Planning and design of the 2020 Needs Assessment began in March 2018. Data collection commenced in June of that year, and data analysis was conducted from January 2019 to May 2020. Figure 7 provides a timeline of the Needs Assessment process, from design through dissemination.

Figure 7. 2020 Needs Assessment Timeline

Rather than simply collecting and analyzing quantitative MCH data from national and state data sources, Arizona’s 2020 Title V Needs Assessment was designed to engage families and the public through a public survey, focus groups, and community forums to solicit qualitative and quantitative data that draws on the experience and knowledge of the communities we serve.

Surveillance data allowed us to identify both desirable and undesirable trends in key health indicators using readily available data from state and national datasets. The public survey solicited information in English and Spanish from 1078 participants statewide. The 25 focus groups engaged 13 hard-to-reach communities to hear their perspectives on health issues, services, and sources of information in their communities. In addition, 135 community members participated in 7 community forums, including one in Spanish, held in rural and urban counties across the state.

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

Early on in the process, we established a Needs Assessment Steering Committee, with 27 members from 12 unique entities, to guide the Needs Assessment process and set priorities. In collaboration with our Needs Assessment Steering Committee, we used this data to identify MCH needs, define priorities, and select performance measures linked to those priorities.

This summary provides a brief overview of Arizona’s Title V Needs Assessment process, including the methods we used to collect and analyze MCH data, and presents findings from the Needs Assessment by population domain. This summary also includes a discussion of Arizona’s Title V Program capacity, including workforce development, partnerships, and collaborations with the larger MCH community. Lastly, we present our new priorities, discuss their development and validation, and describe how they link to our selected performance indicators. 

When we initiated activities for the Title V Needs Assessment, we set forth principles to guide the process:

1. Listen to those who are not traditionally involved.
2. Learn from community members as well as the maternal and child health community
3. Honor and respect the work that others in the community and state had done in previous years to assess the well-being of Arizona’s people.
4. Assess health disparities across communities not only by racial group but also socioeconomic and access status.
5. Use a life course development approach and address the social determinants of health as a framework for health planning.
6. Recognize that social, political, and economic policies and conditions determine health outcomes.
7. Value the community as a core partner in public health and work to assure that equity in health is a reality.
8. Plan, develop, and evaluate programs and systems of care that are comprehensive, community-based, culturally competent, coordinated, and effective.

The process was designed to be consistent with HRSA’s conceptual framework, State Title V MCH Program: Needs Assessment, Planning, Implementation, and Monitoring Process (Figure 8).

Figure 8. State MCH Block Grant Needs Assessment Planning, Implementation and Monitoring Process Diagram

Leadership

A number of internal and external stakeholders were involved in the execution of the Need Assessment. The assessment was led by the Office Chief for Assessment and Evaluation with support from the Block Grant Program Manager and the Title V Director. Appendix B shows the Needs Assessment leadership structure.

The Title V MCH Needs Assessment implementation team conducted tasks like designing and validating data collection tools; acquiring the necessary review board approvals for approaches involving human subjects; collecting data; analyzing and reporting out findings, including the development of this report. Membership in the implementation team involved maternal and child health epidemiologists from the Bureau; the State Systems Development Initiative Program Epidemiologist (Bureau of Public Health Statistics); and colleagues from the University of Arizona; the Tribal Epidemiology Center at the Intertribal Council of Arizona; and the Diné College/Navajo Nation Epidemiology Center.

Steering Committee

The Title V Needs Assessment Steering Committee, with 68 members from 27 unique entities, served as a representative of Arizona’s MCH communities and the local public health system and worked with the Title V MCH Needs Assessment Implementation Team to guide and oversee the overall community health assessment process. This group met quarterly (6 meetings total) to:

•       Provide feedback on data collection approaches and tools
•       Recommend target groups of interest and local individuals for community forums
•       Leverage existing partnerships for participation in assessment activities
•       Promote assessment methodologies
•       Participate in prioritization
•       Advise the implementation team on challenges

Needs Assessment Steering Committee members represented those organizations and individuals that are critical to ensuring commitment and follow-up to the Needs Assessment. Individuals were nominated for the Steering Committee by BWCH’s Office Chiefs and the Title V Director based on their expertise and experience. To ensure equal representation of opinions, members were nominated from across the different population domains. A complete list Steering Committee members’ organizations can be found in Appendix C.

Quantitative and Qualitative Methods

In preparing for the assessment, we reviewed examples from other states to identify possible methodologies to use in our needs assessment. We decided a mixed approach would be the best option for Arizona.

We also reviewed Arizona’s previous Title V and other related Needs Assessments. Several other programs were conducting their respective needs assessments concurrently: First Things First, Arizona Early Childhood Development and Health Board, conducted their 2020 Needs and Assets Report; Department of Child Safety conducted their child maltreatment prevention needs assessment; the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program started their needs assessment update (Appendix D); and ADHS was in the midst of completing their 2019 State Health Assessment.

The needs assessment uses seven different data collection methods to understand the need for preventive and primary care services for the MCH populations in Arizona (Figure 9). The methods are intended to complement each other and bring to the fore inputs from individuals and communities whose voices are not always heard. Each methodology uses a different data source, engages different types of stakeholders as their participants (i.e., parents, providers, youth), and takes place in different locations across the state with the intention that the assessment be as inclusive and comprehensive as possible. Overall the needs assessment includes two quantitative, three qualitative, and two mixed approaches.

Figure 9. Data Collection Approaches in Arizona’s 2020 Title V Needs Assessment

MCH Indicators

Surveillance data allowed us to identify both desirable and undesirable trends in key health indicators using readily available data from state and national datasets (e.g., Behavioral Risk Factor Surveillance System, Youth Risk Behavior Surveillance System, Pregnancy Risk Assessment Monitoring System [PRAMS], Arizona Youth Survey, Hospital Discharge Data, Birth Defects Registry, National Survey for Children’s Health, Arizona and National Birth and Death Data, US Census Data, Oral Health Study). We used the data to construct an Arizona MCH Risk Profile (Appendix A), which shows how Arizona compared to the national average on 47 indicators related to maternal and child health as listed in HRSA’s Title V Information System (TVIS). Arizona is performing worse than the national average on 18 indicators, better than the national average on 25 indicators, and the same as the national average on 3 indicators. Arizona is performing poorly on adolescent mortality, suicide, and well visits

Figure 10. List of Poor MCH Indicators for Arizona

The assessment team further analyzed the indicators in red (Figure 10) to understand why the indicator fared less favorably. Data analyses were conducted by race; income; children with special healthcare needs status; housing; employment; age; and education when data were available and sample size permitted (<25 observations excluded). Trend analysis was also conducted when data were available for the previous four years. Findings from these analyses were converted into infographic style sheets for publication and distribution (Appendix E). Indicators that are considered ‘hot topic’ items for maternal and child health were also further analyzed regardless of Arizona’s performance.

Public Survey

The purpose of the public survey was to seek feedback from the community regarding the most important health needs for each Title V MCH population. The public survey, available in English and Spanish, was promoted through ADHS’s website, social media channels (Facebook, Twitter), and Director’s blog. We also developed a flyer (available in English and Spanish) that we distributed at state meetings and local conferences and provided to BWCH contractors via email. Appendix F shows examples of social media posts and the flyer. In addition, we shared the survey with stakeholders and partners.

Data was collected between August 16, 2019 and February 29, 2020 (194 days). The survey received a non-research determination from ADHS’ Human Subjects Review Board. The survey included questions that collected demographic information; perceptions on social determinants of health; gaps in service needs by MCH population; and open-ended questions that captured general recommendations or suggestions for ADHS. In total, 1078 participants (1025 English; 53 Spanish) provided inputs through the public survey.

Focus Groups

In partnership with University of Arizona’s Mel and Enid Zuckerman College of Public Health, we solicited input from 13 hard-to-reach communities around state, using three approaches:

1.    Statewide meetings
2.    Focus groups and interviews
3.    Community forums

Building on the work of state and county health departments and partners, the team targeted under-represented and under-served groups, consulting both health service providers and users. The Steering Committee identified groups whose voices should be included in the assessment. With the help of many partners, we reached representatives from every county in the state and covered rural, frontier, border and urban locations.  Appendix G shows a map of our qualitative assessment activities.  A team of five faculty and 11 students from the University of Arizona worked on the assessment from June 2019 – August 2020.

Statewide Meetings

We attended statewide meetings on health to get information about MCH needs and to build contacts to help us conduct the focus groups. During the meetings, the team used the River of Life method— an interactive planning tool designed for use with groups of people from different backgrounds—to collect information. Because the tool is visual, everyone can contribute and understand. The team was able to collect 32 River of Life drawings. Appendix G lists the names, attendees, and number of participants for each statewide meeting attended.

Focus Groups and Interviews

The primary goals for the focus groups and interviews were to collect more in-depth information from individuals who are not traditionally heard or who are under-represented in research and services (like those shown in the Venn diagram) and learn about the health needs, services, and information in their community. Participants were selected based on 2 criteria:

1. Resident of Arizona
2. Belongs to the community group or works for an organization that serves this group

The team conducted a total of 23 focus groups (15 with adults, 8 with youth) and 13 interviews. Each focus group had between 5-12 participants. Focus groups and interviews lasted from 1-2 hours and most took place at time that was convenient for participants. Food was provided and participants were given a $20 gift card. With the help of many partners, the team reached 135 individuals from several hard-to-reach communities (Appendix G). Thematic analysis was conducted to analyze the data with inter-coder reliability.

The focus group was approved by the University of Arizona Human Subjects Protection Program. All participants completed written consent forms prior to the data collection. Additionally, youth had parental consent to participate and also completed their own consent form. The number of focus groups was limited by time and financial resources.

Tribal MCH Needs Assessments

For this Needs Assessment, ADHS partnered with the Inter Tribal Council of Arizona and Diné College/Navajo Department of Health Epidemiology Center to conduct Needs Assessments for Arizona’s Native American communities; to better understand their unique MCH needs for preventive and primary care services. Arizona has the largest Native American population of any state and is home to 22 federally recognized tribes, each with their own unique culture. While Native Americans are only 6% of the total population, they bear a disproportionate burden of poor maternal and child health outcomes. Both entities developed their own methodology based on what they understood would work best in tribal lands.

The Inter Tribal Council of Arizona (ITCA) was established in 1952 to provide a united voice for tribal governments located in the State of Arizona to address common issues of concerns. The purpose of the Maternal and Child Health Assessment for American Indians and Alaska Natives in Arizona, Nevada, and Utah report is to provide maternal and child health information for the tribes that are in the Phoenix and Tucson Indian Health Service (IHS) Areas from 2013‐2017. The ITCA team conducted a review of IHS birth data, hospital discharge data, and ITCA WIC Program Data. The team also conducted listening sessions—at conferences and meetings where Tribal Health Directors, Women, Infants and Children Directors, Community Health Representative’s (CHR) and CHR Directors gathered—to engage tribal members and providers:

• WIC Director’s Meeting (July 13, 2018)
• First Things First Summit (August 28, 2018)
• Community Health Representatives Policy Summit IV (August 22, 2018)
• CHR Movement Meeting held at the Arizona Advisory Council on Indian Health Care (September 25, 2018)

Data from each methodology were reviewed and synthesized by the implementation team to gain a nuanced understanding of the health status and needs of our maternal and child health populations. In the sections below, we provide a summary of the noted strengths and needs by population; a concise description of the state’s success, challenges, and gaps related to major morbidity, mortality, health risks or wellness for each MCH population; an analysis of current MCH Block Grant efforts in addressing the needs of its MCH population to determine areas of success and areas in which new or enhanced strategies are needed. Charts and graphs for each of the indicators discussed below can be found in Appendix H.

A more detailed report of the findings by methodology will be published in a report on the BWCH website. Reports from the Intertribal Council of Arizona and Dine College/Navajo Nation MCH Needs Assessments can be found in Appendices I and J respectively.

Women’s Health

This section focuses on wellness visits, early prenatal care, severe maternal morbidity, and maternal mortality as key indicators to monitor women’s health. Other indicators specific to women’s health (e.g., early elective delivery, early term births) are available in Appendix E. For each indicator, we report the aggregate estimate followed by subgroup analyses.

Well woman visits are an annual physical where women of reproductive age (18-44) can receive health services and be advised on how to improve their health before, between, and beyond potential pregnancies. This indicator is one of Arizona’s National Performance Measures (NPMs) and has been on the decline since 2015 when the rate was 61.8%. The current well-woman visit rate is 60.5%.. Women who live in an urban county (Maricopa, Pima, Yuma, Pinal) have a higher well-women visit rate compared to women who live in rural counties. Black women have the highest rate of having attended a well-woman visit during the past year (79.2%); White non-Hispanic women have the lowest (55.2%).

Early prenatal care has been declining since 2014 when the rate was at its highest (74.1%). The current percentage of women that receive prenatal care in the first trimester is 72.6%; a 2.1 percentage point decline. Noticeable disparities exist when analyzing this indicator by racial/ethnic groups. While 75.8% of non-Hispanic White women receive care in the first trimester, only 57.4% of native women do. There are also socio-economic disparities; for example, only about half of women with less than a high school education received early prenatal care.

Severe Maternal Morbidity (SMM) is when there is an unexpected outcome of labor and delivery that leads to significant short- or long-term consequences to a woman's health, including death. In 2015, according to TVIS, the SMM rate for Arizona was 115.9 per 10,000 delivery hospitalizations; much lower than the national estimate of 144.1 per 10,000 delivery hospitalizations.. Between 2016 and 2018 a total of 2,558 Arizonans experienced SMM during pregnancy. Noticeable racial/ethnic disparities are present in this indicator: Native Americans bear the largest burden of SMM, with a rate of 292.6 per 10,000 delivery hospitalizations, which is 3.6 times greater than non-Hispanic Whites, who hold the lowest rate at 82.1 per 10,000 delivery hospitalizations. Disparities by geography are also pervasive in this indicator as women who reside in an urban county have a much lower rate (112.5 per 10,000 delivery hospitalizations) compared to women who reside in a rural county (154.3 per 10,000 delivery hospitalizations).

Maternal mortality is the key outcome indicator when it comes to maternal health and as such is one that we routinely analyze. The latest data for Arizona shows a maternal mortality rate of 20.3 per 100,000 live births; lower than the national estimate for the same year (21.5 per 100,000 live births). Similar to severe maternal morbidity, noticeable racial/ethnic disparities exist within this indicator. Native American women have the highest maternal mortality rate at 70.8 per 100,000 live births; this is a 4-fold difference compared to non-Hispanic Whites (17.4 per 100,000 live births). Arizona’s Maternal Mortality Review Committee deemed that 89% of pregnancy-related deaths were preventable. While this is alarming, it also suggests there is lots of room to improve these outcomes.

Data drawn from the public survey identified Arizonan women's most needed health services and barriers to receiving those services. Lack of insurance and high cost of services were common barriers to care. Women also cited availability of services and lack of childcare to attend appointments as challenges.

Findings from the focus groups and community forums also identified a need for greater preventative services, insurance policies that cover the post-partum continuum of care, and greater community involvement in services.  They identified Arizona’s home visiting programs as a major strength of Arizona’s women’s/maternal health services.

Figure 11. Most Needed Women’s Health Services and Barriers to Care (Public Survey Data)

Infant Health

Over the past two years, preterm births have risen in Arizona. The 2019 preterm birth rate is 9.3% with racial disparities disproportionately impacting Blacks, who have the highest preterm birth rate at 13.2%. Non-Hispanic Whites have the lowest preterm birth rate at 8.7%. The rate does not vary based on geography.

The current infant mortality rate in Arizona is 5.6 per 1,000 live births; up from 5.4 per 1,000 live births in 2016. In 2019 approximately 431 infants died in Arizona with Blacks and Native Americans experiencing the highest rates at 11.9 and 9.8 per 1,000 live births, respectively. The top causes of death for infants in Arizona were (in ranking order): birth defects; short gestation and low birth weight (i.e., preterm); maternal complications; accidents (unintentional injuries); and Sudden Infant Death Syndrome (SIDS).

Figure 12 shows the most needed infant health services and barriers to receiving those services identified through the public surveys.

Figure 12. Most Needed Infant Health Services and Barriers to Care (Public Survey Data)

The focus groups and community forums highlighted the need for culturally appropriate pregnancy and birth support. There is also a significant need for mental healthcare for mothers; access to specialized care; childcare support services after birth.

Children’s Health

The oral health status for children in Arizona has remained the same comparing only two data collection periods. Currently 13.2% of children (ages 1-17) have tooth decay/cavities. This is higher than the national estimate of 11.7%. An oral health study from 2015 reported that 56.8% of kindergarteners and third graders had tooth decay/cavities. Disparities by socioeconomic status exist within this indicator as schools with a high student population (>75%) eligible for free or reduced meals (a proxy for socio-economic status of the neighborhood) had higher rates of tooth decay (66.3%) compared to other schools.

Since 2016, the child vaccination rate for the recommended 7-vaccine series (in box to right) has been declining. The current vaccination rate for Arizona is 56.4%, with a greater rate among children residing in an urban county (56.5%) compared to those residing in a rural county (52.5%).. Nearly 2 out of 3 children with Medicaid insurance completed the 7-vaccine series. Native Americans have the highest vaccination coverage rate at 65.4% compared to blacks at 51.4%.

State and local vaccination requirements for daycare and school entry are important tools for maintaining high vaccination coverage rates and in turn lower rates of vaccine-preventable diseases like measles, whooping cough, and rubella. In Arizona, parents can choose to bypass this requirement through personal exemption. Appendix K shows child vaccination exemption rates in counties by grade level.

The child mortality rate for Arizona is 17.2 per 100,000 children; lower than the national estimate of 19.7 per 100,000.. In 2019 a total of 131 child deaths occurred. Primary causes of death (in ranking order) include: accidents (unintentional injuries); cancers; birth defects; assault (homicide); disease of the heart. There are large racial disparities is mortality: Black and Native American children have the highest rates of mortality (31.9 and 32.5 per 100,000 children, respectively); Latinos have the lowest (13.0 per 100,000).

Figure 13 shows the most needed children’s health services and barriers to receiving those services identified through the public surveys.

Figure 13. Most Needed Children’s Health Services and Barriers to Care (Public Survey Data)

The focus groups and community forums highlighted the need for oral health services and food and nutrition programs to be established or to continue to be provided to children in low resource settings. Child mental health was an emerging topic in a lot of the discussions. The need for more childcare services was voiced in both forums and focus groups.

Children with Special Healthcare Needs

In 2017-2018, approximately 1 in 5 children (17.6%) had a special healthcare need in Arizona. While health insurance coverage was high, with 92.6% of families of children with special health care needs (CSHCN) reporting consistent insurance during the past year, approximately 1 in 3 CSHCN families report having inadequate health insurance to support their medical expenses. CSHCN experienced more adverse childhood experiences (ACEs) compared to their non-CSHCN counterparts. For 2017-2018, 33.2% of CSHCN reported two or more ACEs compared to 19.6% for their non-CSHCN counterparts.

Figure 14 shows the most needed health services for CSHCN and their families, and barriers to receiving those services, as identified through the public surveys.

Figure 14. Most Needed Health Services and Barriers to Care for Children and Youth with Special Health Care Needs (Public Survey Data)

A lot of information was collected from the focus groups and community forums on priority items for CSHCN. A major need identified through these discussions is the need for mental health services for families, since families have to manage complex medical needs in a health system that is complicated to navigate along with juggling family life and their child’s other special needs. Specific to school settings, participants identified a need for more training, resources, and time for teachers to deal with special needs kids.

Adolescent Health

A success story on all fronts, the teen birth rate continues to decline year by year with 2017 reporting the lowest rate for Arizona at 21.9 per 1,000 females (15-19 years). However, this rate is still higher than the national estimate of 18.8 per 1,000. In 2019 there were 4,287 births to teens. Disparities by race and geography persist for this indicator, with the highest percentage of teen births in rural settings (6.8%) compared to urban settings (5.2%). In spite of accounting for only 6% of the total population, Native Americans account for 9.1% of teen births.

Approximately 19.3% of adolescents report being bullied in Arizona. This rate is lower than the national estimate of 21.0%. However, disparities by gender and grade level (proxy for age) exist: females report being bullied at a higher rate (23%) than males (14.8%) and 9th graders report being bullied at a higher rate (29.0%) than 12th graders (12.4%).

Adolescent mortality has been on the rise since 2015. The 2017 adolescent mortality rate is 35.5 per 100,000 adolescents (10-19 years). This estimate surpassed the national estimate of 33.7 per 100,000 adolescents. In 2019, 394 adolescents died in Arizona. Disparities exist in this indicator by geography, gender, and race. Adolescents residing in urban counties had a larger adolescent mortality rate (42.0 per 100,000) compared to their rural counterparts (36.1 per 100,000). Nearly 3 out of 4 adolescent deaths were males. Native American adolescents had a mortality rate of 87.0 per 100,000 compared to 36.7 per 100,000 for non-Hispanic White adolescents. The top causes of death for adolescents were: accidents (unintentional injuries); intentional self-harm (suicide); assault (homicide); cancer; and birth defects.

Figure 15 shows the most needed adolescent health services and barriers to receiving those services, as identified through the public surveys.

Figure 15. Most Needed Adolescent Health Services and Barriers to Care (Public Survey Data)

The community forums and the focus groups provided a lot of information on adolescent needs. Many participants identified a need for more adolescent reproductive health services, specifically provision of contraceptives, relatable and comprehensive sex education, and other teenage pregnancy prevention strategies. Adolescents also mentioned a need for education on and regulation of vaping products, since vaping has become a normalized behavior. Adolescents also brought up the need for mental health services; specifically, educational programs to help families understand the severity of the issue, education and awareness for youth, and mental health services specific to youth and youth issues. Lastly, adolescents discussed how lack of opportunities impacted their health. Youth, particularly from rural areas, felt limited by living in a place where there is a lack of employment and college preparedness opportunities, which ultimately affects their health.

The Arizona Department of Health Services (ADHS) is one of the executive agencies that report to the Governor. On November 6, 2018 Governor Doug Ducey became Governor of Arizona. Arizona Revised Statute (A.R.S. Title 36-691) designates ADHS as Arizona's Title V MCH Block Grant administrator. ADHS Director Cara Christ, MD reports directly to the Governor.

ADHS is organized into four divisions: Public Health Services, Licensing Services, Operations, and the Arizona State Hospital. The Office of Director includes a Native American Liaison, Local Health Liaison, Border Health, Public Information Office, and Legislative Services. An ADHS organization chart can be viewed here. 

The Division of Public Health Services is organized into two primary service lines: Public Health Preparedness Services and Public Health Prevention Services. The Bureau of Health Statistics is also part of the Division of Public Health Services. The Bureau of Women’s and Children’s Health (BWCH) is housed under Public Health Prevention Services along with two other bureaus: Nutrition and Physical Activity (includes the WIC Program) and Chronic Disease and Health Promotion (includes tobacco control and health equity).

BWCH is comprised of five offices: Office of Children’s Health (includes Infant Health and Children and Youth with Special Health Care Needs), Women’s Health (includes Adolescent Health), Oral Health, Primary Care, and Assessment and Evaluation. The Bureau Chief for BWCH currently serves as both the Title V MCH Block Grant Director and Title V Children with Special Health Care Needs (CSHCN) Director. Most of the programs funded through Title V are housed in BWCH. Where the funded programs are not a part of BWCH, there is a clear coordination of efforts.

As of 2020, the Office of Children with Special Healthcare Needs was moved within the Office of Children’s Health. This transition will continue to support the overall mission for children and youth the special healthcare needs (CYSHCN) and will enhance the inclusion of CYSHCN activities and programs into the overall children’s health structure.

BWCH’s MCH programs are primarily preventive or serve as safety net services in communities with limited resources. The majority of these programs are considered “enabling” or “public health services and systems” per HRSA's MCH definition.  Appendix CC lists Title V-funded programs (with a brief description) implemented by BWCH by population domain and offices. Several programs serve more than one population, but for the purposes of the summary table, programs were listed under the population domain they primarily serve. A more comprehensive list of BWCH programs is in Appendix L.

The Capacity Assessment for State Title V (CAST-5) is a set of tools designed to assist state Title V programs in examining their organizational capacity to carry out core maternal and child health (MCH) functions, based on the 10 Essential Services set forth in the Public MCH Program Functions Framework (developed by the Association of Maternal and Child Health Programs [AMCHP] and the Johns Hopkins University Women's and Children's Health Policy Center with HRSA funding) (Figure 16).

Figure 16. 10 Essential Services from the Public MCH Program Functions Framework

The CAST-5 gave BWCH an opportunity to self-reflect on its capacity to support the MCH populations with respect to the 10 essential MCH services and identify ways to improve workforce development over the next five years. Through the CAST-5 assessment of ADHS’s capacity with respect to the 10 essential MCH services, we identified both strengths and weaknesses that ADHS possesses in carrying out key MCH program functions.Results from this methodology showed that ADHS’s Bureau of Women’s and Children’s Health (BWCH) demonstrates strengths in essential MCH services #1, 2, 5, and 10. The internal evaluation ranked ADHS’s capacity to address these services “substantially to fully adequately” but ranked our capacity to address services #4, 7, 8, and 9 as “partially to minimally adequate.” A Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis of our weaker essential services, conducted with the Office Chiefs, resulted in the recommendations to improve Title V Program Capacity. Figure 17 shows the essential service with recommendations for improvement.

Figure 17. ADHS Areas of Weakness on the 10 Essential MCH Services and Recommendations for Improvement (2020)

Executive leadership for maternal and child health is provided by the Director of Arizona Department of Health Services (ADHS), Cara Christ, MD, and Assistant Director for Public Health Prevention Services, Sheila Sjolander. Sheila formally served as Arizona MCH Director until 2013. She holds a Master's Degree in Social Work with an emphasis on planning and policy.

The state MCH workforce is housed within the Bureau of Women's and Children's Health (see III.E.2.a. State Title V Program Purpose and Design for more information on BWCH’s structure). While most of the staff are funded by sources other than Title V, all contribute to the Title V mission and MCH priorities.

BWCH employs 40 full-time staff. Title V funds are used to support approximately 20 positions in BWCH and other parts of ADHS. The following are brief biographies of senior-level management and key staff involved in the Title V needs assessment and application processes:

• Ms. Patricia Tarango, serves as the BWCH Bureau Chief/MCH Director/Title V Children with Special Health Care Needs (CSHCN) Director. Patricia has over 25 years of public health experience and provides overall leadership for the Title V MCH Block Grant and MCH strategies in Arizona. She has a Bachelor’s degree in Social Work, a Master’s degree in Health Administration and Leadership certificates focusing on business and Hispanic leadership/civic engagement.
• Mr. Martín Celaya serves as the Office Chief of Assessment and Evaluation. In this role, he manages collection, analysis, and dissemination of MCH data and leads Title V Needs Assessment and Action Plan activities. He has over 10 years of experience in local, state, and federal public health and holds a Master of Public Health. He is currently a Doctoral public health student in Maternal and Child Health at the University of Arizona.
• Ms. Laura Bellucci serves as the Chief of the Office of Children’s Health. She has over 20 years in public health and currently oversees the MIECHV Grant, Title V Children’s Information Helpline and CSHCN program activities. Laura has a Master’s in Business Administration and an undergraduate degree in Spanish and Sociology. She completed a fellowship with the MCH Public Health Leadership Institute and participated in the Leaders across Borders program, an advanced leadership program funded by the U.S.-Mexico Border Health Commission.
• Ms. Angie Lorenzo serves as the Office Chief of Women's Health. Angie was promoted to the position in May 2020 and has worked at ADHS for 17 years. Angie currently serves as Secretary of the Leadership Committee for the National Network of State Adolescent Health Coordinators and on the Maricopa County Adolescent Health Collaborative Steering Committee.
• Ms. Julia Wacloff serves as the Office Chief of Oral Health. She holds a Master's degree in Dental Public Health and is a registered dental hygienist. She previously served as an epidemiologist with the Centers for Disease Control and Prevention, Division of Oral Health. Julia serves on the Board of Directors for the Association of State and Territorial Dental Directors.
• Ms. Ana Lyn Roscetti serves as Office Chief of Primary Care Director and oversees 7 workforce programs that aim to increase the number of healthcare professionals in underserved areas. She has a Master of Public Health from the University of Washington.
• Ms. Debi Morlan serves as the Bureau's Finance Officer. Debi provides financial and contractual oversight to Title V-funded programs, as well as the other federal and state programs within BWCH.
• Ms. Dawn Bailey serves as the BWCH Family Advisor, is the AMCHP Family Delegate and is employed part time. Dawn serves in an overarching role to integrate family engagement across Title V Program and in a specific role as Children's Health/CYSHCN Family Advisor and serves on several BWCH and external stakeholder workgroups. She has a young daughter with complex medical needs and global developmental delays due to a rare genetic condition.
• Ms. Alison Lucas serves as Block Grant Program Manager and is responsible for Title V activities and deliverables. She has over five years of experience in maternal and child health programming and holds a Master of Public Policy from Georgetown University.

Arizona shares a border with Mexico and is home to 22 federally recognized American Indian tribes. While most of the population resides in two counties, geographically, most of the state is rural or frontier. In building the state’s capacity to serve women and children in a culturally competent fashion, Arizona’s Title V agency routinely collects and analyzes data by race, ethnicity, geography (rural or urban), and border and non-border. BWCH staff are required to complete Culturally and Linguistic Appropriate Standards (CLAS) training annually. 

BWCH works with internal and external partners in every aspect of our work to maximize the capacity and reach of Arizona’s Title V Program and better serve Arizona’s women and children. A prime example is the Title V MCH Needs Assessment Steering Committee. In addition, within ADHS, there is substantial collaboration among programs. Below are a few examples of the partnerships, collaborations, and coordination that occurs within Arizona’s Title V Program; other examples abound in this application. 

The Office of Children’s Health coordinates an agency-wide Zero to Five Workgroup that meets monthly to keep each other apprised of efforts for infants and young children and their families. Activities are shared and opportunities for collaboration are identified. From the onset, major decisions for Arizona’s Maternal Infant and Early Childhood Home Visiting grant have been made by an Inter-Agency Leadership Team (IALT) consisting of state agencies that fund and support home visiting programs. The IALT meets every other month to work towards strengthening Arizona’s Home Visiting System and collaborating to increase high-need services; prevent oversaturation or duplication of programs in communities; and maximize cost-effectiveness.

BWCH’s CYSHCN Program works closely with Newborn Screening, Genetics Services Advisory Committee, the American Academy of Pediatrics – Arizona Chapter, and Arizona Early Intervention Program to identify resources that ensure children and youth receive Early and Periodic Diagnosis and Treatment services. They also work closely with Newborn Screening and the EAR Foundation of Arizona, participating in the monthly Newborn Screening Partners meetings (with representatives from hearing and pediatric subspecialists in genetics, endocrinology, and pulmonology) to discuss emerging practice around newborn screening, diagnosis, and provision of care to children with heritable disorders.

The Offices of Children’s Health and Oral Health collaborate with the Bureau of Nutrition and Physical Activity on home visiting standards and guidelines, including breastfeeding, oral health, and inclusion of children with special needs. Additionally, the Office of Oral Health has established regional oral health workgroups to facilitate strategic planning on the state oral health workforce.

BWCH holds many federal grants that serve the maternal child health population, including Title V Abstinence Education; Personal Responsibility Education Program (PREP); Maternal, Infant, Early Childhood Home Visiting; and Sudden Unexpected Infant Death Registry; Maternal Health Innovation Grant; Enhancing Reviews and Surveillance to Eliminate Maternal Mortality; the Pregnancy Risk Assessment Monitoring System; Primary Care Cooperative Agreement; State Loan Repayment Program and the Oral Health Cooperative Agreement. The State Systems Development Initiative Grant Program is managed through the Bureau of Vital Statistics.

BWCH has multiple partnerships in place with the three public universities that provide education for the health professions—Northern Arizona University in Flagstaff; Arizona State University in Phoenix; and University of Arizona in Tucson.

Collaboration with other state agencies occurs on a regular basis. Recently BWCH worked with the Governor’s Office for Youth, Faith, and Family to respond to a CDC FOA regarding Adverse Childhood Experiences. Additionally, Arizona’s Title V Program partners with First Things First on the development and implementation of early childhood education and childcare programs and the Title V Administrator serves as the ADHS representative on the First Things First Board.

Methods for partnering with tribal and Native American organizations continue to be in place. ADHS leadership has quarterly meetings with the three Indian Health Services Area Office Directors. BWCH collaborates with the Navajo Department of Health on the Navajo PRAMS Workgroup to increase response rates of Navajo Women in the PRAMS survey and most recently in executing the Maternal Health Innovation Program. The Maternal Health Innovation Program has established relationships with the Intertribal Council of Arizona and the Navajo Nation to expand maternal and child health services in tribal lands. ADHS also has in place a tribal consultation policy that includes the completion of an annual report that is submitted to the Governor’s Office every fall.

The Bureau works closely with the county health departments in planning and developing maternal child health programs and initiatives by providing updates to the monthly Arizona Local Health Officer Association meetings and including county health departments in program planning and initiatives.

BWCH will continue to build on the established partnerships with the various agencies, networks, coalitions, families and consumers described above in addition to reaching out to new partners. The Bureau’s programs and initiatives are richer and more impactful as a result of the collective knowledge, resources, and skills that each of our partner agencies, family members, and consumers contribute to improving the health of women and children in Arizona. A list of partnering organizations is located in Appendix M.

We used various methodologies to identify priority needs, hone our new priority statements, and link them to national performance measures (NPMs). First, we identified regional priority needs during the community forums. In addition, colleagues from the Inter Tribal Council of Arizona and Diné College identified priority needs for Arizona’s Native American communities through the two tribal needs assessments (see Appendices I and J for the full assessment). We synthesized and shared these needs with the Steering Committee during the first priority setting meeting (July 24, 2020). Then, we asked the Steering Committee to identify statewide priority health areas by MCH population based on this information and findings from the Title V MCH Needs Assessment, and then vote on the top needs from amongst those identified.

The identification and prioritization of needs began on February 27, 2020 with the first community forum and concluded with the second priority setting meeting on August 13, 2020. During this time the assessment team had to make significant modifications to the methodology to ensure the team and participant’s safety given the COVID-19 pandemic. Efforts were made to ensure that engagement and participation in the process was not jeopardized and new technologies (Zoom and PollEverywhere) were used to collect participant feedback.

Regional Priority Needs

Community forums opened with presentations on Arizona MCH status (based on quantitative data), and then participants were invited to ask questions and provide feedback. Next, we conducted a prioritization exercise to solicit participant inputs on MCH health issues in their communities. The prioritization exercise consisted of three stages:

1. Participants were divided into small groups, and each group was asked to identify 5-7 individual issues in their communities.
2. The facilitation team grouped the individual issues that had been identified into categories.
3. The facilitator invited participants to guide him in placing the categories on a two-by-two prioritization grid. The four sections of the grid were labelled along two dimensions: easier/harder to change and higher/lower need (Figure 19 shows an example prioritization grid from one of the forums).

Spanish interpretation was available at all forums. For the community forums conducted virtually, PollEverywhere was used to identify priority needs and assess ability to address the identified needs. Figure 18 and Figure 19 show how PollEverywhere was used during the Phoenix Virtual Community Forum.

Figure 18. Identification of priority needs via PollEverywhere

Figure 19. Prioritization grid in PollEverywhere

Figure 20 shows top MCH health concerns identified through the forums with the assessed level of need and ability to change. A full list of priority needs discussed in the forums is in Appendix N.

Figure 20. Prioritization trends from the community forums

Statewide Priority Needs

During the first priority setting meeting (July 24, 2020), the Needs Assessment team presented findings from all assessment methodologies to the Steering Committee.  The assessment team also explained the HRSA Performance Measurement Framework and shared the list of proposed NPMs for the 2021-2025 block grant cycle.

Figure 21. Google Jamboard with identified priority needs for women’s health

Committee members then participated in two population domain-specific breakout sessions (which they selected during the meeting registration) in which they identified statewide priorities by population domain based on the finding of the Needs Assessment (and the two tribal needs assessments) and information from the community forums. The conversation in each breakout room was led by a facilitator and a co-facilitator was responsible for documenting key information using Google Jamboards. The facilitators created categories to group similar needs; these categories were then presented to the full group. Each breakout room also had an MCH epidemiologist assigned to respond to any questions regarding the data that had been presented. Figure 21 shows an example from women’s health; Google Jamboards for all the populations can be found in Appendix O.

The steering committee then ranked the priority needs using a dot-voting methodology. A total of 24 steering committee members participated in the ranking. Each member had 3 votes per population domain that they could place on any of the categories that were listed in the Google Jamboard. The priority needs were then ranked according to the number of votes that each priority need received. Figure 22 shows the result of the voting exercise for women’s health.

Figure 22. Women’s Health Prioritization

Figure 23 includes the top two priority needs identified by the Steering Committee for each population domain during the voting exercise. Full results of the voting exercise can be found in Appendix P.

Figure 23. Top Priority Needs Identified by the Steering Committee, by Population Domain

This information was used by the assessment team to draft preliminary priorities. Prior to the second priority setting meeting (August 13, 2020), Steering Committee members had an opportunity to review the preliminary priorities and provide feedback (both a satisfaction ranking and more detailed written feedback, if desired). A total of 30 members participated in this feedback exercise. Figure 24 summarizes results showing that the majority of members were satisfied with the drafted priorities.

Figure 24. Steering committee satisfaction on the priorities

The Title V Implementation Team made small revisions to the language of the priorities prior to the meeting based on suggestions from the Steering Committee that we received through this exercise. The revised priorities were then presented to the Steering Committee for their final approval during the August 13 meeting.

The meeting also provided us with an opportunity to engage the Committee on the topics of family engagement and health equity. Ms. Dawn Bailey, Family Engagement Specialist/AMCHP Family Delegate, gave a presentation on family engagement, as defined by the Title V Program, and led members in a discussion in which they shared ways their organizations currently engage families and ways they can add and strengthen family engagement in their programs. Ms. Teresa Manygoats, Office Chief for Health Equity and Population Health within the Bureau of Chronic Disease and Health Promotion, gave a presentation on health equity and led members in a discussion about what health equity means in the context of their work and how the programs we implement can do more to address current inequities.

2021-2025 Maternal and Child Health Priorities and Selected NPMs

In this way, we incorporated findings from the 2020 Needs Assessment and coordinated with the Steering Committee to develop our new priorities. In many ways, these priorities are a continuation of interventions and strategies that have been at the focus of our work for some time, yet we wanted to put a renewed and explicit emphasis on healthy equity and quality of service provision; for this reason, we included the phrase “equitable and optimal” in many of the priorities. Family engagement is also at the core of the new priorities as a mechanism through which health equity can be achieved.

A team of internal stakeholders had selected an initial list of National Performance Metrics (NPMs) and State Performance Measures (SPMs) in May 2020 so that we could move forward with drafting a scope of work for the MCH Health Arizona Families IGA that we have with the local county health departments. This initial list was reviewed by the Steering Committee and later supplemented with two additional NPMs selected by the counties during their Action Planning. After the selection of our priorities, we reviewed the draft list of NPMs to ensure they linked to our selected priorities. Figure 25 shows our 2021-2025 priorities and their corresponding NPMs.

Figure 25. 2021-2025 Statewide Maternal and Child Health Priorities and National Performance Measures (NPMs)