Child Health, Annual Report FY 2020

The annual report is organized by the two priorities for Child health: Increase the prevalence of children receiving integrated physical, behavioral, mental and developmental health services and Reduce the rate of childhood obesity.

 

Priority: Increase prevalence of children receiving integrated physical, behavioral, mental, and developmental services

NPM 6: Percent of children, ages 9 to 35 months, receiving a developmental screening using a parent-completed screening tool in the past year.

• According to 2018-2019 NSCH data, 34.3% of Ohio children ages 9-35 months received a developmental screening in the past year. This compares with 36.4% of children nationwide in 2018-2019. Previous Ohio rates were 28.5% in 2017-2018 and 33.3% in 2016-2017.

ESM 6.1: Percent of children, ages 9 through 35 months, receiving home visiting services who have received a developmental screening.

• Developmental screenings are required to be completed during the identified intervals within the Ohio Home Visiting Program. Screening data is recorded for each child enrolled within the data system and referral and follow-up is monitored by the home visitors. In FY 19, 70% of children who were enrolled received the developmental screening with the ASQ3 or ASQE2. While this represented an increase from 59% in FY 18, we were cautious in interpreting the difference due to the change in data system and potential differences in measure criteria. Children were included in the FY 19 denominator if the family had at least 1 home visit during the time period (making them “enrolled”) and if they were 30 days or older during the time period (making them “due” for a screen). Children meeting those criteria were also included in the numerator if they had 1 or more developmental screens during the time period (ASQ3 or ASQE2). In FY 20, 65% of enrolled children received a developmental screen. We expected the number of completed screens to be lower this year due to COVID-19. ODH advised home visiting providers to use only telehealth visit options (phone, video, text message, and drop off materials) since mid-March 2020; providers have indicated it is challenging to complete required screening and assessments due to technological issues and distractions during telehealth visits.

 

During FY 20, the Maternal and Child Health Block Grant (MCH BG) Child Health Priority work group continued its collaboration and partnerships with various stakeholder groups who represented public health programs, medical professionals, family organizations, and non-profit organizations to impact the priority to increase the prevalence of children receiving integrated physical, behavioral, and mental health services.

 

According to the 2011-2012 National Survey of Children’s Health, 93.9% of Ohio children aged 0-5 received one or more preventive medical care visit. Eighty-six percent of Ohio children aged 6-11 received one or more preventive medical care visit. According to the 2016-2017 National Survey of Children’s Health, 92.4% of Ohio children aged 0-5 received one or more preventive medical care visit. Eighty percent of Ohio children aged 6-11 received one or more preventive medical care visit. Percentages of children in the identified age ranges have each declined for the 2016-2017 National Survey of Children’s Health when compared to the 2011-2012 National Survey of Children’s Health results. Due to changes in item(s) between survey years the 2017-2018 preventive medical visit data could not be combined; however, 2018 NSCH data indicates continued decreases in preventive medical visits across age groups with 75.2% 0-5, 74.2% 6-11, and 70.9% 12-17. These compare with 2018 nationwide results of 78.8% 0-5, 69.0% 6-11, and 64.8% 12-17.

 

According to 2018-2019 NSCH data, 34.3% of Ohio parents indicated their children ages 9-35 months received a developmental screening using a parent-completed screening tool. Previous Ohio rates were 28.5% in 2017-2018 and 33.3% in 2016-2017. Due to the substantial reported decrease in 2017-2018 the targets were adjusted, and as such the 2018-2019 rate exceeds the FY 20 29.0% target but is still lower than the national rate of 36.4% in 2018-2019.

 

Trainings continued for healthcare providers prior to the pandemic. These in person trainings incorporated best practice/evidenced-based approaches for separate components of the comprehensive well-child visit and were conducted during the reporting period. Trainings included the provision of educational and follow-up resources for providers and families. Following the beginning of the pandemic, trainings for healthcare providers shifted from the in-person platform to a live virtual platform. Although trainings and provision of resources were provided during the reporting period, these continue to be disjointed. Overarching updates for the objectives are reported below, followed by more detailed updates provided for each program.

 

Objective: Increase the number of providers conducing quality comprehensive well-child visit in accordance with best-practice standards and guidelines that include developmental screenings

Programs continued to provide their trainings to healthcare providers to promote best practices and monitored their own screening rates and reported on these to determine changes and needs. Due to the pandemic, the number of healthcare providers who participated in trainings decreased during Ohio’s stay home stay safe orders.

 

Objective: Work with diverse stakeholders to explore the implementation of comprehensive well-child visits best-practice standards and guidelines that include developmental screenings

Programs continue to collaborate with diverse stakeholder groups to promote well care. Programs continued to promote and provide parent materials that could be used to educate families on the next steps for positive screenings (e.g., lead, hearing, vision, dental, ASQ). Programs who had evidenced-based trainings continued to spread these trainings to providers to help increase screening. Programs were asked to review their own data and determine areas of need.

 

Due to the COVID-19 pandemic, physician offices postponed well child visits due to the Ohio’s stay home stay safe orders. The number of children receiving child well visits with their primary care providers dramatically decreased, whether because of practitioner closures or restrictions or fear on the part of families. Noting these challenges, the ODH Early Childhood Health program contract with the Ohio Chapter American Academy of Pediatrics was updated effective July 1, 2020 to include development of resources and professional development for pediatricians and their office staff to address best practices for offices to provide care for young children and allay the fears of the families during the pandemic The contract also continues to provides professional development, continuing education credits, and resources to pediatricians and their office staff in support of obesity prevention messaging, BMI screening, and motivational interviewing through the Parenting at Mealtime and Playtime (PMP) program.

 

Objective: Explore a shared data system to track and share information on screening referral and follow-up services

This objective was removed after year 3 due to inability to collect/link screening data in OCHIDS, the new Home Visiting database.

 

Objective: Explore reimbursement models and standard reporting options

Both the Lead and Vision programs have accomplished this objective. Lead implemented a revised State Plan Amendment (SPA) with Medicaid for lead testing. Vision was granted a new CPT code outside of the bundled well-child visit to bill Medicaid for vision screenings. A MEDTAPP project with Vision on the implementation of the new code was completed in FY 20. The results of this project will spread the use of the new CPT code to bill for vision screenings for the Medicaid population. Standard reporting options across all programs continue to be limited by the inability to implement a comprehensive data system.

 

Early Childhood Health and Safety

Between the years 2013-2017, two of the top four Serious- and Moderate-Risk Noncompliance Violation citations by the Ohio Department of Job and Family Services (ODJFS) in licensed childcare programs in Ohio were related to health. The two most commonly cited violations were care of children with health conditions and administration of medication. In Ohio Department of Education (ODE) licensed programs, between 2015-2017 one of the top three violations was also health related (child medical statement).

 

The impact of pandemic restrictions can be seen in children care program data. During State Fiscal Year (SFY) 2020, Child Care Aware reports Ohio had 5,055 licensed childcare programs, down from 6,426 the year before. This included 2,819 childcare centers and 2,236 family childcare programs (https://info.childcareaware.org/hubfs/2020%20State%‌20Fact%20Sheets/Ohio-2020StateFactSheet.pdf?utm_campaign=Picking%20Up%20The%‍‌20Pieces&utm_source=Ohio%20). While there were 555,567 childcare spaces in Ohio in 2019, there were only 137,352 spaces in July 2020. This fact sheet shows that there are more than 827,626 Ohio children in the 0-5 age ranges, with 370,875 of them living in poverty. They estimate that 555,147 Ohio children under the age of 6 years have all parents in the workforce and need childcare.

 

Objective: Create and Deliver health and safety trainings for early childhood programs

The ODH Early Childhood Health (ECH) and Safety program was created in 2018 to provide training, technical assistance, and develop resources for staff in these systems specifically related to the health and safety of the children in their care. This program joined the ODH Early Childhood Obesity Prevention Program (ECOPP) to improve the childcare and preschool environments for Ohio children. The goal of this program is to improve the safety of early childhood environments in Ohio by providing high quality professional development/workforce development, technical assistance, and resources to ECE professionals with the goal of

reducing the number of health-related Serious- and Moderate-Risk Noncompliance Violations by ODJFS and ODE.

 

The content of these courses support ECE professionals as they work with families to increase the prevalence of integrated services, improve access to health services, and support access to PCMH for CYSHCN. In addition to online trainings, the ECH program planned to host a half day regional Early Childhood Health and Safety Conference in Spring 2020 in conjunction with each of the three ODH Regional School Nurse Conferences at venues around the state. While the first conference was held on February 27th to address the topics of oral health and health equity, the remaining two conference dates were cancelled due to pandemic restrictions.

 

This Public Health Services and System (PHS) strategy seeks to provide professional/workforce development to the licensed child care workers in Ohio. The strategy is being implemented on a statewide level, with collaboration with other state agencies including Ohio Departments of Education, Developmental Disabilities, Jobs and Family Services, as well as with the Ohio Child Care Resource and Referral Agency and the Ohio Center for Autism and Low Incidence. These partners serve on a Steering Committee to review content, provide recommendations and to promote the trainings to their constituents. As mentioned previously, a focus group of ECE providers is convened annually (virtually in summer 2020) to identify training topics and delivery methods.

 

During FY 20, ECH offered each online course every two weeks. These courses all offer “Ohio Approved” hours needed for professional development. There was a surge in requests for courses in May and June as childcare professionals were seeking continuing education credits to maintain their accreditation, so additional classes were offered during that time. During this year, “How to Care for CSHCN” (offered 30 times) was completed by 2,772 people; “How to Survive Cold and Flu Season” (offered 30 times) was completed by 3,131; “How to Manage Asthma” (offered 27 times) was completed by 1,968; “How to Manage Allergies” (offered 27 times) was completed by 2,207; “How to Accommodate Children with Disabilities” (offered 16 times) was completed by 1,129 participants; “Oral Health’ was completed by 359 (offered 8 times); and “Health Equity” (offered 7 times) was completed by 515 participants, for a total of 12,081 completions of online courses for the year.

 

During FY 20, the ECH program participated in two Healthy Kids Healthy Future Technical Assistance Programs (HKHF TAP) funded by the Centers for Disease Control and Prevention (CDC) and implemented by Nemours Children’s Health System (Nemours). One of these opportunities provide ODH ECH staff with an Outdoor Learning Environment course from North Carolina State University, while the other afforded the opportunity to invite 20 partners to participate in the Ohio Equity Workshop presented by IPHI. Program was able to use the information acquired in these trainings to create professional development for ECE professionals.

 

Title V was vital to the implementation of this strategy. Title V funding provided for the staff (.5 FTE) to take the lead to conduct the assessment, course development, and content delivery. In addition, Title V funds were used to contract with the three venues used for the face-to-face conferences (no outlay of funds was incurred for the cancelled events). With Title V support, development of professional/workforce development opportunities for ECE professionals has continued and expanded. Courses were launched throughout the year with large enrollment numbers and strong evaluations. While attendance at the face-to-face conferences were limited due to the pandemic, the online independent studies were well received. Anticipated next steps include development of more training opportunities for this target population, as well as further evaluation of outcomes.

 

Hearing and Vision

The Children's Hearing and Vision program is a program of early detection, diagnosis, and treatment of children with hearing and vision problems by setting the screening guidelines and requirements and providing training to screeners. Title V funding supports the Children’s Hearing and Vision program.

 

Trainings for healthcare providers incorporate best practice/evidenced-based approaches for the separate hearing and vision components of the comprehensive well-child visit. The trainings for healthcare providers were revised to include directions for the correct billing of the new vision screening CPT code that was established in FY 20.

 

Although trainings include the provision of educational and follow up resources for providers and families, these resources continue to be disjointed and cause barriers for follow-up care. New resources were developed for primary care providers to assist in the referral to appropriate eye care providers and audiologists following non-pass hearing and vision screenings. The web-based pediatric diagnostic audiology provider and pediatric vision provider directories assist in the primary care referral and follow-up process by listing contact information, acceptable insurance coverage, ages served, and services provided at each facility listed within the directories. Upcoming revisions to the eye care directory include a separate directory for low vision. Education and outreach were conducted with various screening stakeholders and families to raise awareness and promote the use and availability of these new resources.

 

In response to the pandemic, the Children’s Hearing Program and the Children’s Vision Program developed COVID-19 guidance documents for schools to conduct hearing and vision screenings safely. A total of 812 schools reported they who were unable to complete hearing and/or vision screenings due to the pandemic. In addition, data from the current year is not available for hearing and vision screenings in Ohio due to the reassignment of researcher staff for the pandemic.

 

 

Ohio Healthy Homes and Lead Poisoning Prevention Program

There is no safe level of lead in the body. The primary source of lead exposure in children with elevated lead levels is deteriorated lead-based paint (dust). Other potential lead exposure sources include soil, water, and consumer products. ODH has administered a comprehensive statewide lead poisoning prevention program since 1991. The Ohio Lead Advisory Council (OLAC) provides the Director of Health with advice regarding the policies the childhood lead poisoning prevention program should emphasize, preferred methods of financing the program, and any other matter relevant to the program’s operation. ODH’s lead program provides guidelines on lead testing and medical management, educates healthcare providers, conducts surveillance and case management, conducts public health lead investigations (either directly or through local delegated boards of health), licenses the professional workforce, approves lead laboratories, and provides compliance assistance and monitoring. In addition to Title V funds, the ODH receives funding for lead poisoning prevention from the U.S. Centers for Disease Control and Prevention, U.S. Department of Housing and Urban Development, U.S. Environmental Protection Agency, Ohio Development Services Agency, Ohio Housing Finance Agency, and General Revenue Funds.

 

When a child under six years of age is identified with an elevated blood lead level (lead poisoning), ODH or its delegated authority conducts a public health lead investigation to determine the probable source of lead exposure. If an investigation identifies an existing lead hazard, a Lead Hazard Control Order is issued ordering the property owner to control the lead hazard. If a property owner refuses to control an identified lead hazard, an order to vacate the property is issued, declaring it unsafe for human occupation, especially for children younger than 6 years of age and pregnant women. The ODH Director of Health can delegate the authority to conduct public health lead investigations to local health jurisdictions in accordance with Ohio Revised Code 3472.34.

 

In 2019 (the most recent finalized data available), 165,832 Ohio children under age 6 received a blood lead screening test, compared to the 168,352 children tested in 2018. The Census estimates Ohio population of children under age six is 810,728 (2019 ACS 5-Year Estimates, United States Census Bureau), which equates to 20.5% of children under age six were tested for lead exposure in 2019. The distribution of tests by blood lead level is depicted in Table 1.

 

Table 1: Blood Lead Testing of Ohio Children less than 72 Months of Age in 2019

Result	Number of Children
Not elevated	161,288
Confirmed Elevated Total 5-9 10-44 ≥45 µg/dL	3,33 2,555 956 22
Unconfirmed Elevated	969
Total Tested	165,832

Source: Ohio Public Health Data Warehouse

 

Ohio’s definition of an elevated blood lead level was updated in November 2014 from 10 micrograms per deciliter (μg/dL) to 5 μg/dL based on new guidance from the Centers for Disease Control and Prevention Advisory Council on Lead Poisoning Prevention. All blood lead levels at or above this threshold are now considered to be elevated blood lead levels. In 2019, there were 978 Ohio children with confirmed blood lead levels of 10 μg/dL or greater (0.59% of the total tested population) and 3,533 children with confirmed blood lead levels of 5 μg/dL or greater (2.13% of the total tested population). The 2019 data represent a decrease in the number of children with confirmed elevated blood lead levels compared to 2018 data. There was also a significant decrease in the number of children with unconfirmed elevated blood lead levels, from 1,343 in 2018 to 969 in 2019. This indicates that more children received appropriate follow-up lead testing in 2019, which enabled more children to receive appropriate case management services.

 

Ohio law requires primary care providers to order a blood lead screening test for any child under six years old who is determined to be at risk of lead exposure based on their zip code. High-risk zip codes were determined through modeling of lead testing, housing, and socioeconomic data. The law also requires that a blood lead screening test be performed on all Medicaid-enrolled children at ages 1 and 2, and up to age 6 if a child is found not to have received a previous test.

 

The Ohio Healthy Homes and Lead Poisoning Prevention Program is working with the Ohio Chapter of the American Academy of Pediatrics to improve blood lead testing rates. The responsibility of testing children for lead is on primary care providers, but it is well understood that about 40% or more of children that should be tested for lead never receive a lead test. This project will focus on developing a training plan and new training materials. The training will incorporate quality improvement initiatives so that blood lead testing rates improve in the practices touched by this training.

 

Children with confirmed elevated blood lead levels are now automatically eligible for Early Intervention services from DODD. Early Intervention, known as EI, provides coordinated services to parents of eligible children under the age of 3 with developmental delays or disabilities. A child's team works with the family in their home or other places they spend time in order to develop a coordinated plan called an Individualized Family Service Plan. The team will work through the plan building upon existing supports and resources while discovering ways to enhance the child’s learning and development.

 

An expansion of the Ohio Lead Advisory Council membership through the biennium budget allowed for 4 new appointees: Nicholas Newman, a physician knowledgeable in the field of lead poisoning prevention; Jamie McMillen, a representative from Ohio Realtors; Kelan Craig, a representative of the Ohio Housing Finance Agency; and a representative of the public, who is soon to be appointed. The Ohio Lead Advisory Council (OLAC) was established within the Ohio Revised Code Chapter 3742.32. OLAC is tasked with providing the Director of Health with advice regarding the policies the childhood lead poisoning prevention program should emphasize, preferred methods of financing the program, and any other matter relevant to the program’s operation.

 

Healthy Homes Awareness Month (HHAM) activities were conducted across the state in April 2019. The purpose of HHAM is to provide local health jurisdictions the opportunity to educate and raise awareness in their communities about the benefits of having a lead safe and healthy home. During HHAM 2019, ODH awarded 15 local health jurisdictions up to $10,000 each to increase public awareness about lead poisoning prevention and the tenants of a healthy home (Keep It: Dry, Clean, Safe, Well Ventilated, Pest Free, Contaminant Free and Well Maintained). The majority of HHAM activities focused on public outreach through billboards, banners, radio, television, digital advertising, social media, and local public transportation advertising to disseminate educational messages about lead poisoning prevention and healthy homes. Several local health jurisdictions also pursued in-person outreach, which included attending health fairs, hosting trainings, hosting community meetings, and providing materials to daycare centers and WIC clinics. In addition, some local health jurisdictions visited physicians’ offices and provided staff with materials focused on increasing awareness and knowledge about childhood lead poisoning and increasing blood lead testing of at-risk children.

 

Title V Maternal Child Health Block Grant (MCH BG) funds are vital to the Ohio Healthy Homes and Lead Poisoning Prevention Program. The over 1.3 million dollars of MCH BG funds are used to leverage a 12-million-dollar lead poisoning prevention program. Most of these funds are utilized to pay the salaries of the lead staff who perform the state mandated surveillance activities, implement lead hazard control home repair programs, and provide hundreds of public health lead investigations for affected families each year.

 

Oral Health

The work of the Oral Health Program supports children receiving integrated services. The Oral Health Program is supported by Title V funding. In FY 20, the OHP supported 14 local agencies operating school-based dental sealant programs (SBSPs) in qualified schools with 40 percent or more of the students enrolled in the free and reduced-price meal program. These 14 programs applied dental sealants in qualified schools in 51 of the 88 counties in Ohio.

 

The COVID-19 pandemic resulted in SBSPs stopping sealant placement for 8 months. During this time, the Oral Health Program developed guidelines for SBSPs to start back into schools and operate safely, including using a different sealant material that can be applied without creating aerosols. Funded programs must follow the new sealant placement procedures set forth in the guidelines until further notice. Despite the shutdown from March-November 2020, 12,326 Ohio schoolchildren received dental sealants during the reporting period. This is a decrease of more than 6,000 students from previous years. We expect the number of students receiving sealants to continue to be lower than usual for the remainder of FY 21, but will slowly pick up as the operation of SBSPs resumes.

 

The Oral Health Safety Net Dental Program provides funding for safety net dental clinics in the state to provide comprehensive oral health services to lower income, uninsured persons. In FY 20, funding was provided to four safety net dental clinics to support services provided to the MCH population. Clinics were reimbursed at a rate of $100 per visit for services provided to the uninsured maternal and child health population. ODH reimbursed funded clinics for 2,003 visits between January 1 and September 30, 2020. COVID-19 significantly impacted the number of clients and visits in 2020 since clinics were offering emergency dental care only from mid-March until the beginning of June. While productivity has steadily increased since June, ODH-funded safety net dental clinics have sustained an overall reduction in productivity of approximately 35%. We have seen safety net dental clinics slowly increase their capacity, and we expect that the numbers of patients served will continue to rise through the remainder of FY 21.

 

In FY 20, work began to create an online, interactive oral health curriculum for early childhood education (ECE) providers. The topics for the curriculum were selected based on a needs assessment of providers and include topics such as the prevention of tooth decay, recognizing signs and symptoms or oral diseases, oral injury prevention and first aid, signs and symptoms of child abuse and neglect in the mouth, and assisting families in getting dental care for their child. The curriculum will be available in FY 21 for continuing education credits to home- and center-based ECE providers, including Head Start providers. In addition, the curriculum will be revised for use by staff in WIC clinics.

 

The Oral Health Program also works to integrate oral health into the training provided to other health professionals. For example, in FY 20, OHP staff conducted in-person training at two Early Childhood Health conferences.

 

In FY 20, 61 schools and 11,763 students participated in the school-based Fluoride Mouthrinse Program (FMRP). Unfortunately, after more than 36 years, the FMRP ended in May 2020. The only manufacturer in the U.S. of the sodium fluoride packets used to mix the mouthrinse stopped manufacturing them. Schools were notified that the program would be discontinued at the close of the 2019-20 school year. Unused sodium fluoride packets were returned from participating schools to the ODH warehouse for disposal. The Oral Health Program provided a letter for schools to send home to parents that encouraged them to notify their child’s dentist that their child was no longer going to participate in the rinse program at school so other sources of fluoride could be considered. The letter also contained a list of resources for parents on oral health.

 

Ohio Act Early Team

In FY 20, Ohio Title V joined a state team in applying for the Association of University Centers on Disabilities grant opportunity Support for Early Childhood State Systems Through the Act Early Network. The proposal for the grant was led by the current Act Early Ambassador to Ohio who works at Cincinnati’s Leadership Education in Neurodevelopmental and Related Disabilities (LEND) Program and University of Cincinnati Center for Excellence in Developmental Disabilities (UCCEDD). The grant project goals are to increase awareness about the importance of developmental screening in early childhood and tracking of developmental milestones with the support of the evidence-based Learn the Signs Act Early materials developed by the CDC. Title V staff joined others on the state team including the Part C/Early Intervention, WIC, Ohio AAP, Ohio F2F, Head Start/Early Start. UCCEDD was successfully awarded the funds in September 2020, and Title V will collaborate on and support implementation of the project activities: development of the Act Early Ohio state team, completion of needs assessment, and development of implementation plan including ECHO, outreach and education to Latinx families via community health worker, engagement with social media influencers, and development and launch of a physicians toolkit.

 

 

Priority: Reduce the rate of childhood obesity

SPM 6: Percent of 2-5-year-old children consuming 1 or more sugar sweetened beverage per day.

• According to the 2019 Ohio Medicaid Assessment Survey (OMAS), 16.9% of children 2 through 5 years old consumed 1 or more sugar sweetened beverages (SSB) a day. This is a decrease from 19.2% in 2017 and meets the target of 17.2%. Disparities in this SPM are decreasing but persist. Black children are more likely than white children to drink SSBs (24.2% versus 15.2% in 2019), but the rate has decreased since 2017 (30.3% versus 17.1%). Additionally, children in families with an income less than 207% FPL are more likely to drink SSB than those with greater than or equal to 207% FPL (21.8% vs. 10.9%) but the disparity has decreased since 2017 (26.3% versus 10.9%).

ESM: Percent of children in child care attending an Ohio Healthy Program (OHP) designated child care site. (Note: There is not a Form 10 for this since it is attached to an SPM, not NPM. However, we address it in the narrative.)

• At the end of FY 20, a total of 3,172 children attended one of 329 OHP designated licensed childcare centers in the state. This number is drastically reduced from FY 19 due to the pandemic (16,035 vs. 3,172). With 5,055 licensed childcare programs in the state, this shows that 6.5% of programs are OHP designated.

 

The Ohio ECH program was approached by the CDC via Westat to participate in the Childcare Survey of Activity and Wellness (C-SAW) Pilot Study. The goal of this project is to better understand ECE center practices related to nutrition, physical activity, and wellness to effectively inform state and national programs. The pilot survey will be used to inform the development of a potential national surveillance system enabling states and CDC to track changes over time and obtain data to guide the planning, implementation, and evaluation of national and state obesity prevention efforts. The questionnaire will collect information on the ECE centers’ practices and policies across seven topic areas: (1) Nutrition (including information about meals/snacks served and a limited number of questions on food security, food brought from home, farm to ECE activities, and breastfeeding support practices); (2) Physical activity; (3) Screen time; (4) Staff training on related topics; (5) activities (including curriculum) used by the ECE center to improve their nutrition and physical activity offerings; (6) other wellness topics; and (7) the role of the person (administrative, teaching or both) who completed the questionnaire. ECH staff worked closely with Westat to collect permission and provide childcare and public preschool databases for sampling, with the goal of being in the field in March 2020. The pandemic postponed that project for a year, with it now planned for March 2021.

 

Early Childhood Obesity Prevention Program

Like much of the nation, obesity has reached epidemic levels among 2 to 5-year-olds in Ohio. Ohio’s Pediatric Nutrition Surveillance System (PeDNSS) data collected in 2018 (Ohio 2018 Pediatric Nutrition Surveillance Growth Indicators by Race/Ethnicity or Age) indicate that among children ages 2-5 years, 15.4% are overweight and 12.1% are obese.

 

Based on current statistics researchers have developed the following predictions for adult weight based on childhood weight:

• More than half of current children in the U.S. are going to be obese by 35.
• An obese 2-year-old has only a one in four chance of not being obese at age 35.
• If that 2-year-old is severely obese, the chance of being at a healthy weight at 35 is only one in five.
• By the time that severely obese child is 5, they have only a one in 10 chance of not being obese at 35.

 

The Early Childhood Obesity Prevention Program (ECOPP) began in 2013 and includes several initiatives to address this epidemic including Parenting at Mealtime and Playtime (PMP) and the Ohio Healthy Program (OHP). The overall goal of ECOPP is to deliver consistent messaging to adults who care for children age 0-5 years to prevent obesity in early childhood and reduce risk of physical and mental health outcomes in childhood and adulthood. This is done through modifying three behaviors: healthy eating, physical activity, and screen time.

 

ECOPP leverages funding from Title V, Preventive Health and Human Services Block Grant (PHHSBG), and the State Physical Activity and Nutrition (SPAN) grant to implement PMP and OHP.

 

ODH partners with the Ohio Chapter of the American Academy of Pediatrics (Ohio AAP) to implement to PMP in the clinical setting with healthcare practitioners and in the home environment with community health workers (CHW) and home visitors. The goal is to train and support healthcare professionals to assess obesity and risk factors and counsel parents/guardians.

 

In collaboration with the Ohio Child Care Resource and Referral Agency (OCCRRA), Columbus Public Health, Children’s Hunger Alliance (CHA), and the ODH Maternal and Child Health (MP) grant and Creating Healthy Communities grant, OHP reaches early childcare and education (ECE) professionals in public preschools, licensed child care centers, and family child care homes. OHP includes training and technical assistance to ECE providers around healthy foods, active play, and parent engagement with the goal of achieving policy, system, and environment changes in the ECE setting. Providers who attend trainings, create healthy menus, and engage families are eligible to apply for OHP designation.

 

OHP is a statewide recognition and innovation program, an identified strategy within the CDC’s Spectrum of Opportunities Framework for State-Level Obesity Prevention Efforts Targeting the Early Care and Education Setting.

 

The specific objectives integrated within the Title V Action Plan include:

• Increase the number of at-risk children birth to 5 years receiving interventions to prevent and manage obesity through health practitioners.
• Increase the number of licensed ECE providers that have adopted healthy eating/active living (HEAL) policies.

 

Objective: Increase the number of at-risk children birth – 5 years receiving interventions to prevent and manage obesity through health practitioners.

Efforts focused on 1) launching an online physician learning collaborative on obesity risk assessment and counseling, 2) planning, marketing, and organizing regional obesity prevention trainings for community health workers, home visitors, and other practitioners, and 3) building and leveraging partnerships with other programs and agencies to expand obesity prevention education among professionals who work with families and young children who may be at risk.

 

PMP Wave 7 began October 2019, using the online Quality Improvement Data Aggregator (QIDA). Over the seven waves, PMP has reached 5.4% of pediatricians in Ohio and 0.2% of family practitioners. Of the providers participating in the program, 71% were located in metropolitan counties, 14% in suburban counties, 10% in rural non-Appalachian counties, and 6% in rural Appalachian counties. Participants served 24% of Ohio counties with ≥30% childhood obesity, 55% of counties with >20% African American children, and 12% of counties with >10% Hispanic/Latinx children. All waves showed an observed increase in documentation of three desired outcomes (review of intake/physical activity form, discussion of age appropriate nutrition/physical activity behaviors, provided family a PMP handout) and stabilization of documentation at the post evaluation.

 

Throughout its history, PMP has updated fifteen Pound of Cure handouts for family/caregiver; created sixteen family caregiver PMP handouts, including ten available in Spanish and Somali; six family/caregiver portion advice handouts (four in Spanish); six provider handouts; six provider training videos; a primary care pocket guide for providers; and a mobile app for parents and providers.

 

To expand obesity prevention assessment and counseling into Ohio’s primary care systems, ODH has built partnerships across the Ohio AAP, ODH WIC and Help Me Grow programs, several local health departments and non-profit agencies that employ home visitors, and CHWs. Professional Data Analysts (PDA) is a key partner who assists with evaluation on the all the interventions. ODH continues to make progress with PMP implementation, however, challenges arise in provider recruitment and participation, especially among physicians.

 

For the updated contract that started July 1, Ohio AAP is transitioning PMP away from a QI activity. They are creating an electronic PMP Toolkit which will be available on their website for use by practices implementing PMP for the first time or for those desiring a refresher. They are also creating a PMP Journal Club with monthly articles and activities promoting healthy eating and active living among their patients and families. These resources will also be available for home visitors, community health workers, and other health professionals.

 

Objective: Increase the number of licensed ECE providers that have adopted healthy eating/active living (HEAL) policies.

In order to expand reach across the state, two OHP train-the-trainer trainings occurred during FY 20. Children’s Hunger Alliance (CHA) provided training and on-site technical assistance to 86 family child care providers. ODH created and conducted an in-person physical activity training at the Ohio Afterschool Network Conference in February. The training supplements OHP and provides in-depth activities for ECEs to implement.

 

In a contract with Columbus Public Health, the curriculum and resources used in OHP, including the electronic trainings, were revised and updated. They were also all translated to Spanish. All of the new resources went live October 1, 2020. During FY 20, 3,863 participants completed online courses offered by ODH. In addition, ODH continues to provide a monthly Social Media Toolkit based on the OHP 13 Key Messages to the >1,300 ECE professionals enrolled in the ODH Early Childhood Health Bulletin Board.

 

The Early Childhood Health Bulletin Board is a one-way means of communication from ODH to early childhood professionals. There are 1,350 users. In 2020, a total of 27 messages were sent to only the Early Childhood Health Bulletin Board contacts, with an average open rate of 43.9% and average click rate of 10%. A monthly social media toolkit based on the Ohio Healthy Programs 13 Key Messages has an average open rate of 42.9%. In addition, 53 messages were sent to both the Early Childhood Health and School Nurses bulletin Boards with a 49% open rate, which is 31% above the industry average. There were 66 pandemic related messages sent, 46.8% of the total messages.

 

In FY 19, an analysis of OHP designated sites revealed that they implemented 1,185 HEAL policies and 285 menu improvements. ODH continues to increase OHP participation and designation, with specific focus on ECE providers in areas of need. ODH faces challenges recruiting and engaging providers, particularly in communities disproportionately affected by poor health outcomes. As a result, OHP created a funding opportunity for sub grantees in four regions of the state identified as high need. The subrecipients started October 1, 2020 to provide technical assistance to childcare centers seeking designation or redesignation.

 

Funding through the MP subgrant program supports the designation and re-designation of OHP childcare providers to improve the overall health and nutrition of children. To date subgrantees have achieved train-the-trainer (14), childcare center staff trained (603), technical assistance provided (217), policy changes (151), menu changes (347), family engagement activities (1,068), OHP designation (31), and OHP re-designation (82).

 

Objective: Collaborate with the Oral Health Program to conduct a BMI surveillance within child care centers in Ohio public and private preschools.

The School and Adolescent Health Program, in collaboration with the Oral Health Program, conducted Body Mass Index (BMI) surveillance data collection. The statewide BMI survey of preschool children was completed in May 2017. Of the 82 sites surveyed (18 public preschool programs and 64 Early Childhood Education Centers), 3,098 children ages 2-5 were measured for height and weight for BMI assessment. Results show that 14.1% of low-income preschool-aged (2-5 years) children are overweight, and 11.6% are obese. The data also showed that children that receive financial help for child care have a significantly higher rate of overweight/obesity (36.4%) than children that do not (21.4%). Planning commenced for the next round of statewide preschool BMI data surveillance but has been temporarily put on hold due to pandemic restrictions.

 

Evaluation

PDA serves as an external evaluator for ECOPP. Their work over FY 20 included an ECOPP Annual Program Report for both OHP and PMP, an ECOPP roadmap, reach maps for both OHP and PMP. They worked closely with ODH to create and pilot the Ohio ECE Nutrition and Physical Activity Assessment Tool that will be used by ECE providers to identify current nutrition and physical activity practices and areas for improvement, and will be required for submission for OHP designation. The soft launch for the instrument was October 1, 2020. ODH will use the results for future OHP programming, and ECE program can use the results to select goals for the upcoming year and then evaluate their progress in reaching those goals. Moving forward, PDA will be working with ODH to develop a measurable definition of equity for the program.

 

Below are FY 20 success stories from OHP designated providers:

• “I have a 4yr old child in my care that Mom claims is a very picky eater. She caters to him at home and serves the same few foods over and over. Chicken tenders, macaroni and cheese, corn, apples, etc. Not a wide variety and doesn't offer anything new because child throws a fit and refuses to eat. I decided that they needed an introduction to the wider variety of foods available. So, I made it fun, educational and yummy! First, I showed the child all the different vegetation that animals eat, they showed them things such as many foods come in many varieties. For instance, over 400 kinds of apples. I then allowed them to go to the grocery store with me and gave them the very important job of picking out something new for the group to try. They also got to present it to the group and tell them all about it. We then have a taste testing party and discuss what we liked (or maybe didn't like so much) about the item. I also use our curriculum about other cultures to introduce new foods to the children. We make crafts, dress up, find the area on a map and many other things to learn about new places. All this has been working great. Mom showed up during snack one day and couldn't believe her eyes when her child was munching away on pepper strips and hummus dip! Now we no longer have a picky eater, but one that is super excited to discover new things. Granted not everything we try is going to be liked by everyone, even adults have food preferences, but I am no longer having the struggles with meal times. The kids all look forward to the adventures now.”
• “Staff have become educated further about “fried and processed” foods. It was not considered in the past that “flash-fried” foods then frozen was unhealthy foods. Since being trained in Ohio Healthy Programs training our cooks and menu planner are now more aware of unhealthy foods and taking into consideration how foods are prepared. Cooks are now preparing more foods from scratch and using less frozen, processed foods.”

 

Association of State Public Health Nutritionist (ASPHN) Obesity Mini CoIIN

Ohio is one of 5 states involved in the ASPHN Obesity Mini CoIIN project. The purpose of the project is to support and enhance state level farm to early care and education (ECE) initiatives to increase the quality of ECE nutrition and physical activity environment for young children by July 2020. This project provides technical guidance and support for state teams utilizing a quality improvement process to increase the number of ECEs conducting sustainable, comprehensive farm to ECE. In 2019, a statewide needs assessment was completed by 1,680 ECE educators in Ohio, indicated that 861 are participating in F2ECE, 194 had not heard of F2ECE before taking the survey, 375 plan to start F2ECE activities and 261 do not plan to start. The cost of local items and funding for supplies is the largest barrier and perceived barrier to starting and seasonality of local items was a close second. A lot of interest was expressed in the Ohio Healthy Program and online, self-paced F2ECE modules. All responses present opportunities for action.

 

Asthma Program

While not funded by Title V, the Asthma program works within the BMCFH to improve outcomes related to asthma and improve health equity and has relationships with Title V funded programs. In Ohio children, African Americans and low-income families experience significant disparities related to asthma prevalence and hospital utilization. State data show that asthma-related visits to hospital emergency departments are 4 times higher and asthma-related hospital admissions are 5 times higher among Black children than white children (OHA, 2012-2016). To address these disparities, the ODH Asthma Program (ODH AP) has a significant focus on equity and addressing systemic factors that contribute to poor health outcomes for children with asthma. The ODH AP mission is to is to engage individuals and entities intentionally and consistently across sectors and disciplines to build capacity and promote health equity to eliminate disparities, improve quality of life, and achieve optimal health outcomes for people with asthma in Ohio.

 

ODH AP strategies focus on: promoting inter- and intra-agency collaboration and strategic partnerships to address factors associated with asthma-related disparities; fostering opportunities for healthcare providers and stakeholders to learn about health equity, cultural competence, implicit bias, and structural racialization; and enabling stakeholder engagement to promote community-level approaches to reducing asthma disparities.

 

ODH AP has engaged in a number of activities during FY 20 to address these strategies. Funded local projects that not only work in geographic areas of high burden of our target population, but that also utilize specific health equity strategies to reduce disparities and hospital utilization and improve adherence and quality of life for children with asthma. Developed a health literacy toolkit to inform providers and professionals who work with people with or develop materials for people with asthma to increase understanding of how health literacy affects health outcomes as well as provide actionable strategies to improve communication between physicians and patients.

 

ODH AP is developing an Asthma Health Equity Action Plan to assure the integration of methods and strategies to address disparities into all aspects of asthma care in Ohio. ODH AP conducted formative evaluations such as the Health Equity Affinity Focus Group and key stakeholder interviews, both with African American professionals who work in health equity or with primarily African American populations. The goal of these evaluations was to inform ODH AP regarding the perception of the nature of health equity as identified by African Americans as well as identify strategies to address asthma disparities. These evaluation findings helped inform the Health Equity Action Plan.

 

ODH AP has developed and widely promoted five online courses on topics related to health equity including: Implicit Bias, Community Health Workers, Social Determinants of Health, Asthma and CLAS standards, and Health Literacy and Asthma. ODH AP has conducted several in person trainings of healthcare professionals, nursing students, and early childcare staff.

 

Additionally, the Asthma Program Supervisor holds a master’s degree in Racial Identity and Health Equity in Healthcare Delivery and serves as subject matter expert on health equity. Her work serves as a model for other ODH programs. She also shares her time between the Asthma Program and the ODH Office of Performance and Innovation to inform health equity strategies for the State Health Improvement Plan and agency-wide initiatives. In this role, she also consults with programs such as the Infant Vitality Program, the Early Childhood Program, and the School Nursing Program to identify strategies and activities appropriate for their target population and program objectives to reduce health inequities.