Child's health includes physical, mental, and social well-being. Ensuring healthy growth and development is a primary concern of the Maine Title V program. Maine’s efforts to improve the health status of children during the 2021-2025 period focus in the areas of physical activity, oral health, developmental screening, and childhood immunizations.

Priority: Optimize Children’s Physical and Oral Health

Performance Measure (NPM): Percent of children, ages 6 through 11, who are physically active at least 60 minutes per day.

In Maine, 33.6% of youth aged 6-11 years are physically active for at least 60 minutes per day based on data from the 2020-2021 National Survey of Children’s Health. In 2020-2021 Maine ranked ninth on this performance measure. There were no significant differences in daily physical activity levels by child sex, income, parental education, race, or special health needs status. There has not been substantial change in this measure in Maine over time.

Regular physical activity (PA) is an essential component of a healthy lifestyle; it can play a powerful role in preventing chronic diseases, including heart disease, cancer, and stroke. It also builds strong bones and muscles, can increase physical fitness, may reduce anxiety and depression, and promotes positive mental health. Providing regular opportunities for youth to participate in physical activity will help them establish healthy lifestyles that can prevent these diseases in the future.

Schools are a key setting as the promotion of physical activity has long been a fundamental component of the American educational experience. Over 95% of youth are enrolled in schools. The school day, typically 8-9 hours long, traditionally provides a sedentary setting away from home. Adding physical activity during the school day can reduce the sedentary nature of classrooms and can enhance academic performance. The federal guidelines for Comprehensive School Physical Activity Plan and Society of Health and Physical Educators (SHAPE America) Standards underscore the recommendation that school-age youth should participate in at least 60 minutes of physical activity every day and schools have a significant role to play in helping students achieve this recommendation.

Out of School Sites (OOS): National recommendations from US CDC encourage state systems to work with these settings to improve policies and practices that increase minutes spent being physically active. Afterschool and summer learning programs are well positioned to be key partners in a comprehensive effort to help children grow up healthy. From providing young people with access to nutritious foods to promoting healthy habits and keeping students physically fit, OOS programs can combine and implement multiple approaches.

Strategy: Increase the number of schools and early care and education sites that receive support and targeted outreach to improve policies and meet best practices for increasing physical activity opportunities for youth they serve

During FY22, the Maine Center for Disease Control and Prevention (Maine CDC) worked with Maine Roads to Quality (MRTQ), Maine Department of Education (Maine DOE), Maine Afterschool Network (MASN) and Let’s Go! to identify new or existing sites (schools, early childhood education (ECE), and out of school programs) with policies that do not meet national standards for providing adequate and appropriate physical activity (lacking recess, physical education periods). Targeted professional development is based on the needs of sites, including addressing limited time, space, and remote access. Ongoing constraints created by the COVID-19 pandemic resulted in many partners using online virtual platforms to provide technical assistance, resources, support, and trainings. The types of technical assistance offered include but are not limited to policy review, environmental strategy implementation support, general education, and online training.

The following activities occurred:

During the first quarter of FY22, Let’s Go!, an obesity prevention initiative for children and adults that focuses on healthy eating and active living, analyzed FY21 annual survey data to identify sites to target and engage with. Of all Let’s Go! registered sites (1124), the following were identified as needing further work and support, specific to improving outcomes for physical activity:

• Schools: 215 of the 317 (68%) registered were identified as needing training and technical assistance support for implementation of best practice and higher standards; 102 met best practice and alignment with high standards for physical activity at their sites as defined by Let’s Go!
• OOS: 124 of 125 (99%) sites were identified as needing training and technical assistance support for implementation of best practice and higher standards; only one site met best practice standards.
• ECE: 462 of 472 (98%) registered sites were identified as needing training and technical assistance support for implementation of best practice and higher standards; 10 met the best practice standards.

Over the second and third quarters, Let’s Go! reviewed and updated the “Let’s Go! Guide to Success” environmental assessments for Schools, ECE and OOS programs and aligned with national recommendations to make it a more comprehensive assessment of physical activity (and our other strategies).

Let’s Go! held an annual virtual School Symposium October 29, 2021. The Symposium focus was “Physical Activity Stigma and Bias: Connections to Education, Health and a Positive School Culture”. 103 individuals representing 30 School Administrations attended the Conference. Other training and technical assistance offered included: Online ECE training - Moving Children to Good Health: Physical Activity for Young Children. To date 52 ECE’s received this training. A February 2022 online training for ECE’s and OOS focused on Supporting Policy Change to address sustainable healthy eating and physical activity. 20 ECE’s were represented at this event.

The Maine Association for the Education of Young Children fall conference, originally scheduled for in person was held remotely. The event was an overwhelming success with over 600 ECE sites and related personnel in attendance over the 2-day event. Maine CDC and partners attended the event and co-facilitated two trainings: Physical Activity Learning Session (PALS) a training curriculum for early childhood providers aimed at supporting practice change in ECE programs leading to healthier, more active children (the curriculum/program will be launched in the next fiscal year). The session highlighted the importance of physical activity in child development including cognitive, social-emotional, and motor. Exploring the eight best practice areas of physical activity; ECE trainers and coaches that viewed or attended the session received information on PALS. 41 ECE’s attended or viewed the training. The second training was specific to an evidence-based self-assessment tool for ECE’s called Go NAPSACC (Nutrition and Physical Activity Self-Assessment for Child Care). This online tool is used to assist ECE’s in making quality improvements in many areas of health and wellness. 12 ECE’s attended or viewed the training.

Maine CDC partnered with Medical Care Development (MCD) to contract with Playworks to provide two synchronous virtual workshops in the fall and an action planning session in the spring. The Power of Play workshop centered on learning best practices to create safe and inclusive play opportunities for all students, and the Proactive Group Management workshop focused on key group management strategies adults can use to set students up for successful group behavior.

• Active engagement and attendance in the first two virtual workshops consisted of 29 educators from nine (9) schools. Each school sent a team of educators to learn best practices together and create action steps for implementation at their site. Six participated in the March 22, 2022 action planning session.
• Recruitment activities for the trainings included utilizing Newsletter/Digest and communication with Let’s Go! Coordinators in late September; email communications to all Maine Principals on October 18th; an announcement at Let's Go! Conference on October 29th and a posting in the Maine DOE Newsroom in early November.
• Given teachers’ extremely limited professional development time and bandwidth in SFY21-22 (due to teacher shortages across the state), we chose to make the training content accessible to more educators by including a variety of opportunities for collaboration and self-guided learning. These engagement opportunities included:

• Access to the recorded interactive workshops: 37 additional educators watched these workshops and signed up to receive Playworks resources.
• PlayworksU Online Learning Platform: All participants received a PlayworksU subscription to continue their learning, and in total they enrolled in 52 courses on the platform through their subscriptions.

Over the past year the Maine CDC lead met with the MASN Director to identify areas that can support communication, education, training, and technical assistance for the OOS sites connected to the MASN. This relationship resulted in Playworks being featured on a bi-monthly educational meeting for OOS sites, offering those sites online resources that are offered to all schools.

The Maine CDC lead and Maine DOE continue to coordinate efforts and meet monthly. Promotion of trainings are shared with Maine school staff through multiple communication efforts, including the Maine DOE’s newsletter. The relationship with Maine DOE assists in planning, logistics, implementation, and promotion of all relevant training opportunities.

Additional work focused on a collaboration with MCD’s Healthy Kids Healthy Future (HKHF) initiative that introduced PALS at the Maine Association for the Education of Young Children virtual conference in October 2021. Providers were interested in learning more about the curriculum and training opportunities. In order to sustain this program in Maine, MCD has initiated a PAL’s trainer network. The HKHF Project Coordinator, along with four statewide partners (Let’s Go!, Maine Roads to Quality Professional Development Network, a child care provider, and Family Child Care Association of Maine), became trained in PALS. Over the months that followed the Maine PALS trainers attended the national networking calls and were convened quarterly to network, coordinate, and share lessons learned in support of increasing developmentally appropriate physical activity training in ECE settings.

The WinterKids online training module was made available to over 150 ECE’s through a collaboration with Maine CDC. Working with the state Maternal Child Health Director, resources were secured including scholarships for over 250 ECE sites to receive new resources and access the online WinterKids Preschool training. The Guide to Outdoor Active Learning Preschool Edition binder and training reached 411 ECE teachers that serve over 5,224 children. The Winter Kids program helps children develop healthy lifelong habits through education and fun, outdoor winter activity.

Priority: Optimize Children’s Physical and Oral Health

Performance Measure: Percent of children, ages 1 through 17, who had a preventive dental visit in the past year.

Dental decay and oral health literacy continue to burden the children in Maine. According to the 2021 Maine Integrated Youth Health Survey, about one in ten 5th and 6th grade students missed at least one day of school in the previous year because of problems with their teeth. One objective of the Maine School Oral Health Program (SOHP) is to reduce tooth decay among Maine children and adolescents grades Pre-K through six. To address this the Maine CDC’s approach combines increased oral health literacy, providing classroom oral health resources for school nurses and collaboration with other dental stakeholders on oral health messaging.

In 2020-2021, about 77% of Maine parents reported that their child had a preventive dental visit in the past year which is similar to the U.S. (75.1%), but the lowest in New England.[1] Maine’s performance on this measure has declined over time. In 2016-2017, 85% of Maine children had a preventive dental visit. Young children (aged 1-5) are the least likely to have had a preventive dental visit in the past year (72% vs. 92% of children 6-11 years of age). Children living in families with a household income between 0-99% of the federal poverty level (FPL) are less likely than children living in families with FPL greater than or equal to 400% FPL to have a preventive dental visit (65% vs. 83%). Preventive dental visits are also related to higher parental educational attainment and having private health insurance.

Based on data from Maine’s All-Payer Claims Database, about 16% of Maine children under age 21 did not have dental insurance in 2021.[2] Among children with dental insurance, those insured through Medicaid were less likely than children with private insurance to have had at least one preventive dental visit in 2021. In 2020, there was a precipitous drop in the percentage of children who had at least one preventive dental visit, especially among children insured by Medicaid.1 This rebounded slightly in 2021, but has not returned to pre-pandemic levels.  

Strategy: Maintain support for the School Oral Health Program consultants and administrators

During FY22 the School Oral Health Program (SOHP) disseminated educational materials to schools enrolled in the SOHP. The SOHP provided materials to school nurses and teachers to assist in meeting the Maine Department of Education curricula requirements for teaching oral health lessons and to increase oral health education. During Children’s Dental Health Awareness Month (February) all schools (192) were emailed a Google Drive link containing all oral health classroom resources.

The Children’s Oral Health e-Learning Platform (COHELP) created its first module in 2022. The module, which can be found at: COHELP (mcd.org), is scheduled to go live in FY23. This on-line educational program will be shared with all enrolled SOHP schools and other dental stakeholders. Additional educational modules will be created as funding is secured.

The SOPH provided outreach and technical assistance to schools interested in enrolling in the SOHP. Unfortunately, due to a workforce shortage, the SOHP was unable to open enrollment for FY22 and the goal to increase by 5% the number of new school enrollments and children who receive SOHP services was not met.

The school-based dental hygienists and school oral health Program Manager provided oral health educational resources to school nurses through trainings and technical assistance. Engaging Maine children with oral health literacy promotes good oral health habits resulting in less tooth decay. Educational resources were emailed to all willing and receptive school nurses at the192 enrolled schools.

The SOHP collaborated with other dental stakeholders and partners on shared children’s oral health messaging and resources. The SOHP utilized COHELP to assist with increasing oral health literacy.

Strategy: Provide support and supplies for updated PPE requirements post COVID-19

The SOPH collaborated with SOHP hygienists and volunteers by providing dental public health training, outreach, technical assistance (data collection) and appropriate use of personal protective equipment (PPE) post COVID-19. The SOHP manual was provided to all SOHP hygienists and administrators.

Priority: Ensure early detection and intervention for developmental delay

Performance Measure: 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.

According to the 2020-2021 National Survey of Children’s Health, about 49% of Maine parents of children ages 9-35 months report that they were asked to complete a developmental screening tool for their child within the previous year. Maine ranked 2nd highest on this measure. The U.S. rate was 34.8%. Maine has seen significant improvement on this measure since 2016. MaineCare has been working to improve developmental screening rates among their providers and has increased awareness of the billing code available to providers for conducting developmental screens. As a result, the percent of children enrolled in MaineCare with a claim for a developmental screen increased for three-year olds from 9.0% in 2012 to 25% in 2019. This increase may be due to increased awareness of claim coding for developmental screenings, along with actual increases in screenings. In 2020 the percentage of children enrolled in MaineCare who had a developmental screening decreased slightly to 21% and has remained lower than in 2019 (24.7% in 2021 and 22.1% in 2022).  The decrease may be due to the impact of COVID-19 on well-child visits. In 2016-2017, 91% of children in Maine had a preventive health visit; in 2020-2021, this had decreased to 85.3%.

In 2020, the Maine Department of Health and Human Services (Maine DHHS) created a report in response to LD 1635, RESOLVE Chapter 66, To Improve Access to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services for Children birth to eight years of age. The report included information on Maine DHHS programs providing developmental screening services, including work carried out under the Maine Title V Maternal Child Health Block Grant, Public Health Nursing, Maine Families Home Visiting, and Women, Infants and Children (WIC). One of the report’s recommendations was ensuring families have access to services, which include developmental screening. Although developmental screening did not emerge as one of the top five priorities for child health during the MCH needs assessment, the Maine Title V program decided to include it to align with the Maine DHHS Commissioner’s priority on the importance of screening children for developmental delays.

Strategy: Work with community partners to collaborate and increase referrals for developmental screenings

During FY22, The Maine WIC program screened participants using the federal CDC’s Learn the Signs Act Early (LTSAE) tool. An annual review of these materials also occurred with WIC, Public Health Nursing and Head Start staff. Referrals to health care providers and Child Development Services (CDS) also continued. Data is shared with the WIC Nutritionists, enabling them to see the impact of their referrals and help in encouraging referrals to developmental screening, CDS and health care providers. All referrals are captured in the WIC management information system and alerts are created for the Nutritional Counselor to follow up with the participant on the outcome of the appointment.

The Developmental Milestones were added to the WIC Shopper application so that participants can monitor their child’s development and reach out to their health care provider should they have concerns with their child’s status. The LTSAE Ambassador, CDS Part C and WIC staff developed a poster with quick response (QR) barcodes for WIC, CDS Part B and Part C resources as COVID-19 necessitated the destruction of regular paper resource materials.

Maine Families family visitors complete the Ages and Stages Questionnaire (ASQ), and Ages and Stages Questionnaire-Social Emotional (ASQ-SE) with families at regular intervals. Family visitors complete ASQs, at a minimum, at 2, 4, 6, 9, 12, 18, 24, 30, and 36 months. Family visitors complete ASQ-SEs at a minimum of three times within the first three years of the child’s life. Family visitors worked with local child development services and other specialists to offer referrals for families as indicated by a screening result.

Public health nurses (PHNs) provided infant physical assessments at each home visit, which included an assessment of the child’s development. PHN’s perform physical assessments appropriate for age/condition and document the results in the pediatric physical assessment tool. PHNs monitor children for their ability to express needs. They monitor the child for attainment of developmental tasks expected for age as well as monitor the child’s response to stimulating/nurturing activities. Public health nurses refer to appropriate providers if any assessments are determined to be outside of normal limits.

Priority: Optimize Children’s Physical and Oral Health

State Performance Measure: Percent of children, ages 19-35 months, who have completed the combined 7-vaccine series (4:3:1:3*:3:1:4)

Strategy: Ensure children have access to the required immunizations according to the schedule

The most recent data from the National Immunization Survey for this measure are from infants born in 2019. Based on this survey, 70% of children through 35 months of age completed the combined 7-vaccine series. The 2019 cohort vaccination rate for the United States was 76.4%. Maine’s 2019 data represent a substantial drop from 2018 when Maine’s vaccination rate was 85%. Interestingly, New Hampshire and Vermont had similar declines between the 2018 and 2019 birth cohorts. The decline could be due to disruptions to well-child visits during the COVID-19 pandemic. The United States did not experience a decline during this period. Data for children born in 2019 are still preliminary and will be finalized after the 2022 survey data are available.

The Maine CDC continued to collaborate with the Maine Chapter of the American Academy of Pediatrics (Maine AAP) to promote routine childhood vaccinations. Maine physicians receive best practice communications through the Maine AAP listserv and social media platforms. Information was targeted to help increase children 24-35 months, students 4-6 years, and adolescents receive their routine immunizations.

The Maine CDC promoted and recruited provider sites to enroll in the Maine Immunization Program (MIP), with a focus on ensuring that children in rural areas have access to vaccine. During FY22, the MIP enrolled over 50 new provider sites for COVID-19 vaccination efforts. Many of these additional sites will also be able to carry and offer routine recommended childhood vaccines.

The MIP continued to partner with the PHN Program to offer catch-up immunization visits to all Maine children. These visits are offered in six Public Health Nursing offices located throughout the state. Public Health Nursing utilized the State of Maine immunization information system, ImmPact, to record these immunizations.

As of September 21, 2021, philosophical and religious exemptions for vaccinations for children and students in Maine were removed from Maine’s new vaccination law. This change may lead to an increase in the percent of children 0-35 who receive the full vaccination series in a timely manner. Based on MIP’s survey of kindergarten students, vaccination rates for the 2021-2022 school year were higher than previous years.

Other Efforts

Immunization rates and provider participation are calculated quarterly using the Maine immunization information system, ImmPact. Students in grades K, 7, and 12 are measured using the annual School Immunization Assessment Survey conducted in December of each year. The annual survey results can be viewed on our website at: www.ImmunizeMe.org

[1] National Survey of Children’s Health, 2020-2021.

[2] Children’s Oral Health Network of Maine. 2021 Dental Claims Data Update, 2016-2021 Trends. February 2022. https://www.mainepcoh.org/assets/stock/2021-COHN-Data-Brief.pdf