In 2019, Idaho’s children (60.3%) lagged behind children nationally (62.7%) for maintaining a healthy weight. In the same year, 32% of Idaho’s children between the ages of 6 and 11 were physically active for at least one hour. The 2020 Needs Assessment (NA) highlighted a significant difference in the selection of nutrition and physical activity as a health need for young children ages 1-5 in urban counties (23%) in comparison to rural/frontier counties (0%). Similarly, nutrition and physical activity as a health need for children ages 6-11 was identified at a higher rate in urban counties (34%) than rural/frontier counties (7%).
In consideration of these data and the 2020 NA, the MCH Program has chosen to focus on three priority needs in the Child Health domain for the 2021-2025 state action plan: 1) decrease the prevalence of childhood overweight and obesity, 2) increase immunization rates, and 3) improve maternal and child health access to medical and dental homes.
Strategies in this domain will support NPM 8.1 (percent of children, ages 6 through 11, who are physically active at least 60 minutes per day), SPM 2 (percent of children at kindergarten enrollment who meet state immunization requirements) and NPM 13.2 (percent of children, ages 1 through 17, who had a preventive dental visit in the past year). These strategies and associated objectives are discussed in further detail below.
Childhood Physical Activity and Nutrition
The state selected “NPM 8: Child Physical Activity” to continue focusing on reducing childhood overweight and obesity, and developed the objective of funding and supporting existing programs and initiatives to expand education and activities focused on physical activity and nutrition for children by September 2025. According to the 2019 National Survey of Children’s Health data, Idaho children fare similarly to children nationally for maintaining a healthy weight. About 30.1% of Idaho children were considered overweight or obese (based on BMI) compared with about 31% of children nationally. For the same year, 34.1% of Idaho children ages 6 to11 were physically active for at least one hour every day.
The MCH and Idaho Physical Activity & Nutrition (IPAN) Programs continue to meet quarterly to discuss opportunities to collaborate on childhood obesity interventions. Teaching children healthy habits from the start will help them learn to make healthy choices as they grow older. Through the Healthy Kids, Healthy Future (HKHF) initiative, Idaho childcare providers have the opportunity to promote children’s health by encouraging healthier physical activity and nutrition practices through five main goals: increasing physical activity, limiting screen time, providing nutritious foods, providing nutritious beverages, and encouraging breastfeeding. For FY 2020 (October 2019 – September 2020) 57 childcare providers received the HKHF training through Idaho STARS, which is the state’s childcare training and professional development system. IPAN coordinators located at each of the seven public health districts are tasked with promoting the regional lending libraries for childcares. For a minimal, one-time cost, childcares can access several age-appropriate activities and items for use with their children. Accessing the regional lending libraries is one way that childcares are given the tools to put into action what they have learned in the HKHF trainings and enhance outdoor and indoor play space to encourage physical activity with all ages of children. In 2018, the MCH Program purchased a variety of items and activities focused on encouraging physical activity for all the childcare lending libraries. During FY 2020, a total of 27 childcare centers had access to resources from the lending libraries through partnership with the IPAN Program, and 21 participated in activities such as painting playground areas with stencils demonstrating healthy food choices and physical activities.
In FY 2018, the IPAN Program partnered with the Idaho STARS Program to bring a new educational training to Idaho called Be Active Kids (BAK). This program was developed by the Blue Cross and Blue Shield of North Carolina Foundations. The BAK program is evidence-based, using characters to engage children in active playful experiences and explore their natural surroundings. The Train the Trainer session was held in May 2019. Trainers through the Idaho STARS Program began offering the training statewide beginning in July 2019 and completed 3-hour trainings with 7 childcare facilities in FY 2019. For FY 2020, 47 childcare providers received the BAK training.
The IPAN Program partnered with the University of Idaho – Extension to implement the Farm to Early Care and Education (ECE) program in 10 childcare centers in the South-Central Health District. The Farm to ECE program offered increased access to core elements of local food sourcing, school gardens, and agriculture education to enhance the quality of the educational and nutritional experience in the childcare settings. The Farm to ECE pilot program was implemented from September 2019 through May 2020, and the curriculum and strategies were launched at 10 pilot sites in Idaho’s South Central Public Health District. Educators were asked to lead Farm to ECE lessons and activities four times a month in their classroom after receiving the curriculum, materials, and direction from the Farm to ECE Program Coordinator. Sites included preschools, child care centers, family child care homes, and K-12 school districts.
Between August and December 2020, monthly activities were adapted for children in elementary grades (ages 6-11) and included in the monthly toolkits for providers. This work was initiated to start expanding the focus of the Farm to ECE Program from early childhood settings to an older audience in alignment with NPM 8.1. As of December 2020, Farm to ECE had enrolled 10 childcare providers in the Idaho Farm to ECE Program (5 previous pilot sites and 5 new childcare centers). From these sites, the Farm to ECE team has expanded its engagement to 398 children, reaching 337 children ages 3 to 5 and 61 children ages 6 to 11.
COVID-19 Impact on Childhood Physical Activity and Nutrition
Both BAK and HKHF trainings were adapted due to the COVID-19 pandemic. Some trainings were translated into webinar sessions, helping to fulfill requirements. However, trainings in some regions were cancelled due to reasons such as daycare closures, shifting priorities, or changes in staff and the inability to obtain trainers.
Fit and Fun Playscapes was not as affected by the pandemic since it is able to be completed outdoors with safe social distancing practices. However, due to the seasonal weather in Idaho and varied regional COVID-19 regulations, some areas were unable to complete all planned playscapes.
Adaptations were made in the final two months (April-May 2020) of the pilot program to make Farm to ECE programming accessible electronically. Following state and county guidelines, travel to early care sites ceased in early March 2020 after delivering the March toolkits. Produce delivery, and therefore tastings at the sites, were also discontinued. An e-curriculum was shared with the sites that remained open in April and May, and teacher check-ins occurred over the phone.
The Farm to ECE team provided all schools with a family e-newsletter that was distributed to families via email and social media. It contained activity ideas for quarantined families, tips for how to buy and cook the “Harvest of the Month” vegetables, and links to crucial resources to equitably serve children and families (e.g., where struggling families could go to obtain free meals). These e-newsletters were distributed in English and Spanish.
The Farm to ECE Program recognized the systemic connections between diet, physical health, and emotional health during the COVID-19 pandemic. Farm to ECE strategies embody the theoretical foundations of social and emotional learning in addition to nutrition education. Social and emotional learning (SEL) offers a “broad range of social, emotional, and behavioral skills for children” (McClelland et al., 2017). The range of SEL learning opportunities afforded by Farm to ECE programming helps children with emotional wellness. The Farm to ECE team intentionally incorporated more of these strategies into the curriculum and family newsletters during April-May 2020.
Due to COVID-19, five previous pilot sites were temporarily unable to continue their participation in the program, citing policy changes, safety, and decreased enrollment as external factors informing their decisions.
Immunizations
To address the priority need for improving childhood immunization rates, the MCH Program developed a SPM related to Idaho’s unique needs related to immunizations. For the 2018/2019 Idaho school year, 95.5% of kindergarteners and 93.1% of seventh graders met state immunization requirements for school enrollment. To support this SPM, the MCH team developed the objective of collaborating with the Idaho Immunization Program (IIP) to increase vaccination education and vaccine uptake among MCH populations. Measurement of the objective will be based on an inventory of programmatic activities related to immunizations and IIP data. Strategies to address this objective and SPM are discussed below.
One mechanism to help increase vaccine coverage in Idaho is the Vaccine Assessment Fund. The required state match for Idaho’s Title V MCH Block Grant is achieved through this dedicated fund for state-supplied vaccines for privately insured children. Private insurance companies make a yearly payment into the Idaho Vaccine Assessment fund based on the number of insured children they cover and the vaccine assessment rate. This allows the IIP to purchase vaccines at the discounted federal rate. Idaho is a universal supply state, which means all children under 19 years of age are eligible for state-supplied vaccines regardless of insurance status. Medical providers place orders for vaccines through the IIP and are able to maintain a single stock of vaccines for their pediatric patients. The universal supply is supported by the Idaho Vaccine Assessment Fund, the Vaccines for Children (VFC) Program (covers children with Medicaid or who are uninsured, underinsured, American Indian and Alaska Natives), and the Separate Children’s Health Insurance Program. Ultimately, insurance companies realize cost-savings through the assessment fund. The MCH Program will continue to support the work of the IIP to provide education to the public and health care providers about the importance of immunizations, addressing immunization hesitancy, and best practices to increase immunization rates.
The IIP continues to receive funding from the Centers for Disease Control and Prevention (CDC) and from the State of Idaho to operate the state immunization program. Improving childhood immunization rates is a primary focus for the IIP. Immunization promotion activities continue similar to previous years, including immunization awareness campaigns for the public (with special emphasis on infants, expecting parents, and new parents), provider education and trainings through statewide workshops and conferences, and implementation of the Immunization Quality Improvement for Providers (IQIP) formally known as Assessment, Feedback, Incentive, and eXchange (AFIX), a quality improvement activity targeted to immunization providers conducted throughout the state. IQIP promotes and supports implementation of provider-level strategies designed to help increase on-time vaccination of children and adolescents.
COVID-19 Impact on Immunizations
This past year was historic to the IIP for many reasons, none more important than the coronavirus pandemic. As of May 18, 2021, the IIP coordinated the distribution of 1,634,915 doses of COVID-19 vaccine throughout the state to a broad network of vaccine providers. The IIP also oversaw the administration of 1,181,916 doses, which placed Idaho in the top third of the US with an administration ratio of 72.3%. While the pandemic has been all encompassing, the IIP maintained the childhood vaccination program, ensuring that Idaho’s providers had access to vaccines and program materials for patients who chose to be vaccinated during the pandemic, but experienced a decrease in immunization related strategic activities outside the COVID-19 vaccine. Some changes in the program this previous year have been the addition of COVID-19 staff who have helped grow our network of providers. The additional healthcare providers will extend the reach of those who serve MCH populations.
In 2019, the IIP added a FTE position whose main responsibilities involve data analysis. This position gave IIP and MCH the opportunity to look at data more critically and ensure that decisions are made with the best data possible. IIP also expanded the number of Idaho Provider Immunization Education (I-PIE) trainings over the previous year and included the implementation of continuing medical education credits for participation. IIP hoped to continue expanding the number of I-PIE trainings over previous years in 2020, but instead saw a decrease due to the pandemic.
Also in 2019, the IIP planned and conducted the first Statewide Tribal Immunization Summit in Boise. Tribal partners were invited to Boise to hear from community leaders, Indian Health Services, Portland Area Indian Health Services representatives, as well as IIP subject matter experts. There was discussion from the tribes highlighting both successes and challenges the tribes have been facing with providing vaccines to tribal members. By the end of the day, tribes were able to identify areas of improvement in providing vaccines to children members of their tribes. IIP planned to meet with the tribes again in 2020 to report on their progress in implementing the identified improvements; however, COVID-19-related restrictions forced a cancellation of the follow-up meeting and IIP is now looking towards the next fiscal year to reschedule.
Lastly, COVID-19 further delayed evaluation data analysis of the statewide reminder/ recall project to increase immunization rates for HPV, Tdap, and the meningococcal vaccine. Reminder/recall immunization systems are a proven intervention to help increase immunization rates among infants, children, and adolescents. Future analysis results should yield strategies to resume project methods for those who have fallen behind on childhood vaccines due to the pandemic.
Pediatric Oral Health
To address the priority need to improve MCH population access to medical and dental homes, the MCH Program continues to fund the Idaho Oral Health Program’s (IOHP) contracts with the public health districts (PHDs) for dental care among school-age children. In 2014, the PEW Charitable Trusts assigned the state of Idaho an “A” grade for protecting children from tooth decay with the application of dental sealants. Idaho was one of only five states to receive this distinguished grade. According to the Centers for Disease Control and Prevention (2015), dental sealants are a critical preventive dental service and can reduce decay by 60 to 80 percent in two years after application. Further, school-based dental sealant programs are a great way to reach children and result in cost-savings for families. The reason Idaho is top in the nation for protective sealants is due to many collaborative networks involving private and public entities.
The IOHP has provided preventive oral health services to infants, children, and adolescents, especially those who are at-risk for dental disease, for more than 35 years. The program leverages funding from the Title V MCH Block Grant and the Centers for Disease Control and Prevention, and subgrants with the seven local public health districts (PHDs) to deliver these efforts.
The IOHP works with subrecipients to deliver oral health education (live or virtual) to healthcare providers or pregnant women in various settings (i.e., WIC, Head Start, Early Head Start, Migrant Head Start). This education may take place either one-on-one or in group settings. The program uses the Perinatal Best Practice model outlined by the Association for State and Territorial Dental Directors (ASTDD) as guidance on the delivery of this education. The program encourages subrecipients and other organizations to utilize Smiles for Life: A National Oral Health Curriculum, which is an evidence-based resource for healthcare providers and others to ensure the integration of oral health and primary care. The IOHP also has oral health educational materials available for pregnant women via its Health Tools website. Dental referrals are provided, as needed, in addition to referral resources (e.g. assistance with finding a Medicaid dental provider). PHDs utilize evidence-based approaches to deliver programs to early education childcare providers, pediatricians, and primary care providers.
The IOHP works with the Idaho Oral Health Alliance (IOHA) and other partners regarding the development of the state oral health action plan, and on specific committees, such as the Healthy Me is Cavity-Free Collaborative to ensure a focus on oral health and pregnant women is included. The Healthy Me is Cavity-Free Committee is specifically looking at identifying sustainable system changes or solutions to help prevent and control tooth decay in children ages zero to 6. When funding is available, the program also supports speakers delivering oral health education presentations at various conferences such as the Idaho Perinatal Project Conference.
In addition to the efforts listed above regarding oral health education and pregnant women, the program works with the PHDs to ensure the importance of infant oral health is included in any type of education specific to the target population of pregnant women. The IOHP encourages the PHDs to deliver oral health education on infants to parents and caregivers in addition to preventive oral healthcare services. Preventive oral healthcare services include oral health screenings or assessments, fluoride varnish applications, and dental home referrals as needed. PHDs utilize evidence-based approaches to deliver programs to early education childcare providers, pediatricians, and primary care providers. One of the PHDs, Central District Health Department (CDHD), has implemented the First Teeth Matter Program (FTMP), which has a specific focus on early childhood caries prevention for ages 0-3. The FTMP offers appointments (approximately 20 minutes in length) to parents and caregivers where information on early preventive oral healthcare is provided. During the appointment, a Registered Dental Hygienist talks with the parent or caregiver and performs an oral health screening of the child's mouth. The visit helps determine the child's risk for developing cavities, includes oral health education specific to the child, and consists of a fluoride varnish application. Similar to efforts focused on pregnant women, the IOHP works with the IOHA and other partners on efforts such as the development of the state oral health action plan, and on specific committees like the Healthy Me is Cavity-Free Collaborative to ensure a focus on infant oral health is included.
During the timeframe of July 1, 2019 through June 30, 2020, the IOHP continued to subgrant with the PHDs to deliver fluoride varnish programs, including the delivery of oral health screenings or assessments and fluoride varnish applications, to children with a specific focus on ages 0-5. Fluoride varnish programs are provided at an array of locations (e.g. WIC, Head Start, Early Head Start, Migrant Head Start, childcare centers, and elementary schools). For children ages 6-11, the IOHP subgrants with the PHDs to deliver school-based dental sealant programs, which include the delivery of oral health screenings, fluoride varnish applications, and dental sealants as needed. This program is focused on elementary and middle schools with 50% eligibility in the Free and Reduced Meal Program, or schools in counties considered by population to be 50% or more rural by the U.S. Census Bureau. In addition, the PHDs always deliver oral health education either directly to children, caregivers, parents, or teachers (depending on the type of program being delivered) along with providing a dental home referral as needed. The program also conducts the Idaho Smile Survey, an oral health basic screening survey, every four years to assess the oral health status of third-grade students in Idaho. The program shares the results of this survey statewide to guide programmatic and policy decision making.
As per the 2016-2017 Idaho Smile Survey Report, “More than half, 67.2 percent, of Idaho third-grade students had dental sealants on at least one tooth recommended for sealants. The Healthy People 2020 goal for children aged six to nine is a rate of 28.1 percent or better on one or more of their permanent first molar teeth. The rate has improved in each survey from 2001 with a statistically significant increase of 13.6 percent.” For FY 2020, a total of 1,057 children received dental sealants in school-based settings through the IOHP and a total of 6,075 children received fluoride varnish treatments.
For Healthy People 2030, the goal will shift to 42.5 percent or better for children aged 3 to 19 with dental sealants on at least one tooth recommended for sealants.
COVID-19 Impact on Oral Health
Over the course of the COVID-19 pandemic, the IOHP has remained committed to finding innovative ways to promote oral health while reiterating its importance to overall health and implementing infection prevention and control standards. Over the past year, the PHDs were faced with the inability to serve school-based sealant and fluoride varnish programs and limited educational opportunities within the community and WIC clinics. These challenges intensified existing and developing oral health concerns due to a lack of access to oral health services for children, adolescents, and pregnant women. As a result, the pandemic is heightening concerns about an increase in urgent oral health needs.
While the pandemic did impact the delivery of oral health services, it also promoted innovation and adaptability. Many of the PHDs went virtual with their oral health education to pregnant mothers and presentations to primary care providers. One of the most significant delivery changes was in the clinical operation of oral health services. This resulted in increased personal protective equipment (PPE), including face shields with N95 masks, replacing surgical masks, use of air filtration systems with HEPA filters, and reducing procedures that caused aerosols. Initially, it also brought a complete halt in all oral health services. The IOHP remained in close communication with the ASTDD, Organization for Safety, Asepsis, and Prevention (OSAP), and the CDC on changing oral healthcare delivery guidance and infection, prevention, and control measures.
In addition, the IOHP had to postpone the completion of the Idaho Smile Survey (Basic Screening Survey, due a variety of school policies, differing school schedules (i.e. completely virtual, hybrid, in-person), and an overwhelming sense of uncertainty. The last survey was completed during the 2016-2017 school year and the next will be during the 2022-2023 school year.
The IOHP anticipates that the majority of pandemic-related impacts will be behind them and they move into the 2021-2022 program year. However, the difficulties with serving children and pregnant mothers with oral health services early on during the pandemic resulted in the inability of some public health districts to efficiently use Title V funds. As a result, the IOHP will be implementing an educational campaign to maximize efforts in reaching the focal populations.
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