Child Health: Annual Report

FY 2022 Annual Report

In 2021, there were 469,026 children from age zero to 17 residing in Idaho. Of those, 63% (297,591) were children aged zero to 11. According to the 2020-2021 National Survey of Children’s Health, 92.6% of Idaho children were described as having excellent or very good health, 93% of children had health insurance, and 73% of parents indicated their child lived in a very safe neighborhood. Idaho does not have state-funded preschool programs.

In 2021, Idaho’s children (67%) surpassed children nationally (59.9%) for maintaining a healthy weight. In the same year, 32.6% of Idaho’s children between the ages of 6 and 11 were physically active for at least one hour every day, an increase from 25.2% in 2020. The 2020 Needs Assessment (NA) highlighted a significant difference in the selection of nutrition and physical activity as a health need for young children ages 1-5 in urban counties (23%) in comparison to rural counties (0%). Similarly, nutrition and physical activity as a health need for children ages 6-11 was identified at a higher rate in urban counties (34%) than rural counties (7%).

In consideration of these data and the 2020 NA, the MCH Program has chosen to focus on three priority needs in the Child Health domain for the 2021-2025 state action plan: 1) decrease the prevalence of childhood overweight and obesity, 2) increase immunization rates, and 3) improve maternal and child health access to medical and dental homes.

Strategies in this domain will support NPM 8.1 (percent of children, ages 6 through 11, who are physically active at least 60 minutes per day), SPM 2 (percent of children at kindergarten enrollment who meet state immunization requirements), and NPM 13.2 (percent of children, ages 1 through 17, who had a preventive dental visit in the past year). These strategies and associated objectives are discussed in further detail below.

Childhood Physical Activity and Nutrition

The state selected “NPM 8: Child Physical Activity” to continue a focus on reducing childhood overweight and obesity and developed the objective of funding and supporting existing programs and initiatives to expand education and activities focused on physical activity and nutrition for children by September 2025. According to the 2020-2021 National Survey of Children’s Health, Idaho children fare similarly to children nationally for maintaining a healthy weight. About 27.1% of Idaho children ages 10-17 were considered overweight or obese (based on BMI) compared with 33.4% of children nationally. For the same time period, 32.9% of Idaho children ages 6 to 11 and 13.5% of Idaho children ages 12 to 17 were physically active for at least one hour every day.

The MCH and Idaho Physical Activity & Nutrition (IPAN) Programs continue to meet quarterly to discuss opportunities to collaborate on childhood obesity interventions. Teaching children healthy habits from the start will help them learn to make healthy choices as they grow older. Through the Healthy Kids, Healthy Future (HKHF) initiative, Idaho childcare providers have the opportunity to promote children’s health by encouraging healthier physical activity and nutrition practices through five main goals: increasing physical activity, limiting screen time, providing nutritious foods, providing nutritious beverages, and encouraging breastfeeding. Accessing the regional lending libraries is one way that childcare providers are given the tools to put into action what they have learned in the HKHF trainings and enhance outdoor and indoor play space to encourage physical activity with children of all ages. In 2018, the MCH Program purchased a variety of items and activities focused on encouraging physical activity for all the childcare lending libraries. During FY 2022, a total of 18 childcare centers had access to resources from the lending libraries through partnership with the IPAN Program, and 15 participated in activities such as painting playground areas with stencils demonstrating healthy food choices and physical activities.

In FY 2018, the IPAN Program partnered with the IdahoSTARS Program to bring a new educational training to Idaho called Be Active Kids (BAK). This program was developed by the Blue Cross and Blue Shield of North Carolina Foundations. The BAK program is evidence-based, using characters to engage children in active playful experiences and explore their natural surroundings. The Train the Trainer session was held in May 2019. Trainers through the IdahoSTARS Program began offering the training statewide beginning in July 2019 and completed 3-hour trainings with 7 childcare facilities in FY 2019. For FY 2022, a total of 46 childcare providers received the BAK training.

In FY 2021, health districts were given the option to deliver trainings on other evidence-based programs to childcare providers if HKHF and BAK did not fit their region’s needs or they had reached a saturation point for expanding HKHF and BAK. Southeastern Idaho Public Health chose to implement Color Me Healthy, an evidence-based nutrition and active living training for childcare providers. A total of 9 childcare centers and 25 staff were trained in Color Me Healthy, which included the Shoshone-Bannock Tribes’ Head Start Daycare Center. In FY22, Southeastern Idaho Public Health chose to not continue with the Color me Healthy initiative and instead chose to shift and try the Farm to ECE program.

In FY 2022, the HKHF initiative was discontinued based on feedback IPAN staff received from the health districts who implemented HKHF initiatives about reaching training saturation points in their local communities. IPAN has since shifted its focus to expand implementation of the Farm to Early Care and Education (ECE) program.

Initially, the IPAN Program partnered with the University of Idaho (UI)–Extension to implement the Farm to ECE program in childcare centers in the South Central Public Health District (SCPHD). The Farm to ECE program offers increased access to core elements of local food sourcing, school gardens, and agriculture education to enhance the quality of the educational and nutritional experience in the childcare settings. The Farm to ECE pilot program was first implemented from September 2019 through May 2020, and the curriculum and strategies were launched at 10 pilot sites in SCPHD’s region. Educators were asked to lead Farm to ECE lessons and activities four times a month in their classroom after receiving the curriculum, materials, and direction from the Farm to ECE Program Coordinator. Sites included preschools, childcare centers, family childcare homes, and K-12 school districts.

Between August and December 2020, monthly activities were adapted for children in elementary grades (ages 6-11) and included in the monthly toolkits for providers. This work was initiated to start expanding the focus of the Farm to ECE Program from early childhood settings to an older audience in alignment with NPM 8.1. During FY 2021, Farm to ECE curriculum and strategies were implemented at 11 participating sites within the SCPH district. Program assistance was provided to 2 additional sites managed by health district coordinators in the Public Health-Idaho North Central and Central District Health regions.

As of September 2022, Farm to ECE enrolled 7 childcare sites in the program from the SCPH district area. A total of 301 children, including 57 children ages 6-11, were reached through these 7 sites. Four out of the previous 11 sites shifted out of enrollment due to meeting sustainability standards. They no longer require technical assistance from UI-Extension to function and are now fully self-sufficient. The Farm to ECE program will continue to expand its curriculum in new regions and increase the number of childcare providers participating across the state.

In FY 2022, the MCH Program worked with BSU and IPAN on strengthening ESM 8.1.1 from a simple count of program participants to measuring the percentage of participating centers that include physical activity components as part of the Farm to ECE program. The following response items will be added to the program evaluation in FY 2023: 1) Held activities that promote daily physical activity (e.g. games such as Fruit and Vegetable Yoga, Fruit Tree Stretch, The Oat Lifecycle Game), and 2) “I observed positive changes in children’s participation of physical activity.”

Once new questions were identified the MCH program facilitated a group meeting in Fall 2022 with the University of Idaho, which distributes the survey and conducts data collection. The BSU Center for Health Policy and IPAN also attended the meeting to discuss the feasibility of adding questions to the survey. The University of Idaho was agreeable to including new questions on the survey in order to strengthen our evaluation strategies.

The updated survey with the physical activity-related items will be distributed to childcare centers in January 2023. ESM 8.1.1 will be updated for the FY 2023 annual report to coincide with the start of data collection.

COVID-19 Impact on Childhood Physical Activity and Nutrition

In FY 2022, BAK trainings were adapted due to the COVID-19 pandemic. Previous online iterations of the material were difficult to relay completely in a webinar, and some IdahoSTARs trainers chose not to complete training if in-person wasn’t possible. In addition, many childcare centers requested that any training be held offsite. Health district coordinators were able to accommodate these requests by hosting training at local public health district (PHD) facilities. Some sites have been unable to continue trainings for BAK due to childcare providers shifting needs and interests and a preference for in-person trainings. This shift has reduced the PHDs' abilities to utilize funds for these projects. There have been discussions between MCH and IPAN about completely phasing out this training due to decreasing interest.

In FY 2022, Fit and Fun Playscapes was not affected by the pandemic since it is able to be completed outdoors with safe social distancing practices. Fit and Fun Playscapes while a favorite activity amongst the PHDs and childcare providers, although they are reaching saturation points at local childcare centers. This activity was shifted from MCH funding to another funding source in June 2022 as fewer childcare center spaces are available that haven’t already participated in the program.

In FY 2021, sites enrolled in Farm to ECE were able to bring many of the aspects of the program back onsite, and taste testing resumed. Technical assistance in person was greatly reduced and transferred to phone or email. In FY 2022, childcare providers continued to prefer technical assistance via phone or email. The UI-Extension staff created more online training and materials to disperse to remote locations in response to this shift in how people engage in training.

Immunizations

To address the priority need for improving childhood immunization rates, the MCH Program developed a state performance measure (SPM) related to Idaho’s unique needs related to immunizations. For the 2021-2022 school year, 80.7% of kindergarteners and 75.3% of seventh graders met state immunization requirements for school enrollment. To support this SPM, the MCH team developed the objective of collaborating with the Idaho Immunization Program (IIP) to increase vaccination education and vaccine uptake among MCH populations. Measurement of the objective will be based on an inventory of programmatic activities related to immunizations and IIP data. Strategies to address this objective and SPM are discussed below.

One mechanism to help increase vaccine coverage in Idaho is the Vaccine Assessment Fund. The required state match for Idaho’s Title V MCH Block Grant is achieved through this dedicated fund for state-supplied vaccines for privately insured children. Private insurance companies make a yearly payment into the Idaho Vaccine Assessment fund based on the number of insured children they cover and the vaccine assessment rate. This allows the IIP to purchase vaccines at the discounted federal rate. Idaho is a universal supply state, which means all children under 19 years of age are eligible for state-supplied vaccines regardless of insurance status. Medical providers place orders for vaccines through the IIP and are able to maintain a single stock of vaccines for their pediatric patients. The universal supply is supported by the Idaho Vaccine Assessment Fund, the Vaccines for Children (VFC) Program (covers children with Medicaid or who are uninsured, underinsured, American Indian and Alaska Natives), and the Separate Children’s Health Insurance Program. Ultimately, insurance companies realize cost-savings through the assessment fund. The MCH Program will continue to support the work of the IIP to provide education to the public and health care providers about the importance of immunizations, addressing immunization hesitancy, and best practices to increase immunization rates. As of July 2021, vaccines were administered to 316,172 individuals under 18 years of age who were eligible through the VFC Program and to 246,332 individuals under 18 years of age who were eligible through the Vaccine Assessment Fund. The IIP was not able to provide updated data for FY 2022 due to data exchange issues that could compromise the data accuracy.

The IIP continues to receive funding from the Centers for Disease Control and Prevention (CDC) and from the State of Idaho to operate the state immunization program. Improving childhood immunization rates is a primary focus for the IIP. Immunization promotion activities continue similar to previous years, including immunization awareness campaigns for the public (with special emphasis on infants, expecting parents, and new parents), provider education and trainings through statewide workshops and conferences, and implementation of the Immunization Quality Improvement for Providers (IQIP) formally known as Assessment, Feedback, Incentive, and eXchange (AFIX), a quality improvement activity targeted to immunization providers conducted throughout the state. IQIP promotes and supports implementation of provider-level strategies designed to help increase on-time vaccination of children and adolescents. As of July 1, 2022, a total of 50 VFC-enrolled providers with adolescent patients 13 years of age and 50 VFC-enrolled providers with adolescent patients 17 years of age have participated in the IQIP.

COVID-19 Impact on Immunizations

In FY 2021, the majority of IIP’s efforts continued to focus on providing education, communication, coordination, and distribution of COVID-19 vaccines. Included in these efforts was the development of a large media campaign promoting COVID-19 vaccination with testimonials from real Idahoans on why they chose to receive their vaccine, with a focus on reaching new mothers, young families, adolescents, and children with special health care needs. The real testimonials came from volunteers who also recorded shorter clips with general vaccine support that the IIP will be able to use in the future.

The IIP was also able to partner with a wider network of healthcare professionals, community-based organizations, and other organizations interested in protecting Idahoans. IIP’s goal was to leverage some of the COVID-19 successes and the wider network to increase routine vaccinations following the rollout of COVID vaccines for children 5 years old and younger. Despite building a wider network, the IIP saw notable declines, especially in the spring of 2021, in the administration of routine vaccinations.

In FY 2022, the IIP focused on routine childhood vaccination while continuing to oversee and administer the federal COVID-19 vaccination program. There have been few changes in their ability to use funds or introduce new approaches from FY 2021 to FY 2022 due to the ongoing COVID-19 focus.

Pediatric Oral Health

To address the priority need to improve MCH population access to medical and dental homes, the MCH Program continues to fund the Idaho Oral Health Program’s (IOHP) contracts with the PHDs for dental care among school-age children. In 2014, the PEW Charitable Trusts assigned the state of Idaho an “A” grade for protecting children from tooth decay with the application of dental sealants. Idaho was one of only five states to receive this distinguished grade. According to the Centers for Disease Control and Prevention (2015), dental sealants are a critical preventive dental service and can reduce decay by 60 to 80 percent in two years after application. Further, school-based dental sealant programs (SSPs) are a great way to reach children and result in cost-savings for families. The reason Idaho is top in the nation for protective sealants is due to many collaborative networks involving private and public entities.

The IOHP has provided preventive oral health services to infants, children, and adolescents, especially those who are at-risk for dental disease, for more than 35 years. The program leverages funding from the Title V MCH Block Grant and the Centers for Disease Control and Prevention, and subgrants with the seven local PHDs to deliver these efforts. 

The IOHP works with subrecipients to deliver oral health education (live or virtual) to healthcare providers or pregnant women in various settings (e.g., WIC clinics, Head Start, Early Head Start, Migrant Head Start). This education may take place either one-on-one or in group settings. The program uses the Perinatal Best Practice model outlined by the Association for State and Territorial Dental Directors (ASTDD) as guidance on the delivery of this education. The program encourages subrecipients and other organizations to utilize Smiles for Life: A National Oral Health Curriculum, which is an evidence-based resource for healthcare providers and others to ensure the integration of oral health and primary care. The IOHP also has oral health educational materials available for pregnant women via its Health Tools website. In FY 2021, these materials were updated and translated into Spanish and other supplies were purchased, including sippy cups, washcloths, toothbrushes, floss, and timers to be used as incentives when encouraging regular preventive oral health visits for pregnant mothers, infants, and children. Dental referrals are provided, as needed, in addition to referral resources such as assistance with finding a Medicaid dental provider.

In addition to the efforts listed above regarding oral health education and pregnant women, the program works with the PHDs to ensure the importance of infant oral health is included in any type of education specific to the target population of pregnant women. The IOHP encourages the PHDs to deliver oral health education on infants to parents and caregivers in addition to preventive oral healthcare services. Preventive oral healthcare services include oral health screenings or assessments, fluoride varnish applications, and dental home referrals as needed. PHDs utilize evidence-based approaches to deliver programs to early education childcare providers, pediatricians, and primary care providers. One of the PHDs, Central District Health (CDH), has implemented the First Teeth Matter Program (FTMP), which has a specific focus on early childhood caries prevention for ages 0-3. The FTMP offers appointments (approximately 20 minutes in length) to parents and caregivers where information on early preventive oral healthcare is provided. During the appointment, a Registered Dental Hygienist talks with the parent or caregiver and performs an oral health screening of the child's mouth. The visit helps determine the child's risk for developing cavities and includes motivational interviewing, goal setting, oral health education specific to the child, and a fluoride varnish application. In 2021, the CDH dental hygienist developed a framework for the FTMP to share with other health districts, enabling them to incorporate a similar program in their communities.

During the timeframe of July 1, 2021, through June 30, 2022, the IOHP continued to subgrant with the PHDs to deliver fluoride varnish programs, including the delivery of oral health screenings or assessments and fluoride varnish applications, to children with a specific focus on ages 0-5. Fluoride varnish programs are provided at an array of locations (e.g., WIC clinics, Head Start, Early Head Start, Migrant Head Start, childcare centers, and elementary schools). For children ages 6-11, the IOHP subgrants with the PHDs to deliver school-based dental sealant programs, which include the delivery of oral health screenings, fluoride varnish applications, and dental sealants as needed. This program is focused on elementary and middle schools with 50% eligibility in the Free and Reduced Meal Program, or schools in counties considered by population to be 50% or more rural by the U.S. Census Bureau. In addition, the PHDs always deliver oral health education either directly to children, caregivers, parents, or teachers (depending on the type of program being delivered) along with providing a dental home referral as needed. The program also conducts the Idaho Smile Survey, an oral health basic screening survey, every four years to assess the oral health status of third-grade students in Idaho. The program shares the results of this survey statewide to guide programmatic and policy decision making.

In FY 2022, SCPHD continued to collaborate with two adolescent facilities, Snake River Juvenile Detention Center and the Twin Falls Safe House, to deliver school-based dental sealant programs. Snake River Juvenile Detention Center serves teenagers aged 12-18 years old who have been detained for committing a crime. The Twin Falls Safe House is a short-term facility and serves teenagers aged 12-17 years old who have been removed from their homes temporarily. The adolescents stay until they can return to their own home or a foster home. Through both programs, SCPHD provides oral hygiene and prevention education, and educates youth on the effects of vaping, marijuana, cocaine, meth, heroin, alcohol, sodas, energy drinks, piercings, eating disorders, and Human Papilloma Virus (HPV) infection on the oral cavity.

The 2016-2017 Idaho Smile Survey Report states, “More than half, 67.2 percent, of Idaho third-grade students had dental sealants on at least one tooth recommended for sealants. The Healthy People 2020 goal for children aged six to nine is a rate of 28.1 percent or better on one or more of their permanent first molar teeth. The rate has improved in each survey from 2001 with a statistically significant increase of 13.6 percent.” For Healthy People 2030, the goal will shift to 42.5 percent or better for children aged 3 to 19 with dental sealants on at least one tooth recommended for sealants. Due to the COVID-19 pandemic the next Idaho Smile Survey will not be conducted until the 2023-2024 school year.

For FY 2022, a total of 1,231 children received dental sealants in school-based settings through the IOHP and a total of 6,019 children received fluoride varnish treatments. This is a favorable increase from FY 2021, when a total of 724 children received dental sealants in school-based settings and 2,839 children received fluoride varnish treatments.

The IOHP partnered with the Idaho Oral Health Alliance (IOHA) to develop the state oral health action plan (2021-2026 Oral Health Improvement Plan) and implement the Healthy Me is Cavity Free (HMCF) Collaborative. The 2021-2026 Oral Health Improvement Plan was completed in August 2021 using input from a 51-member workgroup. The plan was shared statewide during the 2021 Idaho Oral Health Summit and IOHA will complete yearly “report cards” to update the progress of the plan and share partners’ efforts in implementing the goals and objectives of the plan. The HMCF Collaborative specifically identifies sustainable system changes or solutions to help prevent and control tooth decay in children ages zero to 6. Both the IOHP and IOHA ensure prioritization and inclusion of efforts for pregnant women. When funding is available, the IOHP also supports speakers delivering oral health education presentations at various conferences such as the Idaho Perinatal Project Conference, Idaho Oral Health Summit, and the Early Years Conference. Additionally, the IOHP and the IOHA will work together to plan and deliver the 2023 Idaho Oral Health Conference. The conference will foster private and public health partnerships between the traditional and non-traditional oral health workforces. Topics will include medical-dental collaboration, innovative ways to improve community oral health, dental Medicaid navigation teledentistry utilization in Idaho, and rural partnership successes.

In FY 2022, the IOHP reran the statewide Maternal Oral Health media campaign from FY 2021. The media campaign aimed at reaching pregnant women to encourage routine preventive oral health care visits and to promote the importance of oral health in infants and children. The campaign included audio messages delivered on Pandora and Spotify, social media messages on Facebook, Instagram, and Pinterest, and a YouTube video. The media campaign had great success. The table below provides an overview of the 2022 campaign:

COVID-19 Impact on Oral Health

In FY 2022, some PHDs continued to face challenges in delivering oral healthcare services due to the COVID-19 pandemic, although many oral health efforts have returned to pre-COVID status. Some PHDs determined it was necessary to go off-site to deliver fluoride varnish clinics. They were very successful in schools and Head Start centers where the programs were offered. In most areas of the state, the PHDs that delivered SSPs noticed increased participation from schools. PHD dental hygienists found additional opportunities to provide oral health education, supplies, and referrals to youth and pregnant women by collaborating and coordinating with leaders of other PHD programs, such as Parents as Teachers and Nurse-Family Partnership programs. The IOHP continues to encourage innovative ways to promote oral health and deliver preventive oral healthcare services.

While the pandemic did impact the delivery of oral health services, it also promoted innovation and adaptability. Many of the PHDs went virtual with their oral health education to pregnant mothers and presentations to primary care providers. In 2021, the Caregiver Education Committee, a subcommittee of the HMCF Collaborative, provided a virtual training for caregivers through the Super Saturday series in which 27 caregivers were educated on children’s oral health. A resource guide, board books, and a stuffed animal to demonstrate toothbrushing were sent to each participant.

In FY 2022, both the Provider Education Committee and the Caregiver Education Committee, sub-committees of the HMCF Collaborative, provided trainings. The Provider Education Committee developed an 8-part webinar series, Putting the Mouth Back in the Body: How Oral Health Affects Whole Patient Care. The one-hour webinars occur every other month and focused on oral health/whole health topics. Featured presenters had varying backgrounds, with some from the medical community and some from the dental community. The Caregiver Education Committee delivered trainings based on a previously successful curriculum from Cavity Free Kids. The first few in-person sessions allowed attendees to participate in fun learning stations where they engaged in oral health activities that could be easily recreated and shared with the children they regularly work with. With illnesses and challenges scheduling the in-person trainings, the remaining trainings moved to a virtual platform and were better attended. However, trainers and participants felt that the virtual trainings still met expectations and provided attendees with the needed skills. With the success of the virtual trainings, this delivery method will likely continue to be used in the future. 

In FY 2022, IOHP had to postpone the completion of the Idaho Smile Survey again due to a variety of school policies and restrictions. The last survey was completed during the 2016-2017 school year and the next survey is planned for the 2023-2024 school year.

The impacts forecasted for FY 2023 are similar to previous years and include fewer in-person offerings, such as WIC clinics. PHD staff will continue to seek off-site venues to offer fluoride varnish clinics and ultimately may see fewer children for services. Some areas continue to have more restrictions in their schools and do not allow visitors. Health districts will need to be strategic in educating school leadership on the importance of oral health, access to care issues, and the valuable preventive services they offer.

Childhood Lead Poisoning Prevention

In FY 2022, the Division of Public Health’s Environmental Health Program (EHP) was awarded funding to reduce childhood lead exposure through primary and secondary prevention strategies. This CDC funding will be provided until 2026. Over the next five years, EHP will work closely with healthcare professionals to ensure a comprehensive system of identification, referral, follow up, and evaluation is in place for children exposed to lead. The goals are to reduce and prevent environmental lead hazards and connect lead-exposed children to medical, environmental, and social services to improve health outcomes.