Ongoing needs assessment activities are two-fold. First, data acquisition and analysis ensure accurate information is delivered to the community in a timely manner. Title V Federally Available Data (FAD) remains a tremendous resource. Epidemiology staff provide basic interpretation of trends and disparate groups. However, as noted in previous reports, limitations include small sample sizes, particularly for small states like Hawaii. Therefore, Hawaii utilizes FAD aggregated multiple year estimates, as is done with local datasets, to facilitate comparison among groups.

The other limitation noted is the grouping of Asian and Pacific Islanders together. Further disaggregation is important, given that subgroups may experience different outcome rates, and therefore may not respond to the same types of interventions. Disaggregation can be done within the state, using codes from the FAD Resource Document, though smaller states have staffing limitations.

The following are the major local data sources used. Programs may access and/or collect additional data to supplement these statewide systems. These local data continue to provide community context and inform program priorities.

• The Hawaii PRAMS (Pregnancy Risk Assessment Monitoring System), administered by FHSD, continues to inform MCH programs and policies.
• DOH’s Office of Health Status Monitoring (OHSM) houses the state’s vital statistics.
• Hospital databases offer information around inpatient and emergency department visits.
• Self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Surveillance System (YRBSS) provide context to objective data.
• Workgroups such as Hawaii’s Child Death Review (CDR), Maternal Mortality Review (MMR), and Domestic Violence Fatality Review offer potential strategies for prevention and are administered by FHSD.
• Workforce data is routinely collected and reviewed by the FHSD Office of Primary Care and Rural Health (working in conjunction with the Hawaii Health Education Center) for federally designated Health Professional Shortage Area and to inform policy and planning efforts related to healthcare access. The data includes the health professions found in Form 11 as well as specialists.

Second, work with partners ensures data are contextualized to local communities and that programs remain relevant to the families served. Data are shared through a variety of venues – mainly through presentations and publications. Data dissemination aims to raise awareness of health indicators and generate discussion regarding key findings to inform actions to address health concerns.

Health status and needs of state’s MCH population

Women/Maternal Health – The population of women of reproductive age (15-44 years) in Hawaii is estimated at 266,000 which represents about 19% of the state’s population. For this domain, Hawaii’s Title V program is focusing on preventive medical visits among women of reproductive age, which has shown improvements over time (69% in 2017, versus 55% in 2011). However, this leaves nearly one-third of women without access to preventive medical care. Subgroup analysis of 2017 data showed that Hispanic (68%) and White (62%) women were less likely to have a visit compared to Asian (76%) and Native Hawaiian and Other Pacific Islander (73%) women. Additionally, uninsured women (49%) were less likely to have had a visit, compared to those with insurance (71%).  Women with less than a high school education (60%) were also less likely to have had a visit, compared to high school graduates (76%), those with some college (69%), and college graduates (65%). There were no differences based on the 2017 analysis by age, household income, or marital status.

Perinatal/Infant Health – There are approximately 23,000 pregnancies and 19,000 births every year in Hawaii. The Title V program focuses on breastfeeding and safe sleep for infants. There is no new PRAMS data; 2015 data remains the latest available.  Hawaii initiation rates remain high (90.2%) and are significantly better than the nation (83.2%). The rate of exclusive breastfeeding for 6 months continues to improve – 33% in 2015, compared to 18% in 2007.

Infants being placed on their back to sleep has shown improvement between 2015 (82%) compared to 2007 (72%). There are still significant disparities, with mothers under 20 years of age (70%), 20-24 years of age (76%), Native Hawaiian (73%), and being at or below 100% of the Federal Poverty Level (FPL) (77%) or between 101-185% of the FPL having lower estimates. Updated PRAMS data will be reported next year.

Child Health – The population of children (under 9 years of age) in Hawaii is estimated to be 176,000, which represents about 13% of the state population. Hawaii’s Title V program focuses on developmental screening, preventive dental visits, and the state measure on child abuse and neglect (CAN) prevention for this domain. Data from 2016-2017 show that the estimate for developmental screening was 39%; not significantly different from the national estimate of 31%. The data also shows that the estimate for preventive dental visits among children was 85%; higher than the national estimate of 80%. Due to small sample sizes, the only disparity noted was that younger children were less likely to have a preventive dental visit (69% of children 1-5 years of age, compared to 93% of children 6-11 and 91% of children 12-17). However, screening data of third graders in 2016 and 2018 data of Head Start children indicate Hawaii’s children have some of the highest rates of tooth decay in the U.S.

State data from 2017 reported 1,297 confirmed child abuse victims, of which 44% occurred among children ages 0-5 years old. Some parental/family factors found in cases of confirmed CAN in Hawaii including inability to cope with parenting responsibilities (63%), drug abuse (46%), chronic family violence (15%), mental health problems (16%), spousal physical abuse/fighting (13%), alcohol abuse (9%), and lack of tolerance of the child’s behavior (9%).

Adolescent Health – The population of adolescents (10-19 years of age) in Hawaii is estimated to be 165,000 which represents about 12% of the state population. Hawaii’s Title V program focuses on preventive medical visits for this domain. Data for 2016-2017 show that Hawaii (75%) was similar to the national estimate of 79%. Groups more likely to have a medical visit included adolescents with a parent who is a college graduate (84%), households at 400% or higher than the FPL (86%), and those living in primarily English-speaking households (77%).

Children with Special Health Care Needs (CSHCN) – The population of CSHCN in Hawaii is estimated to be 48,000 represents 14% of the child population under 18 years of age, and 3% of the larger state population. Hawaii’s Title V program focuses on transition to adult health care for this domain. Data for 2016-2017 show that the estimate for Hawaii (22%) was similar to the national estimate (17%) in those with special health care needs. The estimates in those without special health care needs were the same in Hawaii and the nation (14%). There were no significant differences in reported sub-groups.

Program capacity and systems of care

In FY 2018 FHSD had 337.5 FTE staff with 46 FTE located on neighbor islands.

Hawaii’s Title V program saw the end of its five-year Centers for Disease Control and Prevention Oral Health grant in FY 2019. Hawaii’s subsequent grant application was approved, but not funded. All oral health positions associated with the grant (part-time dental director and office assistant, and full-time program manager) were eliminated. Program updates are provided in the 5-year plan section for NPM-13.2.

In FY 2018 FHSD filled a vacant epidemiologist position utilizing funds from the Centers for Disease Control Preventive Health and Health Services Block Grant. The position will assist with implementation of the DOH Strategic Plan MCH components and expand FHSD data capacity overall.

In December 2018, our CDC-assigned MCH epidemiologist, Dr. Donald Hayes, resigned to accept a position at CDC in Atlanta. FHSD is awaiting information about a possible replacement in October 2019.

Partnerships and collaborations

Partnerships among Hawaii’s Title V programs continue to be robust and varied. One of FHSD’s most important partners is the Department of Human Services (DHS) which administers the major federal social service/entitlement programs including Medicaid, Temporary Assistance for Needy Families, Food Stamps, Child Welfare Services, Childcare subsidies, and Vocational Rehabilitation. The DHS Government Transformation initiative, 'Ohana Nui (‘extended family’ in Hawaiian), continues. Employing a Two-Generation best practice approach, the process is designed to improve and coordinate service delivery to break the cycle of intergenerational poverty.

Collaboration between DOH and DHS has increased with ‘Ohana Nui (ON). Together, the agencies are identifying opportunities for greater collaboration by leveraging resources (e.g., technical assistance, subject matter expertise, and data). The partnership with DHS allows FHSD to expand its reach, particularly to the State’s most vulnerable families, thereby addressing many of the social determinants of health. Partnership examples can be found throughout the report:

• Assistance to integrate a prevention focus in Child Welfare Services,
• Promotion of reproductive health planning and increasing access to contraceptive care in partnership with Medicaid,
• Implementation of the state Child Care program policy for mandated Safe Sleep training of all licensed child care providers, and
• Development of a new Title V-Medicaid Inter-Agency Agreement (a draft currently in progress in Section IV).

FHSD continues its partnership with One Shared Future (OSF), the firm established by the former DHS Director responsible for ON, which support government transformation efforts by building skills and knowledge to support innovation in the public sector. FHSD staff participated in two training series with DHS program managers and attend follow-up meetings of OSF training graduates from across state departments. A modified OSF training was also brought to FHSD (see description in MCH Workforce Development).

Key public-private partnerships continue including:

• Both the Hawaii Maternal and Infant Health Collaborative (HMIHC) and the Early Childhood Action Strategies (ECAS) are multi-disciplinary/public-private partnerships working to improve healthy births and child outcomes. FHSD staff serve in leadership positions.
• Child Death Review, Maternal Mortality Review, Domestic Violence Fatality Review are multi-disciplinary groups that review cases to provide recommendations for prevention efforts.
• The Early Language Working Group makes recommendations to support age-appropriate language development for children age 0-5 years who are deaf, hard of hearing, or deaf-blind.

In FY 2018, the Office of Primary Care & Rural Health began working with the Hawaii Primary Care Association and its Federally Qualified Health Centers members to administer the state Community Health Center Special Fund. The fund ensures healthcare services remain viable for Hawaii’s uninsured/underinsured residents in rural and medically underserved areas. Activities include: monitoring contracts, addressing administrative issues, and responding to emerging community health needs.

Efforts to operationalize needs assessment

Hawaii’s Title V team continues to assure needs assessment is more systematic and integrated into ongoing operations. Program managers across the FHSD provide leadership for the Title V priorities, and the reporting process is used to help build/strengthen staff public health capacity. Dr. Jeanelle Sugimoto-Matsuda with the University of Hawaii Office of Public Health Studies (OPHS) continues to work with staff to strengthen assessment and evaluation. Program progress, achievement of short- and long-term outcomes, and alignment of strategies are reflected in logic models developed for the national performance measures. Logic models for FY 2018 are included in the State Plan narratives and Supporting Documents.

2020 Needs Assessment Planning

The 2020 needs assessment process (NA) generally follows the 2015 process. The process was developed with FHSD managers, staff, and key external stakeholders and is comprised of two phases:

• Issue/Priority Identification/Selection of National and State Title V Performance Measures to be completed in October 2019
• 5-Year Plan with strategies, objectives, strategy measure to be completed May 2020.

As in 2015, many of the same data sources/data collection methods will be utilized; leadership structure; and priority selection criteria.  The graphic below provides a general overview of the process.

Changes to the 2020 process were shaped by ideas shared nationally by other state Title V programs through presentations, peer-to-peer TA sessions, and the AMCHP NA TA Series. Improvements include: guiding principles, guidelines for the process, the formation of an FHSD NA collaboration group, a stronger health equity focus, and greater effort on communications. Also new, FHSD secured services for NA planning/implementation, communications consulting and graphic design. Also, a workplan was completed in April 2019. See the Supporting documents more detailed information.

Needs Assessment (NA) Collaborative Group

The FHSD NA collaborative group was convened to facilitate cross-project sharing among programs conducting or participating in NA. Members include staff from Title V, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, the CAN Prevention (CANP) Program, the State Primary Care Office, and the Early Childhood Systems Coordinator. The group has identified areas of overlap (including data needs), identified other state/community planning efforts to integrate the NAs, and is leveraging resources.

The two contracted needs assessment consultants for Title V and CANP (Dr. Sugimoto-Matsuda) and MIECHV (Dr. Elizabeth McFarlane) are both faculty colleagues at the University (OPHS) which supports coordination. Dr. McFarlane has previous experiences working the MIECHV program as well as providing TA for with the Pacific Jurisdictions Title V programs.

The NA/plans being reviewed as part of the NA collaborative:

• State Hospital Community Health Needs Assessment required under the federal ACA
• Hawaii Department of Human Service’s Child and Family Service Plan (CFSP) for 2020-2024.
• Hawaii Injury Prevention Plan, 2018-2023 guiding document for injury prevention activities under DOH’s EMS and Injury Prevention System Branch.
• State Head Start programs’ self-assessments and community profiles.
• Preschool Development Grant (PDG)
• the Early Childhood State Plan completed by Hawaii Executive Office on Early Learning.