Cross-cutting or Systems Building

This section concerning the domain of Life Course includes the SPN #8 Improving Integration of Information Systems and SPN #8 Smoking Prevention and the NPM #13 Oral Health and #14 Household Smoking. SPN #8 was added as a SPN recognizing the adverse impact of smoking on all population domains and many NPMs and NOMs.

Annual Report - NPM #13:

A) Percent of women who had a dental visit during pregnancy and

B) Percent of children, ages 1 through 17, who had a preventive dental visit in the past year

Oral health is an important part of general health. The second selected NPM in the domain of Child Health is NPM #13A (Percent of women who had a dental visit during pregnancy) and #13B (Percent of children, ages 1 through 17, who had a preventive dental visit in the past year). Access to oral health care, good oral hygiene, and adequate nutrition are essential components of oral health that help to ensure children, adolescents, and adults achieve and maintain oral health throughout the lifespan. People with limited access to preventive oral health services are at greater risk for oral diseases.

Oral health care remains the greatest unmet health need for children. Insufficient access to oral health care and effective preventive services affects children’s health, education, and ability to learn. According to the American Dental Association and the American Academy of Pediatric Dentistry, the dental visit should occur within six months after the baby's first tooth appears, but no later than the child's first birthday. Having the first dental visit by age 1 teaches children and families that oral health is important. Children who receive oral health care early in life are more likely to have a positive attitude about oral health professionals and dental exams. Pregnant women who receive oral health care are more likely to take their children for regular dental check-ups.

State Title V Maternal Child Health programs have long recognized the importance of improving the availability and quality of services to improve oral health for children and pregnant women. States monitor and guide service delivery to assure that all children have access to preventive oral health services. Strategies for promoting good oral health include: providing preventive interventions such as age appropriate oral health education, promoting the application of dental sealants and the use of fluoride, increasing the capacity of state oral health programs to provide preventive services, evaluating and improving methods of monitoring oral disease, and increasing the number of community health centers with an oral health component.

Table NPM #13

Notes - Source – National Survey of Children's Health (NSCH)

New Jersey has selected the following for ESM #13: preventive and any dental services for children enrolled in Medicaid or CHIP. The ESM was selected since all oral health education activities conducted in the school and community settings serve to improve the oral health status of school age children.

The Children’s Oral Health Program (COHP) has provided age-appropriate and developmentally targeted oral health education programs to school-age children covering all 21 counties in the State for over 35 years. It also provides oral health education programs for parenting and community groups and at WIC sites. During the 2019-2020 school year, approximately 39,392 students received oral health and /hygiene education and oral health personal care items including toothbrushes and floss. School and community presentations are conducted in areas of high-risk for dental disease and high-need of oral health services by Registered Dental Hygienists and Dentists, who provide evidence-based oral health and hygiene information, including the oral disease process, tooth anatomy, healthy food choices, reducing use of sugary foods and beverages, tobacco cessation and the dangers of vape and e-cigarette products, positive lifestyle choices to increase health and reduce systemic disease, and oral injury prevention education. As a result of COVID, the COHP revised their presentation education into online formats beginning in 2020. During the 2020-2021 grant year, schools and community groups have had the option of virtual recorded and virtual live oral health education. The COHP operates under the direction of the State Dental Director, Division of Community Health Services, Oral Health Services Unit.

Special school initiatives include the “Sugar-less Day to Prevent Tooth Decay” poster contest for 4th, 5th and 6th grades, “Project BRUSH” for grades K and 1, and “Project Smile” for grades 2 and 3. Special initiatives are designed to engage the whole school community with positive oral health messages

The “Save Our Smiles, voluntary school-based fluoride mouth rinse (FMR) program had 7,294 student participants in 95 schools during the 2019-2020 school year. Regular use of sodium fluoride mouth rinses in FMR programs have been found to reduce dental decay by up to 35%. Only 14.6% of New Jersey residents have access to CWF. In March 2020, school closures by Executive Order resulted in early discontinuation of the FMR program. This program is now permanently discontinued due to the lack of product needed for the program. The one manufacturer of the Fluoride powder packets and Fluoride unit doses ceased manufacturing of these products in late 2019. This affected 150,000 participants in FMR programs nationwide. A Fluoride Varnish program is being piloted through COHP. Due to lack of access to schools as a result of COVID, only small group programs have been held to date. More programs are anticipated in Spring of 2021 as COVID restrictions ease and school districts re-open.

Interprofessional oral health training programs include “Project PEDs (Pediatricians Eradicating Dental Disease), an introduction to Caries Risk Assessment and the application of fluoride in the pediatric medical setting for physicians, nurses and physician assistants and Project REACH (Reducing Early Childhood Caries Through Access to Care and Health Education, for physicians and obstetric nurses to provide information on the importance of oral health care for pregnant women.

The Home Visitation program, in collaboration with the Division of Children and Families, provides training to Home Visiting staff to encourage families to perform daily dental hygiene and the importance of establishing a dental home. Since its inception in 2014, 7,200 families participating in home visiting programs received oral health information and oral health care kits. This program was updated during the 2020-2021 fiscal year and developed into a series of three one-hour oral health trainings regarding vape/tobacco, diabetes and pregnancy. They were presented in January and February of 2021 and attended by a total of 256 participants. These webinar trainings are now available on the New Jersey Learning Management Network, a portal for public health training. This project is ongoing, with a Home Visiting newsletter slated to be released during Spring 2021, and 1200 oral health kits to be distributed to Home Visitation agencies.

Every 2 years, the NJ Department of Health directs the COHP to survey all State Health Officers and Dental Directors to update the Dental Clinic Directory, “Dial a Smile”. This directory, available online on the Department of Health website, serves as a public resource to identify providers of sliding scale, low-cost and no cost clinical dental services, increase access to care, and assist the public to establish dental homes and decrease Emergency Room visits for dental emergencies. Information about the “Dial A Smile” directory and how to find it online is regularly given to community stakeholders and included in COHP special initiatives, programs, and newsletters. The directory is edited periodically upon request and will be fully updated during the Summer and Fall 2021. It can be found online at: https://www.nj.gov/health/fhs/oral/documents/dental_directory.pdf .

The COHP newsletter, "Miles of Smiles" for school nurses is distributed annually each Fall to school nurses throughout the state. In the 2019-2020 school year, 3,258 were distributed. The "Oral Health Facts for Women, Infants, and Children" newsletter is emailed to State WIC Coordinators each Spring. Both contain timely oral health topics of interest and importance for staff to communicate to the populations they serve. These newsletters and other similar resources will be included on the Oral Health Services Unit webpage. The COHP has an ongoing relationship with WIC offices to provide education to their participants, however, due to COVID, WIC sites were closed. In February 2021, a virtual presentation on oral health and pregnancy was given to WIC staff during their regular staff meeting. COHP has offered virtual education presentation as needed and requested for WIC participants. Despite closures due to COVID, 435 WIC participants received education and oral health supplies during the 2019-2020 grant year.

The Oral Health Nutrition and Obesity Control Program reimburses eight Federally Qualified Health Centers to provide at dental visits, a minimum of three nutrition counseling sessions to Medicaid-eligible or uninsured children ages 6-11 who are determined to be within overweight or obese range as calculated by Body Mass Index. In Years 1 and 2 of this grant (Sept. 2018 – Aug. 2020), 4,655 children were screened and received oral health nutritional counseling. Of these, 1,362 were found to be in the overweight and obese range and received two additional counseling sessions. A caries rate of 23.5 % was found in the eligible cohort. The goals of this program are to increase oral health literacy, provide information on proper nutrition and the benefits of physical activity, and improve the dental and overall health for children and their families. Funds for this grant are provided by a 4-year HRSA Support of State’s Oral Health Workforce Activities grant, awarded to the Division of Community Health Services commencing September 2018 and ending August 2022. Program deliverables are overseen by the Oral Health Services Unit.

The Oral Health Services Unit collaborated with the Division of Family Health Services, Doula Pilot Project Liaison, and the Department of Human Services, Division of Medical and Health Assistance Services, NJ Family Care to create an oral health training for Doula staff. The goals for the webinar were: 

1. Provide workforce with basic oral health knowledge to share with families and pregnant people. 

2. Increase oral health literacy of staff working with families and pregnant people. 

3. Provide workforce with information on dental services and resources available in New Jersey and through NJ FamilyCare to share with families and pregnant people thereby increasing access to care and utilization of their dental services, especially for those enrolled in NJ FamilyCare. 

4. Provide a basis for ongoing discussion to assess the needs of community workforce in assisting their families and pregnant people to increase oral health literacy and improve oral health outcomes.  

There were 47 attendees at the June, 2020 presentation. This webinar is now available on the NJ Learning Management Network.

Annual Report - NPM #14:

A) Percent of women who smoke during pregnancy and

B) Percent of children who live in households where someone smokes

Adverse effects of parental smoking on children have been a clinical and public health concern for decades and were documented in the 1986 U.S. Surgeon General’s Report. Unfortunately, millions (more than 60%) of children are exposed to secondhand smoke in their homes. These children have an increased frequency of ear infections; acute respiratory illnesses and related hospital admissions during infancy; severe asthma and asthma-related problems; lower respiratory tract infections leading to 7,500 to 15,000 hospitalizations annually in children under 18 months; and sudden Unintended infant death (SUID).

As a result of the many health consequences, the health costs from smoking in pregnancy are significant. The excess costs for prenatal care and complicated births among pregnant women who smoke exceed $4 billion a year. (See NJ Pregnancy smoking rates in table A below) It has been estimated that a 1% drop-in rates of smoking among pregnant women could result in a savings to the US of $21 million in direct medical costs in the first year. Another $572 million in direct costs could be saved if the rates continued to drop by 1% a year over seven years. Secondhand smoke also has significant health effects on an infant. Pregnant women exposed to second hand smoke have a 20% increased risk of having an infant born with low birth weight, and secondhand smoke exposure also increases the risk for infections in the infant, and even death from SUID (Refer to the Perinatal Risk Assessment [NJ Medicaid recipients] below). Children living with smokers are also more likely to have more frequent and acute asthma attacks, ear infections, and serious respiratory illnesses like pneumonia and bronchitis due to second and third hand smoke exposure. (See NJ exposure in table B below) The cost to care for childhood illnesses resulting from exposure to second and third hand smoke is estimated at $8 billion a year. In addition to the effects during the perinatal period, health consequences for older children and adults (whether from directly smoking or from a second and third hand exposure) are well documented in the literature and include respiratory infections and disease, cancer, and death. In 2018, the New Jersey State Health Assessment Data shows that 51% of nonsmoking high school youth are exposed to secondhand smoke.

Perinatal Risk Assessment Data

*Majority of assessments completed by Medicaid recipients and not representative of state overall

Initiated in 2001 with funding from the NJDOH-Comprehensive Tobacco Control Program, Mom’s Quit

Connection (MQC) is NJ’s maternal child health smoking cessation and education program. There have been changes in the services provided and their capacity to be a statewide program through the years based on availability of funds. MQC utilizes a proactive behavior modification model, offering face-to-face individual cessation counseling, telephone counseling and texting support to assist clients in developing a customized quit plan. Through these direct services, both for consumers and professionals, MQCF focuses its efforts to reach the women and family members who need the help to quit, educate them of the dangers of tobacco use and offer judgement free, evidenced-based treatment methods by Nationally Certified Tobacco Treatment Practitioners and NJ Certified Tobacco Treatment Specialists.

The program was expanded during FY 2015 and Mom’s Quit Connection (MQC) was able to develop a multi-pronged and comprehensive statewide approach to perinatal smoking cessation activities. The new activities include:

• Promoting Mom’s Quit Connection (MQC) to further expand its reach to pregnant and parenting mothers in NJ.
• Increasing capacity of Mom’s Quit Connection with respect to direct services for pregnant and parenting mothers statewide.
• Preventing relapse after delivery.

Twenty target municipalities (TMs) were identified on which to focus MQC outreach and intervention, thus maximizing efforts to areas with the greatest need.  The TM’s were chosen based on the high numbers of pregnant women who used tobacco during pregnancy, and the high rate of preterm delivery among Black, Non-Hispanic women in these municipalities.  Seven of the twenty municipalities were located in five counties outside of the southern region; the remainder were within the seven southern counties. In January 2018, the MQC database software program was redesigned and upgraded to a web-based system using the Salesforce platform in order to support more detailed reporting and integration of planned mobile technology.  

Given the declining rate of maternal smoking and the stagnant and in some cases increasing numbers of postpartum women who were returning to smoking after delivery, MQC chose to rebrand to MQC for Families.  According to the 2017 PRAMS Brief published by the NJDOH, living with other smokers represented the most prevalent indicator for postpartum relapse. Expanding the program to MQC for Families has enhanced its cessation population parameters to include parents and care givers of children under 8 years old along with the pregnant woman to address not only the individual smoker but all smokers in the home environment. By helping the clients quit smoking, there is significant harm reduction for their children. Multi-level interventions are standard, including mailing self-help materials, phone calls, texting and direct individual cessation services. Relapse prevention interventions are an important part of the program to address the high relapse rates post-partum.

From July 1, 2020 thru June 30, 2021, there were 469 referrals to the program, 26% from the Central region, 27% from the Northern region and 46% from the Southern region. 417 of these referrals came from the automated Perinatal Risk Assessment (PRA) system:  referrals were faxed from providers; and, 24 were self-referrals from the MQC website and Facebook page online registration option. All 469 referred clients were sent self-help cessation information and texted the option of enrolling in MQC’s cession counseling program. 35 clients received a Level 1 cessation counseling session, and 27 clients went on to enroll in intensive cessation counseling. There were a total of 178 counseling sessions with clients enrolled in case management and 218 providers received client status reports on newly enrolled and existing clients. Of the enrolled pregnant clients, 95% quit or significantly reduced their consumption and 50% quit completely (the national average maternal quit rate is 24%). Among[CBN1] non-pregnant clients enrolled in cessation counseling, 89% quit or significantly reduced consumption, of which 50% completely quit. Throughout this year, 467 MQCF referred clients and their family members/caregivers were referred to the NJ Quitline.

Due to COVID 19, all work between July 1, 2020 and June 30, 2021 by MQCF was completed through the Zoom or Teams platforms.  MQCF provides statewide training to clinicians, medical professionals, social service agencies and educators on the Ask, Advise and Refer: Brief tobacco Intervention Model (AAR), in an effort to improve assessing for tobacco use and referring pregnant women, mothers, fathers and caregivers who use tobacco to MQCF. AAR, CDC Best Practice intervention, teaches the trainees how to successfully talk to their clients/patients about smoking, how to advise them to quit and where to make a referral that will facilitate the quit. Brief tobacco dependence treatment is effective as stated in the Treating Tobacco Use and Dependence: Clinical Practice Guidelines. From July 2020 through June 2021, 597 professionals received AAR training through the Zoom and Teams platforms.  Professional outreach and networking is vital for reaching new providers, offering MQCF Program Orientations and enhancing their services with professional and consumer education, tobacco resources and a system for direct referral for cessation counseling. From July 2020 thru June 2021, an additional 617 professionals received orientation and information sessions about MQCF and NJ Quitline. MQCF participates in conferences to increase professional awareness of the services that are available. 1710 professionals received information through conference tabling, toolkits, resource requests and networking opportunities.  Approximately 93 pregnant women and families received information about the dangers of maternal smoking and MQCF and NJ Quitline services through formal education sessions via the Zoom platform. Virtual community outreach and partner events reached an additional 461 mothers and families. MQCF staff now follow up (332 letters and emails sent this year) with every new prenatal provider trained on the use of the PRA, about scheduling a MQCF program orientation session and to promote ASK ADVISE REFER training. A vast amount of tobacco resource information has been made available online by MQCF for anyone interested, removing any barriers to access.

This past year, funding from the FHI Prematurity Prevention Initiative (PPI) was utilized to continue MQCF services to target municipalities with the highest rates of black infant mortality, and specifically, Atlantic City and Newark. These efforts resulted in a 6% increase in referrals to MQCF from the Northern region overall, and Essex County moving from the number eleven spot in client referrals last program year to the number one spot this year. According to the MQCF data by target municipalities those communities with highest rates of Black Infant Mortality and adult smoking were approximately 35% of all referrals. These results demonstrate that collaboration and targeted efforts were impactful in reaching mothers most at risk for maternal and infant mortality.

Collaboration with the PPI initiative also facilitated the launch of the Quit for Kids (QFK) texting support Program in May 2020. QFK is offered to stand alone, as texting support to quit or to coexist with the individual MQCF cessation services. To target the difficulties of quitting smoking, texts are personalized for each participant and geared toward their particular triggers, cravings and problems. If the participant would like to talk to an MQCF quit coach they are able to connect through QFK. During the startup year, 16 clients opted to talk to a quit coach. PRA clients with a current or past history of smoking are automatically enrolled to QFK, with an opt-out option. Clients working with MQCF can be enrolled through the client database. The texting program uses the GOMO platform to provide smoking cessation and child development messages to pregnant and post-partum women, as well as dads and family members of children up to eight years old. The goal of the texting program is to engage a broader range of clients, including a demographic naturally drawn to online services, and clients who may not initially be comfortable with one on one counseling. Enrolling with an MQCF cessation specialist is encouraged, but not required. This type of customized perinatal texting programs is relatively new; therefore, extensive analytics and evaluation have been built into the program to help determine its effectiveness in engaging clients and helping them to quit. From May 2020 to June 2021, 590 clients have enrolled in QFK.

MQCF program information remains on the NJ Quitline website and in the downloadable NJ Provider Cessation Toolkit. MQCF is also assisting with cessation content for the PPI website, and “pay attention cards”. MQCF program information is included in the PPI “COVID19 - GO KITS” project, providing supplies and resources for mothers at risk for preterm labor to be better informed and prepared for self-monitoring at home. Go-kits include critical resources such as blood pressure monitor, digital thermometer, face mask and information on achieving a healthy pregnancy and birth. Since the inception of the Go-kit project in March 2020, 1,735 kits have been distributed to New Jersey pregnant and postpartum women. Within the last 6 months 540 kits have been received. To date, 21% of Go-kits were given postpartum women, while 79% were distributed to prenatal women. Tobacco-Free Ride NJ-Clean Air for Kids in Cars (TFR) is a joint project between the FHI-FAS MQCF team and the SNJPC tobacco control program. TFR is designed to educate drivers about the risk of second and third hand smoke and vapor exposure to younger passengers. Those who pledge to keep their cars smoke free for children under 18 receive an incentive that includes a mobile bag, keychain flashlight, tire gage, mini first aid kit, car magnet, and educational materials. The first Tobacco-Free Ride campaign ran from January 17, 2020 through December 31, 2020, and 414 pledges were received from New Jersey drivers in the 2020 pledge year. On January 1, 2021, TFR was relaunched with a focus on keeping cars tobacco free for children eight and younger. There have been 401 unique pledges signed to date.

Tables NPM 14A & B:

1. Percent of women who smoke during pregnancy (last 3 months)

Notes - Data is from the NJ PRAMS Survey

B) Percent of children who live in households where someone smokes

Data Source: National Survey of Children's Health (NSCH)

[CBN1]Susan, we looked for current rate and don’t have the time for that research.