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

Objective 1: By 2020, increase the number of educators and providers that received developmental screening education, support and community resources from a baseline of 4,260 to 18,000. The SAMSHA funded Texas Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health) Expansion Grant initiative, called Texas LAUNCH, closed out at the end of FY19. The Texas LAUNCH initiative was designed to improve the developmental, social, and emotional outcomes of children age 0 to 8 in three selected expansion communities in Bexar County, Tarrant County, and Ysleta del Sur Pueblo. Texas LAUNCH activities focused on implementing best practices within an array of systems supporting young children. Each strategy built upon the others by increasing the early identification of developmental concerns and support for families to access early childhood interventions, strengthening family capacities for promoting children’s development and wellness, and enhancing child care and educational programs to support child success.

The Texas LAUNCH-Early Childhood Committee (TL-ECC), an integral component of the Texas LAUNCH initiative, oversaw the efforts of the LAUNCH community projects and spearheaded the activities within the state to increase developmental screenings. The TL-ECC ranged from 38 to 54 members over the course of the grant and included representation from universities, state agencies with early childhood programs and services, non-profits, community-based organizations, parents, and other organizations.  In FY19, the Maternal Child Health Section (MCHS) strengthened participation of key stakeholders and showed a 163% in growth in attendance from the initial council meeting. MCHS remained dedicated to ensuring a strong parent/family voice in all committee activities and maintained family representation on the TL-ECC committee. While physical attendance was difficult, parents remained engaged in the committee through conference calls which were more easily accessible.

Four TL-ECC in-person meetings were held in FY19. Each meeting provided an overview of the Texas LAUNCH communities’ progress on increasing developmental screening, strengthening families, expanding mental health consultation, and developing the early childhood workforce. Notable successes reported by the Texas LAUNCH communities included:

• Increased workforce development opportunities with high attendance;
• Increased parent engagement in the LAUNCH communities;
• Increased number of partners supporting the local community Texas LAUNCH initiatives through MOUs and increased participation on the local Early Childhood Wellness committees;  
• Successful development and utilization of an electronic data enterprise network in Fort Worth to collect Ages & Stages Questionnaire (ASQ) data electronically, in real time, from child care centers;
• Offered high-quality Early Childhood Mental Health Consultations in Bexar and Tarrant counties; and
• Creation of a coordinated early childhood system in Tarrant County, which allowed for comprehensive service provision.

Through the Workforce Development strategy, Texas LAUNCH aimed to build early childhood competency within the workforce and strengthen the supportive infrastructure for early childhood care within the state. The early childhood workforce included day care and early childcare providers, teachers, healthcare providers, early interventionists, and behavioral health providers. Workforce development efforts included training in infant and young child mental health, trauma-informed practices, as well as dissemination of evidence-based and promising practices to promote mental wellness. By the close of the grant in FY19, over 4,000 individuals were trained in a variety of early childhood practices. Of those, 659 individuals were trained on the ASQ-3 and ASQ: Social Emotional (SE) 2 and 109 participated in an ASQ training-of-trainer (TOT) program. For future workforce development, Bexar County will continue through a partnership with Voices for Children San Antonio, which offers monthly sessions for 200 to 300 early childhood educators on topics relating to Adverse Childhood Experiences (ACEs), self-care, attachment, and resiliency. The Ysleta del Sur Pueblo Lead will continue to offer training in partnership with Child Guidance for Pre-K, Bright Stars, and Early Learning Center staff. Tarrant County has established trained trainers in Parent Cafes, Mental Health Consultation, and ASQ screeners.

The focus of the early childhood screening strategy was to increase developmental and social-emotional screenings for young children in the three expansion communities. Texas LAUNCH had a goal of screening 1,705 children during the grant period. The goal was exceeded, with a total of 3,661 children and families screened, and 1,920 occurred in FY19.

The three communities were successful in implementing the developmental screening strategy. In the two communities that implemented through their partnership with early learning and childcare settings, there was limited reach in the screening activities. In the community that implemented a web-based screening platform, their rate of screening increased dramatically. This has allowed the community to efficiently access screening measures within the home and to expand access to childcare, healthcare, and directly to parents. The developmental screening identified concerns in 45.5% of children, with many experiencing multiple areas of concern. Few concerns were identified on the ASQ SE measure.

About one quarter of children were referred for further assessment or services. Referrals to the local school system were the most common, followed by referrals for child or family mental health services. Few children were referred to their pediatrician, suggesting that physicians may be unaware of the identified concerns.

Male children were more likely than females to be identified with a developmental concern; however, there were no significant gender differences in referral rates once the concern was identified. Native American children were less likely to be identified with a developmental concern than other groups; however, this difference may be due to site differences. The majority of Native American children resided in the Ysleta del Sur Pueblo. Tarrant County, which represented the majority of other children, had higher rates of identification in general. White, non-Hispanic children were more likely to be referred for further services than Hispanic, Native American, and Black or African American children.

Developmental screening was supported by ASQ TOT and sustained with the Help Me Grow affiliation in Fort Worth to provide screening across systems (home visiting, ECI, childcare, pediatricians, etc.). Screening in Ysleta del Sur Pueblo was more accepted by parents and was implemented in all three early education sites on the reservation: Pre-K, Early Learning Center, and Bright Stars Child Care. In Bexar County, ASQ screening was paired with mental health consultation.

To address the family strengthening strategy, the three expansion communities each implemented Incredible Years and Parent Cafes. While evaluation of Incredible Years had some challenges, results suggested that families were satisfied with the program and would recommend participation to others. Only one-quarter of families participating in Incredible Years reported concerns with their child’s behavior and very few parents had elevated levels of parental distress. This outcome suggests that the communities primarily recruited from a general parent population. Parents in the Incredible Years program reported significant changes in their use of harsh and inconsistent discipline strategies; however, there was no noticeable increase in positive parenting practices. Parents reported fewer problem behaviors and less intensity of problems following the intervention, but the differences did not reach statistical significance. Parents expressed resounding satisfaction with their participation in Parent Cafes and almost unanimously indicated a plan to make changes because of their participation.

Parent strengthening has been sustained in Tarrant County with an extensive reach of Parent Cafes offered in ISD’s, faith-based organizations, Autism ABA clinics, and other community sites. In Ysleta del Sur Pueblo, Parent Cafés regularly occur, and Incredible Years is now mandatory for parents whose children attend the Early Learning Center. The Lead also continues to offer the classes to those who are receiving Social Services.

Mental health consultation proved the most difficult strategy to fully evaluate. Since the intervention is relatively brief, an extensive assessment of parent and child functioning seemed unwarranted. Consultants had difficulty predicting the extent of the consultation needed at the outset. However, some key qualitative findings were gathered from the case summaries. Most children were referred for mental health consultation due to disruptive behavior, primarily aggression, hyperactivity, and tantrums. Many of these children were experiencing significant disruption in their lives, including parental divorce, incarceration and foster placement, and had prior exposure to trauma, including family violence, sexual and physical abuse, and death in the family. Mental health consultants primarily served as an expert to examine the adequacy of existing services and provide referrals for additional assessment or services. Although limited, initial outcome data suggests families reported lower levels of stress related to children’s temperament or behavioral issues following mental health consultation.

The three communities had different models for mental health consultation, reflecting the lack of standardization present in the state. In Ysleta del Sur Pueblo, the mental health consultant primarily supported capacity building of early childhood teachers, providing professional development, classroom observations, and supporting classroom approaches to social and emotional learning. In Tarrant County, mental health consultants evaluated children with more significant mental health issues within home visiting and prevention programs, primarily serving in an assessment and referral capacity. In Bexar County, mental health consultants were embedded in early learning or child care settings, providing both consultation and mental health interventions with children and families. These very different approaches suggest the need to provide some standardization to the model prior to additional evaluation studies and wide-scale expansion in the state.

Mental health consultation will continue in Bexar County with a new LAUNCH grant, in Ysleta del Sur Pueblo at all three early education sites, and a new Mental Health Consultation framework has been implemented within several early childhood prevention and intervention programs in Tarrant County.

The MCHS State Child Health Coordinator was selected to represent DSHS on the Texas HHSC Children and Youth Behavioral Health Subcommittee (CYBHS), as a voting member. The CYBHS is the primary advisory committee to the HHSC focused on child, adolescent, and young adult behavioral health and their families. The CYBHS is a subcommittee to the Behavioral Health Advisory Committee (BHAC), which is tasked with advising HHSC on behavioral health issues. The goal of having the MCHS State Child Health Coordinator join CYBHS was to bring early childhood mental, social, and emotional health concerns to the CYBHS to continue the work of Texas LAUNCH as the grant came to an end in 2019.

The TL-ECC enhanced their impact by creating workgroups focused on developmental screening (DS), mental health consultation (MHC), and prevention of suspensions/expulsions (S/E). These workgroups met monthly or bimonthly, creating short-term and long-term goals to address the sustainability of LAUNCH core strategies in existing statewide programs. All three workgroups will be sustained beyond the grant. The state DS workgroup will be led by MCHS to ensure continuation of statewide efforts to increase developmental screening. Quarterly meetings are planned, with the initial post-grant meeting taking time to identify new and continuing goals for the workgroup to pursue. The S/E workgroup is being led by a partnership between the Texas Education Agency , the Texas Workforce Commission, and former LAUNCH staff. This workgroup developed a strategic plan after completing a policy assessment tool and is working to release a document showing how the four key state agencies are working to address suspensions and expulsions in Texas. The MHC workgroup will be supported by the Texas Institute for Excellence in Mental Health at the University of Texas at Austin and Texans Care for Children.

 

One of the largest momentum builders surrounding the work of the LAUNCH communities was the success of Tarrant County in implementing the Help Me Grow (HMG) early childhood system framework. Tarrant County successfully intertwined three national programs (Family Connects, Healthy Steps, and Nurse-Family Partnership) under their HMG model. This connectivity increased the number of screenings performed, number of community resources identified, quality of referrals, and connections of families to needed services. Tarrant County is planning to expand their system in 12 surrounding counties in hopes of replicating their success.

To continue the momentum of the Texas LAUNCH grant, San Antonio received notice of award for a new SAMHSA LAUNCH 5-year grants to include SafeCare parenting, baby court, and health integration. Partners from the TL-ECC are expected to continue support in this new grant.

MCHS collaborated with Texans Care for Children to disseminate A Parents’ Guide to Raising Healthy, Happy Children (Guide) (https://txchildren.org/parenting-guide). The Guide is legislatively mandated to be distributed by healthcare professionals who provide prenatal care or deliver an infant of a pregnant woman who is enrolled in Medicaid. The Guide includes a developmental/behavioral health screening schedule, suggestions of screening/monitoring tools, and resources to address developmental concerns. In FY19, 86,500 Guides were distributed to providers.

In FY19, a total of 17,632 early childhood development and screening modules were completed via Texas Health Steps-Online Provider Education (THS-OPE) modules. The module topics included adverse childhood experiences, attention-deficit/hyperactivity disorder, autism spectrum disorder, behavioral health screening and intervention, depression, anxiety, developmental surveillance and screening, pediatric and newborn hearing and vision screening, and using developmental screening tools.

MCHS and Prevention and Early Intervention (PEI) created an Early Childhood Brain Development video that was released in FY19. The video was created in English and Spanish, with 130 combined views. In FY19, MCHS and PEI continued their collaboration with the creation of a Developmental and Behavioral Screening video for parents, available on the PEI Help for Parent. Hope for Kids website (http://www.helpandhope.org/Parenting_Tips/video.asp). The video teaches parents the important milestones in child development, their role in monitoring and screening, and what to do if concerns arise. The video was released at the start of FY20.

MCHS Public Health Region (PHR) staff completed many activities that addressed NPM 6 in FY19. Regional staff began to more effectively spread the word among their professional colleagues about prompt and accurate identification of children at risk for developmental delays. Most activities focused on updating colleagues at community meetings on the importance of screening and sharing information about Ages and Stages with women during prenatal education activities, one-on-one counseling with clients seeking other clinical services, and networking with local primary care providers. PHR 8 promoted THS-OPE modules on developmental screening during three child care provider trainings. PHR 11 staff adopted an initiative aimed at increasing early language development in bilingual families. Also, a screening was developed and administered in FY19 that assessed a families’ needs in relation to social determinants of health and key public health priorities like child development and behavioral care. Once a need was identified, families were referred to relevant DSHS programs and resources.

Objective 2: By 2020, 500 individuals will be trained in the ASQ and ASQ-SE early childhood developmental screening tools and referral resources in the Texas LAUNCH funded communities.

Texas LAUNCH contractors trained 2,232 individuals on administration of the ASQ-3 and ASQ:SE-2 screening tools in Fort Worth, El Paso, and San Antonio. Because of those trainings, 1,920 children were screened in the three Texas LAUNCH communities in FY19. By the close out of the LAUNCH expansion grant at the end of FY19, 3,661 developmental screens were administered during the 3-year grant, with much of the success being attributed to one community’s implementation of the ASQ Enterprise system.

Performance Analysis:

There was an increase of 747 children receiving developmental screenings in FY19, from the FY18 total of 1,173 children screened. A large part of the increase was due to the implementation of a web-based screening platform in Tarrant County. About 27% of the children screened were referred to additional services. This rate is about 10 to 20% higher than expected, which is largely due to one community implementing most of their screens in an early childhood prevention program, where some risk for developmental or social and emotional problems has led the family to the program. The most common referral was to the local school district (14.6%).

The number of completed THS-OPE early childhood development and screening modules increased from 12,386 in FY18 to 17,632 in FY19. The increase in completed modules was likely due to several of the modules’ (Developmental Screening Tool and Surveillance, Pediatric Depression, and Behavioral Health: Screening and Intervention) extensive update and subsequent release.

The combined total of trained individuals from FY16 (27 trained); FY17 (350 trained) and FY18 (123 trained) provides a 3-year total of trained individuals meeting the ‘500 trained’ goal. An additional 268 attended trainings in FY19 to surpass the goal, to total 768 trained.

Challenges/Opportunities:

The TL-ECC maintained a robust membership, although there was member turn-over during the grant. Members reported increased strength of collaborative efforts and felt that the group created an avenue for communication and networking across sectors.

LAUNCH community stakeholders were largely satisfied with the trainings they received but reported challenges with buy-in of community members and difficulties faced in evaluation.

Opportunities exist to continue to increase provider capacity and capability through the development and promotion of THS-OPE modules.  

Opportunity exists to deploy a coordinated statewide approach to developmental screening initiatives and activities via MCH regional staff.

NPM 7.1: Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9.

Objective 1: By 2020, increase the number of CFRT, educators and providers that are provided child injury education, support and community resources from baseline by two percentage points.

MCHS, MCHS regional staff, and the Office of Injury Prevention (OIP) promoted the use of the THS-OPE injury prevention modules to stakeholders statewide through the Child Safety Collaborative Improvement and Innovation Network (CoIIN). In the dissolution of the Child Safety CoIIN at the end of FY18, the original parties agreed to continue the promotion of the injury prevention modules in FY19. A total of 11,643 providers completed the seven THS-OPE pediatric injury modules showing a 22% increase from FY18. Topics of the modules included: Pediatric Head Injury, Preventing Unintentional Injury, Childhood Trauma and Toxic Stress and Recognizing, and Reporting and Prevention of Child Abuse.

In FY19, DSHS released 44 issues of the Friday Beat, an e-newsletter for school nurses and other school-based professionals, to disseminate information about injury prevention, safety, nutrition, physical activity, obesity, and other relevant health topics. School Health staff continued to use CDC’s Whole School, Whole Community, Whole Child (WSCC) approach during this fiscal year. The WSCC model expands on the eight elements of CDC’s coordinated school health and is combined with the Association for Supervision and Curriculum Development’s (ASCD) Whole Child framework focused on ensuring every child is healthy, safe, engaged, supported, and challenged. The elements are:

• Health Education
• Nutrition Environment and Services
• Employee Wellness
• Social and Emotional School Climate
• Physical Environment
• Health Services
• Counseling, Psychological, and Social Services
• Community Involvement
• Family Engagement
• Physical Education and Physical Activity

The Friday Beat provided 76 unique articles, resources, and educational opportunities related to injury prevention to 6,716 weekly users by the end of FY19, almost a 15% increase from FY18. The information provided school stakeholders with resources on student safety, emerging best practices, and programs to implement within a school setting. Examples of FY19 Friday Beat resources and topics included school-based violence prevention, threat assessment workshops, natural disaster and emergency preparedness, brain injury guidelines, sports injuries, bullying prevention, active shooter training, safe routes to school, poison prevention, child abuse/neglect prevention, standard response protocol training, safe swimming, bike safety, extreme heat safety, and suicide risk and prevention.

MCHS collaborated with Texans Care for Children to disseminate A Parents’ Guide to Raising Healthy, Happy Children (Guide). The Guide is legislatively mandated to be distributed by healthcare professionals who provide prenatal care or deliver an infant of a pregnant woman who is enrolled in Medicaid. The Guide includes age-appropriate tips on how to keep a baby and toddler safe such as appropriate sleeping positions, baby-proofing the home, reducing choking hazards, car seat and bike safety, and safe sibling play. In FY19, 86,500 Guides were distributed to providers.

MCHS funded the Texas Association for the Education of Young Children (TXAEYC) through the Healthy Child Care Texas (HCCT) grant. The grant is designed to train Child Care Heath Consultants (CCHC) to assess and assist childcare centers in providing the best care, safety, and services for the children in their centers. In FY19, 20 people received training to be a CCHC. As part of the HCCT Social Emotional Development (HCCT-SED) initiative, 35 child care centers in Tarrant County participated in training and technical assistance to implement a screening program in their centers. Approximately 250 children were screened during the program. For FY20, TXAEYC will be conducting HCCT-SED in Harris County, with the goal of 50 centers participating. 26 centers have already committed to participating.

Texas was accepted for the Children’s Safety Network’s newly created Child Safety Learning Collaborative for FY19, previously the Child Safety CoIIN. The focus was on motor vehicle safety and suicide/self-harm prevention.

MCHS continued to oversee the legislatively-mandated MEDCARES grant program to develop and support regional initiatives to improve the prevention, assessment, diagnosis, and treatment of child abuse and neglect. MCHS continued to provide Title V funding to MEDCARES providers to increase child abuse prevention efforts, facilitate community training opportunities, and distribute prevention information to parents, providers, caseworkers, and law enforcement personnel. In FY19, MEDCARES contractors provided 431 educational trainings on topics that included child safety, infant care, recognizing and reporting abuse, abusive head trauma, injury biomechanics, conditions that mimic abuse, and the importance of family history. These presentations were given to 7,693 healthcare providers, staff, and medical students; 3,426 protective service staff; 1,177 law enforcement staff; and 947 child advocacy center staff. MEDCARES providers also provided trainings to faith-based organizations, K-12 academic institutions, and childcare organizations to increase recognition and reporting of child abuse.

MCHS remained an active participant in the Early Childhood Systems Integration Group (ECSIG). ECSIG is a multi-state agency workgroup that addresses issues and opportunities to capture the collective impact of programs and services that address the outcomes for young children and their families. The intent of the group is not to start new programs or change processes, but rather better articulate and measure the work already being performed.

ECSIG began using the Results Based Accountability method and created a visual dashboard with user-friendly analysis. This method uses population-level indicators to track statewide trends as well as agency/organizational level performance measures for accountability. In FY19, the group drafted the first iteration of The State of Texas Dashboard for Early Childhood Outcomes (DECO) for three priority areas: 1) Are Children Healthy, 2) Are Children Safe, and 3) Are Children School Ready. To assist in the promotion of the data dashboard, MCHS plans to link the dashboard to our public website with a description of our contributions to the process.

In FY19 the public health region (PHR) staff were active in their early childhood injury prevention activities focusing on child passenger safety, bike / pedestrian safety, general injury prevention, water safety, and Child Fatality Review Team support.

Child Passenger Safety:

PHR staff continued to lead child passenger safety events in their regions as well as support partner inspection and distribution events in FY 19. Statewide, PHR staff inspected 1,800 seats and distributed 1,762 seats.

PHR staff partnered with DSHS Safe Riders, Texas Department of Transportation (TXDOT), Texas A&M AgriLife Extension Service, and several community organizations to conduct car seat check-up events throughout the regions at fire stations, court houses, TXDOT offices, local car dealerships, and in the parking lot of local businesses. Four DSHS staff in PHR 2/3 became Certified Child Passenger Safety Technicians, increasing the number if technicians in the region to nine, while in PHR 8 just over half (13 of 24) of staff are certified technicians. In partnership with Texas A&M AgriLife Extension, a return on investment formula was created and used in PHR 9/10. Economic benefits are estimated at $2,362 per child age 0 to 4 years and $2,832 per child age 4 to 7 years. For every misuse of a car seat that is corrected, economic benefits are estimated at $675. The total economic impact for the 158 new child care seats distributed in FY19 is estimated at $372,196 and for every misuse of a car seat that is corrected, economic benefits are estimated at $122,850. Operation Lone Star (OLS) is an annual week-long public health preparedness operation. DSHS, local health departments, and the Texas State Guard in PHS 11 coordinate the event. OLS is the largest public health humanitarian effort in the country and provides free medical, dental, and other services to low income and uninsured residents at six sites across the region. An added benefit to this event is that it serves as an opportunity to train medical professionals in mobilization for public health emergencies and MCHS staff from PHR 11 are involved each year. Staff scheduled 69 car seat appointments during OLS for car seat inspections within 2-4 weeks of the event. Of the 69 appointments made, 23 car seats were checked and installed and 21 received car seats. Additional car seat inspections events were coordinated with regional partners in PHR 11, at which 259 seats were inspected.

Bike Helmets/Pedestrian Safety:

Staff in PHR 6/5S educated, fitted, and distributed approximately 160 children and youth with bicycle helmets. Bike safety education and proper helmet fittings were provided to 73 children and adolescents in PHR 9/10 and staff provided technical assistance and education to 596 individuals on pedestrian safety. With the success of PHR 11’s Bike Rodeos, staff has generated a train-the-trainer program to partner with other community organizations to host their own Bike Rodeo events. In FY19, PHR 11 staff provided training to seven partners and distributed 600 helmets. A Bike Rodeo Kit was created for partners to adopt after training and obstacle course demonstrations were provided. Staff began developing the kits and anticipate beginning distribution in FY20. The Bike Rodeo Kit includes: a Bike Rodeo Guide, 50 helmets, stop signs, hazard cones, flags, chalk, and sponges. Training was provided to school staff, non-profit organizations, and police departments in two south Texas counties. Instruction comprises an obstacle course that includes: start/stop, bicycle inspection, helmet fitting, hand signals, intersection, straight line control, rock dodge, slalom, circling and changing direction, and observing stop or yield traffic signs. PHR 11 staff provided supports and technical assistance as requested for any Bike Rodeo events by lending out equipment and providing educational resources.

Six staff members from PHR 7 were certified in Texas Trails, Education, and Motorized Management for AT safety. The trained staff partnered with Texas A&M AgriLife Extension, McLane’s Children’s Hospital, and Safe Kids to provide safety awareness education in three counties to a total of 1,000 participants, including children ages 10-19, educators, and school personnel. In PHR 4/5N, local school health advisory committees participate in the Last Ride/ATV Safety presentations and programs with approximately 639 children and 45 adults attending.

Water Safety:

New lifejacket stations were erected and placed at seven new lake locations around PHR 4/5N including marinas, state parks, resorts, and parks for swimming and boating. Three apartment complexes as well as two daycare centers were given life jackets for loaner use. The previous 23 locations already in use continued to be maintained. These stations are equipped with infant, child, youth, and adult size life jackets and a Throw Don’t Go personal flotation devices (PFD). The station includes a sign out sheet, proper fitting instructions for the life jackets, and a large sign with the state law and provisions approved by the DSHS design department and ethics committee. The Throw Don’t Go signs were designed this year by DSHS Office of Communications and added to eight new areas where swimming is prohibited, and the PFDs were added to all new and existing life jacket loaner stations. DSHS prepared an interactive map to show the locations on the website to be used on the DSHS website in the future with pin drop locations. A lifejacket loaner station was demonstrated at the Alabama-Coushatta Pow-Wow. It elicited much interest from visitors and generated interest for a station in the College Station area.

 

PHR 11 staff produced a water safety kit to be distributed along with presentations for staff, children, and parents on water safety. The kit includes water safety education material, sunscreen, water bottles, and sunglasses. Staff plan to include a lifejacket to each kit in the coming fiscal year. Seven Public Housing Authorities in Cameron received presentations. PHR staff conducted presentations for 97 students during two summer school camps on water safety. 

General injury prevention:

PHR 6/5S staff coordinated and facilitated two Progressive Agriculture Safety Day Events. It is recognized as the largest rural safety and health education program for children in North America. Participating children were divided into small groups of 10 to 15 that rotated between educational stations. This one-day event educated 600 children on lessons about motor vehicle safety, animal safety, water safety, and stranger danger. Lesson stations were facilitated by 12 different local agencies.

 

PHR 7 staff educated and promoted Texas Health Steps, and DSHS Friday Beat to school officials, Community Resource Coordination Groups and School Health Advisory Committee participants, Police Departments, and EMS in four counties. PHR 8 staff also promoted Friday Beat and signed up attendees to subscribe to Friday Beat during other activities, such as spinal screening trainings. Staff also partnered heavily with Safe Kids San Antonio for staff education, resources, and community events in several counties. Staff then used these resources and hosted similar events in the rural counties they serve. For example, one PHR 8 nurse collaborated with schools to promote walking school buses using Safe Kids materials and used Clifford the Big Red Dog books on safety, provided by Safe Kids, in many of the presentations to school and aftercare groups. Staff also combined RadKids materials and curriculum for church groups, after-school, and summer daycare programs. Another office used the RadKids program and felt that the kids had learned important information and skills, which they were able to demonstrate in class. Returning students also shared stories where they had used skills learned the previous year. PHR 8 staff also partners with a few border community coalitions to provide community programs. One program, La Cotrina, provides space and helps with recruiting students or other participants. As the result of an interagency meeting, Bandera staff developed a flyer for local law enforcement that promotes DSHS child passenger seat inspections. They hope to have data on its use next year.

 

PHR 9/10 staff provided technical assistance and education on 25 activities that included drowning prevention (24 individuals), bike safety (171 individuals), concussion prevention (77 individuals), suicide prevention (58 individuals), and teen motor vehicle safety (339 individuals).

 

Objective 2: By 2020, increase the percentage of child death reviewed by Child Fatality Review Teams by two percentage points. (Baseline = 37%)

In FY19, MCHS provided input on and review of legislative recommendations to improve child health and injury prevention, in preparation for the next Texas legislature. The report included recommendations on residential swimming pool circumferential insolation fencing requirements and refining Texas’ car seat laws to encourage citizens to keep children rear-facing and in a car/booster seat for as long as possible. The State CFRT will publish the report in April 2020.

In FY17, the Texas legislature passed House Bill (HB) 1549 that required DSHS to provide trainings for Justice of the Peace and Medical Examiners regarding inquests in child death cases. A national training was identified, updated, and vetted to meet this training requirement. HB 1549 also required that DSHS provide review teams with electronic access to the preliminary death certificate for a deceased child. Processes began where death certificates from 2016, 2017, and the beginning of 2018 were provided to local child fatality review teams electronically through the national case report system. Case information auto-populates into the case report system, providing teams with data entry support that they have not received in the past. Death certificates were previously provided to local CFRTs 18 months after the death. This moved to approximately eight months after the death in FY18. DSHS will continue to improve the distribution process with the goal of providing cases to teams monthly.

Local CFRTs are volunteer-based and organized by county or multi-county geographic areas. Team members collect information that corresponds to their disciplines and specific questions in the National Center for Fatality Review and Prevention database. Local CFRTs meet to share what each member knows about the child deaths being reviewed and identify risk factors specific to their communities. Reviews conclude with the question: was this death preventable? Multiple PHRs are in the process of adding counties to existing local CFRTs.

The State CFRT Coordinator participated in the national Southeast Coalition on Child Fatalities (SCCF) meetings of the National Center for Fatality Review and Prevention. The SCCF is a group of state child fatality review coordinators from 14 states that meet bimonthly to discuss updates and current issues related to child fatality review. Also, the State CFRT coordinator attended the yearly Southeastern and Southwestern Injury Prevention Network (SE&SW IPN) meetings, as part of the CDC’s Regional Network Coordinating Organization Program. SE&SW IPN serves as a space for resource sharing, capacity building, and collaboration for state leaders injury prevention within 13 states that bear a high injury mortality rates. The State CFRT Coordinator was elected to the leadership board in FY18 as Member-At-Large. The State CFRT Coordinator is currently the Vice President of the board and will progress to President for the 2020-2021 board. In FY19, the State CFRT Coordinator was on the planning committee for the Texas Injury Prevention Leadership Collaborative meeting that took place in August 2019.

Texas has 83 local CFRTs covering 212 of the 254 counties in the state. Regional MCH staff continued to support local CFRTs through coordination of case reviews, technical assistance to move the groups from review to action, and supporting the development of CFRTs by facilitating meetings and supporting membership development. In FY19 PHR staff participated in reviewing 435 cases of child death. They reviewed 79 cases of sleep-related death and 77 cases of suicide.

Two of the regions, PHR 2/3 and PHR 11, instituted an application program to allow the CFRTs in their regions to seek technical assistance and support of proposed projects to move their groups from reviewing cases to initiating action based on those findings.

Staff continued recruitment of community stakeholders to participate in re-establishing or forming new CFRTs in 17 counties in PHR 2/3 without active CFRTs. Currently, PHR 2/3 support and maintain 12 CFRTs that cover 20 counties across the region. They also provided technical assistance on the Child Death Review data system and data entry, as well as team member recruitment and meeting facilitation. PHR 6/5S staff chaired or co-chaired five local CFRT. PHR 8 made efforts to get all counties covered by a CFRT. The last few counties have been difficult logistically, finding the correct contacts or dealing with contacts who leave their positions, but staff have been diligent in their efforts and anticipate at least two CFRTs should be up and running early in 2020. The state child fatality review coordinator conducted a training for PHR 8 staff in January 2019 to prepare them to better assess the effectiveness of existing CFRTs and to improve CFRT functioning and training. PHR 9/10 staff participated in eight CFRT meetings activities. Of the cases reviewed, the greatest number of deaths in ages 0-9 was attributed to SIDS. In addition to serving as convener for CFRT teams, regional staff also participated in reviews, supported leadership recruitment for teams, and participated in discussions of interventions such as bullying and suicide prevention.

 

Performance Analysis:

The number of completed THS-OPE Child Injury Prevention modules increased from 9,531 in FY18 to 11,643 in FY19.

In accordance with HB 1549, the State CFRT Coordinator now provides death data to local teams electronically. The system change was expected to allow for timelier local death reviews and provide DSHS with current data.

Challenges/Opportunities:

MCHS, SCFRT, and injury prevention partners continued to meet and plan future collaboration activities, data collection, and trainings. 

In FY19, death certificates were provided to local Child Fatality Review teams electronically through a national case report system. Death certificates were previously provided to local CFRTs 18 months after the death. This moved to approximately 8 months after the death in FY18. In FY19, there was still an 8-month lag time in providing the data to local CFRTs as the new process was streamlined. DSHS will continue to improve the distribution process with the goal of providing cases to teams monthly. The hypothesis is this will allow teams to review more cases given the timely manner of death certificate receipt and the ease of access to death certificate information.

While the growth of the injury prevention program and creation of the OIP has allowed for a sharper focus on prevention efforts, the transition process has created some delays. As the data analysis for the legislative report moved from the MCH Epi unit to OIP, there were minor delays in data availability. Future analysis and dissemination are expected to be timelier.

SPM-2 Percent of Texas WIC participants, ages 2-5, in the overweight/obese range

Objective 1: By 2020 decrease the percentage of WIC participants aged 2-5 with a BMI in the overweight or obese range from 28.6% to 24.35%.

In FY19, a total of 4,092 physicians, educators, and social workers completed the three THS-OPE modules identified as appropriate for this measure: Breastfeeding, Nutrition, and Management of Overweight and Obesity in Children and Adolescents.

In FY17, Texas was selected to participate as a technical assistance site for the Children’s Healthy Weight Collaborative Improvement and Innovation Network (CHW CoIIN). The aim of the CHW CoIIN is to facilitate the development, implementation, and/or integration of evidence-informed policies and practices to support State Title V programs to improve health behaviors related to the following work streams: breastfeeding, physical activity, and nutrition for children, adolescents, and young adults, including those with special health care needs. In the Child Health domain, Texas focused on Physical Activity and Nutrition. MCHS led these efforts by bringing together state, non-profit, and university partners to address early childhood physical activity and nutrition issues. The following activities were identified for the Physical Activity and Nutrition CHW CoIIN work stream:

• Develop and implement a coordinated recognition system that includes self-assessments, technical assistance, and training to implement evidence-based nutrition and physical activity standards in child care centers using the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program;
• Create a Child Care Health Consultant (CCHC) technical assistance and training program;
• Develop an obesity prevention education module for parents; and
• Implement the Outdoor Learning Environment (OLE!) implementation and training program.

MCHS, in partnership with the DSHS Obesity Prevention Program (OPP), contracted with several entities to accomplish these goals. MCHS contracted with: Texas Association for the Education of Young Children (TXAEYC) for the CCHC technical assistance training and OLE! program; Texas A&M AgriLife Extension to develop an obesity prevention train-the-trainer program and obesity prevention modules for parents; and the University of North Carolina for the NAP SACC assessment program.

To decrease the percentage of WIC participants aged 2-5 years with a BMI in the overweight or obese range, PHR 2/3 staff promoted the Texas Healthy Communities Assessment toolkit to partners and stakeholders in rural counties without local departments. Two communities were identified as participants of the annual assessment. PHR 2/3 staff offered support to these non-local health department counties, to address low indicators. Both entities were able to address their low indicators without the assistance of DSHS. In addition, another local health department was also identified and DSHS staff contacted them to help address their low indicators and they respectfully declined. On an annual basis, PHR 2/3 will continue to review entities that participate in this assessment and offer support to address low indicators as needed.

PHR 9/10 partnered with a diverse group of community partners from public, private, and non-profit sectors. Efforts resulted in 66 individuals served and led to seven activities that range from one-on-one education to clinic patients, breastfeeding promotion, physical activity promotion, and increased collaboration with WIC.

PHR 11 supported 60 Great Body Shop (GBS) pre-school health programs in childcare centers by distributing materials to centers who were already using GBS but needed to replenish their materials as they continued implementing this program. During FY19, 30 daycare centers continued to use GBS. This was verified by phone interview and via survey administered to Day Care Directors. In addition, two new childcare centers received the GBS training and were provided the starter GBS materials. Eight childcare centers in Cameron County and one in Bee County received ongoing technical assistance and material. Phone interviews and surveys were completed by daycare administration.

Objective 2: By 2020 decrease the percent of children in the fourth grade with a BMI in the overweight or obese range from 42.8% to 40%.

In FY19, MCHS continued to contract with the University of Texas Health Science Center at Houston (UTHealth) School of Public Health (SPH) Michael & Susan Dell Center for Healthy Living to support the activities of the School Physical Activity and Nutrition survey (SPAN). The purpose of the survey is to identify factors that may underlie childhood obesity including dietary behaviors, nutrition knowledge and attitudes, physical activity, social and environmental factors, and Body Mass Index (BMI) levels. The questionnaire also includes questions on body image, depression, sleep patterns, cell phone use, e-cigarette use and other psychosocial issues that impact health behaviors in children and adolescents. The survey is administered in school districts around the state to children in 2nd, 4th, 8th, and 11th grades. The UTHealth SPH faculty, staff, and students continued publication and presentation efforts. SPAN has 35 publications to date with 15 manuscripts in progress. Center staff trained and certified 29 people from outside organizations in SPAN protocols so that they could assure accurate collection of data when administering the SPAN survey and performing anthropometric measurements.

In preparation for data collection during the 2019-2020 school year, the SPAN team met weekly to plan for implementation. Preparation planning included staff hiring and training, IRB submission and approval of project renewal and forms, and the generation of the sampling frame from TEA data. UTHealth SPH and DSHS convened regularly to discuss survey revisions and project updates. Internally, UTHealth SPH completed the literature review and survey reference updates, initial drafts of the revised surveys, and the recruitment video. Ongoing efforts include district recruitment, meetings with district administrations and IRB staff to discuss participation and changes in their research application process, meetings with potential partners across Texas, SPAN manuscripts and publications, staff organization, and additions to the SPAN interactive website.

During FY19, the SPAN project released their interactive website which allows users to explore different breakdowns of the data collected during the last round of the project. Four one-pagers were created in FY19 with SPAN data to be used for educating legislators and policy makers. The principal investigator was invited to present to the World Health Organization on the successes and challenges of this statewide project as well as discuss opportunities to align our work with the international Childhood Obesity Surveillance Initiative (COSI). The work that resulted from the partnership between MCHS and SPAN captured the attention of DSHS’ commissioner who requested to tour the Center where the project is housed.

Performance Analysis: Regional staff are active in assisting with the SPAN survey; the Great Body Shop program; training on My Plate; Learn, Grow, Eat, Go (LGEG); Go NAPSACC; and several other obesity prevention events for children and families.

Recently THSteps has made a push for obesity prevention education modules. Currently there are only three modules available on their site: Breastfeeding, Nutrition and Management of Overweight and Obesity in Children and Adolescents. A total of 4,092 obesity prevention THS-OPE modules were completed.

The UTHealth SPH faculty, staff, and students continued publication and presentation efforts and are recruiting for the next round of SPAN data collection.

Challenges/Opportunities: The percentage of children who have obesity is higher in Texas than in the U.S. and appears to be increasing over time. Efforts to prevent child obesity should begin early in life and should focus on family-based programs, as well as school-based efforts. Large disparities in the prevalence of obesity, as well as related behaviors, exist in Texas, particularly among certain sub-populations, the Texas-Mexico border areas, and some of the PHRs. Obesity prevention initiatives should focus on these areas by providing more resources for programs and environmental efforts that are evidence-based and culturally appropriate.

Opportunities for collaboration with state partners, particularly the DSHS Obesity Prevention Program (OPP), has greatly increased due to agency re-organization. The OPP program now falls under the same leadership in the Community Health Improvement (CHI) Division at DSHS. With the aligning of programs under CHI, staff will more easily be able to coordinate prevention and promotion objectives for early childhood obesity prevention.

Opportunities also exist to work with community partners, local school systems, school health advisory committees, child care centers, state partners, and regional staff to identify evidence-based or promising practices to increase education to child care providers, teachers, and parents on healthy eating and active living programs designed to decrease obesity in children.

NPM 14.2: Percent of children, ages 0 through 17, who live in households where someone smokes.

 

Objective 1: By 2020 increase the proportion of new mothers who report smoking is not allowed in their home to meet or exceed target of 98% (from 2012 baseline of 97%.)

 

PHR 9/10 continued to partner with healthcare systems, community stakeholders, HUD, and others to promote smoking prevention and cessation activities. Staff also partnered with the Regional Tobacco Coordinator to visit several HUD multi-family housing units to promote smoking cessation, refer clinic patients to the Texas Quitline, educate providers, and clinic patients on the dangers of secondhand smoke. The partnership included 117 activities and reached 633 individuals that included providers, community stakeholders, and clinic patients.