In 2020, Idaho’s children (63.5%) surpassed children nationally (61.5%) for maintaining a healthy weight. In the same year, 24% of Idaho’s children between the ages of 6 and 17 were physically active for at least one hour every day. 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 2019-2020 National Survey of Children’s Health, Idaho children fare similarly to children nationally for maintaining a healthy weight. About 29.2% of Idaho children were considered overweight or obese (based on BMI) compared with about 32.1% of children nationally. For the same time period, 24% of Idaho children ages 6 to 17 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 2021 (October 2020 – September 2021) 26 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 children of all ages. 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 2021, a total of 16 childcare centers had access to resources from the lending libraries through partnership with the IPAN Program, and 28 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 2021, a total of 40 childcare providers received the BAK training.
In FY 2021, health districts were given the option to deliver trainings on other evidence-based programs to childcare providers if HKHF and BAK did not fit their region’s needs or they had reached a saturation point of expanding HKHF and BAK. Southeastern Idaho Public Health chose to implement Color Me Healthy, an evidence-based nutrition and active living training for childcare providers. A total of 9 childcare centers and 25 staff were trained in Color Me Healthy, which included the Shoshone-Bannock Tribes Head Start Daycare Center.
The IPAN Program partnered with the University of Idaho–Extension to implement the Farm to Early Care and Education (ECE) program in 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 first 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 (SCPH) 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. During FY 2021, Farm to ECE curriculum and strategies were implemented at 11 participating sites within the SCPH district. Program assistance was provided to 2 additional sites managed by health district coordinators in the Public Health-Idaho North Central and Central District Health regions.
As of October 2021, Farm to ECE enrolled 11 childcare providers, of which 3 new childcare centers were new to the program and 8 returned.
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.
The sites currently enrolled in Farm to ECE were able to bring many of the aspects of the program and taste testing back on site in FY 2021. There was staff turnover in the childcare centers and fewer sites were onboarded than previous years due to facility closures. Technical assistance in person was also greatly reduced and transferred to phone or email.
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 2020-2021 Idaho school year, 83.1% of kindergarteners and 77% 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. As of July 2021, vaccines were administered to 316,172 individuals under 18 years of age who were eligible through the Vaccines for Children Program, and to 246,332 individuals under 18 years of age who were eligible through the Vaccine Assessment Fund.
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
In FY 2021, the majority of IIP’s efforts continued to focus on providing education, communication, coordination, and distribution of COVID-19 vaccines. Included in these efforts was the development of a large media campaign promoting COVID-19 vaccination with testimonials from real Idahoans on why they chose to receive their vaccine, with a focus on reaching new mothers, young families, adolescents, and children with special health care needs. The real testimonials came from volunteers who also recorded shorter clips with general vaccine support that the IIP will be able to use in the future.
The IIP was also able to partner with a wider network of healthcare professionals, community-based organizations, and other organizations interested in protecting Idahoans. Despite building a wider network, the IIP saw notable declines, especially in the spring of 2021, in the administration of routine vaccinations. IIP hopes to leverage some of the successes in COVID-19 and the wider network to increase routine vaccinations following the anticipated rollout of COVID vaccines for children 5 years old and younger.
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. In FY 2021, these materials were updated and translated into Spanish and other supplies were purchased, including sippy cups, washcloths, toothbrushes, floss, and timers to be used as incentives when encouraging regular preventive oral health visits for pregnant mothers, infants, and children. Dental referrals are provided, as needed, in addition to referral resources such as assistance with finding a Medicaid dental provider.
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 (CDH), 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 and includes motivational interviewing, goal setting, oral health education specific to the child, and a fluoride varnish application. In 2021, the CDH dental hygienist developed a framework for the FTMP to share with other health districts, enabling them to incorporate a similar program in their communities.
During the timeframe of July 1, 2020 through June 30, 2021, 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.
In 2021, SCPH collaborated with two adolescent facilities, Snake River Juvenile Detention Center and the Twin Falls Safe House to deliver school-based dental sealant programs. Snake River Juvenile Detention Center serves teenagers aged 12-18 years old who have been detained for committing a crime. The Twin Falls Safe House is a short-term facility and serves teenagers aged 12-17 years old who have been removed from their homes temporarily. The adolescents stay until they can return to their own home or a foster home. Through both programs, SCPH provides oral hygiene and prevention education, and educates youth on the effects of vaping, marijuana, cocaine, meth, heroin, alcohol, sodas, energy drinks, piercings, eating disorders, and Human Papilloma Virus (HPV) infection on the oral cavity.
The 2016-2017 Idaho Smile Survey Report states, “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 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.
For FY 2021, a total of 724 children received dental sealants in school-based settings through the IOHP and a total of 2,839 children received fluoride varnish treatments. This is a noticeable decrease from FY 2020, when a total of 1,057 children received dental sealants in school-based settings and 6,075 children received fluoride varnish treatments.
The IOHP partnered with the Idaho Oral Health Alliance (IOHA) to develop the state oral health action plan (2021-2026 Oral Health Improvement Plan) and implement the Healthy Me is Cavity Free (HMCF) Collaborative. The 2021-2026 Oral Health Improvement Plan was completed in August 2021 using input from a 51-member workgroup. The plan was shared statewide during the 2021 Idaho Oral Health Summit and IOHA will complete yearly “report cards” to update the progress of the plan and share partners’ efforts in implementing the goals and objectives of the plan. The HMCF Collaborative specifically identifies sustainable system changes or solutions to help prevent and control tooth decay in children ages zero to 6. Both the IOHP and IOHA ensure prioritization and inclusion of efforts for pregnant women. When funding is available, the IOHP also supports speakers delivering oral health education presentations at various conferences such as the Idaho Perinatal Project Conference and 2021 Idaho Oral Health Summit.
In FY 2021, the IOHP created a statewide media campaign aimed at reaching pregnant women to encourage routine preventive oral health care visits and to promote the importance of oral health in infants and children. The campaign included audio messages delivered on Pandora and Spotify, social media messages on Facebook, Instagram, and Pinterest, and a YouTube video.
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 continued to face some difficulties serving 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 continues to heighten 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. In 2021, the Caregiver Education Committee, a subcommittee of the HMCF Collaborative, provided a virtual training for caregivers through the Super Saturday series in which 27 caregivers were educated on children’s oral health. A resource guide, board books, and a stuffed animal to demonstrate toothbrushing were sent to each participant.
The PHD dental hygienists also participated in infection prevention and control training to remain compliant with standards set in place to ensure their safety and the safety of the patients when delivering 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.
Additionally, the IOHP had to once again postpone the completion of the Idaho Smile Survey due a variety of school policies, differing school schedules (e.g., completely virtual, hybrid, or in-person), staff shortages, and an overwhelming sense of uncertainty. The last survey was completed during the 2016-2017 school year and the next survey is planned for the 2023-2024 school year.
The impacts forecasted for FY 2022 include fewer in-person offerings, such as WIC clinics, which will result in PHD staff seeking off-site venues to offer fluoride varnish clinics, and ultimately seeing fewer children for services. Some areas have more restrictions in their schools and do not allow visitors. Health districts will have to continue to be strategic in educating school leadership on the importance of oral health, access to care issues, and the valuable preventive services they offer. Due to the fewer health care services delivered, some public health districts were unable to efficiently use Title V funds. As a result, the IOHP will be implementing another educational campaign to maximize efforts in reaching the focal populations.
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