Priority Needs

Strengthen emotional, physical, and social services to achieve equitable and optimal development for children.

National Performance Measures

NPM 6 - Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year NPM 7.1 - Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9 NPM 13.2 - Percent of children, ages 1 through 17, who had a preventive dental visit in the past year NPM 15 - Percent of children, ages 0 through 17, who are continuously and adequately insured

 

In 2021, the Arizona Title V Program priorities for children continued to focus on decreasing the rate of injuries, both intentional and unintentional, for children aged 0-19 years and improving access to quality preventive health services, specifically developmental screening. Injury prevention programs supported NPM 7.1 and 7.2: Injury Hospitalization (rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9 and 10 through 19). The strategies to decrease the incidence of childhood injury continued to analyze child death data to support and train law enforcement agencies, medical examiners, and first responders on death scene investigation and primary prevention efforts in the recognition of unsafe sleeping environments. Technical assistance for emergency departments and support of local Safe Kids coalitions strategies were implemented. BWCH home visiting programs continued to implement a variety of home visiting models to support NPM 6: Development Screening (percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year).

The ADHS Bureau of Women’s and Children’s Health (BWCH) programs continued to experience a level of interruption/impact due to the COVID-19 pandemic; however, stakeholders worked together to shift strategies, establish revised processes, and implement remote/virtual resources to continue supporting children.  The Children’s Health Annual Report will include program updates addressing COVID-19 impact and the strategies implemented to sustain the programs/services.  The impact of COVID-19 is addressed within each strategy and new partnerships/strategies developed as a result of COVID-19 are included at the end of this narrative. The following sections detail the 2021 implemented strategies.

Arizona's Child Fatality Review (CFR) Program contracts with and funds 10 local review teams to conduct in-depth analysis of all child fatalities occurring within the state. CFR reviews are conducted by a multi-disciplinary group of dedicated professionals including: medical professionals, law enforcement, public health professionals, child safety specialists, behavioral specialists, and representatives from Arizona's tribal nations.  Each year the team reviews around 800 child deaths in the state. Teams have been instrumental in the identification of preventable child deaths occurring throughout the state. ADHS used the review data collected to develop prevention strategies, increase public awareness of high-risk behaviors, and promote child safety. The Annual Child Fatality Review Report on 2020 Arizona Deaths, published in November 2021, provided statewide partners with key insights, data, and recommendations concerning child fatalities in Arizona. In addition, regional CFR infographics provide communities with localized data summaries. 

Due to the current state of the pandemic, the CFR program switched to virtual review meetings, which presented new challenges. Arizona’s CFR Program received funding through Proposition 207 (Smart and Safe Arizona Act) to purchase equipment and supplies for the 10 coordinators throughout the state to support this transition to a virtual work environment.

ADHS continued to administer and/or fund a variety of evidence-based or -informed home visiting programs—such as Health Start, High Risk Perinatal Program (HRPP), Healthy Families AZ (HFAz), Nurse-Family Partnership (NFP), Parents as Teachers, and Family Spirit—that are intended to connect families to preventive and primary care. All of the programs work with families and coordinate their referral to other health and family support providers to improve maternal and child health; decrease family violence, including reduction of childhood injuries and maltreatment; ensure families have access to health care and essential health services, including immunizations; enhance child development and a child's school readiness through parent education; and assist families in improving their economic security. Collectively, the home visitation programs completed 45,945 home visits serving 8,931 clients in Arizona in 2021.

 

Figure 14. Summary of ADHS Home Visiting Programs

Programs	Funding Sources	Clients Served in 2021	Implementation Partners
Healthy Families**	MIECHV	1,831	State Agencies, County Health Departments, Community-Based Agencies, Tribal Nations
Nurse-Family Partnership**
Family Spirit**
Parents as Teachers**
Health Start*	State Lottery, MIECHV	2,566	County Health Departments, Community-Based Agencies, Tribal Nations
HRPP	State General, Proposition 207 and Title V	4,534	County Health Departments, Community-Based Agencies

**Evidence-based model
*Promising approach

To address the Title V priority need to reduce infant mortality and morbidity and NPM 4: Breastfeeding, ADHS home visiting programs worked to increase the number of home visitors or community health nurses who are pursuing their certification as an International Board Certified Lactation Consultant (IBCLC) over the next 5 years. In 2021, there were five (5) candidates who qualified and were able to sit for the test. At the time of this report, three (3) had received their test scores and were certified as IBCLCs. Additionally, 12 home visitors completed the Breastfeeding Counselor training program offered through Florida State University.

To address the Title V priority need to increase early identification and treatment of developmental delays and NPM 6: Developmental Screening, ADHS home visiting programs implemented revised measures to monitor new home visitor Ages and Stages Questionnaire (ASQ) training and document the percent of children enrolled in home visiting programs that receive at least one ASQ within one year of enrollment. New home visitors hired during the federal reporting period of October 1, 2020-September 30, 2021 all received ASQ training to be able to provide the screening to families. Seventy-five percent (75.1%) of families enrolled in the MIECHV programs received a timely ASQ screening, which is a 14-percentage point increase from the previous year (when 61% of families enrolled in the program received a timely ASQ screening) and a 31-percentage point increase from 2019 (when only 44% of families did). The completed screening percentage ranges between 14-80% across programs. Eighty-five (85%) of HRPP families received a timely ASQ screening and Health Start provided at least one Ages and Stages (ASQ) screening to 575 children under 1 year of age (60% of enrolled children).  The number of children screened using the ASQ fluctuated slightly between home visiting programs during 2021 as a result of ongoing impact due to COVID-19 pandemic and the decrease of in-person visits.

In 2021, the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) in Arizona provided funding to these evidence-based home visiting programs: Healthy Families (through Arizona Department of Child Safety), Nurse-Family Partnership (through Maricopa County Department of Public Health, Pima County Health Department, and First Things First), Family Spirit (through Coconino County and San Carlos Apache Tribe) and Parents as Teachers (provided by four Native American Tribes: Cocopah, Hualapai, and Navajo Nation). In addition, the AZ MIECHV grant was approved to fund Arizona’s state-funded home visiting program, Health Start, as a promising approach. Through the home visiting programs listed above, MIECHV served 1,831 families in at-risk communities through 25,351 visits, coordinating services across Arizona’s early childhood system.

Phase II of the MIECHV Needs Assessment was completed in 2021. Arizona’s MIECHV program compared those identified at-risk communities in Phase I (completed in 2020) of the analysis with the current list of communities that currently benefit from home visiting services. The comparison showed that under Phase I, a considerable number of communities would stop receiving MIECHV support. These communities reside in the counties of Yuma, Apache, Yavapai, and Cochise. A review of these communities led the assessment team to discover that migrant border, monolingual Spanish-speaking, and tribal communities would be negatively affected by their omission in the identified list of Phase I. A review of each standardized metric showed that the main reason for the deletion of these sites was data unavailability and not a true lower prevalence for most of the HRSA-prescribed indicators.

The unavailability of data in these regions placed these communities at a disadvantage for receiving much-needed services that the communities themselves expressed as part of the HRSA Title V Maternal and Child Health Block Grant Needs Assessment for Arizona. Arizona MIECHV leveraged the findings of this needs assessment and proceeded with Phase II of the MIECHV Needs Assessment.

Infant mortality and the absence of prenatal care were two indicators used under the Perinatal Outcomes domain in Phase I. These indicators are included due to their alignment with the Title V Maternal and Child Health Priorities.

The approach to Phase II utilized updated data from Arizona’s Vital Records to calculate the infant mortality rate and proportion of live births where the mother indicated having “no prenatal care during pregnancy.” The assessment team used the statewide rate for infant mortality and the overall proportion of no prenatal care for comparison. Any county whose infant mortality rate was higher than the state’s rate received 1 point in prioritization. Any county whose proportion of no prenatal care was higher than the state’s average received an additional point in the prioritization. Counties with a priority score of “2” are considered at-risk for the purpose of the MIECHV Needs Assessment. Of the counties assessed (Apache, Cochise, Greenlee, Santa Cruz, Yavapai and Yuma), Cochise and Yuma received a priority score of “2”; therefore, all PCAs within these counties are considered at-risk.

Phase II of the MIECHV Needs Assessment also utilized the Health Status Profile of American Indians in Arizona: 2019 Databook to assess the health indicators for the 22 federally recognized tribal communities of Arizona. In 2019, American Indian residents of Arizona ranked worse than the state average on 53 of 65 health indicators. Some of these indicators include no prenatal care, prenatal care started in the first trimester, infant mortality, post neonatal mortality, drowning and sudden infant death syndrome. As a result, federally recognized tribal communities in Arizona, not already identified as at-risk in Phase I, have been included as at-risk in the Phase II assessment. 

The full needs assessment can be viewed here: MIECHV Needs Assessment

MIECHV supported and leveraged BWCH’s efforts to address the 2021 Title V state priority needs by implementing various strategies. Results and accomplishments for 2021 include:

To address the Title V priority, need to “strengthen emotional, physical, and social services to achieve equitable and optimal development for children,” in 2021 MIECHV supported voluntary evidence-based home visiting programs in at-risk communities and coordinated services across the early childhood system; serving 1,831 families through 25,351 home visits.

Evidence-based home visiting continued to be augmented by professional development provided through training and education, online courses, regular informative e-newsletters, a podcast, and an annual conference. In 2021, 745 home visitors and home visiting supervisors attended the MIECHV-funded 10th Annual Strong Families Home Visiting Conference. The Strong Families AZ Conference Planning Workgroup made the decision to remain on a virtual platform for the 2021 conference.

The conference has historically been a 3-day conference which includes two statewide agenda days and one day of tribal-focused priorities to meet the professional development needs of our tribal partners and those who serve native families throughout the state. In 2021, the Strong Families AZ Conference expanded to be a 4-day conference and included a second day of a priority population focus, working with High Risk Perinatal families. This provided an opportunity for Community Health Nurses and Neonatal Intensive Care Nurses to receive professional development targeted to their role and services that they provide to families.

In addition to maintaining the large conference on a virtual platform, the “Learning Festival,” a once-a-month professional development opportunity for home visitors, also continued. It was originally designed to take the place of conference breakout groups when the conference switched the online platform. It was very successful in 2020 and so continued in 2021. These included but were not limited to cooking demonstrations, author chats, and short presentations to address topics that otherwise would have been included in the in-person conference as break-out sessions. There were 13 learning festivals in 2021 and the number of attendees ranged between 72-152 depending on the topic.

Strong Families AZ, Arizona’s Home Visiting Alliance, also produces The Parenting Brief, a podcast for parents featuring tips from fellow parents and the latest insights from childhood experts hosted by Jessica Stewart-Gonzalez, Office Chief for Office of Children’s Health at the ADHS. The episodes focus on public health topics. The podcast provides an opportunity for caregivers to access accurate public health information in a format that is quick, aligns with how they access other information, validates experiences, and provides resources. In 2021, there were 24 podcast episodes produced on topics like: lead poisoning, nutrition (breastfeeding, first foods), healthy behaviors (sun safety, household safety) and more. The most downloaded episode was on Safe Sleep with almost 1,200 downloads during 2021. During 2021 there were 5,300 downloads of the podcast overall with the majority of listeners accessing it directly from a podcast application on a smartphone. Most individuals who downloaded at least one episode found the podcast through a Google search with the keyword phrases of “support for parents”, “advice for new parents”, and “parenting tips”. The click through rate is 6.36% which is significantly above the industry standard of 2%.

The number of Strong Families AZ newsletter subscribers increased by 23% during FY21 and is sent to 5,739 home visitors, home visiting supervisors, and community partners that serve families enrolled in home visiting programs. In 2021, 96 home visitors completed online professional development courses on the Strong Families AZ website on topics such as: adverse childhood experiences, perinatal mood disorders, nutrition, substance exposed newborns (NAS), communicating a diagnosis, and participant-centered services.

In 2021, MIECHV-funded sites focused their continued quality improvement (CQI) efforts on how to use the 2020 data collected through the MIECHV benchmarks to increase the number of enrolled caregivers that engaged in early language and literacy by singing, reading, or telling stories to their children on a daily basis. In 2020, seventy-six percent (76%) of primary caregivers indicated that they engaged in early language and literacy activities by singing, reading or telling stories to their child(ren) on a daily basis. In 2021, that increased to eighty-seven percent (87%) of primary caregivers that indicated they engaged in early language and literacy activities by singing, reading or telling stories to their child(ren) on a daily basis.

Additional home visiting activities included the ongoing implementation of a coordinated home visitation data management system. In 2021, all programs included in the Efforts-to-Outcomes (ETO) continued their participation in the Data Management Workgroup. The state system reports now include enrollment data, demographic data, zip code/service area data, and continue to work toward establishing a report on developmental screenings and depression screenings completed across models and funders. The coordinated home visitation management system will enhance future MCH assessments and evaluation with home visiting populations in at-risk communities similar to those identified in the MIECHV at-risk communities.

The Health Start Program 2021 updates and activities can be found in the Perinatal/Infant and Women’s Health Annual Reports.

The High Risk Perinatal Program (HRPP) 2021 updates and activities can be found in the Perinatal/Infant Health Annual Report.

The BWCH Home Visiting Workgroup continued to convene to create a shared vision for home visitation within BWCH. In 2021, the workgroup worked collaboratively to address a variety of areas such as safe sleep, ongoing impact of COVID-19, and maternal mental health consultation.  Health Start, MIECHV, and HRPP staff continued to reach out to funded sites to monitor the impact of COVID-19 and share strategies to support home visitors and home visiting supervisors.  In 2021, evidence-based and promising practice home visiting programs continued to reach out to families through both virtual and in-person visits.  In late 2021, home visiting programs began to resume in-person visits as requested by families and/or dependent on family needs.  Home visiting programs in Arizona continue to respond to the needs of young families by purchasing and delivering handwashing stations to remote tribal areas, conducting local food and diaper drives, holding COVID-19 classes online, and delivering many more creative responses across the state.

The workgroup continued efforts to coordinate goals and actions to be congruent with the ADHS Strategic Plan, Arizona Health Improvement Plan (AzHIP) strategies, Title V MCH Block Grant priorities, and home visitation program requirements.  The group met regularly in 2021 and will continue meeting moving forward as this workgroup has already improved communication and alignment of efforts among BWCH home visiting programs.

The Office of Injury and Violence Prevention is housed in the Bureau of Chronic Disease and Health Promotion. In 2021, Arizona’s Title V Program continued to provide funding to and collaborate closely with the Office of Injury and Violence Prevention on initiatives to reduce injury and death among infants and children (e.g., Safe Sleep, traffic injuries, etc.).

The Office of Injury and Violence Prevention provides support to the five local Safe Kids coalitions that are located around the state; additionally, the Office of Injury and Violence Prevention serves as the liaison between Safe Kids Worldwide and the local coalitions. Each coalition works to help families and communities keep kids safe from unintentional injuries, including but not limited to reducing traffic injuries, drownings, falls, burns, poisoning and more. As the Safe Kids Arizona coordinator, ADHS held quarterly meetings to update the local coalitions on what was happening at the national level and to ensure that the local coalitions were aware of any grant opportunities that Safe Kids Worldwide was providing. Currently, there are two local health departments that are the lead agencies for Safe Kids coalitions—Coconino and Yuma Counties—however, the Office of Injury and Violence Prevention also collaborates with Apache, Cochise, Gila, La Paz, Mohave, Navajo, Pinal, Pima, Santa Cruz and Yavapai counties. 

The Office of Injury and Violence Prevention promotes car seat accessibility and child passenger safety (CPS) education in order to reduce traffic injuries and fatalities among infants and children. With Title V funding, the Office of Injury Prevention and Violence Prevention was able to purchase 4270 car seats for these Safe Kids partners. This allows the county health department to provide car seats and car seat safety education to the families in their communities who are most vulnerable. Some of these 4270 car seats were provided to a few HRPP sites, including Abrazo West Campus, some Banner Healthcare Hospitals, Carondelet St. Joes, Flagstaff Medical Center and Valleywise Health (formerly known as Maricopa Integrated Healthcare).

The Office of Injury and Violence Prevention also provides the national Child Passenger Certification training around the state to certify individuals to become car seat technicians, with a focus on rural and tribal communities. Due to the COVID-19 pandemic, providing education and in-person training proved to be a huge barrier and therefore 2021 was very challenging. In July of 2021, the Office of Injury and Violence Prevention partnered with Salt River Maricopa Indian Community and offered a two-day recertification course for those technicians whose certification had expired. It was for Child Passenger Safety technicians who have maintained their child passenger safety knowledge and their hands-on skills, but who, for one reason or another, allowed their certification to expire. It is expected that students attempting to renew their certification have stayed involved in CPS programs and activities and have monitored changes in the field by reading technician updates, attending other CPS classes and working with non-expired technicians.

Also, the Office of Injury and Violence Prevention was able to collaborate with the Coconino County Health Department with one child passenger training in August of 2021.  There was a total of 20 students and 4 instructors as well as one Instructor Candidate. All mitigation measures were taken, including wearing masks during the whole training and social distancing. Hand washing and cleaning of surfaces were always conducted in the morning, before leaving for lunch and before leaving for the day. Hand sanitizer stations were also set up so that during the return demonstration participants and instructors could sanitize their hands.

Originally the Office of Injury and Violence Prevention had planned, in conjunction with the Safe Kids Pima County, to hold a one-day Continued Education Unit (CEU) conference for technicians in the fall of 2021 with Title V funds.  With the participation of national car seat manufacturers, this conference gives technicians from around the state who are not able to attend national conferences the opportunity to have one-on-one time with car seat manufacturers to ask them questions and get answers straight from the source regarding their product. However, due to the pandemic, face-to-face conferences were unable to be held during 2021.

Although the COVID-19 pandemic proved to be a barrier in providing education and resources to new parents, our partners found a way to continue educating their communities through virtual platforms. Education was able to be provided virtually to families. Unfortunately, not every partner or family had access to the internet or phone service allowing for virtual education. Additionally, some partners faced challenges due to staff being reassigned or staff turnover. Due to lack of technology or available staff, not all families who could have benefited from car seat education were able to access it.

Arizona’s Title V Program, through the Office of Injury Prevention and the MCH HAF IGA, Arizona’s home visiting programs, and Arizona’s CFR Program all continue to collaborate closely on Safe Sleep education and sudden unexpected infant death (SUID) prevention. More information on these efforts can be found in the 2021 Perinatal/Infant Health Annual Report.

In 2021, local county health departments used Title V funding they receive through the MCH Healthy Arizona Families IGA (MCH HAF IGA) to work on a number of strategies and activities to improve children’s health and wellbeing, including household safety, promotion of physical activity, teen safe driving programs, and collaborating on and leveraging the state-level Safe Sleep and Child Passenger Safety interventions. More information on the MCH HAF IGA can be found in the Cross-Cutting Annual Report.

Arizona continued and enhanced several strategies to improve oral health for children.  Oral health strategy updates, including Cavity Free AZ Program, School-Based Sealant Program, Fluoride Varnish, and Fluoride Mouthrinse Programs, are outlined in the 2021 Cross-Cutting Annual Report.

BWCH engaged in several continued strategies, partnerships, and meetings to address child health topics, including Adverse Childhood Events (ACEs) and child welfare.  BWCH continues to support and implement the Governor’s Goal Council, ACEs Action Plan, to support the following goals: 1) Reduce the number of ACEs that Arizona children are exposed to; 2) Characterize the data that leads to Arizona having the highest percentage of children exposed to ACEs; and 3) Mitigate the number of adverse health outcomes that are associated with ACE exposure.  BWCH is the lead on several strategies, including the Action Plan’s evaluation and home visitation strategies. BWCH sponsored 11 core questions on ACEs in the 2021 Behavioral Risk Factor Surveillance System (BRFSS). BWCH has sponsored these ACE questions since 2012. BWCH’s internal and external stakeholders have become dependent on this data to better inform their strategies to mitigate ACEs. These data are also used by BWCH to inform our home visiting programs. The ACEs action plan will be refreshed in 2022 and BWCH will participate in several of the efforts to update the plan.

Arizona’s program on Adverse Childhood Experiences (ACEs) was established under the Office of Assessment and Evaluation (within BWCH) in October 2021. An epidemiology program manager position was established to direct and manage the agency’s action plan in collaboration with the Office of Strategic Initiatives under the Director’s Office. With $300,000 in funding support for the next 3 years (allocated in October 2021 through the Smart and Safe Arizona Act – Proposition 207), Arizona expects to increase data collection and analysis capacity, increase the uptake of effective prevention strategies, and increase data-to-action activities.

ADHS partnered with the Mel and Enid Zuckerman College of Public Health at the University of Arizona produced a state profile on adverse childhood experiences utilizing 2018-2019 trend data from the National Survey for Children’s Health (NSCH). The profile was published in May 2021. Essential highlights for ACEs in Arizona are:

• Forty-three percent (43%) of children in Arizona aged 0-17 years experienced one or more ACEs
• The top three ACEs experienced were:
  • experiencing family divorce or separation (24.9%)
  • hard to cover the basics on family’s income (17%)
  • living with someone with an alcohol/drug problem (10.8%)
• Arizona had a higher prevalence of ACEs in all nine ACEs assessed in the NSCH compared to the national prevalence
• Children who were third generation immigrants or beyond (all parents in the household are born in the US) had the highest percentage of experiencing one or more ACEs (45%) compared to more recent immigrants
• Black children had the highest prevalence of two or more ACEs (34%) compared to other racial/ethnic groups
• Children who had no insurance coverage in the past 12 months had the highest prevalence of experiencing one or more ACEs (44%) compared to other types of insurance coverage

The Arizona State University Maternal and Child Health Translational Research Center is collaborating to utilize the same dataset to study Positive Childhood Experiences (PCEs) in Arizona. A white paper and potential manuscript is an expected deliverable of this work in May 2022. In December 2021, using Title V funds, BWCH supported and participated in the 8th Annual Arizona ACEs Summit (theme: Cultivating Trust). The summit consisted of three days of cutting-edge information on ACEs, the science of resilience, and systems change transformation. The summit included critically acclaimed author and speaker Donna Jackson Nakazawa, six workshops to choose from, virtual networking, and keynote from Monica Fulton on Historical Trauma and Cultural Resilience within the Indigenous community.  BWCH will continue participating in the Arizona ACE Consortium, which is dedicated to promoting ideas, policies, and practices that reduce and prevent childhood adversity and build resilience in individuals, families, and communities.

In 2021, ADHS (through BWCH) partnered with Sesame Streets in Communities (SSIC) to implement the SSIC model in Maricopa County. ADHS was one of several partners in Maricopa County to whom SSIC provided strategic consultation, professional development, and marketing and communications support. The aim of this work was to support the existing approach and strategies for improving children’s overall well-being by raising public awareness about the benefits of investing in and supporting children and families coping with adverse experiences, particularly those who have had traumatic experiences related to parental addiction. Together the group participated in virtual listening sessions with community stakeholders and hosted a virtual town hall (May 26, 2021) for Arizona families and partners. Health Start and Empower sites integrated SSIC materials and resources into their existing resources for children and families and selected sites participated in SSIC research activities, such as focus groups and surveys. As a SSIC partner, ADHS has access to the Partner Portal and can access information, materials and resources to share with contractors to support the important work they provide in Arizona communities.  As a result of additional funding from SSIC, the participating Empower sites were also able to enhance their preschool and school-age classrooms with materials to support self-regulation and social emotional development. 

In 2021, Arizona’s Title V Program continued to provide funding to partially support the work of the Empower Program, which is administered through the Bureau of Nutrition and Physical Activity (BNPA). ADHS developed the Empower Program in 2010 as a voluntary program to support licensed child care facilities' efforts to empower young children to grow up healthy. Facilities participating in the Empower Program pledge to adopt 10 standards that support healthy eating, encourage active play, prevent exposure to second- and third-hand smoke, practice sun safety and promote good oral health habits in exchange for reduced licensing fees. In addition, the Arizona Department of Economic Security (DES) collaborates with the ADHS by requiring Empower participation as part of their written child care agreements. Arizona now has almost 3,000 child care facilities participating in the Empower Program – reaching more than 200,000 children. In 2013, the Empower Program was included as a Best Practice within the Association of Maternal and Child Health Programs (AMCHP) MCH Innovation Database. 

The Empower Advisory Committee (EAC) comprises diverse internal and external partners. Internal partners include staff from ADHS’ Bureau of Women’s and Children’s Health (i.e., Sensory Screening Program, Home Visiting Programs, CYSHCN Program, Oral Health), the Bureau of Nutrition and Physical Activity (i.e., WIC Program, Early Care and Education, AZ Health Zone), Bureau of Chronic Disease and Health Promotion (Tobacco), Division of Licensing (Child Care Licensing), Office of Epidemiology & Disease Control (SunWise Skin Cancer Prevention, Smoke-free AZ) and others. External partners are drawn from other state agencies that are aligned with the work of Empower, such as: Arizona Department of Education (Child and Adult Care Food Program [CACFP], Early Care and Education), Department of Economic Security (Arizona Early Intervention Program [AzEIP], Child Care Administration) and First Things First (FTF; Arizona's Early Childhood Agency).

The purpose of the EAC is to advise the Empower Program, develop common and consistent messaging, and align activities throughout Arizona’s early care and education (ECE) statewide systems work around health, nutrition and wellness. The EAC meets quarterly and is continuing the review process for each of the ten Empower standards and standard components.  Stakeholders in standards work groups review the current standard and components and compare to best practices, providing updated recommendations.  This work is projected to be completed in December, 2022, with tentative implementation scheduled for July, 2023.  

In 2021, the Empower Guidebook for Out-of-School-Time (OOST) and self-assessment checklist were developed exclusively for programs serving children from 5-12 years of ages. This will go into effect in July, 2022. Addressing school-aged children in care settings with more age-appropriate examples for Empower implementation has been a request from care providers for several years.

In November 2019, ADHS’s Bureau of Nutrition and Physical Activity (BNPA) was awarded a grant from Nemours, a private children’s health system, to implement learning collaboratives and the Go NAPSACC program statewide and to improve state ECE health and nutrition systems work.  While learning collaboratives continued to be successfully implemented throughout 2021, the continuing pandemic has proved very challenging for ECE programs to consistently participate.  Staffing shortages, illness, closures, pandemic protocol, and staff mental, emotional and physical fatigue have been constant stressors.  Project funders and staff have been very supportive in assisting ECE programs to stay enrolled and engaged in the project, allowing flexibility and make up sessions.  The implementation of statewide Go NAPSACC (Nutrition and Physical Self Assessment for Child Care), an online platform, has seen many developments during 2021.  Arizona has over 50 technical assistance (TA) consultants trained, and almost 300 ECE programs enrolled.  Funding for the next three years for Arizona’s Go NAPSACC has been secured through the support of ADHS, FTF, and DES. Go NAPSACC training courses are being integrated into the AZ Workforce Registry, as well as recognized by the DES State Plan requirements.          

Empower currently has ten online Learning Management Systems (LMS) courses.  In 2020, there was an unprecedented spike in course utilization due to the onset of the pandemic.  During 2021, Empower course utilization normalized as many additional ECE courses were added to the statewide ECE system and registry.  Course user totals for 2021 are as follows:  Overall total was 9,791, and for each topic as follows: Family-Style Meals (1,155), Fruit Juice (1,001), Physical Activity (1,266), Sedentary and Screen Time (1,048), Sun Safety (1,148), Tobacco (631), Toothbrushing (688), Inclusion (973), Breastfeeding (807), and Overview of Empower (884).  Spanish course completion numbers were as follows:  Inclusion (34), Breastfeeding (41), Overview of Empower (30), Family Style Meals (32) and Physical Activity 0-12 (53). These LMS courses are available to anyone free of charge via the Empower website as well as the Arizona Early Childhood Workforce Registry.  Individual certificates are sent out and staff accounts in the registry are updated within 2-3 weeks of course completion. Additional information about the Empower Program can be found in the CYSHCN Annual Report.

With the help of Title V funding, ADHS has partnered with The Arizona Partnership for Immunization (TAPI) to promote immunizations statewide. TAPI is a non-profit statewide coalition formed to foster a comprehensive, sustained community program for the immunization of Arizonans against vaccine-preventable diseases. TAPI was created in 1993 to improve the immunization levels of children in Arizona and later expanded to include adolescents and adults. Cooperative efforts between the public and private sectors have become a major force in implementing system changes resulting in long-term improvements in immunization service delivery in Arizona. TAPI has over 400 members representing over 200 organizations. TAPI's efforts are reflective of the importance of immunizations over the lifespan, and will impact Arizona and its citizens' quality of life.

Community Education: In 2021 TAPI distributed over 150,000 educational pieces to schools, child care facilities, private providers, county health departments, community health centers, managed care organizations and WIC sites. Materials are used for new patient packets and parent outreach and for COVID-19 vaccine information. The TAPI webpage (whyimmunize.org) allows parents, teens, and adults to ask medical experts questions about vaccines and immunizations and was updated to reflect Advisory Committee on Immunization Practices (ACIP) recommendations and COVID-19 outbreak information.

Social Media and Other Public Health Communication: TAPI maintained a Facebook page with consistent "likes” and developed a closed “Parents Who Protect” group to share pro-vaccine stories.  Posts to both pages included flu, measles, mumps, Hep A and COVID-19 outbreak information; water safety; flu information; community awareness for general vaccine education; off to college, Vaccinate Before You Graduate, and other recommendations for young adults; well-baby-visit education; partner links; Tdap in pregnancy, and the importance of adult immunizations. Each quarter TAPI's tweets on Twitter were viewed 15,000-20,000 times. Content included medical exemptions, parent and doctor relationships, National Infant Immunization Week, CDC updates, back-to-school information about vaccinations, Tdap, coverage and exemption data, catch-up vaccines and flu/COVID-19 vaccinations. TAPI participated in national social media partnerships to keep accurate immunization information trending across all immunization coalitions, using the COVID-19 outbreak to educate about the importance of all immunizations.

TAPI responded to local media routinely on appropriate referrals for back-to-school and flu immunizations and in-depth stories on vaccine exemptions, school readiness vaccine education, the development of the COVID-19 vaccine by age and catch-up vaccines disrupted by COVID-19. TAPI worked with pro-immunization spokespeople on childhood/teen immunizations, anti-vaccine stories and outbreaks, and frequently referred reporters to appropriate subject matter experts regarding disease outbreaks and headline events.

Provider Education: TAPI supplied articles for immunization newsletters and health publications for community health centers, hospitals, public health, and professional associations through weekly/monthly emailed updates. Professional groups participated in the flu & COVID-19 Button Up campaigns this year and regularly disseminated immunization education to hospitals and long-term care centers with a heavy emphasis on preventing the twin-demic by promoting wider flu distribution along with COVID-19 vaccines.

The HPV conversations and oral health work groups were maintained to coordinate statewide HPV projects with other agencies and to increase awareness of the HPV vaccine for hygienists and dentists. The groups have developed sets of recommendations to prevent duplication of efforts and to be used during oral cancer screenings for patients under 46 and parents of teens. Materials, messaging, training curriculum have been disseminated to professional programs.

TAPI supported video contests with university health students (winning video here) and developed posters with vaccine QR code quizzes that helped students learn in interactive ways.  The student videos were disseminated and are being used by primary care offices for teen immunization education.  Information from the quizzes was used to better target gaps in knowledge for teen and young adult immunization outreach.

TAPI conducted Immunization Best Practices Trainings for provider office vaccine management staff on using patient education materials and resources. Aiming to improve vaccine delivery and increase immunization rates, in 2021 TAPI hosted 50 virtual statewide trainings for routine and COVID-19 vaccines (reaching over 1700 participants).  After the training, practices that have implemented the CDC Standards of Immunization Practice are encouraged to apply for the Outstanding Immunization Practice Award. As a result of the trainings, 84 practices achieved or maintained 90% coverage level for toddler or teen patients in 2021 and were awarded at the annual Big Shots for AZ dinner. Continuing best practices maintained high coverage levels despite disruption from COVID-19.

Special Project: In 2021, Arizona's percentage of children aged 19-35 months being adequately immunized has remained below our 90% target at 63%. Arizona continues to be challenged by high exemption rates in some parts of the state. TAPI partnered with AzAAP, Arizona Family Practice Association, Arizona Osteopathic Medical Association (AOMA), and state and local health departments to continue vaccine education through media, clinicians and partners to help educate parents looking for exemptions about vaccine safety. 

TAPI developed a speaker program that paired volunteer immunization experts with community events in order to answer questions about routine and COVID-19 vaccines.  They continued to promote vaccine safety and alleviate parent concerns about routine and pandemic vaccines throughout the year.

Though the focus of health agencies was primarily on COVID-19 response, Arizona partners continue to promote immunization coverage in high-risk areas and have been able to continue to protect children from vaccine preventable diseases.

To support families, children and parents with newborns, BWCH and BNPA maintain the Title V Toll-free MCH Helplines. The dedicated service includes three helplines: 1. Breastfeeding; 2. Children Information Center; and 3. Women's, Infant, and Children (WIC) Program.  Information is provided in English, Spanish and Telecommunications Device for the Deaf (TDD). Additional information about Children’s Information Helpline can be found in the Perinatal-Infant Health 2021 Annual Report.

The ADHS Sensory Screening Program, funded through Title V, addresses the Arizona Legislature’s mandate for hearing screening for preschool- through high-school-aged children. The program loans hearing and vision equipment to stakeholders to complete screenings.  The hearing screening reports from schools are due annually and the program received 2,334 hearing screening and 598 vision screening reports for the 2020-2021 school year.

Vision screening reports have historically been lower than hearing screening because there was no law requiring vision screening, but vision screening legislation (SB1456) was passed on August 17, 2019. This bill requires vision screening of children in Arizona upon initial entry to school as well as in not more than two additional grade levels in a district or charter school that provides preschool and/or K-12 instruction. The vision screening law is now officially in the Arizona Revised Statutes (ARS §36-899.10). To assist in the rulemaking process, ADHS has entered into a Memorandum of Agreement (MOA) with Vitalyst Health Foundation to be subject matter experts. The Program is currently in the draft phase of the rulemaking, which should be completed within a year.

The ADHS Sensory Screening Program has automated the hearing and vision loan equipment program through Checkfront, an online booking and reservation system designed to make it easier for stakeholders to reserve hearing and vision screening equipment. The online system allows stakeholders to reserve sensory equipment from locations in Phoenix, Sedona, Yuma, and Tucson. In 2021, the program received 438 reservation requests to reserve 921 pieces of hearing and vision equipment for screening/training.  Through a donation received in 2021 from the Technical Assistance Partnership of Arizona (TAPAZ), the program has been able to purchase an additional 10 Spot Vision Screening Machines, which are used to conduct modern eye exams, to be loaned to schools through the Sensory Screening Loaner Program. This has increased the availability of vision screening equipment, allowing for additional vision screening among Arizona children.

The ADHS Sensory Screening Program has also developed an online reporting database to maintain the trainer/screener certifications, training rosters, and training evaluation through Qualtrics, a research software. The online database allows the program to enter training rosters after completing the training and it generates an email to the trainees with a link to download the certificates along with a training satisfaction survey. The feedback from the training satisfaction survey assists with modifying the training sessions as needed and helps improve the quality of training.  In 2021, the ADHS Sensory Screening Program processed 2,335 certificates through the Qualtrics system. Of the 2,335 certificates, 1,319 were for hearing certificates and 1,016 were for vision certificates. The program screened 205,145 children, 118,978 adolescents, and 81,751 CYSHCN.

The Sensory Screening Program is still being impacted by COVID-19 causing the program to cease in-person training for hearing or vision screeners/trainers. The program is currently working with stakeholders to develop training(s) online using a Learning Management System (LMS). COVID-19 has continued to delay current screeners/trainers getting their vision or hearing certification renewed. An Administrative Order was signed by Dr. Cara Christ, Director of ADHS, to waive or defer requirements to renew certifications until May 31, 2021. The continued impact of COVID-19 caused the program to extend this further until December 31, 2021.

Due to COVID-19 many schools in the State of Arizona were not able to conduct in-person learning and moved to a virtual or hybrid classroom setting. With students not being physically present on-campus, many schools were not able to conduct hearing/vision screenings. To address the schools’ concern and provide continued guidance, the Sensory Screening Program published the COVID-19 Considerations: Checklist and Guidelines for Schools on how to conduct screenings during the pandemic while being compliant with the COVID-19 infection prevention and control recommendations published by the Centers for Disease Control and Prevention (CDC). On March 3, 2021, Governor Doug Ducey signed Executive Order 2021-04, which required all district and charter schools to return to in-person (or hybrid model) instruction after a scheduled spring break or on March 15, 2021. With schools returning to in-person (or hybrid model) the Sensory Screening Program extended the 45-day requirement for conducting screenings and schools had until March 31, 2022 to complete their mandatory hearing and vision screenings.

The State of Arizona mandates the annual collection of sensory screening information based upon the hearing and vision screenings conducted by schools during the school year. Questions were added to consider the continued impact that COVID-19 had on schools administering the sensory screenings. The annual reports were developed using Qualtrics and the Sensory Screening Program published guidance on how to properly fill out the reports.

Moving forward the Sensory Screening Program is devising solutions to better administer the program, including the revision of policies and procedures, enacting evidence-based curriculum, mandating vision screening, expanding the sensory equipment loaner program, and working with stakeholders to provide free sensory screening training for the State of Arizona.

In 2019, the Emergency Medical Services for Children (EMSC) Program was transferred from the Division of Prevention, Bureau of Women’s and Children’s Health, to the Division of Preparedness, Bureau of Emergency Medical Services.

In 2020, the Arizona Emergency Medical Services for Children (EMSC) program collaborated on a number of projects. Program highlights include data collection and analysis, pediatric disaster preparedness, pediatric education, and work in support of the nine EMSC performance measures. January through March 2020, AZ EMSC participated in national EMSC data collection through the National EMSC Data Analysis Resource Center (NEDARC) Emergency Medical Services (EMS) Survey. Seventy-five (75) EMS agencies participated, providing a snapshot of Arizona's progress towards EMSC performance measures two and three (see Appendix H). Additionally, AZ EMSC worked with the Bureau of EMS Data & Quality Assurance section to publish the 2019 Pediatric EMS Incident Report and provided support to the Arizona Prehospital Information and EMS Registry System (AZ-PIERS).

The Pediatric Advisory Council for Emergency Services (PACES) EMSC advisory council met (virtually as a result of COVID-19) on a regular basis. Highlighted activities include the development of a Safe Sleep for EMS Training and Toolkit and a workgroup to address issues related to children and youth with special healthcare needs. The EMSC Manager additionally worked with the Governor's Office of Youth, Faith, and Family to create an Adverse Childhood Experiences training for EMS. The EMSC Manager participated in pediatric disaster preparedness through collaboration with Coyote Crisis Collaborative's mass casualty incident workgroup, the Western Regional Alliance for Pediatric Emergency Medicine's EMSC workgroup, and the HPP Senior Advisory Committee. An intern assisted with the development of resources for Pediatric Emergency Care Coordinators. EMSC educational resources are shared on the ADHS website.

The Arizona Title V Program continues to provide funding to the Arizona Chapter of the American Academy of Pediatrics (AzAAP) to promote Pediatric Prepared Emergency Care (PPEC). AzAAP provides technical assistance to hospitals in Arizona, including to Critical Access Hospitals (CAHs) in rural and remote areas of the state, in order to achieve a higher level of preparedness in caring for children. These efforts include supporting Emergency Department nurses to acquire specialty certification and increasing the number of Arizona Emergency Departments certified as ‘Pediatric Prepared’.

Certifications: In 2021, a total 37-member hospitals across Arizona were certified as ‘Pediatric Prepared’ hospitals (see Appendix I). Certification is available for three levels of care: Pediatric Prepared Emergency Care (25 hospitals), Pediatric Prepared Plus Care (5 hospitals), and Pediatric Prepared Advanced Care (7 hospitals).  The first level of certification, Pediatric Prepared Emergency Care, provides services for pediatric care as part of a general Emergency Department. The hospital refers critically ill or injured children to other facilities and may or may not have pediatric inpatient services available. The second level, Pediatric Prepared Care Plus, provides services for most pediatric emergency care. The hospital has a focus on pediatrics, but ICU services for children are not available. The highest level of certification, Pediatric Prepared Advanced Care, provides services for all levels of pediatric emergency care, includes a pediatric intensive care unit, and has a specific focus on pediatric services.

A total twelve hospitals were re-certified in 2021 (see Appendix J).  In addition, there were ten hospitals that were due for recertification in 2021 (and one that was due for recertification in 2020) that will need to be recertified in 2022 due to COVID-induced postponements. Since mid-2020, all of the site visits have been conducted virtually.  AzAAP anticipates going back to in-person site visits at some point, but they do not have a set date for that.

Trainings: One Certified Emergency Nurse (CEN) course (May 18-19, 2021) was completed with a total of 68 participants. One Certified Pediatric Emergency Nurse (CPEN) course was completed (Aug 18-19, 2021) with a total of 22 participants from 12 different hospitals. One Emergency Nursing Pediatric Course (ENPC) was completed (Apr 17-18, 2021) with a total of 19 participants. 

Webinars: Members of the PEM Committee reported that due to the COVID-19 pandemic, child abuse is on the rise and emergency department professionals are reporting a need for support in this area. The PEM Committee members developed a webinar on “The Role of the Emergency Provider in Understanding and Identifying Child Abuse and Neglect Child” (Jan. 25, 2021) that offered continuing education credits to physicians. There was a total of 35 participants who were offered CME and MOC Part 2 credit.

AzAAP also conducted a webinar entitled “Neonatal Fever – No Sweat, Right?” (May 21, 2021). This CME educational offering was attended by 22 individuals.

Challenge of COVID-19: The COVID-19 pandemic has continued to strain hospitals and their staff. While many have scheduled and completed their site visits, some—especially smaller critical access facilities—have requested extensions to better prepare. AzAAP has worked closely with hospitals to reschedule these visits for later dates. The organization communicates with and provides support to any facilities that express difficulty meeting the criteria set forth by the program. In addition, staff turnover at hospitals within some hospital emergency departments has meant that AzAAP has needed to establish new contacts for this work.

In response to the COVID-19 pandemic, the AzAAP has established the Arizona Pediatric COVID-19 Training Center to provide high-quality education and training around the diagnosis and treatment of pediatric COVID-19.  This work was intended to be funded in 2021 through one-time, one (1) year special funding from the Title V Maternal and Child Health Services Block Grant, but now will continue to be funded at least through 09/30/2022.  The Arizona Pediatric COVID-19 Training Center was created in direct response to the urgent public health crisis to support AzAAP members (pediatric providers) by providing timely information and resources as they navigate the pandemic and provide care to patients and families. The Training Center is the home for a broad range of COVID-19 related resources, webinars, and toolkits; hosts a podcast and a blog; and serves as a resource to help members address concerns and safely provide care to patients. The objective of this work is to promote understanding of and adherence to Centers for Disease Control (CDC) and national-level American Academy of Pediatrics (AAP) guidelines and policy recommendations on infectious disease, immunizations, and infection disease control methods, particularly with respect to pediatric populations and COVID-19, in order to improve patient outcomes. 

Through the COVID-19 Training Center, AzAAP hosts a podcast, ID Talk: Answers from an Infectious Disease Specialist, which is hosted by Pediatric Infectious Disease Specialist and AzAAP Chapter Leader, Dr. Sean Elliott. Each podcast episode is about 20 minutes long and discusses the most up-to-date, Arizona-specific information on COVID-19 and addresses issues surrounding the pandemic, particularly related to pediatric populations. The podcast is available through the AzAAP website and YouTube channel, as well as on Spotify, Pandora, and Apple Podcasts.  There have been over 5,194 total downloads since the inception of the podcast with 2,909 downloads between March and December 2021.

AzAAP produced 18 podcast episodes in 2021, covering topics like: vaccine hesitancy, vaccine requirements for schools, vaccine availability for children, children with special healthcare needs and COVID-19 vaccinations, long-haul COVID-19 in children, myocarditis in pediatric patients, missed immunizations and how to best catch up, among others. A special podcast episode was aired in this reporting cycle in which Jessica Rigler, Assistant Director of Public Health Preparedness Services at ADHS, was interviewed by Dr. Sean Elliott and shared vital information with the podcast audience on the programs and services available through ADHS to health care professionals and the public during this time.

AzAAP also offered a webinar, in collaboration with national AAP and the CDC's infection control training collaborative, Project Firstline, on “Infection Prevention and Control: Vaccination during the COVID-19 Pandemic.” Twenty-two (22) physicians participated.

PICK TEAMS: AzAAP is also implementing the “Promoting Immunization Against COVID-19 for Kids thru Training, Education, Assistance, Mentorship, Support Model (PICK TEAMS)” project, in partnership with national AAP, to bring together health and school officials throughout Arizona to collaborate to identify how to improve COVID-19 confidence and uptake throughout the school environment. A state needs assessment was conducted in 2021 and an Action Plan has been developed with activities planned for 2022. Alison Lucas, Block Grants Program Manager at ADHS, participates in this multi-stakeholder project along with two other ADHS colleagues. There are also representatives from ADE, Arizona School Administrators, and School Nurse Organization of Arizona.

Other efforts to improve vaccine confidence:

Between March and May 2021, AzAAP developed materials focused on improving families’ confidence in vaccines by reducing the spread of myths and misinformation in Yavapai County. Yavapai County has some of the lowest vaccination rates and highest personal belief exemptions in the country. AzAAP engaged an Action Team—comprised of a community pediatrician, a pediatric nurse practitioner, the coordinator for the Vaccines for Children program, and the Director of the Healthy Students program in Yavapai County—to implement culturally effective vaccine confidence strategies within their community. AzAAP launched a targeted social media campaign (a total of 19 social media images) in the county and created magazine advertisements, a magazine article, and a podcast. The social media campaign messages, which highlight the importance of COVID-19 vaccination as well as other vaccinations to protect children and families from vaccine-preventable diseases, began posting in early June 2021 have over 4,000 views each.

AzAAP conducted a needs assessment of pediatric healthcare clinicians related to increasing vaccination in children and adolescents (in partnership with national AAP and the CDC). AzAAP is using this data to assess vaccination needs across the state and develop campaigns and projects to meet these needs. National AAP the survey data by AzAAP with eight other chapters participating in the project (for a total of 560 responses) and engaged an expert communications and design team to turn chapter feedback into tools for members. The creative assets have been shared widely so all AAP chapters can customize and use them for routine immunization messaging. The goal of these images is to promote getting pediatric patients up to date on all routine childhood vaccines (to help them get back to “normal” activities) by visiting their pediatrician’s office. The themes of these images are: (1) “get back on track”, (2) “get back in the game”, and (3) “get back to school”. AzAAP also translated several of the messages into the Apache and Navajo languages with graphics that feature Apache and Navajo infants, children, and teens doing a variety of activities.

AzAAP is participating in the Improving Immunization Rates for Adolescents (IIRA) Learning Collaborative, which began in October 2020, and aims to address adolescent vaccination rates within Arizona by helping pediatricians build confidence in their critical role and meet measurable goals. See the Adolescent Health 2021 Annual Report for more information.

AzAAP formed a Vaccine Preventable Disease (VPD) Committee to strategize on the most pressing issues facing infants, child, and adolescents in the state. The committee is responsible for developing and submitting proposed infectious disease prevention and immunization goals and to develop an annual plan to achieve the approved goals for improving infectious disease prevention and immunization within Arizona. The VPD Committee currently includes 15 provider members from across the state and with diverse backgrounds, including two residents and two medical students.

COVID-19 Challenges: The capacity to navigate and be responsive to pediatric professional needs with the constantly changing COVID-19 guidance has also been a challenge. Through Title V funding provided by ADHS, AzAAP has been able to hire a full-time Manager of Infectious Diseases and Immunizations, which has allowed them to address this challenge and work quickly to support members, children, and families in real time. Having a dedicated staff person allows AzAAP to follow issues, new guidance, and conduct evaluations of members’ needs to better understand how to support pediatric practitioners addressing COVID-19 and providing other vaccinations in our state to improve the health of Arizona children and families.

As AzAAP creates and shares positive evidence-based messaging with caregivers on the best ways to protect their children and families from vaccine-preventable diseases, they have been met with strong anti-vaccination sentiment and have experienced negative comments on their social media posts. These challenges reinforce the compelling need to address parental attitudes and perceptions associated with vaccines and provide trustworthy, evidence-based information to counter the spread of misinformation in order to increase vaccination rates in our communities for the benefit of children and families. In 2021, AzAAP’s Manager of Infectious Disease and Immunizations had the opportunity to attend a six-week training and professional development in social media training to be better equipped to meet this challenge.