III.C.2.a. Process Description
The five-year needs assessment provided Guam an opportunity to reassess MCH services formally. Given the vision, the 2020 Title V Block Grant Needs Assessment provided an opportunity for strategic planning and activity development to improve the health status of the MCH population on Guam. This broad view of the concerns of Guam's community members, health care providers, and advocates, coupled with extensive quantitative data, provided a sound basis for planning MCH service and system development for the future.
With the Bureau of Family Health and Nursing Services Administrator's leadership, who is also MCH Program Director, a Steering Committee was established. This group established the overall strategic direction and methodology for the needs assessment while providing on-going project management and oversight for the process.
Stakeholders included representation from state MCH programs (including MCH Needs Assessment Steering Committee members), family/youth-serving agencies, faith-based agencies, and other key MCH community partners such as healthcare providers, community‐based agency staff, along with representatives from other state agencies and academic institutions. Stakeholders included representatives from public health and other governmental agencies (e.g., Public School System and Medicaid Program), staff from community‐based organizations, and advocacy/interest groups (e.g., GALA and Sanctuary).
Criteria used for selecting stakeholders included their area of expertise and workplace setting, training and experience, knowledge of public health, and their ability to conceptualize at the strategic level, while not solely advocating for a single issue. Members solicited feedback from their constituencies/ stakeholders in between meetings, which greatly expanded this effort's reach.
Methodology
Guam assessed the needs of the MCH population using Title V indicators, performance measures, and other quantitative and qualitative data. The Steering Committee reviewed major morbidity, mortality, health problems, gaps, and disparities for the MCH population to identify the MCH population domain's specific needs based on the analysis of data trends. Specifically, the Steering Committee:
- Reviewed the 2015 Needs Assessment and interim needs assessment findings and noted trends since the last assessment;
- Reviewed recent state, regional and national reports to determine possible issues/problems to be explored in the Guam;
- Identified major data/indicators including trends of health status, access, health needs and health disparities to be included in the assessment for each domain; and
- Determined stakeholder and public input processes.
Quantitative methods used for assessing needs for each of the population domains included reviewing various data sources, including Vital Statistics Data, US Census Data for Guam, Surveillance Systems and Registries, Mortality Reviews, and other Government of Guam Agency Data and Reports, and Youth Behavior Risk Surveys.
Qualitative methods included the use of meetings with MCH clients, stakeholders, parents, and community members. While also identifying any important issues not reflected in the original list developed by the Steering Committee. Most had been considered by the Steering Committee in earlier phases of the needs assessment process of the new issues identified. In addition, qualitative data was received from special population focus groups, such as Project Bisita Home Visiting families, and a review of state plans and reports prepared since the last needs assessment.
We had the unique opportunity to align multiple assessment activities on Guam with our 5-year Title V MCH Needs Assessment. These include the required MIECHV Needs Assessment update. MCH has shared all of the resources available to us from HRSA including guidance documents, invites to relevant webinars as well as our past needs assessments. MCH and Project Bisita held several co-facilitated Needs Assessment Meetings. Our first Needs Assessment Meeting was held in November 2018
In the various stakeholder meetings, we reviewed the priorities, strategies and measures. We explained the changes that were being made to the Block Grant application with regard to pairing down the number of health priority areas if necessary. During the first stakeholder meeting a survey was held for the attendees to complete. The results revealed that stakeholders perceived infants to be the most at risk population. In many cases, there were consistent themes across all population groups. For example, health-related issues that were identified as needs not being met for virtually all populations included:
Substance abuse services (including tobacco, alcohol, prescription, and illegal drugs)
Family planning (birth control, knowledge/education regarding sexual health)
Access to health care (including insurance and quality health care providers)
Obesity and nutrition (including health education and obesity-related health conditions)
Safe environment (including free from violence/crime, as well as physical safety concerns including proper car seats, safe sleeping practices, and quality childcare)
The focus group meeting provided parents and early childhood providers the opportunity to examine and assess services currently being offered in the community. Parents provided feedback on the types of questions and delivery modes to garner input from families receiving early childhood services. Early Childhood providers were given the opportunity to discuss current services and gaps in training, acceptance of services, and job satisfaction. Last meeting was held via zoom. Data was presented to stakeholders on various subjects, the stakeholders were then asked to further discuss the data via zoom breakout rooms.
A stakeholder input session with parents enrolled in Project Bisita I Familia, Guam Early Intervention System, Early Childhood Special Education Preschool, and Head Start Program at the Dededo Farmers’ Market Complex. This group of parents provided suggestions on the types of questions necessary for garnering feedback about home visiting and early childhood services on Guam.
On February 25, Early Childhood Consultant facilitated the first focus group meeting with parents receiving services from early childhood programs at the Dededo Farmers' Market Complex.
At the end of the above process, results were summarized from all activities and presented to the Steering Committee. As expected, the focus areas identified across approaches overlapped due to the impact that many of the issues exert throughout the life course. This phase concluded with the identification of 26 potential MCH priorities spanning the six domains. The Steering Committee met concerning the possible priorities identified with the goal of further refining and prioritizing the issues.
The MCH Project Director, along the Project Bisita, Needs Assessment consultant presented information and updates to both Needs Assessments that are underway at the Guam Learning Council. All feedback and suggestions were noted
Prioritization criteria included considering potential issues in terms of the MCH role, the existence of strategies for intervention, and the ability to demonstrate outcomes/results within five years using specific indicators to measure progress.
Ranking of the health issues was done using the following criteria:
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Relevance as it relates to national priority needs.
- Is the health issue reflective of the Title V national performance measure priority areas?
- Does the Guam Code Annotated mandate a health program to address this health issue?
- Are there significant racial or socioeconomic disparities related to this health issue?
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Ability to be addressed by existing resources and opportunities
- Were there strategies/activities identified to address identified health issues?
- Does the Guam Title V program have existing activities/strategies that will address these health issues?
- Are there Title V resources to address the health issues?
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Ease in monitoring progress in addressing the health issue
- Are there data collected to monitor progress toward addressing the identified health issues?
- Are the overall trends for identified health issues worsening in Guam?
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Impact on the population
- Based on current data, are there many individuals affected by identified health issues?
- Did stakeholders or the general public identify or perceive identified health issues as an emerging or unmet health issue that needs to be prioritized?
This phase concluded with the reduction to 13 potential MCH priorities spanning the six domains.
Next was the final prioritization process and state capacity assessment to determine the MCH priorities for FY2016‐2020, and in keeping with the guiding principles of the process, the Steering Committee focused on the goal of identifying select areas for MCH investment so that a comprehensive set of interventions could be employed at more depth to affect five‐year outcomes. In addition, the chosen priorities needed to be tied to the MCH scope of influence in order to assure the ultimate impact. To do so, the Steering Committee was charged with connecting each potential priority to a national or population‐based outcome measure. To this end, the Steering Committee prepared a justification for each priority highlighting the following: MCH role; data to support the need (severity or numbers affected); effective interventions/strategies that exist to address the issue; the local capacity score for the issue and specific indicators that could be used to measure success within the five years. Each issue was ranked following these discussions, using a grid specifying impact and feasibility along an x and y-axis. This, along with the assessment of state capacity, served as key resources for discussion in determining the final set of eight priorities.
- To Improve maternal health by optimizing the health and well-being of women of reproductive age.
- To reduce infant morbidity and mortality.
- To improve the cognitive, physical and emotional development of all children.
- Promote oral health for children ages 0 to 3 years
- Improve childhood immunizations.
- To improve and enhance adolescent strengths, skills and support to improve adolescent health
- Reduce the use of substances including alcohol, tobacco, marijuana and opioids among youth
- To provide a whole child approach to services to Children with Special Health Care Needs
Data Sources
The following is a description of the data sources used in the Guam Title V Needs Assessment. The majority of these data sources come from national and local level population-based surveys; however; some data come from vital records, passive surveillance systems, and other datasets maintained by either the Guam Department of Public Health and Social Services (DPHSS) or the Centers for Disease Control and Prevention (CDC).
Behavioral Risk Factor Surveillance System (BRFSS)
The Behavioral Risk Factor Surveillance System (BRFSS) is a telephone surveillance system designed by the U.S. Centers for Disease Control and Prevention (CDC). Surveillance is conducted to collect data about modifiable risk behaviors, preventative health practices, and health-related conditions contributing to the leading causes of morbidity and mortality. Information from BRFSS is used to establish and monitor health objectives and plan and implement health promotion programs to improve the American people's health.
There are several limitations to the BRFSS. On Guam, households without a land-line telephone cannot participate in the survey, and some individuals may refuse to participate. Answers are self-reported and are subject to the limitations of self-reported data collection. The physical activity questions ask about physical activity leisure time and exclude physical activity performed as part of an individual's job. Questions specific to diabetes, high blood pressure, and high cholesterol require a clinical diagnosis and might exclude individuals who have a condition but have not been diagnosed.
Youth Risk Behavior Surveillance System (YRBSS)
The Youth Risk Behavior Surveillance System (YRBSS) was initially developed by the Division of Adolescent and School Health (DASH), CDC. The YRBSS monitors six categories of priority health-risk behaviors among youth and young adults, including behaviors that contribute to unintentional injuries and violence; tobacco use; alcohol and other drug use; sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infections; unhealthy dietary behaviors; and physical activity. YRBSS also monitors the prevalence of obesity and asthma.
Limitations of the YRBSS are: survey questions are predetermined, standard, and close-ended, which could fail to identify new and emerging trends and the most important aspects of current problems and issues. Since the prevalence of behaviors is self-reported, students may under or over report behaviors, which results in self-reported bias. School-based survey methods cannot reach those who are attending private schools or are receiving home instruction. Although methodology attempts to survey all enrolled students on a particular day, school-based surveys fail to reach students who are ill, truant, missing on the day of the survey, or are schooled in settings other than the public school system.
Guam Birth Certificate
Information on Guam births is collected from the Certificate of Live Birth. Data items are presented as reported on the certificate. Completeness and accuracy of items may vary by birthing facility. Data for all births that occurred within Guam, resident, and nonresident, are collected. These files consist of all births that occur in Guam for a given year.
There are some limitations related to the use of birth certificate data. For example, some pregnancy health risk behaviors (e.g., alcohol or tobacco use) may be under-reported by the mother completing the birth certificate form. Also, race/ethnicity reporting may present some inconsistencies because of the inadequacy of categories. Another recent issue is how to deal with the increasing number of individuals who identify themselves as multi-racial, which makes it challenging to compare race from data in prior years.
Guam Death Certificate
Death data are compiled from information reported on the Certificate of Death. Data items are presented as written. Information on the certificate concerning time, place, and cause of death is typically supplied by medical personnel or the medical examiner. Demographic information such as age, race/ethnicity, or occupation, is generally reported on the certificate by funeral directors from information supplied by the available next of kin.
Fetal deaths are defined as death before the complete expulsion or extraction from its mother of a product of conception, irrespective of pregnancy duration. The death is indicated by the fact that after such separation, the fetus does not breathe or show any other evidence of life, such as the heart's beating, pulsation of the umbilical cord, or definite movement of voluntary muscles. These deaths are captured in a separate file from the standard death files.
Limitations related to the use of death certificate data include differences in cause of death that could reflect differences in death reporting practices by physicians and the medical examiner. In 1999, the vital statistics program nationwide adopted Version 10 of the International Classification of Disease (ICD 10). Therefore, the cause of death data before and after 1999 should not be compared to one another. In addition, death records do not provide adequate information on factors that may contribute to death, such as an individual's health status prior to death.
Sexually Transmitted Infection and HIV Surveillance System
The Guam STD program at the DPHSS conducts surveillance and research to characterize and track sexually transmitted and HIV infections in Guam. The program collects, compiles, and disseminates information on gonorrhea, syphilis, chlamydia, and HIV infections, and contacts healthcare providers to ensure that clients receive adequate treatment. The program synthesizes data from multiple sources to develop annual Guam STD/HIV epidemiological profiles. These reports are used to inform and guide the STD/HIV program.
Limitations are that program and/or service data is available only from those receiving the services. Generally, those who experience barriers to accessing services are not included. This means that data may not provide insight regarding the neediest or those who are not receiving benefits.
The Guam Medicaid Program
Medicaid was authorized in 1966 to strengthen and extend the provision of medical care and services to people whose resources are insufficient to meet such costs. Corrective, preventative, and rehabilitative and medical services are provided to retain or attain independence, self-care, and support.
The Guam Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program
The Guam EPSDT program is a preventive health program that is free for children birth to age 21 who are eligible for screening, diagnosis, and treatment services to help prevent health problems from occurring or help keep health problems from becoming worse.
National Immunization Survey (NIS)
NIS is sponsored by the National Center for Immunizations and Respiratory Diseases (NCIRD) and conducted jointly by NCIRD and the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention. The NIS is a list‐assisted random‐digit‐dialing telephone survey followed by a mailed survey to children’s immunization providers to monitor childhood immunization coverage.
Data Limitations
As with most health assessments, there are several limitations of the indicators presented in this report.
First, indicators of Guam residents' health status are derived from surveillance data and are often presented over several year periods, during which data collection or analysis techniques may have changed. Any changes in the collection or analysis of surveillance data are noted with the figure.
Second, there is a time lag between when the indicators were collected and when they have been analyzed and are available for the public report. As such, the MCH Needs Assessment includes the most recent year in which data were publicly available, but some data were not available for 2017or 2018 at the time of the publication of this report.
Third, different data sources may use a different indicator. For example, to provide a comprehensive snapshot of adolescent risk-related behaviors in Guam, this report includes data on hospitalizations via utilization data, self-reported behaviors via surveys, and mortality data via vital records. While some of these indicators are based on self-report, others are derived from mandatory reports to the Guam Department of Public Health. Together, these data sources provide insight into the range of issues affecting many MCH-focused populations.
Fourth, some data are not available for specific populations of interest, such as particular villages in Guam, or sub-population groups. This is often due to small sample or population sizes and limitations in data availability for marginalized populations.
Fifth, some data, particularly those based on surveys such as the Behavioral Risk Factor Surveillance System, Youth Risk Behavior Surveillance Survey, and National Immunization Survey, are based upon self-report, which may lead to an over- or under-estimate of the prevalence of the health issue or health behavior. Despite these limitations, the indicators included in the MCH Needs Assessment can provide important insight into health issues affecting Guam mothers, infants, and children and can inform the health improvement planning process.
Broad stakeholder Involvement – Multiple opportunities were provided for input into the needs assessment process that included participation in focus groups and participation in selecting the top priority needs.
Depth and scope of the data analyzed – The 2020 Needs Assessment is the most comprehensive report on the health and health behaviors of women, infants, children, and children/youth with special health care needs. The data were also presented in a manner to ensure availability for advocates, program planners, and policymakers.
Internal stakeholder engagement – The success of the Title V MCH Services Block Grant is dependent on strong collaborative relationships with internal and external partners. There were several opportunities to engage the Division of Public Health leadership throughout the 2020 Needs Assessment and Title V MCH Services Block Grant FY 21 Application Process. This included the development of State Performance Measures and selection of the National Measures.
Effective Collaborative Partnerships - The needs assessment process was strengthened through the partnerships and collaborative efforts involved in the facilitation of the process. These partnerships underscore the collaborative agreements and community partnerships that further structure and develop the Territory's existing programs. These efforts were beneficial in maximizing the efficient use of resources and compiling data on existing programs. This process was also beneficial towards the inception of the development of a comprehensive system for MCH programs (including home visiting) with MCH staff, other public and private agencies, and community stakeholders.
Dissemination
Critical to the needs assessment process is making sure that stakeholders are aware of the overall
process, including selecting MCH priorities for the State. Throughout this process, partnerships and collaborations were vital to its overall success. As part of the MCH program's on-going commitment to both the process and its stakeholders, reporting back is of paramount importance.
An Executive Summary is an essential component of our dissemination plan. Stakeholders will be sent a copy of the summary via electronic mail. This document will be discussed and disseminated through various community and statewide meetings pertaining to MCH priority populations. Additionally, the overall needs assessment will be made public by posting a complete searchable PDF copy on DPHSS's website. All of our stakeholders – from local government and community partners to families – will have the opportunity the view this document and be part of the on-going needs assessment process.
Linkages between Assessment, Capacity and Priorities
As we reviewed the strengths, progress toward health and wellness, needs and challenges, and capacity, we identified priorities based on the input we received and the data trends. We developed the State Priorities based on the data review, assessing our strengths and needs for the populations we serve. Review of the previous state and national Performance Measures, other data sets, work that we have done on various elements of needs of the MCH populations, input from the surveys all played a role in our discussions of needs. We considered the ability to impact, numbers impacted, and shortages of services and the significance of the issue in our discussions.
II.C.2.b Findings
III.C.2.b.i MCH Population Health Status
Women/Maternal
Data from the Guam BRFSS show that an estimated 75.9% of adult women on Guam received a preventive medical visit in 2018 and 70.3 in 2017. The national estimate for 2017 was 70.4%. In 2018, the prevalence of Guam women having a routine check-up within the past year increased with household income level. Fewer women with less than a high school education (63.7%) reported having had a regular check-up within the past year than did women who were high school graduates (78.5%) had some college (74.7%) or were college graduates (84.6%) in 2018.
To increase the awareness and importance of the well-woman visit, MCH has utilized collaborations between programs. Such as Project Bisita, Guam’s Home Visiting Program, has provided referrals for women's health services. Through their work with women and families, they provide education about the importance of preventive and reproductive health care, including sexually transmitted infections (STIs), birth spacing, contraception, and preconception counseling. The program also helps women find health services and reduce or eliminate barriers, such as transportation, to ensure that women can get the health care services they need.
Data from the National Vital Statistics System (NVSS) indicate that the percentage of pregnant women who received prenatal care beginning in the 1st trimester remained relatively unchanged since 215 at 60.9%. The percent of women whose prenatal care initiation was late or received no prenatal care also remained unchanged at 13.4%.
The Prenatal Interview and Examination (PNI & E) is the first antenatal visit for Guam’s MCH clients who suspect a pregnancy. Three areas are addressed during the visit. They are the diagnosis of pregnancy, maternal and fetal health assessment, and the development of a plan for continued care. In 2019, Guam MCH saw 202 women for PNI & E. The highest number of women seen was of Chuukese ethnicity at 41.1%, followed by women who were Chamorro (25.1%) and Filipino (12.9%). The women's largest age group was the age group 20 to 24 at 35.9%, followed by the age group 25 to 29 years at 28.1%, and lastly, the age group 15 to 19 years at 16.2%.
Perinatal/Infant Health
Between the years 2014 to 2018, 193 Guam infants died before their first birthday, an average of 32 infants per year. The mean infant mortality rate for the five years was 9.67 per 1,000 live births. In all the years examined, Guam's infant mortality rate remained higher than the Health People 2020 Objective of 6.0 infant deaths per 1,000 live births.
The Medicaid program covers medical care and services to people whose resources are insufficient to meet the costs. Medicaid may pay for expenses such as prenatal care services or the child's birth for eligible pregnant women.
The infant death rate among infants born to mothers who received Medicaid had fluctuated over the past five years, with a high of 5.5 infant deaths per 1,000 live births among Guam women who were Medicaid recipients to a low of 1.8 per 1,000 live births. The rate of infant deaths per 1,000 live births to non-Medicaid mothers was highest in 2016 when it reached 6.6 per 1,000 live births to its lowest in 2017 at 5.4 per 1,000 live births. In 2018, the infant mortality rate among non-Medicaid mothers was 6.6 deaths per 1,000 live births.
Those who are of lower-income status in the United States have a more difficult time receiving health care. If they do receive health care, it will not be the same type of health care that those of higher socioeconomic status receive. For example, those of lower-income are often on government-provided health insurance. This insurance will be very different from the kind of health insurance that those who have private insurance can access. Those with private insurance are going to have more benefits.
Guam breastfeeding rates are higher among educated and older mothers. They are lowest among mothers who experience more barriers reaching their breastfeeding goals, such as low-income and mother under the age of 20. Differences in breastfeeding rates are seen among infants enrolled in the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC). WIC serves low-income women and children. In 2019, 83% of women enrolled in WIC initiated breastfeeding compared to 75% of women enrolled in 2015.
Child/Adolescent Health
The NPM Guam has selected for this domain is NPM #7: Rate of hospitalization for non-fatal injury per 100,000 children ages 0-9 and adolescents ages 10-19. Guam Memorial Hospital and Guam Regional Medical City, inpatient hospital data, shows a decline in hospitalizations rate from 145.0 to 123.8/100,000 children ages 0-9 and adolescents ages 10-19.
In 2019, injury was responsible for 11 children/young adult deaths on Guam. Twenty-seven percent (27.2%) of hospitalizations and 86.4% of the emergency room visits for children/young adults aged 0 to 24 years were due to injuries. As in the case nationally, the types of injuries vary by age group and have been broken into groups of injuries to those less than one year, one to nine years old, ten to nineteen years, and twenty to twenty-four years of age.
For those through nine years of age, the leading causes for Emergency Room (ER) visits and hospitalizations were because of injuries by falls and trauma (unintentionally struck by an object(s)); for age group ten to nineteen years, the leading cause of ER visits or hospitalizations were trauma and unintentional motor vehicle accidents (occupant or driver); for the age group twenty to twenty-four, the leading causes were unintentional motor vehicle accident (occupant or driver) and drowning.
Developmental screening of children is an efficient and cost-effective way of identifying potential health and behavioral problems. Screenings – which may utilize direct measures administered by pediatricians or indirect measures assessed through parent questionnaires – can help identify children who are not meeting expected developmental milestones. The American Academy of Pediatrics recommends that children receive developmental screening from their physicians three times before their third birthday.
Through 2015-2018, Project Kariñu screened 849 children, aged one month through 6 years of age. The ASQ-3 and ASQ: SE has cut off scores to indicate if children are age typically developing, need monitoring on developmental learning activities, or at risk and need further assessment and/or intervention. The ASQ-3 found that 47% of the children had age typical development; 32% required further evaluation, and 21% needed monitoring. The ASQ: SE found that 63% of the children had no concerns, 27% required further assessment, and 10% had possible behavioral problems.
On Guam, suicide is one of the leading causes of death among adolescents and young adults. More adolescents are hospitalized or treated in an emergency department for suicide attempts. Suicide ideation – thinking about suicide, having suicidal thoughts, and/or considering attempting suicide -- is a risk factor for suicide.
In 2019, 23.8% of Guam high school students reported that they seriously considered attempting suicide during the past 12 months. This was a 9.1% decrease from 2017's data. Female students reported a significantly higher percentage of suicidal ideation compared to male students. Students in 9th and 12th grade were less likely to report suicidal ideation than students in grades 10 and 11.
Rates of young people carrying pregnancies to term have reached historic lows nationally. The 2018 U.S. birth rate among females aged 15 to 17 was 17.4 per 1,000, a 7.4% decline from 2017.
Guam's teen birth rate has fluctuated but has not changed substantially. This could be due to a myriad of factors, including changes in teen sexual activity, contraception use, or attitudes.
Children and Youth with Special Health Care Needs
According to the 2019 MCH Jurisdictional Survey, 4.3% or 2,328 of Guam's children have a special healthcare need. Of those, 51.7% had a Medical Home during the past 12 months. Based on the Needs Assessment results, children and youth with special healthcare needs (CYSHCN) living in Guam face significant barriers when accessing pediatric specialists and sub-specialists, primarily due to physician shortages long-travel distances.
Success in these areas has a significant impact on housing, employment, and education choices. Transition to adulthood is a process that ideally begins early and occurs over time. Youth and their family should be involved in all decisions. Care coordination between providers and services is essential.
In 2019, there were a total of 1,214 youth aged 16 and above with an IEP. Of the 1,214, 993 had an IEP that included coordination, measurable, annual IEP goals, and transition services that would enable them to meet their post-secondary goals.
III.C.2.b.ii. Title V Program Capacity
III.C.2.b.ii.a. Organizational Structure
Guam is governed by a Governor and a Lt. Governor who are elected every 4 years. DPHSS is a line agency under the Executive Branch and is headed by the Director and Deputy Director. There are 5 divisions within DPHSS: DPH, DEH, DSC, DPW and DGA. DPH is overseen by the CPHO and includes the Chief Public Health Office, BCDC, BNS, BCHS, BPCS and BFHNS.
The Chief Public Health Office includes the Office of Epidemiology and Research, Office of Planning and Evaluation, OVS, Physician Services, Dental Program, and Project LAUNCH. BCDC includes the Immunization Program, Foreign Quarantine and Enteric Program, STD/HIV Prevention Program, TB and Hansen’s Disease Program, PHEP Program, Ryan White CARE Program, Laboratory Services, Pharmacy Services and X-Ray Services. BNS includes the WIC Program, General Nutrition Services and Chronic Disease Preventive Block Grant. BCHS includes MSS, BRFSS, Coordinated Chronic Disease Prevention and Health Promotion Program, Comprehensive Cancer Control Program, Diabetes Prevention and Control Program, Office of Minority Health, NCD Control Program and GBCCEDP. BPCS includes the CHCs: the Northern Region Community Health Center (NRCHC) in Dededo and Southern Region Community Health Center (SRCHC) in Inarajan.
The MCH and CSHCN Programs are under BFHNS. Other programs and services in the Bureau include Clinical Nursing Services, District Nursing, Medical Records Section, Title X Family Planning Program, Early Childhood Systems of Care (Project Karinu), Early Home Visiting Program (Project Bisita I Familia), State Systems Development Initiative (SSDI), and the Abstinence Education Program. BFHNS is located at Central Public Health in Mangilao. The main focus of BFHNS services is to provide health care services to uninsured and medically underserved populations. The target populations are women of childbearing age with health risk factors, pregnant women, children 0-8 years old, CSHCN, adolescents, the elderly (55 years and over) and patients with communicable, infectious and sexually transmitted diseases.
III.C.2.b.ii.b. Agency Capacity
The mission of the Guam Department of Public Health and Social Services (DPHSS) is to promote health through the prevention and control of disease and injury. DPHSS, one of the oldest agencies, now has an annual budget of about $60 million in state and federal funds and 400 employees. The Director of DPHSS is the State’s Health Officer and one of the Governor’s key cabinet members. With more than 200 program components organized in its five divisions, DPHSS provides and supports a broad range of services, including inspecting restaurants; vaccinating children to protect them against disease; testing to assure the safety of food and drugs; licensing to ensure quality health care in hospitals and public health; conducting investigations to control the outbreak of infectious diseases; collecting and evaluating health statistics to support prevention and regulatory programs; analyzing and shaping public policy; screening newborns for genetic disorders; and supporting local efforts to identify breast and cervical cancers in their early, more treatable stages.
The Division of Public Health (DPH) administers the Maternal Child Health Services Title V Block Grant, through its Bureau of Family Health and Nursing Services (BFHNS). The mission of BFHNS is to improve the health outcomes of all individuals on Guam by providing preventative education and services, increasing health care access, using data to ensure evidence-based practice and policy, and empowering families. Under the leadership of the Title V Administrator, BFHNS is able to provide comprehensive population-based programming, education, and support to women across the lifespan. The DPH helps to coordinate internal and external efforts to use policy change to improve women's health, increase public awareness of issues impacting the health of women and children, and promote healthy behaviors and environments in community partnerships with other programs and organizations.
The Title V Block Grant supports the capacity of BFH and CYSHCN Programs to promote and protect health and well-being across the six MCH population health domains. It funds health services, health education and promotion, monitoring and evaluation, professional training, and policy development.
Women’s/Maternal Health: MCH assures the health of Guam’s women and maternal population with direct services for prenatal, postpartum, and interception care.
Perinatal/Infant Health: Perinatal and infant health on Guam relies upon preventative services, the promotion of nutrition and breastfeeding, and healthy beginnings for infants and young children. The newborn screening program assures that all infants born on Guam are screened for conditions recommended by the ACMG. Project Bisita, Guam’s home visiting program, promotes healthy birth outcomes and safe environments for Guam’s most vulnerable population.
The newborn health programs provide education to women on the importance of prenatal care, prevention of congenital disabilities, and avoidance of alcohol/tobacco/other drugs pre- conceptually and throughout pregnancy. This education is instrumental in decreasing preterm births and infant deaths, promoting birth spacing at least 18 months apart, and assuring new parents practice safe sleep and other practices to prevent unintentional injuries.
Guam’s Newborn Screening Program consists of both bloodspot (NBS) and newborn hearing screening (NBHS). All infants born on Guam are to be screened unless the parent declines for religious reasons. Hearing screeners in hospitals and birthing centers refer infants not passing the initial hearing screen for further screening or testing by a pediatric audiologist. The Guam EHDI staff provides follow-up and referral to those infants who did not have an initial hearing screen, did not receive a pass result on the initial screen, or are found to be at risk for later development of hearing loss.
Child Health and/or Adolescent Health: The Adolescent Health Program (AHP) provides consultation education, training, and resources to assist health professionals, school personnel, parents, adolescents, other government agencies, and non-profit community programs. DPHSS is working to strengthen the agency’s approach to serving adolescents. The agency largely focuses on reproductive health services and evidence-based pregnancy prevention efforts to inform and educate adolescents about responsible decision-making, family planning, and healthy behaviors. It also encourages parents to vaccinate children against Human Papillomavirus (HPV), Meningitis, Flu, and Hepatitis.
CYSHCN – The CYSHCN Program develops, promotes, and supports community-based systems that enable the best possible health and the highest level of independence for CYSHCN populations. Staff link patients with a medical home, and clinical social workers and parent liaisons link families to community resources and provide family support programs, active congenital disabilities surveillance, transportation assistance; lead surveillance; and sickle cell treatment and care coordination.
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III.C.2.b.ii.c. MCH Workforce Capacity
The Guam Department of Public Health and Social Services (DPHSS) updated the Organizational Strategic Plan in January 2019. DPH continues to prioritize health equity, quality improvement, and workforce development. It has added data quality and access as well as customer service as priority areas of focus. Efforts to address the priority objective “Recruit, Retain and Develop a Competent, Public Health Workforce” are already well underway.
Title V continues to utilize national MCH and AMCHP professional development resources, including the MCH Workforce Development Center. The use of process maps and continuous quality improvement were tools that the Guam team learned and shared with the rest of the Title V staff. Guam continues to use national TA from AMCHP learning labs, MCH Bureau Learning labs, and nationwide consultants' recommendations, particularly for the needs assessment. These TA opportunities not only help develop staff capacity but also provide an opportunity to share Guam’s issues with other states and national centers.
The Title V agency programs also support a substantial amount of training for the MCH workforce statewide. Several federal grants include workforce development as a key strategy/activity, including:
- Maternal Infant Early Childhood Home visiting grant supports training for the Guam home visitors.
- Early Childhood Comprehensive Systems grant supports training for providers on developmental screening tools and protocols.
- Family Planning shares resources from the National Family Planning Training Centers to local providers via
meetings, webinars, and conference calls.
- The Emergency Medical Services grant/sponsors numerous training projects and the Annual EMS Conference.
It should be noted that in the event of an emergency unless granted a temporary exemption from emergency duty, all Department of Health employees may be required to work before, during and/or beyond their regular hours or days in an Emergency Operations Command Center; temporary shelters or perform other emergency duties, including but not limited to a response to or threats involving any disaster or threat of disaster, man-made or natural.
III.C.2.b.iii. Title V Program Partnerships, Collaboration, and Coordination
Family Partnership
The Guam Title V Program understands the importance of family and consumer partnership as a mechanism to strengthen MCH programming at all levels. The Title V Block Grant defines family/consumer partnership as "patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system – direct care, organizational design and governance, and policymaking—to improve health and
health care. This partnership is accomplished through the intentional practice of working with families for the ultimate goal of positive outcomes in all areas through the life course.”
Guam EHDI has had a formal agreement with Guam's Positive Parents Together, Inc. (GPPT), the non-profit parent-driven organization for children with disabilities, since May. This agreement focuses on building and supporting a deaf and hard of hearing (D/HH) Parent Mentor and Support Group, facilitating activities to empower parents of D/HH children to become advocates for their children, and identifying parents to serve as mentors by sharing their
experiences with other families of newly identified infants with a hearing loss and providing information to help parents make the best- informed choices for their children. Title V sits on the EHDI Advisory Board and collaborates with EHDI on numerous projects.
The Deaf/ Hard of Hearing (D/HH) Parent Support Group aims to assist families in navigating through the early intervention system and providing parents with information related to options available for their child, so they can make the best intervention choice to meet the health and communication needs of the child and family.
In September, three parents signed a “Commitment Letter” to be trained as Parent Mentors. Parent Mentors agree to be trained in various areas relevant to parents who have a child ages 0-3 with a hearing loss to provide parent-to-parent support. Parents identified specific topics they felt would guide them in providing support to other parents. In September and November, the GPPT/Project Fitme Project Coordinator, in collaboration with government and private agencies, provided an overview for the Parent to Parent Support Group and Parent Mentors on the following topics: Individual and Family Service Plan (ages 0-3), Individual Education Plan (ages 4-21), and Individuals with Disabilities Education Act and Self-Advocacy.
The GPPT Parent Mentor Support Group children were also invited to attend a three-day Deaf Culture Day Camp held at Huråo Cultural Camp. One child was able to participate in all three days of the Deaf Culture Day Camp. The program aims to give children a rich experience that will make them love the Chamoru language and culture. Planned activities include Immersion Chamoru language lessons, historical field trips, and cultural lessons in dancing, singing, chanting, weaving, cooking, and more.
Kariñu staff facilitated a Peer Family Support Group on July 17, 2018. Parents enrolled in Kariñu were invited to participate in the event. Staff from Guam Behavioral Health and Wellness Center Healing Hearts Crisis Center and the Department of Public Health and Social Services Bureau of Social Services Administration facilitated a Personal Safety Training: “Red Flag, Green Flag” for parents and children, utilizing a candid conversation approach about
appropriate and inappropriate touch. Jamie Freitas, a Kariñu parent, demonstrated how to make Spam Musubi to participants during the event. The Peer Family Support Group provides parents with an opportunity to connect with other parents who share similar situations and challenges.
The Guam Early Learning Council Social Emotional Wellness workgroup created a Multi-Agency Subcommittee meets twice a month to discuss cases with multi-agency involvement. This subcommittee allows all programs to provide input and suggestions for serving the families without duplicating services and lessening the number of visits by programs into the home.
The Guam Early Learning Council Early Learning workgroup focuses on early care and education and includes representatives from all early childhood programs. This group works collaboratively to ensure that children’s learning needs are met.
The Guam Early Learning Parent Engagement workgroup focuses on activities that engage families in the communities. Several early childhood programs have participated in the "Village Play Time" events in the different communities around the island to bring early learning activities to the families.
Guam Title V is an integral partner in each of these workgroups and reports its progress to the Guam Early Learning Council quarterly.
As outlined in our organizational structure, our Title V program is intimately connected with federal investments, such as the State Systems Development Initiative (SSDI), Maternal and Infant Early Childhood Home Visiting (MIECHV), and the Project LAUNCH project, a 5-year award from the Substance Abuse and Mental Health Administration, by virtue of the location of these grant programs within the same section – Bureau of Family Health and Nursing Services.
III.C.2.c. Identifying Priority Needs and Linking to Performance Measures
Guam Title V used data and information from various programs, advisories, data sources, and stakeholders to inform the 2020 Guam Title V Needs Assessment's priority needs selection. Priority needs were selected based upon the findings from collected data and ranking of selected NPMs from stakeholder groups and staff. In addition, while the identified needs are aligned with the broader public health focus on Guam, Title V remains unique in its emphasis on the maternal and child health population groups.
There were 4 additional considerations in determining the final priorities. First, priorities were compared to agency priorities. It was felt that if the political will was already in place around a topic, then additional consideration should be given to including that topic as a priority. The second consideration was whether or not MCH was the leader in a particular topic. A third consideration was alignment with the new Title V grant structure, aligning the population domains' needs. The final step was to consider the programmatic activities currently underway that, with focused attention over the next 5 years, would have the most significant impact on the MCH population.
Overarching frameworks that informed Guam Title V’s priority selection process included: Social Determinants and Health Equity, and Life Course models. The Social Determinants and Health Equity models underscore those disparities in individual and population health outcomes due to differential access to economic opportunities, community resources, and social factors. Economic opportunities may include adequate income, jobs, and educational opportunities. Community resources may include access to quality housing, quality schools, recreational facilities, healthy foods, transportation resources, health care, and a clean and safe environment. Social factors may include social network and support, leadership, political influence, organizational networks, and experience of racism. The role of public health is to establish public policy to achieve health equity and promote population-based strategies.
The priorities that were identified through this process by domain are:
- To improve maternal health and well-being of women of reproductive age. – Women/Maternal Health
- To reduce infant morbidity and mortality. – Perinatal/Infant Health
- To improve the cognitive, physical, and emotional development of all children. – Child Health
- Promote oral health for children aged 0 to 3 years of age. – Child Health
- To improve and enhance adolescents' strengths, skills, and support to improve adolescent health. – Adolescent Health
- Reduce the use of substances, including alcohol, tobacco, marijuana, and opioids among youth. – Adolescent Health
- To provide a whole-child approach to services to CYSHCN. – CYSHC
NPM 1: Percent of women with a past year preventive medical visit
Priority Need – To improve maternal health and well-being of women of reproductive age.
The priority need is to decrease risk factors for adverse pregnancy outcomes among women of reproductive age. A well-woman preventive medical visit provides an opportunity to receive recommended clinical services such as screening and counseling, which can lead to the identification and prevention of diseases to optimize women's health before, between, and beyond potential pregnancies.
Guam Title V envisions a shift to more holistic care for women through the childbearing years, not just during pregnancy. Moreover, when considering the aspects of the DPHSS’s capacity, it was determined that MCH had a much higher likelihood of impacting this NPM based on existing infrastructure and capacity to implement pertinent strategies.
NPM 04: Breastfeeding (A. Percent of infants who are ever breastfed and B. Percent of infants breastfed exclusively through 6 months)
Priority Need: Prevent infant morbidity and mortality
Breastfeeding was selected due to its protective factor against sleep-related deaths and the ability to prevent morbidity among infants, particularly those who are born preterm or with low birth weight. While there is currently a high percentage of infants born preterm and with low birth weight on Guam, promoting breastfeeding will improve infants' outcomes. Guam is clearly lower than the national average in terms of initiation and duration. The advantages of breastfeeding are undeniable. The American Academy of Pediatrics recommends all infants exclusively breastfeed for about six months as human milk supports optimal growth and development. Promoting breastfeeding will provide benefits across the life-course, including preventing infant mortality and morbidity, preventing childhood obesity, and promoting school readiness.
NPM 06: Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool
Priority Need: To improve the cognitive, physical, and emotional development of all children.
In the U.S., about 13% of children 3 to 17 years of age have a developmental or behavioral disability. In addition, many children have delays in language or other areas that can affect school readiness. However, fewer than half of children with developmental delays are identified before starting school, by which time significant delays already might have occurred, and opportunities for treatment may have been missed. Research shows that early intervention treatment services can greatly improve a child's development. The opportunity to identify children at-risk for developmental or behavioral disability through routine screening, therefore, cannot go missing.
Already, there has been a substantial amount of work and energy in the state addressing developmental screening. Through Guam's partnership with Kariñu and CEDDERS, we have trained a large number of primary care practices in using validated tools and have begun to train early care and education providers; developmental screening is also a standard for all evidence-based home visiting programs.
NPM 13.2: Preventive Dental Visit
Priority Need; Promote oral health for children aged 0 to 3 years of age
Children 0-3 years of age have unique oral health challenges due to their dependence on parents and caregivers. Perinatal and Infant Oral healthcare are essential aspects of early intervention, facilitating behavioral changes that result in good oral health, the successful prevention of caries, and the management of an oral disease.
Children 0-3 years of age have unique oral health challenges due to their dependence on parents and caregivers. Perinatal and Infant Oral healthcare are essential aspects of early intervention, facilitating behavioral changes that result in good oral health, the successful prevention of caries, and the management of an oral disease.
NPM 14: B) Percent of children who live in households where someone smokes
Priority Need: To improve the cognitive, physical, and emotional development of all children.
Secondhand smoke exposure causes premature death and disease in children. Children who breathe secondhand smoke are more likely to suffer from pneumonia, bronchitis, other lung diseases, and more asthma attacks and ear infections. Secondhand smoke exposure can cause children who already have asthma to experience more frequent and severe attacks. Exposure to secondhand smoke for as little as 10 seconds can stimulate asthmatic symptoms in children. Babies whose mothers smoke while pregnant or exposed to secondhand smoke after birth have weaker lungs than unexposed babies, which increases the risk for many health problems. Secondhand smoke is a known risk factor for sudden infant death syndrome (SIDS). Healthcare costs associated with prenatal and postnatal exposure to secondhand smoke range from $1.4 billion to $4.0 billion annually.
NPM 09: Percent of adolescents, 12 through 17, who are bullied or who bully others
Priority Need: To improve and enhance adolescents' strengths, skills, and support to improve adolescent health.
Bullying was chosen as the national performance measure that most directly impact the priority need to prevent suicide among adolescents. Bullying can lead to depression and suicide ideation, and possibly suicide attempts. Victims of bullying often become bullies themselves engaged in a negative cycle. Approximately 1 in 4 adolescents either experience bullying or bully others. The prevalence of bullying is higher among middle school students than high school students. Not only does addressing bullying prevent suicide, but it also promotes overall health by preventing feelings of depression and associated behavior, including violence. Electronic bullying is an area that should be examined throughout the five-year reporting cycle as well, as social media usage continues to increase among adolescents. Data examined in the needs assessment showed that Guam’s adolescents frequently engage in violent behavior and weapon-carrying.
Priority Need: Reduce the use of substances including alcohol, tobacco, marijuana, and opioids among youth
Adolescents are particularly susceptible to substance use involvement due to the underdeveloped state of the adolescent brain, which can lead to reduced decision-making ability and increased long-term effects of drugs and alcohol.
Substance-abusing youth are at higher risk than nonusers for mental health problems, including depression, conduct problems, personality disorders, suicidal thoughts, attempted suicide, and suicide. Marijuana use, which is prevalent among youth, has been shown to interfere with short-term memory, learning, and psychomotor skills. Motivation and psychosexual/emotional development also may be influenced (Bureau of Justice Statistics, 1992).
NPM 11: Percent of children with and without special health care needs having a medical home
Priority Need: To provide a whole child approach to services to CYSHCN.
Guam MCH has prioritized appropriate health and health-related services for the MCH population, and the NPM regarding medical home was determined to most closely fit with this priority. There is a large and growing need to coordinate services within a medical home for all children, but especially for CSHCN. An additional benefit is that medical homes are not limited to CSHCN or the MCH population, so that all residents have the potential for improved health care delivery. Guam MCH also feels the NPM regarding transition is important and will seek to incorporate it during the grant cycle as a state performance measure.
NPM 12: Transition (Percent of adolescents with special health care needs who received services necessary to make transitions to adult health care)
Priority Need: To provide a whole child approach to services to CYSHCN.
Improving transitions to adulthood is intended to address the priority need of improving the overall system of care for CSHCN by linking them from their source of pediatric care to an adult medical home. Families must receive services to assist as they transition out of state CSHCN programs. The issue is of increasing significance as children with special health care needs are increasingly living into adulthood. It is also intended to promote their lifestyles by teaching them needed self-help skills as they transition and teaching them to engage in independence and employment when possible. Fewer youth in Guam are receiving the services necessary for transition compared to the nation successfully.
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