Goals and Frameworks: The objective of conducting a comprehensive statewide Needs Assessment was to identify priority areas for Maternal and Child Health (MCH) populations and to improve existing programs to better serve these populations. The goals of the Texas 2020 Title V Needs Assessment included gaining an in-depth understanding of the current MCH issues in Texas and creating an inclusive process for Texans to voice their opinions, needs, and concerns regarding their health. ​Each stage of the needs assessment process depended on extensive community involvement to ensure adequate community representation. The 2020 Needs Assessment process emphasized the life course perspective as a framework to address and reduce health inequities. Special attention was given to creating a safe and inclusive process to facilitate input from under-represented populations. Care was taken to ensure the process included a broad cross-section of Texans and the data collected was representative of the needs of the entire state.

Approach: The Texas 2020 Title V Needs Assessment utilized a multi-methodological data collection approach to capture the current MCH health status, MCH health needs, and MCH workforce capacity. A mixed-methods research approach allowed the team to offset the weaknesses inherent to each type of method. The data collection included four distinct data categories inclusive of both qualitative and quantitative data collection and analysis. The qualitative data collection provided a comprehensive, contextual understanding to the quantitative findings and allowed for more detailed analysis in areas as needed.  

Surveys

Three cross-sectional surveys were created, each with different data collection objectives and target populations. These three surveys included a 1) capacity survey, 2) community survey, and 3) CSHCN survey. Surveys were distributed through a web-based link using the SurveyMonkey platform. The survey design for all surveys included a mix of open-ended, ranking and selection, and dichotomous questions. Surveys were open for responses between June 2019 through December 2019, with the capacity survey closing in September 2019.

Survey respondents were recruited through email survey links shared through existing listservs. Flyers for the Community and CSHCN surveys were also passed out at focus groups sessions, encouraging focus group participants to respond.

Capacity Survey

The capacity survey was designed to seek input from professionals working with MCH populations. The questions were aimed at identifying self-reported competency in analytic skills, leadership skills, knowledge of MCH priorities and policy, as well as self-perceived success in MCH work based on individual experience. This survey also asked respondents to choose their top priorities and performance measures for the State to focus on.

Community Survey

The community survey was aimed at seeking input from all Texas residents aged 18 years or older and was distributed in both English and Spanish. This survey asked community residents to rank their priority needs from a defined list and rate the effectiveness of current MCH state programs in addressing their needs. The questions were designed to elicit clear feedback for improvement and measures of community-perceived success.

Children and Youth with Special Healthcare Needs (CSHCN) Survey

The MCH unit within DSHS designed two surveys to seek information about the CSHCN population. The first survey targeted parents caring for CSHCN, and asked about their experiences, challenges, and needs while caring for their children. The survey was distributed in both English and Spanish. The second survey targeted young adults with special health care needs who had recently transitioned to adult care.

Survey Analysis

Survey data from SurveyMonkey were downloaded directly from the website. All survey analyses were completed using SAS version 9.4.

For each survey, data were first cleaned to remove missing, incomplete or duplicate responses and only unique responses were included. Survey analyses were conducted to calculate mean, medians, percent, and standard deviation for variables of importance.

Key Informant Interviews

Key Informant Interviews (KII) were designed to incorporate the expertise of individuals working with MCH populations and programs in Texas. The MCH Epidemiology team developed an interview tool including broad, open-ended questions to elicit rich, descriptive responses. Key informants were interviewed between June 2019 and November 2019. Interviews were conducted over the phone for greater access to key informants, affordability, and ease for both interviewers and interviewees. In total, the MCH Program staff sent over 700 recruitment emails to key informants and of 122 individuals participated in the interview.

Following transcription of recorded interviews, all files were qualitatively coded by staff. All transcribed interviews were coded in Atlas.ti version 8, a qualitative analysis software designed for multi-user coding and collaboration. Each interview transcript was coded by two separate team members for reliability.

Themes were developed through a six-phase thematic analysis approach outlined by Braun and Clarke [[1]] which begins with first reading all the data, followed by examining all codes for patterns, overlap, and repetition. Codes that had overlap were merged into larger spanning topic codes. Recurring codes and quotes were examined to determine emergent themes.

Focus Groups

To seek detailed community input, focus groups were conducted in 23 cities, including cities in every public health region. For administrative purposed, the state of Texas is divided into 11 public health regions. Considering the vast size and geographic as well as regional diversity, care was taken to ensure focus groups were conducted in all regions spanning the entire breadth of Texas, as shown in Figure 2.

Focus groups were designed to target both community residents and healthcare providers and to capture diverse needs for different regions across the state. Facilities were chosen based on a few criteria including space size, hours of operation, transportation, and location. Focus group sessions included: 1) pregnant women and families with babies, 2) parents of children and adolescents, 3) parents of CSHCN, 4) providers of pregnant women and infants, 5) providers for children and adolescents, and 6) providers of CSHCN. In a few cases, focus groups were combined due to the time restrictions of the chose facility. Focus group staff were trained on a protocol using a focus group guidebook. Each focus group session had a moderator, at least one note-taker, and assistants; all roles were outlined in the guidebook.

Figure 2. Map of Focus Group Site Locations

Figure 1. Map of Focus Group Site Locations

Focus Group Analysis

A similar method of analysis was used for the focus group data as the one outlined in Key Informant Interview analysis. Additionally, focus group data was analyzed for regional patterns and themes.

Thematic analysis was completed for focus groups overall, which included the development of overarching themes, as well as domain specific themes. In addition, thematic analyses were completed by region. To complete these region-specific thematic analyses, transcripts were sorted by region, and, using Atlas.ti software, matrices were built to analyze the prevalence of each code within specific regions. For regions that had a high prevalence of codes, quotes were read thoroughly, and themes were developed from these quotes and codes.

Secondary Data Analysis

Data sources for secondary data analysis were compiled after careful consideration and input from partner programs in Texas including Texas Network of Youth Services, Public Policy Research Institute, and the Texas A&M University. A thorough analysis of existing national and state datasets was conducted to evaluate the current health status of the MCH domains. Within each dataset, specific variables were selected for analysis. Data were stratified by age, race/ethnicity, and gender, based on the topic and available years of data.

Data Sources:

American Community Survey

The American Community Survey is administered by the United States (US) Census Bureau on an on-going basis and collects information about employment, education, poverty status, income, among other topics [[2]].

Behavioral Risk Factor Surveillance System

The Behavioral Risk Factor Surveillance Systems (BRFSS) is a surveillance system in partnership between the Centers for Disease Control (CDC) and DSHS, collecting information regarding preventative healthcare, health risk behaviors, and chronic health conditions for adults 18 years of age and older [[3]].

Current Population Survey

The Current Population Survey is administered by the US Census Bureau and the United States Bureau of Labor Statistics to individuals 15 years and older. The survey collects information about income, job status, school enrollment, family size, insurance status, and other work-related questions[4].

CDC WONDER

The CDC WONDER Online Database includes vital data including birth and death datasets such for all counties within the United States. [[5],[6]].

Feeding America Map the Meal Gap

The Map the Meal Gap project from Feeding America provides information about food insecurity nationwide, by state, and by county.

Healthy People 2020

Healthy People 2020 is managed by the Office of Disease Prevention and Health Promotion within the US Department of Health and Human Services. Objectives span 42 topic areas, and their searchable database includes national and statewide data for each objective [[7]].

National KIDS COUNT

The National KIDS COUNT data center contains national, state, and local data for children under the age of 18 on issues related to child and family health and wellbeing [[8]].

National Performance Measures by the Maternal and Child Health Bureau

From the US Department of Health and Human Services, the Maternal and Child Health Bureau (MCHB)’s National Performance Measures include 15 indicators that cover five maternal and child population domains [[9]].

National Survey of Children's Health

The National Survey of Children’s Health (NSCH) is designed to provide national and state-level estimates on key indicators of the health and wellbeing of children, their families and communities, as well as information about the prevalence and impact of special health care needs. Additionally, the NSCH provides estimates for each state’s Title V Needs Assessment and several federal and state Title V Maternal and Child Health Services Block Grant National Outcome (NOM) and Performance Measures (NPM).

Nutrition, Physical Activity, and Obesity: Trends and Maps

CDC provides an online database with information available for each state on health behaviors and indicators, [[10]] including information on overweight and obesity prevalence, physical activity, breastfeeding, and nutrition, among other topics.

Pregnancy Risk Assessment Monitoring System

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a surveillance system in partnership between CDC and DSHS. The survey is standardized by CDC and currently covers 83 percent of births in the United States. Information collected includes attitudes and experiences before, during, and after pregnancy for women of child-bearing age [[11]]. For this report, the 2017 survey was utilized.

School Physical Activity and Nutrition Survey

The School Physical Activity and Nutrition Survey (SPAN) is a state-wide surveillance system in Texas which monitors the body mass index (BMI) and related variables in children and adolescents in grades 2, 4, 8, and 11 for the 2015-2016 school year [[12],[13]].

State Vital Records

The State of Texas collects and manages Vital Records which includes birth, death, and fetal death certificates, mortality as well as marriage and divorce records [[14]].

Texas Demographic Center

The Texas Demographic Center produces population estimates and fatality for the state of Texas, as well as for individual counties in Texas. Estimates are stratified by age, sex, and race/ethnicity [[15]]. Data from the 2018 population were analyzed.

Texas Hospital Inpatient Records

The DSHS Center for Health Statistics (CHS) collects and produces reports on Texas hospital inpatient records. The Texas Inpatient Public Use Data (PUDF) [[16]] provided data on topics including various pregnancy outcomes and child asthma rates.

Texas STD Surveillance Report

The TB/HIV/STD Epidemiology and Surveillance Branch of DSHS generates an annual report with surveillance data on rates of chlamydia, gonorrhea, and syphilis in Texas. The reported data is stratified by age, sex, and race/ethnicity [[17]].

Youth Risk Behavior Survey

The Youth Risk Behavior Survey (YRBS) is a nationwide surveillance system which collects state-level information from high school students on the topics of sexual health behaviors, alcohol, drug, and tobacco use, and diet and physical activity behavior [[18],[19],[20]].

Prioritization and Stakeholder Involvement:

Several domain-specific and cross-cutting themes emerged from the qualitative and quantitative analysis of all collected data. A panel of over 50 stakeholders serving MCH populations in Texas was created to seek expert opinion on the needs identified through data analysis in order to prioritize key findings and guide selection of performance measures. Themes were presented to stakeholders at an all-day prioritization meeting.

Stakeholders then voted on themes using a tiered voting system (high need, moderate need, or low need), ranking themes based on their expert knowledge of the MCH population. Votes were counted to select a list of high priority needs from the themes identified.

The high-priority needs identified in this meeting served as the fundamental basis for selecting the National Performance Measures (NPMs) that will guide MCH programmatic efforts from 2020-2025. Corresponding Evidence-Based Strategy Measures (ESM) were formulated in conjunction with the selection of State Performance Measures (SPMs). These ESMs allow for annual tracking of strategies implemented by each State to stay on track with their programmatic efforts for meeting the NPMs, and are therefore crucial.

Please see Section V Supporting Document 1 for Footnote References.

The needs assessment identified nine priorities for the health and wellbeing of maternal, infant, child, adolescent, and CSHCN populations within Texas. Priorities were developed from themes that emerged from qualitative and quantitative data, including stakeholder input, population input, and analysis of existing secondary data.

Across populations, access to healthcare in rural communities, mental health throughout the life course, and social determinants of health emerged as needs. Key findings that contributed to the development of the nine priorities are expanded upon by domain, below.

Women/Maternal Health:

Maternal mortality: In Texas, there were 382 confirmed maternal deaths from 2012 to 2015, defined as death during pregnancy or within 365 days postpartum[1]. The rate of confirmed maternal mortality among Non-Hispanic Black mothers (42.6 per 100,000 live births) was 1.5 times as high as the rate among White mothers (27.6 per 100,000 live births) and 2.2 times as high as the rate among Hispanic mothers (19.2 per 100,000 live births).[2] The most common specific causes of death were drug overdose (16.8%), cardiac event (14.4%), homicide (11.0%), suicide (8.6%), and infection/sepsis (8.4%). The top causes of maternal death during pregnancy or within 7 days postpartum were hemorrhage (18.8%), cardiac event (17.5%), and amniotic embolism (12.5%).2

In interviews, many key informants discussed the need to address racial disparities in maternal mortality, specifically among Black women. Some informants connected maternal mortality to infant mortality or preterm births. A 2012 review conducted by the Maternal Mortality and Morbidity Task Force of pregnancy-related deaths found that in Texas, Black women were affected by pregnancy-related death more than any other race or ethnicity.1 The pregnancy-related mortality rate for Black women was 2.3 times higher than the rate for Non-Hispanic White women (13.9 versus 6.0 per 100,000 live births). The pregnancy-related mortality rate was 9.3 per 100,000 live births for Hispanic women and 12.4 per 100,000 live births for women of Other races.2

Mental health: Depression during pregnancy or following birth is common in women. Postpartum depression is treatable, but providers must screen mothers to provide treatment resources[3]. In Texas, 74.1% of White women, 83.6% of Black women, and 81.3% of Hispanic women with postpartum depression symptoms were screened for postpartum depression. Of these women, Black women had the highest postpartum depression symptoms (27.8%), followed by White/Other (14.8%) and Hispanic women (13.6%).[4]

Many key informants and focus group participants discussed maternal mental health as an overarching theme. Respondents described the lack of information and awareness related to mental health for mothers, the limited health insurance coverage for mental health resources, and specific mental health needs like perinatal and postpartum depression. Some key informants and focus group participants linked maternal mental health to larger health outcomes such as maternal mortality.

Infant Health:

Infant mortality: In 2018, the Texas infant mortality rate (IMR) reached a historic low of 5.5 deaths per 1,000 live births. The IMR in Texas has been at or below the national rate for the past 10 years. Moreover, since 2011, the state has consistently exceeded the Healthy People 2020 (HP2020) target of 6.0 deaths per 1,000 live births.[5] However, racial and ethnic disparities in IMR have persisted in Texas, and the overall decrease in IMR observed in Texas over the past decade was not equally distributed across all race/ethnic groups. IMRs for Black mothers have been twice as high as IMRs for White and Hispanic mothers over much of this timeframe.[6]

Leading causes of infant death differed by race and ethnicity. In 2017, the leading cause of death among Black infants was short gestation and low birth weight with 18.3% of deaths per 10,000 live births. Congenital malformation was the leading cause of death among infants of all other race/ethnic groups, with the highest rate of deaths for Hispanic infants.[7]

Through key informant interviews, racial disparities in preterm births emerged as a prevalent theme. This topic was discussed both in the context of maternal and infant mortality, but through a separate lens, focusing on preterm births. Key informants discussed delayed prenatal care as a risk factor for preterm births. As with IMR, there were substantial racial/ethnic disparities in the preterm birth rate. Black infants have had a higher preterm birth rate than do infants of any other race/ethnic group.[8]

Breastfeeding: According to the National Immunization Survey, 83.9% of infants born in Texas in 2016 were ever breastfed,[9] similar to the 2016 national rate (83.8%). Since 2012, Texas has met the Healthy People 2020 (HP2020) target for the proportion of infants having ever been breastfed.[10] However, significant racial and ethnic disparities exist in the rate of women who ever breastfed their infant. Black mothers have reported lower rates of ever breastfeeding than both White and Hispanic mothers.[11]

While a relatively large proportion of Texas mothers reported having ever breastfed, rates of exclusive breastfeeding were significantly lower.[12] Research has shown that the benefits of breastfeeding are greatest when the baby is exclusively fed breast milk for the first 6 months after birth. According to the National Immunization Survey, 24% of Texas mothers reported breastfeeding exclusively at 6 months in 2016.[13] According to the Texas WIC Infant Feeding Practices Survey, among mothers enrolled in Texas WIC in 2018, only 4% reported exclusively breastfeeding at 6 months of age.[14]

Breastfeeding was a prominent theme discussed in both key informant interviews and focus groups. Participants addressed the need for education associated with breastfeeding, including the need for more education for providers and more education for women themselves. Breastfeeding was discussed in terms of need for increased lactation support in the community. They addressed a gap in women who do not qualify for WIC and therefore have limited resources related to breastfeeding available to them within the community. In focus groups, some participants expressed concerns over infant feeding more generally, expressing concerns about family norms of formula feeding impacting mothers’ interest in breast feeding, cultural impacts on likelihood to breastfeed, breastfeeding resources for teenage mothers, and general perceptions of breastfeeding within their communities.

Safe Sleep: According to Texas Pregnancy Risk Assessment Monitoring System (PRAMS) data, 78% of mothers reported placing their infant on their back to sleep in 2017. This percentage has increased by over 30% since 2008. Despite this significant increase, substantial race/ethnic differences still exist. Although the proportion of Black mothers placing their infant on their back to sleep increased by 88% between 2008 and 2017, this proportion was still significantly lower among Black mothers than among White mothers and Hispanic mothers in 2017.[15] 

Key informants and focus group participants discussed the need to promote safe sleep practices and continued safe sleep education. Interviewees indicated that they had personally heard about or seen non-recommended infant sleep practices occurring in their community. As a result of these experiences, they believe there is a need to continue safe sleep education.

Child Health:

Child Nutrition: The percent of children living in food insecurity in Texas is 22%, exceeding the national average of 17% and giving the state the 5th highest rank for child food insecurity in the nation.[16] The percentage of children living in food insecurity has been declining since 2010, but nearly one in four Texas children were still living in food insecure situations in 2017, an estimated 1.66 million children. Living areas with little to no access to nutritious foods can impact the overall health of children and act as a risk factor for obesity and other conditions.[17]

Child nutrition emerged as a theme in both key informant interviews and focus group conversations. Discussions on this topic included what children were eating at school and home, nutrition education, food security concerns, and available resources. Many participants linked child nutrition to other health outcomes, such as diabetes and obesity.

Child Mental Health: Mental health services for children in Texas are extremely limited with low numbers of psychologists available within the state. Based on the 2019 data from the Health Professions Resource Center, 102 of the 254 counties in Texas do not have school psychologists.[18] Based on the National Survey of Children’s Health (NSCH), 21% of children in Texas have one or more emotional, behavioral, or developmental condition as diagnosed by a doctor, such as autism, attention deficit disorder, anxiety, depression, and developmental delays.[19] Given that not all children in Texas have access to a mental health provider, the prevalence of these conditions may be under-reported; actual prevalence could be higher. Of children who needed mental and behavioral health treatment or counseling, less than half received the needed care, with similar rates in Texas to the United States.[20]

Mental health resources for children was identified as a major need through the key informant interviews and focus groups. Participants expressed concern over the lack of mental health resources and the need for mental health resources geared specifically towards children. Several respondents highlighted early childhood development as well as trauma-informed care, especially for children in the child welfare system.

Developmental Screenings: The American Academy of Pediatrics (AAP) recommends all infants and children 9 to 35 months of age receive screenings for developmental delays during well-checks using standardized screening tools.[21] In the United States and Texas, most parents (68% and 63%, respectively) reported that they did not complete a developmental screening with their doctor for their child.[22] The need for increased developmental screenings in children was discussed in focus groups among parents and providers of children. Some parents spoke from personal experience about difficulties getting their child screened. Other focus group participants explained that these screenings need to be more widely available. Participants explained the importance of both providers and families receiving education on milestones and developmental screening.

Adverse Childhood Experiences (ACEs):Household dysfunction, abuse, and neglect experienced during the first 18 years of life have been found to predict a host of chronic diseases, depressive disorders, and even early death, as found by the Adverse Childhood Experiences (ACEs) Study. ACEs are a set of ten experiences reflecting childhood adversity that are linked with negative health outcomes later in life. The higher the number of ACEs a child experiences, the higher the likelihood of developing long term health problems and chronic illness.[23]

In Texas and nationwide, almost 20% of children have experienced two or more adverse childhood experiences. Some demographics are disproportionately exposed to ACEs. Exposure to ACEs declines as household income increases. White populations have overall lower exposure to ACEs compared to Black and Hispanic populations.[24] Health risks are higher for those with increased exposure to ACEs, including increased risk of future violence, chronic health conditions, Sexually Transmitted Infections (STI)s, teen pregnancy, depression, and suicide, among other risks.[25],[26] Focus group participants and key informants discussed risk factors for and outcomes of ACEs, including long term health outcomes associated with ACEs.

Adolescent Health:

Vaping: Vapes or electronic cigarettes are currently the most commonly utilized tobacco product amongst youth. According to the Texas Youth Risk Behavior Surveillance System, 50% of students have tried an electronic cigarette by 12th grade.  By race and ethnic categories, use was the highest in White students at 44.6%, followed by Hispanic students at 41.3%, Black students and 36.2%, and other at 31.7%. Incidence of use increased with increasing grade level, with 50% of twelfth graders reporting trying electronic cigarette products.[27]

A significant number of key informants and focus group participants brought attention to the use of electronic cigarettes among adolescents. This was framed as an emerging issue with potential health risks and widespread use among adolescents.  

Adolescent mental health and suicide related behavior: Key informant and focus group participants addressed mental health broadly, but many focused on the need for adolescent-specific mental health resources. Respondents noted that adolescents are at a unique point in their lives, transitioning to adulthood, and mental health resources should reflect these unique needs. Some addressed the difficultly accessing available resources. Many drew attention to a growing suicide rate and a need for suicide prevention. Some commented on the need for education and resources related to suicide prevention and the larger topic of mental health.

Based on 2017 data from the Child Fatality Review Team, suicide emerged as the top cause of death for 10-14 year-olds and 15-17 year-olds, followed by motor vehicle accidents.[28] The frequency of adolescent deaths by suicide has been rising in recent years in Texas and the U.S., as have suicide-related thoughts and behaviors.[29],[30] In Texas in 2018, the total teen suicide rate was 14.3 per 100,000, with a large discrepancy between males (22.7) and females (5.4). By race and ethnicity, White adolescents had the highest suicide rate, followed by Asian adolescents. The suicide rate was lowest among Black adolescents followed by Hispanic adolescents. The suicide rate was below the national average for Black teens; the other racial and ethnic categories were above the national averages.[31]

Health risk behaviors: Based on National Performance Measures from the United States Department of Health and Human Services and based on state inpatient databases, Texas has had a consistently lower rate of adolescent hospitalization for injury than the rest of the United States, and rates have been declining steadily for both the United States and Texas since 2000.[32] However, adolescents in Texas continue to have behaviors that increase the risk of injury which differs across subpopulations. Focus group participants highlighted the need to focus on health risk behaviors in adolescents. Health risk behaviors can include several components but focus group participants emphasized drugs and alcohol use, vaping, and risky sexual behaviors.

Sexual dating violence was more often reported than physical dating violence across genders, grades, and race and ethnic groups. Females reported experiencing more sexual dating violence than males (22.8% and 9.5% respectively), but physical dating violence was similar, at 7.6% for females and 6.1% for males. Twelfth-graders had the highest percentage of ever experiencing sexual dating violence.[33]

In 2017, 61% of high school students reported having at least one drink in their lifetime and 27% reported having at least one drink in the past 30 days. Percentage of students having ever tried alcohol increased with grade, reaching 74% by twelfth grade. By race and ethnicity, White students had the highest percentage of any alcohol use at 66% and Black students had the lowest percentage at 49%.[34] Use of alcohol within the last 30 days was reported by 27% of high school students. Recent alcohol use was highest amongst twelfth graders at 37%, followed by eleventh graders at 30%. It was lowest amongst ninth and tenth graders at 21% and 22% respectively.[35]

Teens within the 15-17 age range are more likely to die in motor vehicle accidents than children of other age groups.[36] Risky behaviors related to driving include talking on the phone while driving, texting and emailing while driving, driving after having one or more drinks, and riding with a driver who had been drinking. Male and female engagement in these risk behaviors were similar.[37]

Children with Special Health Care Needs (CSHCN) Population:

Transition to adulthood: healthcare and life skills: Transitioning from childhood to adulthood often presents unique challenges for youth with special health care needs. Transitioning to adulthood includes moving from the pediatric to the adult health care system, planning for future educational needs, attaining skills for employment and independent living, and addressing legal changes. In the Title V CSHCN Parental Outreach Survey, 75% of respondents said that they did not feel prepared for their child’s transition, indicating that this time presents substantial challenges and uncertainty for youth and their families.

Key informants and focus group participants described the difficulties in transitioning to adulthood with an emphasis on health care transition and developing life skills for independent living as an adult. They expressed a need for supporting youth and young adults in planning for higher education and vocational training and in developing life and social skills to become productive members in the community.

Young adults may become ineligible for certain health care benefits when they reach adulthood if they fail to enroll into eligible Medicaid-based services after 21 years old. Based on 2016-2018 NSCH data, most of the CSHCN population did not receive the services necessary to transition to adult health care in Texas (87.5%) or in the United States (82.2%).[38] When asked about transition to adulthood, 75% of the Parental Outreach Survey respondents did not feel prepared for their child’s transition to adulthood. Guardians were most likely to report that they had not prepared for their child’s transition in multiple areas including health care, postsecondary education, and addressing legal needs, and most had no help preparing.

Medical home and care coordination: Quality of care can be enhanced for individuals that have access to a medical home. A medical home is not a place but an approach to care. The AAP defined a medical home as “medical care for children and adolescents that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.”[39],[40]

In Texas, about 40% of care received by CSHCN met the criteria for medical home. However, access to this quality of care varied by race and ethnicity, with 70% of Hispanic children, 51% of White children, and 39% of multi-racial and other children not receiving care that met the criteria for medical home, similar to national data.[41] The percentage of CSHCN who received care in a well-functioning system in Texas is 12%, compared to 15% in the United States, which NSCH determined using age-specific measures to assess adequate insurance access, having a medical home, and having no unmet needs or barriers to access of services.[42]

Focus group participants highlighted the need for improved access to primary and specialty providers, resources, and therapies for the CSHCN population, particularly. Some participants explained that they lived in rural communities but in large cities as well. Other parents and providers expressed delays in accessing care, citing barriers such as having health insurance coverage of therapies and the overall cost of therapies. In the CSHCN Parental Outreach Survey, respondents were asked about health care access barriers. The top three barriers to seeking help for their child when sick were not having a medical provider in their community who is comfortable taking care of their child (10.3%), not having money for the office visit or co-pay (10.3%), and that the medical provider is far away (9.5%).

An important aspect of a medical home is coordinating care, which refers to multiple care providers working together to organize and plan patient care and ensure that a child can access care when needed. In the Parental Outreach Survey, more than half (61%) of parents and guardians organized care themselves, suggesting that a significant portion of this population was not receiving coordinated care from health care providers. Of those with care coordination, it was most often received from a case manager, social worker, or community health worker of from someone at their child’s doctor’s office.

Overarching/Non-Domain Specific Health:

Difficulty accessing healthcare in rural communities: Difficulties with accessing healthcare and healthcare providers in rural communities was commonly discussed in focus groups. Many people mentioned that rural communities often lack healthcare resources. Due to this lack of resources within their immediate communities, participants explained that they must travel to see providers, and some indicated a barrier in traveling far distances. Others highlighted the increase cost associated with traveling to receive healthcare.

The Health Professional Shortage Area (HPSA) designation employs a ratio of population to primary care physicians to determine whether an area has a shortage of physicians. The ratio threshold is 3,500:1 and is reduced to 3,000:1 in areas with high needs, such as at least 20 percent of population below poverty level or more than 20 infant deaths per 1,000 live births. Areas that exceed these ratios may qualify for designation as HPSAs. Other factors, such as time/distance to nearest source of care and population composition, are also included in the federal HPSA criteria. Recruiting and retaining health care professionals is an ongoing challenge not only in rural areas but in some urban areas as well. In rural areas, retention of health care professionals is mostly due to population size, whereas in some urban areas, access is limited because many providers do not accept Medicaid or because patients are not enrolled in Medicaid and are unable to pay out-of-pocket.[43] Most counties in Texas are designated as either a whole-county or partial-county HPSA.[44]

Mental health across life course: Mental health resources were a need identified by focus group participants, key informants, and survey respondents. All groups discussed mental health across domains, explaining that nearly all women, infants, children, adolescents, and CSHCN need access and resources for their mental health and wellbeing. One essential item related to mental health across the life course is access to providers.

Respondents to the Title V Community Outreach Survey indicated that finding a mental or behavioral health professional was very or extremely difficult, especially finding one that treats children. In Texas in 2019, only 30 counties met the recommended National Association for School Psychologists student-to-provider ratio (30,000 people or residents to 1 psychiatrist, and 20,000 people/residents to 1 psychiatrist in areas with high needs[45]), including Travis and Bexar counties, which respectively contain the large cities of Austin and San Antonio.[46] Psychiatrist shortage is also a concern. As of 2018, only three counties in Texas met the HPSA recommended mental health ratio. There are almost no child and adolescent psychiatrists in the state practicing outside of major cities in Texas.[47]

Social determinants of health: Social determinants of health encapsulate many of the needs identified through the Tile V needs assessment but can also be classified as a specific need. Key informants addressed social determinants of health (SDOH) in both a broad overview and by discussing specific dimensions of SDOH. Informants discussed implications of SDOH in general, across populations. Most key informants commented that SDOH are a large and complex issue, impacting nearly all elements of health. While informants did not provide many solutions to negative health outcomes associated with SDOH, they did reinforce that attention must be drawn to SDOH to create health equity. Informants agreed that these discussions around SDOH must be had and considered as MCH needs are addressed. 

Please see Section V Supporting Document 1 for Footnote References

Texas has a plural executive branch system with power divided among the governor and independently elected Executive Branch officeholders. Except for the Secretary of State, all executive officers are elected independently, making them directly answerable to the public rather than the governor. The Texas Legislature has a House of Representatives with 150 members, while the Senate has 31 members. The Legislature meets in regular session once every two years (odd-numbered years). During the interim, the Legislative Budget Board (LBB) is one of several statutory bodies that provide direction to state agencies. This 10-member permanent joint committee of the legislature develops budget and policy recommendations for funding appropriations to all state agencies, and completes fiscal analyses for proposed legislation. The joint-chairs are the Lieutenant Governor and the Speaker of the House. The Health and Human Services Commission (HHSC) was created by the 72nd Texas Legislature (1991) to provide leadership and strategic direction for Texas' Health and Human Services (HHS) System.

In July 2020, Governor Greg Abbott announced Cecile Young as the new Executive Commissioner for the Texas Health and Human Services Commission (HHSC). Young previously served in various roles at HHSC, including Acting Executive Commissioner, Chief Deputy Executive Commissioner, and as the Chief of Staff.

The Department of State Health Services (DSHS) is the state agency responsible for the administration of Title V and is housed under HHS and works closely with HHSC, the state agency responsible for oversight and coordination among all health and human services-related state agencies. John Hellerstedt, MD took on the role of Commissioner of Texas DSHS in January 2016. DSHS performs its duties through staff located at the state headquarters in Austin and in eight geographical Public Health Regions statewide; through contracts with local health departments, community-based organizations, and other groups; and in concert with other state agencies and local partners. Funds for agency activities originate from federal grants and allocations, state general revenue streams and local funding provided by contractors. Title V programming and administration is housed within the Community Health Improvement Division, under the leadership of Manda Hall, MD.

DSHS focuses on physical and behavioral health to improve the health and well-being of Texans. This mission is accomplished in partnership with academic, research and HHS stakeholders who work collaboratively to address existing and future issues. DSHS population-based services focus on prevention and education to address disease and minimize the need for future medical interventions. DSHS works closely with other federal, state and local health and human service agencies, particularly those that serve similar populations.

The statutory governance and organizational structure of DSHS play a role in how its functions are performed. As a "home rule" state, local health officials operate autonomously from, but in partnership with DSHS. HHS agencies produce a single plan addressing opportunities and challenges in the Coordinated Strategic Plan for Health and Human Services. DSHS client services, state hospitals and regulatory functions moved to HHSC in 2016 as part of a re-organization.

Contractors provide child health and dental services and prenatal medical and dental services. Primary health care contractors also provide well woman and family planning services for eligible women. The Newborn Screening Program within DSHS provides short-term follow-up for all newborns that have been screened and found to be presumptively positive for rare disorders. In addition, Texas DSHS provides point-of-service screens for hearing and critical congenital heart defects. The Newborn Hearing Screening Program, through Texas hospitals offering obstetrical services, works to ensure all children who have hearing loss as newborn infants or young children are identified early and provided appropriate intervention services needed to prevent delays in communication and cognitive skill development.

The Birth Defects Epidemiology and Surveillance program, established in 1993, identifies, investigates and monitors birth defects in Texas. The program identifies the risk factors and causes of birth defects, supports the development of strategies to prevent birth defects and maintains data in a central registry.

Legislation, focused on child passenger safety, requires children younger than 8 years old, unless they are 4’ 9” in height, to be properly restrained in a child passenger safety seat while riding in an operating vehicle. Child Fatality Review Teams (CFRTs) are authorized under Texas Family Code Sections 264.501-264.515. The CFRT State Committee is a multidisciplinary group of professionals reflecting the geographical, cultural, racial, and ethnic diversity of the state.  CFRTs work to understand the causes and incidence of child deaths in Texas; identify procedures within the represented agencies to reduce the number of preventable child deaths; increase public awareness; and make recommendations to the governor and legislature for effective changes in law, policy, and practices. A childhood immunization law, passed in 1993, mandates age-appropriate immunization of every child in Texas. Exclusions from compliance are allowable on an individual basis for medical contraindications, reasons of conscience, including a religious belief, and active duty in the U.S. Armed Forces.

Building on the success of the Texas Healthy Adolescent Initiative from 2010 to 2018, the Texas Youth Action Network (TYAN) promotes Positive Youth Development (PYD) and Youth-Adult Partnerships (YAPs).  The Rape Prevention and Education (RPE) program is a primary prevention initiative aimed at reducing sexual violence.

Children with Special Health Care Needs Services Program (CSHCN SP) is authorized under Texas Health and Safety Code Sections 35.001-35.013 which states that, for children with special health care needs, the program shall provide 1) early identification; 2) diagnosis and evaluation; 3) rehabilitation services; 4) development and improvement of standards and services; 5) case management services; 6) other family support services; and 7) access to health benefits plan coverage. CSHCN SP Texas Administrative Code rules expand on the details of the above services. Texas Medicaid provides rehabilitation and acute care services to individuals under the age of 16 who are blind or disabled and receiving benefits under Title XVI.

The Maternal and Child Health Section (MCHS) at the Texas Department of State Health Services (DSHS) is responsible for MCH Services Block Grant management, reporting, consultation, and compliance. Within the MCHS, the Maternal and Child Health Epidemiology Unit (MCHE) provides centralized epidemiologic, data, research, and reporting support to MCHS and the Title V supported efforts. MCHE maintains the capacity to provide Title V program areas with expert statistical analysis, data management and performance measure reporting, geographical/spatial analysis, research studies and consultation, and program evaluation and monitoring. The Child and Adolescent Health Branch within MCHS houses the CSHCN Systems Development Group (SDG) as well as Child and Adolescent Health programming. The HTMB Branch houses all Maternal/Women’s Health and Infant/Perinatal Health programming and expertise. Key positions in the MCHU include the Title V MCH Unit Director and the State CSHCN Director/ Child and Adolescent Branch Manager. Key positions within MCHS include the State MCH Director and the Block Grant Administrator.

To assess MCH Workforce Capacity as part of the five-year Needs Assessment, Texas distributed a Capacity Survey to individuals working with and implementing Title V Maternal and Child Health (MCH) programming throughout the state. This survey was designed to assess workforce capacity by collecting data on level of experience and training and by asking respondents to self-assess their skills. Additionally, as respondents were working with the target populations and addressing MCH needs, their knowledge and experience in the field is invaluable when setting priorities and planning for the next five years. Therefore, this survey was also designed to collect their valuable input on needs and themes that should be the focal point for MCH programming for the upcoming years. The survey was completed by 430 respondents.

The capacity survey findings provide a detailed overview of the self-reported and self-perceived workforce capacity of MCH professionals in the State of Texas who responded to this survey. This survey elucidates both strengths and opportunities for growth amongst the workforce dedicated to Title V MCH programming in Texas. This survey also identifies priorities and important themes from people with direct experience working with the target populations. The following are key findings that emerged from the capacity survey.

• Over half of survey participants felt that the success of their MCH programming was average, and only four percent rated their efforts as highly successful.

• In a self-assessment of their skills and knowledge, participants ranked themselves highly in all leadership skill questions and most analytical skills. They also ranked themselves highly on knowledge of evidence-based programming and best practices and knowledge of health disparities.

• In a self-assessment of their skills and knowledge, more participants ranked themselves as having no or basic skills in MCH policy knowledge, analytical skills of identifying and collaborating with researchers with relevant skill sets to improve programs and policies, and knowledge of MCH safety programming.

• Addressing health equity and health disparities were ranked highly by participants as priority needs and cross-cutting themes. This is also relevant to the performance measures that were important to participants, particularly reducing maternal mortality.

• Two additional themes found in priority setting among participants included improved access to services and increased services for transition from childhood to adulthood, including the CSHCN population.

Title V staff build bridges and leverage efforts to build a solid infrastructure, collect and analyze data; design, implement and evaluate programs; and provide technical support and training to promote healthy behavior and improve the health of Texas communities. Collaborative work includes partnering with Health and Human Services Commission (HHSC) to support efforts that coordinate programs and initiatives that serve Maternal and Child Health (MCH) populations across HHSC agencies and programs. Title V partners with internal and external Department of State Health Services (DSHS) partners, stakeholders, and contractors to implement program and reach MCH populations throughout the state. Regional DSHS staff through the 8 Public Health Regions (PHR) play a critical role in assessing and addressing community needs. The Texas Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program is housed at the Department of Family and Protective Services within the Prevention and Early Intervention (PEI) Program. Title V and PEI collaborate on multiple initiatives, and most recently on the Statewide Needs Assessment process to ensure alignment, coordinate data collection and findings, and prevent duplication of efforts for both assessments.

Through the Needs Assessment process and stakeholder feedback, a list of health priorities was determined. These priorities were categorized by common areas and population health domains, then further refined ranked by Title V leadership and key MCH partners resulting in the development and selection of 9 new State Priority Needs (SPN). As DSHS continues to assess needs and address emerging issues in Texas, these priorities reflect the populations served and the ongoing work of the Title V program in the state. Several of the new state selected priorities are a continuation or broadening of priorities previously selected in the previous five-year needs assessment. The following are the SPNs for Texas:

1. Implement health equity strategies across all maternal and child health populations. 
2. Improve nutrition across the life course.
3. Improve the cognitive, behavioral, physical, and mental health and development of all MCH populations.
4. Increase family support and ensure integration of family engagement across all MCH programming.
5. Support health education and resources for families and providers.
6. Promote safe, stable, nurturing environments to reduce violence and the risk of injury.
7. Improve transition planning and support services for children, adolescents, and young adults, including those with special health care needs.
8. Support comprehensive, family-centered, coordinated care within a medical home model for all MCH populations.
9. Improve maternal and infant health outcomes through enhanced health and safety efforts.