Goals, Framework and Methodology

 

Georgia’s Title V Five-Year Needs Assessment was implemented through the lens of the Maternal and Child Health (MCH) program’s core values of prevention and wellness, social determinants of health, life course perspective, and health equity. The needs assessment was conducted by the MCH Section within the Georgia Department of Public Health (DPH), Division of Health Promotion (HP). MCH currently uses the following mission and vision to guide all programmatic efforts, including the Title V Needs Assessment.

 

Mission: To implement measurable and accountable services and programs that improve the health of women, infants, children, including children and youth with special health care needs, fathers, and families in Georgia.

 

Vision: Through the implementation of evidence-based strategies and the use of program and surveillance data, identify and deliver public health information and population-based interventions that have an impact on the health status of women, infants, children, including children and youth with special health care needs, fathers, and families in Georgia.

 

The Needs Assessment Workgroup (NAW) was established to complete the needs assessment. The group, under the leadership of the Title V Director and Deputy Director, consisted of directors and managers from all MCH programs, MCH Epidemiology, Program Evaluation and Performance Improvement, Adolescent Health, Chronic Disease, Office of Sexually Transmitted Disease (STD), and Injury Prevention.

 

The Needs Assessment was organized by six population health domains: Maternal/Women’s Health, Perinatal Health, Children’s Health, Adolescent Health, Children and Youth with Special Health Care Needs (CYSHCN), and Cross-Cutting. Key steps for the needs assessment process are outlined in Figure 1.

 

Figure 1: Georgia Title V Needs Assessment Process

 

Methodology

Quantitative and qualitative methods were used to assess strengths and needs of the MCH population, program capacity, and core partnerships and collaborations that support program efforts. Upon presentation to MCH stakeholders, the qualitative data provided support and meaning to the quantitative data being reviewed for a cohesive landscape of maternal and child health needs within the state of Georgia.

 

Quantitative Methods

 

A thorough examination of the health status of women and children was conducted by analyzing the most current information available by population domain. Trends over time were presented for all data where possible and information was stratified by relevant variables including age, race/ethnicity, education, income, gender, health insurance coverage, and CYSHCN status. Comparisons with national averages and Healthy People 2020 objectives were made when possible to provide better context for the data provided. The following data sources were used:

•                  Behavioral Risk Factor Surveillance System (BRFSS)
•                  Emergency Department Data (EDD)
•                  Georgia Adolescent Immunization Survey (GAIS)
•                  Georgia Immunization Survey (GIS)
•                  Georgia Violent Death Reporting System (GA-VDRS)
•                  Hospital Discharge Data (HDD)
•                  Maternal Mortality Review Committee (MMRC)
•                  National Immunization Survey (NIS)
•                  National Survey of Children’s Health (NSCH)
•                  Neonatal Abstinence Syndrome (NAS) Module
•                  Newborn Screening (NBS)
•                  Online Analytical Statistical Information System (OASIS)
•                  Pregnancy Risk Assessment Monitoring System (PRAMS)
•                  Third Grade Basic Screening Survey (BSS)
• Vital Records: Birth Certificates (BC), Death Certificates (DC), and Fetal Death   Certificates (FDC)
•                  Youth Risk Behavior Survey (YRBS)
•                  Youth Tobacco Survey (YTS)

 

Qualitative Methods

 

Focus Groups

Qualitative data were gathered throughout Georgia to gain further insight into the needs of MCH populations and areas to improve the delivery of public health services. Data were gathered through 10 focus groups with 82 participants throughout the state. The focus groups included three groups of pregnant women/mothers, two groups of men/fathers, three groups of teenager/youth, one group of parents of CYSHCN, and one group of refugee mothers and fathers. Focus group participants were asked to describe their knowledge and understanding of the services offered through Title V, their experiences seeking such services, any unmet health care needs for them or their families, and their perceptions about the needs of their communities. Participants were also encouraged to discuss their experiences seeking health care through telehealth as well as any recommendations for improving Title V programs and services. MCH population and focus group location are outlined in Figure 2.

 

Figure 2: MCH Population and Location

Pregnant Women/ Mothers	Parents of CYSHCN	Adolescents	Fathers	Refugees
Albany	Dalton	Cordele	Atlanta	Dekalb
Dublin		Norcross	Dublin
		Rome

 

Surveys

Three surveys were created to collect information from the public, public health workforce, and partners and stakeholders across the state to identify needs and opportunities to address health needs. The responses to the General Public, Workforce, and Stakeholder Surveys were collected through snowball and convenience sampling. The Workforce Survey was taken by state employees and electronically sent to district staff. The Stakeholder Survey was distributed to partners and stakeholders via the MCH listserv. The General Public Survey was posted on the DPH website as well as shared with MCH partners and stakeholders. Partners and stakeholders were asked to send the General Public Survey out via email, newsletter, social media, and/or post on their agency/organization website. There were 213 responses to the General Public Survey, 144 responses to the Workforce Survey, and 213 responses to the Stakeholder Survey.

 

Interface Between Needs Assessment Data, Priority Needs and State Action Plan Chart

The MCH program, NAW, and Program Evaluation and Performance Improvement team members reviewed data from the quantitative and qualitative analysis in order to select the potential priority needs for the state for the population domains relevant to their work. Staff were asked to primarily consider whether the data indicated an area of need, whether it was measurable, and whether MCH had the capacity and authority to address the need. A total of 34 priorities were selected and brought to stakeholders for prioritization.

 

Stakeholder prioritization was completed in two different methods. First, a meeting was held in Atlanta to encourage the participation of stakeholders in North Georgia. A total of 25 stakeholders representing 25 organizations attended. During the meeting, following prioritization activities and group discussions, each stakeholder individually completed a prioritization tool. The tool was designed to rate each need on a scale of 1 to 5 based on the following criteria: seriousness of the issue, health equity, economic impact, trend, magnitude of the problem, and importance. Stakeholders contributed key activities and strategies within each area of need to inform the development of the State Action Plan Table.

 

The second prioritization meeting was scheduled in Dublin for the stakeholders in South Georgia. The meeting was cancelled due to travel restrictions in response to COVID-19. The prioritization tool was replicated in SurveyMonkey and sent to the South Georgia stakeholders via email. Stakeholders were given a week to rate each priority need and submit the survey.

 

The individual rating tools were analyzed to determine the highest rated priority needs in each domain. When determining priorities, the needs with the highest rating in each domain were considered first. The data and results from the survey rankings were reviewed to assess consistency and confirm an area of need. Needs were then aligned with a NPM when possible.

 

Figure 3: Linkage between Priority Needs and National Performance Measures (NPM)

 

The State Action Plan Table was developed by the work groups for each domain. Strategies were identified based on suggestions from the stakeholder meeting, focus group findings, MCH Advisory Council meetings, and a review of the evidence-based or -informed strategies for each NPM.

 

The following summary provides an overview of the quantitative findings related to the identified priority needs and qualitative findings from focus group and survey responses. Each domain includes a summary of strengths and needs related to the identified priority need and national priority areas.

 

MCH Population Needs

 

Maternal/ Women’s Health

 

Maternal Mortality

From 2012-2015, the maternal mortality ratio was 67 deaths per 100,000 live births; the pregnancy-related mortality ratio was 28 deaths per 100,000 live births. Approximately 66% of the pregnancy-related deaths were preventable. Overall, the five leading causes of pregnancy-related deaths are Cardiomyopathy, Cardiovascular/Coronary, Hemorrhage, Embolism, and Preeclampsia and Eclampsia. Medicaid was the primary payor at the time of delivery for the majority (66%) of maternal deaths occurring at the time of delivery up to a year postpartum. Non-Hispanic (NH) Black women are 2.7 times more likely to die from pregnancy-related causes than NH White women. As maternal age increases, the pregnancy-related maternal mortality ratio increases. Women 35 years and older have a pregnancy-related mortality ratio 2.5 times greater than women ages 25-29.

 

Well-Women Visits

Women’s health consistently was voiced as a priority. Access to care is a need that was expressed as overarching not only for a specific community, but providers, programs, and families throughout the state. Among women of reproductive age (WRA), 69% had seen a doctor in the past 12 months. By race/ethnicity and health coverage, respectively, the percentage of WRA reporting seeing a doctor in the past 12 months was highest among NH Black women and women with health insurance coverage. Among women with a recent live birth in 2017-2018, just over 60% reported a health care visit (HCV) of any type in the 12 months before their pregnancy. Younger women, NH Black and Hispanic women, and women whose payor at delivery was Medicaid were less likely to report a HCV in the year before pregnancy. From 2013-2018, the percent of women with no insurance in the month before pregnancy decreased from 38% to 26%. Hispanic women and women with Medicaid or other insurance at delivery were more likely to report no insurance coverage before pregnancy than women of other racial/ethnic groups or with private insurance at delivery.

 

Family Planning

From 2013-2018, the percentage of women with a recent live birth who reported an unintended pregnancy increased from 5% to 10%. Intended pregnancies were more common among older, White NH and Hispanic women, and those with a private payor at delivery. Among women who were not trying to get pregnant when they became pregnant, use of low-efficacy birth control methods (condoms and withdrawal) was most reported, followed by medium-efficacy methods (the pill, patch or injectables). Use of high-efficacy birth control methods was least commonly reported among women who were trying not to get pregnant when they conceived.

 

Early Prenatal Care

The percent of women who have a live birth that receive prenatal care in the first trimester steadily increased from 51.8% in 2009 to 67.8% in 2018. While progress is being made towards the Healthy People 2020 goal of 84.8%, the goal has not been achieved. First trimester prenatal care entry was less common among Black, non-Hispanic and Hispanic women, teen mothers (ages <20 years), and self-pay women.

 

Postpartum Visit

From 2013-2018, the percent of women who received a postpartum visit with a health care provider remained relatively constant around 90%. From 2017-2018, postpartum care was less commonly reported by Hispanic women and those whose payor at delivery was Medicaid or other insurance compared to NH White and women with a private payor at delivery, respectively. Among women who did receive a postpartum visit, the most commonly reported topics discussed with a health care provider were birth control methods for use after birth (89%), mental health screening (81%), healthy habits (diet and exercise, 62%) and smoking cigarettes (62%).

 

Strengths and Needs

The data indicates areas where Georgia’s maternal population are achieving acceptable outcomes. The percent of women’s first trimester prenatal care visits have steadily increased. The percent of women who received a postpartum visit with a health care provider remained relatively constant. There is a need to reduce the maternal mortality ratio. Not only has the rate increased but there is a stark racial-ethic disparity in pregnancy-related maternal deaths. The rate of unintended pregnancy doubled from 2013-2018 and early prenatal and postpartum care is less common in NH, Black and Hispanic women.

 

Programmatic Efforts to be Continued

• The MMRC provided the state with important findings on the prevalence and causes of maternal mortality
• Perinatal Levels of Care has created a mechanism for levels of care designation and ongoing site verification of birthing hospitals
• Family Planning has developed a provision of resources that increase access to family planning services to women
• The Georgia Perinatal Quality Collaborative (GaPQC) implemented quality improvement activities within participating hospitals assuring resources such as protocol, policies and procedures and staff are readily available

 

Areas of Opportunity

• Continue to implement data to action activities to improve maternal health and well-being and decrease maternal mortality based on findings and causes
• Promote well-women-visits and pre- or interconnection care
• Promote family planning services available through health department

 

Perinatal Health

 

Infant Mortality

The infant mortality rate was 7.1 in 2018. Disparities exist by race, with the rate of death for NH Black infants being twice that of NH Whites. The number one cause of infant mortality are disorders related to preterm birth and low birth weight, while deaths attributable to birth defects are second. From 2008-2017, the percent of live births occurring before 37 weeks (preterm) slightly decreased from 11.9% to 11.4%, making little progress towards the Healthy People 2020 target of 9.4%. From 2015-2017, preterm births occurred most frequently among NH Black (14.0%) than other racial/ethnic groups; women 40 years or older (16.4%) than any other maternal age groups, and deliveries paid by Medicaid (12.3%) than other payors. The percent of live births with a low infant birthweight (<2,500 grams) has remained relatively stable from 9.6% in 2008 to 9.9% 2017.

 

Breastfeeding

Among women with a recent live birth, 84% reported ever breastfeeding or pumping breastmilk to feed their infant. Younger women ,20 years of age or younger, and those with Medicaid or other non-private insurance at delivery were less likely to report ever breastfeeding. Current breastfeeding was less commonly reported by younger women, NH Black and Hispanic women, and those with Medicaid or other non-private insurance coverage at the time of infant delivery. Among Georgia infants born in 2015, under half (44%) were exclusively breastfed through three months of age and one in five (22%) were exclusively breastfed through six months of age. Just over one in three (35%) were breastfeeding at 12 months of age. Approximately one in five (21%) received formula before two 2 days of age.

 

Safe Sleep Practices

From 2013-2018, the percent of women who reported most often placing their infant to sleep on their back increased from 44% to 74%. Among women with a recent live birth in 2017-2018, placing their infant to sleep on their back was less commonly reported among NH Black and Hispanic women and those whose payor at delivery was Medicaid. Just under 90% of women reported placing their infant to sleep in a crib, bassinet or pack and play. Some women reported their infant slept with a blanket (45%), bumper pads (18%) or toys, cushions or pillows (7%).

 

Evidence-Based Home Visiting Programs

Among Georgia women with a recent live birth from 2017-2018, 7% reported receiving a home visit from a health care worker since their infant was born to learn how to care for themselves and/or their new baby. There were no significant differences in reported receipt of a home visit by demographic. Among women who reported a home visit, the most common type of visitor was a nurse or nurse’s aide (38%), followed by someone else (30%), and a doula or midwife (22%). A teacher or health educator (11%) was the least commonly reported type of home visitor.

 

Strengths and Needs

Certain population sub-groups in Georgia are meeting or exceeding national standards. Breastfeeding is being initiated at acceptable rates. Safe Sleep rates have increased. There is a clear need to reduce racial disparities leading to higher infant mortality rates in the Black population in Georgia. Racial disparities are evident in preterm births, breastfeeding rates and safe sleep practices resulting in high infant mortality rates. Breastfeeding initiation and exclusivity have lower rates among younger mothers and with Medicaid as a payor source.

 

Programmatic Efforts to be Continued

• The Georgia 5-STAR initiative has been highly successful in motivating hospitals to take steps toward becoming breastfeeding-friendly
• The Safe to Sleep campaign continues to be promoted to change community norms regarding safe sleep environments
• Evidence -based home visiting programs promote breast feeding and safe sleep practices and is effective in reducing infant mortality and racial disparities
• Risk appropriate perinatal care are being implemented in birthing hospitals
• throughout the state

 

Areas of Opportunity

• Promote the perinatal levels of care designation program and recruit all Georgia birthing hospitals to participate in measuring compliance with the level of care designation
• Implement a referral WIC Peer Counseling referral process
• Build internal capacity and infrastructure to develop strategic plans to advance health equity and reduce disparities in the Black population
• Foster strategic community partnerships to build collaborations and engage in health equity practices

 

Child Health

 

Developmental Screening

In 2016, only two in five (37%) of children aged 9 to 35 months received a developmental screening using a parent-completed screening tool. Substantially fewer NH Black and Hispanic children were reported to receive this screening than NH White children in 2016. From 2017-2018, approximately half of children age 9 to 35 months received a developmental screening using a parent-completed screening tool in the past year; and the disparity in receipt of screening by race and ethnicity persisted as substantially fewer Hispanic and Black NH children were reported to have received a parent-completed developmental screening than White NH students.

 

Medical Home

In 2016, approximately half of non-CYSHCN 0 to 17 years of age received care that met the criteria for having a medical home. NH Black (31%) and Hispanic (40%) children were less likely to report having care that met the criteria for having a medical home than NH White (64%) children. In 2017, just under half (47%) of non-CYSHCN had a medical home, while a greater percentage of NH White children (56%) reported having a medical home than NH Black (40%) and Hispanic (39%) children.

 

Childhood Immunization Rates

Statewide, vaccination coverage at 24 months of age was 84%. Children with a maternal race of Asian, older maternal age, and a private health care provider had the highest coverage. Statewide, the 2018 vaccination coverage for 7th grade students was 93.9%. Statewide, the 2018 vaccination rate for 1 HPV was significantly higher than the 2017 rate, whereas the vaccination rates for Tdap and MCV4 were significantly lower. The statewide vaccination rates for 1 HPV was significantly higher for female students than male students. Statewide coverage rates for all vaccines were significantly higher for students enrolled in public schools than students enrolled in private schools.

 

Physical Activity

In 2016, two out of five (42%) of children aged 6 to 11 years engaged in vigorous physical activity 0-3 days a week and just over a third (36%) engaged in physical activity daily. Hispanic and NH Black children were more likely to have 0-3 days of physical activity per week than NH White children. Hispanic children were less likely to be physically active daily compared to other racial and ethnic groups in 2016 (although this estimate should be interpreted with caution). In 2017, 44% of children age 6 to 11 were physically active at least 60 minutes per day for 1-3 days per week, 27% were physically active for 60 minutes every day, and approximately 5% of children had zero days per week with at least 60 minutes of physical activity. In 2017, almost 60% of NH Black children reported at least 60 minutes of physical activity 1-3 days per week; about 25% NH White and 15% of NH Black children reported this level of physical activity daily.

 

Non-Fatal Injury

From 2009 to 2018, “Other” unintentional injury was the leading cause of emergency department visits for adolescents 1 to 9 years of age, followed by falls and motor vehicle crashes. Motor vehicle crashes were the leading cause of death for children, while accidental drowning and submersion, accidental exposure to smoke, fire and flames, and all “other” unintentional injury followed, respectively. Overall, hospitalization, emergency department visit rate, and mortality rate for unintentional injury among children has decreased over time.

 

Strengths and Needs

A decline has been seen in the rate of hospitalizations due to non-fatal injury among children. Despite the successes seen around developmental screenings, less than half of Georgia’s children receive screening. Additionally, there are disparities in Georgia related to race and insurance status.

 

Programmatic Efforts to be Continued

• Promote developmental screenings by engaging physicians and community-based organizations to increase screening practices
• Promote car seat distribution to prevent injury and death due to motor vehicle crashes

 

Areas of Opportunity

• Improve medical home access through Help Me Grow® (HMG) and telehealth.

 

Adolescent Health

 

Bullying

In 2013, about one in five public high school students reported having been bullied in the twelve months before taking the survey. NH Black high school students were less likely to report being bullied on school property than their NH White and Hispanic peers. Twelfth grade students were less likely to report having been bullied on school property than ninth or tenth grade students. In 2013, over one in ten public high school students reported having been electronically bullied, including through texting, Instagram, Facebook, or other social media, during the twelve months before taking the survey. Female students were more likely than male students to report having been electronically bullied. NH White students were more likely than NH Black students to have been electronically bullied, while twelfth grade students were less likely to report having been electronically bullied than ninth grade students.

 

Suicide

In 2013, about one in ten Georgia high school students reported attempting suicide in the twelve months before taking the survey. Over one in ten high school students reported that in the twelve months before taking the survey, they (1) seriously considered attempting suicide and (2) planned about how they would attempt suicide. Differences by demographic were generally insignificant. From 2011-2017, male adolescents 10 to 17 years of age were over twice as likely to commit suicide than females. Male adolescents 18 to 21 years of age were more than five times as likely to commit suicide than females. For both age groups and sexes, NH White adolescents were more likely to commit suicide than NH Black and Hispanic (males only) adolescents.

 

Transitions to Adult Health Care

In 2016 and 2017-2018, about 15% of non-CYSHCN adolescents 12 to 17 years of age received services necessary to make transition to adult health care.

 

Non-Fatal Injuries Requiring Hospitalization

From 2014 to 2018, “Other” unintentional injury was the leading cause of emergency department visits for adolescents 10 to 19 years of age, while falls and motor vehicle crashes were the fourth and fifth leading cause, respectively. Motor vehicle crashes were the leading cause of death for adolescents, while accidental drowning and submersion, accidental poisoning, and all “other” unintentional injury were fifth, sixth, and eighth, respectively. Though the hospitalization and emergency department visit rate decreased over time, the mortality rate for unintentional injury among adolescents remained stable. In 2013, approximately one in five (21.4%) of high school students had been in a physical fight within the previous twelve months. Of those, male students were twice as likely as female students to have been in a fight (28.1% and 14.3% respectively). Male students were also five times more likely to have carried a weapon in the previous thirty days (30.2%) than their female counterparts (6.4%). Despite this variance, 12% of both male and female students experience physical violence during dating in the twelve months before taking the survey.

 

Physical Activity

In 2016, two out of five (41%) adolescents 12 to 17 years of age engaged in vigorous physical activity 1-3 days a week, one in five (20%) engaged in physical activity daily, and about one in five (17%) did not engage in vigorous physical activity on any days per week. Hispanic (28%) and NH Black (20%) adolescents were more likely to report zero days per week of vigorous physical activity than NH White (12%) adolescents in 2016. In 2017, 35% of adolescents 12 to 17 years of age were physically active at least 60 minutes per day for 1-3 days per week, 35% were physically active for 60 minutes 4-6 days per week, 14% every day, and approximately 15% of adolescents had zero days per week with at least 60 minutes of physical activity. In 2017, zero days with at least 60 minutes of physical activity per week was more commonly reported among NH Black and Hispanic adolescents and 60 minutes of physical activity everyday was most reported by NH White adolescents.

 

Strengths and Needs

Hospitalization and emergency department visit rates have decreased. The prevalence of bullying and the increase in the suicide death rate indicates a need to address suicide, violence and bullying among adolescents. The overall percentages of adolescents transitioning to adult care remains low.

 

Programmatic Efforts to Continue

• Collaboration with Injury Prevention to provide Sources of Strength program to middle and high school students

 

Areas of Opportunity

• Initiate bullying prevention initiatives

 

Children and Youth with Special Health Care Needs

 

Medical Home

In 2016, approximately half of CYSHCN age 0 to 17 years received care that met the criteria for having a medical home. A smaller percentage NH Black CYSHCN (36%) were reported to have care that met the criteria for having a medical home than Hispanic (50%) and NH White (51%) CYSHCN. In 2017, two out of five (42%) CYSHCN had a medical home, with NH White CYSHCN having the highest prevalence of a medical home (49%) and NH Black CYSHCN having the lowest (28%).

 

Transition

In 2016 and 2017, a similar percentage of CYSHCN 12 to 17 years of age received services necessary to make the transition to adult health care – 19% and 14%, respectively.

 

Access to Specialty Care

In 2016, just over two in five (43%) of CYSHCN and 6% of non-CYSHCN 0-17 years of age received care from a specialist doctor (other than mental health professional) during the past 12 months. Just under one in ten (8%) of CYSHCN needed to see a specialist but did not in 2016. During 2017-2018, 40% of CYSHCN and 7% of non-CYSHCN received care from a specialist doctor (other than a mental health professional). In 2017-2018, among CYSHCN, approximately 3% needed, but did not receive care from a specialist doctor; among non-CYSHCN, 2% needed, but did not receive care from a specialist doctor.

 

Care Coordination Services

During 2016 and 2017, more CYSHCN 0 to 17 years of age received needed medical home care coordination during the past 12 months than non-CYSHCN. In 2016, about three in ten CYSHCN needed, but did not receive this care coordination. In 2017, nearly four in ten (37%) CYSHCN needed, but did not receive care coordination. For both years, more CYSHCN did not receive needed care coordination than non-CYSHCN.

 

Strengths and Needs

HMG® Liaisons help families navigate and access services to improve access to information and resources. An effort to ensure that more CYSHCN are receiving the transition to adulthood services is needed as well as initiatives to reduce racial disparities. Half of CYSHCN 12 through17 receive the services necessary to make transition to adult care.

 

Programmatic Efforts to be Continued:

• Family Partnership groups have successfully helped parents navigate the health care system
• Care Coordination Services facilitate CYSHCN in obtaining necessary services
• The system of care from pediatric to adult care, especially in rural areas of the state have been strengthened

 

Areas of Opportunity

Expand the use of telehealth technology to improve access to specialty care services

 

Cross-Cutting

 

Dental Visits During Pregnancy

Approximately one-third of women with a recent live birth from 2017-2018 had their teeth cleaned by a dentist or dental hygienist in the 12 months before pregnancy. Under 40% of women reported having their teeth cleaned during their pregnancy. About nine in ten women reported they knew it was important to care for their teeth and gums during pregnancy, while 75% reported having insurance to cover dental care during their pregnancy.

 

Childhood Dental Visits

In 2016, 88% of CYSHCN and 81% of non-CYSHCN received a preventative dental visit in the past year. In 2017, more than 4 out of 5 children received a preventative dental visit, with slightly more CYSHCN receiving one or more preventative dental visits in the past year (91%) than non-CYSHCN (82%).

 

Smoking During Pregnancy

From 2017-2018, 5% of women reported smoking cigarettes and over 1% reported using electronic nicotine delivery systems (ENDS) during the last three months of pregnancy. Smoking cigarettes during pregnancy was more common among women 20-29 years of age, NH White women, and women with Medicaid at delivery. Among women who reported smoking during the three months before pregnancy, the most common reasons that made quitting difficult were cravings for a cigarette (67%), loss of a way to handle stress (56%), others smoking around them (55%), and worsening anxiety (39%). During pregnancy, women who smoked in the past two years were more likely to report allowing smoking inside their home than non-smokers.

 

Tobacco, or nicotine, use among children and adolescents

One in four Georgia high school students reported ever trying cigarette smoking. NH White high school students (34%) were more likely to report ever trying cigarette smoking than NH Black students (14%). In 2017, 8% of high school students reported current cigarette use, 13% reported current electronic cigarette use, 8% reported use of smokeless tobacco products, and 14% reported cigar use. Cigarette use was slightly more common among rural than urban high school students. Over one in four high school students ever used electronic cigarettes; use of electronic cigarettes (ever and current) was slightly more common in urban areas than rural areas. Use of electronic cigarettes (ever) was more likely to be reported by males (30%) than females (21%). NH White students reported the highest prevalence of ever using electronic cigarettes (36%), followed by Hispanic (28%) and Black (13%) students.

 

Mental Health Evidence-Based Screening

During the three months before pregnancy, 10% of women with a recent live birth from 2017-2018 reported having depression. Depression prior to pregnancy was more commonly reported by women in their twenties, NH White women, and those with a Medicaid payor at delivery. Among women who reported having depression during the three months before pregnancy from 2017-2018, 38% reported having a HCV for depression or anxiety in the 12 months before getting pregnant. As compared to 2013, in 2018, a greater percentage of women reported feeling down, depressed, or hopeless since their new baby was born increased. Among women whose baby was alive and living with them, 4.4% reported using counseling services for depression or anxiety since their new baby was born.

 

Strengths and Needs

Georgia has shown improvements in access to dental services for pregnant women and children. Additionally, the percentage of women smoking during pregnancy in Georgia remained below the national average of 10.7%, however the use of ENDS has increased in both pregnant women and adolescents.

 

Programmatic Efforts to be Continued

• Oral Health education and services to pregnant women through family practice physicians
• Tobacco cessation education for pregnant women during preventive dental visits
• School-based sealant programs
• Community water fluoridation

 

Areas of Opportunity

• Expand education to reach parents, women, and children through home visits, outreach, and education

 

DPH is the lead agency in preventing disease, injury and disability; promoting health and wellbeing; and preparing for and responding to disasters from a public health perspective. The agency’s Commissioner reports directly to the Governor. HP contains the MCH Section, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Oral Health, MCH Epidemiology, and the Program Evaluation and Performance Improvement sections. The MCH section contains the following programs: Title V, Child Health, CYSHCN, and Family and Community Supports programs. DPH recently restructured and added the Clinical and Medical Services Division which includes Chronic Disease, Immunization, Infectious Disease, Nursing, Public Health Pharmacy, the Public Health Laboratory, Refugee Health and the Office of Women’s Health. MCH has primary responsibility for the administration of the Title V Block Grant. The MCH Director serves as the Title V Director. The Title V MCH program sets program policy and monitors compliance with state and federal laws and rules and offers technical assistance to staff in district public health departments regarding Title V programs. The following list provides a description of Title V funded programs.

 

Title V Funded Programs:

 

Babies Can’t Wait (BCW) provides a coordinated, comprehensive and integrated system of early intervention services for infants and toddlers birth to three as outlined by IDEA Part C.
Children First serves as the “Single Point of Entry” to a statewide collaborative system of public health prevention-based programs and services for children with poor health or developmental delays.
Children’s Medical Services (CMS) ensures a community-based, coordinated, family focuses, culturally appropriate, comprehensive system of quality specialty health care services available for Georgia’s children with chronic medical conditions from birth to 21 years of age who live in a low-income household.
Family Planning improves the health of women and infants by enabling family to plan and space pregnancies and preventing unplanned pregnancy.
Injury Prevention provides general support to local coalitions in helping promote safe and injury free lifestyles and behaviors.
MCH Epidemiology (MCH EPI) supports data collection and analysis of all MCH programs and administers the State Systems Development Initiative (SSDI), Early Hearing and Detection Intervention (EHDI) and Pregnancy Risk Assessment Monitoring System (PRAMS).
Newborn Screening (NBS) ensures that every newborn in Georgia has a specimen collected to screen for 35 inherited disorders that would otherwise cause significant morbidity or death.
Oral Health provides community water fluoridation, school-linked fluoride supplement programs for high-risk children, dental sealants and dental health education.
Perinatal Health assures pregnant women in Georgia have every opportunity to access comprehensive perinatal health care services appropriate to meet their individual needs and supports outreach efforts. Perinatal Health addresses infant mortality, maternal mortality and breastfeeding.

 

MCH currently has the capacity through structural resources, data systems, partnerships and competencies to promote the health of all MCH populations. In each domain, MCH initiates partnerships with external organizations to ensure a statewide system of services that are comprehensive community-based, coordinated and family centered. The Title V program serves all 159 Georgia counties. Title V program managers monitor all aspects of program administration in order to ensure a statewide system of services, which reflect the principles of comprehensive, community-based, coordinated and family-centered care.

 

Maternal/ Women’s Health

MCH uses Title V funds to provide services for women of reproductive age. Family planning clinics supported by Title V provide contraceptive counseling and preventive services. Cancer screenings and HPV vaccines are provided in the family planning clinics. MCH actively supports the MMRC and engages in various initiatives to promote maternal health. MCH has epidemiology staff to support programmatic efforts. Data sources used are PRAMS, Vital Records, BRFSS, and Family Planning program data. Women’s Health houses the data for the MMRC and identifies cases for review. MCH and Women’s Health have active partnerships with hospitals, private practice physicians, academic institutes, cancer and HIV screening agencies, the Chronic Disease Prevention Section, HMHB, Georgia Obstetrical and Gynecological Society (GOGS) and March of Dimes (MoD) to ensure a comprehensive system of services for women of reproductive age in Georgia.

 

Perinatal Health
Title V staff supports newborn screening, breastfeeding initiatives, preterm birth initiatives, perinatal regionalization and the Safe to Sleep campaign to promote perinatal health. MCH also participates in the Georgia Perinatal Quality Collaborative (GaPQC) to implement quality improvement projects in participating hospitals. Title V supports epidemiology staff to collect and analyze data on perinatal health. The primary data source used are PRAMS and Vital Records. MCH and Women’s Health has active partnerships with the RPC’s, birthing facilities, private practice physicians, Association of State and Territorial Health Officials (ASTHO), GOGS, HMHB, MoD, WIC, and Worksite Wellness.

 

Child Health

MCH promotes child health through promoting developmental screenings among children, preventing injury and promoting oral health. MCH state, district and local level staff are well-versed in developmental screening and the various tools used to assess developmental screening. The Child Occupant Safety Project (COSP) aims to prevent motor vehicle accident deaths among children. MCH utilizes the State Electronic Notifiable Disease Surveillance System (SendSS) and Babies Information and Billing System (BIBS) to assess developmental screening data. To ensure comprehensive system of services among children, MCH has active partnerships with the Chronic Disease Prevention Section Department of Early Care and Learning (DECAL), Department of Education (DOE), academic institutes, GA Chapter of the American Academy of Pediatrics (GA-AAP), GA Academy of Family Physicians (GA-AFP), Marcus Autism and Emory Autism Centers.

 

Adolescent Health
The Adolescent Health program sits within the Chronic Disease Prevention Section and promotes adolescent health through programs targeting tobacco prevention, sexual violence prevention, teen pregnancy prevention and positive youth development. Title V will partner with the Injury Prevention Program to identify the prevalence and existing prevention programs and legislation on bullying and facilitate improvements in bullying prevention efforts by schools that service the target population.

 

CYSHCN
MCH supports several programs to provide services to Georgia’s CYSHCN. Children 1st acts as the access point for children with an identified special need. BCW provides services for children from birth to three. CMS is established and continues to provide on-going, comprehensive medical care for CYSHCN that are not eligible for state funded Medicaid and SCHIP programs. CMS promotes access to specialty care, care coordination, transition to adulthood and medical homes for CYSHCN. Epidemiologists support data collections for CMS.

 

Cross-cutting

MCH has Title V, CDC, state and private-donated funds to support oral health initiatives. MCH has access to oral health data through PRAMS, NSCH, CMS, and 3rd Grade and Head Start Basic Screening Surveys. The Oral Health program has an Oral Health Epidemiologist. To ensure a comprehensive oral health system of services, MCH has active partnerships with WIC, private practices, dental hygiene programs, academic institutes, schools, the Oral Health Coalition and CDC.

 

Recognizing the importance of investing in an adequately sized, skilled workforce, Title V has built capacity to better monitor and track changing MCH needs, evaluate progress to program goals, and enhance state-local partnerships to advance MCH. HP Administration is responsible for MCH workforce development strategies that ensure recruitment and retention of qualified staff, training and professional development for employees and creative staffing structures that maximize funding resources. MCH, with 47 FTE’s, has 100% of positions filled including all program director and manager positions.

 

Title V Leadership
Director, Division of Health Promotion	LaToya Osmani, MPH
Director, Title V and MCH Section	Jeannine Galloway, MPH
Director, Oral Health Program	Adam Barefoot, DMD, MPH
Director, Administration, Division of Health Promotion	Valerie Newton-Lamb, MSHA
Director, Fiscal, Division of Health Promotion	Debra Chapman
Director, CYSHCN Program	Sharifa Peart, MPH
Chief Nurse, Office of Nursing	Diane Durrence, MPH, MSN, APRN
Deputy Director, Title V	Paige Jones
Deputy Director, Early Intervention	Lisa Pennington MS, MA, LPC
Deputy Director, Child Health Services	Judith Kerr, MPH
Deputy Director, Family and Community Supports	Twanna Nelson

 

 

Cultural Competency
Several methods are used to ensure that culturally competent approaches are used in service delivery across all programs. MCH EPI routinely collects and analyzes data by race, ethnicity and income to assess health equity and inform program activities. A bilingual interviewer is on PRAMS staff to ensure sufficient response rates from the Hispanic population. MCH works closely with community leaders to plan service delivery programs, collaborate on grants and implement culturally competent services that meet the unique needs of populations. In all MCH programs, services and/or educational materials are provided in English and Spanish and include images representative of the target community. The Oral Health program has bilingual staff that will provide outreach education targeted to Hispanic children. The CMS program will arrange for the provision of oral language assistance, from language interpreter and translation services, in response to the needs of Limited English Proficiency (LEP) and Sensory Impaired (SI) individuals in both face-to-face and telephone encounters with CMS. The Child Health program addresses cultural competency through partnering with the state Refugee Health Program and its case managers to address cultures and languages, such as Arabic, Somali, and Swahili. In addition, on our various councils and committees MCH strives to involve individuals representing the diversity of the community and encourages cross-cultural dialogue.

Title V is heavily focused on collaborative partnerships and demonstrate strong commitment to coordinating with others to address emerging and ongoing needs of MCH populations. Both formal and informal collaborative relationships exist that support Title V work. Georgia maintains partnerships to build the capacity of MCH services in the state.

 

MCHB Investments: Title V works collaboratively with other MCHB investments, including but not limited to: State System Development Initiative (SSDI), Maternal, Infant, and Early Childhood Home Visiting (MIECHV), and Healthy Start.
Other Federal Investments: Title V receives other federal investments through CDC funding which includes PRAMS, Oral Health and perinatal quality improvement, as well as USDA funded WIC and Health and Human Services funded Head Start. Title V also works closely with Part C of IDEA and Early Hearing Detection and Intervention (EHDI)
Other HRSA Programs: District coordinators partner with Federally Qualified Health Centers.
State and Local MCH Programs: The state Title V program coordinates regularly with community organizations and local health departments to implement activities.
Other programs within the State Department of Health: MCH partners with several other sections in DPH. MCH partners with the Office of Women’s Health, Adolescent Health, Chronic Disease Prevention, Immunizations, Injury Prevention, STD, and Vital Records.
Other governmental agencies: MCH has strong relationships with the Department of Community Health, Department of Behavioral Health and Developmental Disabilities, the Division of Family and Children Services, Department of Early Care and Learning and the Department of Education.
Public health and health professional educational programs and universities: MCH frequently partners with Emory University, Rollins School of Public Health, Georgia State, University of Georgia, Morehouse School of Medicine, Mercer University, Valdosta State University and Augusta University.
Others: MCH has a contractual relationship with RPC’s to meet the needs of the perinatal regionalization system. GOGS is contracted to administer the MMRC. Relationships with Children’s Health Care of Atlanta and Augusta University will be critical to addressing transition, as these sites have transition clinics that DPH has assisted in establishing and promoting. Parent to Parent and GA-AAP are contracted to support services for CYSHCN. Emory University conducts follow-ups for the Newborn Screening program.
Title V Stakeholder Council: The MCH Advisory Council serves in an advisory capacity to MCH Title V Program; monitors progress; and addresses specific MCH population needs for MCH populations. The MCH Section serves as the lead agency for the Council. The Title V needs assessment and state action plan is the guiding document as it relates to the ongoing work of the Council. The Council is comprised of a multidisciplinary team of professionals with expertise in MCH.

 

Interface Between Needs Assessment Data, Priority Needs and National Performance Measures

 

Title V, NAW, and Promotion Evaluation and Performance staff reviewed all data from the quantitative and qualitative analysis in order to select the potential priority needs for the state in the six population domains. Staff individually indicated their top needs based on the data reports and then a consensus was developed across all members. They were asked to primarily consider whether the data indicated an area of need, whether MCH had the capacity and authority to address the need and if the need was measurable.

 

The individual rating tools were analyzed across the two groups to determine the highest rated priority needs in each domain. The data and results from survey rankings were reviewed to assess consistency and confirm an area of need. Needs were then aligned with a NPM when possible. The State Action Plan Chart was developed, and the strategies were identified based on suggestions from the Stakeholder meetings, focus group findings and a review of the evidence base for each NPM.

 

Eight priorities were developed with at least one priority for each population domain. Development of objectives and strategies, alignment with NPMs, adoption of new state performance measures (SPMs), and the creation of evidence-based strategy measures (ESMs) followed. During this process,10 NPMs and 3 SPM’s were selected to address state needs. The final draft of the MCH Priorities and Associated Measures of the 2021-2025 State Action Plan was developed and presented to the MCH Advisory Council.

 

With similarities to priorities from the 2016-2020 plan, these new priorities expand on previous work or focus on new and emerging issues. Georgia adopted a stronger focus on innovative approaches, improving health equity, and reducing social determinates of health. The table that follows compares the most common themes across all three needs assessment data sources.

 

Relationship Between Priority Needs and Measures

The Georgia Title V Needs Assessment process focused on identifying and addressing issues at the state and local levels. The top state priority issues that most closely aligned with the national priorities and NPMs were selected.

 

Figure 4: Priority Needs and Associated Measures

Prevent Maternal Mortality (Domain: Women's Health)

NPM: 1: Well Women Visit (Percent of women, ages 18-44, with a preventive medical visit in the past year)

Prevent Infant Mortality (Domain: Perinatal/Infant Health)

NPM 3: Risk Appropriate Perinatal Care (Percent of VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit) NPM 4: Breastfeeding ((A) Percent of infants who are ever breastfed (B) Percent of infants breastfed exclusively through 6 months) NPM 5: Safe Sleep (Percent of infants placed to sleep; (A) n their backs; (B) on separate sleep surface; and (C) without soft objects and loose bedding) SPM 1: Reduce the rate of Congenital Syphilis SPM 2: Reduce Infant Mortality in the Black Population

Promote Developmental Screenings Among Children (Domain: Child Health)

NPM 6: Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year

Increase Bullying and Suicide Prevention

NPM 9: Percent of adolescents, ages 12 through 17, who are bullied or who bully others

Increase the number of children, Both With and Without Special Health Care Needs, Who Have a Medical Home (Domain: CYSHCN)

NPM 11: Percent of children with and without special health care needs, ages 0 through 17, who have a medical home

Improve Systems of Care for CYSHCN

NPM 12: Percent of adolescents with and without special health care needs, ages 12 through 17, who received services necessary to make transitions to adult health care

Promote Oral Health Among All Populations (Domain: Cross-Cutting)

NPM 13.1: Percent of women who had a preventive dental visit during pregnancy NPM 13.2: Percent of children, ages 1 through 17, who had a preventive dental visit in the past year

Increase Father Involvement Among All MCH Populations (Domain: Cross-Cutting)

SPM 3: Percent of Fathers who reported increase in knowledge using 24/7 Dads® curriculum in Georgia Home Visiting Program sites