Child Health-Annual Report

NPM #8 Physical Activity – Reduce obesity among children and adolescents.

Please note that some of the strategies and activities listed below impact both the Child and Adolescent Health domains. To avoid duplication, the information will only be listed in this domain, for which it is anticipated to have a larger impact, but it should be noted that some strategies and activities may address a wider age range.

According to the 2019-2020 National Survey of Children’s Health (NSCH) data, 31.2% of Missouri children ages 6-11 years were physically active for at least 60 minutes a day, compared to their national counterparts (26.2%). Girls (33.4%) more commonly met this benchmark for physical activity than boys (29.2%). Survey findings suggest lower physical activity levels for children from college graduate or higher households (Figure 4). Children with public insurance only (32.2%*) were more frequently physically active for an hour daily than their national counterparts (27.5%).

Obesity is complex, and environmental and behavioral factors play a critical role. Healthy eating and regular physical activity are critical to achieving and maintaining good health. Missouri works to implement best practices to ensure all Missourians live in communities that support these healthy habits. Research by the Robert Wood Johnson Foundation (RWJF) forecasted Missouri would spend $12 billion a year on obesity-related health care in 2030 as a result of alarming increases in childhood obesity. RWJF has previously ranked Missouri 17th in the nation for adult obesity. The 2020 Behavioral Risk Factor Surveillance System (BRFSS) reports more than two of every three adults are overweight (35.4%) or obese (34.0%). Some degree of adult obesity is likely reflective of poor dietary habits and sedentary behaviors formed in childhood that persist into adulthood. With that in mind, it is critical to support healthy habits early. About 80% of Missouri school districts provided data through the Department of Elementary and Secondary Education (DESE)/Department of Health and Senior Services (DHSS) data system collaborative. Of those students represented, 9% had asthma and had medication at home or school for the 2020-2021 school year. Additionally, there was an increasing proportion of students with Type 2 diabetes. Obesity and chronic condition prevalence rates are significantly higher among African American and Hispanic communities, which compounds the gap in health equity and educational attainment for children from these minority groups.

Obesity is a complex issue with many solutions, requiring collaboration from multiple organizations. One way Missouri brings these partners together is through the Missouri Council for Activity and Nutrition (MOCAN), the statewide obesity prevention council facilitated by University of Missouri Extension (UME). MOCAN’s member organizations are structured into workgroups specific to settings or topics: schools & child care, physical activity, worksites, food systems, and healthcare. DHSS staff supported through MCH funding participated in MOCAN workgroups to support statewide improvements in physical activity.

Policy and Environmental Changes

Developing a healthier community involves creating a culture that supports physical activity and provides access to safe places to be active. Policy and an appropriate environment are essential in supporting opportunities for children, youth, and families to develop healthy physical activity practices. In FY21, program staff in the Bureau of Community Health and Wellness (BCHW) continued to contract with local public health agencies (LPHAs) to implement policy and environmental changes that increase opportunities for children to engage in physical activity across multiple settings.

Child Care Wellness contracts were issued to six LPHAs to support training and technical assistance of child care providers to improve child care physical activity, nutrition policies, and practices. LPHAs used the University of North Carolina’s Nutrition and Physical Activity Self-Assessment for Child Care (Go NAPSACC) online system to assist child care providers with creating practices, policies, and environments that instill habits that support lifelong health and well-being and track child care providers’ progress. However, due to the demands of pandemic response, LPHAs were unable to complete the Go NAPSACC modules with child care providers.

The DHSS, through BCHW and the Child Care Health Consultation (CCHC) Program, continued to support childcare providers with implementing policies and practices supportive of physical activity. Training, resources and technical assistance related to physical activity policies and practices were provided to child care providers who wanted to become a Missouri MOve Smart Child Care. MOve Smart recognizes child care programs that adopt policies and practices that support children’s physical activity. Five child care programs received MOve Smart recognition in FY21.

The CCHC Program provided 123.5 hours of training and consultation to child care providers on the: recommended guidelines for physical activity and nutrition, implications of a healthy weight on overall health, and the role of breastfeeding in child nutrition and obesity prevention. The program also provided 164.75 hours of health promotion to children in child care on the topics of physical activity and nutrition. Health promotion increased children’s knowledge on the importance of being active and provided examples of activities and games that promote physical activity, visual and hands-on demonstrations of healthy snacks and drinks, and resources and materials to share with their families about physical activity and nutrition. CCHC Program services increased access to information about physical activity and nutrition guidelines for children and families, and promoted involvement in community-based activities. CCHC Program services continued to be inclusive of adults and children of all abilities, encourage family participation in program services, optimize the health of children in child care, and provide resources and opportunities for collaboration with community-based organizations that promote physical activity and nutrition for children. The capacity for LPHAs to deliver CCHC Program services was severely impacted by the ongoing COVID-19 pandemic.

BCHW contracted with Missourian’s for Responsible Transportation to lead and conduct the Missouri Livable Streets Advisory Committee. This group consists of active transportation experts and advocates who collaborate to assist communities with improving accessibility of non-motorized transportation for all users throughout the state. The committee identified a statewide active transportation plan, outlining a vision and framework for improving accessibility, safety and affordability of active transportation, particularly for the most vulnerable populations, as a priority for their efforts. Such a plan will also identify and help prioritize strategies intended to increase multimodal connectivity throughout the state. The committee is seeking collaboration with the Missouri Department of Transportation to assess the active transportation elements of surrounding states in order to evaluate how the plans were created.

Professional Development, Training, and Resources

BCHW staff also provide training and technical assistance on obesity prevention strategies to local communities. To ensure staff are well informed and can provide quality assistance, they participated in professional development opportunities such as annual conferences and other evidence-based training.

BCHW continued to support Missouri communities in their obesity prevention efforts by providing professional development and training opportunities for key stakeholders. Training opportunities included the virtual “More Than Child’s Play, Leading Joyful and Purposeful Physical Activities with Young Children” presented by Diane Craft, a national expert in preschool movement programs. Over 300 child care providers participated. Professional development opportunities were also made available to GO NAPSACC participants through the University of North Carolina’s online training. Additionally, technical assistance and resources were available to assist efforts to increase regular physical activity and healthful eating. BCHW’s MOve Smart website included physical activity training, providing one hour of continuing education for child care providers. In FY21, 288 child care providers completed the MOve Smart training. Child care providers could also access other materials to support physical activity on this webpage, including physical activity cards and videos for use in the classroom.

The School Health Program (SHP) supported school nurses to engage with students and families in addressing overweight/obesity in children. The SHP sponsored education and professional development in best practices (e.g., Lead Nurse Collaborative Meeting and ECHO webinar series for school nurses), collaborated with stakeholders and organizational partners to make tools and resources available to school nurses, and facilitated connections between students and families, schools, and communities.

Partnerships

BCHW staff participated in a number of coalitions and partnerships to help advance progress towards the state’s goals and objectives. Staff were involved in: MOCAN, Missouri Convergence Partnership, Missouri Coordinated School Health Coalition, DESE Missouri Healthy Schools Leadership Team, and the Missouri Complete Streets Advisory Committee. Staff had the opportunity to network and identify collaborative opportunities with other organizations working on similar goals, share available DHSS resources, and leverage funding to increase the reach of their work. For example, staff participation in the MOCAN Child Care Work Group strategic planning process led to alignment of the group’s goals with DHSS goals.

The MCH Services Program continued to contract with the 18 LPHAs that selected promoting physical activity and reducing and preventing overweight/obesity as their  Priority Health Issue. LPHA efforts to prevent and reduce overweight/obesity and increase physical activity among children and adolescents included:

• Clay County Health Department increased the number of childcare centers that reviewed and updated policies for incorporating physical activity into daily classroom curriculum; thus increasing children’s level of daily physical activity. They also increased knowledge among children and their families on the importance of physical activity and nutrition; thus leading to a behavior change of incorporating these lifestyle changes into their daily routine.
• Henry County Public Health Center increased parent’s knowledge on the importance of youth getting a minimum of 60 minutes of daily physical activity; thus directly contributing to an increase in children and families adopting increased physical activity. A community swim event and a bubble walk were held with over 100 children in attendance. A new park, developed to be inclusive for children with disabilities, successfully created opportunities for increased physical activity.
• Jefferson County Health Department worked to increase community education campaigns that increase daily physical activity for youth. A Spring into Wellness Program was implemented in 2021. 31 children age 12 and under signed up and individually logged at least 1,000 minutes/month of physical activity. 18 of those 31 children also had a parent or sibling participate. In addition, the health department partnered with local libraries and created Make and Take activity bags- these included a game that involved some type of physical activity. Lastly, the JeffCo Wellness Walk Project was implemented in collaboration with the parks department. Trail signs, with various physical activity and mental health activities and linked QR codes, were developed and placed on public trails, walkways, and paths.
• Randolph County Health Department worked to increase the number of health care providers who encourage daily physical activity for children ages 6-12. Specifically, they worked with the Moberly Regional Medical Center (MRMC) to implement the 12345 FitTastic! framework and consistent messaging component, and MRMC providers continue to use this framework in their practices. In addition, the health department increased the number of children ages 6-12 participating in daily physical activity by increasing exposure to healthy lifestyle education. For instance, the health department organized the Randolph County Summer Marathon. Participants were encouraged to complete 26.2 miles of physical activity throughout the summer months. 41 children were involved.
• Pulaski County Health Department increased the number of child- and adolescent-focused physical activities. The Adolescents Committed to Improvement via Exercise (A.C.T.I.V.E) program, implemented by four after school programs, collectively impacted over 100 children and adolescents who were trained to complete a 5K. In addition, the health department facilitated an AquaCize class in the summer months for women of childbearing age and children. The class was held at the local pool and encouraged children and families to be active.

SPM #1 Oral Health – Enhance access to health care services for children.

According to NSCH 2019-2020 data, nationally 77.5% of children ages 1-17 years old had a preventive dental visit in the past year. This was a greater percentage than in Missouri (72.5%). A lower percentage of Missouri children ages 1-5 years old (49.6%) had a preventive dental visit than their national counterparts (57.9%). This age group also had a lower percentage than Missouri children ages 6-11 years old (82.2%) and 12-17 years old (81.7%). Children who most frequently had a preventive dental visit in the past year were in college educated households (80.5%) followed by some college or technical school (68.7%), and high school graduate or GED (65.0%) households. Children with private insurance only (77.8%) more frequently had a preventive dental visit than publicly insured only (66.9%) and uninsured (45.2%*) children. Children in two-parent married households (73.6%) reported having more frequent preventive dental visit in the past year than single parent households (70.7%).

The Office of Dental Health (ODH) enjoyed continued success with the PSP, an evidence-based fluoride varnish and oral health education program. Pre-COVID, PSP served about 90,000 children each year; in FY21, 19,608 children participated in the traditional PSP. Each child received an oral health screening by a dental professional, two doses of fluoride varnish, oral health literature and supplies, and oral health education from school staff and volunteer dental professionals. Educational materials were provided by the ODH (for K-12 grade), but some schools choose to use their own materials. Due to the pandemic, many schools did not allow visitors to enter their school building. For those schools, PSP adapted and created ‘Plan B PSP’. Plan B PSP provided grade-specific and narrated educational videos for teachers to show their classes. A Zoom call could also be scheduled with the school’s ODH Oral Health Consultant if they did not have their own educational materials or training. Oral health supplies and literature were provided and fluoride varnish was either applied by a trained school staff member or sent home for parents or guardians to apply to their child’s teeth. 8,598 children participated in Plan B PSP. The ODH’s Oral Health Consultants were also available to school nurses to advise regarding potential dental health needs. School nurses could take pictures of a child’s teeth if there was a questionable issue, and an Oral Health Consultant helped determine the need for dental care. The ODH Program Manager presented a webinar to 78 school nurses in April 2021 on the importance of oral health and promoted the PSP. This was the second-most attended webinar offered by the School Nurse Program and given high reviews. The webinar was recorded for nurses who missed the presentation. In July 2021, an ODH Oral Health Consultant presented a webinar during the Orientation for School Nurses, an orientation for new school nurses and a refresher for established school nurses. The webinar was viewed by 258 individuals.

The ODH continued to promote the use of dental sealants as an effective means to prevent decay on newly erupted molars and is actively seeking new partnerships to provide dental sealants in school-based clinics. The ODH continued to work with two LPHAs and two dental health clinics to apply sealants in their clinics and at local schools.

The ODH’s Five-Year State Oral Health Plan was finalized and disseminated and is still a subject of ongoing communication with partners.

The ODH continued its efforts to:

• Increase access to dental care by providing education about the importance of maintaining the adult dental benefit among MO HealthNet recipients. Information is distributed to policymakers, dental providers, leaders, and oral health stakeholders via the DHSS website and partners like the Missouri Coalition for Oral Health and Missouri Dental Association;
• Contract with the Missouri Primary Care Association (MPCA) to provide education and technical assistance to State Dental Directors from all FQHCs in Missouri. The MPCA also assists the ODH with distributing educational materials regarding the importance of a dental health home for everyone, particularly for pregnant women and children;
• Support the development of the oral health workforce in Missouri through collaborations with the DHSS Office of Rural Health and Primary Care on incentive programs for dental professionals; and
• Implement the “referrals” portion of the PSP, linking children with an identified dental need to local dental providers and coordinated through school nurses and other local champions.

Strategies to enhance access to oral health care services for children also included providing education to public, city officials, dental and medical professionals, and public health authorities about the safety and effectiveness of community water fluoridation for the prevention of dental caries. The ODH also continued to improve the Missouri Oral Health Surveillance System to include updated fact sheets on topics of interest and regional reports compiling oral health statistics and related information. The ODH created a Tableau dashboard with data from our PSP program to break oral health data down by area or county and provide a visual representation of the data. The data can be found on our Missouri Oral Health Data page located at Oral Health Data | Oral Health | Health & Senior Services (mo.gov).

Partnerships

Much of Missouri is a dental health provider shortage area, meaning many Missourians are neither located close to a dentist nor do they have a dental home. COMTREA (a Federally Qualified Health Center (FQHC)) assists parents in understanding the importance of oral health and linking children with dental care to address barriers to dental services such as transportation, ability of parents to miss work, ability to pay, and knowledge of services available. The ODH worked with COMTREA to provide assistance and support as needed in the form of educational materials and handouts.

ODH also partnered with Level Up, a dental program in Kansas City that helps to meet the oral health care needs of low-income children in Clay and Platte Counties. The program has two full-time dentists who provide treatment on-site in schools (with a mobile unit) and at other social service organizations. All dental services are free for children who meet income guidelines. The ODH provided over 1,000 tubes of toothpaste for children seen through this program.

In Missouri, there are approximately 14,000 children in foster care through the Department of Social Services (DSS)–Children’s Division (CD) at any given time. CD has 46 circuits that work with these children, their families, and their foster/kinship placements. These children are part of an underserved population that is facing significant health disparities, including low socioeconomic status and limited access to medical professionals and services. Children brought into state custody are enrolled in Medicaid, a system often lacking the dental professionals needed to ensure equitable access to oral health care. Additionally, in many cases, these children live in areas experiencing dental professional shortages. Combined with barriers to access created by the pandemic, many children were either unable to access oral health care or had their dental appointments canceled and then had to wait months to get them rescheduled. As part of an intra-departmental collaboration between the DHSS–ODH and DSS–CD, foster children were supplied a packet of oral health materials to help improve their oral health and decrease the oral health disparity. Each packet included two applications of fluoride varnish, two tubes of toothpaste, a toothbrush, and two pieces of educational material: Dental Sealant and Baby Teeth Are Important card. Additionally, virtual education was provided in the form of fluoride varnish application training for all the CD staff. The ODH Oral Health educational video series for children (for K-12 grade) was made available for them to learn more about the importance of oral health. These materials were shipped to the CD central office and then distributed to each of the 46 circuits. From there, Children’s Service Social Workers took packets to each child during their monthly home visits. The central office distributed the virtual educational materials along with a short letter of explanation about the packets via their foster/kinship placement listserv, and included the links to the fluoride varnish training and the oral health educational video series. During the monthly home visit, the Children’s social worker gave the packet to the foster/kinship placement caregivers and reminded them about the email that was sent with the educational information. The foster/kinship placement caregivers utilized the oral health items to apply fluoride varnish and repeat the application 3-6 months later as needed, depending on the child’s oral health need. Additionally, the children utilized the toothbrushes and toothpaste regularly. The ODH office received telephone calls from the foster/kinship placement caregivers reporting the packets were a wonderful surprise and would help improve the children’s oral health, and the children were excited to receive the items. The caseworkers expressed their thanks for the opportunity to help families and acknowledged how much it would benefit the children. Overall, this project enabled children to receive some type of oral health preventive service.

The SHP coordinated with the ODH and other programs to provide evidence-based information, resources, and professional development to school nurses supporting them with best practices to educate children and parents about oral health concerns as well as promote the need for annual dental visits and regular preventative practices in oral health. This was accomplished by offering a virtual presentation, to all 106 new school nurses, about the ODH and the programs they offer. An additional virtual meeting was scheduled for all lead school nurses about the ODH and oral health resources available.

The TEL-LINK Program referred 142 callers to dental clinics to increase awareness of community resources to access needed dental health services. The program provided outreach to the underserved population through effective marketing strategies. The marketing strategies included relevant search terms and ads using an online search campaign. When individuals Google key search words such as: “dental clinic near me”, “dental care”, or “help with dental expenses”, the results provide a click-to-call (mobile only) ad, allowing customers to call TEL-LINK with a single click. Providing this type of effective marketing strategy has increased dental referrals. Before these campaigns, the average referral would be less than 14 calls per year for dental care.

The Missouri WIC Program procured infant and toddler toothbrushes to make them available in local WIC clinics. Literature was available to LPHAs, dental offices, and community outreach events such as health fairs. The importance of regular dental care was also communicated through promotion of the use of dental sealants. Referrals and care coordination components of the Preventive Services Program (PSP), described in more detail below, also encouraged regular dental visits for children, particularly those identified with a dental/oral health need.

The CCHC Program provided 10 hours of training and 20 hours of consultation services to child care providers on the importance of oral health, oral health guidelines, and the implications of oral health on overall health. As a result of CCHC consultations and trainings, child care providers demonstrated increased knowledge and awareness of the implication of a child’s oral health on their overall health, and learned strategies they could implement at their child care facility to promote oral health. CCHC trainings also increased child care provider knowledge related to identifying abnormal oral health conditions in infants and young children, oral care and specific implications for Children with Special Healthcare Needs (CSHCN), and overcoming challenges and barriers to providing oral care for CSHCN. The CCHC Program also provided 60.25 hours of health promotion to children in child care on the importance of oral health. As a result, these children were able to verbalize why their teeth are important, what could happen if they do not care for their teeth, and identify unhealthy snacks and beverages that could harm their teeth. These children also participated in visual and hands-on demonstrations of proper tooth brushing and flossing techniques and were provided with educational materials, toothbrushes, and toothpaste to enhance both their excitement surrounding oral care and ability to participate in oral care at home. These educational materials also increase parental awareness on the importance and recommended frequency of preventative dental checkups. CCHC services continued to be inclusive of adults and children of all abilities, encourage family involvement in program services, and provide referrals to outside community resources for children’s oral health services when applicable. CCHC services continued to optimize the overall health of children in child care. The capacity for LPHAs to deliver CCHC Program services was severely impacted by the ongoing pandemic.

The Title V/MCH and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) funded home visiting services, managed under DESE-OOC, are offered in 26 counties and served 1,008 families in FY21 through four evidence-based home visiting models:

• Nurse Family Partnership;
• Healthy Families America;
• Parents as Teachers; and
• Early Head Start Home Based Option.

Home Visiting promoted National Children’s Dental Health Month, which is observed annually in February, to all MCH and MIECHV funded home visitors through the Home Visiting Program’s second quarter continuous quality improvement newsletter, Quality Outlook, and in the Weekly Updates on January 15, 2021 and February 5, 2021. Ordering information for oral health resources from the ODH and the MPCA were emailed to all MCH and MIECHV funded home visitors and supervisors, as well as links to materials, webinars, and other resources that highlight the importance of preventive annual dental care for children. The resources were shared ahead of the virtual Title V/MCH and MIECHV specific home visiting summit held on March 10, 2021. Additionally, a presentation on oral sealants was presented by an oral health Public Health Program Specialist during the virtual Title V/MCH and MIECHV specific home visiting summit. Sealant kits from the ODH were mailed to all locally contracted home visiting implementing agencies for distribution to their enrolled families following the presentation. The presentation included the following resources: Oral Health and The Lemony Lion video and a varnish application demonstration available at the following link.

Other Title V Program Activities Related to the Child Health Domain

The Missouri WIC program continued to offer training and support to local agencies and community partners interested in implementing the WIC Developmental Milestones Program. 76 out of 115 local agencies have implemented the WIC Developmental Milestones Program. The early years of a child’s life are very important for his or her health and development. Missouri parents, health care providers, educators, and others can work together to help children grow up to reach their full potential. The WIC Developmental Milestones Program uses a set of age-appropriate developmental checklists starting at 2 months of age to 5 years based on the Centers for Disease Control and Prevention’s (CDC) LTSAE materials to increase parents’ awareness of developmental milestones and to promote the early identification of potential developmental delay. “Talking is Teaching: Talk, Read, Sing” is an expansion of the language component of the WIC Developmental Milestones Program. 18 out of 115 local agencies have implemented this initiative. “Talking is Teaching: Teaching: Talk, Read, Sing” helped parents recognize their ability to improve their children’s early brain and vocabulary development. Efforts by the WIC program to recruit non-participating local agencies and external partners to implement the WIC Developmental Milestones Program continued. Five agencies were recruited in FY21. Training and support was provided to local agencies interested in implementing the program, including the language component. Implementation training developed by the CDC was used to onboard new local agencies enrolling in the program. Resources for “Talking is Teaching: Talk, Read, Sing” and Developmental Milestones, were available through the online order form, and warehouse literature orders were distributed to WIC local agencies. The CDC Amazing Me books were available in English and Spanish for children 1 – 5 years of age.

The DHSS supported participating entities by providing education and promotional items, including printed materials such as the developmental checklists and the Amazing Me books developed by the CDC. These resources were available for WIC agencies as well as internal and external stakeholders as part of providing educational support and promotion of early identification of potential developmental delays. Monthly updates on various child development topics were posted on the Missouri WIC webpage to provide education and support to local agencies. Wichealth.org developed five lessons to educate parents on Developmental Milestones for infants and children at different ages. Local agencies enrolled in the Developmental Milestones program can utilize these lessons to help enhance parent’s understanding of how to use CDC’s milestone checklists. Along with tips and activities to support healthy development, these lessons highlight the important role nutrition plays in achieving their child’s milestones. Local agencies can refer their participants to these lessons for two out of four required nutrition education contacts within a certification period.

WIC Agencies were required to complete the Association of Public Health Nutritionist (ASPHN) “Introduction to Child Development” training for WIC staff. The Missouri WIC Facebook page hosted monthly posts to promote the program to local agencies and the public. Results from a FY21 local agency survey were used to determine current program participation rates, clinic activities, and training needs from participating agencies, as well as gather data on program interest from agencies not currently enrolled. Feedback from agencies not currently enrolled in the program will be used to design future promotional activities. Three out of 16 (18.75%) non-participating agencies reported interests in implementing the program in FY22. Information was collected on activities the agencies utilized before and during the pandemic to screen for developmental delays. One agency stated, “The same parents who want the nutrition counseling and have questions are the ones who enjoy the milestone program the most.” From the survey, the need was identified to reintroduce the ‘Introduction of Child Development Training.’ This training provides counseling staff information on child development in the first 1000 days and then next 1000 days (2 to 5 years of age).

The SHP surveyed all school nurses to evaluate the effectiveness of resources developed for school health personnel. Information from the CDC was identified as the most useful resource, along with: the DHSS/DESE School Reopening and Operating Guidance; online communication from the School Health Program with timely updates/ announcements; LPHA direct communication, information, and partnerships; and the DHSS/ DESE COVID-19 Webinars for Schools and LPHAs. Direct communication, information and the partnerships developed with LPHAs were also appreciated. Additionally, respondents found a number of individuals very helpful in providing COVID-related information for the school, including the District Lead School Nurse, the State School Nurse Consultant, their District Administrator, and LPHA staff.

Increased stress levels was an almost universal theme, with 92.8% of respondents indicating that their stress levels increased during the 2020-2021 school year compared to before the pandemic, and stress continued to increase into the 2021-22 school year. Many school nurses reported working longer days than in the past and the inability to complete many “routine” school nurse duties, primarily providing health education, oral health and hearing screenings, and follow-up related to health screenings.

The survey also identified positive outcomes from the pandemic, such as: developing new partnerships with LPHAs, the District COVID-19 Team and District Administrators; being given the authority to implement new communicable disease guidelines; and the opportunity to assume new roles, e.g., school spokesperson, contact tracer, and decision-maker for school policies. Survey feedback also included a wide spectrum of emotional responses to the pandemic. While some indicated this was an experience to grow from, and that positive aspects were present, the majority indicated feeling anxious, concerned, discouraged, dissatisfied, drained, frustrated, helpless, overwhelmed, or stressed.

*Please interpret with caution.  The width of the 95% confidence interval exceeds 20 percentage points or 1.2 times the percent value.  As a result, the percentage may not be reliable.