vaccine-preventable diseases. State vaccination requirements, which include school vaccination and exemption laws and health department regulations, permit medical exemptions for students with a medical contraindication to receiving a vaccine or vaccine component, and may allow nonmedical exemptions for religious reasons or philosophic beliefs. To monitor state and national vaccination coverage and exemption levels among children attending kindergarten, CDC analyzes school vaccination data collected by federally funded state, local, and territorial immunization programs.

Guam children entering kindergarten have relatively high immunization coverage levels, even though exemption data has increased over the last 5 school years. While Guam’s coverage rates are high, increasing exemption rates and subsequent decreasing of immunization coverage erodes the integrity of the herd immunity in communities for vaccine preventable disease. As herd immunity is compromised, unvaccinated individuals, children and adults alike, will be placed at a higher risk of contracting vaccine preventable diseases.

Developmental Screening

Although Guam did not choose the NPM for developmental screening, Guam MCH has been working with Guam’s Project LAUNCH, known as Kariñu. Kariñu, which means loving our children in Chamoru, is part of Guam’s Early Childhood Comprehensive System (ECCS) Initiative. The Guam Early Learning Council made the initiative an island-wide, cross-agency collaborative that provides leadership to build and integrate systems; improve the coordination and alignment of programs/services; support ECCS and workforce development; leverage resources; and collect, share and use early childhood-related data.

Kariñu screens the socio-emotional and behavioral development of young children ages birth to five years using the Ages & Stages Questionnaire (ASQ); Ages & Stages Questionnaire: Social-Emotional (ASQ:SE); and Social Emotional Assessment/Evaluation Management (SEAM) Family Profile. Mothers, fathers, and caregivers with children ages newborn to three months are screened using the Edinburgh Postnatal Depression Scale (EPDS). Since the start of Kariñu, more than 480 ASQ and ASQ-SE screenings have been completed. Guam’s Island-wide Developmental and Behavioral Screening System (iDBSS) is an integrated screening, referral, and service delivery system for children birth to age five years that is culturally and linguistically competent and respectful of the diverse ethnic and cultural backgrounds that exist on Guam. The purpose of the iDBSS is to identify children with or at-risk for disabilities early, and if eligible, access early intervention and/or other early childhood services.

In July 2018, the Guam Early Learning Council, Early Promotion and Identification workgroup reviewed and updated the Universal Referral form. The purpose was to ensure the form continues to be user friendly and captures information that would be needed to assist programs in helping families navigate through the system and receive the appropriate services for their child. All early childhood programs continue to use the Universal Referral Form and are part of the iDBSS process.

Reach Out and Read

Reach Out and Read (ROR) is a nationally recognized program where clinicians give new books to families and teach in the clinic visit how to engage their children in a developmentally appropriate way to read. Data has shown that these projects have increased early literacy and language skills, particularly among disadvantaged and more marginalized families.

The Guam Community Health Centers (CHCs) serves a high proportion of individuals who are economically disadvantaged, and many children have levels of health difficulties. Families often come looking for ways they can help improve their child’s developmental outcome in the setting of these challenges. By engaging in ROR, CHCs can give families something that they can do to help their child develop, empowering both the health institution and the families to play a pivotal role in their children’s development and success.

The program’s mission is to help children grow up with books and a love of reading. Although that mission does not mention the process of learning to read explicitly, one major goal of preschool literacy activities is to provide children with some of the cognitive skills they need for successfully learning to read once they get to school. Early exposure to books and reading aloud contributes to a child’s readiness to read and learn at school entry, as does more general language exposure.

Child Obesity

In the U.S., obesity in children is occurring at younger ages than previously and is affecting children as early as age two. Being obese and overweight carries health consequences. Children are at-risk for serious chronic diseases including type 2 diabetes, heart disease and certain types of cancer. The estimated prevalence of overweight/obesity in the U.S. for children ages 2 to 19 years is approximately 32%; however, a recent study suggests that the percent of overweight/obese children of those same ages on Guam is significantly higher than their U.S. counterparts at approximately 39%.

The Children’s Healthy Living (CHL) Program is a program to prevent early childhood obesity and to improve the health of young children. CHL researchers aim to change the context in which child overweight/obesity occurs by building strong partnerships for action within communities. Nineteen activities address policy, environment, messaging, and training, and targeted six behaviors (sleep time, screen time, physical activity, fruits and vegetables, water and sugar-sweetened beverages).

The project partners with local communities in Hawai‘i, Alaska, American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, the Federated States of Micronesia, the Republic of Palau, and the Republic of the Marshall Islands. These are regions that are not surveyed by the Centers of Disease Control and Prevention in its national program to monitor health and nutrition, and thus limited measured data existed about them prior to the program’s inception. However, what data there were suggested that Pacific jurisdictions are some of the most obese countries in the world, and that the problem is growing amongst the children as well as the adults in these regions. Undernutrition also remains a problem in some of these areas, the other face of what is described as the dual burden of malnutrition.

Through a community randomized trial involving measurements of children, households, communities and jurisdictions, the program confirmed this understanding, and through community-based partnership, it is working to reverse this trend. CHL addresses priority areas of food safety, nutrition, and health; agricultural systems and technology; and agricultural economics and rural communities. It supports long-range improvement in and sustainability of agriculture and food systems at the same time that it aims to increase the number of educators, practitioners, and researchers who receive the training and effectively model behaviors necessary to address the complex problem of childhood obesity prevention.

The methods by which the team encourages children to become healthier range from promoting local foods, including produce from students’ own school gardens, to creating environments for active play. Traditional foods, sports, and activities are supported, integrating elements from both traditional and modern global cultures that enhance health. Since the program is designed to be self-extending and integrated into its target communities, it included a provision for undergraduate and graduate scholarships, allowing students to earn degrees and use their training in their home communities.

Through the “Get Guam Healthy Incentive Program” monies were appropriated to promote health, wellness, physical activity and the effective use of social and healthcare services for Medicaid-eligible recipients and other disadvantaged populations through individual, family, and community programs. One of those programs was “Early Start, Fit for Life.” The goal for “Early Start, Fit for Life” is to reduce and/or eliminate non-communicable disease, including common and modifiable risk factors, such as obesity in children, and to promote health, wellness, and physical activity during and after school at Guam Department of Education (GDOE) in order to provide students with the minimum of 25 minutes of instructional physical education. One of the key objectives was to provide Sports, Play, and Active Recreation for Kids (SPARK) training/SPARK curriculum.

SPARK is a research-based physical education discipline designed in order to promote lifelong wellbeing without sacrificing the enjoyment of physical activities or academic achievements. The program is aligned to the NASPE (National Association of Sport and Physical Education) guidelines. SPARK strives to improve the health of children and adolescents by disseminating evidence-based physical activity and nutrition programs that provide curriculum, staff development, follow-up support, and equipment to teachers of Pre-K through 12th grade students.

Furthermore, the Prevention and Health Promotion action team of the Diabetes Prevention and Control Program (DPCP) developed a Diabetes Curriculum for Guam Public Schools grades K-12. The DPCP through its leadership role and as a member of the secretariat of the Guam Diabetes Control Coalition helped launch the Nutrition and Physical Activity Academy Leadership Cohort in 2017. The inaugural class had 22 teachers complete a four-day training in December 2017. The second cohort in 2018 consisted of 15 teachers who completed the training. Seven different curriculums were developed to include one in the Chamoru language. The second cohort aims to produce materials in other languages such as Chuukese, and Pohnpeian.