SPM #3 Address Social Determinants of Health Inequities.

Existing economic and health disparities indicate a continuing need to prioritize efforts to address the social determinants of health (SDOH). Financial stability is one of the primary SDOH. According to the U.S. Census Bureau American Community Survey, Missouri’s poverty rate has declined yearly from 14.8% in 2015 to 12.8% in 2022, which suggests increasing economic stability for some Missourians. However, additional examination indicates poverty is consistently higher among Non-Hispanic Blacks and Hispanics compared to non-Hispanic whites. In 2022, the poverty rate for Non-Hispanic White Missourians (10.9%) was lower than that of both Non-Hispanic Blacks (23.8%) and Hispanics (18.7%). Geographic disparities in poverty also exist; the USDA Economic Research Service reported an urban poverty rate of 11.6% in 2021 compared to a rural poverty rate of 16.3% in the same year.

Healthcare access and quality are also primary domains of SDOH. Racial disparities in both infant and maternal mortality indicate a need to explore improvements in healthcare access and quality as part of efforts to address SDOH. Missouri Vital Statistics data denote the Missouri infant mortality rate in 2022 was 6.5 per 1,000 live births. Though there was previously a reduction in Missouri’s overall infant mortality rate from 2017 (6.23) to 2021 (5.7), the infant mortality rate increased from 2021 to 2022. The racial disparity between Non-Hispanic Black women and Non-Hispanic White women’s infant mortality rate has persisted since 2017 (Figure 8). Additionally, the 2018-2022 maternal mortality rate for Non-Hispanic Black women (43.9 per 100,000 live births) was double that of Non-Hispanic White women (20.6). Plans to address the maternal and infant health disparities are highlighted in the women/maternal and perinatal/infant health domain narratives.

To gain buy-in and build internal awareness and understanding of SDOH across MCH programs and the Department of Health and Senior Services (DHSS) overall, MCH leadership developed a core MCH training plan, including didactic and interactive experiences for leaders, team members, and MCH program staff. The MCH leadership team continues to review existing resources, including the MCH Navigator training, MCH Leadership Competencies, and other evidence-based training methods and content to develop a continuously evolving training plan. The goal is to establish ongoing training requirements for internal MCH program staff and external contractors. This training has allowed program staff to learn foundational MCH skills, understand the impact of SDOH, and effectively integrate strategies to address the root causes of health inequities into policies and program services and activities. For FFY 2023, 102 out of 113 Title V funded staff completed a series of videos and article reviews on the medical home approach and the strengthening families framework from the American Academy of Pediatrics (AAP) and the Center for the Study of Social Policy. Post-training evaluations showed the training modules furthered staff knowledge of the topics presented (see infographic below). Additionally, staff shared the training was valuable for their personal and professional lives (See infographic with quotes below). Beginning in FFY 2024, the training plan will be extended to external contractors.

In alignment with the new DHSS Culturally and Linguistically Appropriate Services (CLAS) Standards Policy, the diverse populations served by Title V are considered at all stages of program and service delivery. MCH programs consider the needs of their target population(s) and how programs are inclusive and non-stigmatizing towards program participants. All programs and services are culturally and linguistically appropriate to provide practical, equitable, understandable, and respectful quality care and services responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Particular focus is given to marginalized and underrepresented populations and communities. The CLAS standards are applied as general guidelines for all programs and services. They provide a uniform framework for developing and monitoring CLAS to ensure they broadly include diverse racial, ethnic, sexual, and other cultural and linguistic groups.

Other Cross-Cutting & Systems Building Efforts

Newborn screening impacts nearly every baby born in Missouri regardless of socioeconomic status and cultural background. The Newborn Bloodspot Screening Program sought to understand the parents’ experience with newborn screening by implementing an improved electronic survey. The survey includes questions assessing barriers to seeking repeat screens or additional testing. The survey asks for voluntary demographic information to ensure data is gathered from diverse participants. Determining areas of the newborn screening population where access or information is lacking has helped improve outreach strategies and enhanced the capacity to provide more meaningful education to parents. The newborn screening team sought out and participated in opportunities to further their understanding of ways to provide more culturally and linguistically inclusive services to the broadly diverse population impacted by newborn blood spot screening. Two program team members attended the 2023 AMCHP conference in New Orleans and participated in sessions focused on SDOH, health disparities and inclusive practices. Following the conference, the program staff collaborated with local doula organizations serving marginalized populations to create a newborn screening education module The doula organization will use the module to train staff providing information to expectant and new parents. Careful attention was given to cultural congruence and inclusive visual representation in the training module. Completion and implementation of the training module is expected in early 2024.

The Newborn Hearing Screening Program (NHSP) incorporated CLAS standards into the program’s initiatives to ensure all babies born in Missouri receive a hearing screening and appropriate follow-up to increase the likelihood children with hearing loss acquire communication skills. The NHSP, Family Partnership Program, and Missouri State University MOHear Project worked together to reflect their commitment to diversity and inclusion. NHSP supported, encouraged, and empowered families with limited English proficiency, including training new NHSP staff on the use of phone interpretation services, updating imagery on the NHSP webpage and brochures to reflect diverse populations, ensuring all parent letters are printed in English and Spanish, and collaborating with an outreach program to provide a diversity training workshop for NHSP, Family Partnership, and MOHear staff.

The TEL-LINK Program collaborated with MO HealthNet to provide 77 referrals for Medicaid services to increase insurance coverage. TEL-LINK also collaborated with partners to provide referrals for various services, such as smoking cessation, dental care, WIC clinics, mental health treatment centers, health insurance providers, and more.

The Newborn Health Program continued to partner with various community health providers to distribute the Pregnancy and Beyond booklet, which contains information about financial resources for pregnant women and children, including MO HealthNet.

The Childhood Lead Poisoning Prevention Program (CLPPP) focused on available data analytics to identify gaps in care and disparities in blood lead testing across the state. CLPPP worked with national partners to develop and distribute culturally and linguistically diverse resources related to lead poisoning prevention. CLPPP identified several resources from the Minnesota Department of Health that were translated into languages besides English and shared those resources with providers, case managers, and risk assessors to enhance educational outreach. CLPPP started a health literacy review of multiple forms and is working to revise the reading level of the forms to a more average reading level. The program will review additional literature to enhance the client's understanding of recommended lead abatement/interim control actions.

Through the Inclusion Services (IS) Program, the Inclusion Specialists at the Department of Elementary and Secondary Education referred families to appropriate services, including those provided as part of child-specific action plans by public school districts. Specialists helped child care providers identify SDOH, such as housing, food access, poverty, or exposure to violence, as possible factors impacting children’s behaviors. This increased knowledge and skill set among child care providers on how to impartially work with and maintain care for children with special needs has reduced preschool expulsion.

The Bureau of Special Health Care Needs (SHCN) Service Coordinators and Family Partners focused on the SDOH for families of individuals with special health care needs. SHCN employs Family Partners to provide the unique perspective of parents of children and youth with special health care needs (CYSHCN). Interpreters are utilized for conversations, and forms are translated into various languages. The Service Coordination Assessment (SCA) is a comprehensive assessment that assesses, identifies, and addresses concerns beyond the scope of services provided through SHCN programs. Examples of topics covered in the SCA include insurance coverage, military service, mobility, transportation, dietary concerns, emotional status, social and physical environmental (such as social inactivity and barriers keeping an individual from getting out into the community or participating in activities they enjoy, as well as home environment safety and stability of living conditions), cognitive concerns, educational/vocational status, family functioning (such as family stability and availability of a support system for the family), and cultural and belief system. SHCN Service Coordinators and Family Partners frequently connect families with resources for food, housing, utility, social support, transportation, and recreational/leisure opportunities. SHCN emphasizes improving the quality of life for participants and families beyond the direct care services provided through SHCN programs. Additional information regarding SHCN is included in the CSHCN Domain narratives.

DHSS leveraged funding from the Centers for Disease Control and Prevention (CDC) State Physical Activity and Nutrition (SPAN) grant to provide a lactation consultant preparation course. It was made available to areas of the state that have low breastfeeding rates and disparities in the care available to women of color. Thirty-one individuals participated in the training. Women of color are being encouraged to become peer counselors or International Board Certified Lactation Consultants (IBCLCs) in areas with disparities in breastfeeding support. Some women encounter barriers to employment as WIC peer counselors, such as part-time hours, lower wages than other employers and lack of a career path. Community partners report access to clinical hours for lactation mentorship and the cost of college courses required to sit for the IBCLC exam are significant barriers for people of color to become IBCLCs. To help remove some of these barriers, the Missouri WIC Program has changed two policies, allowing IBCLCs to fill Breastfeeding Coordinator and Breastfeeding Peer Counselor Coordinator positions, in addition to nurses, nutritionists, and registered dietitians. This change will enable breastfeeding peer counselors to obtain the IBCLC credential and become coordinators. DHSS is providing more resources to help peer counselors become IBCLCs.

The Bureau of Community Health and Wellness (BCHW) received supplemental funding through the CDC SPAN grant to address breastfeeding disparities. The state breastfeeding coordinator worked with BCHW staff to address the high racial disparities in breastfeeding rates in the Bootheel region. Local stakeholders were invited to participate in a Breastfeeding Learning Collaborative (BLC). The Lincoln University (a Historically Black College and University) Cooperative Extension, the Missouri Bootheel Regional Consortium (MBRC) and local public health agencies (LPHAs) in Dunklin, Pemiscot, Mississippi, Scott, and New Madrid counties were identified as critical partners and received compensation for participation. Throughout the BLC, 49 people from 19 organizations participated in a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis exercise to better understand barriers and facilitators to breastfeeding in each county in the Bootheel region. Meeting minutes were used to generate themes for each SWOT category, which will inform future goals and next steps. The BLC facilitated partnerships in the region, and the SWOT analysis will be used to guide future work as funding allows. The supplemental funding also funded a formal training on breastfeeding disparities delivered by Reaching Our Sisters Everywhere (ROSE) to facilitate understanding and shared purpose to address breastfeeding disparities.

The Adolescent and School Health Program (ASHP) implemented the School Nurse Chronic Health Assessment Tool (SN CHAT). The ASHP broadly promoted this resource during school health conferences and other avenues as a tool for school districts to improve the quality of student health information and address student health and education needs appropriately. ASHP staff provided examples of how school nurses can interact with parents of CYSHCN. There are plans to add additional chronic conditions such as autism, cancer, and cystic fibrosis. Additional details regarding ASHP activities to address the SDOH inequities can be found in the Child, Adolescent and CSHCN Population Domains.

As a member of the Medicaid Advisory Council, the ASHP collaborated with the MO HealthNet Managed Care plan, Federally Qualified Health Centers, other state agencies and programs, and funding organizations to provide resources to equip school nurses with information about healthcare plans and services. This information will aid school nurses to assist families to obtain adequate health insurance coverage and access healthcare services and health plan benefits. The outreach materials and patient education are available in multiple languages and are reviewed by health literacy professionals to ensure the messages are appropriate for the targeted audiences. The ASHP used Department of Social Services (DSS) data to review and identify trends in the number of children enrolled in Medicaid annually. The ASHP compared this to data from school nurse records. With the expansion of Missouri Medicaid eligibility to healthy adults, the ASHP worked with school nurses to provide information and resources to support them in assisting families with Medicaid enrollment.

ASHP and the MCH Director are part of the steering committee of the Show-Me School-Based Health Alliance (SBHA), the Missouri affiliate of the National School-Based Health Alliance. SBHA shares the vision that when all children and adolescents have access to health care, they are better prepared to achieve their fullest potential. The Alliance works with partner organizations and community stakeholders to expand the number of school-based clinics and services offered. Barriers to students seeking needed health services include missed school to attend medical appointments and parents missing work to take students to those appointments. The school-based health care model improves access to quality health care and augments achievement and success for ALL children, regardless of race, socioeconomic status, or zip code. School health services play a critical role in ensuring children and youth have access to high-quality, affordable health care and positively impacting students’ health and learning. In September 2019, the SBHA began systematically collecting information across the state to learn what SBH programs exist, who has access to the programs, and what services are being provided. According to the December 2020 report, 57% of K-12 students in Missouri have access to school-based health care.

ASHP collaborated with school health staff in public, private, parochial, and charter schools to collect annual reporting utilizing an online database. This system has been in place for over a decade, and the information is used to identify trends, facilitate planning of state resources, and ensure up-to-date communication with lead nurses. ASHP used the data to monitor the staffing of school health services and identify districts without designated school health staff. The program offered additional support and technical assistance to ensure the minimum level of health services are available. The database also collects district-level data on student’s health insurance status. The data is used as an indicator of healthcare access and is shared with state and local leaders. The ASHP engaged school nurses to utilize the reporting system to investigate options for improving data collection, access, and sharing.

ASHP utilized SDOH categories to inform and organize the quarterly Council for Adolescent and School Health (CASH) activities, professional development opportunities and strategic implementation of plans for future growth. 

The MCH Services Program supported LPHA efforts to:

• Increase the number of clients that received a risk assessment or screening and referral for Medicaid eligibility.
• Assure all women of childbearing age received preconception care services that will enable them to enter pregnancy in optimal health.
• Develop and promote strategies to increase the proportion of women receiving prenatal care beginning in the first trimester.

LPHAs continued to:

• Screen clients for MO HealthNet or other insurance coverage.
• Screen for an identified primary care provider.
• Perform pregnancy testing, prenatal education, and OB/GYN referrals as indicated.
• Provide prenatal case management or referral for pregnant women.
• Assist pregnant women with Medicaid/MO HealthNet program eligibility determination and enrollment.
• Screen clients for an identified dental care provider and provide dental referrals as indicated.

The MCH Services Program and the MCH Director continued to facilitate collaboration between DHSS, DSS, and the LPHAs to provide Missouri Eligibility Determination and Enrollment System (MEDES) updates, maintain open and effective interagency communication, promote adequate health insurance coverage, and improve health care access for the MCH population.

The MCH Services Program continued to contract with 111 LPHAs to address priority MCH issues in their community. In addition to addressing a specified priority health issue (PHI), LPHA contract work plans are required to include evidence-based strategies to address the SDOH, health inequities and gaps/weaknesses in access to care.

• The Jackson County Health Department selected “Addressing SDOH inequities among women of childbearing age” as their PHI and created and adopted a Policy Action Plan to address health disparities and inequities in the county. The health department provided evidence-based training, curriculum, and practices on existing health disparities and inequities to internal and external providers and partners. To ensure regular and effective communication with regional decision-makers, the Community Engagement & Policy Division sent quarterly newsletters to municipal, county, and state policymakers, University Health leadership, and other community stakeholders. The newsletter highlighted department activities, new policies or issue briefs, relevant public health policies, legislative updates, and news stories. The health department hosted a public health orientation for newly elected Jackson County legislators, including an overview of health department capabilities, programs and services. The 2023 Policy Agenda was shared with 189 regional stakeholders, and two quarterly newsletters were shared with 215 regional legislators and stakeholders.

The Child Care Health Consultation (CCHC) Program provided consultation and training for child care providers and health promotion for children in child care at regulated and unregulated child care facilities, including those serving families eligible for the Child Care Subsidy Program. CCHC program services were inclusive to adults and children of all abilities and addressed the SDOH affecting health and safety. These services were provided at no cost to assure all participants had access to services that promote healthy and safe environments. LPHA staff assessed for referral needs and assisted in referrals for health care access, including MO HealthNet for Kids, immunizations, developmental screening, and WIC. CCHC program services assisted child care providers in identifying and utilizing community-based resources and organizations that address health disparities. The CCHC Program Coordinator assisted LPHA staff in developing resources for child care providers and families and health promotion for children in child care. By identifying these resources, more children and families are aware of available resources and have access to health care and proper nutrition. The CCHC staff encouraged family participation in all services and provided consultation and training for child care providers on developing policies and implementing procedures that promote inclusivity and optimal family partnerships for the health and safety of children in child care. Overall, the CCHC program supported the well-being of all children in child care and contributed to building a healthier and more equitable community.

The Safe Cribs for Missouri Program ensured culturally and linguistically appropriate resources were available at participating agencies. The program worked with LPHAs to support initiatives to prevent Sudden Infant Death Syndrome and provide safe sleep education and environments, particularly among low-income families. LPHA staff met clients where they were, providing resources during home visits and when clients came to the agency for other services, such as WIC and the car seat program. This approach made the visit more accessible and convenient for all clients.

Home Visiting programs’ contracted home visitors assessed all clients for insurance status at initial enrollment and periodically throughout enrollment. Home visitors assisted clients/families in the Medicaid enrollment process and provided resources for accessing the Affordable Care Act marketplace. Home visitors also linked clients to the nearest federally qualified health center to speak with a trained navigator and obtain eligibility and enrollment assistance. In FFY 2023, 71.7% (553/771) of primary caregivers enrolled in home visiting had continuous health insurance for at least six consecutive months. This was an increase of 33% from FFY 2022. Insurance coverage ensures children can access adequate and equitable preventive health care, including well-child visits. In FFY 2023, 94.9% (774/816) of children enrolled in home visiting received the recommended well-child visit based on the AAP Schedule of Well-Child Care Visits. This was a slight increase from FFY 2022 (92%). Program staff analyzed data for practices indicating unrecognized disrespect or lack of responsiveness. No differences were noted for well-child visits. During the March 2023 contract-specific professional development session, a presentation was provided on recognizing unconscious negative attitudes toward any specific group(s). Feedback from participants indicated the presentation was well-received and will be utilized in their work with families.

The Office on Women’s Health (OWH) promoted fair and impartial practices across all its programs. The maternal mortality team and Pregnancy Associated Review Board reviewed all maternal deaths for contributing SDOH and discrimination. The data identified issues and supported recommendations to promote fair and impartial practices across the healthcare system. OWH ensured the materials developed and distributed included evidence-based information to address gaps/weaknesses in access to care and health inequities. Additionally, OWH supported doula programs and reimbursement for doula services to increase access for populations most at risk for poor maternal health outcomes, specifically low-income and Black women. The violence prevention team worked across topic areas to develop a training for community health workers that discussed violence prevention and health fairness and impartiality. By addressing SDOH and fair and impartial health care, OWH hopes to prevent violence and reduce maternal mortality.

The Office of Dental Health (ODH) promoted inclusion and equity across all programs. Based on responses from the LPHAs regarding the primary languages of their most frequent clientele, ODH had several pieces of literature translated into seven languages.

DHSS participated in the Association of State and Territorial Health Officials (ASHTO) Suicide, Overdose, and Adverse Childhood Experiences Prevention Capacity Assessment Tool Learning Community. ASTHO and DHSS invited cross-cutting agencies to convene in May 2023. This convening brought together agencies in partnership building, information sharing, and action planning related to addressing and preventing the intersection of suicide, overdose, and adverse childhood experiences (ACEs) throughout the state of Missouri. Participants had the opportunity to engage in conversation regarding existing work and initiatives, gaps and resources, and potential areas of collaboration across sectors. This convening aimed to equip DHSS and other state-level partners with a set of tools to effectively build statewide capacity to address and prevent suicide overdose and ACEs using a shared risk and protective factor approach.

To continue building a comprehensive maternal-child public health system to address the priority needs of Missouri’s MCH population, especially marginalized populations, the MCH Director continued to:

• Build relationships with statewide MCH stakeholders.
• Present on and facilitate a simulation of the Life Course Perspective to undergraduate and graduate students and internal and external partners and stakeholders.
• Initiate and engage in discussions related to the SDOH, health literacy, health disparities, diversity, and inclusion.
• Participate in the Missouri Health Equity Committee.
• Collaborate with the DHSS Office of Minority Health and Health Equity.
• Contribute to Department efforts to create a diverse and inclusive work environment and incorporate the principles of impartiality, diversity and inclusion into programs and initiatives.
• Promote and support strategies to achieve the DHSS strategic goals to:
  • Examine DHSS communication channels through a citizen journey lens to understand and meet the needs of Missourians.
  • Empower people with public health data that is contextual, transparent, relevant, and tailored.
  • Establish a community voices partnership.
  • Create an inclusive work environment that promotes input and trust from all levels and people.
  • Collaborate with health care partners to access data and tailor services to resolve access issues for underserved areas and populations.
• Promote activities and initiatives to ensure access to care, including adequate insurance coverage, for the MCH population and to promote partnerships with individuals, families, and family-led organizations to provide family engagement in decision-making, program planning, service delivery, and quality improvement activities.
• Explore opportunities to expand Missouri’s MCH data capacity and enhance public health surveillance/reporting systems.
• Promote and support efforts to recruit and retain a qualified, diverse, and well-trained MCH workforce.