The Public Input focused on the reviewed 2020-2025 State Action Plan (SAP). PR Title V prepared a report with the proposed SAP and distributed it by email along with the translated FY 2020-2021 State Snapshot and a URL address that would allow them to provide their input and recommendations through Google Forms. It was shared with stakeholders such as members of the HNA Advisory Committee (HNAAC) and the Regional Boards (RBs), as well as other Title V partners.  A period of 3 weeks was allowed for participants to offer their input.

The Form allowed stakeholders to determine if the established strategies were contributing “a lot”, “quite a lot”, “somewhat”, or “nothing” for each of the priorities set in the SAP, as well as to identify unknown strategies. It also allowed stakeholders to make recommendations for each of the strategies, as well as giving suggestions for new strategies and identifying areas for collaboration.

The HNA Steering Committee discussed the SAP input, along with 2023 HNA findings, accounting for resource and staff availability to develop and implement said strategy.  As for those strategies that the MCAHD and the CSMND cannot carry out, PR Title V will reach with other agencies - that also serve the MCA population so they can join us in our efforts.

Forty-eight inputs were received (Figure 1): 56.3% by government agencies, 22.9% by non-profit organizations, 10.4% by private agencies, 8.4% by community and families with CSHCN, and 2.1% by HNA Advisory Committee. Of all the participants 64% belongs to MCAHD Regional Boards.

Figure 1: PR Five Year State Action Plan Participants Distribution

for 2023 Public Input

Table 1 provides a detailed list of the Public Input participants.  The Youth Advisory Council (YAC) met as a group and 15 members provided one input.  Added to the other 47 individuals inputs, about 48 individuals shared their input and recommendations.

Table 1: PR Five Year State Action Plan Participants List for 2023 Public Input

Overall, 90% or more of participants agreed that most of the strategies aimed at improving the health and wellbeing of each population contributed to reach said priorities “a lot” or “quite a lot”. The following is a brief description of the stakeholders’ input by domain.

Women Maternal Health

A total of 7 strategies were proposed to promote health and wellbeing of WRA and 7 to improve birth outcomes.  Six of the seven strategies, according to about 96% of the participants, contributed "a lot" or "quite a lot" to the success of WRA's health and wellbeing.  Most participants—between 92% and 98%—said that all the strategies suggested to improve birth outcomes contribute "a lot" or "quite a lot."

Few participants (4%–6%) thought three strategies contributed to this domain's priorities "a little". These strategies are promoting person-centered services among health care providers and WRA; disseminating and promoting the Prenatal Health Care Services Guidelines to the target population and health care providers; and promoting preventive dental visits among Title V Home Visiting Program (HVP) pregnant participants. The first two strategies are no longer included in the SAP because all the activities were completed as previously stated in the 2023 HNA update. However, the HVP has consistently demonstrated the value of this service, particularly for expectant women with risk factors, so this strategy will continue in the SAP.

About 9% of stakeholders were not aware of the Maternal Mortality Review Surveillance System in PR, and 4% were not aware of the strategy for promoting healthy pregnancy lifestyles through social media and community education activities. This represented a small number of stakeholders; therefore, the committee chose to preserve the strategies as part of the SAP as they effectively support the health of pregnant women and WRA.     

About 42% of the suggested strategies to improve birth outcomes involved educating the population about breastfeeding, prenatal care, or WRA rights in settings like workplaces, health fairs, or schools. Other recommendations were about health promotion and media campaigns (17%). These recommendations are activities considered in the SAP. Prenatal and parenting courses that cover many of the suggested subjects are available through the MCAH Community Outreach Program, which is made up of Community Health Workers (CHWs) and Health Educators (HEs). Participants in the MCAHD receive education on a variety of topics from the Home Visiting Nurses (HVNs) and Perinatal Nurses (PNs). The "Encuentro de mi vida" (Encounter of My Life) prenatal care webpage offers access to the virtual prenatal course as well as details on pregnancy and postpartum care. HNA 2023 showed that social media, websites, and virtual platforms for webinars and workshops have also been utilized frequently and will continue to be used because of their effectiveness.

After discussing the 2023 HNA findings and the Public Input, the SAP for this domain now has 5 strategies to promote WRA health and wellness and 6 strategies to improve birth outcomes.

Perinatal/Infant Health

A total of 10 strategies were proposed to decrease infant mortality.  Six of the strategies, according to about 94% or more of the participants, contributed "a lot" or "quite a lot" to address this priority.

About 4% of the participants concurred that raising awareness of the symptoms and signs of premature births helps "a little" with this priority.  The committee decided that this strategy should be maintained as part of the PDSA because it is crucial for preventing preterm births, which account for nearly 12% of births in PR.

Almost 20% of stakeholders were unaware of the Hard Stop Policy plan. Since hospital employees and administrators are more familiar with this policy, it is unsurprising that some stakeholders are unaware of the efforts made to reduce early elective deliveries before 39 weeks of gestation through this policy. In accordance with Regulation No. 9184 of the PRDOH (requirements for hospital operations), PR MCAHD will keep collaborating with the Hospital Association and March of Dimes to adopt and oversee this practice. Likewise, 17% of the participants had never heard of LOCATe, an approach that is mostly known among hospital staff. The PR MCAHD creates policies and strategies to address high-risk pregnancies and poor birth outcomes with the support of LOCATe when determining the distribution of services across the Island. 

A little over 40% of the recommended strategies for this priority focused on sharing PR MCHAD projects and activities or could be summarized in prenatal and parenting courses offered to the community, as well as the "Encuentro de mi vida" (Encounter of My Life) webpage that supports the outreach initiatives conducted by the CHWs, HEs, HVNs, and PNs.

Following public input and PDSA revision, the SAP for Perinatal/Infant Health will now have 6 strategies to reduce infant mortality.

Child Health

Six strategies were proposed to improve preventive health in children. Five of the strategies, according to about 92% or more of the participants, contributed "a lot" or "quite a lot" to address this priority.

A little under 9% of the participants agreed that promoting the use of the high-risk caries screening tool for an early referral to create a dental home help "a little" in improving preventive health in children. The PR MCAHD efforts to work with stakeholders to encourage the early identification of infants at higher risk for caries are, on the other hand, unknown to 4% of the participants. This strategy was eliminated from the SAP and combined with the promotion of using the screening tool among primary healthcare providers, such as FQHC, as was noted in the 2023 HNA update.

About 37% of the suggested interventions are about parenting and development, education, and functional diversity. Healthy eating, early stimulation, preventive medical exams, security, physical activity, toxic stress, and lovingly enforcing discipline are among the themes that are covered in the parenting courses that the CHWs and HEs offer to the community.

The HNA Steering Committee recommended to only keep 4 strategies in the SAP to improve preventive health in children.

Adolescent Health

A total of 10 strategies, associated with two NPMs (NPM 9 and NPM 10), were proposed to improve health and wellbeing of adolescents. Between 92% to 96% of the participants agreed that seven strategies contribute “a lot” or “quite a lot” to this priority.

The PR Youth Friendly Healthcare Guidelines pilot initiative was unfamiliar to about 13% of the participants. Additionally, 6% of participants were uninformed of the Youth Health Promoter efforts (YHPP), including the initiatives to lessen bullying in schools associated with the YHPP.

Between 2% and 4% of participants report that all strategies contribute "a little" to enhancing the health and wellbeing of teenagers. When compared to the other participants, this is a relatively small share of the group—1 to 2 people.

About 25% of the suggested strategies were focused on agency collaboration, while another 25% were on educational initiatives that address parenting, development, transition, and mental health. A Collective Impact workgroup for youth mental health has just begun under CAHP leadership. Peer-to-peer counseling on the suggested topics is offered through the YHPP and the YAC. Additionally, "Mi nivel máximo" talks about health promotion and other issues specifically relevant to adolescents.

After reviewing the PDSA and as mentioned in the 2023 HNA update, one strategy of this domain was modified, hence the SAP remained with 10 strategies to improve the health and wellbeing of adolescents.

CSHCN Health

Forty-seven (47) stakeholders revised the strategies for NPM 11 and NPM 12. For the eight (8) medical home strategies, 92% of participants agreed that the strategies contribute “a lot” or “quite a lot” to this priority, ranging from 83% for the strategy “continue the efforts to implement the electronic health record system at the CSHCN Program”, to 96% for the “identification of families’ needs and support”, and for “strengthening collaborations”. Two (2) participants (4.5%) reported that the contribution is “none” or “a little” for every strategy. Four percent (3.5%) reported that they “do not know”. For the four (4) HCT strategies, 88% of participants agreed that the strategies contribute “a lot” or “quite a lot”, ranging from 85% for the strategy of “increasing HCT quality at the CSHCN Program”, to 91.4% for “providing HCT tools to CSHCN staff”. Seven percent (7%) reported they believe the contribution would be “none” or “a little” for some of the strategies, and 5% reported they “do not know”.

For the eight (8) SPM1 strategies (early identification and diagnosis of ASD), 92.5% of participants agreed that they contribute “a lot” or “quite a lot”, ranging from 83% for the strategy of the “distribution of the booklet Passport to Health in the Demographic Registry Office”, to 96% for “informing pediatricians, PCPs, childcare centers, Early Head Start, FQHC, WIC, among others, about the early signs of ASD”. Seven percent (7%) of participants (3) reported that the contribution would be “none” or “a little”. Two (2) of them reported the same answer for each one of the strategies. Only one percent (1%) of participants expressed that they “do not know”. For the five (5) SPM 2 strategies (decreased NTD birth prevalence) 94% of participants agreed that the strategies would contribute “a lot” or “quite a lot” to this priority, ranging from 91.5% for the “update and publishing of the PR-BDSPS Report”, to 96% for the “education and follow-up of families affected by NTDs births”.

Seven (7) participants provided recommendations for NPM 11 and NPM 12, most of which are already included as activities in the work plan. One of the participants recommended to increase the number of educative centers. For SPM 1 we received four (4) recommendations and one commentary. Recommendations were aligned with the provision of early interventions. One recommendation was the creation of a registry of certified caregivers so that families could call when they have the need. Three recommendations for SPM 2 were aligned with the increase of promotion about folic acid consumption.  

Final thoughts

The committee's recognition of the need for modification in requesting input from stakeholders and the community was aided by this feedback. Strategies that are unknown or acknowledged to be of "little" contribution in addressing the relevant priorities are target specific and, if discussed in depth, will enable the participants to be more accurate in their assessment of the strategies. On the other hand, most of the recommendations are considered by the SAPs activities, and the remaining recommendations cannot be carried out since they fall outside the reach of PR Title V.

The HNA Advisory Committee hasn't convened in person for three years due to the pandemic limitations. A different approach will be used for the next Public Input. The team will share detailed activities for each SAP strategy during a face-to-face meeting with each Regional Board, the HNA Advisory Committee, the YAC, and other stakeholders, giving attendees a deeper understanding of the PR MCAHD SAP. This way, additional recommendations will be gathered and included into the SAP.