Child Health

Priority Need – To improve all children's cognitive, physical, and emotional development.

National Performance Measure # 6 – Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year.

Developmental Screening

The annual objective for reporting year 2022 was 23%. The yearly objective was not met as stated in the MCH Jurisdictional Survey. An important caveat is that the data for this measure has a wide confidence interval due to the small sample size (CI – 0.3-14.7) of 1,250 children.

Child health is viewed holistically and through a life course development perspective by Guam Title V and Guam DPHSS. Our guiding vision encompasses the child's physical, mental, emotional, behavioral, and spiritual aspects through the phases of growth. Building capacity for disaggregation strategies based on race, ethnicity, and geography is prioritized. We continue to promote the importance and availability of well-child visits, increasing and tracking developmental screening, oral health screening, and childhood vaccinations. We work to reduce barriers to and improve connections to services.

A developmental screening is a formal process using a tool to see if a child is meeting developmental milestones. It is completed by a healthcare provider, parent, educator, or early childhood professional in collaboration with parents. Developmental screenings allow parents to understand their child's development and learning, which can significantly reduce the possibility that the child will have an undetected developmental delay.

The Preschool Development Grant Birth through Five (PDG B-5) funding provided through the Department of Health and Human Services (HHS) Administration for Children and Families (ACF) was awarded to the Guam Department of Public Health and Social Services (DPHSS) in early 2019 to support the development of an Early Childhood Strategic Plan. Throughout the process, young children ages birth through five, and their families were at the core of the work. The collective vision of Guam being "the best place to raise a child" served as the foundation of the efforts, echoed in the aspiration of all who contributed to our island's shared understanding of early childhood. Yet the reality for many Guam families dies not match this vision. The Strategic Plan contained five key strands: 1) Professional Development; 2) Policies and Governance; 3) Maximizing Parent Choice; 4) Data Systems, and 5) Quality, Accessibility, and Support. There were work groups developed to align with the key strands.

The Work Groups included partners such as – Head Start, Pilot Pre-Kindergarten/Gifted and Talented Education (GATE), Guam Early Intervention System (GEIS), Early Childhood Special Education (ECSE), University of Guam Center for Excellence on Developmental Disabilities Education, Research and Services (UOG CEDDERS), Guam Community College and Title V MCH.

PDG B-5, in partnership with other early childhood partners, re-launched the Neni 311, Guam's centralized telephone access point for parents who want information on services and support for young children. Neni 311 was re-launched on April 1, 2022, and is now part of the COVID-19 311 Hotline and is a "warm" line available Monday through Friday, 8 am – 5 pm.

An overview of the revisions and updates to the CDC Developmental Milestones Checklist was held for Care Coordinators that manage Guam’s Neni 311 warm line –

• Guam Early Intervention, Part C Program Coordinators that work closely with new intakes and referrals for early-intervention services. Parent-engaged developmental monitoring using CDC's Developmental Milestones Checklist was also held. Furthermore, online training on "Watch Me, Celebrating Milestones and Sharing Concerns" was completed.
• Project Bisita Home Visitors completed training on Parent-Engaged Developmental Monitoring using CDC's Developmental Milestones Checklist and the online activity of "Watch Me, Celebrating Milestones and Sharing Concerns."
• Guam Early Learning Council members also completed the online training of "Watch Me, Celebrating Milestones and Sharing Concerns."

Title V continued coordination with other early childhood partners to promote and offer additional training and technical assistance opportunities for the Ages and Stages Questionnaire (ASQ 3) and ASQ Social Emotional (ASQ SE).

Guam Title V has remained dedicated to assuring the early identification of children at-risk for developmental and/or behavioral challenges and for improved linkages between families and the services and supports they need. Help Me Grow (HMG) is a national framework that promotes integrated, cross-sector collaboration to build efficient and effective early childhood systems that mitigate the impact of adversity and support protective factors among families. Successful program implementation leverages existing community resources maximizes opportunities and advances partnerships working collaboratively through the implementation and cooperation of four core components: family and community outreach, provider outreach, a centralized access point, and data collection and analysis.

The Guam HMG effort is not exclusively about healthcare or developmental screening alone, even though developmental screening is a crucial component; instead, it is focused on forging partnerships to collectively address issues families face in the context of their communities. The project's focus includes access to quality care and services, social determinants of health, enhanced education and training, sustainability and accountability, and vulnerable populations. Title V and early childhood partners identified the need for resources around three audiences: families, communities, and providers. This became the foundational framework for much early childhood systems-building work and has been integrated into the PDG Strategic Plan.

Families living in Guam often face challenges when navigating the complex healthcare system. Birth to three are critical social, emotional, and cognitive development years that prepare children for school and beyond. Caring and supportive environments that promote optimal early childhood development dramatically increase a child's chance of successfully transitioning to school. Many families may need help finding the resources they need. Opportunities for health care and traditional public health systems. Differential possibilities for better health result from a much broader spectrum of societal structural and institutional norms, laws, policies, and practices.

A sustainable interaction and service delivery system within early childhood is paramount to the success of families and children ages 0-5 in Guam. Maintaining a coordinated and effective cadre of partners within early childhood leads to credible and long-lasting positive youth development. Responsive caregiving and nurturing, balanced nutrition, and safe communities are important for children to live, learn, grow, and develop to their full potential.

Home-visiting programs

Home visits are one of the several service strategies embedded in a comprehensive, high-quality early childhood system that promotes maternal and early childhood health and development. Developmental screening is a required benchmark performance measure for the Guam MIECHV Program – "Project Bisita." Project Bisita promotes and monitors parent-completed child developmental screening tools (ASQ and ASQ SE). In 2022, there was an 85% completion rate of developmental screens out of 79 families enrolled. Project Bisita home visitors are trained and continue to provide child developmental screenings, post-partum depression screenings, family violence, and other training to support families. The home visitors continue to be able to counsel first-time mothers concerned about their infant's growth and development and strengthen the relationship between caregiver and child through the use of protective factors and a source of emotional support by conducting Parent Cafés.  Some of the topics at the cafes' were "Taking Care of Yourself," "Being a Strong Parent," and "Building Strong Relationships with Your Children."

Immunization

To address the priority, need for improving childhood immunization rates, Guam Title V developed a State Performance Measure (SPM) related to Guam’s unique needs related to immunization.

The Federal Vaccines for Children Program (VFC) was established after a measles epidemic in the U.S. and became operational in the fall of 1994 under Section 1928 of the Social Security Act. VFC is an entitlement program for eligible children aged 18 and younger. Provider recruitment to maintain a strong public health infrastructure helps assure high immunization coverage levels and low incidence of vaccine-preventable diseases. The program distributes vaccines at no charge to VFC-enrolled providers to vaccinate children whose parents/guardians may be unable to afford them. This helps ensure children have a better chance of getting all the recommended vaccinations on schedule.

At the national level, CDC uses the National Immunization Survey (NIS) to monitor vaccination coverage among children 19-35 months and teens 13-17 years, and flu vaccinations for children six months to 17 years. The surveys are sponsored and conducted by the CDC's National Center for Immunization and Respiratory Diseases (NCIRD) and authorized by the Public Health Service Act (Section 306). Data collection for the first survey began in April 1994 to check vaccination coverage after measles outbreaks in the early 1990s. USING A STANDARD SURVEY METHODOLOGY, the NIS provides current, population-based estimates of vaccination coverage among children and teens. Vaccination coverage estimates are determined for child and teen vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP), and children and teens are classified as being up to date based on the ACIP recommended number of doses for each vaccine.

COVID-19 Pandemic

The coronavirus represents one of the most challenging and concerning public health crises of the last century. The COVID-19 pandemic was a multi-faceted health crisis severely affecting essential health services. All countries-initiated measures to reduce the outbreak, including social distancing, closure of nonessential businesses, and shifting healthcare resources to the response. This had widespread implications for controlling other chronic diseases and preventable illnesses.

Source: CDC NIS

The COVID-19 pandemic disrupted routine child immunization services and threatened the gains in controlling vaccine-preventable diseases. The World Health Organization (WHO) has stated that routine immunization programs were disrupted in at least 68 countries, affecting more than 80 million children worldwide, especially in poor countries. Reducing child vaccination coverage, even briefly, could increase the number of susceptible children and raise the risk of outbreak-prone vaccine-preventable diseases such as measles, polio, and pertussis.

Source: CDC NIS Survey

While the funding for childhood immunizations does not come from Title V, Title V supports the work of the Immunization Program to raise immunization rates across the lifespan. The Vaccination Coverage of Selected Vaccines among kindergarten children school year 2021-22 shows vaccination coverage with two doses of measles, mumps, and rubella (MMR) was 91.5%, diphtheria, tetanus, and pertussis vaccine (DTaP) was 89.8% and poliovirus vaccine was 90.9%.

Table below on the Estimated Vaccination Coverage Among Adolescents age 13-17 on Guam from 2017 to 2021, the result of the 2021 NIS –Teen, released in 2022, showed the rate of Gu am teens aged 13-17 years old who have received one or more doses of tetanus toxoid, reduced on the diphtheria toxoid, and acellular pertussis (Tdap) since the age of ten years was -72.7%, lower than the national estimate of 89.6%. The percentage of teens up to date on the HPV series in Guam was lower than the national estimate (54% vs 61.7%). Guam's meningococcal conjugate coverage estimate was 71% lower than the national estimate of 89%.

Source: CDC NIS

In 2022, most of the Immunization Program's and Title V efforts focused on providing education, communication, coordination, and distribution of COVID-19 vaccines. Included in these efforts was the development of media campaigns promoting COVID-19 vaccination with testimonials on why individuals choose to receive vaccination with a focus on reaching new mothers, young families, adolescents, and children with special health care needs.

Guam Title V did not change the original priority need, "to improve all children's cognitive, physical development"; however, due to the five-year needs assessment, another priority need was developed – "Promote oral health for children." The Guam Title V Program chose a new National Performance Measures (NPM) #13.2, "Percent of children, ages 1 to 17, who had a preventive dental visit in the past year.”

Oral Health

Oral health is essential to general health and well-being. There is a strong correlation between poor oral health status and other systemic diseases, such as diabetes, heart disease, stroke, and preterm and low-weight births. Tooth decay (dental caries) is a transmissible infectious oral disease resulting from an imbalance of multiple risk factors and protective factors over time. Though the prevalence and severity of tooth decay have declined among school-age children in recent years, it remains a significant problem in some populations, particularly among certain racial and ethnic groups and low-income children.

Dental caries (tooth decay) remains the most common preventable chronic infectious disease among young children and teens in the U.S. Dental caries are five times more common than asthma. If dental decay is left untreated, it can cause pain and infection leading to problems with chewing, swallowing, speaking, and learning. These problems jeopardize children's physical growth, self-esteem, and capacity to socialize. Poor oral health is also associated with missing school and poor school performance. U.S. children are estimated to miss more than 51 million school hours annually due to dental problems. Children with poor oral health are three times more likely to miss school and four times more likely to perform poorly than their healthy counterparts.

In 1967 Congress enacted the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services with Medicaid. EPSDT helps ensure that children in low-income families whom Medicaid covers have access to comprehensive and periodic evaluations to target health conditions and problems for which growing children are at-risk. These conditions include dental disease.

Source: CMS Form 416

Title V's primary activity to address National Performance Measure 13.2 was delivering oral health education to families with children from birth to age 5 through the home visiting program, "Project Bisita." Project Bisita home visitors educate families about the importance of preventive oral health care, including tooth brushing, flossing, and dental visits. Staff also provided families with oral health supplies and materials (i.e., toothbrushes).

The Bureau of Family Health and Nursing Services and the Guam Title V MCH program was granted a TA Oral Health Training with the partnership of the National Maternal and Child Oral Health Resource Center (OHRC) and the Association of State and Territorial Dental Directors to fund and provide oral health training with the lead instructor Dr. Ohnmar Tut.  The training had a lot of preparation between the Project Director of Guam Title V MCH program and with Dr. Ohnmar Tut that began 2 months prior to the training in November 28-29, 2022. There were over 20 participates ranging from RNs, LPNs, Nurse Aides, Community Program Aides, Community Health Workers from four programs.

The oral health training was titled “Fluoride Varnish and Tooth Brushing” that was conducted was done in two days at a Youth Recourse Center and Norther Community Health Center.  The training was split in 2 parts each day.  The training consisted with 10-15 staff each day that they trained in the morning with Theory on Oral Health and Practical training with children ages 4 months to 8 years of age that the staff had “hands-on” training applying “Fluoride Varnish to the children present at the Immunization Clinic.   We also had a potential Dental Officer volunteer to assist in training the staff present.  The training was a huge success that the next Oral health training to be planned for next May 2023.  

Also MCH conducted health fairs (except when COVID-19 restrictions were in place). At the fairs, staff provided education on oral health and gave out supplies. MCH also provided education at WIC clinics. Staff offered education to families about "baby bottle mouth" and its complications.

In 2022, 26 clinical staff were trained to conduct caries risk assessment and apply fluoride varnish by Dr. Ohnman Tut, oral health consultant from the Consortium for Oral Health Systems Integration and Improvement (COHSII). Following the training, staff could perform these activities in the clinical setting, such as the CHCs, MCH walk-in clinics, and Immunization clinics for children. Also part of the training from the Guam Health Disparities Program, these staff work with the community in hard-to-reach areas.

Guam's Title V Program has faced significant challenges addressing the national performance measure 13.2. Several key staff, including the Chief Dental Officer and dental assistances, retired or left the program. Efforts to hire oral health staff are underway but slow. Furthermore, the DPHSS Dental Clinic closed. Many oral health materials, supplies, and pamphlets were boxed up and stored. The dental equipment was either put into storage or surveyed out.

Parent Training

The Guam MCH has been very involved with the Guam Early Learning Council (GELC) and Programs in many committees meeting, Advisory council, subcommittee meetings, and parent activities through out the year of 2022.  Starting around May, 2022 the Preschool Developmental Grant (PDG) slowly started the Zoom Parent Café presentation with parents from the different early learning programs. So, our MCH program coordination and project director are actively involved in the meetings and our parents in the CSHCN and MIECHV programs attend the Parent Café meetings.  Our partners that are involved with the Parent Cafes are: the Guam Head start program, the Guam Early Interventions program, Guam Early Hearing screening, Detection and Intervention (GEHDI)program, Guam CEDDERS, and the Bueau of Child Wellness.  The MIECHV program had three Parent Café’s and the PDG had also two Zoom Parent Cafes in Early August, 2022.

Outreach Activities and Health Fairs

The Guam MCH program and staff have been participating with Departmental and Program outreaches and Health Fairs but only at the last quart of 2022 due to the decrease COVID restrictions that was made.  The MCH program join the Head Start Fitness Fair at the Dededo Gym in August, 2022, the Bureau of Child Wellness Fair at the Micronesian Mall in October 15,2022, Guam Immunization Outreach at GPO mall on August 10, 2022.   The MIECHV Project Bisita program and CSHCN staff participated in “Village Plays” around the island also during the last quarter of 2022 with other early childhood programs that promoted Reading, Writing, and Physical Activity with the child and parents during August- September.