National Performance Measure #7.2: Rate of hospitalization for non-fatal injury per 100,000 adolescents aged 10‑19

 

Evidence-Based or Informed Strategy Measure: Percent of high school students who wear seatbelts.

 

Objectives:

 

• By 2022, reduce the rate of hospitalizations for non-fatal injury from 135.7 in 2016 to 98.7 per 100,000 adolescents ages 10‑19 years
  • By 2023, increase the percentage of students reporting in the YRBS that they use seatbelts from 94.4 in 2017 to 98.2. This survey is only conducted in odd numbered years.
  • Maintain or reduce the rate of emergency department visits due to drowning from 5.7 per 100,000 children ages 10 to 19 years in 2021 to 5.3 by 2026.
  •  By 2023, reduce the percent of students who seriously consider suicide as noted in the YRBS survey from 18.4 in 2019, to 16.6 in 2023. This survey is only conducted in odd numbered years.

New Objective:

• By 2026, reduce the rate of emergency department discharges for traumatic brain injury in age 10 to 19 from 1,125.9 per 100,000 in 2019 to 830.2.  This will start during the 2023 2024 school year, as the MCH IPP will collaborate with the IPC to distribute 1,000 bike helmets.

Strategies:

 

The NH State Violence and Injury Prevention 5-year Plan, 2020-2025[1], was released in April 2020.

This plan focuses on addressing common risk and protective factors across all leading causes of injury in the state. Injury prevention topic areas in the state plan that are pertinent to the MCH Title V Block Grant currently include:

 

• Drowning prevention for ages 0‑19 by promoting the Consumer Product Safety Commission “Pool Safely” program.
• Promoting teen driver safety in high school students ages 15‑19 by facilitating the peer-to-peer Teen Driver Safety Program.
• Preventing suicide in in ages 10‑19 by working with NAMI-NH and the NH Suicide Prevention Council and providing an Annual Suicide Prevention Conference.
• Promote helmet use for youth sports such as bike riding, skate boarding, and skiing to prevent traumatic brain injuries (TBI).

 

Non-fatal injuries present a significant burden to the health care system, particularly to urgent care facilities and emergency departments (ED). Unintentional injuries accounted for the majority of all injury-related visits, which are often seen among both children and young adults. One of the age groups with the highest hospitalization rate is the 10‑14 age group.

 

Note: The data in the charts and graphs below will be different than in previous years because this year’s queries only included cases of NH residents who were treated in, or died in NH. Counts and rates will be lower than in previous reports because of this. This change was made so the most current year of data could be included, which is not yet complete for NH residents who were treated, or died, out-of-state. Data back to 2012 is included to help visualize data trends.

 

Hospital data between 2012 and the first three quarters of 2015 used ICD9 codes. For the last quarter of 2015 and forward, ICD10 codes are used. Not all conditions transfer seamlessly between ICD9 and ICD10 coding. Year 2016 hospital data is the new baseline for inpatient and emergency department data because it uses only ICD10 coding. The death certificate data for 2021 and Hospital Data for 2020 is provisional, as it may be incomplete at this time.

 

The rate of non-fatal injury inpatient (IP) hospital discharges in NH residents aged 10‑19 years had shown a decreasing trend. The data provided in the graph below is from an updated dataset for IP discharges between 2012 and 2020. If the current data trend continues, projections show a potential 30% decrease[2] in the rate of non-fatal injury in the 10‑19-year-old age group between 2016 and 2026. Note: The data for this measure has recently been reviewed and updated so the rates for the base line and target have changed.  During the COVID pandemic, fewer youth were playing sports, and there was a reduction in teen driving due to home schooling, which may have resulted in the reduced injury rates in this age group between 2018 and 2021.

 

 

 

Data Source: NH Hospital Discharge Data, NH DHHS, Health Statistics and Data Management Section (HSDM), June 2023.

 

 

 

The focus areas selected to decrease hospitalizations for non-fatal injury in NH’s adolescent population (ages 10‑19) included motor vehicle safety, concussion prevention, and suicide prevention. The primary focus was adolescent driver safety, which intersected with the second focus area, and concussion prevention. The third focus area is teen suicide prevention.

 

The following graphics and analysis address National Outcome Measures (NOM) #15, #16.1, #16.2, and #16.3 and how they intersect with National Performance Measure (NPM) #7.

 

NOM#16.1 Adolescent Mortality

 

Adolescent mortality has not shown a statistically significant change between 2013 and 2022. Annual counts of adolescent deaths range from 41 to 55 per year. According to the CDC WISQARS, the 10‑19-year-old age group's leading overall cause of death in New Hampshire is unintentional injuries, with motor vehicle traffic being the number one injury-related cause. MCH selected adolescent driver safety as a primary focus area for programmatic activities. The second leading cause of adolescent death is suicide, so this issue was also addressed.

 

 

Data Source: NH Vital Records, NH DHHS, HSDM, June 2023

 

 

 

 

Five Leading Causes of Death, NH Residents, Ages 10‑19 Years, 2011‑2020

Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 5/17/2023.

Note: For leading cause categories in this State-level chart, counts of less than 10 deaths have been suppressed (--).

 

 

NOM#16.2 Adolescent motor vehicle death

 

Evidence-Based or Informed Strategy Measure: Percent of high school students who wear seatbelts.

 

Motor vehicle (MV) crashes continue to be the number one cause of death for adolescents and new drivers. According to New Hampshire Driving Towards Zero,[3] speed and inexperience of novice drivers are the major causes of fatal crashes among teens as reported by the NH Division of Motor Vehicle’s Division of Motor Vehicle Fatal Accident Reporting System. Adolescent motor vehicle death rates for NH residents 15‑19 years old have not changed significantly between 2013 and 2022. Counting the deaths by year showed too few events and did not generate stable or statistically significant rates. The graph below includes all motor vehicle crash deaths: occupants, including drivers and passengers.  These data exclude motorcyclists, pedestrians, pedal cyclists, and ATV crashes. This exclusion was made because NH’s prevention efforts focus on teen drivers and passengers. On average between 2013 and 2022, approximately two adolescents aged 15‑19 died per year in MV crashes who were occupants of a motor vehicle.

 

Data Source: NH Vital Records, NH DHHS, HSDM, June 2023

 

 

ESM#7.2.1 Seatbelt Use: Percent of high school students who wear seatbelts (as a driver or passenger)

 

The 2021 NH Youth Risk Behavior Survey (YRBS) indicates that 95.5% of respondents “Sometimes, most of the time, or always wore a seat belt (when riding in a car driven by someone else).” This percent has increased from 72.4% when it was first assessed in 1993. Passenger seatbelt use is below the 2021 target of 96.5%. The percent of students reporting that they are texting while driving has decreased from 48% when the question was first asked in 2013, to 42% in 2017, but increased to 43% in 2021. A "Hands-Free" law was passed in 2015 that forbids the use of hand-held devices by drivers except in the case of an emergency[4]. The percentage of NH students drivers who reported they did not wear a seatbelt when driving on the YRBS decreased from 26.7 in 2013 to 13.6 in 2021.[5]

 

 

 

Source: NH DHHS, Health Statistics and Data Management Section, “2021 Youth Risk Behavior Survey Results, New Hampshire High School Survey, Trend Analysis Report”

 

Source: NH YRBS, https://www.cdc.gov/healthyyouth/data/yrbs/results.htm, “Sometimes, most of the time, or always wore a seat belt (when riding in a car driven by someone else).” accessed on 6/23/2023.

 

 

Adolescent Driver Safety Programmatic Activities

 

Objective: 

• By June of 2027, increase passenger seatbelt usage reported in the NH‑YRBS data from 83.3% in 2007 to 99.2%.

 

The MCH Injury Prevention Program consulted with the Injury Prevention Center and the Youth Operator Program and decided that removing the observational assessment at NH High Schools was in the program’s best interest. This activity and the measure it provided had limitations and complexities that were difficult to navigate for the reasons that follow. The feasibility of implementing the actual assessment consistently and with validity was out of reach due to both hesitation of school administration to allow the assessment to take place, and lack of human resources to support a thorough assessment. There was no way to know or prove if any of the students who’s driving and seatbelt use behaviors were observed during this assessment were students who were directly impacted by the Youth Operator Programs. Therefore, there was no way to draw a conclusion that there was any change in behavior through these observational assessments, making these assessments not a valid form of data collection for program evaluation. Instead, the program will utilize both the Youth Risk Behavior Survey (YRBS) School Specific Reports and direct program evaluation efforts. The YRBS provides data regarding seat belt use, distracted driving, and impaired driving. The YRBS School Specific population indicators will serve as population indicators to monitor collective behavior over time to which the Teen Driving Program has a contribution relationship. Additionally, the Youth Operator Program Coordinator (YOPC) will use pre and post assessments for each program administered at the individual schools where Teen Driver Programs are being offered. These assessments can be used to directly measure the immediate impact of the program.

 

In 2022, the YOPC was able to measure the following impact through these pre and post survey measures for the Matrix Entertainment “Save a Life” Tour (SALT) program:

 

• Of the 328 High School (HS), students who participated in the SALT and took the post survey 73% said the SALT increased their knowledge on the harms of distracted driving.
• Of the 328 HS students who participated in the SALT and took the post survey 66% said because of the SALT, they are more confident in their ability to make safe choices when driving.
• Of the 328 HS students who participated in the SALT and took the post survey 69% said because of the SALT, they are more confident in their ability to make safe choices when being a passenger.

 

Strategies:

 

• Use of peer to peer initivaites within schools to increase seatbelt usage and overall traffic safety culture for teen drivers.
• Increase parental/caregiver participation and understanding of traffic safety for their teen drivers.

 

 

Systems Building

 

The MCH staff continued to support efforts regarding novice adolescent driving safety. The Youth Operator Program Coordinator, with support from the Injury Prevention Center at Dartmouth (IPC) Program Manager, facilitates the Buckle Up NH and Teen Driver Program committee. Part of this work includes the NH Teen Driving Program (NHTDP).

 

The NHTDP’s primary goals include assisting adolescents in understanding the true risks associated with their driving experience and educating parents and community members in understanding these risks. The program also attempts to change the “driving culture” for NH’s adolescents by using a peer-to-peer evidence-based[6] strategy, which deems driving distracted, impaired driving, speeding and nonuse of seat belts socially unacceptable. During the 2022-2023 academic year, the Teen Driver Program interacted with 40 schools throughout the State to provide resources as needed. Statewide YRBS data is collected and reviewed every other year.

 

During the 2022-2023 academic year, the Youth Operator Program Coordinator worked with numerous community-based groups to maximize the educational outreach of the teen driver program. This included the New Hampshire Public Health Association, substance misuse and prevention coordinators, local law enforcement, Community Alliance for Teen Safety of Derry, Raymond Youth Group Coalition, New Hampshire YouthCAN Coalition, New Hampshire community colleges, parent/caregiver committees and more. National entities such as the Children’s Safety Network, the National Organization for Youth Safety, Students Against Destructive Decisions, and Impact Teen Drivers continue to provide current best practice educational material for the Youth Operator Program Coordinator to review and use when appropriate.

 

 

 

The Youth Operator Program Coordinator collaborated with a representative from Matrix Entertainment to provide 10 New Hampshire high schools with the “Save a Life” tour. The “Save a Life” tour is a comprehensive high impact safe driving awareness program that informs, educates, and demonstrates the potentially deadly consequences resulting from poor choices and decisions made by the operator of a motor vehicle. The program specifically placed emphasis on the following driving situations: driver experience, improper driving behavior, safety restraints, impaired driving, and distracted driving. There are two simulators-one for distracted driving (holding a cell phone and driving), the other is for impaired driving (using an oculus over the driver’s eyes to simulate impaired driving; during the drive time the steering wheel will increase its impaired level by placing a delay on the steering wheel). Both simulators have a screen behind them that shows what is happening so all other students watching are able to interact as well.

This link provides visualizations of the simulator videos:

https://www.youtube.com/watch?v=tRWqJ1fjI5E.

 

The following high schools participated in March 2023: Conant, Fall Mountain Regional, Alvirne, Pinkerton Academy, Newport, Stevens, Woodsville, Littleton, and Bedford.  The Youth Operator Program Coordinator also reached out and invited local police departments, regional substance misuse and prevention representatives and other community youth coalitions such as YouthCAN.

 

The Youth Operator Program Coordinator collaborated and contracted with the Think Fast Interactive organization to provide up to 15 new NH High Schools to receive the Think Fast Interactive program in a three-day tour during April 2023. The Think Fast Interactive Program is a non-intrusive program that provides exposure to participants to and educates them on important information on hard-to-tackle topics.   These topics include the consequences of underage drinking, drug use, traffic safety, distracted driving, and much more, while simultaneously entertaining them in a safe, relaxed, and fun environment.  The program is developed in a manner that is team oriented to encourage participants to interact as a group, thereby mutually acknowledging facts about important awareness topics with their peers. (Teen Driver Safety - ThinkFast (thinkfastinteractive.com))The Think Fast Interactive team worked with the Youth Operator Program Coordinator to customize the awareness topics to be geared toward NH laws, regulations, and traffic safety awareness. The following schools participated: Epping, Milford, Raymond, Lebanon, Kearsarge Regional, Rivendell Academy, Belmont, and Bow. When selecting schools to participate in this program the Youth Operator Program Coordinator reviewed the following: weekly crash reports, the DWI list (focusing on county) and Fatal Reports provided by the Division of Motor Vehicles, press releases provided by the NH State Police regarding motor vehicle crashes, pursuits, and efforts to target the high-risk regions. In addition, The Youth Operator Program Coordinator reviewed and targeted high-risk regions based on the YRBS. There are 187 High Schools in NH and eight schools participated; which is 4% of the NH High Schools.

 

Expansion of online resources will include continued updating of the NH Teen Drivers website www.nhteendrivers.com. The website serves as an updated educational resource for teens, parents/caregivers, schools, and community stakeholder/partners. The websites will include items from partner programs, such as the Distracted Driving Task Force Toolkit Dropbox, as well as instructions and ideas for education campaigns, and more. The Youth Operator Program Coordinator continues to monitor page views and searches on the website to measure its effectiveness. In 2022, the website had 5,661 views and 5,175 searches.

 

 

MCH Specific Activities

 

The MCH’s Injury Prevention Program (IPP) continues working with the Buckle Up / NH Teen Driver Committee (the Committee), comprised of multiple state agencies and organizations; this Committee is working towards the implementation of the New Hampshire Violence and Injury Prevention Plan 2020‑2025, which has a component on traffic safety and adolescent drivers. The Committee is working towards educating more adolescent drivers across the State through collaboration and prevention efforts. In 2022, there were six BUNH/Teen Driver Committee meetings held with 69 participants averaging just over 11 participants per meeting. In addition, the MCH-IPP Administrator and the Youth Operator Program Coordinator both sit on the Governor’s Traffic Safety Commission, which meets to address traffic safety concerns in NH; the IPP Administrator sits on this commission as the DHHS Commissioner’s designee. The Governor’s Traffic Safety Commission completed work on the “2022-2026 New Hampshire Strategic Highway Safety Plan, Driving Toward Zero.”[7]  This plan has several critical emphasis areas including improvement of intersections, distracted driving, impaired driving, speed and aggressive driving, teen traffic safety, and addressing the needs of vulnerable road users such as pedestrians and bicyclists.  The Buckle Up / NH Teen Driver  Committee reviewed the work of the Youth Operator Program throughout the school year and supported to progress of the adult seatbelt law, which fail this year.  House Bill 222, requiring people of all ages on NH roads to wear seatbelts was deemed “inexpedient to legislate” on the House Transportation Committee by a vote of 11-9 on March 8, 2023.  The Buckle Up group also supported the RSA, Section 265:107-a, that passed. The amendment stipulated, “No person shall drive a motor vehicle on any way while carrying as a passenger a person less than 7 years of age unless such passenger is properly fastened and secured by a child restraint system which is in accordance with the safety standards approved by the United States Department of Transportation.”  Lastly, Senate Bill 118, requiring children under the age of two years to be placed in rear facing car seats, passed is awaiting the Governor’s signature.

 

Drowning Prevention

 

Evidence-Based or Informed Strategy Measure: the rate of emergency visits for drowning per 100,000 children age 10 to 19

 

Objective;

Maintain or reduce the rate of emergency department visits due to drowning from 5.7 per 100,000 children ages 10 to 19 years in 2021 to 5.3 by 2026.  The counts for drowning in the age group are below 20 per year, so the rates are statistically unstable.

 

 

 

 

Data Source: NH Hospital Discharge Data, NH DHHS, HSDM, June 2023

 

 

Data Source: NH Death Certificate Data, NH DHHS, HSDM, June 2022

Death counts ages 10-19 were too small, so ages 0 to 19 are shown in the table above.

 

Strategy

 

Drowning fatality is the leading cause of injury death in NH children ages 10‑19 years.[8]  The MCH-IPP Administrator distributed the Consumer Product Safety Commission (CPSC) "Pool Safely"[9] information to parents and children during at several public health and safety events over the last year.  In NH, drowning most frequently occurs in natural water bodies. Although the “Pool Safely” program focuses on swimming pools, the messaging related to attending swimming lessons and always having an adult be actively observant when children are in or near the water, also translates to lakes, rivers, and oceans. Swimming lessons can start with infants, and can occur every year until a child is a proficient swimmer. Teens and adults should be encouraged to take first aid, Cardio-pulmonary Resuscitation (CPR) classes, and learn basic water rescue techniques. MCH-IPP also supported the Injury Prevention Center (IPC) in working with clinical staff to provide lifejackets to youth identified as at risk of drowning and with local communities to provide lifejackets for loaner stations.  More details about these strategies are provided in the “Systems Building” section below.

 

Leading Causes of Injury Death in NH, 2011-2020 Ages 10-19

Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 5/17/2023.

Note: counts of less than 10 deaths have been suppressed (--).

 

Systems Building

 

MCH Specific Activities

 

The MCH IPP Program Administrator requested free materials from the CPSC “Pool Safely” program to distribute at family-oriented events.  Materials include the Water Watcher Lanyards, paper fans with safe swimming information, and brochures with information about safe pool and spa drains, and fencing around pools. On May 25, 2022, during the Safe Kids 301 Bike Rally at the NH Motor Speedway in Loudon, NH, she distributed 157 Water Watcher cards on lanyards. During the Elliot Hospital Health Fair at the NH Sports Plex in Bedford, NH, she distributed 36 Water Watcher cards on lanyards on June 26, 2022. The next event, on June 30, 2002, the Fairy Festival at Greely Park in Nashua, NH, she distributed 125 Water Watcher cards on lanyards. The last event of the season was on September 17, 2023, Derryfest at MacGregor Park in Derry, NH, where she distributed 100 Water Watcher cards on lanyards. Each encounter with the families included reviewing safe swimming recommendations for both the pool and in natural bodies of water and how to use the lanyard.  Adults who received Water Watcher lanyard stated that they would definitely use them at the pool and the beach, and that the item was an excellent idea.

 

 

   

 

After a successful pilot project in 2020, the Injury Prevention Center at Dartmouth Health began a pilot project to provide lifejackets to children in the outpatient Dartmouth Health Children’s Clinic. This was based on a concern that children were participating in aquatic activities without being properly equipped with this vital safety equipment. Recipients are issued a lifejacket based on the clinical provider’s assessment of drowning risk.  Parents were sent to the CHaD Family Resource Center called Molly’s Place, to pick up a lifejacket and parents/caregivers are given instructions on properly fitting the lifejacket.  Since 2020, the program has given out 175 life jackets, with 61 of those happening in 2022.

 

The success of this, and data provided by the NH DHHS-MCH Injury Prevention Program, provided the impetus for the Injury Prevention Center to leverage funds to begin a statewide lifejacket loaner program.  In 2022, a Request for Proposal was sent out and 12 communities from around New Hampshire responded.  Each received 10 lifejackets and signage to begin their projects.  The IPC plans to continue this program and is partnering with another hospital in NH to provide this opportunity in the Seacoast Region.

 

Below is a photo of a life jacket loaner station at Mascoma Lake.

 

 

 

 

 

Concussion

 

 

Concussion in adolescents can be a result of a non-fatal motor vehicle crash, a sports injury, or a fall. The effects of a concussion can be long lasting and vary in severity.

 

NEW Objective: By 2026, reduce the rate of emergency department discharges for traumatic brain injury in age 10 to 19 from 1,125.9 per 100,000 in 2019 to 830.2.  During the 2023‑2024 school year, as the MCH IPP will collaborate with the IPC to distribute 1,000 bike helmets.

NEW Strategy: The Injury Prevention Center at Dartmouth Health worked with the IPP, and leveraged funding from other sources to provide bike helmets to youth to help prevent head injuries.

The IPC continued to partner with hospital pediatric teams in Lebanon and Manchester to maintain and expand the helmet prescription program.  The IPC also worked with communities around New Hampshire through the Safe & Active Grant program, supporting local efforts to teach bike safety and the importance of wearing a helmet every time.

 

Data Analysis

In NH, the annual death count for traumatic brain injury (TBI) in ages 10‑19 is low. Years 2017 to 2021 were aggregated in the table below. Suicide by firearm was the top cause of TBI deaths and motor vehicle crash was the second. Over the last 10 years, there have been no deaths due to concussion in this age group.  Emergency Department (ED) discharge rates for TBI in this age group have been decreasing year to year.  In 2020, the ED discharge rate for TBI was 664.1, and then rose to 814.7 in 2021.  These rates may reflect that fewer youth were participating in sports or attending school in person as the COVID pandemic waned. The target is based on the trend data between 2012 and 2019 because the data for 2020 and 2021 appear to be outliers at this time.

 

NH TBI Death Counts, Age 10‑19 years, 2017‑2021

Source:  NH Vital Record, NH DHHS, HSDM, June 2023

 

 

 

 

Data Source: NH Hospital Discharge Data, NH DHHS, HSDM, June 2023

 

 

Inpatient (IP) discharge rates for TBI for ages 10‑19 showed no statistically significant changes between 2012 and 2021. There were 181 IP discharges between 2012 and 2021.

Data Source: NH Hospital Discharge Data, NH DHHS, HSDM, June 2023

 

The number of cases seen in the hospital as inpatients (IP) or in the Emergency Department (ED) are not a complete count of cases; some children are seen in urgent care facilities or a doctor’s office, and some do not receive medical attention at all.

 

On average, concussion was present in 30% of IP discharges for TBI and 50% of ED discharges for TBI. The most common causes of non-fatal TBI in children ages 10‑19 years in NH are: 1) Struck by or Against, 2) Falls, and 3) MV Crashes. Combining the non-fatal cases of TBI due to MV crash with the number of deaths due to MV crash shows the importance of adolescent driver safety programming.

 

In 2020, there were 500 ED discharges for NH residents age 10‑19 with a concussion, with an average cost per patient of $4,329. These numbers do not include students who may have had a concussion and sought care in a doctor’s office without going to the hospital. There were fewer than five cases in 2020 that sought IP care for more serious cases of concussion, often including additional injuries or complications, with a total cost for those cases being $65,730. In 2020, among ages 10‑19, there were 1,037 children discharged from the emergency department with TBI (including concussion and other head injuries) at an average cost per patient of $4,561. TBI IP care in 2020 for this age group had 12 discharges at an average cost per patient of $75,032.

(Data Source: NH Hospital Discharge Data, NH DHHS, HSDM)

 

In a Journal of Surgery Research article in 2021, Alfrey et al stated, “Helmeted patients involved in bicycle crashes are less likely to sustain a serious head injury, a skull fracture, or facial fractures compared to riders without helmets.”[10]  A review of five published studies on bike helmet used in 2020 showed that, “Helmets reduce bicycle-related head and facial injuries for bicyclists of all ages involved in all types of crashes including those involving motor vehicles.”[11]  NH’s bike helmet distribution and the Teen Driver Safety programs are two specific activities that will reduce TBI in NH’s youth.

 

NEW Systems Building/MCH Specific Activities

 

Many of the causes of TBI are predictable and preventable. Prevention includes:

• Wearing a seat belt whenever driving or riding in a motor vehicle.
• Never driving while under the influence of alcohol or drugs.
• Wearing a helmet while riding a bicycle, skateboard, motorcycle, snowmobile, or all-terrain vehicle; also wearing head protection when batting or running bases, skiing, and skating, riding a horse, or playing a contact sport.
• Installing safety features in the home, such as handrails on stairways, non-slip mats in the bathtub, grab bars in the bathroom, window guards, and safety gates on the top and bottom of stairs (especially when young children are around) to limit falls.

 

The MCH IPP Administrator is an active member of the Safe Kids NH Coalition and programming, and provides technical support to their quarterly meetings, and volunteers at Safe Kids NH events. In 2022 there were four Safe Kids NH Coalition meetings held with 61 members averaging slightly over 15 participants per meeting. The Injury Prevention Center (IPC) works directly with NH communities through the Safe and Active grant and technical assistance program. This program provided best practice education, technical support and safety product donations, such as helmets and life jackets to qualifying NH communities.  In the beginning, this program was funded by a grant from Kohls and recent years has been funded through CHaD Philanthropy funds. In 2022, the IPC provided over 61 NH communities with 3,682 helmets, along with bike and pedestrian safety information, and bike lights. These communities held events such as Bike Rodeo’s where education and safety information were shared and helmets were distributed.  Additionally in 2022, the Safe & Active efforts expanded in offering a Life Jacket Loaner program to 14 NH Communities resulting in 168 life jackets being provided. This program provided life jackets, signage and technical support to NH community based or local government organizations to set up a life jacket loaner station. 

 

Once a year, since 2003, Safe Kids NH has an opportunity to hold a bike safety event at New Hampshire Motor Speedway called Safe Kids 301.  At this event, a safe and unique place for children and their families to ride is provided, as are bike safety checks, helmet checks (and free helmets to those that need them) and a safety fair that includes organizations from throughout New Hampshire, including some DPHS programs such as Tobacco Prevention, WIC, and the Injury Prevention Program.  In 2022 the Safe Kids 301 event had about 300 participants, 65 helmets were given to children for free, and 20 bike safety checks took place.

 

The well child helmet prescription program, and additional safety products, were funded by the Injury Prevention Center through CHaD Philanthropy funds, with clinical partners in Lebanon and Manchester. This program recognizes the importance of health care providers in providing safety information and safety products to their patients and families. In 2022, the program provided 182 Dartmouth Health Children’s patients with helmets and 82 patients with life jackets.  These programs are examples of how MCH BG funds that support the IPC staff are leveraged so funds from other program grants can be used to purchase and distribute needed safety supplies.

NOM#16.3 Adolescent suicide

 

Adolescent suicide death rates for NH residents 15‑19 years old have not changed significantly between 2015 and 2022. The rates are statistically unstable because the annual counts are small.  The suicide death rate for 2022 was 12.0 per 100,000. While annual counts are low and may not be statistically significant, the death of any child is significant and the underlying causes need to be addressed. According to the CDC WISQARS data, suicide is the second leading cause of death in the 15‑19 year-old age group. The most common lethal means of suicide are suffocation, firearms, and poisoning.  The target, for 2026 is a rate of 8.8 per 100,000.

 

 

 

 

Data Source: NH Vital Records, NH DHHS, HDSM, June 2023

 

 

Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 5/17/2023.

Note: counts of less than 10 deaths have been suppressed (--).

 

The NH YRBS question on “Seriously Considered Attempting Suicide (during the 12 months before the survey)” had 24.7% of respondents in 2021. An increase was also seen in the question about feeling hopeless or sad so much that students stopped doing usual activities, in 2021, 44.2%. While females are more likely to consider attempting suicide, males are more likely to die from a suicide attempt.[12]

 

Source: NH YRBS, https://www.cdc.gov/healthyyouth/data/yrbs/results.htm, accessed on 6/23/2023

 

The Trevor Project’s 2021 National Survey of LGBTQ Youth Mental Health found that 19.0% of LGBTQ youth ages 13‑18 and 8.3% of LGBTQ youth ages 19‑24 reported attempting suicide in the past year.”[13] LGBTQ youth are at higher risk of suicide attempt than heterosexual youth.

 

Systems Building

The MCH IPP Administrator represents the DHHS MCH section on the Suicide Prevention Council (SPC). The mission of the state SPC is to reduce the incidence of suicide in NH by accomplishing the goals of the NH Suicide Prevention Plan, which are to:

 

• Raise public and professional awareness of suicide prevention;
• Address the mental health and substance abuse needs of all residents;
• Address the needs of those affected by suicide; and
• Promote policy change.[14]

 

 

The MCH IPP, in cooperation with the Injury Prevention Center (IPC) supported the virtual 19th Annual NH Suicide Prevention Conference presented by the NH Suicide Prevention Council, which took place on Thursday, November 3, 2022. The conference focused on a theme of Refueling Hope. Despite being a virtual conference, the planning committee remained committed to ensuring participants’ safe and comfortable engagement and encouraged self-care by making available a virtual Serenity Room staffed by Survivors of Suicide Loss volunteers during the entire conference. The conference offered Continuing Education Units (CEU’s) and fostered inclusivity and accessibility of all workshops and materials by providing closed captioning and American Sign Language (ASL) interpretive services upon request. Workshop options focused on:

• 988 and NH Rapid Response,
• Considering Ethical Implications of 988,
• Mental Health Needs of Military Members, Veterans and their families,
• Schools and Mental Health Wellbeing,
• Survivor Voices,
• Mindful Planning and
• Prevention for Good Mental Health in Older Adults,
• Navigating Clinical, Legal, Ethical & Personal Issues in Addressing Suicide Risk with Individuals with Substance Use Disorders (SUD) & Mental Health Disorders (MHD),
• LGBTQIA+ Risk and Resiliency
• The closing plenary, Ripples of Hope demonstrating all the positive change and resiliency across NH.

 

The conference had 269 people attended. Almost 34% of attendees were first time attendees to this conference and just over 28% had attended more than five years.  Evaluations were overall positive, with many noting the benefit of a virtual platform, along with hopes expressed to have a future conference in person. All participants rated their knowledge of suicide prevention after the training to the levels of somewhat increased or definitely increased.

 

The MCH IPP was awarded the National Violent Death Reporting System (NVDRS) grant from CDC since 2014. In addition to collecting demographic data on homicides, suicides, and firearm deaths, the data abstractors also review police reports, medical examiner records, and toxicology reports to develop a narrative on the circumstances that lead to violent deaths. The MCH IPP collaborates with the Department of Justice, Office of Chief Medical Examiner on the grant. NH-NVDRS data have been included in the Annual Suicide Prevention Reports since 2017. The Annual Suicide Prevention Reports from 2013 to 2021 can be viewed on The Connect Program website. [15]

 

*******

National Performance Measure #10: Percent of adolescents, aged 12-17, with a preventive medical visit in the past year

 

Evidence Based or Informed Strategy Measure: Percentage of adolescents aged 12-21 at MCH-contracted health centers who have at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year

 

Objectives: Increase the percentage of adolescents aged 12-21 who have had a preventive medical visit at the MCH-funded Community Health Centers (CHCs) from a baseline of 53% in SFY19 to 64% by the end of 2025.

 

Strategies:

 

• Enhance capacity of CHCs to improve access and quality of adolescent services by:

 

• Continuing to establish performance measures that align with national guidelines and promote Bright Futures recommendations
• Promoting advancement toward HP2030 target (82.6%) for adolescent well care visit by ensuring contracted CHCs utilize Quality Improvement (QI) processess to increase the percentage of adolescents who have a preventive medical visit
• Collecting and analyzing performance measure outcome data from CHCs; providing data results and feedback to CHCs for comparison

• Providing education, resources, and QI support through newsletters, Lunch & Learns, and site visits
• Providing technical assistance through group or 1‑on‑1 contact(s) via face to face meetings, remote meetings (e.g. Zoom), email and/or telephone to review, discuss and provide recommendations to adress agency’s identified needs.

 

• Collaborate and Build partnerships by:

 

• Continuing to network with other State Adolescent Health Coordinators including  attending the National Network of State Adolescent Health Coordinators’ Meetings

• Continuing to work with public and private partners through the NH Pediatric Improvement Partnership
• Statewide contracting with CHCs and provision of oversight on adolescent primary care services
• Establishing and using various mechanisms to inform providers and the public about adolescent preventive services via social media, community events, newsletters, etc.
• Looking for opportunities to engage teens in program development and review

 

 

NH Adolescent Health

 

 

     

            NH has historically exceeded nationwide rates in regards to our children’s and adolescent’s overall health. Though, as we look closer, we see in the above graph that as our youth reach adolescence, the percentages drops, but does continue to remain above the national average. [16]    

 

The adolescent preventive medical visit is an ideal opportunity to improve adolescent biopsychosocial health by screening for adolescent health risks, addressing health concerns, and providing referrals and counseling to influence behaviors. According to the 2021 National Survey of Children's Health (NSCH), just as with adolescence overall health, NH has a higher percentage of adolescents ages 12-17 who have had a preventive medical visit than the national average, at 82.3% vs 69.6%. [17]

 

 

 

 

When reviewing the most recent data from NH DHHS Bureau of Program Quality we see that the percentage of preventive visits increased from 2020 to 2021, but that two of the three MCO’s showed decreased percentages of visits between 2021 to 2022.[18] We also see that the percentage of preventive visits is less for those with NH Medicaid versus commercial insurance. Also of note, is that as they age, young adults (18-21) are less likely to complete an annual visit in comparison with younger children/adolescents (12-17).

 

 

                    

As SFY22 performance measure outcome data for the adolescent well-care visit demonstrate, outcomes are variable among contracted CHC’s (range 20-85%) as illustrated in the graph above. MCH continues to encourage CHCs to monitor their performance data at least quarterly and to implement activities throughout the year.

Adolescent preventive services continue to be frequently missed outside of the well-care visit, and MCH continues to focus efforts to support improvement of this measure outcome, including promotion of virtual telehealth visits and catch-up in-person visits.

Keeping all this in mind, NH MCH encourages efforts to improve the percentage of annual visits among young adults as seen in the below social media post.

                                    

Vaccination Coverage

 

NH continues to ensure universal immunization coverage of all children 18 years of age and younger regardless of insurance status through the NH Immunization program. As a result, NH demonstrates high vaccination rates among children and adolescents. These rates will continue to be monitored closely as new data is available to identify and address gaps in routine vaccination resulting from the COVID‑19 pandemic.

 

New Hampshire Vaccination Coverage by Year among Adolescents Age 13‑17 Years

 

 

[19]

 

 

The Child and Adolescent Health Coordinator continues to be involved in both the Vax-Well Coalition and NH’s Live HPV Free committees to network and assist with Pediatric vaccination initiatives. The NH Live HPV Cancer free committee is in the process of creating a call to action letter for Health Care providers including education on increasing awareness of starting the HPV vaccine series at age nine, the ability to “catch up” on the vaccination after 18 as well as the importance of the HPV vaccination being cancer protection for life. The committee has also provided free trainings and webinars on HPV to Health care providers and community partners as well. NH continues to show a higher HPV vaccination rate at 72.3 % versus 61.7% in the US in 2021 which brings us closer to the Healthy People 2030 target goal of 80 %. [20]

 

 

 

 

Reproductive Health

 

 

 

NH continues to maintain one of the lowest teen birth rates in the nation. According to the most recent data available from the CDC, NH’s teen birth rate is less than (5) per 1000 females 15-19 years old. [21] As seen in the below table, teen birth rates have declined every year since 2015 both nationally and in NH.  

 

Both MCH’s Quality Improvement and Clinical Services Program and its Sexual and Reproductive Health Program work to ensure that health care agencies funded by either or both programs are providing the highest level of comprehensive care for adolescents. Program staff also promote public awareness of adolescent sexual health by providing specific information and resources related to sexual health via social media, community outreach (including health fairs) as well as with the “Family Planning Post” Newsletter which includes the sections: “Resources for Providers”, “Trusted Info & Resources for Patients”, “Contraceptive Corner” and “Training and Development”.

Although NH works hard at promoting the HPV vaccine, there is still work to do to promote safe sexual practices and reproductive health as it relates to condom use and youth being tested for HIV and STDs. As per the national 10 year trend report for the YRBS, statistics related to the use of condoms and testing for HIV and STDs are going in the “wrong direction“ (see chart below) showing a lower percentage of students using condoms and also not being tested for HIV/STDs.

 

                                                                    [22]

When looking specifically at NH YRBS data we see a higher percentage of youth (15 % versus 10% as above) using both a condom and effective hormonal birth control .We also see a lower percentage of males (2.2) versus females (17.8) who use both a condom and effective hormonal birth control as well as younger grades (9th = 9%) have a lower percentage of using these methods versus the higher grades (12th grade=16.9 %). 7

 

                                                                 [23]

 

It is also good to see that percentages of NH students who are sexually active are on the decline as well.   

 

Adolescent Health Risk

 

 NH adolescents and young adults’ health continues to be at risk from the use of substances including tobacco, alcohol, and drugs. Unsafe driving, and obesity have also had a negative impact on the health of NH’s youth as well.

 

Drug and Alcohol Use

 

Below is the national data trend table from the most recent YRBS (2021) showing some progress made nationally in the use of alcohol, marijuana and use of illicit drugs .Of concern is the lack of improvement in the current use of prescription opioids as wells as electronic vapor products.

 

[24]

 

NH youth continue to struggle with illicit drug use and alcohol as well, with the majority of the illicit drug use being marijuana The below table from SAMHSA, which shows nationwide use of substances lists alcohol, tobacco/nicotine and marijuana as the most widely used substances nationwide, which also coincides with NH’s YRBS higher usage of marijuana as compared to other states.

 

 

[25]

 

 

 

 

When looking at YRBS results for NH specifically related to substance use, NH students are more likely to be using marijuana as opposed to other substances. Also. NH students were more likely were to be offered /sold drugs on school property than other states.

 

[26]

 

 All MCH-contracted CHCs are expected to screen for drug and alcohol abuse as part of primary care services. Although mechanisms are in place for CHCs to refer individuals with Substance Use Disorder (SUD) for treatment, outpatient and residential substance abuse treatment availability is sometimes limited.

 

 

[27]

 

Despite services either being limited or having a long waiting period at times, the graph above from the DHHS Public Health data portal shows the variety of NH services provided to 98 children/youth who received services through a public funding source in 2022. The most common disorder treated among this age group was for Opioid Use Disorder (77 out of 98) with the most common service type being medication-assisted treatment.[28]

 

Also of concern is NH’s most recent YRBS results is showing NH students are more likely to be electronically bullied as well as experience bullying on school property. This is of concern as studies have shown, including a recent article in AAP (Vrijen et al.,) that individuals who are bullied as well as those who bully others have a higher incidence of substance use. [29]

 

 

[30]

 

Below is a social media post created by the Child and Adolescent Health Coordinator for the NH DPHS social media accounts bringing attention to NH’s incidence of bullying as well as the long-term effects.

 

 

Tobacco Use

 

 

According to the 2021 National Survey on Drug Use and Health (NSDUH), combined tobacco use of students 12 and older within the last 30 days use has increased slightly at 22 % compared to the last year’s rate of 21.7 %.[31]  When looking at the NH YRBS regarding tobacco use NH students were more likely to “not try to quit using all tobacco products” as compared to nationwide results. [32]

 

 

 

 

[33]

 

Despite the increase in 2019, recent NH YRBS data shows an improvement of high school students who are currently using an electronic vapor.

 

The Child and Adolescent Health Coordinator collaborates with the DPHS Tobacco program to bring awareness of smoking cessation programs specifically catered to teens. The following is a snapshot of the Child and Adolescent Health News section of MCH’s recent newsletter sent to contracted CHC’s which contained information on a learning module regarding Teen Tobacco and Vaping. It provided information on NH’s Teen “My Life, My Quit-NH” program.

 

 

Unsafe Driving 

 

There had been an increase in adolescent motor vehicle deaths (2013-2018; three year estimates are provided due to small numbers in single years). However, since 2018 there has been a decline possibly due to the increase in seatbelt usage as reflected in the most recent NH YRBS. (see below). The Child Fatality Review Committee reviewed two motor vehicle deaths this past year and made recommendations which include, but are not limited to a letter to the NH Driver Education Teacher Association regarding CFRC findings as well as increased messaging /public awareness regarding what impaired driving is (driving when anxious, when emotionally distressed, when over tired, when using over the counter/prescription meds, marijuana, etc.).

[34]

 

Below is more information from the most recent NH YRBS showing other unsafe driving habits including texting in which NH has a higher rate of than the National average?

 

[35]

 

Obesity

 

Since 2016 there has been an increase in obesity in children ages 10-17 both in NH (from 9.8 % to 15.2 %) and nationally (from 15.8% to 17 %)[36], although NH does remain below the national average. Children who are overweight can go on to develop other health risk factors such as diabetes and heart disease. Also of concern, per a recent article in JAMA (Dec 2022, Izzuddin M Aris,et al ), in which findings showed that children that live in neighborhoods with limited access to healthy foods had a higher BMI and also an increased risk of child obesity. The Child and Adolescent Health Nurse Coordinator has taken every opportunity this past year to collaborate with community partners and participate in committee workgroups such as SPINE (State Partnership for Nutrition Equity) to help increase access to food programs and more nutritious foods for families. The Child and Adolescent Coordinator also attends community events and health fairs to share information on the importance of physical activity and healthy food choices as well as nutrition resources.

[37]

 

 

MCH Section Current Activities 

 

The Child and Adolescent Coordinator also serves as the Coordinator of the Child Fatality Review Committee (CFRC). The CFRC reviewed three young adult overdoses in the summer of 2022, as well two motor vehicle crashes and three crashes involving “other land transports” in the fall of 2022. Recommendations were made and are in various stages of implementation. More detailed information regarding the recommendations for motor vehicle crashes and “other land transports” have been listed under “unsafe driving” in the NH Adolescent Health Risk section of this report. In the winter and spring 2023, the CFRC reviewed child deaths related to fires. Recommendations were made to increase smoke detector messaging and safe candle burning via social media /press releases, work to include Fire Safety Education checklists (including correct # of detectors) to DCYF and home visiting checklists and to continue to support efforts with fire safety education through the Fire Marshal’s Office and Red Cross.

 

The CFRC continues to work on previous recommendations from the committee regarding suicides and overdoses including continued substance use/misuse trainings, as well as increased trainings for healthcare providers and community partners on Trauma Informed Care (TIC) and Adverse Childhood Experiences (ACES). The committee would also like to see an increase in the Mental Health (MH)/SUD workforce as well as increased accessibility of MH and SUD resources and decreased stigma in utilizing these resources. Many of the recommendations above are included along with strategies in NH’s ten-year mental health plan. NH has also instituted the 988 and NH Rapid Response System with mobile crisis units, which are able to respond to a mental health crisis in each area of the State.

 

In January 2023, the Director the National Center for Fatality Review and Prevention came to NH to provide education and guidance to the committee. She observed a CFRC meeting and made some positive comments regarding how the committee opens with an educational component related to the case review that includes information that can help with more effective fatality reviews and enhanced prevention recommendations. The CFRC and Coordinator continue to utilize information and support from the National Center and still engage in quarterly meetings with the Northeast Regional Team.

 

The NH DHHS combined Fatality Review Committees continues to meet and promotes collaboration between committees so that efforts with common goals and recommendations can be combined and trainings could be shared .The DHHS combined fatality review team also identifies gaps in common policies and procedure to help reduce loss of life in NH. Most recently the Team has created a Fatality Review Resource list that includes information on Data sources and evidenced based practices. The team has also been discussing and comparing their annual reports and some members recently attend a Training Webinar on Best practices in writing annual reports offered by the Child Fatality Review and Prevention national center.     

 

 

Collaborative projects with key stakeholders: 

 

The MCH Child and Adolescent Health Coordinator continues to attend and participate in committees including NH Help Me Grow (NH HMG), the NH Pediatric Improvement Partnership (NH PIP), NH Autism Council and the Medicaid Quality and Case Management re-procurement committee with other community partners to increase awareness of the issues affecting NH youth and to work collaboratively on common health initiatives. Some of these initiatives include creating a centralized access point for referrals with the HMG committee, developing a training for parents with the NH Autism council and working to focus on the most vulnerable populations including youth in foster care with The Medicaid Quality and Case Management re-procurement committee.

 

MCH Contracted Community Health Centers (CHCs)

 

MCH continues to utilize Title V funding to contract with agencies to support adolescent care including increasing statewide access to well care visits. These visits provide an opportunity for youth to receive recommended preventive services and immunizations as well as anticipatory guidance. In 2021, a new focus on services specifically designed for Maternal and Child Health populations was developed with specific strategies and work plans that reflect this focus. Many of our agencies have included more focus on assessing social determinants of health and referring patients to the appropriate resources. Other agencies are working on making sure patients have access to health insurance as well.   

    Through this contracting, MCH has successfully engaged with funded CHCs to ensure access and quality of adolescent care, including integration of behavioral health services. MCH provides agency oversight and ensures accountability by specifying reporting requirements and conducting site visits. Contracted agencies are expected to provide services consistent with Bright Futures/National Guidelines and are required to submit performance outcome data to MCH.

Coordinators’ Meetings

 

Meetings continue to be held twice yearly. The meetings serve as an opportunity to meet virtually with staff from all contracted CHCs to provide them with information, resources, and technical support. Agency representatives for these meetings include agency directors/clinical managers and quality improvement staff members. 

 

The April 2023 Coordinators Meeting presentations included:

 

• MCH Program Updates
  • Focus on expected target population to increase access to Healthcare for MCH population with enabling services.
• Presentation from State Breastfeeding Coordinator from WIC
•    Presentation from Chief of the DHHS Bureau for Children’s Behavioral Health
• Review of SFY 2023 data

 

 

Quality Assurance

 

MCH continues to collects CHC data on 13 primary care service performance measures. Six (6) of these measures assess preventive care for adolescents including:

 

• Body Mass Index (BMI) documentation and education related to nutrition and physical activity for children 3-17 years
• Body Mass Index (BMI) documentation and follow up for patients if their BMI is out of range (18 years and over)
• Depression screening (12 years and over)
• Tobacco screening and cessation for tobacco users (12 years and over)
• Screening Brief Intervention and Referral to Treatment (SBIRT) for substance misuse (18 years and over)
• Adolescent annual well-care visit (ages12-21 years). 

Data collection

 

Aware that some agencies only reviewed their agency data when reporting was due to the State, MCH encouraged agencies to review their own data more frequently (at least quarterly). Current MCH revised CHC contracts the submission of MCH performance measure data to the State twice per year. Following data analysis, the entire MCH Quality Improvement and Clinical Services staff meet for internal discussion. Data is then disseminated to each agency and recommendations for improvement activities to CHCs are provided. MCH encourages CHCs to review all-agency data to understand how they compare to other MCH-contracted agencies and to consider incorporating MCH QI recommendations.

 

 

 

Monthly QA/CQI Calls & Work plans

With many practices finding it difficult to schedule on-site visits due to increased scheduling needs trying to catch-up on missed preventive appointments and immunizations, MCH has pivoted to providing monthly QA/CQI coaching calls to each contracted FQHC/CHC. During these calls, contracted agencies discuss progress on work plans and goals as well as any barriers that they may encounter. MCH staff provide guidance regarding performance measures as well as information on other MCH initiatives happening statewide and connect agencies to appropriate resources to meet the needs of the Maternal Child Health population that they are serving.­­ 

 

Since 2020, 100% of contracted CHCs submitted two-year Adolescent Visit QI work plans. (See a sample excerpt from one SYF22/23 QI Work Plan below).

 

 

 

By reviewing work plans, MCH staff are able to glean insight to the challenges experienced by CHCs including:

 

• Inability to schedule next annual visit while adolescent is in the office due to system only allowing for scheduling of appointments up to six months in advance;
• Inability to capture patients who have received an annual visit elsewhere;
• Inaccuracy of EMR data reporting.

 

 

[1] NH State Injury State Violence and Injury Prevention 5-year Plan, 2020-2025, https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents/2021-11/nh-vip-plan-2020-2025.pdf, assessed on 6/1/2022.

[2] https://www.percentage-change-calculator.com/calculate.php

[3] NH Driving Toward Zero, https://www.nhtmc.com/Dashboard/Safety/, accessed on 6/29/2023.

[4]  RSA 265:79-c Use of Mobile Electronic Devices While Driving; Prohibition, http://www.gencourt.state.nh.us/rsa/html/XXI/265/265-79-c.htm, accessed on 6/28/2023.

[5] NH DHHS, Health Statistics and Data Management Section, “2021 Youth Risk Behavior Survey Results, New Hampshire High School Survey, Trend Analysis Report”, https://wisdom.dhhs.nh.gov/wisdom/assets/content/resources/yrbs-2021/2021NHH%20Trend%20Report.pdf, accessed on 7/01/2023.

[6] Fischer, P. (2019, March). Peer-to-peer teen traffic safety program guide (Report No. DOT HS 812 631). Washington, DC: National Highway Traffic Safety Administration.

[7] The Governor’s Traffic Safety Commission completed work on the “2022-2026 New Hampshire Strategic Highway Safety Plan, Driving Toward Zero,” https://www.nh.gov/dot/org/projectdevelopment/highwaydesign/hwysafetyimprovements/documents/43246-nh-hsip-08042022.pdf. Accessed on 7/01/2023.

[8] WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 6/23/2023.

[9] Consumer Product Safety Commission, “Pool Safely”, https://www.poolsafely.gov/parents/safety-tips/, accessed on 6/26/2023.

[10] Alfrey EJ, Tracy M, Alfrey JR, Carroll M, Aranda-Wikman ED, Arora T, Maa J, Minnis J. Helmet Usage Reduces Serious Head Injury Without Decreasing Concussion After Bicycle Riders Crash. J Surg Res. 2021 Jan;257:593-596. doi: 10.1016/j.jss.2020.08.009. Epub 2020 Sep 12. PMID: 32932191, viewed on 5/17/2023.

[11] Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev. 2000;1999(2):CD001855. doi: 10.1002/14651858.CD001855. PMID: 10796827; PMCID: PMC7025438, viewed on 5/17/2023.

[12] NH Annual Suicide Report, https://theconnectprogram.org/articles/annual-reports/, assessed on 5/17/2023.

[13] Youth LGTBQ Suicide Risk, https://www.thetrevorproject.org/research-briefs/estimate-of-how-often-lgbtq-youth-attempt-suicide-in-the-u-s/, assessed on 5/17/2023.

[14] NH NAMI, NH Suicide Prevention 2020 Annual Report 2021-Annual-Suicide-Report-Final-12-12-2022.pdf (theconnectprogram.org), accessed 5/17/2023

[15] Ibid. NH Annual Suicide Prevention Reports, assessed on 5/17/2023.

[16] Child and Adolescent Health Measurement Initiative. 2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 04/05//23 from www.childhealthdata.org.

[17] Child and Adolescent Health Measurement Initiative. 2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 04/05//23 from www.childhealthdata.org.

[18] Adolescent Well-Care Visits (AWC) | NH Medicaid Quality. (n.d.). https://medicaidquality.nh.gov/reports/adolescent-well-care-visits-awc

[19] Centers for Disease Control and Prevention. (2021, May 14). TeenVaxView. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/index.html

 

[20] Centers for Disease Control and Prevention. (2021, May 14). TeenVaxView. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/index.html

[21] Centers for Disease Control and Prevention. (2023, June 8). FASTSTATS - teen births. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/teen-births.htm

[22] Centers for Disease Control and Prevention. (2023, April 27). Youth Risk Behavior Surveillance System (YRBSS). Centers for Disease Control and Prevention. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm

 

7 Centers for Disease Control and Prevention. (2023, April 27). Youth Risk Behavior Surveillance System (YRBSS).

Centers for Disease Control and Prevention. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm

 

[23] Youth risk behavior survey. New Hampshire Department of Health and Human Services. (n.d.-b). https://www.dhhs.nh.gov/programs-services/population-health/health-statistics-informatics/youth-risk-behavior-survey

 

[24] Centers for Disease Control and Prevention. (2023a, April 27). Youth Risk Behavior Surveillance System (YRBSS). Centers for Disease Control and Prevention. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm

[25] National Survey on Drug Use and health. SAMHSA.gov. (n.d.). https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health

[26] Youth risk behavior survey. New Hampshire Department of Health and Human Services. (n.d.). https://www.dhhs.nh.gov/programs-services/population-health/health-statistics-informatics/youth-risk-behavior-survey

 

[27] Wisdom. (n.d.). NH DHHS Data Portal. https://wisdom.dhhs.nh.gov/wisdom/

 

[29] https://publications.aap.org/pediatrics/article/147/3/e2020034751/77083 Childhood and Adolescent Bullying Perpetration and Later Substance Use: A Meta-analysis | Pediatrics | American Academy of Pediatrics (aap.org)

Childhood and Adolescent Bullying Perpetration and Later Substance Use: A Meta-analysis | Pediatrics | American Academy of Pediatrics (aap.org)

[30] Youth risk behavior survey. New Hampshire Department of Health and Human Services. (n.d.). https://www.dhhs.nh.gov/programs-services/population-health/health-statistics-informatics/youth-risk-behavior-survey

[31] NSDUH National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (n.d.) https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health

[32] Youth risk behavior survey. New Hampshire Department of Health and Human Services. (n.d.). https://www.dhhs.nh.gov/programs-services/population-health/health-statistics-informatics/youth-risk-behavior-survey

[33] Centers for Disease Control and Prevention. (2023a, April 27). Youth Risk Behavior Surveillance System (YRBSS). Centers for Disease Control and Prevention. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm

[34]National Center for Health Statistics. Centers for Disease Control and Prevention (n.d.). http://www.cdc.gov/nchs/data_access/VitalStatsOnline.htm

[35] Youth risk behavior survey. New Hampshire Department of Health and Human Services. (n.d.). https://www.dhhs.nh.gov/programs-services/population-health/health-statistics-informatics/youth-risk-behavior-survey

[36] Child and Adolescent Health Measurement Initiative. 2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 04/05//23 from www.childhealthdata.org.

[37] Child and Adolescent Health Measurement Initiative. 2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 04/05//23 from www.childhealthdata.org.