The Bureau of Family Health’s (BFH) work within the cross-cutting/systems building domain is focused on the bottom tier of the maternal and child health (MCH) pyramid in the development of public health services and systems. The work of this domain solidifies the foundation and growth of all the programming work throughout the BFH. It is focused on building or enhancing workforce capacity especially related to data, implementing and maintaining continuous quality improvement processes, and strengthening systems and infrastructure to enhance program delivery and address key social determinants of health.

 

The BFH monitors the health status of the MCH populations through multiple means including the use of Child Death Review (CDR) teams, Sudden Unexpected Infant Death (SUID)/Sudden Death in the Young (SDY) Case Registry, and the Pregnancy Risk Assessment Monitoring System (PRAMS). While SUID/SDY and PRAMS receive federal funding from the Centers for Disease Control and Prevention (CDC) which is used to support staffing, Title V funds are used to supplement the provision of these monitoring systems and activities by supporting data collection activities and the implementation of prevention strategies based on findings from these data sources.

 

Work within this domain incorporates the maintenance and development of BFH’s public health workforce at the state level by emphasizing and enhancing the usage of these data resources to drive program decision-making. Additionally, the BFH is partnering with current grantees in new ways. The BFH has begun and will continue to develop technical assistance documents and guidance for grantees not only on the development of localized plans to reduce health disparities, but also on the use of evidence-based practices targeted to those populations most at risk of poor health outcomes. The BFH prioritized addressing health inequities in 2020.

 

Priority: Strengthen Title V staff’s capacity for data-driven and evidence-based decision making and program development

 

The first step in data-driven decision making is accessing and interpreting public health data. Title V staff have continually expressed a desire for increased training and assistance in this area. Through the internal workforce survey administered as part of the 2019-2020 five-year Title V needs and capacity assessment, staff indicated additional training on how to use population health data to understand the needs of a maternal and child health population was a priority. Title V staff responding to an internal data capacity and workforce development survey administered in 2021 reaffirmed the importance of training in this area; they identified data access, data interpretation, and using data to understand population needs as areas where they required additional technical assistance.

 

In 2022, the BFH continued to use previously developed resources in an effort to improve Title V staff’s access to and use of Pennsylvania’s (Pa.) maternal and child health data. The internal Title V data dashboard that amasses data from various sources, including the national outcome measure and national performance measure dataset provided by the Health Resources and Services Administration, Maternal and Child Health Bureau (HRSA/MCHB), has been updated regularly with the most current data since its initial dissemination in 2021. Periodic reminders about its utility are provided to staff to encourage its use to inform programmatic decision-making and reporting. In fall 2021, the BFH also developed and implemented a standard data request form and process for program administrators seeking data. This initiative is ongoing, and the goal is to help facilitate staff’s access to internal and external datasets and to track how staff are using data to inform their work. This process requires staff to provide a thorough explanation of the request and provides oversight of and assistance with the procurement of the data and other information relevant to its analysis. In 2022, updated Title V data briefs were disseminated to staff and the public. The static data brief format was developed as part of the 2019-2020 five year MCH needs and capacity assessment and was well received by external stakeholders, agency partners, and Title V staff.

 

Another initiative related to this priority that continued in 2022 was training staff on data disaggregation and steps they could take to assess and break down programmatic data. The BFH developed and delivered two introductory trainings on the concept of data disaggregation and how to disaggregate program data to characterize the population served in 2021. A follow-up training was conducted in June 2022 on how and why to disaggregate program outcome data. The goal of these trainings was to build staff capacity to collect and use program data with intention and consideration of the principles of health equity. These topics will be continually revisited with staff and additional training may be developed in 2023-2024 as improved data collection and utilization continues to be a BFH training priority.

 

Data from a 2023 survey of staff on 2022 training initiatives suggest improvement in this area since 2021 as over 60% of staff indicated they understand data disaggregation as a concept and why it is important. However, the survey also suggested there are barriers to practical implementation of this concept as only half of all staff respondents indicated they have ever disaggregated their data, and many indicated data currently collected are not easily disaggregated or may not be meaningful due to small numbers. Accordingly, this remains an important training priority.

 

SPM: Increase the number of program or policies created or modified as a result of staff’s use of evidence-based, data driven decision making each calendar year

 

Strategy: Assess BFH programs to determine existing data and determine methods for sharing data with internal and external partners

 

Objective: Review BFH programs to evaluate existing data sources and provide supplemental data sources where available to at least 10% of programs per year

 

ESM: Number of technical assistance requests for data made to DBO each year using the established guidelines

 

The Division of Bureau Operations (DBO) uses a workflow process in Microsoft Teams for technical assistance requests. While DBO technical assistance is available for a variety of categories, the primary focus is assisting in setting program goals as well as process and outcome measures that enable programs to track progress toward addressing Title V priorities and performance measures and developing evidence-based program analysis. BFH promotes the use of specific, measurable, attainable, realistic, time bound, inclusive, and equitable (SMARTIE) goals to establish and measure program performance. DBO will also aid BFH staff to assist their grant partners to establish quantifiable incremental goals and collect data necessary to track grantee performance. As described above, a request form in Microsoft Teams has also been created to initiate data requests. Once a request form is submitted, staff meet to discuss what data needs collected, how the data will be utilized, and the sources from which the data will be obtained. DBO will then facilitate the data collection process as needed and obtain any data access required.

 

In 2022, DBO received and completed one technical assistance request, falling short of the ESM goal. DBO received a request for technical support to assist the program evaluation for Easterseals Autism Diagnostic Clinic resulting in a general discussion and review of the resources available to the program administrator.

 

Strategy: Increase staff access and use of National Survey for Children’s Health data sources to enhance program planning, design and implementation

 

Objective: Disseminate annual NSCH data to program staff after it is released on childhealthdata.org each year to support and develop MCH programming

 

ESM: Percent of staff trained annually on availability of NSCH data and how to access that data

 

The ESM was met as over 80% of staff were trained on availability of NSCH data and how to access it. A presentation on the NSCH website was made to Bureau staff at a quarterly staff meeting in December 2022. The presentation included a discussion of the oversample, an exploration of the data on the website, and how to access and analyze it. In addition, U.S. Census staff reported in March 2023 that data collection for the 2022 NSCH was completed, including the completion of the anticipated 1,500 to 1,550 interviews in Pa. That data will be available in fall 2023. The oversample will increase the number of completed surveys in the state and may improve the precision of estimates for rare outcomes and small populations. In July 2022, HRSA approved BFH’s request to transfer MCHSBG funds to U.S. Census to cover the cost of the 2023 oversample.

 

Strategy: To use PRAMS to conduct epidemiological surveillance of the maternal and child health population in Pa.

 

Objective: Annually produce and disseminate at least two PRAMS data analysis products

 

ESM: Percentage of PRAMS data requests resulting in a new or modified program or policy in each calendar year

 

ESM: Number of programs or policies created or modified as a result of the dissemination of PRAMS data analysis products in each calendar year

 

PRAMS, a joint research project between the CDC and state health departments, is a critical and unique source of maternal health data. The project’s mission is to promote the collection, analysis, and dissemination of population-based data of high scientific quality and to support the use of data to develop policies and programs to reduce maternal and infant morbidity and mortality. The CDC requires states to annually report on two ways PRAMS data have been used to drive program or policy development. These reports are then used by the CDC to justify to Congress why the PRAMS program should continue to receive federal funding. Access to and use of the dataset are, therefore, critical to the survival of the PRAMS dataset.

 

PRAMS has been a data source in Pa, since 2007, however, the dataset has been underutilized, even within the BFH. To increase visibility of the PA PRAMS dataset and what it can offer BFH staff and MCH stakeholders, the BFH is producing and disseminating at least two PA PRAMS data analysis products per year. These products may be topic briefs, information sheets, abstracts and posters, journal articles, or descriptive analysis reports. BFH staff work with the PRAMS Committee to prioritize analysis topics and the most appropriate forms of data dissemination. The PRAMS committee is multidisciplinary and specific to Pa. Composed of BFH staff and various MCH stakeholder groups, the committee meets annually to discuss Title V priorities and share updates on PRAMS supplements, PRAMS weighted data, and other topics. For example, starting in May 2021, the PA PRAMS project implemented a 12-month supplemental questionnaire to collect data pertaining to respondents’ experiences with the COVID-19 vaccine. In November 2022, the weighted data from this supplement became available. BFH Epidemiology staff is further analyzing this data and PRAMS staff will develop a data brief based on the findings. This data brief will then be made publicly available on the DOH website and shared broadly with interested parties. In May 2021, PA PRAMS streamlined its data request process and has since received several data requests. The updated process for internal and external PRAMS data sharing allowed for programs and researchers to review the available data. These requests include internal DOH requests from the Division of Newborn Screening and Genetics to provide breastfeeding data and Government Agency Maternal Mental Health Fellows Program to provide data surrounding depression and determining possible disparities related to maternal mental health. PA PRAMS is currently working with the Bureau of Epidemiology’s Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET) team in utilizing PRAMS data to determine how the COVID‑19 pandemic impacted prenatal care and to gain a better understanding of vaccine hesitancy and adherence to COVID-19 mitigation practices. Additionally, PA PRAMS is working with the Bureau of Health Promotion and Risk Reduction to provide breastfeeding data for their CDC SPAN Cooperative Agreement Application. Externally, PA PRAMS has received requests for data to assist Lehigh Valley Health Network conduct research on various screening and counseling topics that occurred during and after pregnancy. PA PRAMS also provided data on how often birthing people are educated on safe sleep habits to the Pennsylvania Perinatal Quality Collaborative for the development of improved educational opportunities within maternal health care providers.

 

To demonstrate how PRAMS data is applied to public health research and process improvement, PA PRAMS provides at least two Data to Actions to stakeholders annually. The two completed Data to Actions demonstrate how PRAMS data have been used to identify needs and help create programs to improve maternal and infant health.  The 2022 Data to Action #1 reflected on a study, “Prevalence and Associated Risk Factors of Postpartum Depression among Mothers in Pennsylvania, United States: An Analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS) Data, 2012-2015”, pertaining to risk factors associated with postpartum depression conducted utilizing PA PRAMS data from 2012-2015. The 2022 Data to Action #2 reflected on the data brief based on data from the PRAMS COVID-19 Supplement, which ran from May 2020 to December 2020. This supplement collected data to gain an understanding of how the COVID-19 pandemic impacted birthing people. The data brief is publicly available on the DOH website.

 

Due to a lack of programs or policies created or modified by entities who directly requested PRAMS data from the Bureau, these ESMs have not been met.

 

Strategy: Increase the number and quality of local CDR team reviews to enhance program planning, design and implementation

 

Objective: Annually increase the number of reviews by local CDR teams that include identification of the underlying causes of death

 

ESM: Increase the percent of CDR cases reviewed by 5% each year

 

As noted elsewhere in this application, Act 87 of 2008 requires that all counties in Pa. either establish a local public health CDR team or collaborate with other counties to operate on a regional basis. The teams are comprised of local professionals including coroners, law enforcement, physicians, mental health providers, substance misuse treatment providers, public health, and child welfare services. The local CDR teams are tasked with reviewing all deaths of children and youth aged 21 years and younger. The purpose of the local CDR teams is to summarize the findings from the reviews of child deaths and to make recommendations regarding how to utilize those findings to inform prevention strategies and programming. The BFH provides training, support, and technical assistance to all of Pa.’s local CDR teams. Over the last decade, the percentage of child deaths reviewed has decreased from a high of 75% for 2013 deaths to 43.2% for 2019 deaths. Deaths occurring in 2020 are the most current data available. Of the 1,664 deaths occurring in 2020, 801 (48.1%) were reviewed and entered in the National Center for Fatality Review and Prevention-Case Reporting System (NCFRP-CRS) by local CDR teams. Many teams were unable to complete a review of all children’s deaths occurring in 2020 due to continued COVID-19 related efforts which impacted the ability of teams to meet and some key team members’ capability to devote time and resources to CDR. Attrition has also adversely impacted teams as key team members and team chairs have retired or moved to new positions.

 

To address the challenges that local CDR teams have meeting the obligations of Act 87, the BFH has explored several options to provide support to local CDR teams. BFH has developed and is piloting a method for sharing recommendations to ensure that the basis for the recommendations and the intended outcomes are clear. In addition, follow-up will be made on recommendations shared within and outside of BFH.

 

BFH has also begun importing information from Vital Statistics into the NCFRP-CRS for all local CDR teams. Importing data from Vital Statistics into the NCFRP-CRS requires less manual entry from the local CDR teams, which BFH expects will lead to improved timeliness and data quality.

 

The State CDR Team prevention framework has not worked as intended. Meeting participation and engagement are low. The framework will be reassessed to determine how the State CDR team can best meet its statutory obligations in a way that is meaningful.

 

BFH has leveraged Title V funds to partner with East Stroudsburg University to assess the current Pa. CDR system. The expected outcomes are to: better meet the needs of the local CDR teams; increase the number of case reviews; and increase the quality of those reviews and subsequent data. In 2022, the vendor surveyed team chairs and coroners in addition to observing several team meetings. The vendor has begun meeting with other states’ CDR programs to understand the breadth of what is possible. Some preliminary assessment findings include:

 

• Rural vs urban differences in CDR participation are significant.
• Formal new chair training is limited.
• Limited time and limited information from out-of-county/state deaths are barriers, even among teams that regularly report data.
• Uniformity in how and when CFRP data entries are made is lacking.

 

The vendor will continue to survey CDR chairs, key stakeholders in areas without functioning teams, and other states’ CDR programs before moving onto making recommendations.

 

The goal to increase the number of child fatality cases reviewed and entered into the case reporting system by local CDR teams by five percent was met this year despite teams being adversely impacted by their inability to meet due to changes in leadership and increases in team member duties related to COVID-19. 

 

Priority: Support and effect change at the organizational and system level by supporting and promoting policies, programs and actions that advance health equity, address the social, environmental, and economic determinants of health, and deconstruct institutionalized systems of oppression

 

The overarching Healthy People 2030 health equity goal is to “eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.” In alignment with this goal, BFH recognizes the deconstruction of institutionalized systems of oppression as necessary to advance health equity and improve the social, environmental, and economic determinants of health.

 

The BFH has maintained its commitment to address and combat health disparities in all MCH populations by maintaining and monitoring language in all grant agreements requiring grantees to do the following:

 

• Develop a plan to identify, address and eliminate health disparities in the populations served by Title V.
• Align their work plan with the goals and strategies of the National Stakeholder Strategy for Achieving Health Equity.

 

The BFH has integrated the health disparities language into grant agreements as the agreements have been executed. Grantees have submitted workplans to BFH project officers in accordance with grant deliverables.

 

At the statewide and Department level, BFH supports and has assigned staff to participate on several health equity and antiracism task forces and workgroups to expand health equity principles and knowledge, ensuring information is being shared with the workgroups and back to BFH staff.

 

The first, the Office of Health Equity (OHE) Culturally Linguistically Appropriate Services (CLAS) taskforce, has six key objectives:

• Foster cultural competence
• Reflect and respect diversity
• Ensure language access
• Build community partnerships
• Collect diversity data
• Benchmark, plan and evaluate

 

CLAS standards help ensure an equity lens across all health care services by considering cultural health beliefs, preferred languages, health literacy levels, and communication needs. In 2021, the OHE set out to include CLAS/Health Equity language in all state documents with vendors. This contract language aims to utilize the National CLAS Standards to provide services in an equitable manner to the populations served, identify specific group(s) or population segments who experience a disproportionate burden, and address the specific social and environmental conditions (social determinants of health) that put disproportionately affected groups at increased risk of a disease, health condition, or problem. The contract language encourages grantees to improve the quality of their work with regards to equity and reducing disparities. Training is provided to DOH project officers as well as grantees. A taskforce sub-committee published a Department-wide CLAS newsletter to educate staff on CLAS standards and notify them of upcoming CLAS events.

 

The second group, the DOH Anti-racism and Health Equity Task Force (ARHETF), formed in May 2021 with BFH staff serving on the steering committee and both the support and training and the policy subcommittees. The purpose of the ARHETF is to lead the DOH’s efforts to become an antiracist institution, mindful of historically disinvested communities; and achieve equity and inclusion for all staff and health equity in the state. In 2022, the DOH Shared Language document containing standard health equity terms and definitions was approved and shared with the Department. Current initiatives include training modules for the terms and definitions, an analysis of Department policies and practices through an equity lens, and an assessment of existing health equity initiatives across the Department. The DOH Health Promotion Program Development Framework, a guiding document for staff responsible for developing and implementing health promotion and health education programs, was also updated.

 

Additionally, staff participate on the Pennsylvania Interagency Health Equity Team (PIHET), which convenes over 12 state agencies working to address health equity, and diversity, equity, and inclusion within their respective sectors. Resources and ideas are shared to strengthen cross-sector collaboration. PIHET is currently developing a Racial Equity Strategic Plan. Finally, staff participate in statewide efforts, including an Anti‑Racism Book Club, and a Diversity, Equity, and Inclusion Interagency Collaboration Workgroup, formally known as the Human Centeredness Community.

 

The BFH recognizes and continues to explore the necessary changes that must occur to increase workforce capacity to identify training and technical assistance resources for staff and grantees so they can identify disparities, the causes, and evidence-informed strategies to address them; understand the impact of institutional racism and structural inequities; measure the effectiveness of interventions; and promote policy and programmatic changes to eliminate disparities.

 

SPM 6(A): Rate of the mortality disparity between black and white infants

 

SPM 7(B): Rate of the mortality disparity between black and white children, ages 1-4

 

SPM 8(C): Rate of the maternal mortality disparity between black and white persons

 

Over the course of the funding cycle, the BFH continues to identify and develop strategies to address the priority to support and effect change toward the advancement of health equity and deconstruct systems of oppression. By doing so, the BFH also aims to narrow the racial gap in adverse health outcomes. As such, the rate of change in reducing the mortality gap for black and white infants, children, and mothers or birthing people will serve as the BFH's long-term measure of progress toward advancing health equity. To improve MCH health outcomes, the gap between racial and ethnic majority and racial and historically marginalized populations must begin to shrink because of comprehensive programming, policy change, and organizational action. The BFH continues to identify ways to orchestrate organizational change from the bottom up by increasing understanding of health equity principles and knowledge of the disparities that exist for infant, child, and pregnancy related mortalities among BFH staff and grantees. As understanding increases among staff and grantees, the BFH will strive to identify additional strategies and performance measures to address the other components of the priority. Due to the complexity of the systems changes required to achieve the targets for these strategies, during 2022, the targets were not met.

 

Strategy: Increase staff understanding of Health Equity principles

 

The BFH established a Health Equity Committee (HEC) in 2018 as part of its commitment to address health disparities and achieve health equity for the maternal and child health population in Pa. To address the complex health equity goals, the HEC developed a three-year workplan, a large portion of which was to identify and address staff’s understanding of health equity concepts, the incorporation and understanding of community engagement, and communication around BFH reporting. Although the three-year work plan was to conclude in September 2022, the HEC was disbanded early in June 2022. Endeavors, collaborations, and resources, internal and external to the BFH, continue to shape the direction of this complex work. 

 

In January 2023, the BFH entered a new phase, the Health Equity Priority Project, expanding health equity efforts across the Bureau. Staff were charged with revisiting their program strategies, as outlined in the state action plan, by using a set of “guiding questions” to evaluate their existing programs. In revisiting the strategies, staff first examined the MCH problem and the health outcome, whether current strategies were appropriate for the population to be served, if input from communities or populations that are intended to be served is supportive of the strategies, and whether strategy implementation is sufficient to impact population health measures. 

 

Second, staff reexamined programmatic areas where the implementation or reporting measures required adjustments to better respond to the program needs, specifically if there was a need for data disaggregation or the development of evaluation measures. Lastly, staff identified existing gaps where strategies (existing or non-existing) do not fully address priority needs.

 

The Health Equity Priority Project is a step in raising awareness of practical application of health equity principles on existing projects and offers an opportunity for staff to practice applying a “health equity lens” to assessing strategies. There is opportunity to build on this initial activity and further incorporate this practice into general operating procedures related to strategy and program development, implementation, and evaluation.

 

Objective: Annually provide at least one training, education or policy guidance technical assistance on principles of Health Equity for all BFH staff

 

ESM: Percentage of staff trained annually on the principles of Health Equity and the effectiveness of Health Equity plans

 

In June 2022, the HEC implemented a two-part series of Health Equity Prerequisite trainings with BFH staff, completing this ESM. The trainings’ key focus areas addressed the following competencies, identified through the 2019 BFH Health Equity Assessment, for staff:

• Health equity and related evidence-based practices including:
  • The historical context surrounding health disparities and health inequity.
  • Power and privilege; and
  • Examining evidence-based practices through a health equity lens.
• Community engagement including using community engagement to identify, track, and measure social determinants of health.
• Communicating about health equity in BFH reporting.

 

At the time of the training, 98% of staff completed the Health Equity Prerequisite trainings. Although the HEC training plan was delayed due to COVID-19 and the HEC training plan has been discontinued with the HEC, efforts to continue trainings on health equity will be explored for the coming year. 

 

Building on the awareness introduced in the Health Equity Prerequisite trainings, trainers from the Governor’s Office of Performance Excellence facilitated a “Continuous Quality Improvement for a Healthier Pennsylvania” training. Held in December 2022, 73% of staff participated in the training. Aligned with principles of health equity, the learning objectives included identifying the connections between bias, social location, and health equity; using continuous quality improvement as a vehicle to improve health equity outcomes; and establishing a continuous quality improvement environment through the Healthy Government Framework. The Healthy Government Framework is comprised of five key principles:

1. Purpose: Clarifying our whys. Why do we exist and why do our customers value what we do.
2. Process: Identifying work creating value for our customers and doing it well.
3. Capability: Ensuring employees have the knowledge, skills, and tools they need to succeed.
4. Management System: Creating visibility into our performance at every level.
5. Human-Centered Mindset and Culture: Putting people, customers, and team members at the cent er of your organization.

 

The HEC administered its second health equity assessment in November 2021. This assessment specifically sought to gather staff feedback on their personal understanding and use of health equity concept, principles, and practices. Analysis of the surveys continued through 2022 to help guide the direction of the Bureau’s health equity work and training needs. A report compiling the findings and recommendations was finalized in January 2023.