Child's health includes physical, mental, and social well-being. Ensuring healthy growth and development is a primary concern of the Maine Title V program. Maine’s efforts to improve the health status of children during the 2021-2025 period focus in the areas of physical activity, oral health, developmental screening, and childhood immunizations.

Priority: Optimize Children’s Physical and Oral Health

Performance Measure (NPM): Percent of children, ages 6 through 11, who are physically active at least 60 minutes per day.

In Maine 35.9% of youth aged 6-11 years are physically active for at least 60 minutes per day. In 2019-2020 Maine ranked fourth highest in the U.S. on this measure and was significantly higher than the U.S. rate of 26%. Parents of girls are significantly less likely than parents of boys to report their child is physically active every day (30% vs. 47%). There were no significant differences in daily physical activity levels by income, parental education, race, or special health needs status. There has not been substantial change in this measure in Maine over time.

Regular physical activity (PA) is an essential component of a healthy lifestyle; it can play a powerful role in preventing chronic diseases, including heart disease, cancer, and stroke. It also builds strong bones and muscles, can increase physical fitness, may reduce anxiety and depression, and promotes positive mental health. Providing regular opportunities for youth to participate in physical activity will help them establish healthy lifestyles that can prevent these diseases in the future.

Schools are a key setting as the promotion of physical activity has long been a fundamental component of the American educational experience. Over 95% of youth are enrolled in schools. The school day, typically 8-9 hours long, traditionally provides a sedentary setting away from home. Adding physical activity during the school day can reduce the sedentary nature of classrooms. Physical activity during the school day can enhance academic performance. The federal guidelines for Comprehensive School Physical Activity Plan and Society of Health and Physical Educators (SHAPE America) Standards underscore the recommendation that school-age youth should participate in at least 60 minutes of physical activity every day and schools have a significant role to play in helping students achieve this recommendation.

Out of School Sites (OOS): National recommendations from US CDC encourage state systems to work with these settings to improve policies and practices that increase minutes spent being physically active. Afterschool and summer learning programs are well positioned to be key partners in a comprehensive effort to help children grow up healthy. From providing young people with access to nutritious foods to promoting healthy habits and keeping students physically fit, OOS programs can combine and implement multiple approaches.

Strategy: Increase the number of schools and early care and education sites that receive support and targeted outreach to improve policies and meet best practices for increasing physical activity opportunities for youth they serve

The COVID-19 pandemic has impacted all of us in many ways, some that will have lasting outcomes. National reports indicate declines in both access to and participation in physical activity in both adults and children. The need for this work has been evident and is now critical to addressing a public health issue. As we move into the next few years, we will need to work diligently to support schools and early care and education sites in rebuilding programs and addressing any long-term barriers created by the pandemic.

Despite school and program closures, quarantines, staffing shortages and safety considerations for exposure Maine was able to pivot to an online approach and continue to engage with our partners to offer training, technical assistance, and support to sites during FY21.

The Maine CDC collaborated with Maine Roads to Quality (an early care and education career development center that promotes and supports professionalism in the early care and education field), Department of Education, Maine Afterschool Network (a program that enables children to have access to quality, inclusive, affordable after school programming), and Let’s Go! (a childhood obesity prevention program that helps schools, early care and education and out of school programs that support sites to increase healthy opportunities for children) to identify sites (schools, childcare, and out of school programs) with policies that do not meet national standards for providing adequate and appropriate physical activity (lacking recess, physical education periods) and provided targeted professional development to enhance policies and practices that impact the quality and quantity of physical activity for children that attend those sites. Targeted professional development is based on the needs of sites and includes but is not limited to in-person technical assistance, policy review, environmental strategy implementation support, and various means of education and training.

Despite the unforeseen complications brought on by the pandemic activities outlined in our state action plan moved forward. Maine achieved the following outcomes:

• Established 2020-2021 baselines for programs meeting best practices. Using available data from Let’s Go’s annual surveys and Maine Prevention Service’s (a Maine CDC and community partner collaborative that works statewide to prevent obesity, tobacco, and other substance use) reporting.

Baseline:

• 134 of the 219 (61%) public School Administrative Units (SAUs) in the state have existing policies that meet best practice and meet standards for PA as defined by Healthy Hunger Free Kids Act 2010.
• 200 of the 577 (35%) Early Childhood Education (ECE) Centers that responded to Let’s Go! annual survey reported meeting best practices and aligning with high standards for PA at their sites, as defined by Let’s Go!.
• 24 of 131 (18%) OOS sites that responded to Let’s Go! annual survey reported meeting best practices and aligning with high standards for PA at their sites, as defined by Let’s Go!.
• Sites not connected to Let’s Go! but are on the statewide technical assistance lists include 219 public SAU’s,1788 current numbers for licensed and unlicensed recognized ECE’s in the state.

• Identified sites that do not have policies that meet best practices and highest standards for PA for this reporting year:
  • 29 of 134 (22%) SAU’s (number of SAU’s enrolled with Let’s Go!)
  • 377 of 577 (65%) ECE’s (number of ECE’s enrolled with Let’s Go!)
  • 107 of 131 (82%) OOS sites (number of OOS sites enrolled with Let’s Go!)
• Provided targeted outreach and support to sites that do not have policies that meet best practices and highest standards for implementing PA:
  • All 134 SAU’s enrolled with Let’s Go! received targeted outreach; additional outreach to the 85 SAU’s occurred to elicit interest from SAU’s in participating in the efforts.
  • All 577 ECE’s enrolled with Let’s Go! received targeted outreach.
  • All 131 OOS enrolled with Let’s Go! received targeted outreach
  • Healthy Kids Healthy Futures provided a Playworks training to 160 ECE’s (some may be duplicative ECE’s so reach numbers are not counted).

Implementation strategies were modified and enhanced through development of online training and technical assistance opportunities in response to COVID-19. To date the following opportunities have been successfully launched.

• Let’s Go! held a virtual School Symposium in October 2020 with 103 participants; 52 individual school systems were represented.
• Let’s Go! contracted with nationally recognized physical activity expert, Playworks to provide weekly PA recorded breaks and activities. Let’s Go! shared these on a monthly basis with all 577 ECE sites and 375 schools that were enrolled with Let’s Go!.
• Trainings and technical assistance pivoted to online only and modifications such as zoom and google platforms were utilized to provide support for in person and team trainings.
• Healthy Kids Healthy Futures also contracted with Playworks to offer three series of online training for ECE and OOS providers focused on developmentally appropriate physical activity grounded in the principles of social and emotional health for children. Trainings were planned and implemented in March 2021. Over 180 providers registered for the 8-hour online trainings and received 8 contact hours that can be applied to professional development and licensing elective training requirements.

Overall, the strategies to pivot to online training, technical assistance, and support for schools, ECE’s and OOS sites went smoothly and were well received. With the increased uncertainty we continue to face (variants of the pandemic, site closures, staffing issues and student/staff exposures) we remain committed to offering online training and outreach for the coming year. We will expand on our FY21 successes, such as offering access to trainings with Playworks and other physical activity programs locally sourced in Maine, and use the lessons learned to continue our work with partners. Throughout FY21 we strengthened these alliances and hope to continue the positive progress in our outreach and support to each setting.

Performance Measure (NPM): Percent of children, ages 1 through 17, who had a preventive dental visit in the past year.

In 2019-2020, about 77% of Maine parents reported that their child had a preventive dental visit in the past year, which is similar to the U.S. (77.5%), but the lowest in New England. Maine’s performance on this measure has declined over time. In 2016, 85% of Maine children had a preventive dental visit. Young children (aged 1-5) are the least likely to have had a preventive dental visit in the past year (60.3% vs. 91% of children 6-11 years of age). Children living in families with a household income between 0-99% of the federal poverty level (FPL) were less likely than children living in families with FPL greater than or equal to 200% FPL to have a preventive dental visit. Preventive dental visits are also related to higher parental educational attainment and having private health insurance.

Dental decay and oral health literacy continue to burden the children in Maine. According to the 2019 (the last year data was collected) Maine Integrated Youth Health Survey, nearly half (45%) of third graders had experienced tooth decay. One objective of the Maine School Oral Health Program (SOHP) is to reduce tooth decay among Maine children and adolescents grades Pre-K through six. To address this the Maine CDC is proposing an approach that combines increased oral health literacy, providing classroom oral health resources for school nurses and collaboration with other dental stakeholders on oral health messaging.

Maintain support for the School Oral Health Program consultants and administrators

During FY21 the SOHP disseminated educational materials to schools enrolled in the program; Maine Department of Education (Maine DOE) has a curriculum requirement for teaching oral health lessons. To make oral health education more engaging and increase oral health literacy, the SOHP provided school nurses and teachers with materials to assist in meeting the Maine DOE curricula requirements and increase oral health education. In lieu of February Children’s Dental Health month the SOHP provided school nurses, of all schools enrolled in the SOHP (180), with oral health educational materials via email.

The SOHP provided outreach and technical assistance to schools interested in enrolling in the SOHP. With the expansion of the SOHP and open enrollment, any new school meeting the SOHP guidelines can utilize the services of the SOHP Coordinator and field hygienists. The FY21 goal was to increase by 5% new school enrollment and children who receive SOHP services. New enrollment concluded in December 2020 (for FY21) with a total of 4 new schools added, resulting in a 2.5% increase. The most significant factor in the decline of new enrollment can be attributed to the pandemic. Schools were closed to outside personnel which included the oral health program presence.

The SOHP collaborated with other dental stakeholders and partners on shared children’s oral health messaging and resources. During the fall of 2020, COVID-19 continued to be of concern and schools limited visitors. With the endorsement of the Maine Association of School Nurses and collaborations with the Maine DOE Nurse Consultant, schools and nursing staff were provided guidance to proceed with SOHP services. The SOHP provided a pre-recorded presentation for the New School Nurse Orientation virtual meeting.

During early FY21 the SOHP collaborated with the Partnership for Children’s Oral Health, From the First Tooth, Opportunity Alliance, Maine General Health, Northern Light Hospital, University of New England, Sun Rise Opportunities, Maine Medical Center, Aroostook County Action Program and St Apollonia to distribute 45,000 dental health kits to Maine students through their community lunch programs. The dental kits consisted of a toothbrush, toothpaste, dental floss and an educational resource card.

Strategy: Provide support and supplies for updated PPE requirements post COVID-19

The SOHP collaborated with public health hygienists working with the SOHP to provide technical assistance and trainings on appropriate personal protective equipment (PPE) throughout the Covid-19 pandemic. Review of appropriate level surgical masks, donning and doffing gloves, Department of Education guidelines for entering a school, proper hand washing technique and hand sanitization with 70% alcohol products. Trainings were held to review the new SOHP handbook, intraoral camera uses, new data collection methods and new responsibilities during the pandemic. The goal of these required trainings was to increase confidence in appropriate use of SOHP provided PPE. The SOHP held two virtual meetings to review the overall program and provide assistance where needed. FY21 meetings were held in August 2020 and January 2021. The SOHP manual was published and provided to all SOHP hygienists and can also be found at: https://www.maine.gov/dhhs/mecdc/population-health/odh/documents/2021SOHP_Handbook.pdf

The school-based dental hygienists and school oral health coordinator provided oral health educational resources to school nurses through trainings and technical assistance. Engaging Maine children with oral health literacy promotes good oral health habits resulting in less tooth decay. Maine tracks progress through the evidence based strategy measure – number of schools receiving oral health educational resources. Educational resources were emailed to all 180 schools in February 2021.

Reassessing the FY22 goals, the SOHP closed enrollment for new schools due to a workforce shortage. Efforts are under way to develop a broader workforce recruitment system and branch out to Community Health Workers (CHW)s to assist with some aspects of the SOHP. CHWs can be trained to perform such tasks as basic screening surveys, data collection and increase care coordination efforts.

Priority: Ensure early detection and intervention for developmental delay

Performance Measure: (NPM): Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year.

According to the 2019-2020 National Survey of Children’s Health, about 42% of Maine parents of children ages 9-35 months report that they were asked to complete a developmental screening tool for their child within the previous year. Maine ranked 15th highest on this measure. The U.S. rate was 36.9%. MaineCare has been working to improve developmental screening rates among their providers and has increased awareness of the billing code available to providers for conducting developmental screens. As a result, the percent of children enrolled in MaineCare with a claim for a developmental screen increased for three year olds from 9.0% in 2012 to 25% in 2019. This increase may be due to increased awareness of claim coding for developmental screenings, along with actual increases in screenings. In 2020 the percentage of children enrolled in MaineCare who had a developmental screening decreased slightly to 21%. This may be due to the impact of COVID-19 on well-child visits.

In 2020, the Maine Department of Health and Human Services (Maine DHHS) created a report in response to LD 1635, RESOLVE Chapter 66, To Improve Access to Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) for Children birth to eight years of age. The report includes information on programs providing developmental screening services in the Maine DHHS, including work carried out under the Maine Title V Maternal Child Health Block Grant, Public Health Nursing, Maine Families Home Visiting, and Women, Infants and Children (WIC). One of the report’s recommendations is ensuring no wrong door for families to access services, which includes developmental screening. Although developmental screening did not emerge as one of the top five priorities for child health during the MCH needs assessment, the Maine Title V program decided to include it to align with the Maine DHHS Commissioner’s priority on the importance of screening children for developmental delays.

Strategy: Work with community partners to collaborate and increase referrals for developmenmtal screenings

The WIC program began conducting developmental surveillance using the federal CDC’s Learn the Signs Act Early (LTSAE) tool. The WIC Nutritional Services is a voluntary program that provides low-cost healthy foods, nutritional education, breastfeeding promotion, and support and referral to other services to women, infants and children who are at nutritional risk. The program is designed to allow women to enroll during pregnancy and for children to remain enrolled up to the age of five. Beginning in 2019, all children seen at WIC were provided with materials on age appropriate developmental surveillance. WIC staff document any developmental concerns found and refer parents to the child’s medical provider for further review. During FY21, WIC made166 referrals.

During FY21, the Maine WIC program participated in the Developmental Screening Initiative Workgroup to encourage coordination across agencies to increase referrals by service providers such as WIC, Public Health Nursing (PHN), Maine Families Home Visiting and Early Head Start for developmental screenings.

Maine Families home visitors complete the Ages and Stages Developmental (ASQ), and Social Emotional (ASQ-SE) screenings with families at regular intervals. Family visitors complete ASQs, at a minimum, at 2, 4, 9, 12, 18, 24, 30, and 36 months. Family visitors complete ASQ-SEs at a minimum of three times within the first three years of the child’s life. Family visitors worked with local child development services and other specialists to offer referrals for families as indicated by a screening result.

Public health nurses provided infant physical assessments at each home visit, which included an assessment of the child’s development. PHN’s perform physical assessments appropriate for age/condition and document the results in the pediatric physical assessment tool. PHNs monitor children for ability to express needs. They monitor the child for attainment of developmental tasks expected for age as well as monitor the child’s response to stimulating/nurturing activities. Public health nurses refer to appropriate providers if any assessments are determined to be outside of normal limits.

According to ESM Review and Resources: National Summary 2018/2020, staff continuing education is directly related to the percent of children who receive developmental screenings. The WIC program provides annual developmental screening trainings for its’ staff and invites, Head Start, and Public Health Nursing staff to participate.

Priority: Optimize Children’s Physical and Oral Health

State Performance Measure (SPM): Percent of children who have completed the combined 7-vaccine series (4:3:1:3*:3:1:4) by age 35 months.

Strategy: Ensure children have access to the required immunizations according to the schedule

The most recent data from the National Immunization Survey for this measure are from infants born in 2018. Based on this survey, 83.7% of children through 35 months of age completed the combined 7 vaccine series. Maine’s 2018 vaccination rate was the 7th highest in the United States.

COVID-19 vaccine planning and distribution consumed most available Maine Immunization Program (MIP) staffing time during FY21. MIP was in a Continuity of Operations for the majority of the year with most educational efforts for childhood/adolescent vaccines deferred.

The spread of COVID-19 throughout the country and Maine’s “Stay Safer at Home Orders” led to a decrease in children receiving their routinely recommended vaccines at well-child visits. Not only were parents hesitant to bring their healthy children to an office that might be seeing sick children, but the healthcare system itself saw a change. Understaffed with redeployments, the new normal became telehealth visits, a visit that unfortunately did not allow children to be vaccinated.

The Maine CDC collaborated with the Maine Chapter of the American Academy of Pediatrics (Maine AAP) to promote routine childhood vaccinations. Most Maine physicians belong to the Maine AAP, receiving best practice communications through their listserv and social media platforms. Communications included social distancing, influenza, back to school campaigns, and routine recommended vaccine improvement strategies. Information was targeted to help increase children 24-35 months, students 4-6 years, and adolescents receive their routine immunizations.

The Maine CDC promoted and recruited provider sites to enroll in the Maine Immunization Program, with a focus on ensuring that children in rural areas have access to vaccine. The MIP enrolled over 50 new provider (including non-traditional providers such as chiropractors and internal medicine) sites to participate in influenza and COVID-19 vaccination efforts. These additional sites were able to carry and offer routine recommended childhood vaccines.

The Maine Immunization Program partnered with the Public Health Nursing Program to offer catch-up immunization visits to all Maine children. These visits were by appointment only and offered in six Public Health Nursing offices located throughout the state. This initiative allowed children who had been deferred from their primary care office due to COVID-19 to receive the immunizations they were due for regardless of insurance status. It also allowed for individuals without a primary care provider (PCP) to receive vaccines necessary for school entry. Public Health Nursing utilized the State of Maine immunization information system (IIS), ImmPact, to record these immunizations.

Other Efforts

The Maine CDC partnered with the Maine Department of Education (Maine DOE) to promote school required vaccinations for school aged students. Public Law, Ch. 154: An Act to Protect Maine Children and Students from Preventable Disease by Repealing Certain Exemptions from the Laws Governing Immunization Requirements went into effect September 1, 2021. This new law removed the allowance of all philosophical and religious exemptions from daycares, schools, colleges, and healthcare facilities throughout Maine. The Maine CDC and Maine DOE worked on the legislative rule changes to implement this law. In collaboration, we released communications to students, parents, and superintendents throughout the state on these new requirements and ways to ensure students receive all required immunizations on time for school entry. Annually the Maine Immunization Program conducts a survey on vaccination coverage rates and exemptions for kindergarten, seventh, and twelfth grade students. For the 2019-2020 academic year, vaccination rates for children entering kindergarten were 94% with a 5% exemption rate. Vaccination rates were slightly smaller for the 2020-2021 academic year, but there was a higher proportion of missing data (>2.0% compared to <1.0% the previous year). The 2021-2022 survey revealed vaccination rates were about 96% with exemption rates at less than 2%.

Additionally, to mitigate the spread of COVID-19, Maine CDC and Maine DOE offered influenza vaccine through School Located Vaccine Clinics, giving students the opportunity to receive influenza vaccines at their school at no cost to parents.