FFY 2018 Annual Report

Cross Cutting and Life Course

Preventive Health – State Priority #5: Increase use of primary and preventive health care services across the life course. 

A life course approach to preventive health care is essential to ensuring healthy families and healthy communities.  Increases in chronic disease such as heart disease, diabetes and obesity impact longevity and health outcomes. Racial and ethnic minority communities experience higher rates of obesity, cancer, diabetes,  HIV/AIDS and maternal mortality and morbidity disproportionally impact women of color.  Children are becoming increasingly vulnerable as an increase in overweight or obesity predisposes them to chronic disease and the numbers are even higher in African American and Hispanic communities.  NY's Title V program selected this as a state priority to focus on preventing disease and illness before they occur with an emphasis on how social determinants impact health to work towards supporting  healthier homes, workplaces, schools and communities, so that New Yorkers can live long and productive lives and reduce healthcare costs.

 

An essential component of any effort to improve birth outcomes must be a specific focus on improving access and utilization of preventive health care services. With 50% of all pregnancies in NY unplanned, impacting the overall health of all women in NY is a key step in improving pregnancy and birth outcomes. To that end, improving access to health insurance and preventive health care is a major priority across the life course. By improving the overall health of NY women before pregnancy and concurrently working to improve the intendedness of pregnancies, Title V can be assured that this work will improve the health status and birth outcomes for all women.

 

Preventive health care services encompass well-woman, preconception, prenatal, postpartum, interconception, well-baby, well-child and well-teen care. Based on analysis of available data and stakeholder input, Title V staff identified access to health insurance as a necessary element to the increased use of preventive services. NY's Title V program continued to rely on key external resources to further develop this scope of work that included: the USPSTF recommendation for preventive care, the AAP Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, and Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines for state Medicaid programs.

 

Building on an initial assessment conducted during the last reporting period, Title V worked to identify and evaluate various program requirements and measures currently used by Title V programs to promote preventive care. Currently, 58%  of all Title V programs include a requirement to promote well woman care and 65%  of programs include a focus on increasing health insurance enrollment. To better understand the types of measures being used, Title V staff worked with colleagues to obtain examples of how requirements and measures promoting preventive health care were being used across all Title V programs. Staff spoke with colleagues across DFH and identified several key programs with a major emphasis on promoting access to preventive care. Broadly speaking, this emphasis was most often seen in program requirements that promote health insurance enrollment, annual well woman visits, as well as assistance accessing preventive services for children and adolescents.

 

One such program emphasizing the role of preventive care is the Maternal and Infant Community Health Collaboratives (MICHC) program. The MICHC program seeks to improve maternal and infant health outcomes for high need, low income or Medicaid-eligible women and their families by supporting the development of multi-dimensional systems of integrated and coordinated community health programs and services. Using a life course approach, MICHCs work to improve preconception, prenatal, postpartum, and interconception health of Medicaid-eligible women by working collaboratively with community partners to implement strategies to: find and engage Medicaid-eligible women and their families in health insurance, health care and other community services; assess a woman’s needs and risk factors and make referrals to appropriate services; coordinate services across community programs; and promote opportunities and supports for women to engage in healthy behaviors.

 

Another Title V program that not only promotes access to preventive health care, but also provides those services, is the NYS Family Planning Program (FPP).  Comprised of a network of 48 subrecipient agencies operating 166 separate clinic sites, the NYSFPP aims to make sexual and reproductive health accessible and affordable to low-income women and men across NYS. This program includes several comprehensive strategies used to promote access to preventive care for residents across NYS. These include, but are not limited to, the provision of required preventive health visits and screenings (including annual well woman visits, routine breast and cervical cancer screenings, vaccinations, etc.), as well as community education and outreach activities aimed at increasing community awareness of the necessity of timely access of preventive care services. NYSFPP clinics are also able to screen and enroll clients in a range of public health insurance options including Medicaid, Family Planning Benefit Program (FPBP), and the Family Planning Extension Program (FPEP).

 

DOH Title V staff also work to improve preventive care access through the continued promotion of developmental screening for all children in NYS.  Currently Title V staff from across the DFH are participating in or leading several major initiatives aimed at improving developmental screenings in NYS. These initiatives include the following collaborations/projects: supporting the inclusion of developmental screening in Title V’s maternal and infant health initiatives; ongoing steps to promote early identification of potential developmental delays and referrals to EI; participation in the ECAC; ongoing work with the ECCS grant with the CCF; and collaborating on several statewide First 1000 Days in Medicaid Initiative workgroups.

 

NY’s Title V program remains committed to ongoing efforts to support the integration of improved developmental screenings in both Title V work and within the EIP. Title V staff working in MICHC and MIECHV programs have continued to make the inclusion of developmental screenings, either directly by program staff or via referrals to appropriate providers, a priority of their work. Current MIECHV activities include facilitation of a parent-completed developmental screening which is reviewed by home visitors and used to determine whether a referral to EI is necessary. MICHC activities include screening children with the Ages and Stages Questionnaire (ASQ) and providing referrals to the state’s EIP when appropriate.  EIP staff continue to focus on increasing developmental screening for all children they serve. The Child Find component of the EIP, which coordinates efforts made by other agencies and community programs that serve infants and toddlers to identify, locate, and track at-risk children using available resources, will also increase emphasis on developmental screening.

 

An important element of these strategies has been Title V’s long-standing commitment to the NYS ECAC workgroup. Convened by the NYS Governor’s Office, this council is comprised of partners from all sectors of the early childhood community. ECAC has a priority interest in promoting children’s development, and a specific focus on increasing rates of developmental screening. To further that goal, ECAC convened a workgroup to advance developmental screening and follow-up, with a focus on policy-oriented interventions. Members of the workgroup have been involved in Medicaid’s First 1000 Days initiative and the ECCS Impact grant.  Title V staff are members of this group and will remain in this capacity throughout the upcoming program year.

 

NYS Title V program also works to support improved developmental screening across NYS through the work of the ECCS Impact grant. The grant supports efforts in three communities, Nassau County (Docs for Tots) and Erie and Niagara counties (Help Me Grow Western NY & CCRN of Western NY). Through a place-based approach focused on an “intentional effort to build, sustain and operationalize community capacity in improving systems around children’s developmental health and family well-being,” the project specifically aims to demonstrate a 25% increase from baseline in age appropriate developmental skills among 3-year-old children in selected NYS communities.

 

The grant supports collaborative quality improvement projects in the three high need counties (Erie, Niagara and Nassau) to improve maternal depression screening and follow-up as well as developmental screening and follow-up for young children.  CCF is working closely with DOH on this grant which was initiated in 2016.  Progress is discussed in the Women’s/Maternal Health Domain annual report.

 

Another unique collaborative opportunity to promote developmental screenings can be seen through the DOH support of the Connections Project (formerly referred to as the Albany Promise Project) which is a regional cross sector partnership where community leaders in Albany, NY come together to support a shared cradle to career education vision. Focused on increasing school readiness among young children in the city of Albany, the Connections Project targets children under the age of five with a range of cross-sector multi-dimensional interventions. The DOH is partnering with Connections, Medicaid managed care plans, and pediatricians to create a pilot program in Albany County that incentivizes pediatricians and health plans to help ensure all children enter school ready to learn. Title V staff participate on the Early Childhood Success Team that has focused on increasing enrollment in quality early childcare programs and increasing the proportion of Albany children performing at or above benchmark when they enter pre-kindergarten.  Concurrently, the NYS Medicaid Redesign Team is conducting a pilot program that is assessing a wide range of benchmarks associated with access and quality of developmental screenings available. This included: number of well child visits, number of children screened above, close to, or below cut-off, the number of children who screened in need that were referred to either EI or CPSE, as well as longer-term outcomes including the number of children screened and number referred who then received services and did or did not show improvement. 

Early in the process, partners identified a key area of concern – the late identification of developmental delays in many school-aged children. Finding that many children were beginning school with delays that could have been identified earlier, partners began an intensive process to better understand the system of child health care and how improved developmental screenings could improve subsequent outcomes for youth.  Screening children at ages birth-4 and then addressing any needs that are present at that point in the child’s life can significantly improve a child’s outcomes as he/she grows.

Beginning with a process map of the current screening, referral, and treatment systems with the community, the Connections Project worked through a collective impact framework. This work included development of mutually reinforcing activities to improve the identification of developmental delays, referral, and service provision systems. While this kind of collaboration is not without its challenges, this dynamic opportunity is working to better inform the Title V support for developmental screenings in ways that could be applicable in other communities across NYS.

 

Title V is also continuing work to support the First 1,000 Days initiative a multi-disciplinary effort to maximize access to services for children and families within the first 1,000 days of life. NY’s Title V program has been selected to partner on several activities as part of this initiative, chief among them working to expand access to Centering Pregnancy and evidence-based home visiting programs. Progress in these areas is discussed in the Maternal/Women’s Health Priority section.  

 

Recognizing the unique barriers impacting the ability of adolescents to obtain preventive health care services and the need to identify strategies that address barriers, staff have been collaborating with adolescent health experts from Cornell University ACT for Youth Center of Excellence (ACT for Youth) to identify the most effective way to obtain adolescent feedback on this topic.  Building on the literature review conducted by ACT for Youth, Title V staff collaborated with experts from ACT for Youth on the development and facilitation of a survey focused on obtaining feedback from adolescents on barriers to accessing preventive services. Title V staff met several times during the project period to review potential questions, brainstorm which topics should be included, and contribute to the development of a plan to distribute surveys to CAPP/PREP providers. The electronic survey was deployed to CAPP/PREP providers early in 2019.  Full analysis of this information is expected in Summer 2019 and will be used to inform program development.

 

To compliment this work and generate a broader understanding of the state-wide health status of adolescents in NYS, a student intern was hired to compile a report of overall adolescent health across NYS.  The student reviewed data and resources from the Division of Chronic Disease Prevention on adolescent health,  cancer prevention , tobacco control, healthy schools, and obesity prevention. Final data sources included Youth Risk Behavior Survey System, National Survey of Children’s Health, National Youth Tobacco Survey and others. A comprehensive report on the current state of adolescent health in New York State based on race, ethnicity, and socio-economic status was completed. Special health care needs populations, geographical location, gender, and sexual orientation were considered when analyzing data.  The information gathered provides a comprehensive snap-shot view with the most available information (as of 2018) on a variety of health information that can be used by public health administrators in making informed decisions, assessing the needs of communities, developing adolescent health-related grant programs, and responding to providers and funders

 

Beyond ensuring preventive care is emphasized in Title V programs, staff also recognized the importance of assessing whether women of reproductive age receive preconception health care. In order to measure the actual implementation of preconception health during routine visits, Title V staff have been working to support the inclusion of a “preconception health” module in the NYS BRFSS sampling. This survey, which broadly represents the non-institutionalized civilian 18 years and older population of NYS, will be used to help Title V staff understand if women are getting these important health care services. The BRFSS contains seven questions on pre-conception health as part of the family planning module, and these data have been analyzed and reports issued. 

 

Oral Health: State Priority #6: Promote oral health and reduce tooth decay across the life course

Oral health remains a key health indicator for women, infants, children and families throughout their lives due to the impact it has on learning, social-emotional wellness and overall health.  The prevention of  tooth decay remains a high priority for the Title V program, not only because of the effects of this disease and the associated social and financial impacts, but also because it is largely preventable and entirely treatable.  According to 2012-2014 SPARCS data, 83.4 per 10,000 children, aged 3-5 years in NYS had a caries-related outpatient visit. NY’s Title V Program is committed to promoting oral health through education, community-based interventions and programming that benefits all NYS residents.

 

One strategy to promote oral health is to provide financial and technical support for maintenance and expansion of community water fluoridation.

 

DOH continues to provide both technical and financial assistance to communities to maintain and expand community water fluoridation (CWF). To ensure adequate technical assistance support, DOH awarded a contract to the NY Rural Water Association (NYRWA) for the period of August 2018-July 2023. The contract is intended to provide technical and guidance, increase water operators’ knowledge about CWF, and help ensure fluoridated PWS are maintained and operated in compliance with all laws, rules and regulations and optimal fluoridation levels are maintained. NYRWA conducts onsite visits at water treatment plants to provide guidance on operating issues, provides technical support to water operators to ensure PWS are fluoridating at the optimal level, and delivers continuing education trainings for water operators on the topic of CWF. During the recent reporting period, NYRWA completed 40 onsite technical assistance visits to 29 unique PWS and held four CWF trainings to 72 water operators.  

 

Financial assistance was also provided to 30 PWS through the DWF Grant program. As reported in previous annual reports, the grants have been awarded in four separate rounds. The most recent funding (fourth round) was released in August 2017 and a total of $4.8 million has been encumbered to support 13 contracts, 11 of which are executed and two are pending.  The grant program can support either Planning and Feasibility Projects (i.e., development of an engineering report to assess the equipment and financial impact of CWF in a community) or Implementation and Maintenance Projects (i.e., upgrade of equipment to maintain CWF).

 

This strategy is measured by ESM LC-6:  Number of public water systems that receive financial and/or technical support from NYSDOH to maintain or initiate community water fluoridation. Over the course of the reporting period, 48 different public water systems (PWS) received technical and/or financial support for CWF from the DOH Drinking Water Fluoridation (DWF) Grant program.

 

The State Priority is measured by SPM #5: percentage of NYS residents served by community water systems that have optimally fluoridated water. For the most recently available data, 70.8% of NYS residents are reported as served by community water systems with optimally fluoridated water in this current reporting year as compared to 71.6% last year. These data are captured by the Safe Drinking Water Information System (SDWIS), which is an Environmental Protection Agency (EPA) database managed by the DOH Center for Environmental Health (CEH). The goal was to increase the percentage of residents, but the percentage has decreased as a result of the discontinuation of CWF in a PWS in Walden, NY, as well as small changes in population size. 

 

While this PWS did discontinue fluoridation, there were additional PWS (City of Ogdensburg and Village of Potsdam) that considered discontinuing CWF. The City of Ogdensburg was concerned about the safety of PWS operators handling fluoride and the cost to fluoridate. DOH staff provided technical assistance and the City of Ogdensburg did not pursue discontinuing CWF.  Village of Potsdam residents raised concerns about the safety of fluoride to the Village Board. DOH staff provided technical assistance to Potsdam’s Village Administrator, the Mayor, and Village Board Members. The Village Board voted to maintain CWF.

 

DOH also provided technical assistance to the Northern Westchester Joint Water Works, which had temporarily ceased CWF at their water treatment plants in Amawalk Catskill. Both water treatment plants are expected to resume fluoridating by the end of 2019.

 

DFH staff, including the Dental Director, Oral Health Unit manager and Title V leadership, developed a compendium of CWF materials. These materials were sent to the four communities above and are available to support future requests for technical assistance.

 

A second strategy to promote oral health is to increase the delivery of evidence-based preventive dental services across key settings, including school-based clinics, primary care practices and public health nutrition programs.

 

The Title V program has prioritized access to preventive dental care through promoting the delivery of care through schools. NYS has the largest School Based Health Center program in the US. SBHC can provide medical and dental services, medical only or dental only. There are 49 hospital or FQHC sponsors (regulated by DOH under Article 28 of NYS Public Health Law) providing dental services in 1,939 schools serving areas with low-income children (as determined by the percentage of students who qualify for the free lunch program) and may have limited access to dental services. The Title V Program has allocated funding to establish the School Based Sealant Program (SBSP), with the goal of expanding of the application of sealants on first-year molars of 2nd and 3rd graders, which is an evidence-based approach to combatting tooth decay.  Twenty-five SBHC providers of dental services were awarded $50,000 per year for five years. SBSP grantees are required to report data to DOH to support the evaluation this strategy. 

 

This strategy is measured by ESM LC-7: Percentage of 2nd and 3rd graders served by School Based Dental Programs (SBSP) who receive sealants. For the current reporting period, 39.1% received sealants compared to 50.5% the previous year. The decrease can be attributed to the inability of three SBSP-funded dental programs to provide services in the 2017-2018 school year due to a lack of dental staff and difficulties with data submission. 

 

DOH partnered with the Oral Health Subcommittee of the Community Health Center Association of NYS, which provides support and advocacy for NY’s community health centers and FQHCs, to establish the Medical-Dental Integration Learning (MDIL) Collaborative. The Collaborative convened from March through August 2018. The primary aim was to reduce tooth decay in children under the age of six by integrating routine oral examinations and screenings, oral health education and counseling, and fluoride varnish application into routine well-child medical visits. Under MDIL, Community Health Centers met monthly for shared learning, facilitated discussions and coaching to improve the oral health status of young children in their communities. Hometown Health Center and Joseph P. Addabbo Family Health Center participated, and both centers improved their fluoride varnish application rate from baseline.

 

The Title V program has begun partnering with two LHDs in Madison County and Jefferson County through funding from the HRSA Oral Health Workforce Grant to address dental workforce needs and access to oral care in underserved areas of the state. DFH Oral Health staff and Title V Dental Director are supporting these LHDs, which have prioritized oral health initiatives in their counties, to promote evidence-based oral health strategies.  Both LHDs have identified increasing the number and type of primary care medical providers who apply varnish in the community as one of their evidence-based strategies. Title V staff have supported the LHD efforts by participating in community meetings, securing experts to provide consultation, and making connections to other agencies and support systems, such as Title V funded SBHC, in their area.  The grant is supporting the development of public health detailing materials and training, modeled off pharmaceutical company techniques to engage healthcare providers, to promote primary care providers’ application of fluoride varnish as part of a routine well-child visit. 

 

Title V staff have continued to collaborate with the DOH Division of Chronic Disease Prevention (DCDP) on addressing sugar-sweetened beverage consumption among adolescent males of color.  The Sugar-Sweetened Beverage Advisory Committee continued to meet to develop and implement a social media campaign to about beverages choices and connection between sugar-sweetened beverage and chronic diseases like obesity and dental decay.  Title V program hosted three face-to-face, expert work group meetings to develop social media campaign strategies and identify best practices to integrate the media campaign into existing chronic disease prevention programs. In Fall 2017, focus groups were conducted in Western NY.  The findings from the focus groups informed the development of marketing materials, including posters (in English and Spanish) and static and video ads, encouraging drinking water as a healthy alternative to drinking sugar-sweetened beverages. Additional focus groups were conducted in Spring 2018 to review the posters and ads with opportunity for feedback for modifications.  A social media and out-of-home advertising campaign was launched in three regions (Western and Central NY and the Southern Tier) from August to October 2018.  

 

Streaming video, display banner, and social media were purchased on YouTube, Snapchat, Twitter, Facebook, Instagram and gaming apps, with known audiences of African American and Hispanic adolescent males, who were the target audience. Digital media was linked to the DOH’s Healthy Beverage webpage with information about sugary drinks, healthy alternatives, and the benefits of drinking water.  Out-of-home advertising included billboards, bus interiors, bus shelters, and exteriors and cooler clings in convenient stores. Posters were distributed to chronic disease-funded programs, SBHCs, community health centers, and middle and high schools in the targeted communities of Buffalo and Rochester, NY.  The posters are accessible on the DOH website at https://www.health.ny.gov/prevention/nutrition/sugary_beverages.    

 

A third strategy to promote oral health is to integrate oral health messages and strategies within existing community-based maternal and infant health programs.

 

The Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Project was integrated into the MICHC Program. The goal of the PIOHQI Project was to integrate oral health strategies into community-based maternal and infant health programs through care coordination and public health detailing. Title V staff worked with the Healthy Baby Network (HBN) and Eastman Institute for Oral Health (EIOH) to engage providers and community partners in finalizing the Oral Health Manual Toolkit and refining individual and systems-level strategies to improve maternal and infant access to oral health care and increase provider capacity. EIOH, in collaboration with HBN, trained 126 participants, ranging from dental care providers, perinatal care providers, and community health workers virtually and in-person on the use of the Toolkit and how providers can address oral health needs among high-need pregnant or parenting women and their families.   

 

DOH has facilitated trainings for all MICHC providers starting with an introductory webinar in April 2017 and four in-person regional train-the-trainer events from July 2017 to February 2018.  The trainings incorporated successful strategies from the pilot site, contained a prepared presentation that can be used by MICHCs to train their staff and prenatal care and dental providers, and provided a platform for MICHCs to meet in-person, learn from each other and share ideas and promising practices for implementing oral health strategies into their programs. All 23 MICHC programs have trained their community health workers, and, where possible, will work to identify oral health champions in their communities, share information with and/or train healthcare professionals through public health detailing, and/or educate partners at community network meetings.

 

Tools and lessons learned from the NY PIOHQI Project were shared with the other HRSA-funded states through a PIOHQI National Learning Collaborative to develop best practice models for integrating oral health care into existing community-based pre/perinatal services. Title V staff conducted a capacity assessment survey of MICHCs before the trainings commenced to identify current practices, resources and technical assistance needs. Feedback from the survey provided information on MICHCs oral health capacity. The survey results informed the content of the MICHC oral health trainings.  Although the PIOHQI grant ended in September 2018, HBN’s partnership with EIOH has continued and is expanding to improve oral health services for pregnant women.  Through ongoing partnerships with EIOH and their Oral Health Advisory Council, quality improvement activities and feedback opportunities will continue.

 

The Pathways to Success initiative is also working to integrate oral health strategies into community-based maternal and infant health programs. Pathways to Success works to develop and implement programs to improve educational, health and social outcomes for expectant and parenting teens, women, fathers and their families. The current project is based in NYC with 3 community colleges and a community-based organization. These projects focus on building collaborations both internally within their organizations and externally with community providers and with other DOH maternal and child health programs to strengthen support networks and referral systems to core services, including personal health, child health, education, employment, concrete supports (e.g. housing, transportation) and parenting supports (e.g. parenting education, healthy relationships). The goal is to establish solid and sustainable collaborations to ensure that young parents and their families are identified early on and receive referrals to needed resources and supports. The Pathways to Success program will share the Toolkit developed by the PIOHQI Project with these organizations to ensure staff that are working with expectant and parenting teens are knowledgeable about oral health needs and appropriate recommendations for this population.

 

This strategy is measured by ESM LC-8 Percentage of pregnant women served by Title V community health workers that have a documented screening or referral for dental services.  DOH tracks aggregate data reported quarterly by all 23 MICHCs to monitor the number of clients who are screened for oral health needs, received appropriate oral health information, and are referred for needed dental services. These data are reviewed quarterly, assessed for accuracy, and presented back to the MICHC programs for quality improvement purposes. In 2018, a reported 56.6% of pregnant women who were served by CHWs had a documented screening for dental issues, and 12.4% were referred for dental services.   

 

A final strategy in the SAP to promote oral health is to strengthen Title V internal capacity, dental public health core competencies and workforce development for oral health surveillance and evidence-based interventions through continued support for NYS Dental Public Health Residency

 

The NYS Dental Public Health Residency Program (NYSDPHRP) was designed to support and build capacity for all MCH oral health programs through the utilization of dental residents’ subject matter expertise in clinical dentistry and public health. The curriculum, based upon the core competencies as recognized by the American Association of Public Health Dentistry, focuses on MCH goals and objectives. Through collaboration and engagement with Title V staff on various MCH programs, the dental residents have a unique opportunity to apply concepts and tools in real public health settings, preparing them to assume critical roles in the practice of dental public health for improving health outcomes. Specifically, NY’s strategy is to strengthen Title V internal capacity by developing core dental public health competencies in residents. During their residency, the residents contribute to oral health surveillance activities and analysis of evidence-based interventions implemented by Title V.  Between 1998 and 2016, NYSDPHRP had 42 graduates, the majority of whom are working as public health dentists in state government and academic and hospital settings.

 

Residents are trained at the DOH and affiliate sites at Eastman Institute for Oral Health (Eastman)and the Jacobi Medical Center. Long-term objectives of the residency program are to maintain a fully accredited training program for dentists interested in careers in dental public health. Affiliation and partnerships are core assets of this program. Given the growing demands and health priorities of the DOH, it is imperative to seek an appropriate training institution that has the capacity to sustain operation of the program for current and future residents. Therefore, administrative changes are necessary to leverage resources available through Eastman that the DOH believes will ensure long-term support for the program.  Eastman is internationally recognized as an institution for postdoctoral training in dental specialties and has successfully maintained accreditation for all other specialty programs through the Commission on Dental Accreditation (CODA), and therefore has the capacity to maintain CODA accreditation for the program.  DOH has been collaborating with Eastman and CODA to transition the program to Eastman and will maintain a program site and continue to work with Eastman to provide training opportunities for public health dental residents.

 

This State Priority is measured by NPM #13.1: Percent of women who had a dental visit during pregnancy and NPM #13.2: children age 1-17 who had a preventive dental visit in the past year.  For 2015 as reported in PRAMs, 51.9 % of women surveyed had a dental visit during pregnancy as compared to the 47.2% in 2016, which was a slight decrease.  For children with a preventive dental visit, the NSCH reports NY at 77, in close alignment to the national average of 77.2   For NOM #14 Percent of children ages 1-17 who had decayed teeth or cavities in the past 12 months, the NSCH reports NYS at 8.4% as compared to 11.7 on the national level for 2016 which demonstrates to commitment NYS has made to promoting and improving oral health. 

 

Healthy Communities – State Priority #7: Promote supports and opportunities that foster healthy homes and community environments.

The objectives and measures in this priority area address a variety of subjects, reflecting the broad scope of factors impacting MCH. This priority area aims to impact physical activity, obesity, wellness, safety, and community social cohesion. Title V programs cannot impact these areas alone, making collaboration a critical focus of this priority area's strategies. The sources of these metrics are national surveys including the NSCH, YRBS, using the most recent data available.  Measured by NPM #8 Percent of children ages 6-11 and adolescents age 12-17 who are physically active at least 60 minutes per day.  For adolescents in grades 9-12, there was essentially no change in physical activity between 2015 (23.3%) and 2017 (23.2%). However, there was a slight increase in overweight and obesity from 27% in 2015 to 28.6% in 2017. For children aged 6 to 11 years, those participating in 60 minutes of daily physical activity decreased from 22.9% in 2016 to 17.1% in 2017.  

 

In the 2017 NSCH survey, 54.6% of NY parents reported that their child lives in a supportive/cohesive neighborhood, which is slightly lower than the national level (56.8%), but higher than those reporting in 2016 (50.1%). This includes parents' responses about whether people in the neighborhood help each other out and watch out for each other's children, and whether they know where to go for help in their community.  Fewer NYS parents reported they definitely agree their child is safe in their neighborhood compared to all parents nationally (57.7% compared to 65.5%, respectively) and the perception of safety remained unchanged from 2016 (57.2%).

 

Stakeholder input obtained in the preparation for this application identified factors including access to healthy, affordable food, safe places to engage in physical activity, and social support as important elements of a desirable community and are believed to have significant impact on families' health and wellbeing. These perceptions are consistent with broader and longstanding public health approaches aimed at supporting healthy communities, including strong commitments to community-driven change, fostering policy, systems, and environmental change strategies, and addressing social determinants of health. These broad, policy-level issues require a collaborative approach; the health sector must work with social services, planners, transportation, and other partners to  begin to create change in NY’s communities.

 

Title V staff also kept abreast of DOH partners’ efforts to  change community environments to improve health outcomes for women, children, and families. The broad scope of environmental-level issues impacting communities' health—physical activity, obesity, wellness, safety, and community social cohesion—require cross-sector involvement. Staff had varying levels of engagement with the following partner programs: Creating Healthy Schools and Communities, Healthy Neighborhoods Program, Regional Centers for Sexual Violence Prevention and Building Resistance Against Climate Effects. Staff monitor the accomplishments of Title V partnerships by tracking programs with activities focused on collaboration or partnerships and outcomes at the community, environmental, or policy levels. Measured by ESM LC-11: Number of community environmental changes demonstrated as a result of enhanced collaborations. During the past reporting period, of 10 programs meeting those criteria, 6 met their community, environmental, or policy level changes as a result of their enhanced collaborative efforts.  

 

Environmental change continues through enhanced collaboration with partnerships from activities of the Title V’s six Regional Centers for  Sexual Violence Prevention (Regional Centers). Since 2014, these Regional Centers have been implementing innovative primary prevention community-level (coalition-building, community mobilization, social norms and policy change) and individual-level sexual violence prevention strategies (Bringing in the Bystander, Shifting Boundaries) with youth and young adults, ages 8-24, from seventeen high-risk counties across NYS. During this reporting period, the work of the Regional Centers was informed by data collection and evaluation activities. There is an ongoing effort to increase the tracking and analysis of state-level indicators of sexual violence outcomes to support healthy community initiatives. This effort includes: assessing data systems and sources for tracking sexual violence, engaging partners and involving stakeholders in the tracking and analysis process, ongoing data management, and the creation of maps, summaries and assessments for program communication. From August 1, 2016 – July 31, 2017, the six Regional Centers, implemented a total of 25 prevention strategies (with 15 (60%) community-level and 6 (24%) societal-level strategies being implemented) and reached a total of 469 individuals through 249 various organizations dispersed throughout high-need counties across the state. Throughout the former 5-year grant period (2/1/14 – 1/31/19), the Regional Centers have completed 807 community-mobilization events (i.e. presentations with community-based organizations and members, youth-led events); 342 coalition-building events; and 82 cycles of evidence-based educational curricula sessions.  

In this reporting period, the DFH Sexual Violence Prevention Program (SVPP) joined the State University of New York Impact Team for Transgender and Non-Gender Conforming students. This team identified that community-based organizations lacked sufficient knowledge to create programs, written guidance, and policies that are inclusive. The Regional Centers and community partners continue to invest considerable time and effort in the development and/or implementation of healthy community-level strategies including healthy nightlife (an initiative aimed to promote a healthy community by engaging bar owners, bar staff, and community patrons to create and build safe nightlife establishments) and healthy school initiatives (an initiative aimed to promote a healthy school community by providing sexual violence prevention education and establishing policies). Studies have shown a significant link between increased sexual violence and alcohol consumption for both perpetrators and victims. As a result, training bar proprietors and their staff on what is sexual violence, how to observe and assess situations for signs of sexual violence, bystander intervention skills building, policy change assistance and environmental assessments are all components of a comprehensive approach addressing all levels of the Social Ecological Model (SEM). Currently there are 26 trained bars, 228 staff/managers/owners trained, and 50 trained trainers throughout the six Regional Centers. Studies also indicate there is a higher incidence of sexual violence, and accompanying behaviors and attitudes, within schools among youth and young adult populations. The Regional Centers and community partners prioritize ages 8-24 years old as studies have shown this is where the problem persists most. School-based interventions for adolescents have shown emerging evidence of effectiveness in “improving gender-equitable attitudes and increasing self-reported likelihood to intervene in situations of bullying and partner violence” (Lundgren & Amin, 2015). Currently, the Regional Centers have been implementing bystander intervention curricula, such as Bringing in the Bystander; other programs for implementation include Shifting Boundaries, Girl’s Circle and Council for Boys and Young Men, and Mentors in Violence Prevention. Currently there are 12 schools, 818 individuals trained, and 53 trained trainers throughout the six Regional Centers. From February 1, 2018 – January 31, 2019,  the Regional Centers have trained 12 schools in various sexual violence prevention/healthy relationship curriculum. Currently, there are 53 trainers across the state qualified to train in various healthy relationship, sexual violence prevention, and bystander intervention curricula such as Shifting Boundaries, Mentors in Violence Prevention, and Bringing in the Bystander.  

 

In the Spring of 2017, a Coalition Assessment Tool (CAT) was disseminated to the six Regional Centers and partners to evaluate the effectiveness of each Region’s established coalitions. There were 64 responses to the survey, representing approximately 20 coalitions and committees. About 95% of the coalitions/committees represented by the survey results are working on sexual violence prevention directly and the small minority are principally crisis service providers. Over 70% of respondents could agree that their coalition had a clearly defined purpose and goals, regular meetings and communication, and the support of community leaders and key stakeholders.  The area identified for improvement was to expand diversity and representation of underserved populations on the committees and coalitions. The process of creating, disseminating and analyzing the CAT identified collaboration as a standout among coalitions, community-based organizations and DOH. Therefore, a collaboration plan template was developed to focus on identifying effective measures for collaboration.  

 

Although strong collaborations are required to achieve community environmental change that result in positive outcomes, collaboration is often loosely structured or undefined. To provide support and evaluate enhanced collaborative efforts, Title V staff have developed an evidence-informed collaboration framework tool for structuring, measuring, and monitoring collaboration at both the state and community levels. This strategy was a new area of work for Title V program.  To begin, a graduate student intern from the SUNY Albany School of Public Health conducted a literature review in Summer 2017 to identify elements of or best practices for collaboration to inform development of a new framework. This information was used by Title V staff to create a draft collaboration plan template, which was then circulated among select Title V staff for comment. Components of the template include establishing a shared purpose, outlining the team’s ground rules, defining team members and how they will work together (e.g., communication, decision making, meeting schedule), and defining milestones or objectives, a work plan, and measures of progress. The Regional Centers had been selected to pilot the collaboration plan template with their local-level partners throughout 2018. In Summer 2018, another graduate student intern from the SUNY Albany School of Public incorporated the collaborative framework template into the Regional Centers evaluation plan, more specifically the work plan and a tracking tool) for dissemination and subsequent data collection and analysis for the Regional Centers’ new project period (February 1, 2019 – January 31, 2022).  Based on the results of this pilot, the template will be disseminated to Title V staff to establish future state-level partnerships and to Title V programs for local-level use.

 

Further community-level collaborative efforts are supported through the MICHCs.  The MICHC initiative seeks to improve maternal and infant health outcomes for high need, low income or Medicaid-eligible women and their families by supporting the development of multi-dimensional community systems of integrated and coordinated community health programs and services. MICHCs work to improve preconception, prenatal, postpartum, and interconception health of Medicaid-eligible women by working collaboratively with community partners to implement strategies to: find and engage Medicaid-eligible women and their families in health insurance, health care and other community services; assess a woman’s needs and risk factors and make referrals to appropriate services; coordinate services across community programs; and promote opportunities and supports for women to engage in healthy behaviors. MICHCs utilize Community Health Workers (CHWs) to assist Medicaid-eligible women of reproductive age to effectively access continuous and coordinated health care and other needed community services responsive to their needs and risk factors. On a systems level, MICHC programs work with community partners in the health and social services arena to: assess resources, prioritize community needs and strengths; and implement community-level strategies to address the needs identified. For example, in one upstate community, the MICHC program identified transportation to essential services as a barrier to women receiving needed services. In response, the MICHC program worked with the local transit authority to improve bus routes by adding additional stops in less populated, vulnerable neighborhoods.

Efforts such as Pathways to Success also demonstrate a strong community partnership to enhance the lives of young parents.  The Pathways to Success initiative funds three community colleges and one community-based organization to create and sustain supportive systems that help expectant and parenting teens and young adults succeed through health, education, self-sufficiency and building strong families. The initiative utilizes an Asset and Risk Assessment (ARA) tool that helps Pathways staff to assess the needs and existing resources for young parents and their families. This structured interview tool enables funded projects to identify and prioritize assets and needs and develop a tailored list of referrals for each program participant. The ARA tool is also conducted over multiple client contacts, helping build a relationship between program staff and student participants, as well as providing opportunities to reassess needs and outcomes of referrals previously made.

 

In addition, Pathways staff have conducted a needs and resource assessment, including key informant interviews and focus groups, targeted to the priority population to identify the barriers and assets relevant to accessing needed services and achieving school success. The focus groups targeted expectant and parenting young people and focused on resource utilization and gaps between needs and resources. The key informant interviews targeted internal and external partners, and focused on community resources, linkages, strength of relationships, gaps in resources, and perceived needs. Data from both focus groups and interviews will aid in the identification of current needs for expectant and parenting young people, existing resources to meet the needs of this population, and gaps between needs and resources. By collecting these data from both young people and representatives of organizations which serve them, this  assessment process identifies priority areas of need, and assists to determine which resources could be better utilized to improve services in the community.

 

This State Priority is also measured by: NOM #15 Rate of death in children aged 1 through 9 per 100,000.  NY is far below the national average at 13.3 as compared with the national average of 17.5 in 2015.  NOM 16.1 Rate of deaths in adolescents age 10-19 per 100,000.  NY is again below the national average at 21.5 vs. 31.6.   Finally, NOM #20 Percent of children and adolescents who are overweight or obese (BMI at or above the 85th percentile).  NY again is below the national average of 13.9 at 13.1 as reported in 2015 YRBS data. 

 

Health Equity - State Priority #8: Reduce racial, ethnic, economic and geographic disparities and promote health equity for MCH population. 

While numerous interventions have positively impacted MCH health outcomes over the years, persistent health inequities, especially racial, ethnic and geographic, have continued to manifest. As stated in NY's FY 2018 application, NY's Title V program includes health equity as a life course priority to ensure a stronger concentration on improving access to quality, comprehensive health and supportive services across all domains. 

 

To fully meet the needs of all New Yorkers, NY’s Title V program has made a concerted effort to incorporate a Health Equity framework into all aspects of NY’s Title V program. Since Fall 2016, Title V initiated the development and implementation of a series of strategies aimed at improving health equity in NYS as it relates to MCH. 

 

As with all State Priorities (SP) across Domains, Title V staff focused on improving data collection and measurement of Title V initiatives to identify health disparities. Coordination expanded among the Title V staff and research groups within the DOH Bureau of Chronic Disease Research and Evaluation, Bureau of Injury and Occupational Health, Office of Minority Health and Health Disparities Prevention (OMH-HDP), OHIP and PHIG, to provide performance and outcome measures for each SP area.   

 

For several years, DOH has had a PA dashboard which tracks many public health elements at the county level. The PA dashboard enables partners to use these data to tailor their efforts and track impact. Title V program decided to pattern the MCH dashboard on the DOH PA dashboard.  Plans for the MCH dashboard were developed and Title V staff worked with OPHP to identify pertinent data elements that could be tracked at the county level.  The ability to view county-level data that mirror national and state metrics in NY’s SAP that include race and ethnicity will allow partners to address Title V priorities on the local level and strengthen NY’s efforts to promote health equity and improve the health and wellness of the MCH population.  Targets were established by the Title V data committee for each of the measures and the dashboard is now live and regular updates are planned.

 

Social determinants impact health equity, and therefore it is imperative that staff develop an understanding of the complex interconnection of various social, environmental, and systemic issues that often manifest in health inequity. Additionally, NY’s Title V program recognizes that all staff members bring with them their own experiences, history, and bias which can make proactively addressing health equity even more challenging. To improve Title V staff’s understanding of health equity, additional training and support beyond the typical onboarding process and education is being planned.

 

Title V staff worked to improve the internal capacity of Title V staff to promote and support health equity in all aspects of work. Promotion of health equity requires a unique, often tailored, approach.  As noted in earlier applications, DFH established a cross functional health equity team for this purpose.  To ensure each SP focused on health equity, each member of the health equity team serves as a subject matter expert (SME) for the other SP areas.  That team member ensures that a health equity lens is placed on each SP area, with at least one strategy or initiative focused on improving health equity.  Title V staff investigated the disparities that exist, strategies and mechanisms that Title V programs are currently using to address disparities and/or health equity, possible additional areas for intervention and committed to at least one health equity area on which to focus for each SP.  Increasingly, health equity team members are called upon by Title V to lend their expertise in program discussions and new initiatives to ensure that they include ways to improve equity.   

 

Continuing to emphasize the importance of increasing staff capacity to proactively address health equity issues, Title V staff worked to finalize implementation plans for a comprehensive health equity curriculum. Required of all Title V staff, including administrative and support staff as well as interns, this multi-session curriculum was selected and compiled by the Title V Health Equity team with a goal of building a solid foundation of health equity understanding. Using the DOH Learning Management System (LMS) ensures that participation in training modules are effectively tracked across all Title V Staff. Using resources from a variety of partner organizations including; HRSA-funded Region 2 Public Health Training Center (PHTC), a partnership of three Council on Education for Public Health accredited schools of public health, including Columbia University Mailman School of Public Health, Rutgers School of Public Health, and the University of Puerto Rico Graduate School of Public Health, along with the University of the Virgin Islands Community Engagement and Lifelong Learning Center, and NYSACHO, this training series is meant to ensure all Title V understand the ways in which the can work to directly improve health equity through their day to day work.

 

Based on a comprehensive review of available modules, the four courses selected were: 1) From Concept to Practice: Health Equity, Health Inequities, Health Disparities & Social Determinants of Health, 2) Health Literacy for Public Health Professionals, Center for Community Health Lecture Series: 3) Bridges out of Poverty and 4) Health Equity Data to Action. All staff working in the Title V program will be required to complete the training over a four-month period.  Objectives from the four courses were collected to form the basis for an evaluation plan for the curriculum.

 

Title V staff continued work through the Fall of 2018 to finalize plans and packaging of the online modules of this curriculum. After a collaborating with NYSDOH partners in the Office of Public Health Practice, Title V staff were able to finalize the format and sequence of trainings. On February 5, the DFH Division Director sent an email to all Title V staff informing them of the availability of this new training resource and the expectation that all staff would complete the full curriculum by May 2018. Staff were encouraged to complete one module per month, and upon completion, will be required to take the post-test. Those who had not attended the Bridges into Health and Healthcare training in April 2018, were asked to complete the same pre-test prior to starting to complete the training series. 

 

Of those that completed that Title V Health Equity Learning Series pre-test, only 12% of staff felt “extremely” or “very” comfortable explaining the difference between health inequities and health disparities or how social determinants of health impact the health, productivity and wellbeing of MCH populations,  Level of comfort increased slightly in terms explaining  how health literacy influences and affects the health and wellness of MCH populations with 28% responding with either “extremely” or “very”.  In terms of responsibility, 83% of respondents indicated “extremely” or “very” when asked if they believe DFH has an organizational responsibility to promote health equity, but only 64% indicated that same level of belief about their individual responsibility. A second post-test survey will be deployed to all Title V staff upon completion of the full Health Equity Training Curriculum. Scores will then be analyzed to evaluate if curriculum successfully increased staff knowledge and understanding of health equity concepts, as well as their comfort and ability to integrate that information into their routine work. 

 

While doing research on available training resources, Health Equity Team Members identified an opportunity to supplement the online training modules with an in-person option for the “Bridges Out of Poverty” training. Following positive feedback from participants who attended the live training, Title V staff worked with national experts to organize a DFH-specific training on the “Bridges into Health and Health Care” curriculum, a supplement to the existing online training. On April 13, 2018 a one-day, intensive training focused on building knowledge and understanding among all Title V staff of the complex institutional and interpersonal dynamics of accessing health and health care in America, especially for lower income individuals, was held. Owing to the high level of interest in this training among both the internal and external partners of DOH Title V staff, several members of DOH Center for Community Health were invited to attend, along with a group of master’s in public health students from the SUNY School of Public Health. Approximately 124 people were in attendance.

 

All participants began the session by completing a short evaluation, which served as a pre-test for the entire Title V Health Equity Training Learning Series. Focused on establishing an initial baseline of staff competency, this pre-test included 10 questions designed to assess the level of understanding and self-efficacy Title V staff have in addressing issues related to health equity. This survey was collected before the start of the Bridges training and was analyzed to develop a baseline pre-test score for the collective Title V staff.

 

Title V staff also continued to work with the EBCoP to develop a health equity-focused book club that is held during hours outside of the normal work day, for any staff who choose to participate.  The purpose of the book club is to offer a non-threatening venue in which issues related to health disparities can be discussed by a diverse group of interested members to increase awareness and understanding.  As of March 2018, the book club has read and discussed two books: The Immortal Life of Henrietta Lacks by Rebecca Skloot and The Hillbilly Elegy: A memoir of a Family and Culture in Crisis by J.D Vance and My Beloved World by Sonia Sotomayor.

 

An important component of health equity is ensuring a connection and understanding of the priorities, needs and opinions of the communities served.  Title V staff focused on the development and piloting of a Community Listening Forum/Session (CLF) protocol for use in all Title V procurement development and program implementation and evaluation. Title V staff adapted the CLF resources provided by the OMH-HDP for use in Title V programs. Staff obtained training materials, resources, marketing information, and findings from a series of large-scale CLFs conducted across NYS.

 

In the past year, Title V staff continued to focus on using the Community Listening Session model to gather information from members of the priority population to inform the development of programs and activities. In the summer of 2018, under the leadership of Governor Cuomo to address the significant disparities related to maternal mortality, Title V staff conducted seven community listening sessions across the state in the summer of 2018.

 

Based on maternal and infant outcome data, the DOH identified seven communities experiencing poor birth outcomes with an emphasis on those demonstrating racial disparities.  Following this analysis, listening sessions were planned for Buffalo, Syracuse, Albany, Bronx, Brooklyn, Harlem and Queens.  The DOH Maternal and Infant Community Health Collaboratives (MICHC) programs were engaged as partners to plan and conduct the listening sessions.  The MICHCs recruited other community partners to assist with engaging community participants and to help facilitate the sessions.  Community participants included recently and currently pregnant women and families, with an emphasis on engaging black women who have experienced an adverse birth outcome. 

 

The listening sessions, entitled “Voice Your Vision – Share Your Birth Story”, lasted between two and three hours and included on-site child care.  The listening sessions were organized to allow participants to drive the focus of each conversation.  Loosely centered around four topics (planning for pregnancy, pregnancy, childbirth, and the postpartum period), facilitators introduced each topic and kept participants on topic while scribes at each table captured participant feedback in real time.  Each session had about 35 community participants and began with DOH leadership, including Commissioner Zucker framing the purpose of the session.  Participants were engaged in a discussion on the barriers and issues impacting their birth experiences.  After the discussion, participants shared important points discussed during the process.

 

At the conclusion of these sessions, the written record of participant feedback, taken by scribes, was analyzed and summarized to produce a statewide report identifying overarching themes. This report summarizes what participants reported at the listening sessions and is currently under review.

 

Common barriers expressed across all seven listening sessions included: 

• Access to health care (limited facility choice, quality of provider and facility care).
• Poor communication with health care providers (especially feeling providers were not listening to them, that they were not given enough time with providers, and that few providers reflected their lived experience).
• Lack of information and education from providers.
• Racism and its impact on the quality of care received.
• Disrespect from health care providers, including support and administrative staff.
• Lack of social supports.

 

And common suggestions for addressing the racial disparities in maternal mortality included:

• More black and Hispanic health care professionals, reflective of the community.
• Increase health care professionals’ awareness of racial disparities in health outcomes.
• Train health care professionals on the impact of implicit bias on health care outcomes.
• Increase provider support during the postpartum period.
• Increase availability of social support for example, birthing classes, group prenatal care, doulas, midwives, community health workers and parenting classes.
• Increase availability of community services and resources, for example, community health worker services and home visiting services.

 

Across all seven listening sessions, participants asked for better understanding of the reasons why black women have poorer pregnancy health outcomes, and acknowledgement of the impact of race and racism on those outcomes. Participants asked for action to address the racial disparities in maternal mortality, and particularly focused on how health care systems and practices may perpetuate continued racial inequities.  Participants asked for the elimination of barriers that prevent women from getting quality health care services and asked for increased supports needed to help with a healthy pregnancy. 

 

Participants affirmed that all NYS mothers and babies should have the same opportunities to achieve optimal health and positive birth outcomes, regardless of race, ethnicity, community of residence, insurance coverage, or hospital of delivery. 

 

A commitment to health equity extends well beyond NY’s Title V program.  Over the past year, a Racial Justice (RJ) Workgroup was formed led by the CCH director, Nora Yates and comprised of staff members from all divisions with CCH.  The workgroup is charged with proactively promoting a racial justice framework throughout the work of CCH (including: Title V activities, epidemiology, WIC, SNAP, tobacco control, cancer prevention services, and more). Activities of the RJ workgroup take place within the context of a performance management infrastructure leading to the development of a series of RJ focused performance measures to guide the work of CCH.

 

Each division was charged with creating two measures, one internally focused (i.e. staff development, training, and capacity building) and one externally focused (i.e. community collaboration, coalition building, engagement of priority populations). The Title V program continues to play a major leadership role in the development of these performance measures. Building on several years of successful health equity focus, RJ workgroup members elected to develop a single internal performance measure to be used across CCH, based largely on Title V MCHSBG activities led by DFH for the past several years. This performance measure mirrors the format and evaluation of Title V MCHSBG work and dramatically expanded the staff  required to complete a comprehensive online training on health equity. Title V staff further impacted the development of several external performance measures (PMs) by modeling a community listening session protocol that was adopted by several other divisions as a way to increase community input and participation in program development.

 

Finally, the CCH RJ workgroup supported the facilitation of a two-day training on Racial Justice theory and practice by a national expert, Dr. Joia Crear-Perry. Broadly covering the complex and systemic factors contributing to racial inequities in health outcomes (esp. birth outcomes) this interactive training was available to most Title V staff working on maternal mortality, morbidity, or other women’s health activities. This training enabled participants to better understand the historical and root causes of institutional and structural racism that continue to impact health outcomes today. Participants were able to discuss and define strategies to implement within their ongoing work that would proactively address the role of race and racism in creating unequal outcomes for women and families in NYS. Work with Dr. Crear-Perry will continue through collaborative activities and consultant work via the RJ workgroup. 

 

The Title V program recognizes the value and importance of understanding and addressing health equity to improve the health and wellness of all New Yorkers and will continue efforts to ensure all families have access to quality primary and preventive health services.  The priority placed on addressing health disparities is integrated throughout NY’s work and in this report.  It is clear through efforts spearheaded by Governor Cuomo related to maternal mortality and efforts through DOH and Title V, there is a strong commitment to addressing this significant public health priority.  (Refer to the State Overview and information contained in the Maternal and Women’s Health and Perinatal and Infant Health section of this report for further details regarding New York’s health equity efforts.