Massachusetts has four Crosscutting priorities for 2020-2025:
- Eliminate institutional and structural racism in internal MDPH programs, policies, and practices to improve maternal and child health.
- Engage families, fathers and youth with diverse life experiences through shared power and leadership to improve MCH services.
- Eliminate health inequities caused by unjust social, economic, and environmental systems, policies and practices.
- Support equitable healing centered systems and approaches to mitigate the effects of trauma, including racial, historical, structural, community, family, and childhood trauma.
Priority: Eliminate institutional and structural racism in internal MDPH programs, policies, and practices to improve maternal and child health.
Title V aligns its key strategies for this priority with the MDPH Racial Equity Movement (REM), which aims to eliminate institutional and structural racism in MDPH programs, policies, practices, and workplace. Focusing on racism is not at the exclusion of other forms of inequity; rather, an explicit focus on racism can also increase Title V’s capacity to address inequities, such as those faced by people with disabilities or people who identify as LGBTQ+. Being explicit about the role of racism in public health is key to being able to identify intentional, actionable strategies to promote health and racial equity. Over time, success of the REM will be demonstrated by a workplace that is safer and more inclusive; staff who are engaged, aware, respectful, and healthy; programs that are community-centered and equity-informed; policies that are actionable, systems-focused, and responsible; and communities that are inclusive and engage partners in meaningful change toward improved individual and community health.
Objective 1 (SPM 3). By 2025, increase to 95% from baseline (64% in 2019) the percent of BFHN and BCHAP staff who have used any racial equity tool or resource in their work.
The REM responds to the need to improve the public health workforce’s capacity to promote racial equity within the walls of MDPH, its programs, and the community. MDPH staff are developing tools and resources to identify and address institutional racism within core elements of public health work, such as community engagement, procurement, and data collection and analysis. The performance measure for this priority tracks improvements in staff capacity to use these tools in the implementation and monitoring of MDPH-funded programs.
Racial Equity Movement
Part of the C-DREC model is that bureau-specific racial equity teams continue to assess and address the unique needs and opportunities within their bureaus. Therefore, the BFHN Racial Equity Steering Team (REST) and the BCHAP Racial Equity Leadership Team (RELT) continued to oversee the work of the REM in their respective bureaus. Functional workgroups operating across bureaus – including professional development, procurement, policy, and evaluation – also continued to move the work forward, though at a slower pace as many staff have been involved in the pandemic response and vaccination efforts, and unable to commit as much time to the REM workgroups.
Professional development provides the foundation on which the rest of this work builds. In FY21, MDPH partnered with the Racial Equity Institute (REI) to offer trainings to all interested staff. REI’s two-day Phase 1 training is designed to develop the capacity of participants to better understand racism in its institutional and structural forms. Moving away from a focus on personal bigotry and bias, this workshop presents a historical, cultural, and structural analysis of racism. With shared language and a clearer understanding of how institutions and systems are producing unjust and inequitable outcomes, participants leave the training better equipped to begin to work for change. Funding was pooled from Title V and a variety of other sources to support these training opportunities. This was a departure from previous years, in that these trainings now receive investment and support from the entire Department, compared to previous years when they were centered solely around BCHAP and BFHN. From July 1, 2020-June 30, 2021, REI offered two modified, virtual trainings for MDPH staff.
In addition, in FY21 MDPH offered three racial equity labs for MDPH staff who have completed a two-day training to further their racial equity practice. The labs, planned and facilitated by external consultants, focused on diagnosing the specific challenges staff may be facing in their program or office, looking at the problem from a structural lens. They explored topics such as: role in the structural lens, head/heart integration, racial justice PDSA support (plan, do, study, act), and new tools for Critical Race Theory applications, e.g., Racial Equity Impact Assessments, solving problems collectively using capsules, pushback circles for managing difficult conversations, and group dynamics.
To build on the training and support integration of that learning into daily practice, MDPH has worked over the past few years to continue to develop internal capacity for racial equity facilitation and support. In FY21, a cohort of 20 racial equity practitioners, including many Title V staff, collaborated to facilitate post-training integration spaces in cross-racial teams. During these integration spaces, staff debrief the content from the two-day REI training, consider how what they have learned fits into the MDPH context, and start to think more concretely about how to integrate racial equity into their daily work. The racial equity practitioners meet monthly to connect, build community, offer support, and provide updates on their work together.
Other opportunities for MDPH staff to engage in ongoing learning and dialogue included affinity groups, quarterly town hall meetings, and monthly racial justice lunch and learns. These events aim to promote common language, shared understanding, and authentic support for a public health framework centered on racial equity. Examples of topics covered during racial justice lunch and learns, and quarterly town hall meetings included feedback on the MDPH Diversity and Inclusion Plan, informing project selection for an institutional equity pilot, discussing tenets of White Supremacy Culture, and recommendations for centering equity in the COVID-19 response.
Racial identity affinity groups underscore the different roles for White people and people of color in racial equity work and provide an opportunity for staff to deepen their understanding of their personal roles in promoting racial equity and contribute to productive dialogue on racism and health. In FY21, there were quarterly affinity groups for White allies, people of color, Asian American and Pacific Islanders, men of color and Black people. Key challenges with the affinity groups continue to be how to meaningfully sustain the work that begins in affinity and how to engage leadership in this process, as it can be difficult to share space and be vulnerable with people in differing positions of power.
A key strategy in the five-year action plan, and the performance measure for this priority, is developing tools and resources to identify and address institutional racism within core elements of public health work – such as program planning, community engagement, procurement, and data collection and analysis – and build staff capacity to use them in the implementation and monitoring of MDPH-funded programs. In FY21, the REM procurement workgroup took steps towards a more equitable process by which applications for MDPH funding are reviewed. The workgroup created and disseminated a slide deck template to support the trainings of Request for Response (RFR) reviewers, facilitators, and notetakers and to provide RFR drafters with a concrete tool to integrate racial equity into RFR review training. For example, the training template:
- Guides the RFR drafters to define explicitly (race, gender, age etc.) whom the proposed program plans to serve with suggestions about avoiding coded language.
- Encourages RFR drafters to specify what has been done to prepare applicants to answer questions related to racial equity, including the program’s expectations for responses.
- Emphasizes the importance of comments on an application’s strengths and weaknesses, which is especially helpful for smaller organizations or organizations that have not previously contracted with MDPH.
- Provides suggestions for the facilitator to ensure that all voices are heard and that no team member dominates the group’s thinking and scoring.
Progress was also made on developing tools and resources to identify and address institutional racism within public health data collection and analysis processes (see discussion below about the Racial Equity Data Road Map).
The BFHN/BCHAP Racial Equity Survey is the data source for the performance measure for this priority (the percent of BFHN and BCHAP staff who have used any racial equity tool or resource in their work). The survey aims to understand staff knowledge, beliefs, and practices regarding racial equity work. The survey was most recently conducted in April 2019. Due to the COVID-19 pandemic, it has not been conducted since; however, MDPH plans to readminister the survey Department-wide in FY23. See the FY23 application for more information.
In April 2019 there were 174 survey respondents, of whom 29% identified as people of color and 71% identified as White. Key findings include:
- 78% of respondents feel comfortable explaining the difference between health inequities and health disparities (compared to 44% in 2017)
- 96% feel an individual responsibility in their job to promote racial equity (compared to 89% in 2017)
- 83% would like to use racial equity strategies to design, deliver and evaluate their programs (compared to 75% in 2017)
Findings from the survey indicate that most staff are interested in greater access to resources and tools to integrate racial equity into their work. Although MDPH has created new tools or curated existing tools, some respondents expressed that they were not aware of or had trouble finding the tools. It was also made clear that there is room for improvement in fostering an equitable workplace culture at MDPH, such as with respect to hiring practices and opportunities for career growth/promotion.
The successes and challenges experienced in FY21 show that the REM is part of transformational organizational change. MDPH strives to make short-term gains to maintain momentum and staff engagement, with understanding that real, lasting change takes time.
Racial Equity Data Road Map
In December 2020, a cross-departmental workgroup at MDPH – the Racial Equity Strategic Pathway Implementation Team (RESPIT) – released the Racial Equity Data Road Map to improve the use of data as a tool to eliminating structural racism. The Road Map is a collection of guiding questions, tools and resources that offers a suggested methodology for using data to address racial and ethnic inequities in service delivery and health outcomes. The Road Map guides its users to authentically engage the community, frame data in the broader historical and structural contexts that impact health, communicate that inequities are unfair, unjust and preventable, and design solutions that address the root causes of these issues. It is intended to be a living document that is updated based on feedback from its users.
In FY21, RESPIT focused on tracking how the Road Map is used by MDPH programs, providing technical assistance to users, and external dissemination. The Road Map webpage on mass.gov was launched on December 7, 2020. In its first year, the webpage was visited almost 6,000 times and the Road Map has been downloaded over 3,000 times. RESPIT members gave numerous presentations to state and national audiences about the Road Map, including the MDPH Bureaus of Family Health and Nutrition, Community Health and Prevention, Infectious Diseases and Laboratory Sciences, Substance Addiction Services, and Environmental Health, as well as external partners in the education, child welfare, and nutrition sectors.
The Racial Equity Data Road Map has also received state and national recognition. In January 2022, the Journal of Public Health Management and Practice published “The Massachusetts Racial Equity Data Road Map: Data as a Tool Toward Ending Structural Racism.” This paper is being nominated for the CDC Shepherd award in the Health Equity Science category. In addition, the RESPIT team received the 2021 CityMatCH award for Effective Practice at the State Level – Improving Public Health Practice Through Effective Use of Data, Epidemiology, and Applied Research. The Team was also awarded an MDPH Commissioner’s Citation as part of the MDPH Employee Performance Recognition Awards.
Objective 2. By 2025, increase the percent of BFHN staff of color from 36.8% to 42.6%.
A secondary objective to measure progress on this priority is the percent of staff of color in BFHN. Over the next five years, key strategies for this objective are to foster a workplace culture that acknowledges and addresses the impact of systems of oppression on staff to improve staff retention, and to center equity in the BFHN hiring and recruitment process.
Institutionalizing Racial Equity: Hiring Project
From November 2020-March 2021, MDPH implemented the Institutionalizing Racial Equity: Hiring Project. This project aimed to improve a policy and/or practice through the application of a National Association of Chronic Disease Directors (NACDD)-developed tool, Moving to Institutional Equity. This tool guides users through a process to identify and review internal policies and practices that impact public health operations, projects and decisions. After receiving input from staff, MDPH decided to focus on standardizing racial equity into the hiring process.
The objective of this project was to institutionalize principles and approaches to advance racial equity into the hiring process across MDPH. This will result in the hiring of people who understand the connection between structural racism and public health and who want to join MDPH in improving the quality of life for all MA residents while eliminating the marginalization and inequities that disproportionately threaten the lives of communities of color. The goal is inclusive of efforts to attract, select, and hire candidates from a broad range of background and experiences.
MDPH partnered with Health Resources in Action (HRiA) to form a cross-functional implementation team that met regularly in FY21 to discuss institutionalizing racial equity principles and approaches into the hiring process. A March 2021 report outlines next steps and recommendations for implementation. The priority areas and desired outcomes are:
- Posting language: Revise the language in job postings across MDPH to contribute to standardizing racial equity into the hiring process.
- Recruitment and posting logistics: Define the best ways to clarify and expand how and where to recruit candidates to create the largest available pool of qualified candidates for selection.
- Selecting candidates: Improve the process of identifying and culling resumes of qualified candidates to racial equity as part of the standard screening criteria.
- Interview questions: Ensure interview questions produce an accurate assessment of candidates and include language for racial equity.
- Interview panel and assessment: Ensure that interview panels consist of trained and diverse members who understand the goal of racial equity in public health.
Together, these components can provide the content and framework for developing annual action plans for implementation across Bureaus and Offices.
BFHN Racial Equity Steering Team
BFHN’s Racial Equity Steering Team (REST) has three goals: 1) to lead and coordinate the development and implementation of the Racial Equity Movement across BFHN; 2) eliminate structural and institutional racism in BFHN programs, policies, and practices; and 3) to foster a healthy and equitable work environment within BFHN. In early FY21, REST convened multiple working groups to address these goals, including one to address BFHN’s internal culture. The intent of this team is to help foster a workplace culture that acknowledges and addresses the impact of systems of oppression on MDPH staff, including microaggressions, to improve staff retention.
Partway through FY21, with the onboarding of a new BFHN Bureau Director, the REST working groups paused to ensure there was a shared vision and plan for advancing the Racial Equity Movement within the Bureau. Beginning in April 2021, a small group of REST members and racial equity practitioners facilitated deep dives with BFHN leadership and solicited input during an all-staff meeting on what is working well and what the barriers are to getting involved in the Racial Equity Movement. These conversations laid the foundation for the development of a BFHN Racial Equity Key Driver Diagram (KDD) in FY22. A KDD is a tool for building and testing theories for improvement. It visually displays and articulates ideas and connects them to a shared aim. The KDD will be structured around 1) primary drivers, which are critical system elements that are necessary and sufficient to achieve the aim of advancing racial equity, 2) secondary drivers, which are elements that will result in a change in the associated primary driver and 3) change ideas for each secondary driver that could be implemented at the bureau, division, or individual level. The KDD will serve to re-focus and re-energize BFHN’s commitment to advancing racial equity, including a focus on fostering a workplace culture that acknowledges and addresses the impact of systems of oppression on staff to improve staff retention.
Additional activities to eliminate institutional and structural racism in internal MDPH programs, policies, and practices.
Culturally and Linguistically Appropriate Services (CLAS)
The National CLAS standards seek to eliminate barriers to access, improve quality of care, and address the social determinants of health that drive disproportionate rates of disease between different populations. The MDPH Office of Health Equity (OHE) systematically supports and monitors MDPH’s internal and external efforts to meet the CLAS standards and ensure the use of CLAS as a framework for performance management and quality improvement (PMQI).
In FY21, due to the competing priorities during COVID-19, the annual CLAS Internal Assessment was not administered. However, findings of FY17-FY20 CLAS Internal Assessments were shared with MDPH Seniors Operations to document trends and patterns and area of improvement across the department, especially in the areas of data analysis, language assistance services provision, and monitoring CLAS implementation with contracted vendors.
In FY21, OHE provided CLAS technical assistance to six bureaus and their vendors; offered CLAS trainings to 12 programs within MDPH, shared resources with MDPH staff including the Making CLAS Happen Manual, the Racial Equity Data Road Map, MDPH Language Access Plan, MDPH Race, Ethnicity, and Language data collection guidelines, and Budget for Equity Tool. The Budget for Equity Tool assists people new to contract management or for more experienced users to ensure that program and vendors allocate adequate funding for language assistance services, which are crucial in advancing access and equity for people for whom English is not their first language and people who communicate differently.
OHE is updating chapters of the Making CLAS Happen Manual that focus on collecting diversity data and benchmarks, incorporating language from the Racial Equity Data Road Map. Edits to the chapter on building community partnerships will incorporate language about MDPH’s community engagement principles and efforts.
Determination of Need Program (DoN)
In FY21, the Office of Health Equity helped facilities to identify gaps, discuss available resources, share culturally appropriate communication materials, and provide support to facilities staff as they are facing shortages in staffing and translation equipment. MDPH staff contacted 50 healthcare facilities and, working with the Forum of Coordinators of Interpreter Services, disseminated educational updates and communication materials related to COVID-19.
Priority: Engage families, fathers and youth with diverse life experiences through shared power and leadership to improve MCH services.
Objective 1 (SPM 4). By 2025, increase to 50% from baseline (38.1% in FY19) the percent of Title V programs that offer compensated family engagement and leadership opportunities.
Family engagement in the design and delivery of programs is crucial for improving outcomes. Effective engagement acknowledges that the expertise and lived experience families bring to the partnership is as valuable as the expertise of the professional partners, and families should be compensated for their expertise in meaningful ways. Therefore, the state performance measure for this priority is the percent of programs funded through the Title V federal-state partnership that offer compensated engagement and leadership opportunities for families, fathers, and youth. In FY21, 35.6% (16 out of 45) programs offered compensated opportunities, a decrease from the FY19 baseline of 38.1% (16 out of 42). The goal is to reach 50% by 2025. The decrease is due to a larger number of Title V programs being included in the denominator, as well as competing priorities for both families and MDPH staff during the COVID-19 pandemic. Programmatic efforts to address this priority and measure in FY21 are described below. In the coming year, Title V will continue to address institutional barriers (e.g., allowable grant costs, income tax documentation, established organizational culture, institutional racism) to ensuring families receive fair and consistent financial compensation for their partnership and leadership roles.
Title V Implementation Team
The Title V Family Engagement Implementation Team met monthly to monitor progress on implementing strategies and meeting objectives outlined in the state action plan and to facilitate collaboration and communication across bureaus and programs. In FY21, the Implementation Team reviewed the Action Plan for Objective 1 and identified short and long-term activities for each of the six strategies. To build a strong foundation for the work within this priority, the group agreed to prioritize Strategy 1, which focuses on understanding and improving coordination and alignment of MDPH family engagement efforts. Activities prioritized for FY21 included: 1) Complete a landscape assessment to identify all family engagement activities across MDPH Title V programs; 2) Participate in the statewide, cross-agency Family Engagement Coalition to advance adoption of the Family Engagement Framework across MDPH programs, and; 3) Broaden membership of the Implementation Team to include the experiences and perspectives of male caregivers, families whose primary language is not English, and families from diverse racial and ethnic groups.
Title V staff, including several members of the Implementation Team, continued participating in the statewide Family Engagement Coalition. Two members of the Team also continue to serve on the Steering Committee for the Coalition. In FY21, the Coalition held regional meetings to engage family and community partners in discussions about implementation of the Family Engagement Framework, “Strengthening Partnerships: A Framework for Prenatal Through Young Adulthood Family Engagement in Massachusetts.” These conversations had a specific focus on implementation with a racial equity lens, including identification of potential unintended consequences. The outcomes of these meetings will inform the development of Framework materials for families and training modules on the Framework for staff across the health, human service, and education fields.
Office of Family Initiatives (OFI)
OFI is a resource to MDPH and community partners to support effective engagement of families whose children have special health needs, disabilities and/or chronic illness. OFI aims to create opportunities for families to grow the confidence and skills to partner in the development and implementation of policies, programs and practices that ensure a responsive system of care. OFI staff are all parents of children with special health needs (SHN), most of whom have gone through the MA Early Intervention (EI) system. Staff work at the regional and state level to provide information, referral, parent to parent support, skill building and opportunities for engagement to families and youth. OFI has long acknowledged the value of family and youth partnership by providing compensation for their time and expertise. This commitment levels the playing field by ensuring that everyone working on a project is paid, erasing the notion that families are merely volunteers.
In FY21,182 parents participated in the Share Your Voice program and served as advisors to Title V programs. These families shared their voice and lived experience through the COVID-19 Community Impact Survey, surveys from CDC, the Massachusetts Statewide Family Engagement Center, Massachusetts legislatively mandated Chapter 171 survey, and surveys from the Department of Elementary and Secondary Education. Family and youth voice was included in the development of Youth & Young Adult Transition Tool Kit and through attendance at conferences and meetings. OFI continues to build relationships with organizations where families from diverse cultural and linguistic backgrounds sought help. OFI uses a cultural brokering approach so that organizations are comfortable allowing MDPH to meet families whose children have special health needs, disabilities and chronic illness. This approach remains particularly effective in populations where disability is not directly acknowledged. The trusting relationships that have been fostered over many years allowed staff to share information about Title V and other health-related resources with families at 23 trainings with 170 families. Some of the families engaged through this work are now taking part in Title V activities such as serving as advisors, helping to develop peer support groups, participating as Parent-to-Parent mentors, and attending trainings and conferences.
The Early Intervention Parent Leadership Project (EIPLP), a project of OFI, is designed to reach families early in their EI journey. Staff, all of whom have received EI services for their own children, inform families about how they can actively participate in the EI system, either at their local program, within their region or at the statewide level. In FY21, over 28,000 families received the Parent Perspective newsletter which shares information about EI, the early childhood system of care and opportunities for participation.
The EIPLP Family Engagement and Collaboration Coordinator continued to serve as the Co-Chair of the BFHN Racial Equity Steering Team and helped to develop and deliver Racial Equity training for MDPH EI staff and the EI Interagency Coordinating Council (ICC). In addition, she supported 14 family members whose children have special health care needs to serve on the ICC, a federally mandated body that advises the EI/Part C agency and continued to provide training and support to a cohort of family leaders on the MDPH Young Children’s Council. Family TIES and EIPLP were co-sponsors of the FCSN’s 2021 Visions of Community annual conference. Over 900 parents and professionals attended the conference virtually, which provided workshops and information about specific special health needs, family engagement, youth transition and public benefits.
OFI works across Title V and in other state and non-governmental agencies to represent the needs of families of CYSHN. FY21 activities included serving on the Emergency Medical Services for Children, Universal Newborn Hearing Screening, and Center for Birth Defects Research and Prevention advisory committees. The OFI Director is the MDPH representative to advisory councils of three of the agencies that comprise the state Protection and Advocacy Network for Individuals with Disabilities. These include the MA Developmental Disabilities Council and the two University Centers for Excellence in Developmental Disabilities Education, Research and Service in MA. This offers a platform to share information about health-related issues and health inequities, youth and young adult transition needs and resources, and opportunities to support family involvement. The OFI Director presents annually to fellows at the LEND programs and meets individually with fellows interested in learning more about family engagement.
Universal Newborn Hearing Screening Program (UNHSP)
UNHSP has a long history of compensated family involvement. Since its inception, a parent has held a paid staff position. There are currently two parents on staff and one hard of hearing staff member. The legislatively mandated UNHSP Advisory Committee includes two parent members and two members that are deaf or hard of hearing. Currently, a parent chairs the Committee. During the COVID-19 pandemic, all public meetings were held remotely, allowing additional parents to participate.
Activities in FY21 remained mostly virtual, allowing families from across the state greater access to educational opportunities. Ninety-seven people participated in three educational presentations: a Deaf attorney presented on the relevant federal laws that provide for equal education for deaf and hard of hearing students; an educational audiologist presented on the importance of the child’s school team; and another educational audiologist presented on supporting hearing aid usage in young children. UNSHP held five Facebook Live events for parents, which have received over 1,600 views, as well as social events with 81 participating families with children who were deaf and hard of hearing. Building off the successful event from the previous year, a story time was co-hosted with Boston Children’s Hospital Deaf and Hard of Hearing Middle School Program. In addition, 35 people attended an event co-hosted with the Massachusetts Commission for the Deaf and Hard of Hearing Children’s Specialists. UNHSP sponsored 16 families to attend the virtual Early Hearing Detection and Intervention (EHDI) meeting. To ensure families felt supported during this virtual learning opportunity, UNSHP created a Padlet to provide information to attendees and a texting service to communicate with families and held a virtual pre-meeting and virtual social event for participants. Families reported feeling more connected to each other and to program staff at the conclusion of the weeklong meeting.
Care Coordination
The Care Coordination program continued to serve families of children with special health needs through a family-centered and racial equity lens. The program adheres to a family empowerment capacity-building model. Care Coordinators initially model for families how to access services and navigate systems, with the goal of families being able to advocate for themselves. This process values the unique linguistic, literacy, or intellectual needs of the parent/family.
Families partnered with coordinators in completing assessments, drafting care plans, and accessing services and resources. As a result of the pandemic, the program leveraged virtual platforms to offer family engagement activities across the state, increasing family participation by eliminating geographical barriers. In FY21, the program facilitated five times more family engagement activities than the prior year (108 compared to 20 in FY20). Activities have been informed by the needs and desires of families to learn and connect with one another. In that regard, these activities have also reflected the cultural and linguistic preferences of families. As part of a revision of the MDPH employee performance review, a self-reflection tool and a rubric were developed to assess family engagement throughout the continuum of the relationship between the Care Coordinator and the parents.
In addition, the Care Coordination program recruited 136 families to attend the 2021 Visions of Community virtual conference. A Care Coordinator, in partnership with a local Pediatric Palliative Care program, presented a workshop in Spanish with the goal of providing the families with tools to tell the life story of their children with special needs.
MassCARE
In FY21, MassCARE continued to engage and hire family members as peers who work at community health center sites to provide supportive services. Peers also participate in the delivery of Project CAATCH educational sessions, an MDPH program to engage women and young adults who are HIV-positive and have fallen out of care. MassCARE also piloted a youth mentorship program with one youth from each site in FY21. Mentorship will become a core MassCARE service in FY22 to assist youth towards life transition goals and support leadership development in youth/young adults living with HIV.
Pediatric Palliative Care
The Pediatric Palliative Care Network (PPCN) implemented several strategies to enhance and expand family engagement in FY21. First, the PPCN Program Director decided instead of reconvening the Family Advisory committee, to create targeted short-term opportunities to solicit family input. Five parents/caregivers received stipends for their review of the annual PPCN Family Survey. They provided critical feedback on the addition of new questions on quality of life, advanced care planning and PPCN services during COVID-19. In addition, PPCN recruited six parents to serve on the Advisory Committee for the PPCN Outcome Evaluation. Given the shift to a qualitative evaluation comprised of focus groups and key informant interviews, PPCN parents and caregivers have been instrumental in representing families in a range of activities from how to effectively recruit families to participate in focus groups to the design of the focus group questions. Parents are compensated by the vendor overseeing the PPCN outcome evaluation, Commonwealth Medicine. The Advisory Committee chairperson is a parent, and she has exemplified the many benefits of parents serving as leaders including increasing the quality of the evaluation process.
Second, PPCN increased family engagement capacity at individual PPCN programs. The OFI Director presented on the Family Engagement Framework to the PPCN Program Managers in December 2020 on how to operationalize family engagement. At the same time, a music therapist at one of the PPCN programs chose to work with MDPH for her student internship for her Masters’ degree. She conducted interviews with PPCN staff to assess their knowledge of the definition of family engagement and their capacity to integrate parents/caregivers in leadership roles within their programs.
Essentials for Childhood
The Essentials for Childhood (EfC) grant has been focused on bringing a racial equity lens to the project, which has helped the team identify that there was need for more community and family leadership and engagement on the grant, honoring the invaluable contributions that lived experience and community voice bring to the project’s work. As a result, during the FY20 project year, EfC team members recruited a family leader, a father who leads a local fatherhood initiative, to participate on the EfC Racial Equity Team, Communication Connections, and Leadership Action Team. Over the course of FY21, the EfC grant continued to recruit, and compensate, other family and community representatives to the various collective impact (CIT) and the Leadership Action (LAT) teams. This included bringing on an additional family leader to the LAT and three family leaders to the Economic Opportunity Team.
In addition, to ensure that community voices not only help inform the initiative, but truly engage in initiative decision-making and planning, the EfC Racial Equity team outlined a need to develop and institute a Community Governance Board, which will guide the work of the initiative. During the reporting period EfC staff worked with a current family leader to develop a process and begin recruiting members for this group.
MECCS/Young Children’s Council
Family leadership was a core MECCS strategy to address inequities in early childhood developmental health. With the grant ending in July 2021, MECCS prioritized identification of opportunities to sustain its family leadership activities. At the state level, MDPH agreed to continue the MECCS-facilitated Young Children’s Council (YCC) as an advisory group for MDPH early childhood systems initiatives. MECCS has been leading an effort for the YCC to become a platform for families to directly inform MDPH programs. Five family representatives were engaged in the council in FY21. Additionally, in FY21, MECCS and Title V supported two Parent Fellows from Families First in an internship to identify and create opportunities to strengthen parent leadership in the YCC. The Fellows developed an orientation for new family leaders as well as recommended changes to YCC meeting practices, including leading the development of YCC community agreements. MECCS community partners in Chelsea and Springfield developed sustainability plans for their family leadership activities, including identifying alternative funding sources for parent leader compensation. In Chelsea, the Family Navigator position was absorbed into the operations of a Chelsea-MECCS partnering agency. In Springfield, the MECCS backbone agency agreed to continue to fund and host the Springfield parent leadership group as well as engage several family leaders in some of their family support and early education programming.
MA MIECHV
In FY21, MA MIECHV leveraged lessons learned from participation in the Home Visiting Collaboration Improvement and Innovation Network (HV CoIIN 2.0) to support parent engagement in MA MIECHV CQI activities. Through participation in HV CoIIN, local implementing agencies (LIAs) recruited family members to participate on their improvement team and attend learning sessions. Family leaders included caregivers or parents of a child currently or previously enrolled in home visiting services who are interested in participating in improvement efforts at the systems level in service of other families. Successful integration of parent leaders and partners in CQI efforts is a primary driver in the HV CoIIN process and improvements were seen in three of the four participating LIAs.
The focus on parent leadership in CQI continued in the HV CoIIN Lead the Change Network to scale and spread past practices identified in HV CoIIN 2.0. LIAs participating in the Lead the Change Network learned new skills and tools to better engage families in CQI efforts. LIAs used the “Toolkit to Build Parent Leadership in Continuous Quality Improvement” to identify strategies for recruiting and retaining families as members of their Advisory Committees and local CQI Teams. LIAs had the opportunity to access a Family Leadership Coach through the Education Development Center (EDC) to receive support building meaningful partnerships with families that can contribute to systems-level improvements that address the root causes of challenges. Over the course of participation in HV CoIIN, all four participating LIAs successfully engaged families in CQI efforts through CQI Team meetings, co-facilitation of groups, and surveys.
Starting in FY21, MA MIECHV hosted an Associate from the CDC Public Health Associate Program (PHAP) for a two-year placement (FY21 and FY22). Functioning as the MA MIECHV Family Engagement Coordinator, the Public Health Associate supported efforts to engage families as partners contributing to home visiting programming at the state and local levels. Beginning in October 2020, the Associate joined the Title V Family Engagement Implementation team and the Young Children’s Council to facilitate information sharing on family engagement best practices. The Associate engaged in cross-bureau discussions that guided MA MIECHV in developing a strategic family engagement plan to incorporate the Massachusetts Family Engagement Framework’s strategies into program planning and implementation in collaboration with LIAs.
MA MIECHV LIAs leverage participant testimonials from home visiting clients to highlight the positive impact of home visiting for a variety of purposes including legislative advocacy and tailored outreach. In FY21, the Associate developed a resource guide to support LIAs to elevate the voices and experiences of families grounded in ethical storytelling principles. Once MA MIECHV finalizes and pilots this resource guide, MA MIECHV will create a coaching structure to provide ongoing technical assistance to LIAs to ensure the storytelling process is parent-centered and trauma-informed.
MA MIECHV also compensated families for their engagement and leadership in program planning and implementation at the state and local levels. Among these opportunities, MDPH hired as consultants four community evaluators (who led focus groups for the MIECHV and Title V needs assessments) to collaborate on efforts to translate needs assessment recommendations into practice, such as prioritizing strategies for inclusion in the FY22 MA MIECHV procurement and contextualizing racial and ethnic inequities in performance measure data. In March 2021, MA MIECHV also recruited, trained, and compensated 10 family representatives to review funding proposals for the MA MIECHV procurement.
Office of Sexual and Health & Youth Development (OSHYD)
OSHYD’s Leadership Exploration and Development (LEAD) internship program provided youth an opportunity to participate in paid youth-facilitated projects to address a need in their program or community. During FY21, OSHYD funded internships across 13 youth serving agencies. Projects focused on topics such as youth leadership for youth with disabilities, peer-led suicide prevention strategies, civic engagement, and mental health awareness. LEAD internships provided youth an opportunity to earn a living wage for 12 weeks, gain valuable leadership skills, and provide feedback to OSHYD-funded programming. LEAD also allowed youth to deepen their relationships with a trusted adult in their community-based agency during the COVID-19 pandemic, which has deepened isolation for many youth and young adults.
Child and Youth Violence Prevention Programs
MA Perinatal-Neonatal Quality Improvement Network (PNQIN)
PNQIN’s Neonatal Family Engagement Collaborative is now in its third year. It is a multi-site collaborative focused on reducing racial/ethnic and linguistic disparities in family engagement practices that occur among level II Special Care Nurseries (SCNs) and level III Neonatal Intensive Care Units (NICUs). In this project, the voices of families, and their roles as leaders in local and statewide work, are a priority. PNQIN engages families of all backgrounds to serve as equal partners with NICU/SCN staff on local teams and at the project leadership level.
Fifteen hospitals are engaged and 10 have signed data use agreements and are entering data into the collaborative data collection tool. Hospitals have submitted nearly 40 “plan-do-study-act” cycles focused on four key drivers: 1) Provider-family communication; 2) Social supports (addressing unmet basic needs and adverse parental mental health); 3) Parental engagement in “hands on care,” such as skin-to-skin care and breastfeeding; and 4) Discharge planning. In FY21/FY22, there have been presentations from a NICU parent who started her own community-based organization focused on supporting families during their NICU stay and in bereavement practices; understanding the NICU experiences of LGBTQ+ families; NICU literacy programs; and applying QI in family centered care. The spring summit will focus on parental mental health during and after the NICU stay.
PRAMS for Dads
In FY21, MA PRAMS continued planning for a survey for fathers, “PRAMS for Dad,” to collect data about their experience during pregnancy and the birth of their child, and their experiences with COVID-19 testing, vaccination, health status, social determinants of health, mental health and racism during the COVID-19 pandemic. PRAMS for Dads will provide valuable data to understand the experience of fathers during the perinatal period, which will help inform MDPH programs approaches and strategies to be more representative and inclusive of fathers. MDPH received funding for PRAMS for Dads through the CDC COVID-19 Disparities Grant, which began on July 1, 2021.
Priority: Eliminate health inequities caused by unjust social, economic, and environmental systems, policies and practices.
The performance measure for this priority is the percent of families living in a household with poor economic resources. This reflects an adverse childhood experience that can have lasting effects on health, well-being, and opportunity. It has significant effects at critical periods of development, cumulative burden across the lifespan, and across generations. Key strategies to address this priority are centered around five social determinants of health domains, as defined by Healthy People 2030: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality.
According to the COVID-19 Community Impact Survey, seven out of 10 workers experienced disruptions to their employment due to the pandemic. Needing to take care of children was a commonly reported reason for changes in employment status among parents, especially for those who were Hispanic/Latinx or Multiracial, spoke a language other than English, were younger, LGBTQ+, parents of children with special healthcare needs, had lower annual household income or lower educational attainment. A third of parents who lost their jobs and 40% who reduced hours or took leave noted needing to take care of children as a reason. Youth have been asked to take on more adult responsibilities, including providing childcare and financial support to their families. More than 1 in 5 youth in many populations have had to help their families financially more during COVID-19, including youth of color, youth with disabilities, and youth who speak a language other than English.
Essentials for Childhood: Paid Family and Medical Leave
The goal of Essentials for Childhood (EfC) is to prevent child abuse and neglect by promoting safe, stable, nurturing relationships and environments. MA EfC focuses on strengthening community support for families through social connectedness and economic supports for families. The initiative centers racial equity in response to evidence that health inequities, including childhood adversity, can be tracked by the disproportionate burden that communities of color bear from structural inequality.
In 2018, MA Paid Family and Medical Leave (PFML) legislation was passed into law; the program launched on January 1, 2021 covering most leave types with the remainder of leave options available as of July 1, 2021. Funded through employer and employee contributions PFML provides up to 26 weeks of combined family and medical partially paid leave. Leave coverage types include: 1) medical leave to manage a personal serious health condition, 2) family leave to care for a family member or to bond with a child, and 3) family leave to care for a family member who is a member of the armed forces. Most workers in MA are eligible for leave and the law protects employees’ jobs, benefits such as sick and vacation time, health insurance, and protects against retaliation for taking leave. In FY21, the Department of Family and Medical Leave (DFML) received 18,165 applications for family leave for bonding with a child following birth, adoption, or foster care placement.
Evidence has linked PFML to better family and child health outcomes including improved parent-infant bonding, increased initiation and duration of breastfeeding, reduced parental depression and stress, and reduced emergency room visits for infants due to head trauma.[1],[2],[3] While MA anticipates that the PFML will provide additional economic support to families, the COVID-19 pandemic and economic crisis has placed many more families at risk for financial instability and poor health outcomes. In FY21, Title V and EfC project staff continued to strengthen the development and promote the upcoming rollout of PFML by 1) participating on the DFML Medical Provider Advisory Council, offering input with a public health and racial equity lens and recommending strategies for outreaching to families with young children; 2) participating on a committee facilitated by the Coalition for Social Justice; 3) MDPH PFML Outreach and Data Teams strategized ideas on how to support PFML through data analysis to understand equitable uptake and long-term impact of PFML on family outcomes; and 4) using the aforementioned strategies, MDPH staff drafted a partnership outline for DFML on how MDPH could support program outreach and understand program utilization. The partnership outline entails: 1) pursuing outreach strategies through MDPH’s extensive network of direct and indirect services and existing connections and collaboration with other state agencies to support knowledge of and access to PFML benefits, and 2) sharing data, with the inaugural DFML data release in October 2021. DFML and MDPH-based data sources will be used to measure access, uptake, and utilization of the benefit through the analysis of race, ethnicity, and language and other demographic and administrative data. Data analysis will further inform outreach strategies.
Essentials for Childhood: Earned Income Tax Credit
EITC, combined with the Child Tax Credit and other credits, brings significant resources into the community, reduces poverty, and improves family health outcomes. In 2018, the federal EITC program helped approximately 5.6 million people nationwide rise out of poverty.[4] In FY21, the EfC Economic Opportunity team continued to support strategies and build partnerships to increase the number of eligible families who file for the EITC through Voluntary Income Tax Assistance (VITA) sites.
In FY21, EfC Economic Opportunity team staff worked in partnership with The Neighborhood Developers (VITA site) and MGH Chelsea Community Health Center to revise their collaborative referral process for the 2020 tax filing season and to share this resource with other communities that were interested in developing partnerships and referral relationships between community health centers and VITA sites. The referral process resource consisted of a one-page document to assist health center staff in referring families to the local VITA site. The document contained sections on a) how to make the referral including a sample script; b) information on the VITA sites services such as languages offered and COVID-19 safety protocols; c) a direct electronic referral link; d) commitment from the VITA site to prioritize health center families for the eligibility assessment; and e) brief background information on EITC as one of the nation’s most effective anti-poverty programs.
EfC staff also applied and were accepted to participate in the CDC’s 6-month EITC Policy Implementation Lab, convening a cohort of EITC stakeholders across MA to join. With monthly national sessions followed by Massachusetts-only coaching calls, the MA Policy Lab team outlined a common goal of wanting to collectively work to build out EITC messaging, coordination, and tax prep services across the Commonwealth to increase access and uptake. Specifics included: a) upgrading messaging around social determinants of health and EITC especially to health audiences, b) convening tax preparation providers to advance statewide virtual access infrastructure in coming years, c) continuing to adapt EITC/tax preparation activities to better meet people where they are, and d) revisiting and re-applying the statewide asset development/financial empowerment plan to current state and local policies and programs as a pathway to family financial stability and community empowerment. The team also outlined the need for resources to sustain and continue to coordinate the group; Essentials for Childhood staff offered to play the convening role to advance the work.
Finally, EfC staff continued to participate on committees, such as the Medical Tax Collaborative and the Healthy Families EITC Coalition, that work on strengthening economic opportunities and enhancing EITC benefits for families in MA, including supporting linkages with the medical community. EfC and Title V staff disseminate information and resources from these coalitions to stakeholders to increase knowledge of and access to these entitlements.
Essentials for Childhood: Community Connectedness
In FY21 the EfC Community Connection Collective Impact Team continued to work on a Community Connectedness Toolkit, to be developed from the various strands of the EfC project. The toolkit will include families’ preferred approaches to accessing supports and services to promote their young children’s development. Initial elements of the Toolkit include community wellness measures and a Municipal Inspiration List, which identifies effective community-level services and supports for parents to access to support their young children’s development. In the wake of the national racial reckoning during the summer of 2020, the EfC team thought more deeply about how to engage with communities in ways that truly value the expertise and experience of community members. This included questioning plans for developing a Toolkit and what the resources contained within that Toolkit might be. Ultimately, the group determined that developing a Toolkit is still valid if community members have significant input into its development and the tools document processes that allow power and resources to be shared with greater equity.
SSI and Public Benefits Training and Policy
In FY21, the SSI and Public Benefits Training and Policy Specialist in the Division for Children and Youth with Special Health Needs (DCYSHN) played an important role partnering and communicating with external stakeholders to align efforts and resources to improve social and economic systems, policies and practices that support families, especially those with children with special health needs. The activities included participating as a member of external stakeholder coalitions including:
- Children’s Health Access Coalition (CHAC), which provided input on state legislation, budget and policy to ensure access to important sources of public benefit programs that relate to health and wellness for all children in MA (e.g. MassHealth, Department of Transitional Assistance (DTA), and housing assistance programs). CHAC members included health care providers, MA chapter of AAP, MA Family Voices, community-based social service organizations, child health advocates and legal services organizations.
- Immigrant Health Access Coalition (IHAC), which monitored and provided input on legislation, budget and policy that affected health care and social services benefits for immigrant households. IHAC members included MA Immigrant and Refugee Advocacy Coalition, community-based and faith-based agencies, and legal services organizations.
- Disability Determination Services Advisory Committee, to provide input on ensuring access to SSI and MassHealth benefits for low-income children with disabilities and chronic illness to access health care and financial benefits for food, housing and nutrition.
- Statewide Special Education Advisory Panel, which provides annual recommendations to State Board of Education. The panel addressed equitable education services to all students, regardless of economic status, geographic location, race or ethnicity. Special attention was given to root causes of over-representation of certain racial or ethnic populations in special education and in disciplinary action, such as institutional lack of responsiveness to cultural and socioeconomic differences among children and their families.
In FY21, the SSI and Public Benefits Training and Policy Specialist provided training and technical assistance to health and social service providers, hospitals, EI programs, community-based organizations, and parents of CYSHN on SSI, MassHealth and other means-tested public benefits programs. She also played a critical information-sharing role during the COVID-19 emergency. Through relationships with external stakeholders (Health Care for All, Disability Law Center, MA Health Connector, Mass Law Reform Institute, Protecting Immigrant Families Campaign), she received updates on important federal, state and local agency operations changes, legislative and regulatory updates. Information included SSI and MassHealth extensions and flexibilities during COVID-19 as well as updates on DTA cash assistance/nutrition programs, and housing assistance. Important updates were electronically distributed to BFHN and DCYSHN staff to share with their community networks and directly with families.
Occupational Health Surveillance Program
The mission of the MDPH Occupational Health Surveillance Program (OHSP), housed in BCHAP, is to promote the health, safety and quality of life of working people in MA. This is done by collecting and analyzing data about work-related injuries, illnesses, and hazards; using this information to develop prevention programs and policies; educating workers, employers, and health care providers to address occupational health and safety problems; and integrating occupational health into other public health activities at the state and local levels.
In FY21, OHSP supported the Young Workers Project (YWP), which includes population-based surveillance that informs efforts to improve access for youth to employment that is safe, accessible, stable, and well compensated. In FY21, YWP served as analytic lead on the youth employment section of the COVID-19 Community Impact Survey (CCIS). Thirty-nine percent of youth reported working. Youth were asked to take on more family responsibilities such as taking care of younger siblings and providing financial support. Youth were twice as likely to report losing a job during the pandemic than adults (19% v 10%). Sixty-three percent of youth who were currently employed worked outside the home putting them at increased risk of COVID-19, and many were not provided protections by their employers, such as PPE, social distancing, and training to reduce COVID-19 exposure. Youth were asked to continue their education while working and helping out more at home; many youth worked in industries and occupations hit particularly hard by the pandemic such as restaurants and health care. Youth who graduated during the pandemic may have had a hard time entering the workforce during the pandemic as 28% of youth reported wanting help finding a job. The future economic and social impacts from COVID-19 will be acutely felt by youth for years to come.
OHSP also continued to lead the MA Youth Employment and Safety Team (a group of eight state and federal agencies) and coordinated efforts to protect and promote the health and safety of young workers across the Commonwealth. OHSP continued to work closely with community partners such as the MA Coalition for Occupational Safety and Health to promote equity-focused work. While the MA Safe Jobs for Youth Poster Contest was put on hold due to the pandemic, the Youth Employment and Safety team continued to meet regularly, discussing topics such as how to support youth obtaining work permits during the pandemic and developing guidance for worksite inspections during the pandemic.
Catastrophic Illness in Children Relief Fund
The Catastrophic Illness in Children Relief Fund (CICRF) provides financial assistance to MA families caring for children with special health needs and disabilities. The Fund reimburses high medically related expenses for a child with special health needs under age 22 that are not covered by insurance, public benefits, or other financial source. The family must have “catastrophic expenses” related to their income; eligibility is defined by law as medically related expenses exceeding 10% of income from all sources in a 12-month period (plus 15% of any amount over $100,000).
In FY21, CICRF provided over $1.9 million in financial support to 166 families caring for CYSHN who met the eligibility criteria listed above. The children assisted by the CICRF have a variety of diagnoses, typically come from families with lower incomes, and have some form of health insurance coverage. Most notably, during FY21 approximately 76% of the families who received assistance had annual incomes of less than 200% of the federal poverty level ($53,000 for a family of four in 2021). In addition to providing financial assistance to families, the Fund provides families with information, referrals and technical assistance related to accessing other financial supports, such as hospital financial assistance programs for outstanding medical bills, programs for vehicle and home modifications, rental/mortgage payment assistance programs, and
fuel assistance programs. As a result, many families who have been determined ineligible for the Fund due to the financial criteria have received other types of support from the Fund. Five out of six CICRF program coordinators speak other languages (Spanish, Haitian-Creole, and Portuguese), improving program capacity to explain documentation needs and complex Fund policies directly to families.
During FY20, CICRF began a project through a MDPH Lean Six Sigma Yellow Belt course to streamline the Fund’s application process and shorten waiting time for families to know if they are eligible for financial assistance. Due to the pandemic, this project was put on hold; it was restarted in April 2021 and will continue through FY22. As part of the project, CICRF will engage with families for feedback in how to improve communication and timeliness of the application review process. In addition, CICRF will continue to develop and strengthen relationships with community partners in the Haitian, Vietnamese and Cambodian populations of Greater Boston and Lowell to increase awareness of resources available in the MDPH Division for Children and Youth with Special Health Needs (DCYSHN).
The COVID-19 pandemic increased financial stressors on families, especially due to reduced income, lack of qualified childcare or in-home staff to care for their children with disabilities, and racial inequities in exposure to the virus. In FY21, CICRF staff identified and reimbursed 41 families $15,981 as part of the Emergency Family Support Funding program created by DCYSHN to assist families directly impacted by the COVID-19 pandemic. CICRF staff will continue to build awareness with other state agencies, health care providers, community partners, family advocacy organizations, and families about the existence of the Fund as a potential financial resource.
Division of Sexual and Domestic Violence Prevention and Services (DSDVPS)
Sexual and domestic violence are social determinants of health that impact all aspects of survivors’ lives, and are experienced inequitably by women, girls, women and girls of color, people who identify as LGBTQ+, people with disabilities, and women and girls who live in rural communities, among other historically marginalized populations. Exposure to violence directed at one’s mother was identified as an adverse childhood experience associated with negative long-term health outcomes in the original ACEs study. This exposure has also been found to be associated with adverse short- and long-term outcomes for children in multiple life domains. For boys, exposure to intimate partner violence (IPV) against one’s mother during childhood has been found to increase their risk for perpetrating violence against intimate partners as they mature.
DSDVPS-funded sexual and domestic violence agencies work to prevent and mitigate the impacts of sexual violence and IPV and help survivors attain safety and well-being through a variety of strategies, including supporting families in accessing concrete supports. During FY21, DSDVPS-funded agencies provided access to a range of housing services, including emergency shelter services, housing stabilization, and shelter advocacy to help clients find emergency shelter, obtain housing advocacy to help clients find and/or apply for housing, and engage in economic advocacy.
Childhood Lead Poisoning Prevention Program (CLPPP)
Lead exposure disproportionately impacts lower income communities and communities of color, making it a critical health equity issue. Children living in low-income communities in MA are nearly four times more likely to have elevated blood lead levels than children living in high-income communities. Multi-race children are three times more likely to exhibit dangerous levels of lead in their blood. Black children are nearly two times more likely to have lead poisoning than White children. Historical housing policies that have perpetuated segregation and limited opportunity for home ownership for people of color, such as redlining, have led to the increase in risk factors for lead poisoning in Black communities, including older housing stock, dilapidated housing, and fewer owner-occupied housing units.
In accordance with Lead Law requirements, the Childhood Lead Poisoning Prevention Program (CLPPP) implements a multi-tiered case management strategy to mitigate childhood lead poisoning, focusing on the child, their family, and the home environment. A team of three individuals, including a clinical care coordinator, a community health worker (CHW), and a code enforcement lead inspector, deliver case management services to the family and foster linkages to community-specific resources. The CHW component of CLPPP’s case management model is funded as part of the collaboration between CLPPP and BFHN and is supported by Title V funds.
Because of mandatory universal screening and reporting, CLPPP effectively identifies lead-exposed children in a timely manner. Through the electronic case management and surveillance database deployed in October 2019, children with a blood lead level (BLL) 10µg/dL or greater receive additional evaluation and services. In FY21, CLPPP processed 211,688 blood test results for 197,676 children. Of those screened, 562 had lead poisoning and were referred to the CLPPP team for case management. Due to COVID-19, most home visits were conducted virtually. This presented a significant learning curve and operational shift for CHWs and CLPPP families. In FY21, CHWs conducted 397 lead exposure assessment interviews, resource referrals, and follow up visits to families with lead exposed children.
CLPPP uses surveillance data to identify geographic areas and populations at highest risk for childhood lead exposure. Appropriate population-based, primary and secondary prevention interventions are targeted to children less than 6 years old with an emphasis on those areas and populations identified as being disproportionately affected. Identifying high-risk communities involves analysis of elevated blood lead incidence rates and data on known risk factors, such as low-income and old housing. CLPPP targets an average of 18 high-risk communities each year, defined as those communities whose adjusted average annual incidence of childhood BLLs ≥ 10 μg/dL is higher than the state, provided that those communities had at least 15 cases over 5 years. The incidence rate for each community is adjusted for the prevalence of families with an income to poverty ratio <200% and the prevalence of housing units built before 1978 (using US Census data).
In June 2021, CLPPP and BFHN co-hosted a focus group with families that previously received CLPPP services. Despite rigorous recruitment and offered compensation, the focus group was not well attended. However, the mothers that did attend were excited and engaged. The focus group provided a space for parents to share their experiences, exchange ideas, and offer program feedback. Program participants spoke favorably of CLPPP’s services and suggested areas for improvement: education on prenatal and alternative sources for lead exposure and resources to guide families when services end. In FY22, CLPPP will identify and start implementing targeted activities for service improvements.
In spring 2021, CLPPP became aware of multiple recalls concerning LeadCare II devices. LeadCare are point of care devices used to test lead levels in-house at a provider’s office. Subsequent recalls prompted CLPPP staff to conduct direct outreach to over 50 pediatricians using LeadCare devices. CLPPP was also able to use the Health and Homeland Alert Network to notify an additional 9,000 physician assistants and nurse practitioners. In FY22, CLPPP will examine the recalls and their impact on screening rates and lead testing access.
Care Coordination
The Care Coordination Program provides access to the Family Support Fund for families receiving Care Coordination services. Under this program, families may request respite and other support services if their child(ren) have special health needs, complex care requirements, and or multiple disabilities. The Family Support Fund provides a mechanism for these families/caregivers to receive short-term relief and support in caring for their child. All support and respite services are tailored to meet the unique needs of each family. Care Coordinators and the family work together to assess family needs for support and jointly develop the application for funding. Funding categories include respite, services, equipment, and supplies reimbursement. In FY21, 531 families were able to receive this support.
F.O.R. Families
The F.O.R. Families home visiting program assists families transitioning from homelessness to stable housing with securing basic needs such as healthcare, housing opportunities, childcare services, and financial resources. Families are referred to the program by the MA Department of Housing and Community Development (DHCD) and their contracted Emergency Assistance shelter providers. These referrals are for families with the most complex physical, social and emotional challenges. Families served in this program experience barriers such as poverty, homelessness, mental/behavioral health challenges, immigration issues and limited English proficiency. Home visitors link families to services to prevent or mitigate adverse health outcomes. Staff provides assessment, supportive counseling, and referrals to community resources. Challenges to accessing services for basic needs include mental health issues, substance use disorder, and domestic violence. During the COVID-19 pandemic, the program conducted virtual visits with families.
F.O.R. Families offers assessment and case management for families with identified risk factors, such as mental health issues, child welfare concerns and inadequate healthcare. Of the 141 families assessed in FY21, 21% of the heads of household were employed and 15% were disabled/unable to work. Fifteen percent of household reported they have run out of food; of those, 42% reported that this occurred monthly. To address these needs, home visitors collaborate with shelter providers to supply the families with transportation, employment opportunities, meal programs and other necessities.
Home visitors also identify risk factors and provide linkages to services to prevent or mitigate poor health and/or developmental outcomes. In FY21, 36% of caregivers reported concerns with their child’s development, specifically in psychological and behavioral areas. Families with children under three years old are routinely referred to Early Intervention; 12% of the program’s participants had a child receiving EI services. Referrals to Head Start and childcare are offered for non-school aged children to provide increased social opportunities.
MA MIECHV
Home visitors continued to support families in addressing barriers to pursuing educational goals and make referrals to education programs other community resources. In FY21, the Healthy Families Massachusetts (HFM) program focused CQI activities to increase the percent of participants who have not completed high school who are enrolled in high school or a HiSET (high school equivalency) program. Despite successful CQI activities within local programs, statewide impact was limited. In FY21, 37% of primary caregivers who enrolled in home visiting without a high school degree or equivalent subsequently enrolled in, maintained continuous enrollment in, or completed high school or equivalent during their participation in home visiting. This represented a slight increase from 36% in FY20. Home visiting programs noted that enrolling and maintaining enrollment in educational programs was not a priority for many program participants during the COVID-19 pandemic. Home visitors will continue to support families in addressing barriers to pursuing educational goals and make referrals to education programs other community resources.
EIPP
EIPP home visitors supported families in accessing concrete supports such as housing, financial income, childcare, and food with the support of the Community Health Worker who provides navigation and interpreters services to EIPP participants. In FY21, of the 281 participants enrolled, 43.8% were supported in accessing clothing and other material needs, 18.5% were referred to housing/shelters, 21% were referred to SNAP, 11.7% were referred to Transitional Aid, 8.5% were referred to childcare services, 3.2% were referred to a local food pantry, and 1.4% were referred to SSI. Amid the pandemic, families were less likely to accept referrals for services outside their home.
Priority: Support equitable healing centered systems and approaches to mitigate the effects of trauma, including racial, historical, structural, community, family, and childhood trauma.
Objective 1 (SPM 6). By 2025, increase by 10% above baseline (to be established) the percent of BFHN and BCHAP staff that report a workplace culture that reflects a safe and supportive environment to mitigate primary and secondary trauma.
Title V Implementation Team
Trauma affects individuals, communities, and systems. According to the San Francisco Department of Public Health, “trauma informed systems work is based on the understanding that our service delivery systems can inadvertently reinforce oppression and create harm. When our systems are traumatized, it prevents us from responding effectively to each other and the people we serve.”[5] The performance measure for this priority tracks Title V efforts to improve policies, practices, and conditions to increase MDPH’s capacity to operate as a trauma-informed and healing-centered organization. Healing Centered Engagement, developed a framework for understanding ways to mitigate multiple levels of trauma by taking a holistic approach to healing that is explicitly political; restores individual and community cultural and spiritual identity; and is asset driven.[6]
In FY21, the Title V implementation team for this priority included staff from the Division of Violence and Injury Prevention (DVIP), the Division of Sexual and Domestic Violence Prevention and Services (DSDVPS), the Division of Pregnancy, Infancy, and Early Childhood (DPIE), the Division for Children and Youth with Special Health Needs (DCYSHN), and the Office of Health Equity. Supported by a Boston University School of Public Health MCH Fellow, the implementation team built an understanding of healing-centered engagement strategies and frameworks that foster racial equity in the work environment. The team championed Healing Centered Engagement through presentations to BFHN and BCHAP staff and leadership, such as the DSDVPS presentation on “Moving from Trauma-Informed Care to Healing Centered Engagement in Racial Equity Work” at the MDPH Cross-Departmental Racial Equity Collaborative.
In FY21, building on a previous trauma-informed organizational assessment tool, the MCH Fellow also supported the team in revising the organizational assessment (which will be the data source for this SPM) to explicitly include race/ethnicity of respondents and additional questions on experiences of equity, resilience, and healing. The fellow conducted a literature review and key informant interviews with MDPH staff to understand organizational culture and awareness of healing-centered approaches in the workplace and collaboration with stakeholders with expertise in trauma-informed assessment and healing-centered engagement.
During the internal review and approval process of the organizational assessment, the implementation team learned that the tool will also need to be reviewed by the MDPH legal office in collaboration with the state employee unions before disseminating to MDPH staff. The assessment tool remains in the review process with the hope that it will be approved in FY23. Once approved, the organizational assessment will be administered in at least two Bureaus (BFHN and BCHAP) to measure performance and progress on this Title V priority. Results will support recommendations to improve workplace culture by ensuring equitable, healing centered public health systems and approaches to mitigating trauma.
Objective 2. By 2025, use surveillance data from multiple sources to develop a data dashboard that measures Adverse and Positive Childhood Experiences (ACEs and PCEs) to inform program and policy strategies that promote healing centered engagement at community, family, and individual levels.
In FY21, the implementation team expanded to include staff from the CDC-funded Preventing Adverse Childhood Experiences (PACE) Data to Action Grant, which, like the Essentials for Childhood grant, aims to measure and promote community factors that promote safe, stable, and nurturing environments. The PACE Surveillance Subcommittee worked to determine data sources, including NSCH, YRBS, BRFSS, Covid Community Impact Survey (CCIS)and PRAMS, to begin to develop an Adverse Childhood Experiences/Positive Childhood Experience surveillance system. Staff from the PACE grant worked with the Director of the Office of Population Health to create a plan for developing a community dashboard within the Public Health Information Tool (PHIT) that would allow communities to access data ACE/PCE data specific to their community to inform community strategies to implement healing centered approaches to promote positive childhood experiences and mitigate adverse childhood experiences.
Division of Sexual and Domestic Violence Prevention and Services (DSDVPS)
DSDVPS identified four indicators of resilience that can be tracked at the statewide level and shared with community service providers and other partners to inform work with MCH populations. In FY21, DSDVPS used 2019 MA High School Youth Health Survey (2019 MA HS YHS) data to obtain initial results for these four indicators:
- In 2019, 31.7% of MA high school youth reported engaging in volunteer activities during a one-week period. This is slightly higher among youth who also reported ever experiencing dating violence (40.7%) and unwanted sexual contact (42.7%).
- In addition, 61.2% of MA high school youth reported being involved in organized group activities (sports, youth clubs, etc.) in a one-week period. This percentage was lower among youth who also reported ever having experienced dating violence (54.9%) and slightly higher among students who reported ever having experienced unwanted sexual contact (62.8%).
- Among high school youth who reported that they needed to talk to an adult, 85.6% reported that they did talk to an adult when needed. This percentage was slightly higher among high school youth who also reported having experienced dating violence (89.3%) and slightly lower among high school youth who also reported ever having experienced unwanted sexual contact (81.2%).
- Ninety percent (90.0%) of MA high school youth reported that their neighborhood is safe or very safe. Percentages were lower among youth who reported ever having experienced dating violence (77.1%) and unwanted sexual contact (82.9%).
Additional activities to support equitable healing-centered approaches to address trauma
Additional efforts to address this priority that do not relate directly to the performance measure or other objectives are described below.
Division of Sexual and Domestic Violence Prevention and Services (DSDVPS)
DSDVPS funds rape crisis centers, domestic violence community-based services and shelters, intimate partner abuse education programs, supervised visitation centers, and programs for children who are exposed to domestic violence. DSDVPS-funded agencies provide direct services that incorporate practices of healing-centered and trauma-informed engagement. They participate in a variety of professional and community capacity-building strategies that promote resilience and trauma mitigation related to sexual violence and IPV experiences, such as coalition/task force meetings, community mobilizing, and professional training series.
In FY21, DSDVPS partnered with the MDPH Bureau of Substance Addiction Services to enhance program planning through trauma-informed and healing-centered approaches to address co-occurring conditions. Training and cross-training opportunities are under development for FY22 and beyond that will bring substance use and SDV staff members together to learn how safety and healing from both types of trauma can impact an individual and their world.
In partnership with the MDPH Office of Health Equity (OHE), DSDVPS enhances access to services for people with disabilities, as data show that people with disabilities experience higher rates of sexual and domestic violence. In FY21, DSDVPS worked with OHE to pilot test a new electronic version of the MA Facilities Assessment Tool (MFAT). The tool combines federal ADA and state Architectural Board guidelines for physical access to buildings and services for all MDPH-funded agencies. The tool’s designer, The Institute for Human Centered Design, used feedback from the pilot to develop a newer, easier-to-navigate electronic version of the MFAT that is compatible with e-reading software. MDPH SDV providers tested the beta version of the MFAT in FY21, and the tool was finalized shortly after the close of the fiscal year.
In FY21, DSDVPS also partnered with the MA Women of Color Network (MASSWCON) to increase the effectiveness of services and supports for Black women survivors and their families across the MA SDV Field. MASSWOCN held quarterly convenings to train and discuss 1) findings about the leadership of women of color in SDV programs 2) training for women of color to assume leadership in SDV organizations and 3) development of best practice guidance for working with Black communities on sexual and domestic violence. MASSWOCN disseminated a report of best practices throughout SDV organizations. The Governor’s Council on Sexual and Domestic Violence and several domestic violence high risk teams throughout MA have committed to reviewing and using the findings from this report.
Division for Children and Youth with Special Health Needs
FY21 brought opportunities for professional development on trauma-informed care to DCYSHN program managers to provide guidance in the workplace and with families of CYSHN. In August 2020, trainers from the Boston Public Health Commission shared two sessions on trauma informed care: “Trauma Resilience and Equity: Developing Shared Language and Foundational Knowledge” and “Promoting Health Equity and Resiliency During COVID-19: Exploring Best Practices for Naming and Addressing Racism from a Trauma-Informed Lens.” In April 2021, an MSW/MPH BUSPH graduate intern/UMass Medical School-E.K. Shriver Center LEND Fellow presented further trauma-informed training entitled “Trauma-Informed Care: Providing and Receiving” after interviewing the program managers for their needs. These trainings set the foundation for naming trauma-informed care/healing centered supports as a Division value to be interwoven in its work, much as racial equity and family engaged approaches have been.
Child and Youth Violence Prevention Unit (CYVPU)
The Child and Youth Violence Prevention Unit’s (CYVPU) Safe Spaces for LGBTQIA+ youth, community, and school-based programs continue to promote equitable, healing-centered approaches to address traumatic experiences and environments involving culture, education equity, and collective healing.
In FY21, Safe Spaces programs continued to provide drop-in spaces, a critical element for the programs to a create safe and affirming space for LGBTQIA+ youth to be with other youth who identify in similar ways, or to engage in culturally affirming activities. Youth who have accessed this unique model have reported that they feel like they “belong” and “matter” and that they manage their everyday life “better now than before.” They also conducted outreach and engagement to reduce COVID-19 infections; increased access to mental and medical health care needs not covered by insurance; assisted in accessing basic needs such as meals and housing; and provided behavioral health support within the drop-in center or subcontracted with a behavioral health specialist.
The CYVPU also continued its partnership with MDPH’s Division of Sexual and Domestic Violence Prevention and Services to provide the three-part Sexual Trauma Training Series. These trainings included “Introduction to Crisis Counseling,” which is designed to develop basic crisis counseling skills and interventions specific to sexual violence; “First Disclosure Training,” which provides best practices for responding when someone says they've experienced sexual violence; and “Trauma Training 101,” which provides youth workers with tools to support young people who have been exposed to violence.
Finally, CYVPU’s Gun Violence Prevention initiative ensures agencies take a trauma-informed approach to their work with violence-affected youth. The initiative supported the Training Center for Excellence to provide trainings to program staff to support skills and knowledge development, which included a strong trauma component.
School Based Health Centers
In FY21, the SBHC program hosted a virtual workshop, The Toll of Working with Trauma: Understanding Self-Care as an Ethical Imperative, to support the SBHC workforce during the COVID-19 pandemic. The training covered the scope and impact of trauma and provided an in-depth understanding of the toll that working with people who have been through trauma has on human service professionals. Discussion themes included: toxic stress and the impact on our bodies; how the pandemic is impacting people from a mental health perspective; a trauma-informed concept for managing the stress of uncertainty called Safety, Predictability and Control; features that promote resilience in ourselves and our students; and how to best care for ourselves.
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