NPM 6 - Percent of children, ages 9 through 35 months, receiving a developmental screening using a parent-completed screening tool
Introduction: Developmental Screening
For the Child Health domain, Hawaii selected NPM 6 Developmental Screening as a priority based on the 2015 five-year needs assessment. By July 2020 the state seeks to increase the proportion of children ages 9 through 35 months, receiving a developmental screening, to 40.0%. Aggregated data from 2017 to 2018 show the estimate for Hawaii (36.5%) did not meet the 2019 state objective (39.0%) but was not significantly different from the national estimate of 33.5%. The differences between the 2017-2019 annual indicators were not statistically significant; thus, developmental screening rates remained relatively stable. Based on 2017-2018 data, there were no significant differences among reported subgroups; that is, by health insurance, household income poverty level, nativity, race/ethnicity, sex, and household structure. After reviewing baseline data and consulting with program staff, state objectives for 2020 to 2025 were updated to reflect an annual increase of one percentage point.
Developmental screening is a continuing priority from the 2010 needs assessment for Hawaii’s Title V agency, the Department of Health (DOH) Family Health Services Division (FHSD) which coordinates federal, state, and local efforts on screening, referrals, and services. The DOH Strategic Plan also identifies developmental screening and service referral as a priority area. The developmental screening leads for FHSD are the Children and Youth with Special Health Needs Program (CSHNP) Early Childhood Coordinator and the Early Childhood Comprehensive Systems Impact (ECCS Impact) Grant Coordinator. Title V convenes internal partners through a Developmental Screening Workgroup with representatives from FHSD early childhood programs. Members include representatives from:
- Hi`ilei Hawaii Developmental Screening Program – offers on-line or paper copies of the Ages and Stages Questionnaire:3 (ASQ:3) for families of children birth through five years.
- Home Visiting Services Unit – receives funding from the Maternal, Infant and Early Childhood Home Visiting (MIECHV) grant. Its home visitors work with parents to complete the ASQ.
- Newborn Hearing Screening Program – oversees the Early Hearing Detection and Intervention data system for hearing screening of children birth through age 3.
- Early Intervention Section (Hawaii’s IDEA Part C agency) – provides services and supports for children birth to age three who have a developmental concern.
- Early Childhood Comprehensive Systems Impact (ECCS Impact) Grant – focuses on developmental screening of children birth through five years for Maui County.
- FHSD Programs within the District Health Offices from Hawaii Island, Maui, and Kauai.
There is also broad collaboration with agencies and stakeholders beyond FHSD, working towards the goal of creating a statewide systematic approach to developmental screening. Hawaii works with medical partners, early childhood providers, and community-based non-profits who conduct developmental screening and ensure children are connected to services or supports if a concern is identified. Also, the Executive Office on Early Learning’s Early Childhood State Plan for 2019-2024 identifies screening as a priority in the area of Family Health, Safety, and Wellbeing. Hawaii received a federal Preschool Development Grant Birth through Five (PDG B-5) and developmental screening is included as a strategy in the PDG B-5 Strategic Plan. It is also a priority strategy for the Early Childhood Action Strategy (ECAS), a non-profit public-private partnership, focusing on children’s issues prenatal through age eight.
Nationally, developmental screening is promoted through various grants and guidance documents. HRSA emphasizes partnership with healthcare and early childhood care/education providers through the ECCS Impact Grant, since these two communities promote developmental screening of children for optimal development and school readiness. Guidance from the national American Academy of Pediatrics (AAP) policy statement recommends that children are screened using a validated screening tool at 9, 18, 24 or 30 months. Screening should also be part of the well-child visit per the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines for the Medicaid program. In Hawaii, Medicaid is administered by the State Department of Human Services (DHS) Med-QUEST Division (MQD).
Hawaii’s five developmental screening strategies focus on systems-level approaches, and follow guidance from three sources:
- the federal ECCS Impact Grant,
- HRSA’s Title V “State Technical Assistance Meeting” in March 2016, and
- the National MCH Evidence Center.
The five strategies are:
- build systems and infrastructure,
- implement family engagement and public awareness activities,
- ensure data collection and integration,
- address social determinants of health and vulnerable populations, and
- assess policy and public health coordination.
The last strategy is assessed via a Policy and Public Health Coordination Scale (PPHC) designed to monitor implementation of the systems-level approaches and is used as the NPM 6 strategy measure (ESM 6.2).
The HRSA ECCS Impact best practices promote working with early childhood providers to ensure that screenings are done as part of their assessment of children’s development. This approach is also reflected in the National Association for the Education of Young Children (NAEYC) Accreditation Standards, as well as the Head Start Performance Standards for childcare providers. The National Institute of Early Education Research also includes “Screenings, Referrals and Support Services” as one of their quality benchmarks for early education programs. Hawaii works with all programs to ensure strongest evidence and implementation of its strategies.
Research provided by AMCHP and the MCH Evidence Center were reviewed to identify additional evidence for Hawaii’s strategies. Findings indicate support for training of health care providers on developmental screening, and screening through home visiting programs, although further evidence is needed. Following these promising practices, Hawaii provides community-based trainings on the ASQ:3 to both healthcare and early childhood providers. Although quality improvements in both healthcare settings and systems-level approaches were found, Hawaii’s Title V agency does not have direct control over healthcare settings and therefore chose a systems approach to continue quality improvement practices.
FHSD, as the state Title V program, serves as a convener and coordinator for strategy implementation. Title V does not directly fund program supports for the development screening strategies. The activities and efforts are largely funded by the federal ECCS Impact grant which provides an ECCS Impact Coordinator who oversees developmental screening activities in Maui County and provides funding for Maui County and statewide screening activities. Title V-funded staff provide overall management, data and epidemiological support, and administrative support for the NPM. Updates on the five strategies are provided below.
Strategy 1: Systems Development – Develop infrastructure to coordinate developmental screening efforts.
The activities for this strategy focus on developing guidelines and a toolkit to standardize organizational practices for screening and referral for those needing services. The strategy also includes working with partners to develop infrastructure for training and technical assistance for service providers. Hawaii has strong partnerships with a variety of early childhood and healthcare providers. While DOH does not have direct control over the healthcare system, childcare and early childhood partners can implement strategies and training directly without having to work through insurance companies for reimbursement. Hawaii continues to work with both the healthcare and early childhood community since both are necessary for optimal health and development of children.
Guidelines on Screening and Referral
In 2018, the Hawaii Title V agency worked with partners to complete the “Hawaii Developmental Screening and Referral Guidelines for Early Childhood and Community Based Providers.” The guidelines continue to be used statewide to promote screening efforts. The purpose of the guidelines is to provide basic information for those conducting developmental screening of children ages birth through five years of age. They are based on the following national resources:
- AAP Policy Statement of Developmental Surveillance and Screening Guidelines;
- The Centers for Disease Control and Prevention (CDC) Act Early Campaign;
- Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents;
- Caring for Our Children national standards for early care and education settings developed by the National Resource Center for Health and Safety in Child Care and Early Education (NRC);
- Head Start Performance Standards; and
- NAEYC standards.
The guidelines also include local best practices and were vetted with early childhood and medical providers and other key stakeholders. The Maui ECCS Impact Community team, which serves as advisors to the grant, used these guidelines to ensure screening and referrals are provided to children and families in Maui County. This document can be found on the Department of Health website: https://health.hawaii.gov/cshcn/hiileihawaii/
Workforce Training: Conduct Community-Based Training on Developmental Screening
The ECCS Impact grant supported five family service providers to receive a training-of-trainers on the use and implementation of the ASQ:3 and Ages and Stages Social Emotional Questionnaire 2 (ASQ-SE2). The team subsequently provided training to over 200 Maui providers on the screening tools and general child development concepts. In addition, seven Maui programs have established or updated their developmental screening practices. Because these trainers belong to long-standing community agencies, they serve as a stable training resource for the entire county. One of the trainers also works for the state’s largest childcare resource and referral agency that trains home visitors and childcare providers statewide; therefore, training will be available on all islands. Title V also works with Hawaii’s CDC Act Early Ambassador who is providing training on developmental screening to healthcare providers. In September 2019, he conducted a training for family and childcare providers statewide on developmental screening and child development. Title V continues this collaboration and other partnerships to promote training to both healthcare and early childhood providers.
Strategy 2: Family Engagement & Public Awareness
The activities for this strategy focus on engagement with families to promote understanding of the importance of developmental screening and child development.
Work with Family Partner Organizations
Hawaii’s CSHNB Early Childhood Coordinator works closely with the Family Hui Hawaii who conducts parent support groups. The Hui regularly conducts developmental screening with families both in their program and at community events. The Hui has been instrumental in assisting with the development of family-friendly messages to promote the importance of developmental screening. On Maui, the ECCS Impact Coordinator worked with the Family Hui to create Child Activity Kits that encourage family engagement to promote children’s development. These kits include activities that complement ASQ screenings and promote children’s development along five domains: gross motor, fine motor, communication, personal-social, and problem solving. The kits are intended to be distributed through partner programs represented on the Maui ECCS Impact Community team to use and evaluate with their families.
Website to House Screening Documents
Hawaii works with the Early Childhood Action Strategy (ECAS) which is a public-private collaborative that works across sectors to increase the number of young children in Hawaii who are born healthy, develop on track, are ready for school when they enter kindergarten, and are proficient learners by third grade. The CSHNB Early Childhood Coordinator leads the ECAS On-Track Health and Development Team. Documents on screening are housed on the ECAS website which provides access to all seeking information about child development (https://hawaiiactionstrategy.org/). Additionally the DOH CSHNB website houses information about developmental screening on its website that is accessible to the public: https://health.hawaii.gov/cshcn/aboutus/.
Strategy 3: Data Collection and Integration
The activities for this strategy focus on analyzing and reviewing data to identify high-risk populations and communities.
Reviewing/Developing Data Sources
Finding population-based data sources that effectively track developmental screening rates is challenging. Many available sources focus on screenings conducted by healthcare providers. Yet, healthcare providers do not always conduct the screenings during short office visits, nor do all children have medical homes. Thus, it is important to collaborate with all of Hawaii’s early childhood service providers to assure a comprehensive system for development screening.
Hawaii’s Title V works with the DHS MQD to access screening data extracted from EPSDT Claims forms. MQD also reports these data to the Centers for Medicare and Medicaid Services annually, via its “Form CMS-416: Annual EPSDT Participation Report.” The database tracks the number of individuals eligible for EPSDT, the expected number of screenings, the total screens conducted, and the number receiving services or treatment as a result of screening. Unfortunately, the EPSDT dataset has a major limitation in that the data track healthcare visits and use that indicator as a proxy for actual screenings.
Similar limitations exist with the National Survey on Children’s Health (NSCH) data used for NPM 6 which asks parents about screenings which occur in a healthcare provider office. As discussed above, developmental screens also occur in other service settings which are not reflected in the NPM data. Thus, Title V focuses on collecting additional data from its programs such as FHSD early childhood services and the ECCS Impact grant in Maui County.
Develop Internal Family Health Services Division (FHSD) Tracking System
A data system was created among four of FHSD’s early childhood service programs: MIECHV, Early Childhood Comprehensive System Impact Grant focusing on Maui County, Hi’ilei, and Early Intervention. Data from the MIECHV Home Visiting program for 2018 showed that of the 767 children enrolled in the program, 79% of children were screened for developmental delay. Hawaii’s home visiting program screens at 9, 18, 24 and/or 30 months, following guidance from the national AAP.
Hawaii’s Hi‛ilei Developmental Screening Program provides parents and caregivers an option of completing an online screening or completing a paper copy of the developmental screener that is mailed to them. Hi‛ilei data from 10/1/2018 through 9/30/2019 show that 27 children birth through five years were screened. Most of the families who use Hi‛ilei are from Oahu, where the majority of the state population is located and where most outreach efforts are conducted.
Hawaii’s ECCS Impact grant collects developmental screening data from two major childcare providers serving Maui County. Over the past year, roughly 118 three-year-old children have been screened by two primary agencies (an Early Head Start program and a Family Child Interaction Learning Program). The ECCS Impact Coordinator hosts bi-monthly community meetings to discuss the data from the ECCS project including the number of children screened from within the referral range, and number referred and connected to services. The statewide team meets annually to discuss ECCS and Medicaid EPSDT data. The Title V Workgroup will be convened to share these data and discuss enhancements and community supports that can promote developmental screening and referrals in the community.
Referrals to Early Intervention (EI) come from various sources, and FFY 2018 data (7/1/2018 – 6/30/2019) show that 3,416 children were referred, with 57% of referrals coming from Primary Care Providers, 20% from parents, 10% from other healthcare providers, 2% from social services, and 2% from child welfare. Of the 2,622 children evaluated, 2,220 (85%) were found eligible for EI services.
Develop Process for Communicating Data Story
Developing a data system for FHSD and the state around screenings and referrals was hindered by the different time frames in which data are collected, and the different ages at which children are screened. While the NPM focuses on capturing data on developmental screening only, the Hawaii team feels it is more important to follow what happens to the children who are identified with a developmental concern so that children receive necessary supports and services to promote their optimal development.
Strategy 4: Social Determinants of Health
The activities for this strategy focus on working with partners to identify vulnerable populations who would most benefit from developmental screening.
Develop Process for Identifying Vulnerable Populations
As part of the work with the Preschool Development Grant Birth through Five, Hawaii underwent a process for identifying vulnerable populations throughout the state. The strategic planning process included a needs assessment that identified communities where access to health care and information about child development was most needed. According to the assessment, rural communities statewide and neighbor islands faced the greatest needs, since medical and specialty services are concentrated in urban Honolulu. FHSD Neighbor Island Coordinators also share information on emerging needs in their communities at the CSHNB Children and Youth with Special Health Needs Program Staff meeting. Substantial information on vulnerable populations are shared through this venue.
Work with Stakeholders to Address Supports for Vulnerable Populations
Hawaii has a growing homeless problem and recognizes that children who are living in homelessness may be more susceptible to developmental delays. One of the state’s largest emergency shelters, the Institute for Human Services (IHS), provides short-term stabilization through shelters that lead to permanent housing. The CSHNB Early Childhood Coordinator works with the IHS Program Director to address the challenges faced by children and families whose main concerns are finding stable housing, adequate employment income, and other concrete needs. The CSHNB EC Coordinator, as part of the Early Childhood Action Strategy, is working with IHS to track the developmental screening of children and referrals to services.
Strategy 5: Policy and Public Health Coordination
The purpose of this strategy is to track infrastructure development within Family Health Services Division’s efforts to improve developmental screening rates of children.
ESM 6.2 Policy and Public Health Coordination Scale
To track and monitor progress on Title V efforts to improve developmental screening rates of children, Hawaii developed and uses a Policy and Public Health Coordination Scale (PPHC, see below). The scale reflects the activities in the NPM 6 logic model and workplan and includes Systems Development, Family Engagement and Messaging, Data Collection/Integration, Addressing Social Determinants, and Policy & Public Health Coordination. The scale ensures there is a mechanism to monitor and track activities in the first four strategy areas. Since ESM 6.1 was largely completed, the PPHC scale was adopted as a new ESM 6.2 in last year’s report. Completion of the scale is self-reported by the EC Coordinator who oversees all the activities.
The total possible points for the scale are 30. The FY 2019 indicator was 23 and met the annual objective set at 12. Progress was made in systems development, family engagement, and addressing vulnerable populations. The rating scale is used by the EC Coordinator to track progress on the NPM 6 strategies even prior to its formal adoption as an ESM last year. Scores show steady improvement since FY 2017 when the score was 9.
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0 Not Met |
1 Partially Met |
2 Mostly Met |
3 Completely Met |
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Systems Development |
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x |
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x |
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Family Engagement and Public Awareness |
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x |
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x |
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Data Collection and Integration |
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x |
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x |
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Social Determinants of Health and Vulnerable Populations |
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x |
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x |
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Policy and Public Health Coordination |
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x |
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x |
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Total Score |
23 out of 30 |
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The Evidence Center partnered with the MCH Workforce Center to conduct a remote training for the Title V Leadership Team on Results-Based Accountability to help strengthen Hawaii’s ESMs. Targeted technical assistance was provided by both organizations on NPM 6 and its new ESM. The Title V agency continues work to strengthen its ESMs by shifting from process to outcome impacts/measurements when possible. Hawaii acknowledges that the PPHC rating scale is subjective and may be difficult to implement elsewhere, given each state’s unique strategies and activities. However, the scale addresses all the components of Hawaii’s system approach and serves as a useful quality improvement measure, a practice which is cited as having moderate evidence by the MCH Evidence Center.
Current Year Highlights for FY 2020 through April 2020
This section provides highlights of current developmental screening activities for FY 2020, including initial impacts and changes from the early days of the COVID-19 pandemic in Hawaii.
Hawaii continued to work with the ECCS Impact grant and other partners, with meetings conducted virtually. Access to online developmental screening through Hi‛ilei has become even more vital. With telemedicine services becoming the new normal for doctors’ visits, there is concern that parents will not be taking their young children to the doctor for the immunizations and developmental screening normally conducted during well-child visits. For children younger than two, it is critical that they receive their immunizations as well as the 18- or 24-month screens per the AAP and CDC COVID guidance. Hawaii will find avenues to assess this challenge given the extended period of the COVID-19 pandemic and as a result, the Governor’s Stay-at-Home Orders.
Plans for FY 2020 started positive, with the new ECCS Impact Coordinator fully prepared to expand grant activities having been in the position for a year. Connecting Maui pediatricians to the CDC Act Early Ambassador started in FY 2019, and there were plans for more concerted efforts and joint opportunities to occur in the spring.
Title V’s CSHNB met with the Hawaii Project Extension for Community Healthcare Outcomes (ECHO) which is a medical education/mentoring model using telehealth that builds primary care capacity while improving access to specialty health care in rural communities. The Title V Rural Health program coordinator serves on the ECHO steering committee. Early in FY 2020, the Title V CSHNB worked with Project ECHO to plan a training series on newborn metabolic screening, developmental screening, and Early Intervention Services. A survey was sent to medical providers and these topics generated the most interest. The CDC Act Early Ambassador was scheduled to conduct the developmental screening webinar, with information about referral sources provided by the CSHNB EC Coordinator. The second webinar was going to focus on the Title V Early Intervention program which provides services to children identified by the screening. Because of the COVID-19 outbreak, however, the CSHNB series was postponed and replaced by more timely topics on telemedicine, trauma-informed care, and self-care. Hawaii will conduct the originally planned trainings starting in June.
Before the COVID pandemic, the ECCS Impact Coordinator began working with the Maui WIC office to conduct developmental screenings using the ASQ in WIC waiting rooms. This pilot effort utilized Public Health Nurses, highlighting Maui’s collaborative strengths. Because the pilot program was interrupted by the COVID closure of WIC offices, only preliminary data were collected: 55 children were screened, and four children were identified as needing monitoring and connected to services.
The EC Action Strategy Team focusing on children’s health planned to work with IHS homeless families and children to track and monitor developmental screening and referrals. Because of COVID-19 prevention and control practices, the project has been postponed. Head Start Programs that provide learning opportunities and developmental screening to children in the homeless shelter have also closed. The Team is reassessing how to support virtual developmental screening for families in the shelter.
Hawaii had also begun discussing the use of the Survey of Well-being of Young Children (SWYC) as a developmental screening tool with healthcare and early childhood providers, since it was recently added to the national AAP validated screening tools list. The CSHNB Chief and EC Coordinator reached out to AAP Hawaii and the State Med-QUEST Medical Director to discuss use of the tool. Training on the tool would need to be developed, and referral sources would have to be compiled, for this tool to become effective as an option. Because the SWYC is a free tool and covers behavioral and family wellbeing (social determinants of health), in addition to developmental screening, referrals may be broader than IDEA Part C (EI services) and B programs (Department of Education services). Hawaii will continue to work with partners to see if this is a viable tool, especially with the severe economic impacts on families due to COVID-19 that may create greater stresses on a family’s ability to afford food, housing, healthcare, and childcare.
Because of the mandatory restrictions on physical distancing, many programs which conduct home visits suspended in-person visits, including the Early Intervention Section (EIS). While referrals are still accepted, EIS cannot conduct in-person visits for multi-disciplinary evaluations. EIS modified eligibility guidelines to temporarily include “presumed eligibility” so a child may receive EI services until eligibility can be determined. EIS evaluators will use information submitted with referrals, including any developmental screening results or developmental information, in determining whether a child is “presumed eligible.” When ASQ screening results submitted with referrals fall in the “referral range,” the child will be presumed eligible for EI services. Children who are not “presumed eligible” will be referred to the Hi‛ilei Developmental Screening Program.
Review of Action Plan
A logic model for Title V NPM 6 was modified based on the ECCS Impact Grant to include Title V measures (NPM, ESM, NOM). Strategies were developed with consideration of community, statewide, and national efforts. Strategies included input from partners and additional feedback from families and providers solicited at conferences and community events. The major strategies for the work plan revolve around the areas of Systems Development, Family Engagement and Public Awareness, Data Collection and Integration, Social Determinants of Health, and Policy and Public Health Coordination.
By working on these five strategies, Hawaii plans to meet its NPM of increasing the number of children receiving a developmental screening using a parent-completed screening tool by addressing systemic challenges, working with families to promote understanding of the importance of completing the screening tool, using data to address areas of concern, and working on policy and public health coordination. By addressing all areas of the logic model and rating scale, there will be consistent information and guidance to providers. Hawaii will also address social determinants of health to focus efforts on communities of greatest need. Hawaii continues to use this logic model to guide its work on strategies and activities.
Challenges Encountered
Challenges remain in the areas of data, policy, and messaging.
Data: There is no unified data collection system on developmental screenings to monitor children who are screened, referred, and receiving service in the state. Other states have similar challenges because no one data system collects developmental screening and referral efforts. Because of this, efforts to target communities and populations of greatest need are hampered. Medicaid CMS-416 Claims Data provide basic information on participation and service utilization for the Medicaid child health program for low income families. Approximately 40% of Hawaii’s children are insured through Medicaid. Generating screening data for this population would be invaluable to develop effective strategies. Currently, EPSDT data use is limited because the data track healthcare visits, and not actual screenings. Hawaii will collaborate with Med-QUEST (Medicaid agency) and the state Medicaid Ombudsperson to explore other data sources, as well as other quality assurance measures such as Pay for Performance, so Medicaid and other insurance plans can acquire better screening data.
Policy Implementation: There are national policies on developmental screening from both the medical and early childhood community. As part of the Bright Futures Guidelines, developmental screening should be part of the well-child visit. The AAP recommends developmental screening at 9, 18, 24, or 30 months, as well as annual screenings after age 3. The pediatrician or primary care physician’s office is where most children younger than age five are seen on a regular and consistent basis and should be the place where developmental and behavioral problems are identified. However, not all providers follow the national recommendations. Also, parents expect their pediatricians to give them guidance on developmental issues but may turn to other community systems (childcare providers, home visitors, community non-profits, family members) if the pediatrician does not fill this role. Lack of appropriate guidance and referrals may result in delays in diagnosis and appropriate intervention. Over-screening by different community systems may also lead to confusion if one provider says a child may have a delay, and another provider says the child is fine. Oftentimes, providers use a “wait-and-see” approach if a child misses a major milestone, while others will rescreen if there is a concern. Otherwise, a child will be screened at the next interval if they are in an early childhood program or at the next doctors visit. Both parents and providers need to understand the importance of recognizing delays early, since early intervention may improve outcomes for children.
Public Awareness and Messaging on Importance of Developmental Screening: There is still a general lack of awareness about the importance of developmental screening. Messaging around developmental screening emphasizes the need to identify children who have a developmental delay. However, consumers need more information to understand what screening involves, the purpose, and how it helps support child development. Hawaii continues to work with family groups to address this issue. Because of COVID-19, many screening opportunities are not currently available (i.e. early learning environments, in-person home visits and early intervention services). It is even more imperative that families have their children screened to ensure there is progress toward meeting developmental milestones and identifying concerns as soon as possible.
Overall Impact
Hawaii has many engaged partners willing to promote developmental screening and who recognize the importance of timely access to services and supports if a delay is identified. Both the DOH Strategic Plan and the Executive Office on Early Learning’s Early Childhood State Plan and Strategic Plan identified developmental screening as a key priority. By working together to address this issue, providers and partners are now more aware of the importance of developmental screening using a validated screening tool, ensuring needed referrals are timely, and communication with the medical home. More work can be done to promote a more seamless system of screening and referral.
More effort is also needed to reduce the stigma that may prevent families from seeking follow-up services for their child. Normalizing the conversation and making screenings part of a well-child visit or a routine early childhood practice helps to ensure screenings and follow-up occur. Partnerships with the AAP-Hawaii Chapter and Medicaid also help to share consistent information about screenings and referrals, including the availability of the online ASQ through the Hi`ilei program. These partnerships help make a greater impact in Hawaii. With more promotion of accessible tools for families, an increase in the number of children receiving a standardized screening is anticipated.
Hawaii still shows a relatively high rate of developmental screening, with 39.1% of parents reporting completion of a developmental screening tool, as compared to the national rate of 31.1%. Efforts by programs like MIECHV and many other early childhood programs who conduct developmental screenings help contribute to this high percentage. However, this still leaves most of Hawaii’s children who are not receiving developmental screenings, and better outreach could be done to promote its importance. Working with early childhood providers, efforts will continue to promote developmental screening and sharing of information with the medical home.
NPM 13.2 - Percent of children, ages 1 through 17, who had a preventive dental visit in the past year.
Introduction: Child Oral Health
For the Child Health domain, Hawaii selected NPM 13.2 (children’s oral health), based on the 2015 five-year needs assessment. Aggregated data from 2017-2018 show that the estimate for Hawaii (85.6%) met the 2019 state objective (85.0%), and was higher than the national estimate of 79.7% for preventive dental visits among children. With this baseline data, the state objectives through 2025 reflect an approximate 5% improvement over 5 years. Children 1-5 years of age had a lower visit estimate (72.3%) compared to children 6-11 years of age (92.0%) and 12-17 years of age (91.8%). There were no other significant differences in reported subgroups by household income, poverty level, language spoken at home, nativity, race/ethnicity, sex, and household structure based on the 2017-2018 data provided.
The related Healthy People 2020 for this measure is: increase the proportion of children, adolescents, and adults who used the oral health care system in the past year to 49%. Hawaii far exceeds this target for children.
Although data from national surveys indicate Hawaii’s rates of oral health status and service utilization are similar or better than the rest of the U.S., clinical data reveal a very different story. A 2015 oral health Basic Screening Survey (BSS) revealed Hawaii’s third graders have the highest rate of caries in the U.S. and some of the highest rates of urgent care needs. Within this group key disparities exist. Children who are low-income, have Medicaid coverage, and/or are Native Hawaiian or Pacific Islander suffered disproportionately throughout the state. A BSS of children enrolled in the Hawaii Head Start program reveals similar findings for young children from low income families.
A major contributor to the problem of dental disease is the lack of community water fluoridation. In the U.S., Hawaii has the lowest proportion of residents with access to fluoridated drinking water, at 11.3% according to the Centers for Disease Control and Prevention (CDC). In Hawaii, only federal military installations have fluoridated water sources. Fluoridation efforts continue to generate substantial community opposition. In addition, all the county water supply agencies strongly oppose fluoridation due to the additional operational costs and burden.
Workforce issues also contribute to Hawaii’s poor dental rates. Despite Hawaii’s favorable ratio of dentists to residents, most of the State’s primary and specialty care providers are located on the island of Oahu (Honolulu County). Like many states, Hawaii also has a shortage of providers willing to treat Medicaid clients. The situation is particularly acute on the neighbor islands and in low income areas of Oahu. Moreover, Hawaii does not have a school of dentistry. Only programs for dental hygienists and dental assistants are available in state.
The critical nature of Hawaii’s oral health is reflected in the five consecutive “F” grades received by the Pew Charitable Trusts’ state report cards for children’s oral health. While not funded, the Hawaii State Department of Health (DOH) does have statutory responsibility for assessing dental needs and resources, planning and providing services, conducting education and training, and applying for federal funding for oral health infrastructure/services.
In 2013, the DOH received a five-year CDC oral health infrastructure-building grant which ended in August 2018. Hawaii submitted a new application for CDC funding in 2018. Although the application was approved, the grant was not awarded due to insufficient funds. Family Health Services Division (FHSD), the Title V agency, is the DOH lead for oral health population-based activities and administered the CDC grant. With the end of the CDC grant, staffing was lost and population-based services largely ended.
When needed, Title V partners with the DOH Developmental Disabilities Division (DDD) dental staff which operates several dental clinics on Oahu serving primarily adults with disabilities and other special needs.
Due to the loss of program staff and funding, strategies were revised to reflect Title V’s reduced resources and activities.
Strategy 1: Program Development Explore & pursue options to staff State Oral Health Program
The importance of dental program leadership and staffing is critical to sustain any program activity. With no local health departments or dental school, the State Oral Health Program (SOHP) is key in providing statewide leadership for public health surveillance, evaluation, and planning functions. In addition, given the state’s unique diversity in ethnicity, language and cultural practices, many best practices may not translate to Hawaii. The SOHP plays an important role to promote and adapt evidence-based oral health practices in both public and private settings by supporting workforce training, policy guidance, and research.
With the end of the five-year CDC oral health infrastructure grant in August 2018, FHSD lost SOHP staff including a half-time Dental Director and Office Assistant and a full-time Program Manager. The FHSD Division Chief now serves as the state dental contact but program activities have largely ceased.
In 2019 a budget funding request to support the SOHP staffing and operations was not included in the Governor’s budget proposal. Title V continued to explore other funding options to support oral health activities.
Strategy 2: Surveillance-Maintain oral health surveillance activities
Following the state oral health surveillance plan, DOH continues to collect oral health data through surveillance surveys including PRAMS and YRBS. The oral health data is available on the DOH data warehouse website, Hawaii Health Matters. Data activities were limited in 2019 with vacancies in FHSD’s two epidemiologists positions.
Partnering with the DOH Office of Planning, Policy and Program Development (OPPPD) epidemiologist, FHSD analyzed and distributed state hospital and emergency department data for dental-related utilization. The information was shared with the Hawaii Oral Health Coalition.
An MCH Bureau Graduate Epidemiology intern published an article in the Hawaii Journal of Health that analyzed YRBS dental visits data. Disparities in dental care utilization were confirmed among Hawaii public high and middle school students based on age, race/ethnicity and number of risk behaviors:
- students older than 14 years of age were less likely to visit the dentist compared to students who were 14 years of age or younger,
- Pacific Islander, Native Hawaiian, Hispanic/Latino, Filipino students and those who did not identify as a single race/ethnicity were more likely than whites to visit the dentist,
- Students having four or ≥ five risk behaviors were associated with lower likelihood of dentist visits compared to those with no risk behaviors.
Strategy 3: Partnership/Coalition-Building-Support ongoing partnerships and coalition-building activities
The CDC oral health grant required the SOHP to build partnerships throughout all its project work and focus on coalition building. Partnerships allowed Hawaii to leverage limited resources to support public health activities.
Substantial progress was made in 2019 to establish a formal organizational structure for the Hawaii Oral Health Coalition (HOHC) with by-laws, elected officers and defined membership categories. Previously, the coalition operated as an informal network of dedicated stakeholders. Coalition activities included:
- Oral health community leaders met to formally adopt the HOHC mission, vision, values, and operating structure/guidelines. The HOHC is organized around seven standing committees that continued to work on establishing priorities.
- Officers was elected and interim leadership for each committee was confirmed.
- Advocacy priorities for 2020 were approved and a statewide collaborative communication network established.
- A website established at www.hawaiioralhealthcoalition.org.
- The Hawaii Public Health Institute (HPHI) and the Hawaii Children’s Action Network (HCAN) received grants to support/staff the HOHC. Funders included the DentaQuest Foundation, the Hawaii Community Foundation, AlohaCare (Hawaii Medicaid health insurer) and the DOH Family Health Services Division. HPHI was confirmed as the HOHC fiscal agent.
- The HOHC oral health network extended to over 300 individuals statewide. Development of an online membership management system was explored by the HOHC membership committee.
A new ESM was created for FY 2020 focusing on the state coalition work. ESM 13.2.3 is the number of organizations and individuals participating in State Oral Health Coalition meetings and activities. Although the formal membership enrollment registration system was not established in FY 2019 there were 64 participants in the meetings that helped establish the HOHC organizational structure a slight increase over the previous year’s meeting participants.
Other partnership activities included the pilot teledentistry programs on Hawaii island and Maui. The DOH dental director for the Developmental Disabilities Division is providing technical assistance for the project. The site at the West Hawaii Community Health Center is in its fourth year providing services to young children at Head Start, WIC, a traveling preschool and a homeless transitional housing complex. The pilot has seen over 1,000 children and is now in discussions with the Department of Education to expand the program to public elementary schools in their service area.
A second teledentistry pilot project on Maui is partnering with the Native Hawaiian Health Center to serve young children at Head Start and WIC as well as a senior assisted living facility. The project also includes an oral health professional educational component in collaboration with the Maui Community College Dental Hygiene School. The VDH project is a promising practice in the AMCHP Innovation station.
Current Year Highlights for FY 2020 through April 2020
Here are some highlights of current oral health activities for FY 2020 including early impacts & changes from the COVID pandemic in Hawaii.
- In FY 2020, FQHCs continued to provide dental services and provide reimbursement for telehealth dental visits and application of silver diamine fluoride.
- Hawaii Title V continued its support of the HOHC, providing funding to HIPHI.
- During the 2020 legislative session the HOHC advocated for the reinstatement of Hawaii adult Medicaid dental benefits. Passage appeared promising based on cost estimates from the state Medicaid program. Unfortunately, with the COVID-19 pandemic, the Legislative session was suspended and the legislation died.
- The HOHC established a membership management system which was rolled out as just before the start of the COVID-19 pandemic. The Coalition plans to actively campaign for official enrollment for network members later in the year.
- HOHC leadership have routinely met to respond to COVID-19 concerns in the dental community during this crisis including sharing safety/infection control guidelines initially for emergency and, as of June, regular dental visits. The Coalition identified sources to secure personal protective equipment and encouraged purchasing partnerships among dental professionals.
- The 2020 Title V needs assessment did not select oral health for children as a continuing Title V priority due to the lack of available funding and resources.
The logic model was updated, reducing the number of strategies to reflect decreased public health activity since Hawaii Title V no longer has staffing or funds for program operations. However, the logic model resources were expanded to reflect the partners in the State Oral Health Coalition activities. Oral health data sources critical for ongoing surveillance efforts were also detailed to reflect the infrastructure services supported by Hawaii Title V.
Overall Impact
The CDC oral health grant supported program activities to rebuild the SOHP infrastructure capacity lost in the 2009 recession including: leadership, data surveillance, partnership and coalition-building as well as assessment and planning. The grant’s accomplishments helped elevate dental disease as an important public health issue and build community capacity to support ongoing oral health work through the state Coalition. The Coalition will continue to convene and coordinate the state’s dedicated oral health stakeholders, community-based programs, and strong advocacy agenda.
Challenges, Barriers
The primary barrier to progress will again be securing sustainable funding for SOHP staffing and operations. While FHSD continues to explore funding options to help support ongoing public health functions little program activity is possible without resources.
SPM 4: Rate of confirmed child abuse and neglect cases per 1,000 children aged 0 to 5 years.
Introduction: Child Abuse and Neglect in Hawaii
The 2015 needs assessment confirmed that Child Abuse and Neglect (CAN) prevention should continue as a priority under the Child Domain. Child maltreatment stands as a foremost concern in the state. Community needs span the spectrum from primary prevention services to support families as well as improvements to the Child Welfare Service system to prevent children entering foster care.
Originally, Hawaii aligned this 2015 priority with NPM 7, which addresses hospital-related injuries. However, the benchmark was too broad to measure progress for CAN prevention. In 2018 under the current Title V grant guidance, Hawaii elected to establish CAN prevention as a SPM using confirmed cases as the measure.
The objective for SPM 4 was set: by July 2020 the state seeks to reduce the rate of confirmed CAN cases per 1,000 children aged 0 to 5 years to 5.8. The FY 2019 indicator is 5.5 and met the 2019 objective of 5.8. Objectives for 2020-2025 were updated. Objectives are set at 5% improvement over 5 years.
While death due to the abuse of a child is an infrequent event, there were still 1,296 unique confirmed child abuse victims in 2018 in Hawaii (latest available data). By maltreatment type:
- 54% of victims experienced neglect or medical neglect,
- 10% suffered psychological abuse,
- 31% were threatened with harm,
- 19% experienced physical, and
- 34% were sexually abused.
- 30% sex trafficking
(Hawaii Department of Human Services, Child Abuse and Neglect in Hawaii, 2018, https://humanservices.hawaii.gov/wp-content/uploads/2018/06/2017-CAN-report-print.pdf).
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Note: A child may have more than one maltreatment type and may have been reported more than once during the one-year period, but the same maltreatment is counted only once. Sex trafficking was added in 2018. |
Confirmed abuse or neglect was essentially the same for males (637) and females (639).
The Title V Child Abuse and Neglect Program (CANP) is administratively located in the Maternal and Child Health Branch (MCHB) Family Support and Violence Prevention Section (FSVPS). This Section is made up of the sexual violence, domestic violence prevention, parenting support programs, as well as the Maternal Infant and Early Childhood Home Visiting (MIECHV) program. The CANP is funded by the Administration for Children and Families (ACF), under a Community-Based Child Abuse Prevention (CBCAP) grant. While Title V does not directly fund CAN prevention activities, it does fund key staff related to the program including the FSVPS Section supervisor and other MCH Branch support staff such as the Branch research statistician.
Child abuse and neglect are complex problems rooted in unhealthy relationships and environments. Preventing CAN requires addressing factors at the individual, relational, community, and societal levels. Hawaii’s four CAN prevention strategies reflect a broader public health systems approach, specifically to:
- Collaborate on and integrate child wellness and family strengthening activities across programs.
- Develop a child abuse and neglect surveillance system.
- Raise awareness about the importance of safe and nurturing relationships to prevent child abuse and neglect.
- Provide community-based training and technical assistance promoting safe, healthy, and respectful relationships to prevent child abuse and neglect.
While CAN Prevention is not a Title V NPM, research presented by the MCH Evidence Center from the Child Safety Network supports Hawaii’s cross-cutting strategies that leverage partnerships to support evidence based/informed programs and practices.
Strategies and activities to address the SPM 4 objectives are discussed below.
Strategy 1: Collaborate on and integrate child wellness and family strengthening activities among programs.
The complexity of risk factors relevant to prevent and reduce CAN requires collaboration with diverse private and public organizations in the community, including those that directly engage in CAN work, as well as agencies addressing broader community concerns (e.g., housing, employment, safe neighborhoods, substance use, etc.). Key collaborations are described below.
Under the guidance of the ACF Children’s Bureau, the CANP Coordinator, Hawaii Family Court judges, Judiciary and DHS staff came together to serve as the State Team to develop the 2020-2024 Child and Family Service Plan (CFSP). The CFSP is a five-year strategic plan that sets the State’s vision and goals to strengthen the child welfare system. It outlines initiatives and activities to administer and integrate programs and services that promote the safety, permanency, and well-being of children and families. The State Team completed a revised vision and year one goals for collaboration. The Plan is a requirement for Hawaii Department of Human Services (DHS) to receive federal Title IV-B child welfare services funding for the State.
The Family Strengthening and Violence Prevention Section (FSVPS) programs collaborate to address similar preventive factors and shared systems resources. The FSVPS programs often share funding, resources and data, and coordinate training and technical assistance (TA) opportunities. These prevention programs help to create a foundation for healthy relationships among parents and future young adults.
The Sexual Violence Prevention Program’s primary prevention included: sexual violence-related trainings, TA, and outreach targeting middle and high school-aged students, statewide community action teams; University staff and students; public and private agencies. Trainings on health/respectful relationships for high school football coaches was conducted to help mentor young athletes.
The Domestic Violence Prevention Program activities included: support for the Domestic Violence Fatality Review (DVFR) statewide team to develop findings/recommendation to prevent family/inter-personal violence; conduct DV trainings and outreach and implement systems changes in partnership with public and private agencies. Educational topics include teen dating violence, connecting the dots of violence, and promoting healthy relationships.
Home visiting supports pregnant moms and new parents to promote infant and child health, foster educational development and school readiness, and help prevent CAN. Federal MIECHV funds are used to support the Hawaii Home Visiting Program (HHVP) providing voluntary, evidence-based home visiting services to at-risk pregnant women and parents with young children. Home visiting services are provided statewide using the evidence-based programs – Healthy Families America, Parents as Teachers, and Home Instruction for Parents of Preschool Youngsters. In fiscal year 2018-2019, the seven home visiting programs in Hawaii provided direct preventive services to 718 parents and 692 children including 71 families who had at least one child with a disability. MIECHV also partners with Title V early childhood and perinatal programs to promote family/child wellness.
The MCHB Parenting Support Program (PSP) administers family strengthening contracts for parenting and child development services statewide. Services include The Parent Line (http://www.theparentline.org/), a telephone warm-line for parents, information dissemination on child development and community resources; short term in-home parenting support, and parent-child interactive education groups for homeless families. The contracts provide access to CANP resources and services to families. The PSP also supports activities conducted by the Keiki Injury Prevention Coalition (KIPC) and Safe Sleep Hawaii (SSH). KIPC is a collaboration of over 150 organizations and agencies committed to preventing injuries. SSH provides statewide leadership in preventing infant deaths by providing education on Safe Sleep Practices following American Academy of Pediatrics (AAP) guidelines.
Title V programs collaborated with community partners to sponsor a Toxic Stress/Resilience and Trauma Informed Care Conference. The purpose of the conference was to increase knowledge about the neurobiology of toxic stress, Adverse Childhood Experiences (ACES), and transgenerational/historical trauma impacting Native Hawaiians. The conference also expanded collaboration across service delivery sectors. The sponsors included the FSVPS programs, the Children with Special Health Needs (CSHN) Branch, the Executive Office of Early Learning (EOEL), Early Childhood Action Strategy (ECAS), and the Hawaii Preschool Development Grant.
To support CAN prevention statewide, the FSVPS programs collaborated with the District Health Offices (DHO) in Maui, Kauai, and Hawaii counties to provide violence prevention trainings and TA for community-based programs working on CAN prevention/family strengthening. These efforts helped reach the state’s largely rural communities. The DHO staff serve on the CWS Citizen’s Review Panel and are actively engaged in CAN prevention program planning and policy development activities.
- Safe and nurturing families
- Equitable access to services
- On-track health and development, and
- Healthy and welcomed births.
This statewide public-private collaborative brings together government and non-government organizations to align priorities for children prenatal to age eight, and to strengthen and integrate the early childhood system by streamlining services, maximizing resources, and improving programs to support the state’s youngest children. The Title V CANP and Sexual Violence Prevention Coordinators serve on the Safe and Nurturing Families team. The team developed short and long-term Action Plan outcome measures and completed the evaluation methodology for a messaging campaign.
A Steering Committee was formed to support the creation of Hawaii’s first CAN Prevention Plan. The plan will be a framework to guide community activities to prevent of all forms of CAN and other ACEs. Committee members includes the CANP Coordinator, Hawaii Children’s Trust Fund Advisory Committee members, DHS, Liliuokalani Trust, ECAS, and several community-based agencies.
CBCAP programs are required to address child maltreatment prevention for special populations, such as adults and children with disabilities, youth at risk for homelessness, and members of underserved or underrepresented groups. The CANP program is focusing on adults and children with a disability, specifically individuals affected by prenatal exposure to alcohol that fall under the general descriptor of Fetal Alcohol Spectrum Disorder (FASD). The CANP Coordinator served as a core member of the FASD Action Team for over 12 years. In 2019, the CANP program provided funding and participated in the planning of a statewide FASD conference on creating an environment to transform FASD from a single focus condition to a systems concern. Local and national speakers presented current practice models to over 200 parents, probation officers, medical professionals, mental health and substance abuse professionals, attorneys, judges and other community members.
Other key partners in CAN prevention include the Domestic Violence Action Center, Hawaii Children’s Trust Fund, and Healthy Mothers Healthy Babies.
Strategy 2: Develop a Child Abuse and Neglect (CAN) surveillance system.
Surveillance is vital to provide health information to guide planning, implementing, and evaluating public health practice, policy, and programming. Without consistent, reliable data it is difficult to accurately assess the magnitude of child maltreatment in relation to other public health problems, and limits the ability to identify groups at highest risk, monitor the effectiveness of ongoing prevention and intervention activities, and measure changes in the incidence and prevalence of CAN over time. Developing a centralized repository for public and private CAN data enables a clearer and accurate picture of CAN in the islands.
The University of Hawaii Public Health program was contracted to create an inventory of existing secondary CAN data sources. The scope included agency, survey, and program data related to risk and protective factors. Data is available at a sufficient granular level to allow analysis by island, county, zip code, census tract, race/ethnicity, age, and gender. The data analysis also produced mapping of high-risk indicators for each island.
Data sources included:
- Hawaii Pregnancy Risk Assessment Monitoring System (PRAMS) data on substance use before, during and after pregnancy, domestic violence and maternal depression
- Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavioral Surveillance System (YRBS) data on domestic and sexual violence and high-risk behaviors
- Hawaii Child Death Review data on intervention strategies;
- Home Visiting performance measure data
- DHS Child Abuse and Foster Care reports
- National Survey of Children’s Health data on ACES and resilience measures
Further analysis is needed to address the challenges of working with such diverse datasets to develop findings that inform CAN prevention programs and policies. Title V will work with stakeholders to continue these efforts.
The FSVPS programs sponsored events and initiatives focusing on building awareness and knowledge of strategies to prevent family violence. The events focused on families, caregivers, service providers, and the community at-large. Activities included ‘Wear Blue Day’ and family activity days conducted in partnership with the state libraries where more than 1,600 children and parents/caregivers participated in hands-on fun activities to learn about positive parenting, family engagement, and child development. Child development professionals were available to share information about child behavior, nurturing the emotional, physical, intellectual, and social development of children, and offer referral information.
Another activity was the screening of the documentary Resilience followed by a facilitated discussion. Feedback included the need to support policy change, funding more programs to address toxic stress, and the need to focus on prevention and treatment. More than 350 adults participated in this activity.
The documentary was also screened by Oahu’s west side with discussions led by the community leader of houseless encampment. Conversations focused on investing in the community and the importance of having a stable adult in a child’s life. Participants reported feeling motivated to advocate for better programs to combat child adversity and toxic stress. Statewide media coverage on local TV and radio shows promoting the events provided brief introductions about toxic stress and resilience to a larger audience.
Keiki TALK, a Ted Talk-like event, hosted a presentation on toxic stress and the impact on a child’s developing brain. The event was attended by business, policymakers, community, and philanthropic leaders. This was an opportunity for non-public health leaders to understand the role their organizations play in preventing child maltreatment. Attendees discussed ideas on building resilience and mitigating the causes of toxic stress in local communities.
Maui County has two CAN prevention collaboratives: 1) the Ho`oikaika Partnership - a coalition of more than 60 Maui County agencies - that raises awareness about CAN, educates parents and providers about available resources, educates parents, professionals, and the public about the risk and protective factors associated with CAN, and provides training to businesses, social services agencies, partners; and 2) Islands of Hope (IOH) - a collaborative effort of Maui Child Welfare Services, Casey Family Programs, and Ho`oikaika Partnership - that supports a County-wide public-private safety net to protect and nurture children, strengthen and support families, and improve opportunities for vulnerable children, youth and parents. The signature initiative of IOH is a One-Stop Shop resource center located inside one of Maui’s largest shopping centers staffed by volunteers from public and private organizations.
In May 2019 the MCHB, in partnership with the MOD Hawaii Chapter, Healthy Mothers/Healthy Babies Coalition, the Maternal and Child Health Leadership Education in Neurodevelopmental Disabilities (MCH LEND) program, sponsored the Hawaii Fatality Summit. The Summit provided information on the role and work of three fatality review initiatives - the Child Death, Domestic Violence Fatality, and Maternal Mortality Fatality. In addition, two violence tracks addressing childhood adversity and domestic violence were offered. The Summit provided the opportunity to identify areas for collaboration particularly for CAN and domestic violence prevention.
The ECAS work conducted by the Safe and Nurturing Families Team focused on building a violence prevention communication framework designed to increase awareness of all forms of family violence—including CAN and intimate partner violence. The effort will ‘reframe’ how this public health issue is presented and addressed across disciplines. Draft messages and visual graphics were tested across all ECAS Teams and a 5-7-year communication sustainability plan was created.
Strategy 4: Provide community-based training and technical assistance promoting safe, healthy, and respectful relationships to prevent child abuse and neglect.
Research suggests that in 30-60 percent of the families where either domestic violence or child maltreatment is identified, both forms of abuse co-exist. Children can suffer from a range of behavioral problems when witnessing or being exposed to violence in the home, even if they are not the direct victim. FSVPS programs continued to collaborate on training and TA focusing on topics such as the impacts of children exposed to violence, ACEs, protective factors, resilience, and promoting safe, healthy, and respectful relationships.
The Sexual Violence Prevention program continued to fund training on the Futures Without Violence Coaching Boys into Men (CBIM) program and curriculum. The Centers for Disease Control and Prevention recognizes CBIM as an effective and promising prevention program. The curriculum provides high school athletic coaches the resources to promote respectful behavior among players and helps prevent relationship abuse, harassment, and sexual assault. By learning about healthy relationships at a young age, these boys will carry forward the learned skills and behaviors into their own families and communities.
The HHVP offered ongoing training and TA to their contractors promoting child development, encouraging positive parenting, and working with caregiver participants to set attainable goals for the future to prevent CAN.
Current Year Highlights for FY 2020 through April 2020
Below are some highlights of current CAN prevention activities for FY2020, including the impacts and changes from the early days of COVID pandemic in Hawaii.
CBCAP entered into a new collaboration with the Hawaii State Department of Education (DOE) to participate in the planning and implementation of a 5-year trauma recovery project called Ho`oikaika (striving toward strength). The overall purpose of the project is to build the capacity of trauma sensitive schools by improving the current system of support. The project focuses on students from low-income families who have experienced trauma resulting in a negative impact on their educational experience.
The CBCAP Program will initiate corresponding prevention efforts in the school communities selected to be part of the pilot. This new collaboration intersects with ongoing public/private efforts to improve workforce competencies and systems to adopt trauma-informed responsive approaches. Aligned with the DOE project, the CBCAP Coordinator participates as a member of the Hawaii Core Implementation team in a Learning Community training under the National Council of Behavioral Health. The training is providing tools and skills to support bringing a trauma-informed, resilience-oriented approach to the behavioral health and community service organizations participating in the DOE project. It is a mechanism to strengthen collaborations across system including DOE, DHS, community mental health providers, and DOH. Initial conversations were held with a leader from the faith community to collaborate on strategies to support and promote resilience to a west side Oahu community. The community has long-standing social and health problems such as youth and parent incarceration, generations of fatherlessness, involvement with the child welfare system, and the highest number of confirmed child maltreatment for the state.
Fact sheets addressing CAN prevention, intimate partner violence prevention, sexual violence prevention, ACEs, and resilience were drafted and are being finalized for distribution.
ECAS implemented a soft launch of three PSAs to promote healthy family engagement using the theme: Nurture Daily. The PSAs broadcast on TV, radio, and social media. Message themes are: Take Time to Share a Story, Take Time to Share a Compliment, Take Time to Teach Life Skills, and Share Time Helping Each Other.
COVID-19 stay at home orders instituted in March alarmed many social service agencies concerned about the increased potential for family violence including CAN. The closure of workplaces, businesses, public amenities, and shelter-at-home orders; created greater social isolation and stress for families. Also, the furlough and layoff of thousands of workers imposed further economic anxieties on families that could increase the risk of family violence.
Many Hawaii health and social service agencies responded with social media, TV, and radio messaging campaigns, creating new remote resources for family support, and providing information on family violence and mental health resources. MCHB developed several public service announcements (PSA) focusing on safe and nurturing families, healthy relationships, and promoting the state Parent Line resources. The PSAs were broadcast statewide on major local media platforms. MCHB also secured three time slots on a local television station with tips on staying connected, keeping children busy and happy at home, and managing stress. ECAS and Hawaii Children’s Action Network are serving as information/service hubs for parents, service providers regarding COVID resources.
MIECHV program staff worked with their contractors to successfully transform in-person home visiting contacts to virtual format home visiting platform with their families.
The decision was made to pause the work on the child abuse and neglect (CAN) surveillance system. Because of COVID, there is an urgent need to refocus on developing new and expanding existing services and resources for families, service providers, state and county offices, and the general public.
Review of Action Plan
The CAN logic model below describes an overview of current activities. Preventing child abuse and neglect cannot be addressed as a stand-alone public health concern. The logic model confirms the importance of acknowledging and addressing contextual conditions that impact and influence CAN negatively or positively, in tandem with programs that specifically target violence prevention. The logic model also captures the broad array of service partners/resources to address CAN in Hawaii: Title V and DOH programs, State Executive Departments, namely the DHS/CWS, Judiciary, and Office of the Attorney General. Other critical local partners include funded programs such as Healthy Mothers Healthy Babies, Hawaii Children’s Action Network, Na Leo Kane, Domestic Violence Action Center, and the Sex Abuse Treatment Center. CAN prevention is supported through national resources including but not limited to FRIENDS, the National Center for Community-Based Child Abuse Prevention (CBCAP), CDC, SAMHSA, Prevent Child Abuse America, and the Children’s Trust Alliance that provides training and technical assistance, and the California Evidence-Based Clearinghouse for Child Welfare.
The logic model will be revised next year with the removal of Strategy 2 - develop a CAN surveillance system - because the work will be integrated into larger state planning efforts including the creation of a Hawaii CAN prevention plan. It will be replaced with the new strategy - build and expand the primary prevention collaboration work under the Hawaii Family First Prevention Services (FFPSA) Act. This Act is requiring complex, systems changes regarding the infrastructure and financing of the child welfare system. One of the major changes is the ability to use federal Title IV-E foster care funding to support programs that prevent the placement of children and youth into the foster care system. The CBCAP grant is identified in the Act as an instrumental partner because of its focus on the primary prevention of CAN.
Challenges and Barriers
With the new federal FFPSA legislation, child welfare systems face the enormous challenge to prevent CAN and reduce the number of children being placed into foster care. The goal of FFPSA is to ensure children are safely reunified with family or find a permanent home. A more comprehensive, systems building approach is required to achieve and sustain change that both addresses systemic issues, as well as implementation of service innovations. The challenge will be to create a well-functioning system of care that is coordinated with shared principles, processes, and practices across social service agencies and community partners.
Some of the challenges include:
- Coordinating different funding requirements, time frames and budget periods, differing performance measures and data collection methods
- Limited staffing resources and vacancies
- The complexity of preventing child maltreatment and the broad scope of services and disciplines engaged in this effort
Given the complexity and scale of system improvements required, time and flexibility are needed to address the barriers that are encountered. Discussions continue with partners and stakeholders to use innovative/evidence-based strategies to address these challenges and sustain progress.
Overall Impact
Hawaii FFPSA work resulted in strengthening partnerships across state agencies – DOH, DHS, Judiciary, and the DOE. Each agency adopted the state vision and outlined their agency’s role in the partnership to move this federal legation forward.
Important systems changes resulted as private and public programs began to integrate Trauma Informed Care (TIC) into client services. Agencies adopting TIC include the DHS Child Welfare Section and their contractors, the Hawaii Community Foundation, Early Childhood Action Strategy (ECAS), DOH, FSVPS, and Partners in Development. Potential benefits associated with TIC are:
- creating safer physical and emotional environments for clients, families, and staff
- reducing the possibility of re-traumatization
- creating environments that care for and support staff
- increasing the quality of services, reducing unnecessary interventions, reducing costs
- creating a resiliency and strengths-based focus
- increasing client and family satisfaction
- increasing success and job satisfaction among staff
Access to federal TA resources, specifically, MIECHV, CBCAP, CDC Rape Prevention and Education, and the CDC Preventive Health and Health Services Block Grants were instrumental in creating greater state capacity to address the prevention of CAN.
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