Child Health, Annual Report FY 2019

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 2017-2018 NSCH data, 28.5% of Ohio children ages 9-35 months received a developmental screening in the past year. This compares with 33.5% of children nationwide in 2017-2018 and represents a decrease from 33.3% for Ohio children 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 represents an increase from 59% in FY 18, we are 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).

 

The Maternal and Child Health Block Grant (MCH BG) Child Health Priority work group was created to bring a diverse group of public health programs, medical professionals, family organizations, and non-profit organizations together to discuss the priority to increase the prevalence of children receiving integrated physical, behavioral, and mental health services. This group represents a multidisciplinary approach to promote well-child care throughout the state through the use of core and supporting members to ensure all components of the well-child visit were incorporated into each visit for every child.

 

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 the 2017-2018 NSCH, 28.5% of Ohio parents indicated their children ages 9-35 months received a developmental screening using a parent-completed screening tool. This is a sharp decrease from the 2016 NSCH, when 41.1% of Ohio parents indicated their children ages 9-35 months received a developmental screening using a parent-completed screening tool and a continued decrease from 33.3% in 2016-2017. The target of 41.6% was net met.

 

The group met bi-annually through the FY 19 to further partnership and collaborative opportunities. Trainings for healthcare providers incorporating best practice/evidenced-based approaches for separate components of the comprehensive well-child visit were conducted during the reporting period. Trainings included the provision of educational and follow-up resources for providers and families. However, trainings and provision of resources continue to be disjointed and this continues to be a barrier. 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.

 

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.

 

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 will be completed in FY 20. Standard reporting options across all programs have been 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).

 

During State Fiscal Year (SFY) 2019, Ohio had 7,442 licensed child care programs, which included 4,349 child care centers, 266 Type A Homes, and 2,827 Type B Homes (https://jfs.ohio.gov/cdc/docs/CCLicensingReport2019.stm). Child Care Aware (https://cdn2.hubspot.net/hubfs/3957809/State%20Fact%20Sheets%202019/Ohio%202019.pdf shows that there are more than 695,420 Ohio children in the 0-4 age ranges, with 171,801 of them living in poverty. They estimate that 556,558 Ohio children under the age of 6 years need child care.

 

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. The program was informed by an extensive needs assessment conducted in early 2018 to identify existing training resources as well as gaps. The components of this needs assessment included survey of early childhood education staff regarding topics of interest and preferences in modes of training; survey of school nurses serving schools with early childhood education programs; interviews with program leadership at the ODE (including Head Start), ODJFS, DODD, OCCRRA; focus groups with ODJFS and ODE childcare licensing specialists, Resource & Referral agencies, and with early childhood educator program staff; and review of available training regarding health and safety topics. This new 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. ODH continues to work with licensing specialists in ODJFS to provide outreach on these courses so that they can be assigned to non-compliant child care programs as part of their corrective action plans. We expect that this work will reduce the number of health-related Serious- and Moderate-Risk Noncompliance Violations by ODJFS and ODE. ECH held Steering and Planning Committee meetings with Ohio agencies including ODJFS and OCALI, and fifteen child care providers from across the state to determine interest in and need for new training topics.

 

Child Care Aware reports that there are 18,630 center-based child care workers in Ohio. In addition, they report that there are 2,949 family child care homes. Together, this identifies 21,579 child care staff eligible to take ODH ECH courses on health and safety. Between the online launch in January 2019 through September, more than 4,000 ECE professionals completed the course. Course evaluations were positive.

 

In addition to online trainings, the ECH program hosted a half day regional Early Childhood Health and Safety Conference in Spring 2019. Topics including Caring for Children with Disabilities in Early Childhood Settings and Caring for Children with Asthma in Early Childhood Settings were offered as a pre-conference to the annual ODH Regional School Nurse Conference held at three conference locations across the state. Attendance at these conferences grew over the course of the season and the conferences received position evaluations. These courses are also being transitioned to online trainings. 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 CSHCN.

 

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 was also convened to identify training topics and delivery methods. They also participated in the piloting of the first training and have provided speakers for some topics.

 

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. With Title V support, development of professional/workforce development opportunities for ECE professionals was initiated. Courses were launched throughout the year with large enrollment numbers and strong evaluations. While attendance at the face-to-face conferences were initially lower than anticipated, better means of advertising were utilized to increase attendance to expected levels. 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. Recently, Preschool Vision Screening Collaborative: Successful Uptake of Guidelines in Primary Care was published in the November issue of the Pediatric Quality and Safety Journal highlighting Ohio’s best practices within a vision screening during a well-child visit.

 

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. Education and outreach were conducted with various screening stakeholders and families to raise awareness and promote the use and availability of these new resources.

 

Data from the current year indicates that a total of 1,137 health care professionals received vision screening training during the last reporting period. Those who received the evidence-based training reported to have a projected 167,457 children that will be impacted after receiving the in-person training. A total of 2,163 students and healthcare professionals participated in the various online trainings that were offered during the last reporting period. Data submitted through the 2018-2019 Annual Vision Screening Report indicated that a total of 460,265 children were screened, 43,465 of those children were referred for follow up, and only 22.5% percent of those children received follow-up treatment.

 

Data from the current year indicates a total of 695 health care professionals received hearing screening training during the last reporting period. Those who received the evidenced-based training reported to have a projected 75,320 children that will be impacted after receiving the in-person training. A total of 512 students and healthcare professionals participated in the various online trainings that were offered during the last reporting period. Data submitted through the 2018-2019 Annual Hearing Screening Report indicated that a total of 415,670 children were screened, 21,540 of those children were rescreened, 11,548 children were referred for follow up, and only 20.4% percent of those children received follow-up treatment.

 

In addition to providing training, equipment, and technical assistance to ensure compliance with the Ohio Department of Health Hearing and Vision Screening Guidelines and Requirements to increase developmentally appropriate screenings, the MEDTAPP project Increasing Equity in Children’s Vision and Eye Health Quality Improvement Project has been approved for implementation began January 2020 with ten primary care physician practices.

 

This project aims to strengthen screening protocols, improve access to diagnostic exams and treatment, and bolster capacity for surveillance and performance measurement to contribute to the development and support of a comprehensive approach. This project aims to also increase the number of individuals in need of care who ultimately receive comprehensive eye exams and necessary treatment. Results of this quality improvement effort can provide much-needed data that will drive improvements in vision screening practice, reduce disparities in receipt of preventive vision care services, and guide uniform best practices in children’s vision health. Conclusion of this project will occur in 2021.

 

The overall outcomes being assessed will include but may not be limited to:

• The outcomes for children who received a vision screening prior to their 6th birthday indicating normal vision;
• The outcomes for children who received a vision screening prior to their 6th birthday indicating worse than normal vision and referral to an eye care specialist via use of reimbursement codes 99173, 99174, and/or 99177; and,

• The variation of treatment based on insurance type, race, ethnicity, age and sex.

 

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 2018 (the most recent finalized data available), 168,352 Ohio children under age 6 received a blood lead screening test, compared to the 169,547 children tested in 2017. The Census estimates Ohio population of children under age six is 837,388 (ACS 5-Year Estimates, United States Census Bureau), which equates to 20.1% of children under age six were tested for lead exposure in 2018. 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 2018

Result	Number of Children
Not elevated	163,153
Confirmed Elevated Total 5-9 10-44 ≥45 µg/dL	3,856 2,737 1,100 19
Unconfirmed Elevated	1,343
Total Tested	168,352

Source: Ohio Public Health Data Warehouse

 

Ohio’s threshold for 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 2018, there were 1,100 Ohio children with confirmed blood lead levels of 10 μg/dL or greater (0.65% of the total tested population) and 3,856 children with confirmed blood lead levels of 5 μg/dL or greater (2.29% of the total tested population). The 2018 data represent a decrease in the number of children with confirmed elevated blood lead levels compared to 2017 data. There was also a significant decrease in the number of children with unconfirmed elevated blood lead levels, from 1,514 in 2017 to 1,343 in 2018. This indicates that more children received appropriate follow-up lead testing in 2018, 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. The Oral Health Program supports 14 local agencies to operate dental sealant programs in schools with high participation in free and reduced meal program in 43 counties. This helps prevent tooth decay resulting in improved school attendance. Additionally, an early childhood oral health curriculum will be updated during FY 20. The Oral health staff will be working collaboratively with the tobacco program to assist in providing technical assistance and training regarding tobacco use and oral cancers. Additionally, ODH will continue to partner with the Ohio Dental Association through the OPTIONS program which serves to find pro bono oral health professionals to work with populations of need across the lifespan but will target the MCH population, specifically women of childbearing age as well as the early childhood population. To improve integrated care, the oral health team is working to provide health care provider education on the importance and safety of dental care during pregnancy; training of primary care providers in oral health assessment and fluoride vanish application during the well-child visit; and developing customized oral health education materials for early childhood programs within the ODH.

 

Dental sealants prevent the most common type of tooth decay seen in children. Tooth Assessment Trainings for Registered Dental Hygienists were conducted to ensure quality assurance in selecting the correct teeth to apply dental sealants. Two trainings were conducted one in Central and one in Southeast Ohio according to the training plan calendar and cycle. A total of 18,793 children received dental sealants during the reporting period.

 

 

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 19, a total of 16,035 children attended one of 324 OHP designated licensed child care centers in the state, estimated to equate to 5.7% of children attending a licensed child center were in an OHP designated site.

 

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 2016 (Ohio 2016 Pediatric Nutrition Surveillance Growth Indicators by Race/Ethnicity or Age) indicate that among children ages 2-5 years, 15.3% are overweight and 12.5% 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 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 (OhioAAP) 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 grant and Creating Healthy Communities grant, OHP reaches early childcare and education (ECE) professionals in public preschools, licensed child care centers, and family 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.

 

During 2015-2018, ODH and partners (Ohio Department of Job and Family Services, Ohio Department of Education, and Ohio Head Start Association) participated in a Pediatric Obesity Collaborative Improvement and Innovation Network (CoIIN) focused on increasing healthy eating and activity in early childhood. The team of experts conducted 9 focus groups with 66 ECE providers around the incorporation of healthy eating and active living into Ohio’s Quality Rating and Improvement System (QRIS) called Step Up to Quality (SUTQ). Although the recommendations were not accepted for inclusion in SUTQ, ODH and partners continue to strive for nutrition and physical activity related policy, system and environment changes in the ECE settings.

 

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

 

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 6 began October 2018, using the online Quality Improvement Data Aggregator (QIDA). Twenty physicians completed PMP online. Four technical assistance webinars were provided to all health professionals who were enrolled in the program. The fifteen physicians who completed the program increased documentation of growth trajectory (increased 44%), nutrition counseling (increased 50%), physical activity counseling (increased 51%), blood pressure (increased 32%), and family history (increased 36.1%). There were minimal improvements in the documentation of weight status, motivational interviewing, and goal setting. The participating physicians provide care for an estimated patient population of 84,000 children.

 

In 2017, PMP was expanded to include home visitors and a pilot training was held. In early 2018, PMP expanded to include CHWs, using the HUB Pathways Model, again hosting a pilot training with that audience. This work continued into 2019, with eight additional trainings taking place- five were geared at home visitors (two of which were combined to include home visitors and CHW in that specific region), two HUB-specific trainings, and AAP’s kickoff annual meeting training. A total of 182 individuals were trained during this time.

 

Sustainability of the trainings with home visitors and CHWs included follow-up survey three months following the training. Confidence reported by the 24 individuals that followed up with the survey reported an average confidence of 87% across all levels. This is similar to the confidence levels reported immediately after the trainings. Nearly 33% stated that they used the mobile app, and 67% of participants use the handouts a few times each month to 1-3 times per week.

 

To expand obesity prevention assessment and counseling into Ohio’s primary care systems, ODH has built partnerships across the OhioAAP, ODH WIC and Help Me Grow programs, several local health departments and non-profit agencies that employ home visitors, and CHWs working in the HUB model. Professional Data Analysts (PDA) is a key partner who will assist 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.

 

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 19. Thirty-three trainers were approved to provide OHP trainings and technical assistance to ECE providers.

 

ODH launched two rounds of a social media campaign to raise awareness of OHP among parents of young children. The social media campaign in June and July included 400,000 impressions on Pandora, 400,000 digital display impressions, and 912,000 social media impressions on Facebook and Instagram. The social media campaign in July through September included 200,000 impressions on Pandora, 427,000 digital display impressions, and 2.3 million social media impressions on Facebook and Instagram.

 

Children’s Hunger Alliance (CHA) provided training and on-site technical assistance to over 60 family child care providers- 21 of those providers achieved OHP designation for the first time and 30 providers were re-designated. CHA is also assisting ODH in a pilot data collection project for a survey to parents of children who are enrolled in family child care homes with OHP designation. The Family Behavior Survey collects information on OHP healthy eating and physical activity topics that are implemented in the child’s home. The questions capture which topics the ECE provider has shared with the family and which practices have been tried at home (e.g., reduced screen time, increased active play, more family meals, healthier food choices). To date, 48 responses have been received. Results of the pilot will be analyzed in early 2020 and ODH will make necessary revisions before the survey is administered statewide for all ECE 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.

 

FY 19 was the first full year of OHP online trainings. The 4 trainings for Session 1 are self-paced modules and Sessions 2 and 3 are live webinars. During FY 19, 1,383 participants completed Session 1 online, 44 participants completed the Session 2 live webinar, and 49 participants completed the Session 3 live webinar. All 3 of these sessions were offered by ODH. OHP trainings are also offered in-person throughout the state. During FY 19, there were 214 in-person OHP trainings (all sessions) and 43 online trainings, with a total of 3,651 participants.

 

In FY 19, an analysis of OHP designated sites revealed that they implemented 487 HEAL policies and 475 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.

 

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.

 

Evaluation

PDA serves as an external evaluator for ECOPP. Their work over FY 19 included an OHP Content and Delivery Comparison fact sheet and report that shows the variations in OHP training content and delivery across organizations and programs, an Annual Program Report for both OHP and PMP, and an ECOPP roadmap. PDA examined data collection efforts over all six waves of PMP and created a data collection summary. In addition, PDA drafted a PMP specific report that summarized the entire program from inception to current wave, including recommendations on data collection efforts. PDA will finalize an ECOPP program evaluation plan and analyze the results of the OHP Family Behavior Survey pilot project in FY 20, in addition to expanding recommendations and evaluation support for the PMP program.

 

ECOPP also collaborated with PDA to create 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. The tool will be piloted in FY 20 with key partners and 5-10 ECE providers and then available statewide. ECOPP ODH will use the results for future OHP programming.

 

Below are success stories from OHP designated providers:

• Children have been introduced to a greater variety of food and are now starting to try more fruits and veggies.
• This past year, classrooms have implemented offering water not only at meal times but also throughout the day by having a jug and cups available to children. This has increased their intake of drinking water.
• Since I have taken the Ohio Healthy Program, I have stopped serving all processed meats and have stopped serving store bought French fries and hash browns. This will reduce the amount of fat intake for the children I care for.
• The children and I have reduced the sugar we consume. We drink water more often and use fruits, vegetables, and herbs to flavor it.
• We have found that by implementing the Water First for Thirst policy, more children are choosing water at snack time and are also requesting water for thirst throughout the school day. We no longer serve juice at all.
• There has been much success since implementing the Ohio Healthy programs. There has been an impact among the families and children we serve. Due to the population that we serve healthy food and choices aren’t always available. So, through our new menus we have been able to show children that healthy food can taste good and be enjoyable. The children look forward to lunch every day and have developed a taste for water. The most exciting part is our program called Food for Long Life. This program allows us to send the families and children home with a bag of healthy food, like fruits and vegetables. We send them home with tasty recipes that goes along with the items in the bags. The families love the bags because for that week it’s an extra source of food that’s healthy. The children are excited to come to school and talk about the fruits and vegetables that were in their bag. During the day, the children can participate in a cooking a class that uses the items from the market bags. After they help make the dish the children can taste the food. Some love the dish so much that they encourage their parents and family to make the healthy dish with them. These are just a few success stories from our implementation of Ohio Healthy Programs.
• Participating in the Ohio Healthy Programs trainings has helped me to change my diet and exercise daily to make myself healthier. In doing so, I have lost 16 pounds.

 

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 don’t 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 intentionally and consistently engage individuals and entities 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 19 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.