NPM #6 Developmental Screening – Support adequate early childhood development and education.

 

Developmental screening is a short test to tell if a child is learning basic skills when he or she should, or if there are delays. Early identification of developmental delays is critical to the provision of timely interventions so that the adverse impact of such developmental delays is mitigated over the life course spectrum for the child. Since 2006, the American Academy of Pediatrics (AAP) has recommended that assessment for developmental problems among young children be incorporated into every preventive health visit and that formal screening occur at regular intervals, including the 9-, 18-, and either 24- or 30-month well-child visits.

 

According to data from the 2017-2018 National Survey of Children’s Health (NSCH), 32.7%* of Missouri parents reported they completed a standardized developmental screening tool during a health care visit, compared to 33.5% nationally. Nationally, children with special health care needs (CSHCN) (45.9%) were more likely to receive a standardized developmental screening than children who did not have a special health care need (32.3%). Two-parent married households in Missouri had a higher percentage that had a developmental screening (37.5%)* than their national counterparts (36.9%). In Missouri, 40.1% of those with private insurance received a developmental screening compared with 38.5% nationally. Fewer Males in Missouri (27.4%)* received a developmental screening than females (37.5%)*.

 

Comprehensive developmental screening can improve lives and outcomes for children and families. Since those who work with infants and young children can play a key role in the early identification of developmental delays, partnerships with public health providers, early childhood professionals, and home visitors are key to implementing developmental screening tools. The Missouri Department of Health and Senior Services (DHSS) collaborated with multiple stakeholders to make sure resources were available to educate families about key milestones.

 

Public Health Providers

The Missouri Women, Infants, and Children (WIC) Program and the University of Missouri collaborated to create the Missouri WIC Developmental Milestones Program which is based on the Centers for Disease Control and Prevention (CDC) “Learn the Signs. Act Early.” (LTSAE) public health campaign. This is a developmental milestones awareness initiative, which refers parents to physicians for developmental screening. CDC funded the training and technical assistance needed to take the program statewide while Title V funds were used to purchase the materials used at the WIC clinics. In FY2019, 80WIC local agencies applied to participate. The WIC Developmental Milestones Program also uses a set of checklists and family-friendly wall and floor graphics to increase parents’ awareness of developmental milestones and to promote the early identification of potential developmental delay.

 

The Maternal Child Health (MCH) Services Program surveyed the Local Public Health Agencies (LPHAs) regarding the type of infant and early childhood developmental screening being provided and the screening methods and tools being utilized. Forty-two LPHAs reported providing infant developmental screening and referral for suspected/identified delay, although no consistent screening tool was reported as being utilized, and 96 reported referring infants for developmental screening. Cape Girardeau County Public Health Center reported using the Denver Developmental Screening Tool at the health department’s rural health clinic. The WIC departments of Barry, Carter, Hickory, Polk, and Texas county health departments among several other LPHAs were part of a pilot phase in the implementation of Developmental Milestones , a screening and educational program developed by the Missouri Department of Health and Senior Services in partnership with the University of Missouri based on CDC’s LTSAE public health campaign. Columbia-Boone, Kansas City, Phelps/Maries, Randolph and St. Louis county health departments reported using the Ages and Stages Questionnaire-3® (ASQ3). A total of 94 LPHAs reported working with community partners to provide infant developmental screening and/or referral. Not all of the LPHAs were aware what screening tool(s) were being utilized by outside referral agencies. However, Butler County Health Department reported the Ages and Stages Questionnaire®: Social-Emotional (ASQ®:SE) and ASQ3 were utilized by the Early Head Start Home Based Program, Lincoln County Health Department reported the Parents as Teachers (PAT) Program used the ASQ and DIAL-4, Springfield-Greene and Taney county public health agencies reported PAT used DIAL-4, and Vernon County Health Department reported the PAT and Early Head Start programs use the ASQ3.

 

In FY2019, materials were developed to implement the “Talking is Teaching, Talk, Read, Sing” public awareness campaign that empowers parents and caregivers with fun and easy ways to improve their child’s learning. The program helps parents recognize that they have the power to boost their children’s early brain and vocabulary development through simple, everyday actions such as describing things they see while walking outside, singing songs together during bath time, or walking through the grocery store. A train-the-trainer session was developed for staff from WIC, Head Start, home visiting programs, and the Missouri Library Association. Training and implementation of the program continues to expand during FY20.

 

A child’s chronic exposure to low lead levels can cause developmental and neurologic problems that are extremely difficult to detect at the time of exposure and which may not be evidenced until years later. At well child checks, physical examination, as well as environmental evaluation and blood lead screening are often necessary to assess whether a child is at risk of lead poisoning or has already ingested or inhaled lead dust or particles. The Child Lead Poisoning Prevention Program (CLPPP), funded by the CDC, collaborates with public health providers to increase blood lead screening levels and educate the public regarding the risks in children.

 

LPHA and MO HealthNet Health Plan lead case managers, WIC program staff, and pediatric clinicians in the state were provided lead education information and materials via mailings, conferences, newsletters, exhibits, and during lead case management trainings provided by CLPPP staff or by pediatric environmental toxicologists. The Healthy Children and Youth (HCY) Lead risk assessment questionnaires and testing forms were used during Medicaid well-child visits and were available and encouraged to be used for all children. Additional educational child lead poisoning prevention information and materials and resources were provided to LPHA and MO HealthNet Health Plan lead case managers and WIC program staff. These entities and clinical staff may then distribute the educational information to the children and families across the state whom they serve. A specific school related publication, “Educational Interventions for Children Affected by Lead” or its’ web site address was provided to primary care providers and school staff.

 

CLPPP also provided lead education information and materials to LPHAs, Health Plans, WIC Staff, and to School Nurses. CLPPP, in collaboration with Title V Program staff, implemented an outreach, education, and screening campaign to WIC, LPHA and Health Plan Lead Case Manager’s, school nurses, and Pediatric Clinicians regarding lead poisoning prevention and screening recommendations. Title V Program and/or CLPPP staff provided educational lead information including recommended screening and follow up practices including long term developmental assessments for children who have experienced lead poisoning to clinicians (Physicians, Nurse Practitioners, Physician Assistants, Primary Care, Family Care and Pediatric Practice Clinicians and school nurses) via mailings, public health messages, or exhibits or conferences and presentations, when applicable.

 

CLPPP lead risk assessors and lead case managers increased their focus on referring children and families to DESE First Steps program whenever a child’s venous blood lead level was at 10 mcg/dL or higher. Going forward, CLPPP staff plan to increase the awareness of parents, school nurses, school special services staff, and health care providers regarding the ongoing monitoring of all children who have experienced chronically low to moderate levels of blood lead poisoning as well as those who have experienced high levels. Many parents, school nurses, special services staff, and health care providers are not aware that children with chronically elevated or high blood lead levels need to be monitored developmentally, cognitively, and behaviorally especially at education levels of first, fourth, and sixth or seventh grades for increased special services or physical or behavioral health referral needs. Addressing any problems or delays with early interventions is most likely to have the best outcomes for these children. Many parents and health care providers do not remember to pass this information on to schools and many school district health forms do not specifically request documentation of children’s history of blood lead levels.

 

Missouri continued participation in the Maternal Child Environmental Health (MCEH) Collaborative Improvement & Innovation Network (CoIIN) to support and improve coordinated systems of care to address the needs of maternal, infant, and child populations that are at risk for, or experience exposure to lead. Since 2018, activities included: forming a state team, participating in planning and evaluation webinars, implementing outreach and education campaigns in targeted areas of the state, and presenting at Learning Sessions. This project began the development of a strong partnership between Missouri’s Title V Program and CLPPP. Plans are to continue COIIN project activities and partnerships to more effectively improve lead poisoning prevention efforts. Each year, new areas of high risk will be identified and targeted for outreach and education.

 

Early Childhood Professionals

In FFY2019, the Child Care Health Consultation Program offered 7 hours of continuing education trainings for child care providers, 1.5 hours of specialized consultation, and 3 technical consultations regarding developmental screening service referrals and well child care. The purpose for offering this service is for more families to be educated about the importance of, and referred to a direct source for developmental screening and well child care so that children receive additional support, if needed.

 

Staff with the Section for Child Care Regulation (SCCR) referred child care providers to the Inclusion Specialists when there were concerns regarding the development of a child in care. SCCR staff provide the contact information for the Inclusion Specialists and the information is also located on the SCCR website. Child Care providers are able to seek assistance from the Inclusion Specialists to implement strategies and make environmental changes to accommodate the needs of the child in care while maintaining compliance with rules and regulations. The recommendations may include changing the room arrangement, providing training to the staff, assisting with scheduling, guiding providers to adapt programming, or providing resources. The Child Care Inclusion Specialists assisted families to locate and coordinate services to meet the developmental needs of the children they serve. Inclusion specialists assess the needs of the child in relation to proper child care placement. Through child observation and consultation with the family, they are able to ascertain what services the child is currently receiving, identify what might be available, and assist with the coordination of services moving forward.

 

In St. Louis, Vision for Children at Risk (VCR) implemented LEAP (Learning Everything at Pace) Ahead St. Louis. VCR is using the Brooks Publishing Ages and Stages Questionnaire Enterprise system to track developmental and social/emotional screenings completed by VCR and their 16 partner sites. In FY19, 1,236 screenings were completed by partner sites, online, or by family advocates. The Boone County Early Childhood Coalition created an online screening hub for parents and providers to complete screenings using the Survey of Wellbeing of Young Children (SWYC) online and track children. Their goal is to increase the number of children being screened in Boone County.  

 

In FY19, Missouri continued working with the National Maternal Child Health Workforce Development Center (Center) until the cohort ended in May 2019. The, now titled, Missouri Milestones Matter Program team held focus groups with parents of young children in child care and child care providers in 2019. The team met in-person with the Center coach and staff over a 3-day period in February 2019. The information gathered during the focus groups and the February meeting was used to draft the changes to the back side of the CDC LTSAE checklist and begin drafting an implementation guide. The team also worked with Center staff on a process map for referrals. The LTSAE checklists were then tested in four child care facilities in the spring of 2019 with a plan to begin the pilot phase in the fall of 2019. Data collected in the test phase demonstrated the need for more structured training during the pilot phase. The team recruited 19 child care facilities to begin piloting in the fall of 2019. An all-day in-person training was held in September with funding from the Title V Block Grant with the expectation for the pilot sites to begin using the checklists in October 2019.  

 

Home Visiting

In FY19, 95.5% (399/418)  of eligible enrolled children ages 9, 18, and 30 months received a developmental screening using Ages and Stages Questionnaire-3® (ASQ-3), a validated screening tool through Maternal, Infant and Early Childhood Home Visiting (MIECHV), Building Blocks (BB), and Healthy Families Missouri Home Visiting (HFMoHV) programs. ASQ-3 developmental screening tool consists of 21 questionnaires. It is used to screen children ages 2 months to 60 months; each questionnaire contains 30 developmental items including communication, gross motor, fine motor, problem-solving, and personal/social development subscales. Parents or caregivers try activities with the child and check the box that best describes what the child can do (yes, sometimes, or not yet). The DHSS home visiting program has kept this measure at a high level by sending bi-monthly reminders to each agency about which clients have an upcoming screening due within 30 days. Specifically for ESM 6.1, 93.5% (261/279) of eligible enrolled children, ages 1 year through 3 years, received a developmental screening using the ASQ-3.

 

During the March 2019 Annual Home Visiting Summit, a repeating breakout session on the CDCs LTSAE program was offered to all home visitors. This presentation focused on strengthening the bonds between home visitors and families, as well as between caregivers and children, through the use of discussion and activities around development.

 

Additional resources shared with all GHC contracted home visiting staff through the Missouri Home Visiting Gateway Weekly Update included:

• 10/4/18 - Boston Basics are five evidence-based parenting and caregiving principles that encompass much of what experts find is important for children from birth to age three.
• 3/1/19 - First Steps is Missouri's Early Intervention system that provides services to families with children, birth to three years of age, with disabilities or developmental delays. Resources:
  • Missouri First Steps Program Brochure
  • General Information
  • Eligibility Criteria
  • Regional Contact Sheet

• 6/28/19 -The Devereux Center for Resilient Children (DCRC) is committed to promoting partnerships between the most important adults in a child's life - parents, family members, as well as early care and education professionals.  Resources:
  • Infant/Toddler Activities
  • Preschool Activities

 

In addition to the efforts listed above, additional resources are available to educate families on the importance of developmental screening. The Newborn Health program distributed the Pregnancy and Beyond book, which outlines developmental milestones to correspond with each well-child check and encourages parents to discuss these with their doctor if their child is not reaching these milestones. These booklets are handed out at hospitals and doctors’ offices and cover pregnancy, infancy, and childhood up to age 5. Public awareness materials focused on the importance of developmental screening were available at health fairs and conferences throughout the year. The public awareness materials included a new growth chart that has developmental milestones for children birth to age six. The growth charts have been very popular being ordered by schools, clinicians, and early childhood programs.

 

The Text4baby program sends out 12 customized text messages (1 per month) during a child’s first year of life to parents who are enrolled. These text messages center on normal development for the child’s first year of life and encourage parents to speak to their doctor if their child is not meeting the normal developmental stages. Cumulative data from program participants since January 1, 2015, shows that 72% took their child to their 6-month well-child check and 84% took their child to the 12-month well-child check.

 

NPM #7 Injury Hospitalization – Reduce intentional and unintentional injuries among children.

 

Injuries (intentional and unintentional) are the leading cause of mortality and morbidity in Missouri children. Missouri’s rate for non-fatal injury related hospitalizations among children 0 through 9 years of age, decreased by almost 10% from 133.3 per 100,000 persons in 2017 down to 120.4 per 100,000 persons in 2018.Unintentional injury deaths continue to be the leading cause of death among MO children 1-9 years old, and in 2018, the main causes were motor vehicle accidents (13) and Exposure to Smoke / Fire / Flames (14), followed by drowning (10). In 2018 nearly 17,000 Missourians were admitted to an emergency department or hospitalized with a traumatic injury to the brain (TBI). In addition, there were 2,999 youth under the age of 15 who presented in Emergency rooms or were admitted as an inpatient with a TBI. Of those 1,568 were caused by falls or jumps (the leading cause of TBI in the 0-14 age group); 429 by auto accidents; and 794 were incurred from being struck by or against. Almost all of these tragedies are preventable, which is why Missouri implemented strategies to collaborate, raise awareness, and provide resources to address this issue.

 

Certain strategies in Missouri for NPM #7 impact both the child and adolescent populations. However, to avoid duplicative narrative, strategies were only listed in one or the other population domain. Activities that had a larger focus on the child population are listed below, but it should be noted that some may address a wider age group.

 

Traumatic Brain Injury

Title V Block Grant funds were used to purchase 16,000 copies of Missouri Greenbook: Living with Brain Injury. Those who survive a TBI can face effects that last a few days, or the rest of their lives. Effects of TBI can include impaired thinking or memory, movement, sensation (i.e., vision or hearing), or emotional functioning (i.e., personality changes, depression). These issues not only affect individuals but can have lasting effects on families and communities. Recovering from a TBI is a lifelong journey and part of the recovery involves learning as much as possible about TBI. Having information about what has happened and other challenges the individual may encounter is essential to coping and managing a TBI. The goal of the Missouri Greenbook “Living with Brain Injury” is to provide anyone touched by brain injury with information and resources to assist with the journey of recovery. The book is distributed during conferences/exhibits and to the general public. It is a guide for survivors, families, and caregivers, and has a specific, dedicated section related to child and adolescent brain injury.

 

The National Association of State Head Injury Administrators (NASHIA) held its 30th Annual State of the States (SOS) meeting in Kanas City, Missouri, September 24th through 26th, 2019. The conference featured a variety of topics presented by national, federal, state, and other professionals who are experts and leaders in brain injury research, prevention, rehabilitation, employment, and service delivery. DHSS Bureau of Special Health Care Needs staff and Adult Brain Injury Service Coordinators were granted the opportunity to attend the NASHIA conference where they gained knowledge about brain injury prevention for children, adolescents, and adults. In addition, they can use that knowledge in the field when conducting outreach, presentations, and home visits with individuals that have sustained a traumatic brain injury. One Service Coordinator said the following about attending the conference: “Attending the 2019 NASHIA conference was a wonderful experience. I learned so much about how Missouri programs compare to other states, common resources, and I got the pleasure to network with a lot of wonder people and agencies. Most importantly, I enjoyed listening and learning from others that share the same passion of advocating for individuals that have sustained a brain injury.”

 

Local Public Health Agencies (LPHAs)

A strong local public health network is needed to promote health and protect the public from public health risks. LPHAs addressed injury prevention in their communities through their MCH work plans. The MCH Services Program assisted their efforts as listed below.

 

Promote General/Traffic Safety

A total of 88 LPHAs reported providing general safety education; 95 LPHAs reported providing car seat education, installation, and inspection; 84 reported providing education on proper seat belt usage; and 93 reported providing child passenger safety education. Traffic safety highlights included:

• Dunklin, Harrison, Laclede, Miller, Putnam, and Texas county health departments among many others continued to have at least one Certified Passenger Safety Technician on staff and provided child passenger safety seat inspections, education, installations, and free child passenger seats as needed for children that did not have a child passenger seat or were in unsafe seats due to size, weight, and/or expired/damaged seats.
• Harrison County Health Department hosted two car seat events in partnership with over 20 community businesses/organizations including a local car dealership in which over 150 total individuals participated; safety information was presented on cars, car seats, seat belt safety, and never leaving a child alone in a car, among many other motor-vehicle safety topics.
• McDonald County Health Department utilized their independently-developed and award-winning “Buckle Buddy” program to educate area children in preschool through second grade about the importance of booster seats and proper seatbelt usage; the program utilizes actual safety seat displays and incorporates songs and humor to educate children.
• Many LPHAs utilized existing partnerships to provide car seat and seat belt safety education to area child care facility staff and discussed referral options available to share with parents (i.e. car seat inspection/installation, etc.).

 

Prevent Unintentional Injury

A total of 85 LPHAs reporting addressing home and school safety, 68 reported addressing bicycle safety, 22 reported addressing farm safety, 29 reported addressing all-terrain vehicle (ATV) safety, and 66 reported addressing fire safety. Examples of this work included:

• Henry County Health Department partnered with a local organization to host a bicycle rodeo during summer school in which school-aged children were properly fitted for and provided bicycle helmets.
• Laclede County Health Department provided poison prevention education at the Parents As Teachers "Safety Fair;" provided bicycle safety at a local child care facility "Transportation Fair;” broadcasted “Health Reports” three times weekly in which topics like ATV safety were regularly discussed; and continued a project developed by a Lebanon Senior High School student - "Check Baby" in the distribution of colorful lanyards with the reminder message to not forget the baby in a vehicle.
• Johnson County Health Department collaborated with community organizations (i.e. PAT, PTA, school nurses, head start, pediatric offices, etc.) to educate on the importance of child lead testing, conducted educational programs to area childcare facilities on lead poisoning prevention, promoted adopting lead testing policies for enrollment, and began conducting on-site lead testing with parental consent.
• Madison and Linn county health departments offered fire safety education to local child care providers and children.
• Cass, Pike, and Randolph county health departments offered regularly scheduled Safe Sitter® and babysitting courses to students in sixth through eighth grades, which included choking, first aid, and CPR.
• Moniteau County Health Center participated in the local Ag Safety Day event to educate students on farm and bicycle helmet safety. The LPHA also collaborated with the local Parks and Recreation department to implement a policy change to require the use of mouth guards during contact sports, formerly only a recommendation.
• Pulaski County Health Department provided safety classes to area elementary school children on child passenger and seat belt safety, school bus passenger safety, and bicycle and playground safety.

 

Suicide/Violence/Substance Abuse Prevention

Multiple LPHAs targeted their efforts to address suicide, violence, and/or substance abuse prevention in their MCH Work Plans. Additionally, a total of 98 reported addressing child abuse and neglect, 54 reported addressing domestic violence, and 52 reported providing bullying prevention information and training. Highlights of this work included:

• Clark County Health Department established a Parent Advisory Council in which members attended Parent Café Trainings to become trainers for the community; the multiple Parent Cafés that were established were well received by community members and received positive responses from attendees.
• Putnam County Health Department offered free parenting classes to community members, facilitated Parent Cafés, and hosted Mother-Son Adventure and Father-Daughter Spring Fling Dance events free to children in preschool through fifth grade.
• Butler, Iron, Linn, St. Francois, Vernon, and Webster county health departments conducted anti-bullying education to children in child care facility settings.
• Crawford County Health Department (CCHD) hosted a community baby shower in partnership with Home State Health in which expectant mothers received information on a variety of topics including alcohol and drug abuse and shaken baby syndrome. Staff utilized a shaken baby doll to demonstrate to participants the dangers and effects of shaking a baby and discussed soothing and coping mechanisms to manage a crying baby. CCHD began routinely distributing shaken baby information with every infant birth certificate issued and provided education on toilet training to parents at every two-year old WIC certification appointment.
• Stone County Health Department coordinated and implemented DEA prescription drug takeback events in collaboration with local pharmacies and the Stone County Community Health Coalition, in which over half a ton of medications were collected and properly disposed of from six total events held in the county.
• Many LPHAs collaborated with community partners to successfully pass community ordinances for Prescription Drug Monitoring Programs (PDMP); other LPHAs provided training to community members and first responders on proper Narcan usage and distributed Narcan to area first responders and law enforcement.

 

Water Safety

A total of 66 LPHAs reported addressing water safety, with several reporting using the Josh the Otter educational curriculum.

• Camden County Health Department (CCHD) continued their Water Safety efforts, partnered with the Missouri State Water Patrol and Make a Wish Boat Ride Program, and supported the Life Jacket Loaner Boxes in two locations. The boxes were stocked with life jackets for all ages to use as a loaner and return after use. CCHD also continued to provide stencils to grow the number of locations in the area that have “Life Jacket Zone” painted in an eye-catching bright orange to remind boaters of all ages to don life jackets as they approach boat ramps, docks, and water access areas.

 

Child Care Providers

In FFY2019, the Child Care Health Consultation (CCHC) Program offered 1,382 hours of continuing education trainings for child care providers, 608.25 hours of health promotions for children in child care, 147 hours of specialized consultation, and 53 technical consultations related to child safety and injury prevention topics. This included information about bullying, fire, guns, poisoning, alcohol, drug, motor vehicle, TBI, playground, child abuse, sun, lead poisoning, CPR/First Aid, suicide, and water. By offering these services, the CCHC Program increased knowledge of child care providers resulting in safer child care environments. Health promotions also increase the knowledge of the children. In addition, one new continuing education training was developed to certify child care providers in Mindfulness and Movement (CCHCs must have attended a training of trainers in order to certify child care providers). Using this certification training, child care providers will gain the ability to recognize and address physical and emotional reactions to the current environment; engage in mindful movement practices to physically release stress, anxiety, and trauma; use tools to improve social skills and emotional intelligence; and gain an understanding of how to implement these techniques in a classroom setting. Six new CPR/First Aid trainings were also approved for use in certification of child care providers.

 

The Section for Child Care Regulation (SCCR) continues to provide access to the online Child Care Transportation Safety Awareness training. This training is available at no cost to child care providers. In FFY19, 3,522 child care providers completed the training. SCCR will continue to host the training and will update it as needed to ensure that the content is reflective of current laws, policies, and protocols. To access the training go to http://health.mo.gov/safety/childcare/onlinetraining.php.

 

Injury Prevention

The Injury Prevention Program serves as the state lead for Safe Kids Worldwide and provided funding for nine Safe Kids coalitions covering 54 counties in Missouri. Too many families don’t have access to the information and resources they need to keep their kids safe from tragedies such as drownings, car crashes, fires, and falls. These coalitions are a grassroots network that work closely with community partners to fill that gap and prevent unintentional childhood injuries. Program areas addressed by the coalitions included child passenger safety, bicycle safety, fire safety, firearm safety, safe sleep, water safety, poison control, heatstroke prevention, and other areas based on community needs. The coalitions offered a broad array of activities to achieve the performance goal, which included providing car seats and education to parents of young children, conducting car seat checks, working with water patrol to provide water safety education, hosting educational events, and conducting media campaigns with prevention messages. In FFY19 these coalitions provided services to over 135,000 children and parents through over 1,100 educational events. At these events over 3,200 child safety seats were distributed and over 45,000 car seat checks were conducted. To increase workforce development, the Safe Kids Missouri Leadership Workshop was conducted in September to educate coalition leaders and other partners about a wide range of topics; including information from the Department of Health and Senior Services Emergency Response Center, Missouri Department of Transportation, and car seat distribution programs in Missouri.

 

Stories shared by Safe Kids Coalitions included:

• One woman in southwest Missouri was in a dilemma. Her sister, who had 3 children all under 4 years of age, had committed suicide. Overwhelmed by grief and loss, she was unable to pick up the children who were located 100 miles away, because she had no car seats for them. This happened on a Saturday night, and the plea for help came through the Coalition’s Facebook page. The local Safe Kids Coordinator immediately contacted the woman and arranged to meet her the next morning. Two infant seats and a high back booster seat were provided at no cost and properly installed. Without resources provided by Safe Kids and the community coalition, this incident, and others similar to it, would have never been possible.
• The St. Louis Safe Kids Coordinator was walking in the hallway at the hospital when a mother approached her saying that she looked familiar. She was asked if she was the person who taught the Baby Safety class. Since she did teach that class, the woman proceeded to introduce her to her son, whom she had been pregnant with during the class. The woman thanked her for everything and said she remembered everything she had been taught during the class; NEVER sleep in the same bed with her baby, not to have anything in the baby’s pack-n-play such as blankets, and that if her baby came early (as she was concerned she would deliver early) to use a laundry basket as an emergency safe sleep environment. The woman stated her son had been born early at 33 weeks and spent time in the NICU. The woman also stated she felt the instruction provided during the class had saved her baby’s life!

 

The Injury Prevention Program coordinated the Missouri Injury and Violence Prevention Advisory Committee (MIVPAC), which serves to provide advice, expertise, and guidance to the Missouri Injury Prevention Program and to establish injury prevention as a state priority. The Committee consists of representative members from state agencies, local and regional government agencies, non-government bodies, and consumers. Its goal is to reduce the morbidity and mortality of children aged 0 -19 years due to injuries and violence. MIVPAC continued to focus on work addressed in the MIVPAC Strategic Plan, review data to determine critical target areas for injury prevention, and identify evidence-based interventions to address the priorities established by the Strategic Plan.

 

DHSS received funding from Missouri Department of Transportation (MoDOT) to collaborate with emergency medical services, firefighters, and local public health agencies to train staff to be Child Passenger Safety Technicians (CPST). Twenty-eight staff were certified from the following counties:  St. Charles County, Marion County, Lincoln County, Barton County, Mississippi County, Mid-County, Logan-Rogersville, Hickory County, and Camden County. Title V MCH Block Grant funding was used to provide over 750 car seats to the counties who participated in the training and to the Safe Kids Coalitions.

 

Lead Poisoning Prevention

Child Lead Poisoning Prevention Program

Lead poisoning is a potential poisoning injury to many children in Missouri. If a child experiences very high lead levels, hospitalization for chelation may be needed. Parents who understand the dangers of lead and recognize the many potential sources of lead exposures in their child’s environment are better able to avoid/prevent/reduce the child’s risk of lead poisoning. The Child Lead Poisoning Prevention Program (CLPPP), funded by the Center for Disease Control and Prevention, has an active role in lead assessment and education campaigns through collaborative efforts with the Department of Social Services (DSS), DHSS, and MCH programs and through LPHA and WIC agencies. DHSS/Bureau of Environmental Epidemiology/Adult Blood Lead Epidemiology and Surveillance (ABLES)/CLPPP programs partner with DSS (which administers the Medicaid fee for service and Medicaid/MO HealthNet Managed Health Plan programs) to require Medicaid providers and Medicaid Managed Health Plans to use lead risk assessment questionnaires for Medicaid children and pregnant women. Medicaid managed health care plans are also required to provide lead case management for all Medicaid children they serve up to age 21 years. Usage of the questionnaires requires initiation of direct discussions by the clinician with their clients regarding possible exposure sources and health concerns regarding lead exposure and lead poisoning and prevention. They serve as an effective educational tool used at well-child checks. These questions often result in increased blood lead testing if it is discovered that lead exposure has already occurred or is suspected to have occurred; and thus may lead to more opportunities for environmental testing of residences. 

 

When the children’s homes (where the child had elevated blood lead levels), included women who were pregnant or other young children living or visiting there, the family was encouraged to have the pregnant woman and other young children’s blood levels tested to ensure that they hadn’t had significant lead ingestion as well.

 

This year, Missouri’s CLPPP continued to offer more lead case management, more home visits by nurses, and more home lead assessments by licensed lead risk assessors by providing services at lower blood lead levels in this period. Case managers provided services to families whose children under the age of 72 months had elevated blood lead levels of 5 mcg/dL or higher through LPHAs and at blood lead levels of 10 mcg/dL or higher through Medicaid MO HealthNet Health Plan lead case management protocols. Home visits by environmental lead risk assessors were offered by most state jurisdictions at confirmatory venous blood lead levels of 10 (rather than 15 mcg/dL) and higher. When a lead risk assessment is performed, a licensed lead risk assessor takes samples of substances or surfaces in the home’s interior and exterior environment to identify the source/s of lead exposure (soil, water, dust samples, lead paint samples, food, cosmetics, or from take home occupational or hobby related sources, toys, etc.). Once the sources are identified, the home owner/landlord and the family are educated in proper and safe ways to perform interim controls and how to safely remove the lead sources identified. The lead risk assessors make return visits to the home to be sure that the sources of lead identified have been adequately addressed to meet “clearance standards.”

 

DHSS environmental lead risk assessors also initiated a new practice to provide basic lead information to families of children with venous blood lead levels in the 5-9 mcg/dL range. DHSS lead risk assessors now mail packets of information about the health effects of lead, the need for adequate nutrition and hygiene, and include EPA information about how to safely prevent or significantly reduce further lead exposure.  Mailing these packets increased follow-up phone calls with the lead risk assessors. A number of concerned parents called the lead risk assessor who provided the information to further discuss their particular home situation and how to deal with the probable sources of lead in their home or for guidance in how to address issues with their landlords.

 

Other CLPPP activities also included multiple and diverse educational outreach efforts to the general public, and to targeted areas of the state with low testing rates, or areas of the state with higher risk, as well as to LPHAs interested businesses, clinicians, and other relevant organizations or groups.

 

NPM #14 Smoking – Reduce childhood exposure to secondhand smoke.

 

The home is the place where children are most exposed to secondhand smoke. According to NCSH 2017-2018, 21.8% of Missouri children live in households where someone smokes compared with 14.9% nationally. Nationally, children from high school graduate households were the most likely (26.0%) to be living with smokers, followed by households with some college (19.7%) and less than high school (18.6%), and college graduate (7.7%) households. The proportions of children exposed to secondhand smoke in Missouri were higher than the national figures for high school graduate households (37.5%), some college (28.2%), and college graduate households (11.5%). In addition, Medicaid insured children were more likely to be exposed to secondhand smoke in the home (22.2%) than their privately insured (10.5%) and uninsured (15.2%) counterparts nationally. Missouri children who were privately insured (15.6%) or on Medicaid (34.2%) also had higher percentages of secondhand smoke exposure than their national counterparts. In Missouri, 21.7% of non-CSHCN children lived in households where someone smoked compared to 22.4% of CSHCN. Unmarried two-parent households had the highest proportion of smoking in Missouri (37.7%)*. This was greater than single parent households (28.6%) and more than double the proportion for two-parent married households (17.5%). Children age 12-17 years old had the highest percentage in Missouri (23.3%), compared with (16.2%) nationally. Compared with their national counterparts (16.3%), a greater percentage of non-Hispanic White children were exposed to smoking in Missouri (23.4%).

 

Missouri has made progress in increasing the number of communities that have ordinances to prevent secondhand smoke exposure in public places. In 2019, there were 37 communities with comprehensive smoke-free ordinances in Missouri, which is more than double the number of communities (15) in 2010. Teaching youth about the dangers of tobacco use and increasing smoke-free laws and policies such as smoke-free homes and vehicles can have a positive impact on the MCH population.

 

In FFY2019, the Child Care Health Consultation (CCHC) Program provided six hours of continuing education trainings for child care providers regarding the dangers of secondhand smoke, and one health promotion for children in child care regarding smoking prevention. The purpose for offering these services was to decrease the number of children exposed to secondhand smoke by increasing child care provider knowledge about the dangers of secondhand smoke to children’s health. In addition, one new continuing education training regarding the effects of vaping was developed for use in training child care providers, and one new children’s health promotion regarding the dangers of smoking and vaping was developed for use in educating children.

 

The MCH Services Program supported LPHA efforts to eliminate exposure to secondhand smoke and identify and eliminate tobacco-related disparities among population groups. Of the 114 LPHAs, 25 reported providing classroom tobacco-avoidance education, 97 reported having tobacco-free policies and/or ordinances in place for public buildings and/or public spaces, 32 reported participating in secondhand smoke prevention campaigns, 30 reported participating in electronic cigarette prevention campaigns, and 102 reported providing maternal tobacco assessment, cessation, and education and referral to the Missouri Tobacco QuitLine.

 

Highlights of the LPHA efforts included:

 

• Springfield-Greene County Health Department (SGCHD) worked with landlords and renters to adopt smoke-free housing units in Springfield and because of their efforts, there were 5,334 newly designated smoke-free units spanning 16 properties. SGCHD also assisted in the development of the Missouri Vape-Free Schools Toolkit, which serves as a guide for schools in the development of comprehensive tobacco-free and vape-free policies.
• Kansas City and Miller County health departments provided presentations to area students specific to the dangers of vaping.
• Lincoln County Health Department hosted an anti-vaping presentation in which parents, students, and educators in attendance were educated by law enforcement officials and health department staff on the dangers of using vaping products.
• Dallas, Mississippi, and St. Charles county health departments collaborated with area schools to provide youth tobacco education in elementary, middle school, and high school settings.
• Howell County Health Department provided the youth tobacco education program Tar Wars® to area fourth and fifth grade students.
• Taney County Health Department used MCH funds to purchase the ALL STARS program curriculum and provided training to 700 junior high students on the evidence-based substance use prevention program, which included the prevention of tobacco use.
• Many LPHAs worked with community partners to ensure current tobacco-free ordinances and policies already included or were edited to include the use of vaping products.

 

State Outreach Efforts

Although not funded through the Title V block grant, certain outreach efforts are noteworthy due to their likely impact on the MCH population and partnerships with programs funded by Title V.

 

Policy Initiatives

The Tobacco Prevention and Control Program (TPCP) contracted with 14 schools and one non-profit youth organization to implement the Taking Down Tobacco (TDT) Program during the 2018-19 school year. The TPCP conducted 3 trainings to teach the program coordinators how to implement TDT. Three trainings were also conducted with the 15 participating schools/non-profit organization to teach 2 youth from each contractor the Taking Down Tobacco 101 training and training-of-trainers. Half of the participating schools were members of FCCLA chapters (Family, Career and Community Leaders of America) resulting from a partnership with the state FCCLA program. A total of 30 youth and 15 adults were trained this reporting period.

 

Two universities strengthened their existing tobacco-free campus policies, five communities passed policies to raise the minimum age of tobacco sales to 21, and one community passed a smoke-free community policy bringing the total to 37 statewide.

 

All 100 of Missouri’s Public Housing Authorities (PHAs) implemented a smoke-free housing policy per the US Housing and Urban Development’s required June 2019 deadline. The TPCP provided the PHAs a Smoke-Free Public Housing Toolkit on a flash drive labeled with the department’s and TPCP's new smoke-free housing logo, weatherproof "100% Smoke-Free Building" signs created by the program, a supply of "Proud to be a Smoke-Free Property - Smoke-Free Housing" window clings, and a supply of Missouri Tobacco Quitline cards, along with an order form to order additional supplies of each. PHAs subsequently ordered an additional 244 smoke-free housing signs and 401 window clings.

 

NPM #15 Adequate Insurance – Ensure adequate health insurance coverage and improve health care access for MCH populations.

 

According to NSCH 2017-2018 data, 67.2% of Missouri children were adequately insured compared with 67.5% nationally. The percentage of adequately insured children differed by age groups and CSHCN status. Missouri children ages 12-17 (60.5) had the lowest rates of adequate insurance coverage, followed by 6-11 year olds (67.0%) and 0-5 year olds (73.8%). Children with special healthcare needs (64.6%) were less frequently adequately insured than non-CSHCN (67.9%). Missouri high school graduate households had the highest percentage of children who were adequately insured (72.5%) compared to households with some college education (69.6%) and college graduate households (63.7%). However, the percentage of college education households that were adequately insured in Missouri was lower than nationally (67.1%). Those in Missouri with private insurance (62.6%) were less adequately insured than those on Medicaid (87.0%). Medicaid recipients in Missouri were also more adequately insured than their national counterparts (81.9%). Two-parent unmarried households (67.1%)* were more adequately insured than two-parent married households (66.9%) and single parent households (65.7%) in Missouri, but less than their national counterparts (70.8%). Nationally, non-Hispanic Blacks (71.3%) are more adequately insured than non-Hispanic Whites (67.0%) and Hispanics (66.0%). This was mirrored in Missouri, as non-Hispanic Blacks (74.3%)* were also more adequately insured than non-Hispanic Whites (66.7%) and Hispanics (62.2%)*.

 

In FY19, 80% (558 out of 702) of Missouri primary caregivers enrolled in Department of Health and Senior Services’ (DHSS) funded home visiting programs had continuity of health insurance coverage for 6 months in the previous  year’s  enrollment. Since Missouri did not participate in Medicaid expansion, many low-income adults, the population targeted for home visiting services, do not have sustainable insurance coverage following the closure of MO HealthNet for pregnant women coverage 56 days after the birth of the baby. The Missouri home visiting team, in collaboration with Department of Social Services (DSS), improved and expedited the Medicaid enrollment process for home visiting clients by developing and continuing to update a Q & A document, which home visitors use to educate clients on navigating the Medicaid enrollment/eligibility process for pregnant women. Additionally, DSS provided a point of contact for home visitors to reach if there are issues with getting eligible clients enrolled in a timely fashion. Getting pregnant primary caregivers enrolled in Medicaid more quickly has enabled the clients to initiate prenatal care earlier in their pregnancies. Specifically for ESM 15.1, the percent of primary caregivers and children with health insurance at one year post enrollment among Missouri DHSS Home Visiting program participants was 89.5% (307/343).

 

Access to adequate health insurance continues to rank as a high priority for Missouri’s MCH populations, particularly for Medicaid populations. There are many barriers for access to healthcare, and rural areas in general tend to experience large gaps in access to preventive, primary, and dental care. This is a prominent issue in Missouri where 99 of its 115 counties are classified as rural. Of the 126 licensed general acute care hospitals in Missouri, 59 are located in rural areas, with 25 of these classified as Critical Access Hospitals, which offer a limited range of services. A total of 84 of the 106 Primary Medical Care Health Professional Shortage Areas (HPSAs) in Missouri are in rural areas.

 

In 2017, 78 of Missouri’s rural counties had poverty rates above the state average. As of 2017, the poverty rate for rural residents (16.2%) was 35.0% higher than the urban poverty rate (12.0%). The lack of access to care can have serious consequences for vulnerable populations, particularly pregnant women. Deficiencies of rural healthcare result in a higher burden of illness among rural women when compared to their urban counterparts. The lack of physicians, limiting technology, and transportation issues, compounded with the economic state of many rural Missouri residents, is cause for concern in the area of women’s health.

 

Due to these access issues, rural Missourians tend to have less access to postpartum healthcare, and experience a delay in prenatal care due to an inability to get an appointment with a healthcare provider. In general, rural Missourians have higher emergency department (ED) utilization rates for all diagnoses than urban residents. Females in rural areas have higher ED utilization rates than males. This can be interpreted as an indication that primary care is lacking in rural communities, and that this deficiency impacts females more than males.

 

Health care resources in rural Missouri are limited, even for those who have health insurance, have no financial difficulty, and have access to transportation. Receiving adequate health care for those who are low-income, uninsured, and geographically isolated can be even more challenging. By working with health care providers and communities, access to care can be improved for the underserved. Title V worked to both ensure adequate health insurance coverage and improve health care access for MCH populations through education, referrals, and by providing resources and technical assistance.

 

In FFY19, over 35,000 Pregnancy and Beyond booklets were distributed to health care providers and other providers throughout the state. The Pregnancy and Beyond booklet is a tool for a pregnant woman and her health care provider to track the progress of her pregnancy. The book allows women to record their health information. Taking the book to prenatal visits can help women remember questions and write down special instructions from their health care provider. The book discusses the importance of prenatal care and shares the phone number for TEL-LINK, if a woman does not know where to go for prenatal care. TEL-LINK is the Missouri DHSS’ confidential, toll-free telephone line for maternal and child health care. The purpose of TEL-LINK is to provide information and referrals to Missouri residents concerning a wide range of health services. Callers requesting referrals are transferred to the appropriate agency. In FFY19, TEL-LINK referred 258 callers to Medicaid/MO HealthNet services. Another resource, Text4baby, allows women to enroll in the program to receive three text messages each week. The program delivers customized messages within the first few weeks of pregnancy about free or low-cost healthcare. During week 12 of pregnancy, participants receive a text that reads “Need help paying for prenatal care visits? Medicaid pays for pregnancy check-ups & delivery. Info at 800-835-5465 or finder.healthcare.gov”. Another text is sent in week 15 that states “Even if you feel great, a pregnant woman needs check-ups with a Dr. /midwife (CNM/CM). For help with costs, call 800-835-6465 or finder.healthcare.gov”. Accumulative data since July 1, 2016 showed that 8% of enrollees in the Text4baby program did not have insurance at the time of enrollment, and 66% of those enrollees applied for Medicaid.

 

The Bureau of Genetics and Healthy Childhood (GHC) served 1,087 families through four evidence-based home visiting models. During FY19, home visitors from these models assessed all home visiting clients for insurance status at initial enrollment and periodically throughout enrollment. As needs for health care coverage were identified, home visitors assisted clients/families in the Medicaid enrollment process and through referrals to the Affordable Care Act (ACA) marketplace. Clients were referred to their nearest federally qualified health center to speak with a trained navigator in order to obtain eligibility and enrollment assistance. Data from FY19 indicated that 96% of children and 85% of primary caregivers enrolled in home visiting had insurance coverage through Medicaid, private, or other insurance at some point during the preceding year. The following resources were shared with all contracted local implementing agencies to help home visitors better understand ACA marketplace changes and uncertainties in order to assist their clients:

• 11/9/18 - November 1st marked the first day of Open Enrollment for 2019 health plans under the Affordable Care Act (ACA)  Open Enrollment only lasts for a short time—it ends on December 15.
• 11/16/18-12/14/18 Weekly Updates-Free, in-person help is available!  Cover Missouri is a Missouri-specific website for assistance in enrolling in the ACA marketplace during open enrollment.
• 9/13/19 - New insurance resources are located on the Missouri Home Visiting Gateway under Resources and the heading Maternal & Child Health Insurance. The newly added resources include information about Home State Health, Missouri Care, and United Healthcare.

 

The majority of LPHAs worked to ensure adequate health insurance coverage and improve health care access for the MCH population, and of the 114 LPHAs:

• 107 reported screening clients for MO HealthNet or other insurance coverage,
• 101 reported screening for an identified primary care provider,
• 106 reported performing pregnancy testing, prenatal education, and OB/GYN referrals,
• 67 reported providing prenatal case management and/or referral for pregnant women, and
• 71 reported assisting pregnant women with Medicaid enrollment eligibility.

 

LPHAs strive to provide services to cover the gaps in service areas that result in improved health care access for the MCH population. Some highlights of these service areas for the local agencies include:

• Franklin County Health Department offered assistance to pregnant women in the completion and submission of their Medicaid applications on site in an effort to expedite the Medicaid enrollment process and reduce the incidence of missed prenatal appointments due to lack of insurance coverage.
• Clark County Health Department helped arrange transportation for individuals with Medicaid in need of medical services.
• Livingston County Health Center’s Certified Diabetic Counselor provided one-on-one consultation and education for individuals with diabetes and their family members regardless of an individual’s insurance status.
• Moniteau and Wayne county health departments offered reduced-price laboratory testing (e.g. lipid panel, Hemoglobin A1C, etc.) to under- and un-insured women.
• Grundy County Health Department offered free newborn home visits to mothers, regardless of insurance status, in which a nurse provided support and education on infant care, postpartum care, and breastfeeding.
• Multiple LPHAs offered temporary Medicaid enrollment services to pregnant women and offered assistance in the coordination of WIC services and scheduling of the initial prenatal appointment with a local OB/GYN provider.

 

LPHAs reported an increased health equity focus and increased staff education on providing resources and services equally to everyone to ensure equal access to health care and reduce health disparities. Adair County Health Department provided special immunization and communicable disease services to a large Congolese population, and several LPHAs provided special services to Amish and Mennonite populations, including special mass immunization clinics and after-hours private clinic visits.

 

In FFY2019, the Child Care Health Consultation (CCHC) Program offered 1 hour of specialized consultation and 1 technical consultation regarding health care access; 6.5 hours of specialized consultation and 25 technical consultations regarding WIC referral; and 0.5 hours of specialized consultation and 5 technical consultations regarding MO HealthNet service referrals. Consultations are provided to child care providers and/or the children and families they serve to assist in meeting a particular need. Consultations regarding referrals provide connections to local resources to help fulfill a child’s need, specifically access to care, insurance, and WIC. By offering these services more families receive education and are referred to a direct source for insurance and/or WIC enrollment, so that more children are adequately insured and have access to needed health care and proper nutrition. As a result, child care providers are aware of services within the community and are knowledgeable to make referrals to families when needed in the future.

 

The School Health Program (SHP) continues partnership with DSS/MO HealthNet to provide resources for school nurses to assist students/families with Medicaid enrollment and utilizing local health care services. Since October 2017, the School Nurse Link (www.schoolnurselink.com) has been an online resource for school nurses. This web resource provides a link for school nurses to access information about Medicaid/MO HealthNet programs for children and families as well as benefits available for each of the managed care plans in which MO HealthNet participants are enrolled. SHP continues to promote the School Nurse Link as a resource available to all Missouri school nurses as they work to support families to access services and utilize their healthcare and insurance benefits, as well as help to find health insurance resources.

 

To improve the utilization of health insurance covered services, SHP works with other programs and agency partners to communicate the health needs and services access concerns to the Managed Care Organizations (MCO) that contract under the MO HealthNet program of Missouri Medicaid. This has benefitted the students and school health services across Missouri in a few notable ways. Students with Asthma prescribed rescue inhalers can now be provided a second inhaler for the school health room as a covered benefit, and the processes for obtaining the air chamber spacers for using them has been improved. By understanding the challenges families experienced in their processes, the MCOs have addressed their systems to improve outcomes for children and manage the cost of care.

 

Using the statewide School Health Online Reporting System (SHORS), SHP tracks and monitors Missouri student data. The voluntary reporting provides aggregate trend data on chronic health conditions as well as access to healthcare. SHP continues to encourage school nurses to include assessment of student health insurance status as a routine question in student enrollment. The SHP database indicates a growing number of school districts are collecting this data for reporting, with an increase from 47% of the reporting schools indicating that they ask about student health insurance status in 2016-17 to a rate of 70% reporting on student insurance status in 2018-19.

 

SHP serves as a member of the Show Me School Based Health Alliance of Missouri (SMSBHA) advisory board, and is working with member partners to expand access to care in school-based health care programs. These programs have increased in 2018-19 to be present in at least one site in 50 of the 114 counties plus 1 independent city in Missouri. SHP is also a collaborating partner with the SMSBHA members to bring resources to schools/school nurses for enrolling children and families in Medicaid/MO HealthNet, including partnership with FQHCs, Legal Aid Society programs, and local advocacy organizations.

 

As a partner in the SMSBHA, SHP has actively undertaken activities focusing on the high and increasing number of children that are no longer enrolled in Missouri Medicaid/MO HealthNet. It came to the attention of many agencies and organizations that children were losing their eligibility and questions arose as to why, as well as if they had transitioned to private insurance plan coverage. The SMSBHA project engaged the SHP as a resource to assist families with the MO HealthNet enrollment and to understand why their eligibility for coverage was changed. The SMSBHA partners identified a gap in the communication between families and the MO HealthNet organization for annual renewals. The SHP and partner organizations created informational materials to work with schools, school nurses, and families to provide information and resources and assist families with the processes to get children enrolled with health insurance coverage.

 

SHP continues to support the Academy of American Pediatrics (AAP) and Center for Disease Control and Prevention (CDC) Training, Education, Advocacy, Mentorship, and Support (TEAMS) framework as a tool for systematic review, evaluation, and improvement of school health services in a growing cadre of school districts. The identified critical issues and emerging action plans among the participating school districts demonstrate that they recognize the role school nurses have in the medical home, especially students with chronic health conditions and healthcare needs. Overall, the focus of the improvement plans being developed by these school districts is to improve access to care through school health services actively participating in care coordination and supporting the student for academic success. For the 2018-19 school year, three additional districts were added, bringing the number of school districts the SHP is supporting with resources and technical assistance to implement the TEAMS framework to 20, with student enrollment ranging from 955 to 23,854 in these school districts.

 

To implement best practice in school nursing and school health services, SHP monitors identified school health office staffing needs using the annual Staffing Survey in the online data base of reporting districts. Many of the small and rural districts identify a need for RN supervision for the LPN and health aides staffing the health office. In 2018-19, the Missouri School Boards Association (MSBA) engaged with SHP for guidance in providing RN supervision services for school districts unable to identify a local resource. A full time RN position has been established within MSBA and services are available statewide to school districts.

 

The Office of Dental Health (ODH) works closely with the Coalition for Oral Health (MCOH), Missouri Primary Care Association (MPCA), and Missouri Dental Association (MDA), all of which address access to quality dental care in Missouri. These organizations are well positioned to effectively communicate about oral health topics with legislators, the Governor, and other high-level decision makers in Missouri. The ODH consulted with MO HealthNet to successfully continue the adult dental benefits for participants. 

 

Access to primary care dentists is severely limited throughout most of rural Missouri. A total of 79 of the 95 Dental Health HPSAs in Missouri are in rural areas and 12 counties lack a dentist. Teledentistry increases access to dental care in areas of the state where dental specialists are not available. It reduces the time and cost burdens of traveling outside of one’s community. Patients can instead go to a nearby clinic in their area and then a dentist, working remotely, can screen and diagnose that patient through a videoconference. The off-site dentist can review records and make decisions about needed dental treatment, which a local dental hygienist may be able to provide. Since 2017, MO HealthNet has included two codes for teledentistry on the list of covered dental codes. This provides opportunity for a virtual dental home that works beyond the limitations of geography. ODH had two teledentistry contracts available through two grants received on September 1, 2018. These provided those in underserved communities access to dental care and allowed the dentist to receive MO HealthNet reimbursement, which will provide the dentist sustainability to the program after the completion of the contract with ODH.

 

ODH is a recipient of the Health Resources and Services Administration (HRSA) Oral Health Workforce grant. Through this grant, the goal is to build Missouri’s Teledentistry workforce by contracting with a hygienist and dentist to perform teledentistry in nursing home and school settings, provide an educational opportunity at the Missouri Primary Care Association conference, and increase the number of educational workshops and technical assistance for Teledentistry. Through these efforts, the aim is to increase teledentistry options in Missouri and reduce the number of people who lack access to dental care. The technical assistance contract has been awarded and assistance provided. The teledentistry workshop was held in November, 2019. Also through the HRSA grant, ODH contracted with LPHAs to provide fluoride varnish to WIC participants and other high risk children who visit their LPHA. This is a Medicaid reimbursable expense, so the goal is for the program to become self-sustainable. It also provided limited preventive care to high risk children who may not have access to that service due to a shortage of dental providers. As of September 30, 2019, ODH has contracted with five LPHAs to provide fluoride varnish to their WIC participants, as well as any child who comes to their health department for services. About 200 children have received this important service, along with oral health education.

 

ODH is also the recipient of the CDC State Actions to Improve Oral Health Outcomes grant, which contracts with a dental program to provide dental sealants onsite at schools. Since September, 2019, ODH has contracted with Lincoln County Health Department (LCHD) to provide and promote dental sealants in schools in both Lincoln and Shelby Counties. Through this contract, LCHD bills Medicaid, for those eligible, in order to utilize this often under-utilized benefit and thus improve the oral health of children in those high-risk areas.

 

SPM #3 Oral Health – Percent of children, ages 1 to 17 years, who had a preventive dental visit in the last year.

 

According to NSCH 2017-2018 data, nationally 79.7% of children ages 1-17 years old had a preventive dental visit in the last year. This was a greater percentage than in Missouri (70.9%). A lower percentage of Missouri children age 1-5 years old (43.7%) had a preventive dental visit than their national counterparts (59.7%). This age group also had a lower percentage than Missouri children age 6-11 years old (83.4%) and 12-17 years old (81.0%). The children in Missouri who most frequently had a preventive dental visit in the last year were in college educated households (79.4%) followed by some college (72.7%), and high school graduate (58.2%)* households. Privately insured Missouri households (77.7%) more frequently had a preventive dental visit than Medicaid (62.5%) and uninsured (49.6)* households. In Missouri, children in two-parent married households (74.4%) reported more commonly having had a preventive dental visit in the last year than single parent (69.5%) households and two-parent unmarried households (42.2%)*.

 

Learning good oral health care and establishing regular (at least annual) dental visits at an early age is important. Tooth decay is the most common childhood disease, but it is preventable. During regular dental visits or as part of public health programs like the Preventive Services Program (PSP) or dental sealant programs, children can receive fluoride varnish or dental sealants, which are each important for the prevention of tooth decay. Infants and toddlers can suffer from “baby bottle tooth decay,” which is caused by frequent, prolonged exposure to drinks that contain sugar. This often occurs when children are allowed to drink sugary drinks from bottles or sippy cups, especially when they are put to bed with a bottle. Only breast milk, formula, or water should be put in bottles to avoid this problem.

 

Among older children, tooth decay can lead to problems eating, speaking, and learning. Poor oral hygiene can lead to poor self-esteem. Later in life, poor oral health can lead to pregnancy complications, trouble controlling diabetes, and increased risk of heart disease. Links between poor oral health and other chronic diseases such as stroke, pneumonia, and dementia are also being studied. The Office of Dental Health (ODH) is committed to improving the oral health of all Missourians through education, prevention, partnership and leadership.

 

The importance of dental visits among children was reinforced in literature, namely through the “Healthy Smiles from the Start” booklet. It was distributed by the ODH via its collaboration with the Women, Infants, and Children (WIC) program, Home Visiting Program, and Federally Qualified Health Centers (FQHC). This booklet gives tips to parents on their young child’s oral care, when to see a dentist, and teething. The importance of regular dental care was also stated within the context of the ODH’s promotion of the use of dental sealants. Referrals and care coordination components of the PSP, described more below, also encourage regular dental visits for children, particularly those who have been identified as having evidence of a dental need.

 

WIC program’s role in preventing oral health problems in women, infants, and children is through education and referral. Nutrition counseling to parents and guardians of infants and children includes proper care of the gums and teeth at home and feeding practices that reduce the risk of developing early childhood caries. During annual certification visits and prenatal and postpartum visits, participants are asked dental-health related questions to assess their children’s dental health. Children may then be referred to a local dentist, if necessary. Through a grant with the Missouri Foundation for Health in conjunction with HRSA’s Oral Health Prevention and Workforce Improvement Project, five LPHAs partnered with ODH to provide fluoride varnish to their WIC participants, and any other child 0-18 years of age, who came into their health department. These five LPHAs started the spring of 2019, and through September of 2019 provided 185 children with fluoride varnish. Not only did they receive the benefits of fluoride varnish, but they also received oral health education and oral health supplies, such as a toothbrush and toothpaste. Besides providing the public health benefit of fluoride varnish to children, the LPHAs also submitted and received Medicaid reimbursement to MO HealthNet for the Medicaid children who received varnish.

 

In FFY19, the Missouri WIC program purchased 57,600 youth toothbrushes, 30,600 baby teething toothbrushes, and 4,300 brochures titled ‘A Healthy Smile for Your Young,’ which were distributed by the counseling staff in the WIC local agencies. Healthy Smiles from the Start training was a coordinated effort of the Missouri Dental Association (MDA), the Missouri Department of Health and Senior Services (DHSS) Oral Health program, and the Missouri WIC program to provide dental health care education through a webinar. During FFY19, WIC Program risk factor 381 Oral Health Conditions was assigned to 3,321 participants: 251 infants, 1,095 children (1-5-years of age), 1,002 prenatal women, and 655 non-breastfeeding and 318 breastfeeding women.

 

Genetics and Healthy Childhood (GHC) supported Home Visitors were provided ordering information for oral health resources from ODH during the annual March 2019 Home Visiting Summit. Additionally, through the Missouri Home Visiting Gateway Weekly Update, the following resources were shared with GHC supported home visitors:

• 2/15/19 - The 2019 Oral Health Policy Conference features presentations on technology, system change to increase access to oral health care, and work to address our oral health challenges.
• 3/8/19 - Now You’re Brushing for Two: This infographic encourages pregnant women to get a dental check-up before delivery.  

 

During FY19, ODH received Title V funding to promote water fluoridation through a multi-media campaign in southeast Missouri. The multi-media campaign highlighted the importance of drinking fluoridated water, the importance of regular dental check-ups, and good oral hygiene habits. More information on this campaign can be found in the Women/Maternal Health (SPM #6) section of the State Action Plan.

 

The SHP is a partner on the Missouri Coalition for Oral Health and continues to partner with ODH to support school participation in dental sealant programs and fluoride initiatives throughout the state. At the annual Health Office Orientation (HOO) in July 2019, oral health materials were included in the “Resources” session. This three-day workshop offers an orientation for nurses and heath room aides without prior work experience in schools and an overview of information regarding school nursing practice. SHP included speakers from ODH to present at the HOO (65 attendees) and share about the resources and local services available to school nurses. The Oral Health Program provided the Dental Health Guide for School Nurses to the attendees. Participants at the HOO also received maps for locating and contacting community dental services, contact information for the PSP staff, and updates on fluoride and dental sealant programs for schools.

 

The ODH enjoyed continued success with the PSP, which is an evidence-based fluoride varnish and oral health education program. PSP served 91,384 children during the 2018-2019 School Year. Each child received an oral health screening by a dental professional, two doses of fluoride varnish, oral health literature and supplies, and oral health education. The oral health education was either provided by school staff or the dental professionals that volunteer to operate PSP. Educational materials were provided by ODH (for each grade, K-12), but some schools chose to use materials included in their health education curriculum or collaborate with non-profit entities like Delta Dental’s Land of Smiles Program.

 

A Basic Screening Survey (BSS) is a nationwide effort to determine the oral health of the nation’s children and completed every five years. A BSS is a survey of randomly picked schools, based on their Free and Reduced Lunch Rate, who allow state/local officials to screen the oral health of the school’s third graders. ODH worked in conjunction with the Association of Territorial and State Dental Directors (ASTDD) who randomly picked schools and assisted in analyzing the data to assess the oral health of Missouri’s children. Missouri’s BSS began in the summer of 2018 through the selection of 53 schools to participate and was completed by June 2019. Findings from the BSS showed approximately 55% of Missouri’s third grade children have a history of tooth decay, which is lower than the national average of 62%. However, 29% of Missouri’s third grade children have untreated tooth decay, which is higher than the national average of 22%. This could be one indicator for lack of access to care.

 

Missouri has been singled out in recent years for its poor status in terms of dental sealants. In response, ODH promoted the use of dental sealants as an effective means to prevent decay on newly erupted molars. This promotion occurred as part of the PSP. Dental sealant literature, produced with MCH Block Grant funding, was distributed to dental clinics, FQHCs, LPHAs, and other partners. ODH also acquired funding during 2016 for a Missouri Dental Sealant Program from a private foundation to contract with four clinics to provide sealants to children. The Missouri Dental Sealant Program is designed to operate in high-need schools, defined as having at least 50% of students eligible for the Free and Reduced School Lunch Fee program. This statewide program is an extension of a pilot project previously funded by a HRSA Oral Health Workforce Grant from 2013-2016. From August 2017 to July 2019, 36,847 sealants were placed on the teeth of 14,183 children. The BSS found that 30% of Missouri third grade children have dental sealants, which is still lower than the national average of 42%, but an increase of 5% over the past three years (as compared to state data from the PSP).

 

In FFY2019, the Child Care Health Consultation (CCHC) Program offered 14 hours of continuing education trainings, 37 hours of specialized consultation, and 4 technical consultations for child care providers, and 183 hours of health promotions for children in child care, regarding children’s oral health. Components of these services stress the importance of good oral hygiene and routine dentist visits, while also promoting oral hygiene policy development among child care facilities. The CCHC Program’s goal through offering these services is to promote oral health practices in child care and increase the number of children receiving dental care. As a result, child care providers and children become aware of oral health issues and the importance of regular oral health care.

 

Through screening, referral, and participation in the provision of preventive dental services, the LPHAs worked to increase the number of children, ages 1 to 17 years, who had a preventive dental visit in the last year. Of the 114 LPHAs, 95 reported screening clients for an identified dental care provider and providing dental referrals, 91 reported having community partners who provided oral health screening and referral, and 35 reported providing dental screenings and/or services. More specifically,

 

• Vernon County Health Department has a nurse on staff that helped provide fluoride treatment to uninsured children in the Miles for Smiles mobile dental unit.
• Caldwell and Harrison county health departments offered the PSP fluoride rinse, screening, referral, and education program.
• Laclede County Health Department conducted dental screenings in the WIC program and referred to the local FQHC as needed. The FQHC offers dental services on a sliding scale fee to under- and un-insured children and adolescents.
• Pulaski County Health Department provided toothbrushes, toothpaste, and floss to community members, including children, and referred to the local FQHC as needed.
• Since April 2005, the Lincoln County Health Department (LCHD) dental clinic has been serving children and adolescents with Medicaid, Medicare, and those who are under- or un-insured by providing services on-site and in schools. The LCHD dental program received a $46,000 grant through DHSS to expand their Teledentistry program and will be partnering with the Shelby County Health Department (SCHD) to facilitate dental services in Shelby County schools and assist SCHD in determining the feasibility of their own Teledentistry program.
• Dallas County Health Department has a Bright Smiles Program in which MCH contract funds were utilized to pay a part-time coordinator to conduct regular brushing and oral health education to students in kindergarten through second grade at a local elementary school.
• Clay County Public Health Center’s school-based dental program provided free dental screenings, oral health education, dental sealants, and fluoride varnish applications to Clay County students.
• Joplin City Health Department partnered with a local dental school in which dental students provided education on oral care once a week to WIC participants.
• St. Louis County Department of Health provided oral health education with toothbrushes and toothpaste and reported providing dental services at three health department clinic sites.

 

Lastly, multiple LPHAs collaborated with community partners to host mobile dental vans at the health department, school(s), and other community sites.

 

SPM #7 Physical Activity – Percent of children ages 6 through 11 who are physically active at least 60 minutes per day.

 

According to the 2017-2018 NSCH data, 37.4% of Missouri children ages 6-11 years old were physically active for at least 60 minutes a day, compared with their national counterparts at 27.7%. Boys in Missouri (38.9%)* more commonly met this benchmark for physical activity than girls (36.1%)*. Compared with their national counterparts (26.2%), a higher percentage of those who lived in Missouri suburbs (37.8%)* had at least an hour of activity a day. In Missouri children from college graduate households less frequently (22.1%) reported having 60 minutes of physical activity per day than those from some college (44.5%)* and high school graduate (46.6%)* households. Medicaid recipients in Missouri (52.6%) were more frequently physically active for an hour daily than their national counterparts (29.1%). Obesity is complex and environmental and behavioral factors play a critical role. Healthful eating and regular physical activity are two critical components in achieving and maintaining good health. Missouri works to implement best practices to ensure all Missourians live in communities that support both of these healthy habits. 

 

Recent research by the Robert Wood Johnson Foundation (RWJF) forecasted Missouri would spend $12 billion a year on obesity-related health care in 2030, as a result of alarming increases in childhood obesity. RWJF also ranked Missouri 17th in the nation for adult obesity. The Behavioral Risk Factor Surveillance System (BRFSS) reports that three out of four Missouri adults have at least one chronic disease, and more than two of every three adults are overweight (35.4%) or obese (32.5%). Today’s children are tomorrow’s parents, a major influencer of children’s diet and physical activity habits. Poor dietary habits and sedentary behaviors formed in childhood are likely to persist into adulthood making it critical to support healthy habits early. Through a Missouri Department of Elementary and Secondary Education (DESE)/Department of Health and Senior Services (DHSS) data system collaborative, Missouri school districts reported that increasing numbers of school-age youth are living with complex chronic conditions, such as asthma (10%) and diabetes (0.34%), with many depending on schools for support. Obesity and chronic condition prevalence rates are significantly higher among African American and Hispanic communities, which compounds the gap in health equity and educational attainment for children from these minority groups.

 

Certain strategies in Missouri for SPM #4 impact both the child and adolescent populations. However, to avoid duplicative narrative, strategies were only listed in one or the other population domain. Activities that had a larger focus on the child population are listed below, but it should be noted that some may address a wider age range.

 

Obesity is a complex issue with many solutions. Each solution requires multiple organizations come together to achieve change. One way Missouri brings these partners together is through the Missouri Council for Activity and Nutrition (MOCAN), the statewide obesity prevention council facilitated by University of Missouri Extension (UME). MOCAN’s member organizations are structured into workgroups specific to settings or topics: Schools & Child Care, Physical Activity, Worksites, Food Systems, Messaging, and Policy. DHSS staff supported through MCH funding participate in MOCAN workgroups to support statewide improvements in physical activity. 

 

The Bureau of Community Health and Wellness (CHW) and the MOCAN Physical Activity Workgroup continued their efforts to build and expand the Missouri Livable Streets Advisory Committee. The advisory committee is a collaborative network of statewide stakeholders who serve to channel information and provide guidance for moving Missouri communities towards inclusive, mobile, and healthy places. Members continued to provide guidance to DHSS in shaping future Livable Streets activities. The advisory committee’s work focused on: building a collaborative network of stakeholders from across the state; providing information through the Livable Streets website; encouraging inclusive designs and programs; and reaching communities throughout Missouri. In FY19 the Advisory Committee supported the active living strategy of the Centers for Disease Control and Prevention (CDC) (1807) grant that targeted the adoption of Livable Streets policies and plans in ten rural communities.

 

In FY19, the Missouri MOve Smart Child Care physical activity recognition program guidelines and supporting materials, including the online training, were updated. The guidelines were simplified and the application process was streamlined. CHW expects the number of MOve Smart recognized child care providers to increase once the revised guidelines are promoted more widely.

 

In FY19 CHW concluded a pilot project with Columbia/Boone County Public Health and Human Services to use 12345 Fit-Tastic! MAPPS for Change with child care providers. The five key elements of the MAPPS for Change are: consistent use of message, consistent assessment of weight status and lifestyle behaviors, healthy lifestyle plan for all, policies and practices to create environments that enable healthy eating and active living, and statistics and storytelling to track and promote success.

 

The pilot began in July 2018 and was carried into FY19. Columbia/Boone utilized the 12345 Fit-Tastic! Early Childhood Toolkit to create three levels of certification, Bronze, Silver and Gold as described below.

• Bronze (implementation) level includes: Providing opportunities to get physical activity every day, limit recreational screen time, offer 1% or skim milk to kids ages 2 and older, limit or eliminate sugary drinks; provide water, and serve at least two different fresh, frozen, or canned fruits or vegetables every day. 
• Silver (communication) level includes: Displaying 12345 Fit-Tastic! posters inside the early child care and education (ECE) facility, sending home the 12345 Fit-Tastic! letter to families, and providing families with 12345 Fit-Tastic! healthy habits handouts. 
• Gold (policy) level includes: Adopting a policy that incorporates all Bronze and Silver level requirements using policy ideas from the 12345 Fit-Tastic! sample policies in the Early Childhood Toolkit.

 

Columbia/Boone targeted ECE settings, schools, and out-of-school programs to increase the number of childcare centers, out-of-school programs, and schools adopting policies to encourage healthy habits for kids in their facilities. Beginning with a baseline of 0, the LPHA contacted 107 ECEs in and around Columbia to see if they would be interested in participating in the 12345 Fit-Tastic! pilot. Sixty responded to the inquiry, 56 said they were interested in participating in certification at the Gold level, which includes adopting policy. Seven ECE facilities reached Gold certification by September 30, 2018, with an unduplicated number of 489 children reached and 21 policy changes implemented. During FY19 an additional 22 child care centers worked to achieve the 12345 Fit-Tastic! Gold level certification reaching a total of 1,613 children.

 

Tracking baseline performance indicators from ECE facilities’ baseline point of zero, with consistent engagement targeted toward prevention, followed by assessment, showed improved education about health resulting in a long-term positive project outcome with several more ECEs on a waiting list to become 12345 Fit-Tastic! certified.

 

Specific 12345 Fit-Tastic! initiatives included:

• The Child Care Health Consultation Program offered 17 continuing education trainings and 1 hour of specialized consultation for child care providers and 17.5 hours of health promotions for children specifically using 12345 Fit-Tastic!
• Through a collaborative agreement with the Children’s Mercy Kansas City Weighing In Program, the MCH Services Program provided training on the 12345 Fit-Tastic! Healthy Lifestyle Initiative to 15 LPHA staff in FFY2018 and their partners, representing 11 LPHAs, continue to implement the 12345 Fit-Tastic! framework as part of their three-year FFY 2019 – 2021 contract work plans in local healthy lifestyle initiatives.

 

DHSS partnered with the DESE Director of Missouri Healthy Schools on a CDC grant to provide professional development and technical assistance to schools on wellness infrastructure, nutrition environment, comprehensive physical activity programs, and managing students with chronic disease in the school setting. The five-year cooperative agreement started in June 2018. The cross-department leadership team is working with seven priority local education agencies (LEAs) intently and also providing professional development opportunities to reach additional LEAs.               

 

CHW also continued contracts with eight LPHAs to facilitate a self-assessment and planning process for 11 school sites using the CDC’s School Health Index (SHI) Self-Assessment and Planning Guide. Schools identified strengths and weaknesses of their policies and programs that promote health and safety and developed action plans for improving student health. School sites made health and wellness improvements that included:

• one school site worked on improving health and wellness of their faculty and staff through health screenings.
• five school sites worked on improving their school wellness efforts through the addition of health education to the curriculum, adding water bottle filling stations, enhancing the membership and function of their School Health Advisory Council, changing to non-food rewards, offering healthy food in fundraisers and concessions, establishing alternative discipline instead of taking away recess, updating health and wellness policies, providing education to children and families with chronic conditions, and promoting the wellness policy on the school website.
• seven school sites worked on improving their physical education program and physical activity opportunities through adding updated physical education equipment, establishing before and after school walking clubs, updating the PE curriculum, enhancing professional development opportunities for teachers, adding a bike rack and initiating a community wellness event, and incorporating classroom brain breaks.

 

The School Health Program (SHP) participated with Children’s Mercy, UME, and other agencies and organizations across the state on MOCAN Schools Workgroup to identify and implement best-practice programs in schools and communities to promote opportunities for physical activity and access to nutritious foods.

 

Integrating physical activity into young children’s lives is essential for creating a foundation of movement and activity that they will carry with them throughout the rest of their lives. Physically active children learn habits in early childhood that greatly increase their chances of remaining physically active through their young adult and teenage years and into adulthood. In FY19 CHW leveraged support from CDC’s 1807 grant and UME to initiate the Go Nutrition and Physical Activity Self- Assessment for Child Care (NAP SACC) Program to assess child care providers’ current practices in both physical activity and nutrition. In May 2019, CHW trained 13 LPHA Child Care Health Consultants, five Child Care Aware of Missouri consultants and four UME Nutrition and Health Specialists as Go NAP SACC Technical Assistance (TA) Consultants to provide training and technical assistance to child care providers in adopting healthy nutrition and physical activity practices and policies. By September 30, 2019, 37 child care providers had registered with a TA Consultant to participate in the Go NAP SACC project, effecting 1,563 children. Of these 37 child care providers, 18 completed a pre-self-assessment in Physical Activity; 12 in Outdoor Play and Learning; 10 in Screen Time; 21 in Child Nutrition; 7 in Breastfeeding and Infant Feeding; 7 in Farm to Early Child Care; and 6 in Oral Health. After completing the pre-self-assessment, the TA Consultants guided the child care providers in creating and completing goals. The top physical activity goals selected by the providers included the reduction of sedentary time for infants, toddlers, and preschoolers (19); increased teacher participation and interaction during physical activities with children and infants (11); and increased outdoor and indoor physical activity for children (10). Other goals included professional development, enhanced policies and family education on infant and children physical activity, outdoor play, and screen time reduction, among others.

 

In FFY2019, the Child Care Health Consultation (CCHC) Program offered 73 continuing education trainings for child care providers, 552 hours of health promotions for children in child care, 87 hours of specialized consultation, and 5 technical consultations regarding the importance of physical activity and nutrition. Through offering these services, the CCHC Program works to promote physical activity and nutrition in child care and increase the number of children engaging in activity and healthier eating. As a result, child care providers and children become aware of the many benefits of physical activity and proper nutrition. An example of a children’s nutrition health promotion is the use of the research-based curriculum, Learning About Nutrition Through Activities (LANA) health promotion kit, which provides hands-on learning to promote increasing fruit and vegetable consumption to children. An example of a children’s physical activity health promotion includes the use of a stethoscope and jump rope. Prior to and immediately after jump roping, the children use the stethoscope to listen to their heart rate and have a discussion about why their heart rate changes, what’s happening in their body, and why physical activity is important. When possible, the importance of combining regular physical activity with proper nutrition is incorporated in physical activity and nutrition related health promotions. In addition, one new continuing education training for child care providers regarding how to incorporate vital nutrition in children’s meals and the benefits of including children in simple food preparation was developed and approved for use.

 

The MCH Services Program supported LPHA efforts to increase the percentage of children who are physically active for at least 60 minutes per day, prevent and reduce childhood obesity, and identify and eliminate obesity-related disparities among children 6-11 years of age. Of the 114 LPHAs:

• 87 reported providing child care and school-based programs to prevent obesity and encourage physical activity.
• 64 LPHAs reported providing worksite wellness campaigns to encourage physical activity.
• 63 LPHAs promoted healthy lifestyle initiatives - 14 participated in park improvements in their community, 19 participated in sidewalk and safe street enhancements, and 21 partnered with their community to install and/or enhance walking trails and environmental facilities.
• 46 LPHAs provided cooking, preserving, and gardening classes, 17 maintained farmer’s markets with SNAP and/or EBT benefits, and 33 provided community gardening.
• Numerous LPHAs facilitated MOve Smart, 12345 Fit-Tastic!, Girls on the Run, and a variety of other physical activity campaigns.

 

MCH Services Program staff participated in the LPHA Healthy Lifestyle Learning Collaborative and served on the MOCAN School Health Work Group and other regional and state collaborative groups to promote healthy lifestyles and weight for children. Numerous LPHAs participated in local community coalitions to promote healthy lifestyle choices. The MCH Services Program contracted with 19 LPHAs to increase the percent of children/adolescents ages 6 through 17 years, who are physically active at least 60 minutes per day. Specific LPHA activities and accomplishments included:

• Barry County Health Department helped facilitate through local coalition efforts the addition of mile markers to local walking trails in which the city provided match funding efforts.
• Hickory County Health Department (HCHD) opened the HCHD Fitness Center available for use to all community members. HCHD encouraged and help facilitate local farmers and ranchers working with local schools to promote the ever-growing farm-to-school movement.
• Dallas County Health Department staff offered Kids in the Kitchen classes in area schools.
• Franklin and Henry county health departments were actively involved in Girls on the Run programs within their counties.
• Warren County Health Department continued to manage the Warren County Community Fitness Center, offering a variety of physical activity classes/activities for children and youth, including homeschoolers, individuals with disabilities, and participants in emergency need programs.
• Howell County Health Department offered gardening classes to area community members and continued its active involvement in the local West Plains Community Garden.
• Columbia-Boone County Public Health and Human Services continued to promote the 12345 Fit-Tastic! message at local events including Adventure Club meetings at three elementary schools and the Pumpkin Fun Run (a Show-Me-State Games event).
• Joplin City Health Department offered cooking classes for WIC participants with children with special dietary needs.
• Morgan County Health Center offered free cooking classes in partnership with the local UME office and community partners.
• Cape Girardeau County Public Health Center in partnership with Healthy Communities Coalition hosted free cooking demonstration classes that educated participants on shopping healthfully on a limited budget.
• Polk County Health Department staff assisted in the decision-making process for community sidewalk repairs and improvements.
• Butler County Health Department collaborated with the local School Health Advisory Committee to create a health and wellness campaign targeting elementary school-aged children and assisted administration staff from three schools within the county in the implementation of 12345 Fit-Tastic!
• The Cole County Health Department partnered with the Healthy Schools Healthy Communities grant leaders and the CeMOWECAN coalition to provide cooking classes, gardens, and fitness programs to four area elementary schools. Local policy changes have been made to incorporate healthy food options at local school event concessions.
• Barton County Health Department worked with schools to educate staff on importance of physical activity and the benefits of implementing brain breaks across all grade levels.
• Jefferson County Health Department (JCHD) worked with local libraries to supply activity kits designed to promote active and healthy lifestyles for children and families. To promote the activity kits, JCHD teamed up with the libraries and other local organizations to hold free “Game Days” throughout the summer.

 

* Interpret with caution due to sample size limitations.