Delaware’s 2010 Title V needs assessment identified the following priorities in the domain of child health: reducing obesity; reducing unintentional injury; and increasing rates of developmental screening.  Not surprisingly, our 2015 needs assessment showed that we continue to have needs in all of these areas. However, after completing a systematic prioritization process, increasing healthy lifestyle behaviors (related to obesity prevention) and increasing developmental screening rose to the top as the Title V priorities in the child health domain for the next five years.  The Title V priority focused on increasing oral health checkups for children ages 0-17 was also identified in our 2015 Needs Assessment efforts.  Originally assigned to the Cross-Cutting Population Domain, our Oral Health for children has been moved to the Child Health Domain due to the change in population domains described in the latest version of the Block Grant Guidance.  Similarly, our report for Oral Health for Pregnant Mothers has been moved to the Women’s Health Domain.

While injury prevention is not included as a stand-alone priority area in our action plan, elements of injury prevention will be addressed through our work in the adolescent domain around bullying. In addition, Delaware’s continued work to prevent infant mortality will address aspects of injury prevention relevant to infancy, namely safe sleep. Please refer to the narrative for the infant and adolescent domains for more details on activities and plans in these health areas.

Developmental Screening – Annual Report:

Delaware’s Early Childhood Comprehensive Systems Impact program continues with activities on universal developmental screening promotion through on-going strong partnerships with Delaware 211/Help Me Grow, statewide PEDS and ASQ initiatives in physician practices and early child care centers, respectively.  For the 2018 calendar

In 2018, pediatric practices signed up to use the Parents’ Evaluation of Development Status (PEDS), administered 28, 231 screens, - this is a 3,000 increase from the previous year-(2017). Of the 28,000, approximately 20,000 were screens of unique children (unduplicated counts) – and it represents about 20% of the estimated children 0-8 years in Delaware screened. In the ECCS catchment areas covering the following ten zip codes; 19703, 19720, 19801, 19802, 19804, 19805, 19806, 19809, 19947 and 19973 over 1100 ASQ online screens were completed by the end of 2018. It is estimated that about a third of the ASQ online screens in Delaware are completed on children residing in the ECCS place-based community catchment areas. In those catchment areas about 181 early child care sites have reported data on children while about 32 pediatric practices sites have also done so. Since 2016 to the end of 2018, when the data was analyzed, approximately 2640 unduplicated children had had an ASQ screen administered. In the similar fashion, since 2013 to the end of 2018, 1180 unduplicated children had been screened in pediatric practices implementing the PEDS tool. It is important to note that not all Delaware pediatricians have signed up to use the PEDS tool while the ASQ is used mainly in most Delaware STARS (QRIS) level and a few family owned child care centers across the state. 

With this knowledge that fewer family owned child care centers administered developmental screens, the ECCS Impact Team, continued with its partnership with the Division of Libraries to promote developmental screening among library patrons.  Parents of young children who visit the libraries were invited to consider doing a developmental screen if they had not had a screen done in the last six months.  The partnership with state libraries also led to another collaboration with the Division of Social Services (DSS)—tagging onto the Division’s existing partnership with the Libraries to provide TANF and SNAP services through on-site social service workers, to library patrons. In this collaboration, the DSS has agreed to work with ECCS Impact partners to ensure developmental screening services are offered to the library patrons who show up for social services. For this fiscal year, ECCS Impact partners developed a protocol or guidelines for social service workers in terms of the standards of operation. Working with the New Castle Place-Based Community teams, we set up a schedule in identified libraries that will be offering developmental screening services on specific days. The idea is for families in those communities to be aware of area libraries offering developmental screening services in certain days.

In another partnership to promote developmental health and screening we were successful in finally engaging the Women, Infants and Children’s WIC) program through a Centers for Disease and Control grant awarded to the University of Delaware’s Disabilities Studies program. The WIC Program is a conduit to thousands of children and families living in poverty, and research shows that targeted educational programming in which WIC staff are trained as change agents has shown great success.  As a result the grant calls for using WIC clinics an ideal setting for integrating developmental monitoring and language enrichment programming into an existing array of services offered to a large and diverse population of children and families. The intervention was implemented at seven full-time WIC centers across the state.  It was launched with an in-person training for WIC staff on integration of the “Learn the Signs. Act Early.” (LTSAE) materials into visits with families. It was then followed by visits by the project staff to WIC clinics to set up LTSAE materials during the first month of intervention, which includes attaching milestone blocks to hallway floors; hanging milestone growth charts on walls; posting CDC Milestone Tracker app flyers on walls; providing WIC staff with an adequate supply of developmental checklists and parent kits.

When families show up for their certification and recertification visits, WIC staff are encouraged to offer parents the opportunity to complete a brief developmental checklist for their child. Staff will review the checklist when complete.  Parents are provided a copy of the check-list, a parent kit and a download of the CDC Milestone Tracker app to promote continued developmental monitoring at home. When developmental concerns arise, parents are referred to Help Me Grow/2-1-1 for a developmental screen to be administered over the phone. Help Me Grow staff will then make a referral for early intervention or some other resources depending on the results. Though this project has a short timeframe, we hope to maintain the relationship with the WIC program in one capacity or the other.

In 2016-2017 Colonial school district, and their ECCS Place-Based Community that is represented by the Colonial Readiness team began using the online ASQ.  The ASQs was linked to the preschool website, and was made available publicly. The Child Find (Part B} team continued to provide community screenings at Head Starts and childcare centers using the DIAL instrument. The decision was made to switch from the DIAL and use the ASQ as the only screening tool.  The switch would allow for better family involvement, reach more childcares (family and centers), provide screening for children starting at birth (the DIAL's age range is 2:6–5:11), while reaching more families with children not enrolled in any center.  A promotional campaign was started to encourage school districts to switch. The team reached out to childcare programs, Head Starts, superintendents, staff of various units at the Department of Education and community partners at their sites/centers to explain the switch and its cost benefits. 

By the end of this fiscal year the Colonial Place-Based Community team would have reached out to most of Delaware’s school districts, successfully persuaded them to use the Ages and Stages tool for developmental screening instead of the DIAL. It is reported that only 3 out of the 18 school districts that offer developmental screening are still not committed to switching to the ASQ.

In addition to reprinting a host of promotional materials on developmental screening, Help Me Grow/2-1-1; milestone information and others, Delaware’s team was also successful on sending out monthly blogs on the Maternal Child Health website Delaware Thrives.com. The promotional materials can be ordered free of charge on the DEThrives website. Furthermore, we ran an outdoor media campaign to increase public awareness about the links between developmental screening and school readiness. In partnership with our communications vendor, Worldways Social Marketing, the ECCS team developed messaging targeting parents to learn the connections between brain development and developmental screening. The messages asked “Is Your Child School Ready?”  This is then followed up with a Call To Action for them to call HMG/2-1-1 to get assistance if they suspect their child has a delay. The campaign was recently released in April of 2019 and can be found on the transit bus system (DART) and the bus shelters. The campaign was also ran on Spanish radio in Sussex County with follow- up calls to interview someone from the team who was Spanish-speaking.

Within the first three years of the project, the State of Delaware and its two place-based teams (New Castle and Sussex) have undertaken the following actions toward achieving the overall project aim:

Enhanced Data Collection and Surveillance of ASQ and PEDS Data at Zip Code Level. Within the first three years of the project, the state-level ECCS workgroup has finally been able to analyze data collected via the two chosen evidence-based screening tools – i.e., ASQ and PEDS – at the zip code level. Since the two place-based teams are defined geographically (i.e., New Castle comprises of eight zip codes and Sussex comprises of two zip codes), both teams are now able to have a better surveillance of the number and percentage of screened children who reside within their respective areas. In addition, both ASQ and PEDS data has become easier to access in more real-time via partnerships with the Delaware Office of Early Learning (OEL) and Vanderbilt University, respectively. Finally, the ability to potentially track children residing within these two catchment areas has now allowed both teams to generate a baseline from which to drive improvement by the end of the project period.

Improving Reported Referral and Follow-Up. Beyond the enhanced data collection and surveillance given above, the state-level team has been working closely with child care programs, pediatric sites, Help Me Grow/211, and Child Development Watch (Delaware Part C) to better track referrals and follow up for children identified at being at a higher risk for developmental delay. The improved tracking of children will help ensure that an improvement in age-appropriate developmental skills is met by the end of the project period, especially given the larger number of children screened through efforts taken through this grant (i.e., efforts such as community outreach events, promotional materials on developmental screening given at hospital discharge, etc. have increased the numbers of children screened)

Healthy Lifestyles – Annual Report:

Childhood obesity rates remain high in Delaware, as in the nation. The 2017 Youth Risk Behavior Survey results for Delaware indicate that approximately 16.6% of youth are overweight, which represents an increase from the 2015 YRBS of 15.8%.  When broken down by gender, both females and males saw an increase in percentages with 17.8% of females was considered overweight in 2017.  This represents an increase from 2015 where 17.3% of females were overweight.  Males saw increases as well with 15.4% in 2017 as compared to 14.4% in 2015.  The most recent results from the Delaware Survey of Children’s Health (DSCH) estimates that 36% of children ages 2-17 are overweight or obese. Nemours conducted the Delaware Survey of Children’s Health (DSCH) in 2006, 2008, 2011, and most recently in 2014. The 2014 DSCH was conducted from July 2014 to May 2015 by telephone, including cell phones. The survey results can be found at https://www.nemours.org/about/policy/delawaresurveychildren.html.

The statistics for related health behaviors, physical activity and healthy eating, provide more insight into the root of the problem, and also possible strategies to address it. According to the 2016-2017 National Survey of Children’s Health, 23.8% of Delaware’s children ages 6-11 engage in vigorous physical activity every day.  For children ages 12-17, that number declines to 13.9%.  According to the 2011/12 National Survey of Children’s Health, 5.5% of children ages 6-11 and 13.9% of children engaged in vigorous physical activity, however in this survey, “vigorous activity” was defined as physical activity for at least 20 minutes that made them sweat and breathe hard.  In the 2016 survey, vigorous activity included duration of 60 minutes and the question asked the number of children who exercised at least 60 per day for all seven days of the week therefore it is not possible to compare the two surveys for trend analysis. 

Although we have selected healthy lifestyles as a Title V priority within the child health domain, this is clearly an issue that spans the life course. Promotion of healthy lifestyles and prevention of obesity are statewide priorities, with clear leadership from entities such as the State Health Improvement Plan, DPH Strategic Plan, the Healthy Neighborhoods initiative, the Health Promotion Bureau/PANO Program, Nemours Health & Prevention Services, and the Delaware Healthy Eating and Active Living Coalition. With this leadership and infrastructure firmly in place, our Title V program continues to collaborate, including advocating for the unique needs and concerns of children, including those with special health care needs, related to healthy eating and physical activity.

Another strategy we employed to address healthy lifestyles was to examine existing MCH programs and services where we do play a lead role in order to identify opportunities to infuse messaging and content related to healthy lifestyle behaviors.  For example, to support our work in raising parental awareness of development and milestones, we created a concept called “QT30.”  Conveying the importance of spending 30 minutes of quality time with your child each day (QT30), this message is supported by a booklet full of ideas for activities that support children’s growth and development.  While the activities in the booklet have been aligned with Delaware’s Early Learning Foundations, we were able to leverage a perfect opportunity to review the activities from the lens of physical activity and healthy eating.

Our DPH partner from the Health Promotions/Disease Prevention Bureau - Physical Activity, Nutrition, and Obesity (PANO) has been instrumental in supporting our MCH priority for increased physical activity for children ages 6-11. Utilizing our marketing resources and in partnership with the PANO Program, we have finalized the print version of our Health Eating & Physical Activity (HEPA) booklet and have been circulating booklet to our community partners for the past two years.  The HEPA booklet infuses movement into a reading activity, or use of healthy foods instead of candy in a color sorting activity. In addition we have incorporated messages about healthy eating and physical activity into our DE Thrives website and providing training and/or materials to home visitors to empower them to promote healthy lifestyles among their clients.  In 2018, over 4,000 HEPA booklets were distributed to our community via programs and events such as Delaware State Fair’s Annual “Kids Day”. Community partners can place their own orders for these booklets, free of charge, from the Materials page of dethrives.com.  To support increased marketing messages for healthy eating and physical, we have increased our social media message posts from 48 in 2016-2017 to 65 in 2017-2018.  Marketing efforts from the PANO group have also incorporated our messaging and have provided a consistency between both groups.  In 2018 PANO distributed 5,500 Healthy Eating/Active Living materials (activity books, lunch boxes with messaging on it; bottled water with “5-2-1 Almost None” messaging) at the School Day Wilmington Blue Rocks baseball game. 

In support of our Title V strategies and goals, the PANO program promoted events aimed at getting the children to increase their physical activity. In May, 2018 PANO participated in the North Dover Elementary Super Science Day to teach kids the importance of 60 minutes of physical activity every day by conducting an experiment on the outcomes engaging in just 10 minutes of moderate to vigorous physical activity on memory for academic achievement.  Approximately 60 children engaged in this event. 

MCH collaborated with DPH’s Health Promotion Bureau to take materials and initiatives created through their Preventive Health & Health Services Block Grant and disseminate them through MCH programs, services, and partner networks. To support our healthy lifestyles messaging, we worked with the Health Promotion Disease Prevention (HPDP) Bureau in its evaluation of the first year of “FitnessGram®” data.  Nineteen local school districts (LEA – local education agency) and 24 Charter schools received information (messaging and informational resources) on increased daily physical activity, particularly during the school day and its effect on academics and cognition. HPDP epidemiologists identified barriers to conducting a thorough analysis of LEA FitnessGram data for the 2017/2018 and 2018/2019 school years. Several districts failed to provide complete data making it difficult to translate data. LEAs and Charter schools continue to receive information on further training opportunities for FitnessGram implementation (monthly). The lack of dedicated resources for professional development (for PE teachers) is one barrier to schools and districts which creates a need for additional partnerships to deliver this training to our teachers. HPDP is among a partner network collaborating with cross-sector agencies within DHSS & DOE to identify resources that would enable a concentrated effort to effectively implement FitnessGram and a thorough analysis of its data. 

Oral Health for Children – Annual Report:

MCH work centered on improved oral health outcomes for children relies heavily on our partnership with our sister DPH agency, the Bureau of Oral Health and Dental Services (BOHDS). Our Home Visitors and contracted Health Ambassadors are offered professional development training and service education throughout the year and take care in sharing that information with the families being served in Delaware.  This includes training and education that encourage families to have their children seen by a dentist starting at age 1. 

Based on information from 2015 Needs Assessment, DPH has chosen to address National Performance Measure 13.1 and 13.2 which seeks to increase the percentage of women who had a dental visit during pregnancy along with increasing the percentage of children, ages 1 through 17, who had a preventive dental visit in the past year. According to the latest National Survey of Children’s Health, the percent of children ages 1-17 who received one or more preventive dental care visits increased from 77.2% in 2011/12 to 81.6% in 2016/2017 which is slightly higher than the national average of 79.5

Delaware’s Oral health national priority work focuses on not only national data, but also feedback gained from local professional development trainings.  Evaluations are given to participants and those are reviewed for enhancements and opportunities for improvement in the training curriculum.  Over the last two years, feedback on professional development trainings have offered us the opportunity to hear from childhood day care providers, school nurses, and organizations who work with our families with children with special health care needs.

Our stakeholder survey suggestions and comments show us that there is a need for additional marketing and education on the oral health care coverage for both children and pregnant mothers.  Another pressing need as shown in the survey findings is the need for adult oral health care coverage from Medicaid.  We are delighted to report that the approved FY20 budget includes $1.3 million to provide adult dental coverage as part of the Medicaid service starting April 1, 2020.

To address our community outreach and education efforts, MCH maintains strong ties to various committees and agencies that support overall children’s health, including oral health.  Our BOHDS staff and leadership participated in the 2018 Safe Kids Conference where they were offering educational materials to attendees representing school nurses, nurses, and early childcare providers.  Some attendees made inquiries for possible professional development trainings and the BOHDS team is working to schedule those trainings. 

MCH also worked with BOHDS to cross-pollinate education opportunities by supporting an open panel discussion focused on families with children with special health care needs.  The event was coordinated by Family SHADE, which receives funding from Title V, and included a four member panel representing oral health professionals, pediatricians, the education community – Delaware Technical Community College adjunct professor, and a family representative.  The event was attended by partner organizations that support the children with special health care needs community and families.  The message provided was centered around helping the community understand the roles of dentists, pediatricians, and educators along with advice and counseling from family representative organizations who offered insight to navigating insurance issues that families face when getting their children oral health care.

Our DPH Dental Director, Dr. Conte has maintained his connection with the community partners in Sussex County by working with MCH and the Sussex County Health Coalition to provide educational presentations at two “Dollar Dinners”.  These dinners an opportunity for families to enjoy a health family dinner for $1 per person and are held in varying locations in Sussex County.  Events such as these attract families from many cultures and socio-economic status.  Dr. Conte works hard to tailor his message to the audience and these dinners provide ample opportunity for him to educate the entire family unit, including grandparents (many of whom are caring for their grandchildren), on the importance of oral health.  Most recently, one of our ECCS Impact local teams partnered with young families to provide information on developmental screening as well as provide free screenings from a dental hygienist.

One way we found to support the efforts underway in BOHDS is to help with marketing information provided in the newsletters.  The latest edition, https://dhss.delaware.gov/dhss/dph/hsm/files/impressions_spring2019.pdf  was distribution through the SCHC network of 600 community partners as well as our home visiting programs.  It is in this edition of the newsletter Delaware Smiles Campaign is highlighted.  “Now in its third year of implementation, the DSCP has gained support from schools and providers all over the state and broadened its scope of school-based services in specific areas.” This program directly influences our work to increase the percentage of children who receive an annual dental checkup by reducing the barrier of transportation for children and especially for those who may be in need of urgent dental services.  It is also in this issue that BOHDS calls out the impact of E-Cigarettes and vaping on oral health.  Besides the issues related to increased chances of cancer, addiction, respiratory and host of other illnesses, BOHDS outlines the increased risk of cavities and increased risk of oral cancers (as well as other oral health problems) associated with vaping, especially in youth who appear to be engaging in this risky behavior at an alarming rate.

Our social media messaging efforts for the past year reflect varying results from the different sources.  The number of hits on our Healthy Smiles, Healthy You webpage on dethrives.com has seen a dramatic drop in traffic in July 2017-May, 2018 with only 434 hits.  Hits more than doubled this past year between July 2018 and May 2019 with 1,101 hits.  Partial explanation for this drop is that the Healthy Smiles, Healthy You webpage went live in the fall of 2016 and a major marketing campaign was done to kick off the webpage.  The number of hits to the Bureau of Oral Health and Dental Service, Division of Public Health webpage was steady from previous years and stood at over 5,000 for the same timeframe.  Our video views from this webpage are up slightly from 45 to 57 for the same time periods as above.  The number of social media posts on Facebook was 10.

To address the promotion the practice of early childhood medical practitioners providing oral health screenings, fluoride varnish application, anticipatory guidance, and dental referrals by age one, MCH supported BOHDS in their education and promotion efforts through marketing materials and broad dissemination of their newsletter to our community partners. While our Medicaid claims data illustrated a dramatic uptick in these services being provided in the FY17 annual reporting year, this year the data shows a decrease in the number of physicians who billed for fluoride varnish application has been reduced to 12.  The drop from 17 in 2017 to 12 in 2018 is attributed to a number of individual pediatricians moving to the large health system networks of Nemours and Christiana Care Health Services and are billing under those entities.  Nonetheless, we continue be encouraged that many of our pediatric providers are taking an active role in offering limited oral health services to children in Delaware.