PRIORITY: Decrease Overweight and Obesity Among Children
Interpretation of Performance Data on, NPMs, ESMs, SPMs, and SOMs:
ESM 8.1.1: Percent of physical education teachers receiving professional development related to 50% of PE class time spent in moderate to vigorous physical activity
This is a new Year 2 ESM, which was not included among the Year 1 ESMs for the child overweight and obesity priority area.
ESM 8.1.2: Percentage of TN counties in which trainings related to mental health and physical health have occurred
This is a new Year 2 ESM, which was not included among the Year 1 ESMs for the child overweight and obesity priority area.
ESM 8.1.3 Number of Gold Sneaker certified childcare facilities
There were 643 Gold Sneaker certified childcare facilities at the end of Year 1. This number was just shy of the target of 700. However, there was improvement as 94 centers were added since the baseline of 549 in 2020. One major challenge was the COVID pandemic, which hindered any further progress being made as many facilities had to close or otherwise change their operations. In addition, during this period, the Gold Sneaker initiative was still in the process of conducting new training and recertifying all facilities due to changes in policies.
ESM 8.1.4: Percent of LHD primary care clinics writing HPHP prescriptions annually
This is a new Year 2 ESM, which was not included among the Year 1 ESMs for the child overweight and obesity priority area.
ESM 8.1.5: Number of Healthy Parks Healthy Person prescriptions written
There was a cumulative total of 195 HPHP prescriptions written by local health department (LHD) health care providers as of the end of Year 1. This number far exceeded the target value of 50. As the HPHP prescription program only commenced in the fall of 2020, there was no baseline value on which to base a reasonable estimate of how many prescriptions providers might write during that first year. Promotional efforts by both TDH, LHD health educators, and TDEC staff to raise awareness of the program as well as subsequent interest from providers far surpassed expectations. The data are even more surprising given the impact of the COVID pandemic, which most likely reduced the overall number of patient visits to primary care clinics. Yearly targets for 2022-2025 have been revised accordingly.
ESM 8.1.6: Percentage of TN counties with completed built environment projects
This is a new Year 2 ESM, which was not included among the Year 1 ESMs for the child overweight and obesity priority area.
ESM 8.1.7: Percent of eligible venues offering the Double Up Food Bucks Program
This is a new Year 2 ESM, which was not included among the Year 1 ESMs for the child overweight and obesity priority area.
SPM 6: Percent of schools with at least 50% physical education class time spent in moderate to vigorous physical activity
This is a new Year 2 ESM, which was not included among the Year 1 ESMs for the child overweight and obesity priority area.
SPM 7: Rate of Double Up Food Bucks purchases per SNAP recipient
This is a new Year 2 ESM, which was not included among the Year 1 ESMs for the child overweight and obesity priority area.
SOM 3: Percent of public school 6th graders who are overweight or obese
Tennessee public school sixth graders are at the upper end of the age range for the child domain. Therefore, obesity and overweight data within this group is a good measure of progress in meeting long-term goals and outcomes for this priority area. In 2021, the risk of overweight or obesity actually increased to 45.0% from the baseline of 43.64% in 2017-18, which is a statistically significant difference. It usually does take some time for programs and initiatives to make a positive impact on long-term objectives. However, it is likely that progress was further impeded by COVID’s influence on remote learning and limited physical activity and healthy nutrition opportunities and programs. In addition, as the data are based on direct height and weight measurements, school closings during the height of the pandemic could have greatly skewed results.
SOM 4: Percent of WIC recipients aged 2-4 years who are overweight or obese
Although limited to a specific population, WIC data are the only ongoing source of overweight and obesity information among the preschool age group in Tennessee. Therefore, WIC BMI data represent another key source for a long-term outcome related to this priority area. In 2021, the risk of overweight or obesity in TN WIC recipients ages 2-4 increased slightly to 32.0% from 31.2 in 2020, but the rate was substantially higher compared to pre-COVID levels (i.e., 25.5% in 2019). However, during the pandemic, the WIC program waived the requirement for in-person height and weight measurements, which could have greatly biased the results. Other aspects of the pandemic that limited opportunities for physical activity outside the home could have been a factor as well.
Sufficient physical activity is a major factor in maintaining healthy weight. Therefore, the measure is a key short to medium term outcome for the child overweight or obesity priority. The combined 2019-2020 National Survey of Children’s Health (NSCH) percentage of TN children ages 6-11 who are physically active at least 60 minutes every day was 30.6%. This rate represented a slight decline or higher risk since the 2017-2018 baseline (31.5%) and was short of the 2021 target by over a percentage point. However, the difference is not statistically significant, and there are too few years of data yet in this cycle to detect any trends. Although the NSCH is the source for MCH national performance and outcome measures, the state sample size is small even after combining years of data. Therefore, the confidence interval around percentages is fairly broad and the sensitivity for determining statistical significance is low for all but the most substantial differences in percentages.
NOM 19: Percent of children, ages 0 through 17, in excellent or very good health
This long-term outcome is the primary measure of overall health status. The combined 2019-2020 National Survey of Children’s Health (NSCH) percentage of TN children ages 0-17 in excellent or very good health was 89.0%. This represented a slight increase or improvement since the 2017-2018 baseline (88.7%) and was just short of the Year 1 target. However, the difference is not statistically significant, and there are too few years of data yet in this cycle to detect any trends. Although the NSCH is the source for MCH national performance and outcome measures, the state sample size is small even after combining years of data. Therefore, the confidence interval around percentages is fairly broad and the sensitivity for determining statistical significance is low for all but the most substantial differences in percentages.
NOM 20: Percent of children, ages 2 through 4, and adolescents, ages 10 through 17, who are obese (BMI at or above the 95th percentile)
NOM 20, which is specific to only adolescents ages 10 – 17, has not been a measure for this priority area for either Year 1 or Year 2 of the current MCH cycle. The overweight/obesity priority is in the child domain where the priority age range is approximately 0-11. However, there is a state outcome measure (SOM 2) related to obesity among WIC recipients ages 2-4. Information on this measure can be found under SOM 4 above.
Accomplishments and Challenges (based on FY2021 Action Plan):
Strategy 1: Support school-based efforts to promote physical activity and good nutrition
Activity 1a: Collaborate with the Tennessee Department of Environment and Conservation (TDEC) and the Department of Education Coordinated School Health to increase the number of statewide physical activity clubs (walking, running, etc.) in both school-based, community-based sites from 275 to 285 clubs.
Report 1a: During the reporting period there were 1,194 schools that reported implementing a run club. The challenge was determining the number of run clubs per school.
Activity 1b: Partner with the Department of Education Coordinated School Health staff to provide professional development on school physical education and physical activity to at least 10 local education agencies with an emphasis on areas with the highest youth obesity rates.
Report 1b: During the reporting period,173 schools that offered professional development on before school physical activity programming, 103 offered professional development on CSPAP (Comprehensive School Physical Activity Programs), 1,017 schools offered professional development on physical activity best practices, 1,247 schools offered professional development on physical education best practices, and 1,063 schools offered professional development on using physical activity in the classroom. These opportunities were offered in 136 school districts statewide.
Activity 1c: Partner with the Department of Education Coordinated School Health (CSH) staff to provide professional development on promoting healthy lifestyle choices before, during, and after school to at least 50 PHEs and local education agency staff (Smart Snacks in Schools, Junior Chef, National After School Association's HEPA standards, etc.)
Report 1c: During the reporting period, 538 schools offered professional development on nutrition, 1,212 schools offered professional development relating to the importance of breakfast for students, and 7,793 staff received professional development and technical assistance on strategies to create a healthy school nutrition environment.
Strategy 2: Promote Gold Sneaker voluntary recognition program for licensed childcare centers
Activity 2a: Participate in 1-2 meetings with the TN Department of Human Services to promote the Gold Sneaker 3 Star requirement and explore opportunities to add Gold Sneaker requirements to licensed childcare standards.
Report 2a: During the reporting period, the Director of Chronic Disease and Health Promotion, Health Promotion Director and Gold Sneaker Program Director participated in 3 meetings with TDHS to discuss the licensing standards and the requirements for Gold Sneaker to be included in the 3 Star Quality Childcare Program. The discussion focused on Gold Sneaker policies, program compliance, promotion to childcare centers and overall evaluation of the Gold Sneaker Program. Challenges included postponing and cancelling meetings and closures of childcare centers due to COVID restrictions and guidelines.
Activity 2b: Provide a minimum of 1-2 trainings on the Gold Sneaker policies for public health educators, TN Department of Human Services staff, and Child Care Resource & Referral Center staff, and other partners statewide.
Report 2b: During the reporting period there were no in-person trainings conducted due to Covid restrictions. There were 5,582 unique Gold Sneaker online trainings completed in English and 7 in Spanish on the Tennessee Child Care Online Training System (TCCOTS) platform. The online training included: Gold Sneaker guidelines and policies, strategies to adhere to policies and licensing standards, educational materials, and program resources.
Activity 2c: Identify and disseminate educational resources to Gold Sneaker certified daycares that support implementation of Gold Sneaker policies related to physical activity, nutrition, and tobacco exposure.
Report 2c: During the reporting period, the following resources were distributed: Gold Sneaker Childcare Provider and Parents and Families rack cards, toolkits and resource packets for certified providers, access to Ask Gold Sneaker for technical assistance, and educational and advocacy opportunities provided on the Gold Sneaker web page. Challenges included childcare centers closed due to COVID restrictions. Due to the closures, many locations did not have the ability to access or receive educational resources.
Activity 2d: Increase number of daycares that complete the voluntary Gold Sneaker certification from 535 to 600.
Report 2d: At the end of this reporting there were 643 certified Gold Sneaker childcare centers.
Strategy 3: Partner with healthcare providers to promote physical activity counseling during well-child visits
Activity 3a: Identify a minimum of 5 health provider champions including pediatricians and family practitioners, to increase the awareness and use of the Healthy Parks Healthy Person park prescription program for patients and their families to increase physical activity.
Report 3a: During the reporting period there were approximately 25 health provider champions, including MDs, APRNs, FNPs, and RNs that promoted the Healthy Parks Health Person program as well as provided prescriptions for outdoor recreation and physical activity. The provider champions covered 7 rural regions and 2 metros.
Activity 3b: Promote the use of the Healthy Parks Healthy Person park prescription program and app by PHNs, WIC staff, and other health providers in 10 local health departments.
Report 3b: During the reporting period HPHP was promoted by Health Promotion staff and Public Health Educators in county health department in all 95 counties. HPHP revised and released a new app that provided a user’s physical activity history, park activities notifications, reward refunds and a provider portal. There was over 10,700+ app users and over 1,630 rewards earned by active participants. There were also 195 HPHP provider prescriptions given to patients ages 1 through 61. Providers included MDs, APRNs, RNs and LPNs in local and metro health department clinics. Challenges included a decrease clinic visits and clinic closures due to Covid restrictions.
Strategy 4: Promote policy, systems, and environmental change (PSE) strategies to increase physical activity and promote access to healthy food and beverages
Activity 4a: Support local communities who set a goal with Primary Prevention Plans from community needs assessment of reducing consumption of sugary drinks with an emphasis on distressed and at risk counties.
Report 4a: During the reporting period Public Health Educators from 10 distressed and burdened counties provided programs and activities focusing on reducing consumption of sugary drinks and increasing water intake. Twelve (12) events and programs were conducted reaching approximately 3,850 students, children and youth, and community members. The activities included: Re-Think Your Drink and Drink More Water campaigns and community festivals and health fairs promoting healthy nutrition including the importance of water consumption. Challenges included school and community organizations closed due to COVID restrictions. Several programs were delayed or cancelled reducing the number of programs implemented. In addition to reducing consumption of sugary drinks there were 236 built environment primary prevention projects completed addressing access to health programs and services.
Activity 4b: Identify a min of 5 partners to develop and implement strategies that increase access to healthier food and beverage options with an emphasis on distressed and at risk counties.
Report 4b: During the reporting period, the Project Diabetes program awarded funds to several community-based organizations and schools to develop and implement strategies that increase access to healthier food and beverage options. Six (6) organizations and schools conducting programs and activities included: 1) Maury County Schools - school gardens and cooking classes and rethink your drink campaigns; 2) MTSU- Hydration stations installed and a Drink Up Blue Raiders campaign; 3) Nourish Knoxville – Double Up Food Bucks at farmers markets and farm stores in East Tennessee; 4) University of Memphis – installed lactation rooms on the Memphis and Jackson campuses; 5) UT Memphis Medical School - Culinary Medicine Program - Medical school education to teach evidence-based nutrition, core culinary skills, mindfulness, behavior modification using the principles of culinary medicine; and 6) Paris & Henry County Healthcare Foundation – installed hydration stations with a social marketing campaign to encourage reduction of sugary beverage intake. In addition, Public Health Educators implemented Soda Free Summer Programs in Lawrence, Robertson, Marshall counties. Challenges included school and community organizations closed due to COVID restrictions. Several programs were delayed or cancelled reducing the number of programs conducted.
Activity 4c: Promote joint use agreements that encourage after-hours use of school and community facilities for reactional activity.
Report 4c: There was little promotion of joint use agreements during this time period due mostly to COVID restrictions and challenges. Overall, 119 LEAs had protocols or policies for joint use agreements, which represented a reduction of 5 LEAs from the previous year.
Strategy 5: Promote the mental health benefits of physical activity
Activity 5a: Provide training, resources, and tools for 10 health departments promoting the mental health benefits of being physically active in nature.
Report 5a: During this reporting period, training and resources promoting the mental health benefits of being physically active in nature was provided to health promotion staff and public health educators in 7 regional health offices and 6 metro health departments (including local health departments in all 95 counties). Some of the resources included: The Trailhead, a free and open online community for children and nature champions, including practitioners, educators, parents, researchers, and anyone committed to connecting children, families and communities to the benefits of nature; Healing in the Outdoors webinar discussing connection to nature, nourishment and care for the land, and understanding how time in nature can enhance physical, mental and emotional health and well-being; Cities Connecting Children to Nature toolkits including Advancing Equity In Children’s Connections To Nature, Tools to Bring Nature’s Benefits to Children, and the Strategy Tool: Nature Connection in Early Childhood Sites. Challenges included postponing and cancelling trainings due to Covid restrictions.
Activity 5b: Partner with the Department of Education Coordinated School Health staff to provide professional development on the mental health benefits of physical activity to at least 8 local education agencies with an emphasis on areas with the highest youth obesity rates.
Report 5b: During the reporting period there was one LEA receiving professional development on the mental health benefits of physical activity. There were 80 participants. The challenge was providing professional development during the COVID pandemic.
Priority: Increase Prevention and Mitigation of Adverse Childhood Experiences
(ACEs)
Interpretation of Performance Data on, NPMs, ESMs, SPMs, and SOMs:
ESM 8.1.8 Percent of staff with an increase in ACEs and TIC knowledge as evidenced by post training evaluation:
The program was unable to track progress on ESM 8.1.8 in Year 1 as the staff person that was involved with this project is no longer with the agency.
ESM 8.1.9: Percent of families with improved protective factors score.
During FY21 of the 790 participants for whom data had been completed 49.9% had an in increase in PFS. Data are not available before this timepoint for comparison.
ESM 8.1.10: Percent of families enrolled in CHANT care coordination who partially or fully complete pathways identified
This is a new indicator for FY2021. The current status is higher than the expected outcome for FY2022. CHANT has been focusing on ensuring correct data entry and focusing on pathway progression for the families currently being served.
SPM 8: Percent of children with two or more ACEs.
During FY20, 20.6% of Tennessean children had two or more ACEs. The data for FY21 has not been released yet by the NSCH.
SPM 9: Percent of substantiated child maltreatment cases among families served by home visiting programs
During the FY20, 21.7% of the 92 children reported to DCS had substantiated cases while 9.8% of the 294 reported in FY21 had substantiated cases. Therefore, there was an 11.9% decrease in the percent of substantiated cases in FY21 compared to the cases substantiated in FY20.
SPM 10: Percent of caregivers who experience intimate partner violence and do not receive professional support services among families served by home visiting.
During FY2020 and FY2021, any caregiver participant in the TN EBHV program, who experienced intimate partner violence were referred to, and received professional support services. Thanks to the tireless efforts from the TN EBHV local implementing agencies’ staff.
SOM 5: Percent of adults reporting chronic obstructive pulmonary disease (COPD)
The percent of adults reporting Chronic Obstructive Pulmonary Disease (COPD) did not change significantly between 2019 (9.7%) and 2020 (9.5%). This stagnation is likely a consequence of a relatively slow decline in Tennessee’s adult smoking rate due to a myriad of factors including inadequate tobacco control policies, increases in stress during the COVID- 19 pandemic, and aggressive marketing tactics by the tobacco industry.
Accomplishments and Challenges (based on FY2021 Action Plan):
Strategy 1: Increase knowledge and practice of ACE and Trauma Informed Care (TIC)
Activity 1a: Develop and implement online ACEs training for TDH staff, including those in the CHANT and EBHV programs. Increasing the awareness of the impact of ACEs on families will provide a better understanding of what has happened to families and how to offer services in a supportive manner.
Report 1a: ACEs trainings were provided to approximately 77 TDH Central Office staff in fall 2019. The Early Childhood Initiatives (ECI) Professional Development Director position has been vacant for 1-year. Further, TDH is in the process of redefining Departmental ACEs strategies to address increasing Protective Factors and resilience.
Activity 1b: Develop and implement online TIC training for TDH staff, including those in the CHANT and EBHV programs. Through this training TDH staff and CHANT and EBHV programs will be able to integrate trauma informed practices into their work with families, mitigating the impact of ACEs.
Report 1b: No activities to report for Year 1. The Early Childhood Initiatives (ECI) Professional Development Director position has been vacant for 1-year.
Activity 1c: Provide ACE and TIC refresher training for child fatality teams as part of their ongoing training. This training will provide information and insight to teams on the impact of ACEs and trauma and assist in understanding the impact on social determinants of health.
Report 1c: An annual child fatality review training was held virtually on May 12, 2021 in which representatives from all 34 local child fatality teams throughout the state were invited. During the training, a session was conducted, by the National Center for the Review and Prevention of Child Deaths, on discussing ACEs and life stressors that impact child fatality. New questions were included in the national database to better collect information about ACEs and life stressors when reviewing a child death.
Strategy 2: Ensure a strong start for children by promoting a healthy parent-child attachment through implementation of home visiting programs throughout the 95 counties of Tennessee.
Activity 2a: Teach positive parenting skills through home visitation in partnership with local EBHV implementing agencies. This will include encouraging social-emotional learning and parent-child relationship whose instability has been exacerbated by the COVID-19 global pandemic.
Report 2a: TDH continues to provide EBHV services in all 95 counties in Tennessee through 15 Local Implementing Agencies (LIAs). LIAs delivered home visits virtually during the COVID-19 pandemic to maintain continuity of services safely.
Activity 2b: Provide health education through EBHV home visiting programs in counties throughout Tennessee. Communicating the importance of children having a medical home to parents promotes high quality and culturally effective integrated care
Report 2b: TDH continues to provide EBHV services in all 95 counties in Tennessee through 15 Local Implementing Agencies (LIAs). EBHV home visitors discuss medical home with enrolled families.
Activity 2c: Provide supportive care and additional services to families and children through EBHV home visitation. By connecting families with concrete services and knowledge of parenting and child development improve protective factors which mitigate or prevent ACEs.
Report 2c: TDH continues to provide EBHV services in all 95 counties in Tennessee through 15 Local Implementing Agencies (LIAs). EBHV is a proven strategy to mitigate the impact of adverse childhood experiences (ACEs). Further, EBHV promotes protective factors with enrolled families. Home visitors also complete the Ages and Stages Questionnaire (ASQ) with enrolled families to ascertain possible developmental issues.
Strategy 3: Intervene to lessen immediate and long-term harms by linking families to health and social services.
Activity 3a: Screen and assess families for enrollment in CHANT to identify health and social needs that have long term impact on families and children. By identifying the needs of families immediate, priority services can be provided to families.
Report 3a: CHANT continues to offer Screening and Assessment to families through a telephonic intervention within 2 weeks of the birth of a child, using birth data available through the health department. Also, local health departments have both internal and external referrals and provide a screening and assessment within 3 days of receipt of these referrals. The CHANT website now has an electronic referral link that is received by local health departments the same day it is received. Challenges in telephonic referrals have resulted in families that we were not able to reach through our phone outreach are placed on a 6 month call back schedule to attempt to engage at that point of time. TDH is working to find a vendor that will provide the ability to directly text message families concerning their needs and offer a screening and assessment.
Activity 3b: Provide referrals to families for identified health care and social service needs. Identifying which of the sixteen pathways of care families have identified as needs increase the protective factors within a family by providing concrete services at the time identified.
Report 3b: Families are identifying their needs and the Pathways of Care are being utilized in the development of a plan with the family. A challenge has been to identify the most critical needs a family has within those 15 pathways. This year Priority Pathways have been identified to allow focus on the most critical needs and to add any emergent needs the families are experiencing. Screening and assessments conducted through telephonic outreach now have health/safety issues that are identified as “red flags”. Families identified with a “red flag” issue are prioritized and sent to the Team Lead for that county to be triaged appropriately.
Activity 3c: Assist families in navigating the healthcare and social services system through the CHANT care-coordination model. Aiding in navigating any of the sixteen pathways, including obtaining a medical home or an EPSDT, is solution focused as barriers and other obstacles are addressed. Through this family resiliency is increased as a strategy to eliminate and mitigate ACEs the family might have experienced.
Report 3c: CHANT staff have received training on accessing the social services system and how to assist families in obtaining an EPSDT, immunizations, and/or obtaining a primary care physician. Rural Health Departments no longer provide EPSDT services and encourage families to obtain a Primary Care Physician and set up a medical home. CHANT staff now assist the local health departments with families that have barriers to obtaining a medical home. Families that also want to participate in CHANT complete a screening and assessment to identify other needs the families might be experiencing. Families that only want connections to a PCP or obtaining a medical home are assisted telephonically through the TDH Call Center even if they do not wish to have CHANT services.
Strategy 4: CHANT and EBHV will screen and link families to mental health
services
Activity 4a: Screen primary caregivers and families for depression using the Edinburg depression screening tool in EBHV home visiting programs and at CHANT screening and assessment. Depression can impact someone’s ability to care for themselves or a child. Early identification can result in earlier access to treatment.
Report 4a: All EBHV enrollees are to be screened with the Edinburgh Postpartum Depression Screening (EBHV). 2,641 families were enrolled in EBHV services from October 1, 2020 – September 30, 2021.
Activity 4b: Refer families and caregivers identified in EBHV home visiting programs and CHANT that have elevated depression screening scores to mental health providers. Risk for those experiencing depression include withdrawal, disconnecting from your baby/child, difficulty completing everyday tasks and fear of hurting yourself or others. Depression treatment includes medication and/or talk therapy and has an impact on preventing and mitigating ACEs.
Report 4b: In 2020, 86% of caregivers enrolled in EBHV who screened positive for depression received a referral to mental health services. In 2021, 92.90% of caregivers enrolled in EBHV who screened positive for depression received a referral to mental health services.
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