NPM 6 - Percent of children, ages 9 through 35 months, receiving a developmental screening using a parent-completed screening tool

 

Introduction: Developmental Screening

For the Child Health domain, Hawaii selected NPM 6 Developmental Screening as a priority. based on the 2020 five-year needs assessment. By July 2025, the State sought to increase the proportion of children, ages 9 through 35 months, receiving a developmental screening, to 45.0%.

 

Data: Aggregated data from 2019-2020 showed the estimate for Hawaii (41.2%) met the 2021 state objective (41.0%) but was not significantly different from the 2020 indicator (31.6%) and the national estimate of 36.9%. Due to the small sample size, results for this measure should be used with caution. The related Healthy People 2030 Objective for developmental screening (35.8%) was met. There were no significant differences in reported subgroups by health insurance, household income; but again, this may be due to the small sample size.

 

Objectives: Considering the baseline data, data limitations, and the HP 2030 objective, the State objectives through 2025 were set to reflect an annual increase of one percentage point.

 

Title V Lead/Funding: Developmental screening remains a priority since 2010 for Family Health Services Division (FHSD), which coordinates federal, state, and local efforts on screening, referrals, and services. In FY 2022, the lead for this priority transitions from the Children with Special Health Needs Branch (CSHNB) Early Childhood Coordinator (state-funded) to the new HRSA ECCS grant funded coordinator located at the division level. Title V does not directly fund developmental screening program staff and activities but does support management, epidemiology, data, and administrative positions that contribute to the NPM.

 

Partnerships: There is broad collaboration among statewide agencies and stakeholders working toward a statewide systematic approach to developmental screening. This includes medical partners, early childhood providers, and community-based nonprofits who conduct developmental screening and ensure children are connected to services or supports if a concern is identified. Development screening is also identified as a priority in several key state plans, including:

• Executive Office on Early Learning (EOEL) Early Childhood State Plan for 2019-2024
• EOEL Early Childhood Strategic Implementation Plans “Early Childhood Health and Family Wellness”
• Early Childhood Action Strategy (ECAS) and the Hawaii Community Foundation (HCF) and DOH’s Infant and Early Childhood Behavioral Health Plan
• Maui County plan for the early childhood collective impact team, Kākou for Keiki (translation: All of us [together] for children).

 

Strategies/Evidence: Hawaii’s five developmental screening strategies focus on systems-level approaches and follow guidance from three sources:

• Federal ECCS Impact Grant, which was a five-year grant from 2016-2021 focusing on establishing a system for developmental screening in Maui County
• HRSA’s Title V “State Technical Assistance Meeting” in March 2016
• The national MCH Evidence Center

 

The five strategies are:

• Build systems and infrastructure
• Implement family engagement and public awareness activities
• Ensure data collection and integration
• Address social determinants of health and vulnerable populations
• Assess policy and public health coordination

 

The last strategy is assessed via a Policy and Public Health Coordination Scale (PPHC) designed to monitor implementation of the systems-level approaches and is used as the NPM 6 strategy measure (ESM 6.2).

 

The HRSA ECCS Impact grant best practices promote working with early childhood providers to ensure that screenings are done as part of their assessment of children’s development and is supported by:

• National Association for the Education of Young Children (NAEYC) Accreditation
• Head Start Performance Standards
• National Institute of Early Education Research benchmarks for early education programs

 

Hawaii works regularly with these programs to ensure the national standards are implemented.

 

Research compiled by AMCHP and the MCH Evidence Center indicates that there is evidence-based support for training of healthcare providers on developmental screening and screening through home visiting programs, although further evidence is needed. Following these promising practices, Hawaii provides community-based trainings on the Ages and Stages Questionnaires (ASQ) to both healthcare and early childhood providers. Although quality improvements in both healthcare settings and systems-level approaches were found to be effective, Hawaii’s Title V agency does not have direct control over healthcare settings and therefore chose a general systems approach to continue quality improvement practices. The Evidence Center indicates that Hawaii’s ESM 6.2 has ‘moderate evidence’ related to QI activities.

 

Updates for 2021 on the five strategies follow.

 

COVID Impacts: Safety restrictions eased as COVID cases remained manageable and vaccination numbers increased. Childcare, early learning programs, and public schools returned to in-person learning in Fall 2021. Doctors’ offices continued to implement safety protocols and began in-person as well as telehealth visits. Resurgent pandemic concerns may have led to renewed delays in healthcare visits and could have also led to fewer children receiving screenings for developmental delay. With increased vaccination numbers, pandemic restrictions continued to loosen in FY 2021.

 

Strategy 1: Systems Development – Develop infrastructure to coordinate developmental screening efforts

The activities for this strategy focused on systems and policy development to support increased child developmental screening. Hawaii’s healthcare and early childhood sectors are crucial partners to ensure that the four stages of developmental screening: screenings, referrals, services, and supports occur.

 

Guidelines on Screening and Referral: “Hawaii Developmental Screening and Referral Guidelines for Early Childhood and Community Based Providers” are available online at https://health.hawaii.gov/cshcn/hiileihawaii/ to provide standard information for those conducting developmental screening of children ages birth through five years of age. They are based on national resources, including the American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC) “Learn the Signs. Act Early“(LTSAE), Bright Futures, and other resource centers.

 

These guidelines also include local best practices and were vetted with early childhood and medical providers and other key stakeholders. Because of the pandemic and the shift to connecting with families remotely, the guidelines were revisited with stakeholders to ensure the information was relevant for either in-person or virtual screenings. Adding a seven-day timeframe from positive identification to service referral is under consideration in order to expedite the referral process and also minimize the wait time for families to receive services. However, it may also serve to reduce the number of programs conducting screenings since programs may not be able to meet the recommended timeframe.

 

Workforce Training: Hawaii received a second LTSAE technical assistance grant from the CDC in 2021. A needs assessment was conducted with system partners who participate in the developmental and autism screening process. Strategies to address barriers to care and improve resiliency among children and families are being developed and implemented. Hawaii’s LTSAE Team (comprised of the LTSAE Ambassador, a Project Assistant, and the CSHNB Early Childhood Coordinator) presented to child welfare programs, Early Head Start/Head Start Health Specialists, WIC Nutritionists, and the MCH LEND enrollees on the different screening tools and the referral processes for children identified with a developmental concern. Several ASQ trainings were also conducted for early childhood programs statewide, including EOEL Resource Teachers who will screen children in the EOEL Pre-Kindergarten program.

 

COVID generated greater provider interest in online tools/services. Five major Maui family service organizations partnered to use the ASQ Online Enterprise program, and training was provided to program staff so online screening services could be offered to families.

 

The ECCS Coordinator on Maui collaborated with the LTSAE Ambassador to work with Maui pediatricians to promote more developmental screening. However, the pandemic resulted in switching in-person training to online and may have resulted in reduced provider/client attendance. Providers showed interest in the new developmental screening tool, the Survey of Well-being of Young Children (SWYC), but expressed concern that referral source to meet family well-being needs were not readily available. Most Maui early childhood providers continue to use the ASQ-3 and ASQ:SE2. Training is available for providers to learn more about this tool.

 

New ECCS Grant: Hawaii applied for and received new funding for ECCS Health Integration Prenatal-to-Three Program (HIPP), which shifted the ECCS grant focus from community-based development screening systems building to statewide infrastructure building of a coordinated maternal and infant childhood system of care to strengthen developmental screening supports, among other outcomes. Since the ECCS HIPP grant requires the formulation of a strategic plan, the completed developmental screening strategies and outcomes will be integrated into this Title V priority.

 

Strategy 2: Family Engagement & Public Awareness

This strategy focused on engaging families to promote the importance of developmental screening and child development. The continuation of COVID restrictions resulted in many childcare program closures and other family support programs shifting to online platforms in 2020-21. Through 2021, families continued to struggle with job/income loss while also taking primary responsibility for the daily care and education of their children. This raised concerns among providers about increased substance use, family violence, and mental health concerns that was exacerbated by social isolation due to the pandemic. While promoting child development remained a priority, service providers focused on addressing more immediate family and child needs and messaging on self-care.

 

Outreach to Families: Many family organizations moved to online platforms and conducted virtual family support group meetings to connect families. One parent group, Leadership in Disabilities and Achievement of Hawaii (LDAH), conducted parent groups using Facebook Live. The CDC LTSAE project coordinators presented on the LDAH Facebook Live presentation, which was attended by 56 participants and was recorded and archived on the LDAH website.

 

Social Influencers: The LTSAE project tested the use of social influencers to help promote the importance of developmental screening. Three mothers with young children between the ages of birth through five were selected as social influencers to reflect the target population. The influencers were provided a stipend of $1,500 to promote the material and information through Facebook, Instagram, and Facebook Live. Through the use of the social media platforms, the influencers were able to promote the free CDC Milestones app to track a child’s developmental milestones with a total of 972 likes and 1,264 views. On an Instagram story poll, most of the 109 parents of children birth through five had not heard about the app or the material.

 

Kākou for Keiki, Maui County’s early childhood ECCS Impact team, used Facebook and Instagram to promote developmental screening, family engagement skill building/opportunities, program supports in the community, and caregiver self-care as a means to promote healthy development in children ages 0-5. The ECCS Impact team also printed and distributed postcards that marketed the CDC Developmental Milestone App, VROOM App, and Spotify playlist links for young children in order to encourage on-track development. Postcards were distributed at prenatal, fatherhood, early childhood, and early literacy community drive-up events. Developmental, social emotional, and health/wellness kits were also offered at medical offices and food distribution sites, reaching over 400 families in Maui County in 2021.

 

Screening Information Websites: Hawaii continues to work with the Early Childhood Action Strategy (ECAS), a public-private collaborative that focuses on children’s issues from prenatal through age eight. The CSHNB Early Childhood Coordinator leads the ECAS On-Track Health and Development Team. Documents on screening are housed on the ECAS website, which provides information about child development (https://hawaiiactionstrategy.org/). The DOH CSHNB website houses developmental screening information on its website: https://health.hawaii.gov/cshcn/aboutus/.

 

Throughout 2021, FHSD and other direct service programs for children and families saw varying levels of service utilization due to COVID restrictions. As vaccinations rates increased and services reopened, client services started to increase but did not return to 2019 levels. Based on a general decline in screening services numbers, Hawaii embarked on a public awareness campaign to promote in-person well-child visits to ensure that biometrics and preventive screenings could be conducted. More information on the campaign is available in SPM 5.

 

Strategy 3: Data Collection and Integration

This strategy originally focused on internal collection of developmental screening data among Title V early child programs. This activity has been completed, thus the work has shifted to acquiring population-based developmental screening data to monitor system needs.

 

National Survey on Children’s Health (NSCH) data: The latest NSCH data for this NPM is for 2019-2020, which may not reflect the full impact of COVID. In addition, there are several issues with the NSCH data that limit its utility to inform planning and address health equity. While the survey provides standard state-level estimates, the subset of data reported for this measure is small and estimates are unstable and do not reflect clear trends. For instance, although the 2021 indicator (41.2%) is higher than the 2020 data (31.6%), it is not statistically significant and we cannot conclude screening increased since the difference may be due to variability. Moreover, the race/ethnicity data collected by the NSCH is not specific and defined in enough detail to reflect Hawaii’s Asian, Native Hawaiian, and Pacific Islander populations, and county-level data is not available to help inform preventive strategies.

 

FHSD explored NSCH survey oversampling for several years with the MCH Bureau, but there are too many cost/administrative barriers. The NSCH survey question asks parents about screenings that occur only in a healthcare provider’s office; however, Hawaii’s developmental screening efforts include work with early childhood providers and other community-based service organizations, so the data may be incomplete and not include the efforts of the Hawaii team and partners since they occur outside of healthcare providers’ offices.

 

Medicaid: The Hawaii Medicaid Program did not report on the CMS healthcare quality measure for Developmental Screening for up to age 3 in 2020. Only 28 states reported on this optional measure. However, a new Medicaid RFP issued in 2021 included development screening as a health priority for Hawaii’s five state Medicaid insurance plans, and data should be available on this CMS QA measure in the future.

 

While Medicaid healthcare providers are requested to document developmental screening information in client records, it is unclear to what extent health insurers are collecting and using the aggregated data for performance or quality improvements. Also, healthcare providers may not use validated screening tools but may instead be relaying on their clinical judgment or observation to identify concerns. Although health insurance coverage is relatively high in Hawaii, families may experience obstacles to scheduling well-child visits and therefore miss the recommended developmental screenings.

 

The Hawaii State Department of Human Services (DHS) Child Care Program requires all parents/caregivers at licensed childcare programs to report developmental screening and other health data for each child, but none of this data is currently reported to DHS and is kept on file by the childcare provider.

 

Title V Program Data: Developmental screening data is collected and reviewed for quality assurance and monitoring from FHSD’s early childhood programs: MIECHV, ECCS Impact Grant, Hi’ilei, and Early Intervention. Data is currently available for 2021.

 

Data from the MIECHV Home Visiting program for FFY 2021 indicated that of the total of 559 children enrolled in the program, 222 children were eligible for screening. Per AAP screening recommendations and MIECHV reporting requirements, 71.6 % of the eligible 222 children were screened for developmental delay. Of those children with positive screens for developmental delays, 85.7% of children received services in a timely manner, an over 10% improvement from last year.

 

The Hiʻilei Developmental Screening Program provides parents and caregivers the option of completing an online screening or completing a paper copy of the developmental screener through the mail. FFY 2021 Hiʻilei data shows that a total of 16 children birth through 5 years were screened. Two of the children were found to be in the “monitoring” range. Five of the children were found to be in the referral range and information on activities to support their children’s optimal development were provided to the parents.

 

ECCS Grant: By the end of the ECCS Impact grant, screening data was collected from at least fifteen childcare and early education providers serving Maui County. In FY 2021, the providers screened 324 children, a substantial increase over the past five years of the grant. At the grant ending, over 500 children were screened. To sustain efforts beyond the grant, Maui now has nine certified ASQ Trainers who will offer ongoing trainings to providers at least two to three times a year.

 

Early Intervention Service (EIS): In 2021, of the 2,640 evaluations that were conducted, the majority of the referrals were found eligible. With the pivot to telehealth during the pandemic, EIS conducted partial evaluations to identify developmental delays since the standardized tool (Batelle Developmental Inventory) could not be administered in person. If the team felt the child was within age expectations and the family concurred, the child was deemed ineligible. Effective April 1, 2021, EIS used the Developmental Assessment for Young Children (DAYC), which is a standardized tool that can be done remotely via interview. All children with partial evaluations were reevaluated and eligibility established unless the child exited prior to the initiation of the DAYC.

 

EIS referrals come from various sources, with 61.6% of referrals coming from primary care providers, 24.4% from families, 11.7% from community providers, 0.3% from resource caregivers, and 1.9% from child welfare. Programs providing referrals include childcare, home visiting, public health nursing, Early Head Start, and healthcare or social service providers.

 

Developing a coordinated data system for FHSD around screenings and referrals was difficult to address since programs collect data using different parameters, including timeframes and the different ages at which children are screened often based on funding guidance.

 

Strategy 4: Social Determinants of Health

This strategy focused on partnering with programs and agencies that work with underserved populations.

 

In late 2019, the Kauai WIC office piloted the use of ASQs and a program was slated to start in Maui WIC clinic waiting rooms, which was disrupted by COVID closures. The CDC LTSAE team did a presentation to the WIC Nutritionists on a simpler CDC Checklist for 2- and 3-year-olds, referring families to the appropriate agencies if there is a developmental concern. The protocol for using the checklist was developed by WIC administrative staff. The launch of this effort began during the pandemic at a time when WIC enrollments increased and visits switched from in-person to remote. Hawaii will be monitoring the effectiveness of this pilot.

 

SWYC: In FY 2020, Title V began discussions with the AAP–Hawaii Chapter and Hawaii’s Medicaid agency to promote use of the SWYC since it was added to the national AAP list of validated screening tools. Because the SWYC is a free tool and also covers behavioral and family well-being (including social determinants of health), referrals may be broader than IDEA Part C (EI services), and Department of Education developmental services. Hawaii will continue to work with partners on adoption of this new tool, which can also help screen and identify social economic needs of children and their families.

 

To support physician concerns about an accessible referral site to provide information for families, planning is underway to create a centralized resource directory of state services. To provide more responsive accessible resources, the site will include county specific resources. Title V is part of a workgroup led by Hawaii’s First Lady to create the directory, ‘No Wrong Door.’ The system will have coordinated intake and referral process to access a large array of state services. The system is operational currently but is adding more services and users.

 

Strategy 5: Policy and Public Health Coordination

The purpose of this strategy is to track FHSD’s infrastructure development efforts to help to improve developmental screening rates of children.

 

ESM 6.2 – Develop and implement Policy and Public Health Coordination rating scale to monitor developmental screening efforts around the areas of systems development, family engagement, data collection/integration, and addressing vulnerable populations.

 

	2018	2019	2020	2021	2022	2023	2024	2025
Annual Objective		12.0	18.0	24.0	27.0	30.0	30.0	30.0
Annual Indicator		23.0	26.0	26.0

 

ESM 6.2 Policy and Public Health Coordination Scale

Hawaii developed a Policy and Public Health Coordination Scale (PPHC) to monitor progress on Title V efforts to improve developmental screening rates of children. The scale (below) reflects the activities in the NPM 6 logic model and workplan, including Systems Development, Family Engagement and Messaging, Data Collection/Integration, Addressing Social Determinants, and Policy and Public Health Coordination. The MCH Evidence Center rated this ESM as a strong quantifiable measure. Completion of the scale is self-reported by the EC Coordinator who oversees all the activities.

 

The total possible points for the scale are 30. The FY 2021 indicator was 26 and met the annual objective set at 24. Despite the pandemic, progress was made in systems development, family engagement, and addressing vulnerable populations. The rating scale is used by the EC Coordinator to track progress on the NPM 6 strategies. Scores show room for improvement in the areas of family engagement, social determinants of health identification, and work with stakeholders.

 

Element	0 Not Met	1 Partially Met	2 Mostly Met	3 Completely Met
Systems Development
Develop guidelines and toolkit for screening, referral, and services.				x
Work with partners to develop infrastructure for ongoing training, technical assistance, and support for providers conducting developmental screening activities.			x
Family Engagement and Public Awareness
Work with families and parent organizations to develop family-friendly material explaining importance of developmental screening and how to access services.			x
Develop website to house materials, information, and resources on developmental screening.				x
Data Collection and Integration
Develop data system for internal tracking and monitoring of screening, referral, and services data.				x
Develop process for on-going communication to review data findings and adjust for better outcomes for children and families.				x
Social Determinants of Health and Vulnerable Populations
Develop process for identifying vulnerable populations.			x
Work with stakeholders to address supports and targeted interventions for vulnerable populations.			x
Policy and Public Health Coordination
Develop Policy and Public Health Coordination Rating Scale.				x
Conduct process for annual assessment of rating scale.				x
Total Score	26 out of 30

 

Current Year Highlights for FY 2022 (10/1/2021 – 6/30/2022)

Re-examining Strategies: Hawaii is reviewing its strategic approach to improve development screening given the new ECCS grant in 2021, new Medicaid developmental screening quality measures, and opportunities/changes in healthcare delivery due to COVID.

 

ECCS Grant: As the new ECCS strategic plan is developed, the activities pertinent to development screening will be incorporated into the Title V developmental screening plans. One of the performance measures for the new ECCS HIPP grant is to increase developmental screening. ASQ Training continues to be conducted to encourage this outcome. In May 2022, approximately 100 participants were trained in the ASQ tool, including the DOH Public Health Nurses (PHN). Discussions have begun to include PHN resources at Maui County WIC sites to encourage developmental screenings and provide referral supports, when necessary.

 

To assure family input to the ECCS strategic plan, the University Center on the Family and the Hawaii Children’s Action Network will develop and conduct a survey of families with pregnant women, infants, and children to:

• Assess the support families receive from state and federal programs, including but not limited to WIC, SNAP, Medicaid, and childcare subsidies
• Collect input on policies, programs, and systems improvements that are needed for families with young children.

 

Media Campaign: The Fall 2021 media campaign to promote child wellness visit was generally well received by providers and the community. Reach data is available in SPM 5. The campaign will relaunch starting July 2022 with a revised message that will promote ‘check-ups’ and preventive screenings, including development, vision, hearing and behavioral.

 

Medicaid: Under the Title V/Medicaid Inter-Agency Agreement, a Title V data request was submitted that included developmental screening data. The following data was provided for FY 2021. The percentages representing only children under Medicaid are somewhat lower than the NSCH data.

 

Developmental Screening in First Three Years of Life - Birth to one year	21.19%
Developmental Screening in First Three Years of Life - >1 year to 2 years	26.00%
Developmental Screening in First Three Years of Life - >2 years to 3 years	20.66%
Developmental Screening in First Three Years of Life - Total	22.41%

 

Title V plans to partner with Medicaid in the future to help increase these rates.

Health Equity: The CDC Learn the Signs Act Early material were translated into Chuukese, Marshallese, and Samoan to help better understand child development. The Milestones Moments booklets are given to families to write down notes before their next well-child visit and gives information about developmental milestones. The booklets will be printed for distribution.

EPSDT-related data: Medicaid child providers are currently asked to complete a detailed EPSDT visit form that specifically asks about completion of developmental and other preventive screens. Medicaid reported it successfully migrated these data to an electronic collection and management system. They are working to share the data in the future.

NSCH: FHSD began work on a proposal to secure grant funding for an NSCH oversample to include Hawaii specific race/ethnicity groups and county level data. However, meetings with the NSCH & U.S. Census staff made clear that funding is not the only challenge. There are substantial administrative requirements/barriers to access the oversample data through a Census Regional Data Center (RDC) that are prohibitive. Hawaii does have an RDC and would need to work with a site on the continent. In addition to developing a research application to attain ‘security clearance’ to an RDC, there is also a requirement for two in-person logins at an RDC before permission is granted for remote access to dataset. Without an oversample, the NSCH data will continue to have limited value for program planning and policy development unless the MCH Bureau expands the survey samples sizes for states, especially those with ethnically diverse populations.

 

Telehealth: With telemedicine services becoming the new normal, there is a concern that parents are opting out of in-person doctor’s visits where young children would normally receive immunizations and developmental screening. Online developmental screening tools may provide greater access to parents more comfortable with online services. Moreover, federal pandemic relief funding is expanding broadband and telehealth services to under-resourced community statewide.

 

Review of Action Plan

A logic model for Title V NPM 6 was developed based on the ECCS Impact Grant that ended in 2021. The strategies reflected initiatives at the community, statewide, and national efforts and included input from partners and feedback from families and providers solicited at conferences and community events. By working on these five strategies, Hawaii planned to increase the number of children receiving a developmental screening by addressing systemic challenges. With the revision of the developmental screening strategies in FY 2022, Hawaii will revise its logic model in next year’s report.

 

 

Challenges Encountered

A recent needs assessment conducted by the Hawaii Act Early COVID-19 team found several challenges in expanding developmental screening, some of which are COVID-related and ongoing infrastructure development. Challenges remain in the areas of policy, data, and messaging. There are five challenge areas to be addressed.

 

Timeliness of referrals continues to be a concern. Hawaii’s Title V Developmental Screening partners must ensure timely and accessible interventions. When concerns arrive, providers conducting screenings are required to refer children in the “referral range” to EIS within seven days after being identified, per the Federal IDEA statute. The seven-day referral standard must be more widely promoted and adopted to assure timely referrals are consistent.

 

Lack of Coordination. Another common issue is lack of coordination during referral and intake. With EIS strict confidentiality standards in conferring with referring providers, the referral process is hampered when signed consents are difficult to attain.

 

Access School Services. Once referrals are made, parents of children with developmental concerns have difficulty accessing appropriate school services. Frustration, avoidance, and adversarial perceptions are outcomes when parents combat community stigma and burden of proof as to how the newly discovered developmental issue adversely impacts their child’s education. A standardized consideration to consistently use screening results in the school evaluation to better support parents will improve the process.

 

Data Limitations. Data to help inform planning and policy is another challenge. The funding and administrative barriers are too prohibitive for Hawaii to pursue an NSCH oversample that could generate more stable estimates for NPM 5, disaggregated data for Hawaii ethnic groups, and county-level estimates. While developmental screening data from Medicaid healthcare providers is an important data source, much of Hawaii’s developmental screening is conducted by family service agencies. At this time, there is no systematic data source to determine the actual number of screens and follow-up conducted by these service providers.

 

Public Awareness. Building public awareness and effective messaging to encourage universal developmental screening. COVID created additional challenges to accessing preventive care/screenings, given the drastic shift of family priorities to more immediate needs. Even as mandates were lifted and workforce returned, prioritizing developmental screens remained elusive; however, there is an opportunity to create a more responsive and accessible system. Efforts through the CDC LTSAE grant and the new ECCS grant will help to address barriers and competing family priorities; however, work may be delayed due to ongoing COVID and slow recovery.

 

Overall Impact

Statewide Partnerships: Over the past five years, Hawaii was successful in convening statewide stakeholders to develop and maintain standard guidelines for developmental screening. The Early Childhood State Plan and other early childhood coalitions continue to identify developmental screening as a key priority. Providers and partners work collaboratively to stress the importance of developmental screening through a validated screening tool. All understand the method to include referral process, including timely and consistent communication with the child’s medical home. The work to promote a more seamless system of screening and referral is continuing.

 

ECCS Grant: Hawaii’s ECCS Impact grant was able to complete its goal to develop a sustainable system of development screening and referral for Maui by increasing awareness, changing organizational practices, establishing partnerships/networks (including family engagement and leadership), and training capacity on the screening tools. Parental engagement to support developmental skill-building opportunities and better understanding developmental and social emotional milestone stages for children 0-5 years old was found to be the most valuable support offered.

 

Providers: Title V continues to make progress working directly with pediatric providers in the AAP-Hawaii Chapter and in collaboration with Hawaii’s CDC Act Early Ambassador, Dr. Jeff Okamoto. Title V will continue to work with the Medicaid program to better reach and support this underserved population.

 

Committed efforts by programs like MIECHV and other early childhood programs to conduct developmental screenings contribute to statewide efforts. Currently, most children are not receiving developmental screenings. Working with early childhood providers, efforts will continue to promote developmental screening and sharing of information with the child’s medical home. Normalizing screening in early childhood services and well-child visits will ensure developmental monitoring and follow-up occur.

 

Data: Accessing Medicaid developmental screening quality assurance data was helpful but only if it can be used to engage Medicaid plans and providers to increase screenings. Approximately 50% of Hawaii’s children are insured through Medicaid, with enrollments significantly increasing during COVID. EPSDT office visit data, when available, also provide vital insights into child health and provider performance.

 

Hawaii will continue to explore and advocate for improved national and state data on developmental screening.

 

 

 

SPM 1 - Rate of confirmed child abuse and neglect cases per 1,000 children aged 0 to 5 years

 

Introduction: Child Abuse and Neglect Prevention

The 2020 needs assessment confirmed that Child Abuse and Neglect (CAN) prevention should continue as a priority under the Child Domain. Child maltreatment stands as a foremost concern for the state. Community needs span the spectrum from primary prevention services to support families, as well as improvements to the Child Welfare Service system to prevent children from entering foster care.

 

Data: The latest data for confirmed child abuse cases are reported in the State Department of Human Services (DHS) 2020 Child Abuse and Neglect Report. The state objective was met as the rate decreased slightly between 2019 and 2020, from 5.7 to 5.0 per 1,000 children aged 0-5 years, possibly due to COVID shutdowns. Cases decreased in the number for children ages 0-5 years from 608 in 2019 to 542 in 2020. Infants under one year of age continue to account for the highest percentage of abuse (15%). Overall, children five and under accounted for 42.5% of all confirmed cases, a slight decrease from 43.7% in 2019. The report presented geographic disparities by community. Hawaiian/Part Hawaiian children are overrepresented among confirmed CAN cases for all age groups, reflecting long-term disparities due to historical racism and discrimination.

 

The types of confirmed maltreatment types between 2019 and 2020 saw decreases in sexual abuse (37% to 36%), neglect (36% to 25%), and threatened harm (30% to 23%). Sex trafficking increased in 2020 to 26% from 18% the previous year. Two deaths occurred in 2020 compared to one in 2019. There was also a significant increase in the number of children whose abuse resulted in serious injuries, from 30 to 43. In 2020, the highest reported factors contributing to the abuse or neglect of children of all ages were inappropriate child-rearing methods (70.6%), inability to cope with parenting responsibility (64%), and drug abuse (42%). Confirmed CAN cases reflect only a small portion of potential incidents of family violence.

 

Objectives: Reviewing the baseline data, the objective was set at a 5% improvement over the next five years.

 

Title V Lead/Funding: The Title V Child Abuse and Neglect Prevention Program (CANP-P) is administratively located in the Maternal and Child Health Branch (MCHB), Family Support and Violence Prevention Section (FSVPS). The Section also includes: the sexual violence and domestic violence prevention programs, parenting support program, and the Maternal Infant and Early Childhood Home Visiting (MIECHV) program. The CANP-P is funded by the Administration for Children and Families (ACF), Community-Based Child Abuse Prevention (CBCAP) formula grant. While Title V does not directly fund CAN prevention activities, it does fund key staff positions related to the program, including MCH Branch support staff such as the Branch research statistician.

 

Strategies: Child abuse and neglect (CAN) are complex problems rooted in health inequities and unhealthy relationships and environments. Preventing CAN requires addressing factors at the individual, relational, community, and societal levels. For 2022, CAN strategies were revised to reflect a broader public health systems approach:

• Support the collaboration and integration of family strengthening and child maltreatment prevention programs and activities across federal, state, local and private programs, and organizations
• Promote safe and nurturing relationships by raising community knowledge about resilience and adverse childhood experiences
• Provide training and technical assistance to community-based, prevention-focused programs to strengthening families and prevent child abuse and neglect
• Collaborate with the Hawaii Department of Human Services primary prevention Initiatives
• Promote Health Equity by addressing disparities in confirmed CAN cases

 

CANP-P addresses primary prevention and secondary prevention work. Grant funds are used to support:

• Community-based efforts to develop, operate, expand, enhance, and coordinate initiatives, programs, and activities to prevent CAN
• Support the coordination of resources and activities to strengthen and support families to reduce the likelihood of CAN
• Foster understanding, appreciation, and knowledge of diverse populations in order to effectively prevent and treat CAN

 

Evidence: While CAN Prevention is not a Title V NPM, research presented by the MCH Evidence Center from the Child Safety Network supports Hawaii’s crosscutting strategies that leverage partnerships to support evidence-based/informed programs and practices.

 

COVID Updates: COVID-19 upended Hawaii with enormous economic and social implications. Given the increased number of families living in virtual confinement coupled with massive economic disarray, the pandemic created the conditions for a rise in family violence. Lockdowns and pandemic-related economic impacts exacerbated factors typically associated with family violence, such as increased unemployment, stress associated with childcare and virtual schooling, and increased financial insecurity. Poor coping strategies, including the increased use of alcohol and other substances, could elevate the risk of abuse. Client contacts with the Domestic Violence Action Center increased nearly fourfold from 519 in 2019 to 3,038 in 2020. The need to develop safety plans with clients rose from 692 to 1,066 in the same time period. The number of reported child abuse cases grew from 4,697 in 2020 to 5,389 in 2021, a 15% increase.

 

Updates for 2021 on the five revised strategies follow.

 

Strategy 1: Support the collaboration and integration of family strengthening and child maltreatment prevention programs and activities across federal, state, local and private programs, and organizations  

This strategy focuses on the key system partnerships CAN-P supports to assure a coordinated system of services to prevent and address CAN. State, local, and community programs have distinct strengths and expertise in reducing CAN and building safe and resilient families and communities. Interagency collaborations across child-serving systems include public health, child welfare, education, early childhood service providers, and other public and private systems work. Together, these sectors help strengthen and support families to address the needs of children and their parents/caregivers. A list of the major agencies/programs follow.

 

Department of Education (DOE): DOE is a key agency partner in efforts to identify, treat, and prevent CAN. CANP-P collaborated with the DOE Trauma Recovery Project to ensure low-income students who experienced trauma received trauma-specific mental health services. The Project expands the capacity of DOE counselors and other staff on the use of Trauma-Informed Care (TIC) as the standard across the DOE. TIC practices ensure agencies and programs serving children and families that experienced any form of violence understand the impact of trauma on child development and how to effectively minimize its effects when providing services. DOE staff were invited to participate in three CANP-P sponsored TIC technical assistance (TA) opportunities and training events.

 

CANP-P continued to support the DOE Family Resource Center (FRC) initiative that established four pilot, school-based FRCs on the island of Oahu. Family resource centers (FRCs) are community-based resource hubs where families can access supports to promote their health and well-being. CBCAP monies sponsored FRC Standards Certification Training, developed by the National Family Support Network (NFSN) to build the quality of staff practice.

 

Department of Human Services (DHS): DHS is a key partner in addressing CAN since it houses Child Welfare Services (CWS) and other state entitlement programs. CANP-P collaborations are described in Strategy 4.

 

Hawaii Children's Trust Fund (HCTF): HCTF is a public-private partnership between the Department of Health (DOH) and the Hawaii Community Foundation (HCF) that administers grant-making funds for the HCTF. The funds are used to ensure a strong network of family strengthening services and promote child abuse and neglect prevention. HCTF work is carried out through a statewide Coalition, an Advisory Board (AB), and an Advisory Committee (AC) to ensure diverse/broad community input. The DOH serve on all HCTF governing bodies.

 

Strategy 2: Promote safe and nurturing relationships by raising community knowledge about resilience and adverse childhood experiences

This strategy highlights CAN-P efforts to raise awareness/knowledge to prevent CAN and strengthen families.

 

CANP-P continued to participate in the development of the Nurture Daily website (https://nurturedaily.org/families), a comprehensive resource for families and service providers to support the healthy development of Hawaii’s children and strengthen families through the five protective factors. The website includes user-friendly information, activities, games, webinars, event announcements, and resources for families.

 

Nurture Daily is a project of the Safe & Nurturing Families initiative of the Early Childhood Action Strategy (ECAS), a statewide, public-private collaborative designed to improve the system of care for Hawaii’s youngest children and their families.

 

CAN-P funds were made available to the neighbor island CANP Coalitions to respond to immediate family needs during COVID as well as provide information on family supports to help alleviate stress that could contribute to CAN. Activities included drive-by events with families receiving basic needs hygiene, sanitation, and food supplies. Informational brochures on positive parenting, family resilience, safe sleep, and more were also distributed. Children received education packets and games promoting family-time activities. The events also offered opportunities to talk with an agency staff with specific questions or needs.

 

Strategy 3: Provide training and technical assistance to community-based, prevention-focused programs to strengthening families and prevent child abuse and neglect

Through COVID, the CANP program continued to sponsor and support virtual trainings.

 

Webinars: CANP-P funded four unique webinars open to private and public agencies and their staff involved in CANP and family strengthening. The webinar topics addressed the effects of trauma, common responses to trauma, and ways to mitigate negative responses. The webinars included:

• Stamp Resilience Into Your Brain – building mental resources and inner strengths.
• Using our Brains to Create Safe, Connected, Empowered Organizations and Communities – how neuroscience informs actions that help regulate the stress response system.
• When Stress Becomes Toxic – addressing stress.
• Micronesian Migrants in the US: – how health issues, social determinants of health, and effects of COVID-19 played a part in disparities and inequities in the Micronesian community; how services could be more culturally aware.

 

The CBCAP grant requires awardees conduct outreach to special populations including children and/or adults with a disability since children with disabilities may be at higher risk for abuse or neglect. Parents of a child with a disability may experience more stress addressing special needs and sometimes financial burdens. CBCAP funds sponsored a virtual miniseries conference devoted to building the knowledge and the skillsets of individuals and organizations that work with individuals and their families diagnosed with Fetal Alcohol Spectrum Disorders (FASD). Miniseries topics were: “Behavior Belongs in the Brain,” “Recognizing FASD and Modifying Approaches to Enhance Optimal Outcomes for Individuals, Families, and Providers,” “Realities and Responsibilities” (conducted by a person living with FASD), and a panel discussion on “Current Activities and Trends in Hawaii.”

 

The CBCAP requires efforts to enhance parent leadership and participation in planning and implementing grant-funded and related CANP initiatives. To accomplish this, the CANP-P participated in funding two virtual Parent Leadership Training Institute (PLTI) cohorts. PLTI is an evidence-based model that provides parents technical skills/knowledge to be effective advocates for children and to be change agents in their community. Parents attend 20 evening sessions and also complete a community project putting learned skills into practice. Several of the PLTI community projects address CANP: create a support group for pregnant women who were abused as children; support a program for girls to develop their leadership skills and self-confidence to keep them out of sex trafficking; an indigenous-based leadership program for mothers and daughters; and an art program for youth living at a transitional shelter to use their voices to share their stories of challenges being turned into victories.

 

Strategy 4: Collaborate with the Hawaii State Department of Human Services primary prevention Initiative

This strategy focused on the partnership with the DHS Child Welfare Services (CWS) program that investigates CAN reports and provides services to assure the safety of children who are subject to or at-risk for CAN.

 

In 2018, the federal Family First Prevention Services Act (FFPSA) was enacted to turn the focus of the current child welfare system toward keeping children safely with their families to avoid the trauma that results when children are placed in out-of-home care. In response to the new prevention focus, CANP-P is partnering to write and implement the Collaboration Section of the State Child and Family Services Plan (CFSP). Activities focus on three areas:

• Supporting the Hawaii Zero To Three Court initiative
• Expanding the DHS Child Welfare Ohana Time system of care and services, (Ohana means family in Hawaiian)
• Improving connections to family resources including identifying service gaps

 

Strategy 5: Promote health equity by addressing disparities in confirmed CAN cases

CWS data clearly shows disparities in confirmed CAN cases by geography, race/ethnicity, and age. Not to be forgotten are equity issues of children with disabilities.

 

Native Hawaiian children are consistently overrepresented in the number of confirmed CAN cases. By age, infants and toddlers experience a higher risk for abuse or neglect. Each island has areas with high numbers of confirmed cases, normally low-income and under resourced areas.

 

CBCAP funded community-based providers serving populations and areas at high risk and families disproportionately impacted by COVID. The initiative promoted use of Protective Factor supports known to mitigate risk of CAN, including providing basic necessities for families and computer equipment to access remote schooling and needed medical care. Community organizations distributed bedding, small appliances, hygiene items, toiletries, PPE supplies, clothing, children’s activity books, diapers, laptops, and hotspots.

 

The Title V Family Support and Violence Prevention Section and the Early Childhood Coordinator with the Children with Special Health Needs Branch collaborated on the planning and implementation of a two-day virtual summit addressing the unprecedented needs of the Hawaii’s early learning communities due to COVID. The summit included cultural-informed approaches to prevent ACEs by addressing Hawaii’s historical and generational trauma and acknowledging the historical trauma experienced by Native Hawaiians and other ethnic groups.

 

Current Year Highlights for FY 2022 (10/1/2021 – 6/30/2022)

Hawaii CANP Program is refocusing and consolidating Title V strategies to the following three areas:

• Training/workforce development
• Child maltreatment prevention activities
• Public awareness.

 

Health equity is braided or blended across each of the primary areas.

 

Contracts with community organizations to promote Protective Factor strategies continue through CANP public awareness events and family fun activities on all the islands. Activity initiatives must be designed to target special population families such as children with disabilities, homeless or at-risk for homelessness, Native Hawaiian/Pacific Island families, and families residing in shelters or public housing.

 

CBCAP is funding development of a CANP-P training plan, including CANP topic areas, subject-matter expert speakers, and a directory of asynchronous online (self-directed) learning websites with Protective Factors serving as the framework.  The potential audiences are broadly defined including cross-sector agency administrators, professional and field staff for family support agencies and programs, as well as nontraditional persons and the general community.

 

CBCAP received a five-year, $1M award under the American Rescue Plan Act (ARPA). Contracts were awarded for Community Resource Coordinators in each county to expand and manage the acquisition and distribution of concrete supports to meet the needs of vulnerable family populations, i.e., single parents, families with a parent with a history of incarceration, kinship families and others.

 

CANP-P supported certification of trainers on the National Standards of Quality for Family Strengthening and Support. Expanding the number of certified trainers cross sectors will support better system coordination by promoting common language, quality improvement practices, and measures for Family Strengthening and Family Support programs, including Family Resource Centers, home visiting programs, and child development programs.

 

CBCAP supports the launch of the new ECAS initiative - Aloha At Home. It is rooted in Hawaiian values and the Protective Factors to guide and ground families as they pursue stronger connections. The first phase of the Aloha At Home promoted activities that build positive and healthy interactions between young children and their parents/caregivers using simple activity ideas and free activity boxes available through the website.

 

CBCAP is sponsoring a PLTI pilot targeting special population families, such as residents in public housing, fathers, parents of a child with a disability, parents who have experienced incarceration, parents who were involved in child welfare, and adults who were in the foster care system.

 

CANP-Program continues to be involved in the DHS State Team work implementing the Collaborative piece of the Child and Family Service Plan and the DOE evidence-based Family Resource Center (FRC) initiative.

 

The 2022 State Legislature passed two FRC related bills to fund a fulltime a state Family Resource Coordinator position and establish an FRC at the state correctional facility on Oahu. DOH and DOE will partner with DHS on the development of a state FRC plan and implementation activities. CANP-P will be involved in these tasks.

 

Another other CANP related bill passed in 2022 creates the country’s first statewide Office of Wellness & Resilience focused on prioritizing wellness and resilience efforts across the state departments and creating a trauma-informed state to better serve local families and improve community health. CANP-P and several Title V programs are involved in this effort.

 

Review of Action Plan

The revised CANP logic model provides an overview of the strategic approach to prevent CAN. The effort cannot be addressed as a standalone public health concern capturing the broad array of public partners/resources to address CAN in Hawaii. The logic model also confirms the importance of acknowledging and addressing contextual conditions that impact and influence CAN negatively or positively, in tandem with programs that specifically target violence prevention.

 

 

Challenges and Barriers

Reaching Families during the Pandemic: Services to communities and families were offered virtually, which resulted in a number of challenges. Some service providers did not have sufficient IT equipment. Clients residing in rural areas of the state often lacked access to broadband, digital devices, and skills to use the software programs. In response, federal relief funds were used to support the purchase of IT equipment for community providers and families. CBCAP funds were used to support at-risk Micronesian communities to procure IT supplies and subscriptions to assist children in participating in distance learning and attend telehealth appointments.

 

Workforce Shortages: The Hawaii Children’s Trust Fund Coalition members participated in a workforce development/training survey. Members reported common recruitment and retention challenges such as:

• Job applicants often lacked the necessary position-related credentials.
• Salary levels affected attracting qualified applicants.
• Staff workload stress grew due to number of agency’s vacancies.
• Use of hybrid virtual work scheduling did not support staff needs.
• Lack of professional development and career pathways for current staff.

 

In response to the challenges, some organizations expanded professional development trainings. The DHS/CWS expanded online learning opportunities for staff.

 

Reduction in Mandated Reporters: The impact of the pandemic is reflected in the reduced number of cases attributed to educational and medical personnel. In 2020, confirmed cases linked to educational staff reports dropped to 91 vs 197 in 2019. Medical personnel are the second highest mandatory CAN reporters in Hawaii. In 2020, 276 CAN cases were reported by medical professionals compared to 320 confirmed cases in 2019. CAN awareness training resources/opportunities are being expanded to more nontraditional reporters.

 

Overall Impact

Key overall CANP impacts include:

• Establishing collaborative prevention strategies in DHS 2020-2024 Child and Family Services Plan such as expanding Ohana Time with families.
• Continued coalition building and partnerships with state and community-based programs and organizations.
• Sponsoring and expanding accessibility of trainings via virtual platforms is increasing knowledge, skills, and/or attitudes of staff who work with families including those who may be at-risk for CAN. 
• Successful implementation and operation of the DOE school-based Family Resource Centers pilot in spite of pandemic restrictions.
• Act 129 signed into law by the Governor that establishes the FRC Pilot Program within the DHS and the coordination of the DOH, DOE, and. Requires the Departments of Human Services, Education, and Health to public and private entities to develop and implement family resource centers.

 

 

 

SPM 5 - The percentage of Medicaid children receiving six or more well-child visits in the first 15 months of life

 

Introduction: Well Child Visits and Immunizations

For the Child Health domain, Hawaii added this state priority in 2021 to promote child wellness visits and routine immunizations, especially for young children. The priority is a result of ongoing assessment and concerns raised during COVID that many families were postponing or delaying care due to provider office closures, lockdowns, and safety concerns.

 

Data: The data for this measure is from the annual state CMS Medicaid Core quality assurance measure: Children receiving six or more well-child visits in the first 15 months of life. The 2021 data shows child wellness visits did decrease significantly in 2020 to 63.8% from 73.2% in 2019. There is a second CMS quality measure for well-child visits that showed 75.9% of 3-6-year-olds had a CWV in 2021, slightly better than 73.8% in 2020. There is no disaggregated data for these measures and no national comparison data for FFY 2021 at this time.

 

Data from the 2019-2020 National Survey on Children’s Health indicated 79.7% of children 0-17 years had a preventive visit in Hawaii; an estimated 60,661 children did not receive a preventive visit. The percentage of those receiving a preventive visit by age group:

• 87.6% of children ages 0-5 years
• 78.2% ages 6-11 years
• 73.4% ages 12-17 years

 

All Hawaii rates were comparable to the U.S. estimates. There was no comparison data from previous years.

 

Objectives: Considering the baseline data, and the HP 2030 objective, the state objectives through 2025 were set to reflect one percentage point increase annually.

 

Title V Lead/Funding: The Title V leads for this project include: the Home Visiting Program, the Early Childhood Systems Coordinator, FHSD Public Information Officer (PIO) and Title V grant coordinator. The PIO, who was an essential lead for the effort, is funded by Title V. Other programs include EI, Lead Screening, WIC, and CSHN. State general funds were used to cover the major costs for the media and community outreach campaign.

 

Partners: The key external partners are the American Academy of Pediatrics-Hawaii Chapter (AAP-H), State Medicaid program, and Hawaii Children’s Action Network (HCAN).

 

Strategies/Evidence: Hawaii plans to conduct a public awareness campaign to promote child wellness visits particularly for young children.

 

Strategies include:

• Collaborate with pediatric providers and community advocates to promote messaging on the importance of well-child visits
• Conduct a public awareness campaign and measure the effectiveness of messaging (i.e., increased visits to the doctor, increased number of vaccinations for the home visiting population)
• Build capacity for developing pediatric champions to promote ongoing messaging campaign

 

Although there is no specific MCH evidence on well-child visits, the evidence for Adolescent Well-Visit strategies and Medical Home were reviewed. Patient reminders are identified as emerging evidence in increasing well-child visits. Another added value of the medical home model indicates collaborating with home visiting serves as emerging evidence. An MCH Evidence Center brief on public health messaging also indicated some emerging evidence for this strategy, especially in reinforcing a mass media campaign with social media and community coordination.

 

Strategy 1: Collaboration with Pediatric Providers

In 2020-21, nationally and locally delayed younger child wellness visits emerged as a major concern during COVID shutdowns. Nationally, the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services released data early in the pandemic, documenting dramatic decreased rates of child immunizations and well-child visits. The concern was amplified by the national AAP, which launched a national ‘Call Your Doctor’ campaign in May 2020. The federal MCH Bureau also launched a similar social media campaign, “Well Child Wednesdays,” in 2020-21 and funded innovative projects to increase child wellness visits.

 

In 2020-21, the Census Pulse survey data confirmed that Hawaii residents were delaying care due to COVID concerns. Most Title V service programs saw overall reductions in service provision due to COVID as in-person visits were halted and services shifted to virtual or phone visits, continuing through early 2021. Title V early childhood programs were particularly concerned about delays in child wellness visits among the families served, potentially missing routine immunizations and critical preventive screenings for children ages 0-5 years. Through 2021, the increased availability of adult COVID vaccinations resulted in safety restrictions removed with services reopening.

 

In Spring 2021, Hawaii convened a workgroup to develop a public awareness campaign to encourage more Child Wellness Visits (CWV), especially for young children. Most doctors’ offices were reopening for in-person visits with well-established safety procedures and easy access to PPE (initially in short supply). Workgroup partners included: representatives from the local chapter of the AAP (the president and vice-president), Hawaii DHS-Med-QUEST (Hawaii’s Medicaid agency), Family Health Services Division, DOH Chronic Disease Prevention and Public Health Promotion Division, and the Hawaii Children’s Action Network (a local advocacy organization for young children and families).

 

The workgroup began planning the campaign and was able to secure state funds for the project. Contracts were executed with media vendors, AAP-Hawaii, and HCAN; the latter to coordinate community resources for the campaign.

 

The workgroup met to:

• Develop effective messaging

• Collect parent input to help identify the barriers to accessing care
• Test messaging with families in home visiting programs, Parent Leadership Training Institute (PLTI), and other Title V service programs
• Identify referral options for families to help secure health insurance or find a provider, if needed.

 

AAP-Hawaii leadership provided helpful input in developing effective messaging, guidance with the general campaign, direction/timing in coordination with its provider membership, and recruiting doctors for the commercial campaign filming in their medical offices. Additionally, pediatricians with diverse backgrounds were enlisted to reinforce the messaging through media appearances. Both the Medicaid Medical Officer, who is also a pediatrician, and the Medicaid Clinical/Community Services Nurse were also key planning partners. Both assisted with requesting evaluative data and coordination with the state’s Medicaid health plans.

 

Based on input from family focus groups, the campaign tagline was developed: Time for Check Up: Call Your Keiki’s Doctor Today. Keiki in the Hawaiian language means child. The location of the campaign message takes place in a doctor’s office, identified as a ‘trusted messenger’ by the focus groups. Other key focus group findings were incorporated into the media messaging campaign:

• Inclusion of a ‘real’ family with small children
• Explanation and demonstration showing that doctors are following COVID safety precautions for in-person visits
• Explaining why wellness visits are crucial, especially after delays: for routine immunizations, screenings, physicals
• Explaining that, even if a child is not sick, it’s important to visit your doctor/healthcare provider annually. Visiting the pediatrician makes sure your kids are healthy and to ensure their optimal physical and mental health.

 

The group also coordinated with efforts by the Hawaii Oral Health Coalition’s social media campaign to promote child dental visits, also demonstrating that in-person dental visits were safe.

 

Strategy 2: Conduct Public Awareness Campaign

Originally, the media campaign launch was set for September 2021, well-after public schools opened in August to full in-person instruction (after more than a year of distance learning due to COVID). The September launch was timed to avoid any conflict with health messaging promoting routine immunizations required for school entry, as well as COVID vaccinations for eligible adolescents (from age 12, at the time).

 

The planning committee also closely monitored progress on national FDA approvals for a COVID child vaccinations for ages 5-11 years to avoid interference with any media planned for the child vaccine rollout. Conducting parent focus groups to develop and test effective messaging also extended planning efforts.

 

The major campaign delay occurred due to the severe summer surge in COVID cases and hospitalizations relating to the highly infectious Delta variant. The surge occurred at a time of lessening safety restrictions in the state and the general public sentiment that COVID was nearing an end with vaccination availability. The Delta surge, however, proved far more virulent than the initial COVID outbreak in Hawaii, with all hospitals reaching or exceeding capacity and suffering significant healthcare workforce shortages. Hundreds of emergency healthcare personnel were flown in from other states to address the staffing shortages. The surge led to the Governor issuing a public national plea for visitors to temporarily postpone vacation/trips planned to Hawaii.

 

With schools opening during the Delta surge, the Department of Education struggled to ensure the health and safety of children, teachers, and staff. Conflicts occurred over the adequacy of safety procedures, testing on campuses, and the accuracy of COVID case reporting for all 257 Hawaii schools. Despite mask mandates, several hundred COVID cases and several COVID clusters were reported throughout the school system in the first few months. This created hardships on families, who were required with little notice to pick up their children based on potential disease exposure and then find COVID testing, which was not widely available at the time.

 

It was decided that the height of the Delta surge, coupled with school reopening, was not a conducive time to launch the WCV campaign. Campaign planning continued through FY 2021. Below is some key information developed for the campaign:

 

Messaging: Time for a Checkup

 

Media Campaign: Television ad time was purchased during the news broadcast and on a local ethnic radio station, focusing programming to the Chuukese, Filipino, and Samoan populations. A promotional toolkit for pediatric and family service providers was planned, but not completed, due to COVID variant surges (first Delta and later Omicron). Community partners were busy addressing more immediate needs resulting from COVID in workplaces, homes, schools, and childcare sites.

 

Website: A website was developed at www.keikicheckup.com, which housed information from the national AAP Chapter, as well as information on locating a pediatrician with information from the Med-QUEST provider directory.

 

Metrics: The team would rely largely on media viewership measures (i.e., number of views) to document the reach of the messaging campaign. Title V programs that track CWV as a part of their client visit data would also monitor changes.

 

Measures of Effectiveness: Finding a population-based metric for the most underserved children proved challenging. Title V decided to use data from the state Medicaid program. Child wellness visit data is reported by Hawaii as one of the managed care plan quality measures. Surveillance data from the National Child Health Survey (NSCH) on child preventive visits for ages 0-5 years was considered, but the aggregation of data over two-year periods and the small sample size limited the use of data for evaluation.

 

Strategy 3: Build Capacity for Pediatric Champions

Although the primary focus of the project was to conduct the public awareness campaign promoting annual well-child visits, Hawaii used this opportunity to build capacity for pediatric champions by supporting AAP members as speakers for improving child health. Pediatric providers actively participated in media activities, including the production of the public service ads (voiceovers, “actors”) as well as providing live and taped interviews on morning TV shows and news programs. These providers represented diverse populations by race, ethnicity, and gender.

 

While Hawaii recognizes that some children are cared for by varied primary care providers, parent focus groups identified pediatric healthcare providers as trusted sources on information for their children (vs the Department of Health, politicians, celebrities, or ‘paid’ actors, who were not seen as trusted).

 

The local AAP-Hawaii Chapter also worked on developing pediatric champions and assisted providers with professional training on public speaking. Hawaii partners continued to work together on the following:

• Developed list of provider speakers for speakers’ bureau for other media opportunities
• Worked with AAP-Hawaii Chapter to augment resources, if needed, for other media campaigns and opportunities to promote pediatric champions
• Promoted collaboration with healthcare providers, insurers, and other critical partners including families.
• Worked with AAP-Hawaii Chapter on other medical home messages, COVID-related information, and other Title V priority issues

 

Current Year Highlights for FY 2022 (10/1/2021 – 6/30/2022)

The planning group decided to delay the CWV campaign until the surge in COVID cases lessened and the AAP provider membership expressed readiness to support in-person visits again. Plans were revised to launch the campaign in November – December 2021. Public Service Announcement (PSA) commercials targeted adults, ages 25-54, in approximately 245,271 households. The paid media campaign included television spots coupled with live morning news interviews and taped news stories with pediatricians discussing the importance of the well-child visits. The radio spots also ran over the two-month period and were translated into Chuukese, Tagalog, Ilocano, and Marshallese languages, which were determined to be the populations having the lowest number of well-child visits per service provider. Print campaign materials were developed and shared on community websites.

 

The messaging was also shared through the DOH Community Bulletin, which is the state source for COVID-related information and resources. The Bulletin featured short interviews with families, providing a family-focused perspective on the importance of CWV.

 

Display ads were drafted and shared with community partners and agencies to post on their websites. Medicaid also shared the PSA and digital ads to promote more wellness visits via their managed care contractors. Previews of the commercial were shared with pediatricians via the AAP to prepare providers for potential increased calls from families wanting to schedule a visit.

 

Building on the success of the first campaign, additional funding was secured in June 2022 for a follow-up campaign, focusing on the importance of well-child visits and preventive screenings (developmental, hearing, vision, lead, behavioral), using footage from the original campaign. Planning is being conducted with the same organizational group, with TV and radio messages scheduled to be aired prior to September 2022.