National Performance Measure 06: Percent of children, ages 9 through 35 months, receiving a developmental screening using a parent-completed tool

 

In Wisconsin, too few children ages nine months through 35 months receive a developmental screening using a standardized parent-completed tool. Nationally, 34.8% of children received a developmental screening using a parent-completed screening tool in the past year (2020-2021 National Survey of Children’s Health).

 

Objectives

 

Objective	2021 Data	2022 Data
Increase the percentage of children in Wisconsin, ages nine months through 35 months, who receive a developmental screen using a parent-completed tool from 43.1% to 47.4% (+10%) by 2025.	42.8% (2019-2020 National Survey of Children’s Health)	43.9% (2020-2021 National Survey of Children’s Health)

 

Evidence-based Strategy Measures

 

Measure	2021 Data	2022 Data
Percent of medical providers trained who report using an evidence-based screening tool	38%	52%
Percent of medical providers trained who report a change in knowledge related to developmental screening age interval recommendations	No data to report due to COVID-19	92%
Percent of community developmental screening training participants who report an increase in knowledge regarding developmental screening	No data to report due to COVID-19	No data

 

Collaborate with the Wisconsin Lead program to align and support activities with medical providers, childcare providers and others.

 

Prior to the COVID-19 pandemic, Wisconsin struggled to test every recommended child for lead poisoning. In 2019, only 67% of one-year-old children enrolled in Medicaid services were tested for blood lead levels, even though Wisconsin Medicaid requires that all those children be tested. Wisconsin has seen an even steeper decrease in blood lead testing due to the pandemic and a recall of point-of-care blood lead tests. The Adolescent and Child Health Improvement team (SPM05 in the Adolescent domain narrative has more details on this team’s purpose and activities) reviewed strategies that members had implemented in their electronic health records and within their clinics to increase the rates of lead testing. The Title V program also collaborated with the Wisconsin Lead program to offer a virtual developmental screening refresher training to 72 local health agencies.

 

The Wisconsin Title V program funded the Wisconsin Lead program in 2022 to support staff capacity to provide technical and on-site assistance to local public health agencies and to collect and interpret results of environmental samples from homes of children who screened positive for lead poisoning. Program staff also worked with four other states interested in implementing isotopic signature analysis. The use of isotopic analysis to identify lead source exposure was first explored by the Wisconsin Lead program and the Wisconsin State Laboratory of Hygiene. These programs continue to explore opportunities and collaborations to share lead exposure and developmental screening messages.

 

Plan and coordinate the implementation of the CDC (Center for Disease and Control Prevention) WIC (Women, Infants, and Children) Developmental Milestone Checklist small pilot program.

 

The Learn the Signs. Act Early program is an evidence-based program developed by the CDC to improve early identification of developmental delays and disabilities, including autism, by promoting developmental monitoring and encouraging screening. This is mainly accomplished by incorporating tools and messaging into existing programs that serve infants, children, and their families, such as WIC.

 

The Title V program added a developmental screening project option for local and tribal health agencies to put their annual Title V funding toward in 2022 which allowed local and tribal health agencies the ability to intentionally select developmental screening as the focus of their Title V funded work. Two local health agencies also opted to join a WIC Developmental Milestone Project Pilot. Wisconsin Title V staff and the two pilot sites joined the Association of State and Public Health Nutritionists’ monthly meetings to learn from other states doing similar work. Pilot sites met with Title V staff and the CDC Act Early Ambassador monthly to check in on implementation strategies and processes. Despite barriers and challenges set by the COVID-19 pandemic, the pilot sites continued to pursue the incorporation of the Learn the Signs. Act Early. program materials and started tracking data for face-to-face WIC visits. Implementation of the program for virtual visits has been more challenging. Title V continues to collaborate with the Association of State and Public Health Nutritionists to add resources to the newly developed website, Wisconsin platform Online Nutrition Education (ONE), an innovative tool that combines videoconferencing, online education including developmental milestones, lessons supporting secondary material, a message center and a link to the WIC App.

 

Coordinate and provide developmental screening trainings to medical providers throughout Wisconsin.

 

The Wisconsin Medical Home Initiative promoted children’s health and development through direct, targeted outreach and support to primary care clinicians, public health professionals, and families through outreach and their website. The Wisconsin Medical Home Initiative also worked with local community coalitions and other partners to coordinate and facilitate developmental screening trainings for medical providers and their teams, and community organizations throughout 2022.  Additionally, they led a virtual developmental screening training to Wisconsin-based HMOs. Four trainings were scheduled for providers however there was low attendance due to the COVID-19 pandemic.

 

In 2022, the Wisconsin Medical Home Initiative provided two full health system trainings at Bellin and ThedaCare. At ThedaCare, 28 clinics participated with 190 providers on developmental screening within well-childcare, as well as mental health screening tools. At Bellin, 29 family practice and pediatric clinics participated with 205 providers and 300 nurses. The training continued to be offered in a virtual format to expand reach and limit the spread of COVID-19. Of the 705 developmental screening pre-surveys that were completed by medical providers/staff, 52% reported that they do not currently perform screening using a standardized validated tool and 48% of providers/staff reported that they do perform screening. Among those who indicated they currently perform developmental screenings, 88% reported using the Ages and Stages Questionnaires-Third Edition (ASQ-3). Of 334 post training evaluations completed, nearly everyone indicated that their knowledge of developmental screening increased and that the training increased their awareness of the recommended referrals and resources for children with concerning screening results (92% and 91%, respectively). A virtual training webpage was also built for developmental screening refreshers.

 

Outreach continued with Chorus Community Health Plan throughout 2022 with four trainings scheduled however there were no attendees. A virtual refresher training was offered as well. Staff from Chorus Community Health Plan sent a survey to plan providers to learn about current developmental screening practices with minimal response. Shared health systems that have been trained in their entirety and need a refresher may be a better option in the future.

 

Collaborate to promote awareness, education, and programming for advancing developmental monitoring and screening in Wisconsin communities.

 

As was the case in 2021, COVID-19 pandemic response efforts resulted in reduced time to address activities related to developmental screening especially in the first half of 2022. Twelve local health agencies and three tribal health agencies opted to address developmental screening with their annual Title V funding. These agencies engaged a total of 65 sites who provided developmental screening education to 2,420 participants and served a total of 3,346 children younger than six years old. Sites received Learn the Signs, Act Early Milestone Moment Booklets, and information for recommended developmental screening for all children at well-child visits to assess development at nine, 18, 24, or 30 months.

 

The Wisconsin Medical Home Initiative worked in collaboration with the Title V program, local and tribal health agencies, and the Wisconsin CDC’s Learn the Signs. Act Early. program partners to promote developmental surveillance across the state. The creative idea to promote developmental surveillance on gas station televisions was started by the Lac Courte Oreilles Mino Maajisewin Home Visitation Program. The CDC Learn the Signs Act Early Milestone Tracker app video was showcased on local tribal gas station pumps through a digital marketing grant that the Lac Courte Oreilles Child Support Program received in 2018.  When coming up with such a unique approach, the grant manager stated, “I try to think about the community at large and not just the participants of a program. How can we reach those that are not (already) connected to a program or a provider and share this information?” The Lac Courte Oreilles team showcased their work at a Developmental Screening Learning Community Call where local and tribal health agencies from across the state gathered to share project progress and collaborate. Other partners shared strong interest in running a similar campaign and the project took off. Generously funded by the Wisconsin Learn the Signs. Act Early. program, this promotion ran at 40 gas stations across the state. Target areas included 15 local and tribal health agencies as well as areas of the state that were significantly impacted by COVID-19.

 

Local health agencies requested trainings on developmental screening, so in collaboration with the Lead Program and the Wisconsin Medical Home Initiative, developmental screening trainings were offered to 72 health department staff across the state.

 

Coordinate with the Wisconsin Medical Home Initiative to provide technical assistance related to developmental screening to local and tribal health agencies.

 

Initial one-on-one calls for local and tribal health agencies were held in January of 2022 and 85% of participating agencies joined (11 of 15) their efforts to resume their maternal and child health-focused work. Those who did not participate indicated this was due to COVID-19 response taking priority at that time.

 

Three learning community calls were held throughout 2022 where these 15 local and tribal health agencies could come together to share successes, troubleshoot barriers, and learn about various topics such as the Learn the Signs. Act Early. program and the Regional Centers throughout Wisconsin that support families with children and youth with special health care needs.

 

Provision of individual agency support was based on needs identified by individual local and tribal public health agencies. Some examples of technical assistance resulting from these check-ins included:

 

• Grant and Iowa counties had many new staff and were provided a ‘Developmental Screening basics’ training, which was held with both counties at once

 

• A connection was established with a University of Wisconsin professor to support and fund the future gas station videos and promotional ideas

 

• Vilas County completed the Brooke’s ASQ train-the-trainer series

 

Facilitate and promote social and emotional health and access to mental health services through administration of the Wisconsin Child Psychiatry Consultation Program and HRSA Pediatric Mental Health Access Program, collaboration with the Office of Children’s Mental Health, and partnerships with Well Badger Children’s Mental Health Navigator and the Wisconsin Medical Home Initiative to conduct mental health screening trainings.

 

The Child Psychiatric Consultation program began in 2014, supported by an allocation from the Wisconsin State Legislature. Since then, the Wisconsin Department of Health Services has contracted with the Medical College of Wisconsin to implement this program across Wisconsin. The Title V program continues to provide contract administration, project management, and support to the Medical College of Wisconsin to implement this program across Wisconsin’s five regions and in Milwaukee County. In addition to the current funding from the Wisconsin State Legislature, an additional allocation began in July 2022 adding $500,000 to this project, totaling $2,000,000 each year. Active enrollment continued across all regions of Wisconsin with 442 clinics enrolled, 2,069 providers enrolled, and 7,690 consultations provided since the program’s inception through December 31, 2022. Encounter data continued to show that most primary care providers were calling about children and adolescents ages six to 20 years old, and the most common reasons for consultation were general medication questions/education, diagnostic questions, care coordination, resource referrals, and parent guidance.

 

Title V staff facilitated quarterly check-in calls with program staff to discuss program improvements and marketing opportunities such as the joint branding of the Child Psychiatry Consultation program logo and the Wisconsin Department of Health Services logo on annual reports. Staff collaborated to create a yearly Child Psychiatric Consultation program Brief Report that highlights cumulative outcome data to increase program awareness in the provider community. The program continues to build primary care provider capacity to support the behavioral health needs of children and families. Enrolled providers shared a trusting relationship with a child psychiatrist and received efficient and timely expert consultation and access to ongoing education and support. They also received referral assistance for local mental health resources.

 

Since receiving a five-year Pediatric Mental Health Care Access program grant from the US Maternal Child Health Bureau in October 2018, Child Psychiatry Consultation program services have expanded to additional primary care providers in southern rural Wisconsin, and a fifth regional hub was established with Viroqua Medical Center. This grant supports a part-time child psychiatrist and regional coordinator. Active provider enrollment continued in 2022.

 

In August 2022, the Wisconsin Department of Health Services announced the availability of one-time funds made available through the Bipartisan Safer Communities Act (BSCA) (P.L. 117-159) which reauthorizes and expands the Pediatric Mental Health Care Access program. This program is authorized by Title III, § 330M of the Public Health Service Act (42 U.S.C. § 254c-19) and promotes behavioral health integration into pediatric primary care by supporting pediatric mental health care telehealth access programs and education.

 

The Title V program implemented a minimally competitive funding process and identified five agencies to address the behavioral health needs among children and adolescents in Wisconsin and provided statewide and/or regional support to professionals and communities while implementing the following priorities:

 

• Advance equity and racial justice

 

• Advance access to quality behavioral health education, training and resource support

 

• Enhance identification, access, and support for individuals with behavioral health care needs and their families

 

• Foster positive mental health and associated factors through professional and community education and support

 

The five agencies selected were: the Wisconsin Women’s Health Foundation’s Children's Mental Health Navigator; Red Maple Consulting; University of Wisconsin-Green Bay; The Lakes Community Health Center; and Friendship House.

 

The Pediatric Mental Health Care Access Program Grant continued to support the development, implementation, and maintenance of a Children's Mental and Behavioral Health Navigator tool in 2022. The tool was developed by the Title V funded Well Badger Resource Center with guidance from mental health professionals and families with lived experience. The Wisconsin Children's Mental and Behavioral Health Navigator is a free, confidential, online tool designed to help parents, caregivers and professionals in Wisconsin navigate (find, access, pay for) mental and behavioral health services and support for children, adolescents, and young adults under the age of 21. It provides a customized guide to connect kids and families with the resources and support they need and deserve.

 

The Office of Children’s Mental Health continues to serve as the backbone organization to supporting collective impact activities through a multidisciplinary stakeholder group known as the Collective Impact Council, which met virtually in 2022. The Title V program is a collective impact partner and actively participated in the council meetings and impact partner teams. Teams met monthly to work on strategies, then presented activities and challenges to the council for large group analysis.

 

The Office of Children’s Mental Health partnered with ArtWorks in Milwaukee, Wisconsin to release brand new imagery for Children's Mental Health Week 2022, promoting a new collective impact focus of Social Connectedness of Youth through acceptance and awareness. Governor Evers proclaimed Thursday, May 5, 2022, as Children's Mental Health Awareness Day, View the proclamation here.

 

Title V staff continued to engage in council activities such as suicide prevention and the Wisconsin Youth Risk Behavior Surveillance System, Child Psychiatry Consultation program, Project Apple, and the Children’s Mental Health Navigator Resource.

 

The Department of Health Services received $175,000 under a state appropriation (Wisconsin Act 117) beginning July 1, 2020, to create and administer a school-based mental health consultation pilot program in Outagamie County. Wisconsin Title V staff continued to have a leadership role in this project which provides consultation services to support school-based providers, assisting with the management of students with behavioral health problems and provided referral support for students. The Psychiatric Registered Nurse supported marketing to additional schools through calls, in-person meetings and school events, and monitored the school district’s enrollment. This project will likely conclude in June 2023.

 

Strengthen collaboration with other programs and grant-funded projects to promote and improve developmental screening rates, referrals, and early intervention.

 

The first Help Me Grow affiliate in Wisconsin was established by the grassroots group First Five Fox Valley in 2021. Fox Valley, Outagamie, Calumet, and Winnebago counties were targeted for the start-up and implementation of this evidence-based national model. In 2022, a rural expansion of the Fox Valley system included Green Lake, Marquette, Shawano, Waupaca, and Waushara counties, and a new affiliate system in Kenosha County. First Five Fox Valley is creating the infrastructure for a statewide Help me Grow Wisconsin system and conversations are taking place in Brown County and other areas in northern Wisconsin for new affiliate start-up systems in the future.

 

Utilizing the Help Me Grow system allowed childcare providers to join the developmental screening efforts while having access to free screenings and navigator support. For example, one childcare center in Appleton participated in the work and completed 29 ASQ-3 screens with 20 being scored as reassuring and 9 scored in the monitoring or concerning zones. The Help Me Grow navigator position worked with families to get connected to Birth to 3 and other resources as needed. The navigators are key supports to childcare providers, taking the burden off them and ensuring that families can maneuver through the complicated system. Throughout 2022, Title V staff met regularly with First Five Fox Valley to explore collaboration and partnership opportunities. Meetings led to a better shared understanding of each other’s programs.

In spring of 2022, the Title V program funded the Wisconsin Medical Home Initiative to train the entire ThedaCare Health System of family practice and pediatrics clinic teams in the area of developmental surveillance and screening. Focusing on the ASQ-3, these trainings set the foundation for the collaboration between health care providers and the Help Me Grow system. ThedaCare and Help Me Grow have teamed up to develop family navigation supports that have cross-sector functions throughout rural Wisconsin. This work is part of an Advancing a Healthier Wisconsin Endowment grant, awarded in 2022 that aims to implement the Help Me Grow model within a rural context and a partnership with ThedaCare to research and develop a blueprint that can be adapted for other health systems. The First Five Fox Valley director stated, “Partnering with the Medical Home Initiative has expanded the capacity of Help Me Grow in many ways. By their team providing training to health care professionals and family resource navigators on the ASQ developmental screening tool, it has saved precious grant funds and helped expand our reach to rural communities."

In 2022, the Wisconsin American Academy of Pediatrics, Title V program, and Child Psychiatric Consultation program produced 12 behavioral health podcasts to support and broaden mental health awareness for primary care clinicians. The Wisconsin Chapter of the American Academy of Pediatrics released Doctor to Doctor: A Pediatric Mental Health Podcast in the summer of 2022. The series featured compelling and practical conversations with psychiatrists, psychologists, and experts in pediatric mental health to address what primary care clinicians needed to know about common conditions prevalent amongst children and adolescents today. The 12-part series, each 30-minutes in length, brings in one-on-one conversations between professionals to bridge those knowledge gaps across a broad array of topics including anxiety, depression, attention deficit hyperactive disorder (ADHD), substance use disorders, trauma, and more. These podcasts were promoted statewide in 2022. 

The Act Early State Team brings the Title V program together with multiple key early childhood and disability stakeholders to coordinate the improvement of early identification systems and care for children with autism spectrum disorder and other developmental disabilities. In partnership with Act Early Ambassador and the Wisconsin Care Integration program, a provider education workgroup formed to identify and address provider educational needs related to developmental screening. In 2022, the group provided guidance and training to the HMO Children’s Community Health Plan as the organization prepared for upcoming changes in developmental screening reporting requirements. The group established a relationship with First Five Fox Valley, Wisconsin’s Help Me Grow affiliate. Workgroup members met with the First Five Fox Valley Director several times in 2022 to identify ways Act Early State Team members could support provider education efforts and actively participated in the provider education workgroup in 2022.

 

The Act Early Family Leader group held regular meetings to coordinate and develop outreach strategies for medically underserved families, including families living in resource-poor rural or urban areas, and Black and Latino families. This work group is made up of nine leaders and includes representation from rural, urban, Black, Latino, and LGBTQIA+, parents and self-advocates with lived experience. “Bright Spots” interactive webinars continued in 2022. These webinars are an opportunity for Act Early State Team members to spotlight innovative work relevant to Act Early State Plan goals. These 20-minute presentations followed by group discussions also provided a way for members to stay connected with one another in between Act Early State Team meetings. There were five Bright Spot webinars in 2022. Work groups including Title V program staff continued to identify and respond to current barriers and identify opportunities to improving early identification of developmental delays, developmental and autism monitoring, screening, referral and evaluation, and access to early intervention. Project goals continued maintaining an ambassador-led state/territory team that included key early childhood program partners, and developed, implemented, and evaluated a plan to improve early identification of developmental delays/disability. Five community connectors (family members with lived experience or program staff with knowledge of Birth to 3) were hired to disseminate early identification materials in their respective communities.

 

The four-year initiative, Innovation in Care Integration for Children and Youth with Autism Spectrum Disorders and other Developmental Disabilities, continued throughout 2022. The initiative aims to increase early access to developmental and autism spectrum disorder screening, assessment, and early intervention among medically underserved populations across Wisconsin through provider education, family navigation services, and building sustainability and dissemination. The Wisconsin Care Integration Initiative provided trainings and family navigation to twelve primary care clinics serving large populations of medically underserved children from birth to five years old. This initiative also worked to integrate efforts with ongoing Title V program activities for family engagement, early identification, and health equity. The team was expanded to include additional family leaders who bring experiences as parents of children with autism or other developmental disabilities and represent medically underserved populations in Wisconsin. In 2022, a bilingual, bicultural Latinx parent of a child with autism was hired to provide family navigation to Spanish-speaking families.

 

Partner with the Wisconsin Collaborative for Healthcare Quality to lead and facilitate the Adolescent and Child Health Collaborative to improve developmental screening and adolescent well visit rates within medical groups and clinics across Wisconsin.

 

 A full report for this strategy can be found in the Adolescent Health section.

 

Collaborate with the Family Foundations Home Visiting Program to promote developmental screening and referral.

 

The Wisconsin Maternal Infant Early Childhood Home Visiting program continued to collaborate with the Title V team to strengthen developmental screening and promotion. Data from state Home Visiting staff was shared with the Title V program and included information regarding:

 

• Children with a timely screen for developmental delays using a validated parent-completed tool

 

• Home visits where primary caregivers were asked if they have any concerns regarding their child’s development, behavior, or learning

 

• Children with positive screens for developmental delays (measured using a validated tool) who receive services in a timely manner

National Performance Measure 08.1: Percent of children, ages 6 through 11, who are physically active at least 60 minutes per day

 

Too many children in Wisconsin are considered overweight or obese by BMI standards (30.7% of ages 10-17 is used as a proxy measure from the National Survey of Children’s Health), which is a strong predictor of poor health outcomes throughout their lives. Data comparisons from 2021 to 2022 show the percentage of children with an overweight or obese classification increased slightly and the percentage of children who are physical activity at least 60 minutes per day went down. In choosing to address this performance measure, Wisconsin identified the following goals:

 

Objective	2021 Data	2022 Data
Decrease the percent of children in Wisconsin with an overweight or obese classification from 30.5% to 28% (-8.2%) by 2025.	30.5% (2017-18 National Survey of Children’s Health, ages 10-17)	30.7% (2020-2021 National Survey of Children’s Health, ages 10-17)
Increase the percent of children, ages 6 through 11, who are physically active at least 60 minutes per day from 30.8% to 33.9% (+10%) by 2025.	30.8% (2017-18 National Survey of Children’s Health, ages 6-11)	29.9% (2020-2021 National Survey of Children’s Health, ages 6-11)

 

Evidence-based Strategy Measures

Measure	2021 Data	2022 Data
Percent of local and tribal health agencies in Wisconsin receiving Title V funding who chose the physical activity and nutrition project option	New in 2022; no data available for this year	9.3% of local and tribal health agencies in Wisconsin selected the physical activity and nutrition objective

 

Develop and implement strategies for local and tribal health agencies focused on physical activity and nutrition, based on community input from 2021 survey results.

 

In 2022, Wisconsin Title V staff and partners from the  Wisconsin Department of Health Services-Chronic Disease Prevention Program, the Wisconsin Department of Children and Families, and healthTIDE at the University of Wisconsin-Madison School of Human Ecology formed the Title V Physical Activity and Nutrition (PAN) workgroup to develop initial strategies around NPM 08.1. This group developed and distributed an online Physical Activity and Healthy Eating Survey for community-based partners and organizations across Wisconsin to provide input on barriers, priorities, and opportunities to implement physical activity and nutrition related strategies in their communities.

 

Key findings from the survey were used by the Title V Physical Activity and Nutrition workgroup along with statewide partners from the University of Wisconsin-Madison Division of Extension Health and Well-Being Program (UW-Madison Extension) to identify physical activity and nutrition related strategies local and tribal health agencies could implement with Title V funds. The following strategies were incorporated into the Physical Activity and Nutrition objective offered to agencies for the first time in 2022:

 

• Partner with UW-Madison Extension staff (county-level) to support health in children ages 6-11 years old

 

• Partner with K-5th grade schools and local partners on school wellness requirements

• Partner with local afterschool/out of school time programs and community organizations to support opportunities for improved physical activity and nutrition in children (ages 6-11)

 

The 2021 Physical Activity and Nutrition Survey findings indicated that 93% of respondents were interested in training opportunities, therefore an overall goal for 2022 was to collaborate with healthTIDE and UW-Madison Extension to build workforce capacity of local and tribal health agencies around policy, systems, and environmental changes to support increased physical activity and healthy eating among children, 6-11 years old.

 

Building workforce capacity of state Title V programs and integrating public health nutrition into Wisconsin’s Title V NPM 08.1 were the overarching goals of the Children's Healthy Weight State Capacity Building Program funded by the Maternal and Child Health Bureau and administered by the Association of State and Public Health Nutritionists. Wisconsin was one of three states that participated in this project which also focused on building partnerships and optimizing nutrition-related data. Specific progress around workforce capacity and data optimization is described in additional strategies below and in the Children's Healthy Weight State Capacity Building program Year 1 and Year 2 evaluation reports and logic model.

 

FIGURE 1

 

 

Engaging with partners was critical to develop and advance strategies. Title V staff participated in several groups including Healthy Early, the Wisconsin Farm to Early Care and Education workgroup, Wisconsin’s Title V Adolescent Health team, Wisconsin Department of Health Services-Chronic Disease Prevention program statewide meetings, and one-on-one partner meetings with partners identified previously in the Public and Private partnerships narrative of this submission. Staff also joined a workgroup coordinated by Adolescent Health staff around school policy development further described under NPM 07.2.

Networking with faculty from the University of Wisconsin-Madison School of Human Ecology interested in mental health, physical activity, healthy eating, early childhood development, family well-being, mindfulness, and fatherhood emerged in 2022. This provided an opportunity for Title V staff and partners to connect with research and projects related to various Title V performance measures.

Title V staff collaborated on several letters of support for funding applications. Letters included support for the University of Minnesota (UMN) School of Public Health application for a Maternal and Child Health Bureau’s Public Health MCH Nutrition Training Grant. The request for five additional years of funding to support training and technical assistance around maternal and child health nutrition in eight states included Wisconsin’s Title V program. Letters of support for nutrition-related initiatives bolstered applications from the Wisconsin Department of Agriculture, Trade, and Consumer Protection for a state Farm to School program and the Illinois Public Health Institute’s application to the USDA School Food Transformation Grant program for a regional food system transformation initiative focusing on strengthening availability of and access to nutritious foods in schools (notified of award in 2023).

 

Conduct and fund participation in Community Conversations, to incorporate a health equity lens and include community member’s voice to shape future efforts.

 

As part of a contract with the Title V program, healthTIDE coordinated five virtual and in-person community conversations with second generation, US-born parents and caregivers of children from Latino communities in Wisconsin. They also collaborated with the Great Lakes Intertribal Council to hold three community conversations with one Wisconsin tribal nation. Community member facilitators were trained on the community conversation process and facilitated conversations within their community. The purpose of these conversations was to center voices of Wisconsin parents and caregivers to support health, wellness, and well-being of families including, but not limited to, challenges and successes related to healthy eating and physical activity. Community-leader facilitators were involved in the cultural and qualitative analyses along with healthTIDE and the University of Wisconsin-Madison School of Human Ecology which will be disseminated in 2023. Additional community conversations were planned with four other Wisconsin tribal nations but due to the amount of time needed to develop unique data agreements for each sovereign tribal nation these conversations were delayed.

 

Continue Title V representation in Healthy Early meetings to support statewide collaboration among stakeholders.

 

Healthy Early - formerly known as the Wisconsin Early Childhood Obesity Prevention Initiative - formed in 2007and is a state-wide collaborative of multi-sector partners working to advance equitable eating and physical activity opportunities for children and families through policy, systems, and environmental changes. Priorities include family engagement, strengthening resources, network growth, and exploring out-of-school time needs. The collaborative conducted an equity evaluation in 2019 resulting in restructuring the group to include Healthy Early Leaders. This allows for more diverse partners, community and family feedback, and community leader engagement.

 

In 2022, Healthy Early focused on implementing this plan through small group meetings to recruit Health Early Leaders. Leaders helped to make critical decisions for the collaborative and set strategic direction and priorities. Healthy Early’s goal is that 60% of leaders have lived experiences and represent marginalized communities. Wisconsin’s Maternal Infant Early Childhood Home Visiting staff started serving as a Healthy Early Leader in 2022 and was integral in the development of the Healthy Early at Home Resource. This resource for families was developed with input from a diverse group of individuals from Black and tribal communities and will provide a framework for culturally specific information around healthy eating, physical activity, and overall well-being when completed in 2023.

 

Formalize a voluntary nutrition and physical activity steering team with the Association of State Public Health Nutritionists to enhance partnerships and capacity.

 

Results from the 2021 Physical Activity and Healthy Eating Survey identified over 100 contacts interested in staying engaged with physical activity and nutrition work in Wisconsin. Before inviting partners to participate in a new steering team, the Title V team decided they should develop the need, purpose, structure, and roles and responsibilities for coordination of such a group and identified strategies for engaging with public health professionals. Considerations for a nutrition and physical activity steering team were also incorporated into the project previously mentioned with the Association of State Public Health Nutritionists. Changes in Title V staff mid-year led to a vacancy in this performance measure, pausing this strategy.

 

In late 2022, the Wisconsin Department of Health Services-Chronic Disease Prevention Program conducted a community coalition survey to identify partners across the state working on physical activity and nutrition initiatives. The Title V Physical Activity and Nutrition workgroup felt the results of this survey could provide additional insight into potential partners and narrow the scope for a statewide steering team around physical activity and nutrition in 2023.

 

Collaboration with the Wisconsin Department of Health Services-Chronic Disease Prevention program and the new structure for Healthy Early were important options to consider in connecting interested partners with existing groups rather than creating an additional group at a time when public health staff capacity is stretched thin, both locally and statewide.

 

Enhance Title V’s workforce capacity to implement nutrition and physical activity (social, physical, and mental) programming for the Maternal and Child Health (MCH) population through skill building and peer-to-peer learning opportunities.

 

A collaboration between the Title V Physical Activity and Nutrition workgroup, UW-Madison Extension, the University of Minnesota School of Public Health’s MCH Nutrition Training program, and the University of Minnesota Extension’s Department of Family, Health, and Well-Being were integral in developing this strategy. A collaborative learning model was rolled out in 2022 to build capacity of local and tribal health agencies around knowledge and skills needed to implement policy, system, and environmental changes around physical activity and healthy eating strategies. The key elements of the model were:

 

• Systems Approaches for Healthy Communities Course

 

• Peer Learning Calls

 

• Coaching & Technical Assistance

 

• Implementation Resources & Guidance

 

Systems Approaches for Healthy Communities Course This course was comprised of five learning modules, provided a foundation for policy, systems, and environmental changes around physical activity and nutrition as well as community and partner engagement and outreach. Course registration was offered at no cost to local and tribal health agencies in 2022 thanks to a partnership with the University of Minnesota School of Public Health MCH Nutrition Training program, the recipient of a Public Health MCH Nutrition Training Grant through the Maternal and Child Health Bureau.

 

FIGURE 2

 

Peer Learning Calls

Four Learning Calls were hosted in 2022 to support participants in applying training content and to provide peer-to-peer learning and networking opportunities. Building and maintaining community partnerships was woven into each call to help agencies think about potential partners. UW-Madison Extension paired Health and Well-Being Educators (Healthy Eating, Active Living, Behavioral Health and FoodWIse) with local and tribal health agencies. UW-Madison Extension also built and distributed an evaluation survey tool used after each learning call to gather qualitative and quantitative feedback. Most participants in the calls somewhat agreed that they gained new knowledge or skills and knew how to apply what they learned to their work promoting nutrition and physical activity in their community (n = 13, 81%).

 

Coaching & Technical Assistance

Participating agencies were assigned coaches who provided support and technical assistance in registering and completing course modules, networking with other agencies, and building partnerships. Technical assistance was offered through email check-ins and one-on-one calls. To better support agencies, coaches completed the Systems Approaches for Healthy Communities Course. Coaches were partners from UW-Madison Extension, healthTIDE, Rock County Health Department, UMN School of Public Health, UMN Division of Extension, and Wisconsin Title V staff. Due to a vacancy in the position for the Physical Activity and Nutrition performance measure lead, Title V staff had limited capacity to provide coaching.

 

Following the final learning call, coaches offered agencies one-on-one check-ins to discuss next steps to move towards implementation, such as completing:

 

• School wellness assessments the Alliance for a Healthier Generation, CDC and Action for Healthy Kids

 

• Out of School Time assessments like the Out of School Nutrition and Physical Activity Assessment Tool

 

• Other assessment resources from University of Madison Division of Extension

 

Dr. Abby Gold (University of Minnesota Extension) and Dr. Jamie Stang (University of Minnesota School of Public Health) provided technical assistance to the Title V team throughout the rollout of the learning model. UW-Madison Extension established an internal infrastructure to onboard all Health and Well-Being Extension Educators in the University of Minnesota Systems Approaches for Healthy Communities course and anticipate all staff will complete the course by the end of 2023.This has provided valuable feedback and suggestions for improvement in course facilitation with local and tribal health agencies.

 

FIGURE 3

 

Implementation Resources & Guidance

Following the Peer Learning Calls an email summary was sent to participants and included the call recording for those unable to attend and links to resources and opportunities pertaining to the module(s). Feedback gathered after the first three calls indicated LTHAs wanted information on existing resources, funding opportunities, and assessment tools around physical activity and nutrition strategies. Partner organizations presented at the final learning call of 2022 to provide guidance on moving towards implementation.

 

• Wisconsin Department of Children and Families: Out-of-School Time Based Resources & YoungStar

 

• University of Wisconsin-Madison Division of Extension:School-Based Resources on Relationship Building

 

• Wisconsin Department of Health Services-Chronic Disease Prevention Program: General physical activity, nutrition, and obesity resources & Wisconsin Nutrition and Physical Activity Roadmap

 

• University of Wisconsin-Madison Environmental Design Lab: Wisconsin School Garden Network & Youth Gardening/Outdoor Based Learning

 

• Wisconsin Department of Agriculture, Trade, and Consumer Protection: Farm to School program

 

• Wisconsin Department of Public Instruction: School-Based Resources around physical activity and nutrition, suicide prevention, professional development, and Wisconsin’s School Health Award.

 

The Community Engagement Assessment Tool is used to identify areas of improvement in how agencies engage family, youth, and community members. Agencies use results to develop an action plan identifying at least one practice change around community engagement. Completing the tool is required for agencies in year two of the Physical Activity and Nutrition objective, however since 2022 was the first year of this objective, the tool was not required but will be in 2023. Community engagement is covered in Module 3 of the Systems Approaches for Healthy Communities Course.

 

FIGURE 4

 

Local and tribal health agencies worked with a total of ten sites implementing various physical activity and nutrition activities. Sites included schools and school districts (80%), an after-school program (10%), and a healthcare center (10%). The sites served a total of 12,505 children ages 6-11 who primarily identified as white (58.0%), followed by Hispanic or Latino (20.2%), and Black (11.5%). Local and tribal health agencies shared specifics about the activities that they implemented with eight of the sites they worked with in 2022 (Figure 6).

 

FIGURE 5

 

 

Participant feedback was gathered through post learning call evaluations and one-on-one conversations with local and tribal health agencies and coaches. Title V, healthTIDE, and UW-Madison Extension staff met regularly to talk through challenges and opportunities for improvement. Based off this feedback several improvements were made to the learning model:

 

• Increased number of learning calls to align one call with one module, rather than condensing multiple modules into one call

 

• Shortened the timeframe for completing the course to 6 months, rather than 12

 

• Allocated more time on each learning call for networking and peer-to-peer sharing

 

• Provide individualized coaching for counties who completed the Systems Approaches for Healthy Communities course

 

Several barriers that impacted the ability of local and tribal health agencies to complete the Systems Approaches for Healthy Communities course and participate in learning calls and coaching opportunities included the COVID-19 pandemic response and staff turnover. These barriers limited agencies' capacity to focus on maternal and child health objectives overall and caused fewer staff than anticipated to complete all course modules and move to partnership building, assessment, and implementation (10 completed/46 registered). On a positive note, seven of the nine agencies that opted to address this work in 2022 decided to continue this work in 2023, showing a strong interest in continuing to build on progress and learning.

 

This performance measure offered opportunities for workforce development for MCH Trainees from the University of Minnesota School of Public Health. Trainees supported digitizing the Out-of-School Time Assessment Tool, developing training materials, and conducting analyses of Community Conversation data. The Title V Physical Activity and Nutrition workgroup compiled a list of potential projects in anticipation of having future trainees to support this objective.

 

Utilize Maternal and Child Health nutrition related data sources in programs, initiatives and local and state policy, systems, and environmental changes in Wisconsin.

 

National data on children's nutrition status is sparse and the Title V grant does not offer a national performance measure specific to child nutrition. In 2022, the Title V Physical Activity and Nutrition workgroup partnered with the  Association of State Public Health Nutritionists to submit a proposal to the National Survey of Children’s Health that would expand child nutrition and physical activity data points. The goal was to include nutrition-based questions on the National Survey of Children’s Health for all ages, not just the current 0–5-year-old range. The proposal was reviewed by the National Survey of Children’s Health and was included in question testing, but due to concerns with overall length of the survey, additional questions around physical activity and nutrition will not be included in the 2024 National Survey of Children’s Health. The proposed questions will continue to be refined and tested with the goal of being included in a future survey.

 

Despite roadblocks, there were gains in leveraging other physical activity and nutrition related data to inform the Title V program in 2022. Leaning on a 2021 partnership, the Title V Physical Nutrition and Activity workgroup collaborated with the Wisconsin Department of Children and Families, Professor Rebekah Lee from the  Harvard University Prevention Research Center on Physical Activity and Nutrition, and MCH Trainees from the University of Minnesota School of Public Health to digitize the evidenced based Out of School Nutrition and Physical Activity (OSNAP) assessment tool into Wisconsin’s online reporting system (REDCap) for childcare providers. This tool, now called the Wisconsin Active OST Healthy Bites Assessment, is used by technical consultants contracted by the Wisconsin Department of Children and Families to support childcare, out of school time and afterschool sites participating in the YoungStar quality rating improvement system. The tool, available in English and Spanish, identifies practice changes and improvements around physical activity and nutrition. Completing the tool and implementing changes can improve overall site ratings. This tool also allowed the Title V team to view data in aggregate from around the state and use it to prioritize technical assistance and resources around nutrition and physical activities in out-of-school time settings.

 

Title V staff and trainees presented an overview of the tool at a Wisconsin Department of Health Services Family Health Section meeting and at the Regional Title V Directors meeting in 2022. Information on Wisconsin’s tool was also showcased at the Association of State Public Health Nutritionists 2022 annual meeting. Trainees and healthTIDE staff provided training to YoungStar’s technical consultants on completing the assessment tool with providers and providing follow-up support to sites implementing changes identified through the assessment. They also collaborated to develop a handout/infographic on improving physical activity and healthy eating during out of school time to support implementation of changes. Supporting Families Together Association, the technical consultant for the YoungStar program, was slated to shift to Shine Early in 2023 and this impending transition impacted the ability to complete the assessment tool with and gather data from sites in 2022. The previous assessment training was recorded, and materials have already been modified for future consultant on boarding in May of 2023.

 

Staff vacancies limited capacity and progress around this work in 2022.

 

Children’s Health Alliance Food Insecurity Pilot-Project

 

Funded by Wisconsin’s Title V program, the Wisconsin Medical Home Initiative brought together partners from health systems and community-based organizations in the Milwaukee area to pilot the Food Insecurity and Health project. Short-term goals of the project were to strengthen communication across food banks, food pantries, and primary care clinics to increase food security and health of children and youth. Long term, the partners Children's Wisconsin, Feeding America Eastern Wisconsin, and Friedens Food Pantries are working to link health systems and community-based organizations to connect families with food and health resources. Data You Can Use has been working with the project since 2020 as an evaluation partner and supports planning. An orientation packet was developed for new team members (to support onboarding) and the Milwaukee County Health Department will be engaged starting in 2023.

 

Gathering input from families who utilized food pantries on how clinics and pantries can work together was a priority in 2022. Four family/community focus groups were held at Friedens Food Pantry and Feeding American Eastern Wisconsin (one group was with families whose primary language is Spanish and three with those whose primary language is English). Feedback will be incorporated into future strategies for engaging with families such as moving toward more one-on-one conversations. A Practice Summary & Implementation Guidance for the project was accepted by the Association of Maternal and Child Health Programs MCH Innovations Database in 2022 and further describes the timeline, lessons learned, costs, and next steps. In 2022, Children’s Health Alliance received an 18-month funding award from the Wisconsin Title V program to continue this work through June 2024.