PROGRAM OVERVIEW

Title V of the federal Social Security Act of 1935, also known as the Maternal and Child Health (MCH) Program Block Grant, is the oldest federal-state partnership to support the health and well-being of all mothers, children, and families, including those with special health care needs.

Guam's Title V MCH Program supports critical MCH Programs services across the island. Its over-reaching goal is to improve the health and well-being of mothers, infants, children, and adolescents, including children and youth with special health care needs (CYSHCN).

Role of Title V

Guam Title V supports an island-wide comprehensive, community-based, and family-centered system of services. The Title V program is housed within the Bureau of Family Health and Nursing Services (BFHNS), Division of Public Health, which houses other important MCH programs such as WIC and the Immunization Program. The island-wide staff reach and integration of Title V across Bureaus with the Division of Public Health is vital to addressing MCH needs. Coordinated and integrated systems of care are a priority across all MCH programs. Especially for CYSHN, a population uniquely served by Title V. BFHNS manages a continuum of linked services to ensure that CYSHN is well connected to and supported by health, education, and social services in their communities.

Guam's Title V program is viewed as a maternal and child health leader. It convenes stakeholders, disseminated data, and implements best practice programs to improve population health. Title V leadership sits and many tables to ensure that priorities are aligned and that opportunities to utilize Title V funds are leveraged appropriately. In addition, it uses its position to address health care system challenges, such as improving the quality of services, highlighting the need for adequate insurance, and emphasizing the importance of addressing social determinants of health in the MCH population.

Title V is a convener and collaborator in addressing MCH issues and enhances initiatives funded through other sources, such as the federal home visiting initiative. Federal Title V funding is critical to support program staff not covered by local funding. Within Guam DPHSS, the Title V priorities and performance measures framework provide a unifying vision resulting in improved communication and more significant collective impact.

Guam’s Title V Maternal and Child Health (MCH) Program operates under the vision of the Guam Department of Public Health and Social Services (DPHSS) to promote better health outcomes, reduce health risks, and support stable and safe families while encouraging self-sufficiency.

The mission of BFHNS is “to provide community health nursing services by synthesizing nursing practice and public health practices which focuses on health promotions, disease prevention, early detection and treatment of health problems and the restoration of health of individuals, families, and communities.”

Guam's Title V is viewed as a leader in the maternal and child field. Guam Title V serves an important policy and systems-building role, as evidenced by the fact that funding is dedicated to population-based and enabling services such as newborn screening and immunization services. In addition, it was positioned to assist in addressing health care system challenges, such as improving the quality of services, highlighting the need for adequacy of insurance, and emphasizing the importance of addressing social determinants of health in the MCH population.

Guam’s MCH Population

Assessing State Needs

The Guam Title V conducted a Needs Assessment along with the Maternal Infant and Early Childhood Home Visiting (MIECHV) Program in 2019 and 2020. Findings from these assessments informed the selection of priority needs, strategies, objectives, and measures for the 2021-2025 Title V Action Plan. Guam used a mixed method approach, which allowed the program to gather information from internal and external partners. In-person stakeholder meetings and virtual domain meetings comprised the methods of assessment strategies. These strategies also ensured the continued engagement of stakeholders in the planning, implementation, and evaluation process. The Territorial Epidemiologists worked with the Guam State Systems Development Initiative (SSDI) staff to provide data to measure progress and inform decision-making around objectives and measures.

There were eight National Performance Measures (NPM) and five State Performance Measures (SPM) were chosen to align with priority needs. The needs assessment identified two overarching principles to be applied across all priorities, performance measures, and strategies: 1) to ensure health equity for MCH populations and 2) to promote partnerships with individuals and families in decision-making.

The national measures are well-woman care, breastfeeding, development screening, oral health care for children, bullying, transitional health care for children with and without special health care needs, medical homes for children with and without special health care needs, and household smoking. The state-specific priorities are infant deaths, immunizations, and adolescent suicide.

The priority needs related to performance measures are discussed in the respective health domains. Progress is monitored by tracking each of these performance measures.

Women’s Health Domain

Priority Need - To improve maternal health by optimizing the health and well-being of women of reproductive age.

Performance Measures - NPM #1 – Percent of women ages 18 through 44 with a preventive medical visit in the past year.

The health and well-being of the mother before, during, and after pregnancy is essential not only for the woman but also for the newborn. Women who maintain a healthy lifestyle during the preconception period are less likely to experience adverse pregnancy and obstetric outcomes and more likely to experience better health postnatally and across the life span.

Well-woman visits are essential to a women's overall health and well-being. It provides an opportunity to receive recommended clinical preventive services, discuss their health, and prevent or help identify serious health concerns before they become life-threatening.

In 2021, the MCH Women's Health Clinic (WHC) saw 878 women, a decrease of 19.5% from the previous year. The largest age group to be seen in the WHC were women within the age group 20-24 years at 35.7%, followed by women aged 25-29 at 26.6%, the age group 3034 years at 16.4%, and lastly, the age group 15-19 years at 13.6%. The most significant proportion of women seen at the WHC was Chuukese women at 45.3%, Pohnpeian women at 15.4%, and Chamorro women at 15%.

Perinatal/Infant Health

Priority Need - To reduce infant morbidity and mortality

Performance Measures - NPM # 4 A) Percent of infants who are ever breastfed B) Percent of infants breastfed exclusively through 6 months

The American Academy of Pediatrics recommends that all infants are exclusively breastfed for six months to support optimal growth and development. Breastfeeding has health benefits for infants and mothers, including significant benefits to the mental health of both mothers and babies. For infants, breastfeeding can reduce the risk of asthma, obesity, SIDS, diabetes, ear infections, and some respiratory diseases. For mothers, breastfeeding can reduce feelings of anxiety and postnatal depression, reduce post-partum hemorrhage, and may decrease the likelihood of developing breast, uterine and ovarian cancers. The 2021 Guam birth certificate data indicated that 82.5% of mothers initiated breastfeeding at hospital discharge. This slightly increased by 2.6% from what was reported in 2020. The 2021 percentage surpassed Healthy People 2020's 81% breastfeeding initiation rate target.

Child Health

Priority Need – To improve all children's cognitive, physical, and emotional development.

Performance Measures - NPM # 6 – Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year and NPM # 14.2 - Percent of children ages 0 through 17 who had a preventive dental visit in the past year

The role of Title V has been to provide safety net services and assure all children have access to well-child, nutrition, and immunization services. Direct preventive well-child health services identify growth and development issues according to the standards recommended by the American Academy of Pediatrics (AAP). Assuring well-child exams and immunizations has been a hallmark activity for MCH Title V. During the 2020 needs assessment, this remained a priority with much discussion about early childhood development and mental health and addressing adolescents' mental/behavioral health.

Home visiting should be viewed as one of the several service strategies embedded in a comprehensive, high-quality early childhood system that promotes maternal and early childhood health and development. Developmental screening is a required benchmark performance measure for Guam's MIECHV Program "Project Bisita.” Project Bisita promotes and monitors parent-completed child developmental screening tools (ASQ and ASQ SE). In 2021, there were 41 completed screens out of 69 Project Bisita families.

Adolescent Health

Priority Need – To improve and enhance adolescent strengths, skills, and support to improve adolescent health.

Performance Measures - NPM # 9 – Percent of adolescents, ages 12 through 17, who are bullied or who bully others

Bullying severely affects a child's health, sense of well-being, safety, education, and emotional development and dramatically increases the risk of self-injury and suicide. According to the 2019 CDC YRBS survey, 14.5 percent of Guam students were bullied on school property, and 12.4 percent were bullied electronically. Bullying is defined as an attack or intimidation to cause fear, distress, or harm that is either physical (hitting, punching), verbal (name calling, teasing), or psychological/relational (rumors, social exclusion); an actual or perceived imbalance of power between the bully and the victim; and repeated attacks or intimidation between the same children over time. Data from the 2019 Youth Risk Behavior Survey indicate that a significantly higher number of students experiencing bullying described their grades as Ds and Fs in school during the past 12 months. The number of ninth-grade students reporting being bullied is significantly higher than for 10th, 11th, and 12th-grade students. Female students are significantly more likely than males to have experienced some form of bullying, name-calling, or teasing in the past year.

Children and Youth with Special Health Care Needs

Priority Needs – To provide a whole-child approach to services for Children with Special Health Care Needs.

Performance Measures - NPM # 11 – Percent of children with and without special health care needs, ages 0 through 17, who have a medical home, and NPM # 12 – Percent of adolescents with and without special health care needs, ages 12 through 17, who received services to prepare for the transition to adult health care

Guam’s Title V Program maintained its critical role in key areas: Information and Referral, Education and Advocacy, and Systems of Care for children and youth with special health care needs. Title V assisted families in accessing appropriate care and services by providing information and referral services to healthcare, insurance, and community resources for children, youth, and young adults with special healthcare needs, to best meet the child's needs.

In 2021, the Guam MCH Program conducted the Annual CYSHCN Satisfaction Survey to find out from parents/caretakers of CYSHCN about the quality of services they were receiving. The results showed that 51.9% of CYSHCN were currently being seen by a physician, nurse, or social worker for their specific condition(s). This was a 19.2% decrease from 2017 data. When asked if parents/caretakers were involved in decision-making for their child, 92.6% of parents/caretakers were involved in decision-making. This was a substantial increase of 44.6% from the 2017 data. When asked if they (parents/caretakers) could pay for their child's needs with private/public insurance, 72.7 stated they were able, an increase of 27% from 2017. Lastly, when asked if their child was receiving transition services, 51.9% said that their child was receiving such services.

Partnerships and Collaborations

Multiple collaborations are also ongoing between Title V programs and other Guam DPHSS program areas. Those partners include the Office of Vital Statistics, the section of Community Health that houses - Chronic Disease Prevention, Tobacco, Guam Cancer program, Breast and Cervical program,  and the Guam Diabetes Program, the HIV and STD Prevention Program, the Guam Family Planning program, the Guam WIC Program, the Guam Immunization Program, the Bureau of Primary Care Services ( Northern and Southern Health Centers), the Division of Senior Citizen, the Division of Public Welfare, including the Medicaid State Office, the Child Proctive Services(CPS), Division of Environmental Health and The Office of Performance Improvement Management.

Other partners within the community that have collaborated with the mission of MCH are; the Guam Memorial Hospital Authority (GMHA), the Guam Behavioral and Wellness Center, the Department of Youth Affairs, the Guam Housing and Urban Renewal Authority (GHURA), The University o Guam the Guam CEDDERS, the Guam Early Hearing ,Detection, and Intervention (GEDHI) program the Department of Education Head Start program, Guam Early Intervention Services, the DOE Special Education program, and the Guam Medical Regional Center (GRMC), to name a few who have made a difference with the MCH population.

Guam MCH has long-standing relationships with numerous public and private organizations and service providers to carry out the scope of work within the MCH Block Grant. Initiatives for partnerships with governmental and non-governmental agencies continue to flourish in Guam. The methodology for supporting and initiating such collaborations comes from different sources. The directives for the collaborations often come from political leaders and state agency heads. Where the Needs Assessment is concerned, partnering methods are developed through strong networking and seeking out nontraditional partners to bring to the table. Guam's needs assessment process has revealed the need to implement collective impact strategies and strategically align partnerships for more focused work. These partnerships are vital to the strength of any Needs Assessment process and to improving outcomes for Guam families.

COVID -19 Impact

The pandemic highlighted many gaps in services, aggravated disparities, and other issues felt more strongly by vulnerable populations, many of which are common to multiple population groups. Diminished access to health-related and financial services was exacerbated as agencies, and private businesses closed completely or shifted to virtual methods, resulting in lower rates of preventive health care. The re-direction of much of the public health workforce to assist in Covid's response also meant a delay or gaps in surveillance, implementation activities, and progress toward goals – meaning that some effects of the pandemic may not be fully known for some time.

The impact on the Guam MCH population includes, but is not limited to, increased mental health issues; loss of social support and connection; increased risk of preterm births, stillbirths, and other pregnancy complications; increased violence, childhood adversity, and trauma; disrupted health care, social services, and education; and increased economic hardship such as food insecurity and unemployment. Guam Title V will continue to monitor other secondary impacts of the pandemic on Guam families.

The Covid pandemic also affected Title V planning and implementation. The five-year needs assessment and action-planning process for the new five-year cycle (2021-2025) was largely finalized in 2020 before the severity of the pandemic was understood.