Arizona, one of the fastest-growing and most diverse states in the nation, has around 7.2 million residents. Almost half of Arizona’s population belongs to a racial or ethnic minority group. Arizona is home to 22 federally recognized tribes—including the largest tribe in the US, the Navajo Nation—and almost 400,000 individuals identifying as American Indian/Alaska Native.

Geographically, Arizona is the 6th largest state in the US and shares a 389-mile border with Mexico. Arizona has a shortage of medical providers, which is particularly acute in sparsely populated, rural areas of the state. With 733 federally designated Health Professional Shortage Areas (HPSAs), Arizona needs 667 full-time primary care physicians, 485 dentists, and 227 psychiatrists statewide to eliminate these HPSAs.24

Impact of COVID-19

 As of April 26, 2023, there have been 2,468,340 cases and 33,395 deaths due to COVID-19 in Arizona.29 That is a rate of 33,857 cases per 100,000 population— currently the fourteenth highest rate among all states.30 The COVID-19 pandemic in Arizona has laid bare long-standing inequities in health outcomes and provisions, particularly among indigenous populations. While Arizona is still experiencing new cases and hospitalizations associated with COVID-19 they have significantly decreased over the past year and a half. As of May 2023, there have been about 1,200 cases in a single week reported in Arizona as compared to the 157,814 cases in January 2022. Arizona has been fortunate that the number of cases, hospitalizations, and deaths have remained low although Arizona has experienced upticks in hospitalizations in June and November of 2022. As of May 11, 2023, over five and a half million Arizonans (76.5% of the population) had received at least one dose of the COVID-19 vaccine.

AZ Title V program has shifted from pandemic response to recovery, Title V program is reviewing the data to increase understanding of how the pandemic has affected Arizona’s maternal and child health (MCH) populations, apart from the immediate impact of the disease. Some trends that are being monitored include increased incidence of domestic violence, diseases of despair (e.g., depression, anxiety, suicide, drug misuse), risky behaviors among adolescents (i.e., unprotected sex, drug use, driving choices), and reduced utilization or uptake of preventive services, childhood immunizations, and developmental screening. These secondary impacts of the pandemic are likely to last for a while, and it will be important to identify and address them with targeted actions and resources in the coming years.

Structure of the Title V Program

Arizona’s Title V Program is implemented by the Arizona Department of Health Services (ADHS), one of the executive agencies that report to the Governor. Arizona Revised Statute (A.R.S. § 36-691) designates ADHS as Arizona's lead state agency for the administration of Title V. The mission of ADHS is to promote, protect, and improve the health and wellness of individuals and communities in Arizona.

Within ADHS, the Title V Program is administered by the Bureau of Women’s and Children’s Health (BWCH). Most of the programs funded through Title V are housed within BWCH, which is organized into four offices: Children’s Health (includes infant health and children and youth with special health care needs), Women’s Health (includes adolescent health), Oral Health, and Primary Care Office (PCO). Ms. Laura Luna Bellucci, Chief, of the Bureau of Women’s and Children’s Health (BWCH), currently serves as the Title V Maternal and Child Health (MCH) Director and the Title V Children with Special Health Care Needs (CSHCN) Director. Where Title V–funded programs and activities occur outside the BWCH, there is clear coordination of efforts between BWCH and the outside partners. The BWCH Office of Assessment and Evaluation successfully transitioned to the Bureau of Assessment and Evaluation (BAE) in May of 2022, with Mr. Martín Celaya serving as its Bureau Chief. The new Bureau has continued to support Title V data, needs assessment, and evaluation activities. More information about the new Bureau of Assessment and Evaluation can be found in section III.E.2.b.iii.a. MCH Epidemiology Workforce.

Role of the Title V Program

Through Title V funding, the program leads, implements, funds, and partners on activities to reduce mortality and morbidity among women and children, eliminate health disparities in health outcomes and access to services, and increase access to health care. As demonstrated in the 2022 Annual Report narratives, Arizona’s partnership with the Health Resources and Services Administration (HRSA)’s Maternal and Child Health Bureau (MCHB), through the Title V Block Grant, has allowed Arizona to leverage federal and non-federal resources to improve the health status of Arizona’s mothers, infants, children and adolescents, including children and youth with special health care needs (CYSHCN) and their families. In 2022, Arizona’s Title V Block Grant proudly served 978,971 and will work to sustain efforts through the strategies and activities proposed in this application. These activities underscore the importance of our numerous public and private partners in fully executing the mandate of Title V.

Title V in this short Executive Summary highlights some key activities below. More information can be found in the population domain narratives and Appendix A provides a table of Title V–funded programs by population domain.

The Title V Program provides leadership to and participates in several workgroups that bring together stakeholders around specific topics of importance to our Title V populations. These groups, which include the Maternal Health Task Force, Safe Sleep Task Force, Adolescent Health Alliance, Arizona Oral Health Coalition, the Preconception Health Alliance, the Collective Impact for Child Safety and Well-Being, and the Pediatric Advisory Council for Emergency Services (PACES), serve to identify needs and challenges and set agendas to address these. For a list of groups view Appendix B.

An essential role of the Title V program is to increase education and awareness of issues that affect our populations. For example, in 2022, the program continued to fund the Arizona Chapter of the American Academy of Pediatrics to develop resources and share up-to-date information regarding COVID-19 and children with pediatric providers in Arizona. This project has since evolved into the Pediatric Infectious Disease Training Center. In addition, Title V funding has been used to create reports, including the Maternal Mental Health and Substance Use Related Death in Arizona that will assist in the identification of future areas for intervention and guide effective and evidence-based efforts towards the reduction of adverse maternal health outcomes. In 2022, BWCH rolled out a new Safe Sleep Toolkit, developed with Title V funding and is being disseminated through the Strong Families AZ home visiting alliance and the ADHS Office of Injury and Violence Prevention.

The Title V Program also provides workforce and professional development training programs to strengthen the skills and knowledge of Arizona’s medical and public health providers. For example, the Office of Oral Health (OOH) provides professional development opportunities for dental providers and program administrators on dental health issues, in partnership with the Arizona Alliance for Community Health Centers, the Inter-Tribal Council of Arizona, and the Greater Valley Area Health Education Center. The Child Fatality Review partners with the Maricopa Medical Examiner’s Office to provide training on Sudden Unexpected Infant Death to law enforcement and first responders around the state. The training was placed on hold due to COVID-19 but will continue later in 2023.

Through Title V funding, funded partners also implement direct services (or fund partners to implement direct services), such as family planning and reproductive health services, hearing and vision screening, home visiting support, and oral health and medical services for uninsured and low-income children.

Arizona’s Title V Program collaborates with other State agencies, local governmental organizations, and private entities to promote and implement activities that address our priority needs. For example, Title V funds close to two million dollars to local county health departments to implement programs that address our state priority needs and selected National Performance Measures (NPMs). Within ADHS, Title V program collaborates with the Bureau of Nutrition and Physical Activity (BNPA) to implement the Empower Program (which promotes health and wellness in state-licensed childcare facilities), promote breastfeeding, and maintain the Title V Toll-free Helplines; with the Bureau of Chronic Disease and Health Promotion on childhood injury prevention programs, like car seats, safe sleep, and tobacco cessation; with the State Laboratory Services on newborn screening; and with Public Health Statistics on the Arizona Birth Defects Monitoring Program. The Title V program also collaborates with other state agencies involved in child welfare, such as the Department of Education and the Department of Child Safety.

The Title V program in Arizona provides both monetary and non-monetary support, such as technical assistance and coordination, to many non-governmental and community-based organizations, academic institutions, professional associations, hospitals, clinics, and other private entities that are furthering the aims of the Title V Program.

Another key role Arizona’s Title V Program plays is to provide referrals, linkages, and access to care. A principal means of doing this is through the various home visiting programs (e.g., MIECHV, High-Risk Perinatal Program, Health Start). The CYSHCN team is also, as part of the Mountain States Regional Genetics Network, working with partners in Newborn Screening, Arizona Early Intervention Program (AzEIP), Arizona American Academy of Pediatrics (AzAAP), and Phoenix Children’s Hospital to increase use by pediatricians of the Developmental Delay Algorithm for genetic referrals.

An essential activity of the Title V program is collecting, analyzing, and disseminating MCH data. The data helps the Title V program identify areas of need and emerging issues, assess program effectiveness, measure improvement, and channel federal and state funding where it can be most impactful. This data is also vital for our community partners. An area of particular importance within data collection and analysis is the identification and designation of Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas/Populations (MUA/Ps). Title V programs work with the PCO to complete the statewide assessment of areas for HPSA designation.

Family engagement and health equity are two guiding principles that are interwoven throughout the Title V strategies across all population health domains. Family engagement is a key strategy to identify and understand health inequities and help address those inequities.

More information can be found in the III.E.2.a. State Title V Program Purpose and Design section of this application.

Maternal and Child Health (MCH) Needs and Priorities

AZ Title V program employed seven data collection approaches during the 2020 Title V MCH Needs Assessment to better understand the primary and preventative health service needs of Arizona’s Title V populations. In addition to collecting and analyzing quantitative MCH data from national and state data sources, Arizona’s 2020 Needs Assessment was designed to engage families and the public through a public survey, focus groups, and community forums to capture qualitative and quantitative data that draws on the experience and knowledge of the communities served.

Surveillance data allowed Arizona to identify both desirable and undesirable trends in key health indicators using readily available data from state and national datasets. The public survey, available in English and Spanish, solicited information from 1,078 participants statewide on specific programmatic needs and included an assessment of 20 social determinants of health. The focus groups identified 13 hard-to-reach communities to hear their perspectives on health issues, services, and sources of information in their communities. In total, 23 focus groups were held inclusive of 15 adult groups and 8 youth groups. Community forums collected information on service needs at the local, and regional levels and solicited feedback on how difficult participants assessed it would be to address those needs. A total of seven community forums were held in rural and urban counties—including one in Spanish (open to Spanish-speaking community members across the state)—and 135 community members participated.

The Title V program also engaged Arizona’s 22 federally recognized tribes to assess the MCH needs of Native American/indigenous communities through a contract with Diné College to conduct a Needs Assessment for the Navajo Nation and the Inter-Tribal Council of Arizona (ITCA) to conduct the Needs Assessment for the other 21 federally recognized tribes. These assessments leverage BWCH’s ongoing relationship with Arizona’s tribal partners to identify and support efforts to address their unique MCH needs.

To guide the assessment process and set priorities, the Title V program established a Steering Committee with 68 members from 27 organizations. They provided feedback on data collection approaches and tools, recommended groups and individuals for community forums, leveraged existing partnerships for participation in assessment activities, promoted assessment methodologies, participated in the prioritization process, and guided the selection of our priorities and NPMs.

Based on findings from the 2020 Needs Assessment and in coordination with the Steering Committee priorities were developed and are listed in Figure 1. In many ways, these priorities are a continuation of interventions and strategies that have been the focus for some time, yet renew an explicit emphasis on health equity and quality of service provision; for this reason, AZ Title V program included “equitable and optimal” in many of the priorities. Family engagement is also at the core of the new priorities as a mechanism through which health equity can be achieved. In coordination with Title V program managers, the Steering Committee, and local county health departments, selected NPMs and State Performance Measures (SPMs) to measure and track progress on our priority needs (Figure 1).

Based upon feedback from HRSA it was advised that the Arizona Title V program reduce EMS to only one to three per NPM. As part of our 2022 Visioning Meetings, a series of strategic planning meetings held each year with internal partners to assess our Action Plan strategies, objectives, and related measures, the team decided to do a deep dive into the ESMs. The State of Arizona went from 42 ESMs (10 Women/Maternal Health, 8 Perinatal/Infant Health, 9 Children’s Health, 9 Adolescent Health, 6 Children and Youth with Special Health Care Needs) to a total of 21 ESMs (4 Women/Maternal Health, 4 Perinatal/Infant Health, 6 Children’s Health, 6 Adolescent Health, 1 Children and Youth with Special Health Care Needs). Cutting the ESMs by half will allow our Title V Program to have more meaningful and measurable strategies.

Figure 1. 2021-2025 Statewide Maternal and Child Health Priorities and National Performance Measures (NPMs)