Report for the application year: Oct 2021 - Sept 2022
NPM 7.1: The rate of hospitalization for non-fatal injury per 100,000 children, ages 0-9
Strategy 7.1.2: Support and expand statewide systems (e.g. Help Me Grow, Learn and Grow, ILP, and home visiting programs) for parents and caregivers, providers, educators, and community-based service agencies in use of standardized screening tools and provider education for developmental screening.
Another important role that HMG-AK plays is offering the Ages and Stages Questionnaire (ASQ) and the ASQ Social Emotional (ASQ-SE) developmental screening tool for free online, as well as providing follow-up and referral with every family who participates. In addition to providing universal developmental screening, HMG-AK assists WCFH with the facilitation of the statewide Universal Developmental Screening Advisory Committee (UDSAC). The Early Childhood Systems Program Manager within WCFH established the UDSAC in 2020. This was done to provide statewide leadership on developmental screening collaborative initiatives. The UDSAC builds on the efforts of the Governor’s Council on Disabilities and Special Education (The Council) Universal Developmental Screening Task Force. This task force was convened in 2017 to move forward the vision for all children to receive age appropriate and timely developmental screenings.
The purpose of the UDSAC is to bring key stakeholders together to ensure that all Alaska children and their caregivers have access to developmental screening. The committee will accomplish this through streamlining efforts to maximize efficiency; coordinating data sharing; ensuring access to training of developmental screening and screening tools for all voluntary or mandated screeners, including early childhood education, home visitors and health care providers; providing stakeholder input on the statewide Ages and Stages Questionnaire (ASQ) online system; and increasing family-focused education on developmental screening. Members include parents (who are compensated), multiple State agencies, direct providers from rural and urban communities, and the leadership of community early childhood coalitions from the Alaska Early Childhood Network (ECN).
The UDSAC has four active work groups to achieve their overall goal. The first focuses on increasing family-focused education on developmental screening. Through this group, a digital PSA to promote developmental screening was created to gain familial knowledge and interest in developmental screening and connect them to the free online ASQ screening through the HMG-AK website.
The second work group focuses on ensuring access to training on administering developmental screening for all provider types. Based on the recommendations of this group and the results of the new statewide environmental scan on developmental screening (see below), medical providers were highlighted as needing the most assistance in accessing training on developmental screening. In response to this, HMG-AK and WCFH worked closely together to build four accredited training opportunities within the State of Alaska learning management system. Medical providers of all types can now receive training in person or asynchronously online on developmental monitoring and screening and receive continuing education credits upon completion. The Title V MCH Director served as a nurse reviewer for continuing education purposes. Next steps to this project include active promotion of the training opportunities in partnership with HMG-AK and Health Care Services.
HMG-AK provided training on developmental monitoring and screening at two ECHO sessions. The first was at the School Health ECHO, which has 80-100 participants a week consisting of school nurses, school counselors, and other school staff. The second was the Home Visiting ECHO, where HMG-AK concentrated on providing information to all home visiting models and professionals on how developmental monitoring and screening can be done with fidelity and be meaningful for the family while in a virtual setting.
In addition to increased training opportunities for medical providers, this work group also partnered with a large Head Start agency to add them to the statewide ASQ Online system and train all their leadership staff to become ASQ trainers. The Alaska child care quality recognition and improvement system (QRIS), also known as Learn & Grow, also paid for staff to become trainers in the ASQ so participating child care providers statewide have access to free ASQ training and can actively implement the developmental screening tool.
The third group focused on stakeholder input on the statewide ASQ Online system. The group conducted two full sessions of mind mapping, which resulted in Early Intervention/Infant Learning Program (EI/ILP) and WCFH currently working to organize an MOU so that the Early Childhood Systems Program Manager can have access to the system to help proactively manage it, pull data to inform the UDSAC, and partner with EI/ILP to consider re-structuring the system to be more inclusive of all developmental screening provider types. Over the last year, WCFH and EI/ILP has added large organizations to the system, restructured a few ASQ Online Enterprise accounts, researched and planned for larger restructuring of the system, and planned for the transition to the upcoming implementation of the updated ASQ-4 developmental screening tool.
The final work group focused on coordinating data sharing. This group decided that the first step to coordinating data sharing was to build and conduct a statewide developmental screening environmental scan and gap analysis. This hadn’t been done since 2017 and updated information was needed to evaluate the current landscape of developmental screening in Alaska. The survey was released in December 2021 to all provider types statewide, and results were released to the UDSAC and the public in the spring of 2022. Results of the scan highlighted the increased need for training on developmental screening, especially among medical providers. 45.6% of survey respondents indicated that lack of training on developmental screening was a barrier to providing the service. This includes training to medical providers on how to get reimbursed by Medicaid and other insurance types for developmental screening services.
The scan also highlighted growth in developmental screening in that 92% of survey respondents indicated that they use the ASQ developmental screening tool, versus the 66.2% reported by respondents in the 2017 survey. In addition, it was noted that 90.3% of the participating agencies served the Alaska Native population, 88.4% served low-income families, and 74.2% of survey participants served rural populations.
Finally, a Medicaid ad hoc work group was brought together for stakeholder feedback related to developmental screening policies to increase the amount of developmental screening reported to Medicaid by eligible providers. Developmental screening is one of the reporting indicators for the Child Health Insurance Plan (CHIP), however like many other states who have chosen this indicator, they have experienced inaccurate data collection which shows a much lower developmental screening rate than what is reflected in other statewide developmental screening data sources. The group made the following recommendations:
- Revise the allowance of reimbursable developmental screening tools to reflect the American Academy of Pediatrics (AAP) endorsed tools only.
- Increase the rates for Medicaid reimbursement of the AAP recommended developmental screening tools.
- Remove the billing barrier of a modifier by Medicaid to promote increased use reporting of developmental screening in Alaska.
- Consider reimbursement by Medicaid for developmental screening done by other professionals, such as Early Intervention/Infant Learning Program staff.
State Medicaid staff participated in the creation of the statewide environmental developmental screening scan, so that the data they needed on barriers to Medicaid reimbursement was collected to help inform policy change.
Strategy 7.1.3: Support the Alaska Strengthening FamiliesTM initiative by promoting Knowledge of Parenting and Child Development through support for statewide developmental screening; by considering resilience and other protective factors in analyses and publications; and by providing workforce training.
In addition to the progress made by the UDSAC in developmental screening (see strategy 1 above), WCFH has continued to support the work of HMG-AK as the recipient of the CDC Act Early COVID Response grant. The state Act Early Team was originally created to advise on the grant activities and team members included HMG-AK, staff from WCFH, EI/ILP program staff, the Department of Education and Early Development 619 staff, the Alaska LEND Without Walls (Leadership Education in Neurodevelopmental and related Disabilities), the Alaska Mental Health Trust Authority, and the University of Alaska Center for Human Development. The purpose of the grant was to support increased developmental health promotion and activities that support resiliency building in families. The grant funded three projects that promoted resilience in families and knowledge of developmental milestones for better connection to early identification, resources, and referrals. Materials created are available for free, statewide to any provider that serves children up to the age of three. This grant opportunity was extended for a second year and the Alaska Act Early team continued to update, add, or build upon the three projects listed.
The three projects funded involved:
- Updating the CDC milestone moments booklet to be more culturally functional for Alaskan families. In the second year of this project, printing and distribution of this free resource continued and an estimated 10,000 copies have ordered and distributed thus far.
- Creating companion documents to the Ages and Stages Questionnaire developmental screening tool, which are culturally respectful and useful for Alaskan Families. Families and professionals in the Norton Sound and the Southeast regions of the state participated in this activity to create two supplementary documents. In the second year, a contractor was hired to conduct in-depth interviews with community members in the Norton Sound to ensure that the ASQ companion document met their needs and reflected their culture and way of life correctly. The Early Childhood Systems program manager and HMG-AK also created a developmental screening toolkit for Alaska Head Start agencies to host culturally appropriate and relevant developmental screening events while still meeting Head Start standards.
- Updating the CDC Amazing Me! Children’s books to include wording that reflect Alaska culture and illustrations by Alaskan artists. In the second year of this project, one of the books was adapted to Tagalog, as this language adaptation was the most requested by providers. In addition, all the books were highlighted for promotion through three new videos for families. See one of the videos here. An estimated $15,000 books were printed and distributed statewide thus far.
These materials have been promoted widely by both the Early Childhood Systems Program Manager and HMG-AK staff, including but not limited to the Maternal Child Health and Immunization conference, the Alaska Head Start Association meetings, the All Alaska Pediatric Partnership symposium, and the Home Visiting and Behavioral Intervention in Early Childhood ECHO series.
WCFH also helped promote resilience and other factors in the home visiting realm and in Alaska communities through multiple training and messaging opportunities. This included the new Home Visiting ECHO series, the weekly statewide home visiting bulletin, and through consistent messaging to the Alaska Early Childhood Network (ECN). These platforms allowed for dissemination of information on topics such as self-care for home visiting professionals and caregivers and promotion of current Alaska Strengthening Families training opportunities. Alaska Strengthening Families has been customized for Alaska Native cultures and integrates traditional cultural strengths as protective factors. Some of the home visiting workforce also received Facilitated Attuned Interactions (FAN) training, where professionals working with families learn how to promote family engagement and build staff reflective capacity.
On behalf of WCFH, the Early Childhood Systems Program Manager is also an active member of the Alaska Impact Alliance (AIA). The AIA is a working group of child welfare stakeholders, which includes Tribal, public, and private sector innovators and agency leaders building a statewide community-based prevention network that reduces the need for child protective services interventions. One of the many things that AIA members do is work together to ensure needed training is available and provided to clinicians and prevention practitioners. They advocate for and collaborate on the increased usage of culturally relevant services, promising practices, and evidence-based models in prevention. The AIA also has an internal community engagement team that provides the AIA with local information through research and relationship, informs and assists the AIA in building culturally competent programming represents the AIA and affiliated programs in the community, and promotes AIA prevention programs within the community.
Strategy 7.1.4: Review all child deaths through the Maternal Child Death Review, generate actionable recommendations for all preventable deaths and increase awareness about the MCDR program among the public, clinicians, and policymakers.
MCDR maintained a multidisciplinary committee with subject matter expert panelists including representation of Alaska’s cultural and regional diversity. During the reporting period, MCDR reviewed 27 child deaths (age 0-17). Approximately one-half of these were aged 13 and older, and one third were infants. (Please refer to the Adolescent and Perinatal Infant Domain Reports for further information regarding cases reviewed for these age ranges). Most deaths reviewed involving children aged 1-12 occurred during 2020 and were due to accidents. However, due to the rolling review schedule based on records availability and abstract completion, this is not necessarily representative of most the common causes of death in this age group. Child maltreatment, including inadequate supervision and failure to access health or behavioral health services, was often identified as a contributing factor in child deaths, including deaths from accidents and suicide. Sample recommendations from the review of these cases include the following:
- Siblings of children whose deaths are under investigation should be interviewed at a Child Advocacy Center to document interviews and link families to needed resources and services.
- School districts should provide basic avalanche awareness and safety education for children beginning in middle school and continuing in high school.
- Schools should provide water safety education to kindergarten and grade school students.
- Local municipal, Tribal and/or state governments should provide basic water safety education specific to community norms and geography for rural residents through local events and announcements, PSAs and culturally specific materials for distribution by public safety, schools, and village health aides.
- Public safety and weather service should issue warnings to community members about seasonal and weather-related safety hazards in remote/rural communities such as ice break-up and flooding.
- Municipal, Tribal and other governments should provide boating safety education to community members in villages where transportation via boats is a community norm.
- The State of Alaska and local schools should partner with communities to assess and improve road safety in their communities.
- The State of Alaska should increase funding for those covered by Medicaid to provide a variety of choices for medically adaptive resources such as glasses.
- Alaska School Districts should take a proactive approach (as opposed to relying on parents/guardians to self-advocate) to identify and support children who may need developmental screening, including assessment for FASD.
MCDR continued to be impacted by delays in receiving records needed to conduct reviews. By the end of the report period, the problem was improving with a new electronic request process implemented for obtaining records from one of the state’s largest law enforcement agencies and an MOU with the largest agency in draft form to alleviate problems caused by a new background clearance requirement implemented by this agency. Additional challenges impacting the number of cases reviewed included a vacancy in the Epidemiologist position from July through the end of the report period. There were also workload issues related to a heavier abstracting burden due to restrictions on records sharing with reviewers, and the Program Manager’s other responsibilities such as the state’s Title V Block Grant Coordinator. A positive factor has been the program’s continued focus on dissemination of recommendations through various channels including conference presentations and engagement in workgroups as prioritized at the beginning of this block grant cycle, and a more recent increase in supporting the implementation of recommendations.
A significant amount of staff attention is directed towards maternal and infant deaths due to dedicated grant funding support for these cases which provides funding support for contracted records abstraction. This impacts capacity to focus on mortality among toddlers and young children. However, the program has not lost sight of the need to leverage its evidence-based process to provide insights in support of child maltreatment and injury mortality prevention. Two of the three core MCDR staff members during the report period had subject matter expertise in child protection and the program is supported by many staff in the MCH Epi Unit, including Dr. Robyn Husa and her work on Adverse Childhood Experiences (ACEs), and the Unit’s Scientific Director, Dr. Jared Parrish, whose work on the topic of child maltreatment categorization is mentioned below (see strategy #7.1.12). MCDR also has several long-standing committee members who have strong child forensic medical and child protection backgrounds and who readily lend their expertise and time to support the program’s efforts in this area.
The program has needed to exercise adaptability as it adapts to fluctuations in workload and turnover of staff which is not unusual for roles that involve exposure to challenging topics. To some degree, vicarious trauma exposure is inherent to MCDR’s work. However, the Program Manager continues to advocate for trauma-informed workplace practices and review protocols whenever possible. The Epidemiology Specialist who left the program during the reporting period expressed strongly that had she not needed to relocate out of state for family reasons she would have stayed in the position after being with the program for more than five years. Practice changes have been implemented to maximize the time and attention staff and volunteer committee members spend working on cases that have at least some chance of preventability and which balance numerous competing priorities including the need for (1) in-depth and detailed reviews, (2) efficiency and completion of as many case reviews as possible each year, (3) high quality, consistent and complete data on mortality, (4) dedicated staff time to provide education about the program and build collaborative partnerships, share information and recommendations and, (5) support the implementation of recommendations. Program adjustments made include a new process for preliminary review of deaths due to natural causes by two clinical experts to determine preventability. If these reviewers find at least some chance of preventability, the case goes on to a full multidisciplinary panel review as usual. If not, the preliminary reviewers capture core data elements which are entered into the national database by MCDR staff, and the file is retained according to standard records retention policy and available for special reviews (i.e., of mortality related to certain medical conditions) or other reasons. MCDR will also move to a five-year cohort model during which it will review all child and maternal deaths which occurred during the first three years. Deaths which occurred during the other two years will continue to be identified, but the lengthy records request, abstraction and review process will not occur except as required by grant performance measures and as needs for topic-specific special reviews are identified. While a challenging decision, the motivation for this lies in the many hundreds of prevention recommendations the program has accumulated through its years of meticulous death review, many of which are made over and over, and which are deserving of attention and a chance to be put into practice. While neither the small MCDR team, nor the WCFH section, has capacity to lead implementation of more than a handful of recommendations, the program’s committee of experts who are knowledgeable about and invested in the process lends powerfully to mobilization of partnerships.
During the report period, the MCDR Program Manager was appointed to the Children’s Justice Act Task Force (CJATF), which is an example of a space in which the program’s data and recommendations can be shared with agency leaders who have influence over the statewide response to child abuse and community partners who participate in policy activities to address child maltreatment. With the assistance of Dr. Parrish and several other MCH Epi staff, the Program Manager prepared a presentation for the CJATF’s three-year strategic planning committee including data and recommendations pertaining to the justice, health, and social service systems and nonprofit agencies in which task force members serve as leaders. The meeting will be held in October 2022 and priority areas which the CJATF may support recommendations implementation include child sexual abuse/exploitation and trafficking, interpersonal violence and its role in child maltreatment, SUIDs and suicide, and standardization of the investigation and systemic response to suicide and other unexpected deaths in children of all ages.
In November 2021, the MCDR Epidemiologist delivered a presentation for providers on child deaths due to injury. While some of the presentation focused on mortality among adolescents due to suicide, there was also a section on unintentional injury mortality. The sample recommendations mentioned earlier in this section were among those shared with the provider audience at this presentation. Below are screenshots from the segment of the presentation on unintentional injury:
The MCDR Program Manager presented child fatality review data and prevention recommendations at the Alaska Public Health Association (ALPHA) Annual Summit through a poster presentation on findings and recommendations related to family violence (IPV) in child mortality. At the ALPHA Summit, the MCDR Program Manager also facilitated a panel discussion on standardized multidisciplinary death scene investigations and co-presented on data about families’ experiences with alcohol and substances and accessing care during the pandemic. Lead presenter was the Executive Director of Recover Alaska, a local nonprofit working on prevention of alcohol misuse. Other presentations including data and prevention recommendations on child mortality and the MCDR review process are mentioned in the perinatal/infant and adolescent domains.
Strategy 7.1.5: Support school nurses and counselors with injury prevention education and trauma informed care best practice information.
Suspension indicators from the Department of Education and Early Development (DEED) were added into the ALCANLink project data and analyzed. These analyses found that ~4% of children experienced a suspension by 3rd grade and that children with 2+ ACEs were 2.2 times and those with 4+ ACEs were 5.3 times as likely to experience a suspension during this early period relative to those with 0-1 ACEs. Along with other prior published findings linking elevated ACEs to poorer school readiness and early performance these data were presented at multiple conferences (e.g., School practitioner association, All Alaska Pediatric Partnership Meeting, and 9th Annual Advanced Trauma Training Institute).
Strategy 7.1.6: Provide analytical and programmatic support for statewide systems (e.g. New Generations) to promote screening for families in child development, family violence, addiction, and mental health.
As mentioned previously, WCFH has provided analytical and programmatic support for the statewide ASQ online system through the creation and utilization of an MOU with EI/ILP. This has allowed WCFH to gain access to developmental screening data and provide technical assistance in improving the system for increased developmental screening participation and more accurate data.
The statewide developmental screening environmental scan project was also done by the Early Childhood Systems Program Manager and staff from MCH Epidemiology, in partnership with HMG-AK and an intern student from the University of Alaska Anchorage. This data will be used to inform UDSAC activities over the next few years to help promote and expand universal developmental screening.
The Early Childhood Systems Program Manager, as a member of the AIA and in partnership with the Office of Children’s Services (OCS), also participates in a work group focused on building a map of all evidence-based prevention programs in Alaska, based on the Title IV-E Prevention Services Clearinghouse. Through this project, OCS and other AIA partners will be able to see which areas of the state have less access to the programs they need to prevent child abuse and neglect and out of home placement. This led to the identification by OCS that the Parents as Teachers (PAT) home visiting program, as a well-supported evidence-based model, should be prioritized for expansion. The PAT home visiting model includes requirements for consistent screening of family participants, including but not limited to, developmental screening, intimate partner violence, and maternal depression. Due to this, OCS has provided WCFH funding to nearly double the amount of existing State-funded PAT program and provide training for up to 20 new PAT Affiliate educators. Starting in July of 2022, OCS met with WCFH staff to plan expansion over the next four years. This expansion planning has also included increased research and planning to reinstate the PAT state office, which will ultimately provide increased technical assistance and training to home visitors (not just the PAT model), including continuous quality improvement initiatives for both home visiting data and screening of families.
As part of sustainability efforts of the past Early Childhood Comprehensive Systems (ECCS) grant cycle, the Program Manager also co-facilitates the Alaska Early Childhood Network (ECN). The ECN supports communities in improving their early childhood systems to build more resilient families through public education, resources sharing, and direct partnership with families to ensure their voices are heard and included in the community. The communities that participate in the ECN are educated and work to promote universal screening, provide support for the social-emotional needs of young children, and actively work to reduce ACEs.
In partnership with the Alaska Center for Safe Alaskan’s, MCH Epidemiology was able to acquire continued funding from the American Public Health Association (APHA) to build upon work previously conducted. This funding is supporting the development of a “prebirth household assets” screening tool. This tool incorporates predictive risk modeling of pre-birth household challenges with elevated ACEs, child welfare involvement, and poorer education performance using Alaska data. The application is focused on providing systematic approaches to clinical providers for detecting households that likely would benefit from help by parent navigation resources (e.g., Help Me Grow). This project conducted focus groups with clinical providers to understand what type of information that should be included in the output, how it could best be fit into clinical practice flow, the general appetite for this type of screening tool, and how the tool should look and feel. Early predictive models built by ALCANLink were leveraged by the Alaska Division of Public Health to apply for a 1115 Medicaid waiver that includes allowing for billing of “families and children at-risk” of developing a substance use disorder or mental illness. The elements (risk factors) identified through the modeling were mapped onto available Z-Codes that established the Home-based Family Treatment Services Qualifying billing codes.
Given this connection with the 1115 and the ALCANLink models, the natural progression was to develop a tool that could support clinical providers’ identification and services provided. The project is working to establish thresholds of risk: Currently high-risk detection threshold has an overall accuracy of 0.77, Sensitivity of 0.66, Specificity of 0.82, and Positive and Negative Predictive values of 0.67, and 0.82 respectively. The overall model has an AUC of 0.826. Among Moderate risk the specificity is reduced (0.82 to 0.62) but sensitivity is greatly increased (0.66 to 0.87). The balance of what threshold will largely depend on the capacity of the provider and the referring entity, which is primarily directed at making referrals to Help Me Grow.
The image below depicts the general design and flow of the screening application after the focus groups.
Throughout the year, the CUBS program continued to collect, analyze, and disseminate survey data on a variety of indicators of child wellbeing. An online mode of data collection was launched in September 2022 with database preparations and testing conducted throughout the previous summer. The intent of the additional mode of data collection is to increase access to more individuals, including those with lower income and less flexible schedules, however it is possible the online mode will only impact participation of people with access to technology or in urban areas. CUBS staff are actively monitoring online responses to better understand how the new mode may impact overall survey estimates as well as response rates and participation by different demographic groups.
The CUBS Coordinator presented qualitative and quantitative data from 2020 CUBS at the February 2022 Maternal Child Health and Immunization conference in a presentation titled, Early Pandemic Impacts on Alaska Families: New data from the 2020 CUBS survey. CUBS participants in 2020 reported fewer well-child checks for their 3-year-olds and fewer social interactions like playing with children outside the home on a regular basis. One CUBS participant commented, “Before Covid-19 the medical clinic…would call and have me schedule wellness appointments, let me know of vaccines due, etc. After Covid-19 I received no phone calls. He’s 3 yrs. old and only had one dental exam at 2 yrs. old because I requested it. He appears to be healthy but I just hope there's something I'm not missing. It just feels like nothing else matters besides Covid.” The CUBS program also responded to multiple data requests throughout the year and shared data directly with partners, including contractors conducting regional needs assessments in Sitka, Mat-Su and Valdez, the Alaska Public Health Association, and a hospital grant writer. The Coordinator co-authored with the Section of Chronic Disease Prevention and Health Promotion a peer-review journal article about a study that used CUBS data to evaluate the Play Every Day campaign to reduce sugar sweetened beverage consumption among pre-school aged children.
The MCH Epidemiology Unit was successfully matched with a CSTE fellow who started in September 2021. One of the major projects the fellow is working on is to develop a comprehensive ACEs surveillance system and centralize information on ACEs from multiple disparate systems. Working with a small internal workgroup and researching a variety of existing survey tools related to ACEs, the CSTE fellow has designed a statewide adult survey to measure ACEs in Alaska. This project has been named, OARS, the Overcoming ACEs with Resilience Survey. OARS will replace using BRFSS as the default tool due to the challenges of getting the ACEs module on the BRFSS system and need for data related to protective factors, resilience, and severity to direct prevention efforts already underway. After completing a draft survey, the Fellow collaborated with the Alaska Health Communications Neuro Lab in August and September 2022 to examine the survey’s flow and participant engagement via eye-tracking and emotion detection software before finalizing the tool.
A peer-reviewed publication using the ALCANLink data was published documenting a link between pre-birth household challenges and early school readiness and performance. This study expanded the work of the ALCANLink project by moving beyond child maltreatment outcomes and drawing the link between household challenges and multiple child indicators. Specifically, those born into households with 4+ challenges have persistent and elevated risks. Given the well documented relationship between school success and high school completion on a myriad of health and economic outcomes into adulthood, supporting our family’s ability to establish environments conducive to health development is critical. In response to these analyses, interest in understanding the relationship between household challenges and early school suspensions was investigated. Even though the analysis had low power, associations between the 4+ challenge group was noted.
Additional work by ALCANLink was conducted through a contract provided by the Association of State and Territorial Health Officials to expand the childhood outcomes. This project linked Medicaid records of the birth child to identify injury-related health care utilization during the first 2years of life and similarly to other outcomes noted a stepwise relationship between number of pre-birth household challenges reported and increases in risk of the outcome, with those experiencing 4+ experiencing the persistently highest relative risk.
One benefit of the rich data collected by PRAMS in Alaska is the oversampling of the Alaska Native population. This oversampling enables focused analyses to support increased understanding on the factors that may be contributing to disparities. A PhD candidate at Washington University at Saint Louis utilized PRAMS and CUBS data to investigate relationships between reported violence and child outcomes among the Indigenous populations of Alaska. The candidate is an indigenous researcher, and rather than doing comparative analysis to further document already well documented disparities, focused on group analyses to identify mutable factors.
As has been mentioned, MCH Epidemiology has been developing a data visualization tool through R Shiny to enable public access to both CUBS and PRAMS data. To enable public access however, the Senior Scientist had to work extensively with State IT and legal teams. To enable more rapid deployment rather than work to develop an internally hosted application, use of shinyapps.io was identified. This however required the development of a standardized protocol for use and can only use publicly available micro data. To meet this, the Senior Scientist conducted extensive Statistical Disclosure Control (SDC) on the CUBS and PRAMS data to identify the criteria for the creation of a public use data file that can be hosted on the shinyapps.io server.
Strategy 7.1.8: Continue to expand data sources for ALCANLink and increase the use in evaluating programs to better understand child health and development outcomes and identify specific populations in need of intervention.
The MCH Epidemiology Unit has a long history of conducting data linkages. ALCANLink is a validated systematic linkage project that has enhanced descriptive, analytic, and evaluation analyses. With all data linkages, the Unit seeks to be intentional and directional. Sources are only linked when there is a clear question or identified need, and the elements used are carefully selected. This ensures the Unit operates under the “minimum necessary”, and for the most part, have audiences for the information produced. An emphasis has been on the early childhood period, and data sources such as the Infant Learning Program have had new agreements created but due to challenges with data quality and completeness have not yet been linked.
To improve understanding of the impact that PAT is having on children, with a focus on child maltreatment and early school performance and readiness, the MOU between DEED and WCFH was expanded to enable linkages with both the PRAMS cohort and PAT participants. By having these two sources a case-cohort analyses can be completed to understand program impact. Initial analyses were completed but relied on voluntary sharing of the PAT programs, and therefore had low power to parse the data in a meaningful manner for substantive assessment. Efforts to increase the number of PAT programs providing data were successful, but the duration of time between birth and school greatly limits the number of participants. It is anticipated with another year of follow-up the power will be greatly enhanced.
Additional linkages with Medicaid and Alaska Court data were made to analyze early childhood injuries and begin focusing on understanding the population that experiences incarceration and that have children in the home.
Strategy 7.1.9: Partner with the Section of Chronic Disease Prevention and Health Promotion (CDPHP) and Tribal health systems on childhood injury prevention.
Due to the strong relationships documented between ACEs and adult health outcomes, measuring ACEs has been a priority. Adult ACEs prevalence had been measured in Alaska nearly ten years ago using the BRFSS module. This year a workgroup was convened to advocate for measurement of adult ACEs again in 2023. The workgroup determined that the BRFSS tool, while informative, was likely not feasible due to the amount of space required to add the ACEs module and the inability to comprehensively measure protective factors. Given where Alaska is with ACEs prevention work, it was apparent that simply quantifying the prevalence will do little to enhance prevention efforts. To fill this gap, the MCH Epidemiology CSTE fellow was asked to lead the development an adult ACEs survey. After receiving input from multiple partners, including Tribal and rural community partners, survey development was initiated. An extensive collection of validated questions related to ACEs and resilience were complied. The survey asks about ACEs and protective factors at all levels of the socio-ecological framework. Called the Overcoming ACEs through Resilience survey (OARS), final testing with the neuro-lab at the Centers for Safe Alaskans is being completed for validation testing. IRB determination is being sought, and funding to pay the contractor to conduct electronic based survey is being organized. It is anticipated that the survey will go live during the first quarter of 2023. Of note, during the development of this tool, community focused partners expressed concern over the lack of community level data from these large state-based surveys. To address this, the CSTE fellow is willing and able to help individual communities collect qualitative data around ACEs and resilience that can contribute to context of these statewide estimates. The intent is to reduce the perceived conflict and leverage and combine efforts of both the state and individual community-based efforts to enhance the overall understanding of ACEs and ways to prevent the impacts of them.
To support the work of ACEs, the MCH Epidemiology Unit is creating a centralized data repository of the ACEs data available, which includes the BRFSS module that was asked, Children’s Health Survey, and ALCANLink data. This will ensure that the most current information related to ACEs is available to all partners.
Additional injury focused work has been directed at supporting the Section of Chronic Disease and Health Promotion (CDPHP) injury prevention program to meet the goals of the CDC Core funding for injury prevention. This includes facilitating connections of the EIS officer in the Section of Epidemiology to compile the descriptive epidemiology of Traumatic Brain Injury and review documents. The Senior Scientist in MCH Epidemiology is trained in injury epidemiology and provides technical assistance on multiple injury related topics, serves on the Statewide Injury and Violence Prevention Partnership, and serves as a co-editor on the statewide epidemiology bulletins for non-infectious disease bulletins.
Strategy 7.1.12: Improve the reliability of maltreatment-related mortality classifications (particularly those related to child neglect and negligence) through a pilot study.
As the below graph illustrates, child maltreatment is an important factor in child mortality, including in many cases which are not the result of abusive injuries inflicted by caregivers which would typically have a manner of death listed as homicide. These data point to the need for consistent and concerted effort in Alaska, as well as nationally, to accurately quantify and describe maltreatment as it occurs in all child mortality cases to target prevention strategies and supports for families.
Presented by MCDR staff at Pediatric Grand Rounds, November 2021
Child fatalities are difficult to quantify due to a variety of issues including case definitions, data completeness, personal bias, and many others which are well-documented in the literature. The state child welfare agency is responsible for annually documenting and reporting deaths resulting from child maltreatment that meet the CAPTA definition. It is understood these definitions underestimate the number of deaths where maltreatment likely contributed to the death, because they are essentially limited to those which are “legally defensible.” To address the limitations of restrictive case definitions and to bring a public health perspective to this area, a public health classification tool was developed and tested by the Senior Scientist in the MCH Epidemiology Unit. The classification tool applies new terminology to eliminate multiple conflicting meanings for “child maltreatment” which can result in confusion. The public health classification centers on caregiver behavior as a causative factor in deaths, encompassing deaths identified as homicide by the medical examiner where the perpetrator is a caregiver, deaths designated as maltreatment by child welfare, and deaths resulting from the caregiver behavior that is contrary to a known and well-documented public health recommendation.
A series of developed case scenarios were used to test the classification tool by participants identified and invited through the network of contacts accessible through the National Center for Child Fatality Review and Prevention (NCFRP) including fatality review coordinators, case abstractors, and committee team members. The concordance between participants and with the a priori gold standard was assessed. After completion, minor adjustments were made to the tool based on qualitative feedback. A peer-reviewed manuscript is currently being developed with a goal to be submitted by the end of 2022. It was determined that to measure deaths resulting from caregiver behavior in a reliable (repeatable) manner, a hybrid of the CDR and National Violent Death Reporting System (NVDRS) approaches will likely be needed. Below is a screenshot of the draft classification tool.
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