Needs Assessment Update
Alaska’s most recent five-year needs assessment was conducted in early 2020. A health equity priority was added in 2021, and the Title V program has been working to integrate equity considerations into ongoing needs assessment considerations. The following is an update on needs assessment approaches, findings and adjustments.
ongoing needs assessment activities
The MCH Epidemiology Unit supports ongoing primary data collection and surveillance activities and continuously analyzes data from secondary sources. Epidemiologists analyze quantitative data and produce reports to disseminate information that is accessible for internal and external audiences. This year, staff conducted analyses to examine outcomes including Neonatal Abstinence Syndrome case confirmation and costs analysis, suicide risk and protective factors, trends in congenital syphilis, maternal mortality, critical congenital heart defects, and how changes in household challenges impact subsequent child welfare reports. Qualitative data is collected through survey comments as well as through MCDR committee recommendations and descriptions of factors in mortality. CUBS “back page” comments on resources utilized or needed are shared by email with WCFH and DPH leadership where appropriate.
The Section also utilizes external sources of relevant data and works with internal and external partners to collaborate on needs assessment projects. Over the past year, the Title V Coordinator and MCH Epi Unit Manager worked with a student at the University of Alaska Anchorage on a project examining Perinatal Health Needs of Native Hawaiian/Pacific Islanders in Anchorage. This project involved a series of one-on-one interviews with people from this community to gain a better understanding of factors that influence perinatal health outcomes. The MIECHV program is working with an external contractor on a community readiness survey, including interviews, to see if a rural hub village has the community capacity and infrastructure for a MIECHV-funded home visiting program.
WCFH advisory committees, including the Alaska Perinatal Quality Collaborative (AKPQC) Steering Committee, the CYSHCN Advisory committee, the Early Hearing Detection & Intervention (EHDI) Advisory Committee, and the Youth Alliance for a Healthier Alaska (YAHA), meet throughout the year to provide input on strategies and objectives and provide the perspective of those with lived experience on WCFH programs and population needs. Many of these committees have at least one family member or consumer participant. Professional development opportunities created or organized by WCFH, including the Home Visiting Summit, ECHOs (Home Visiting, Perinatal and Family) and the Family Engagement and Leadership Training (FELT), and the annual Maternal Child Death Review/PQC Summit conduct evaluations as part of the training. These trainings target partners, funders, providers, administration, and families.
Title X sub-recipients conduct ongoing customer satisfaction surveys and summarize the results quarterly for their advisory committees that, then, provide recommendations for service delivery improvement. WCFH, as the recipient of the federal funds, is responsible for assuring that any recommendations are followed through on. Title X services inherently include annual preventive health visits for all Title X clients, so this work is contributing to “moving the needle” on this Title V performance measure.
Changes in Health Status and needs of the mch population
Areas of need in all population domains remain similar to those identified during the 2020 Needs Assessment. These include mitigating the impacts and drivers of substance misuse across population categories; facilitating connections to behavioral and mental health information, resources, and services; and addressing trauma and ACEs by increasing social supports and promoting safety in interpersonal relationships.
The COVID-19 pandemic intensified the impact of behavioral and mental health conditions, and this impact continues to reverberate more than three years after the onset of the pandemic. The state is still assessing the impact of a staggering number of excess deaths in 2021 and 2022. This was manifested in the Title V priority population of pregnant people, with 2021 having a 109% increase in the pregnancy-associated mortality ratio compared to the average ratio for the prior 5 years. Fortunately, so far fewer pregnancy-associated deaths have been identified in 2022. Alaska continues to experience a disproportionate number of maternal deaths from violence. Suicide, overdose and homicide are leading causes of maternal mortality, particularly among Alaska Native women. Intimate partner violence is often identified as a contributing factor across all causes of maternal deaths (MCDR Fact Sheet, Supporting Document #1). Substance use is also a frequent contributing factor in maternal mortality, but MCDR case reviewers noted that substance misuse and IPV co-occur more often than not in Alaskan maternal mortality cases. MCDR case review also found that lack of access to perinatal healthcare or social services was identified in 44% of cases (reviewed 2016-2022), and since recent years have included improvements in identifying specific factors such as access, this is likely an undercount. These findings have contributed to the implementation of the AKPQC initiative on substance-affected pregnancies using approaches that center the need for trauma-informed, holistic interventions that acknowledge the role of maternal safety and support in recovery.
Rates of obesity, hypertensive disorders, and diabetes continued to rise among birthing people in Alaska. This increase mirrored an ongoing increase in SMM among all Alaskan births from 2020 (1.6%) to 2022 (3.0%). During 2018-2022, SMM rates were highest among Alaska Native (3.0%) and Black (2.6%) birthing people. Increases in the rate of SMM over the past 3 years were most striking among residents of the Interior and Northern regions, although Anchorage and Southwest regions also had increases.
In 2021, 62% of Alaska women ages 18-44 years of age had a past-year preventive health visit (BRFSS). This is the second year in a row of a decline in this indicator; a trend similar to other noted drops in preventive health care visits associated with the COVID-19 pandemic (such as well-child checks for children). WCFH used Title V funding to support the inclusion of the following question on the 2021 Alaska Behavioral Risk Factor Surveillance System (BRFSS), to be asked of all women who had a routine check-up in the past year: “During that visit, did a doctor, nurse, or other health professional ask you if you wanted to become pregnant in the coming year?” This question improves the physician’s ability to provide appropriate care by educating patients about contraception options if they do not want to become pregnant and are not currently using contraception. If the patient does want to become pregnant, it can prompt a discussion about preconception health and things they could do to ensure a healthy pregnancy. It also provides an opening to discuss healthy pregnancy spacing. Among women with a past-year preventive health visit, 21% said that their provider asked if they wanted to become pregnant in the coming year.
In response to questions that arose during recent collaborations with local midwifery groups, WCFH and the AKPQC worked with Vital Records to add new questions to the Alaska birth certificate in 2022 to collect information on planned place of delivery and planned attendant at birth. Among planned birth center and home births in 2022, 25% occurred at a hospital, while 99.7% of planned hospital births did occur at a hospital. Further analyses of these new data are anticipated over the upcoming year. In Alaska, many people living in remote villages do not have much choice when it comes to where they have their baby. WCFH staff continue to hear stories of challenges and stress on people flown into hub communities or Anchorage to deliver. We hope to continue to work with community partners to identify areas where Title V programs can alleviate some of these challenges.
Areas of need for the perinatal/infant and child populations include increasing the number of children who live in safe, stable, nurturing environments. For the perinatal/infant domain, priorities also include improving social supports to prevent and reduce the impact of Adverse Childhood Experiences (ACEs) and prevention of substance misuse among caregivers of infants and toddlers and women of childbearing age.
After two years of increases, Alaska’s overall infant mortality rate dropped in 2022 (preliminary data) to 6.1 per 1,000 live births, which was similar to the overall average rate for the past decade and close to the U.S. rate of 5.5 per 1,000 births in 2021. Neonatal mortality also declined in 2022 compared to 2020 and 2021, however postneonatal rates were higher in both years compared to 2020. While it appears that 2022 returned closer to pre-pandemic norms for infant mortality in Alaska, the MCH Epi Unit and MCDR team are still analyzing the data and reviewing these deaths to better understand the impacts of the pandemic on this MCH outcome.
For each year 2016-2020, SUID was consistently the leading cause of death among Alaskan post-neonates and ranged between 17-25% of neonatal deaths. The average disparity rate ratio (2017-2021) for Alaska Native infants compared to white infants was 3.0. The disparity rate ratio in 2021 was 2.6, which was unexpectedly low, especially following the largest disparity observed of the five years at 3.5 in 2020. Unfortunately, this was not due to improvement, as the infant mortality rate for Alaska Native infants, at 14.2/1,000 live births, was the highest reported of the five years. However, the rate for white infants of 5.6/1,000 live births represented an even greater proportional increase, compared to prior year rates for white infants. Comparison of these disparity rate ratios by neonatal and post-neonatal periods reveals a substantially greater disparity for Alaska Native post-neonates (1.7 neonatal compared to 7.7 post-neonatal).
Substance misuse is tied to child maltreatment and SUID. In 2021, 5.9% of people who delivered a live birth drank alcohol during the last 3 months of pregnancy, 7.3% used tobacco, and 7.6% used marijuana at any time during their pregnancy. Prenatal cigarette use has been declining for the past decade, however e-cigarette use doubled in 2021 compared to prior years, to 2.3% overall. Neonatal Abstinence Syndrome has increased from 9.3 per 1,000 delivery hospitalizations in 2016 to 15.1 in 2021 (HFDR).
After a decade of annual increases, the preliminary overall preterm birth rate for Alaska in 2022 indicated a slight drop or leveling off compared to 2021. However, it appears the rates continued to increase among Alaska Native and Black people while declining only among White and Native Hawaiian and Pacific Islander people. The rising preterm birth rate has occurred primarily among late preterm and clinician-initiated preterm births.
While approximately 10% of Alaskan children ages 0-17 are reported to child welfare for suspicion of maltreatment during an average year, cumulative estimates show that among children born in Alaska, approximately 43% are reported, with 14% substantiated, for an allegation of harm before age 12, and 8.3% experience a removal (ALCANLink). A recent study conducted by the MCH Epi Unit that used CUBS data to approximate experience of ACEs found that 47.3% of Alaska 3-year-old children over the past decade have experienced at least 1 ACE. ACEs related to financial hardship were most comment, followed by substance abuse in a close family member and neglect.
Behavioral and mental health resources are a huge need for the adolescent population. YRBS data through 2019 indicated increases since 2007 in students feeling sad or hopeless, and considering, planning for, and attempting suicide in the past 12 months. Compared to the last survey, fewer students and staff indicated “0 times” for how often they observed students engage in delinquent behaviors at school and at school events within the past 12 months (59%) as well as how often they had seen other students engaging in drug and alcohol use at school or school events in the past 12 months (73%) (SCCS).
For all Alaskan children aged 3-17 years in 2020-2021, at least 21.6% had at least one mental, emotional, developmental, or behavioral problems. Trauma and the effects of adverse childhood experiences are known to impact both short and long-term mental health of individuals. In Alaska, 1 in 3 children by the age of 7 will be reported to the Office of Children’s Services for some type of maltreatment, while Alaska’s rate for children in foster care is 150% more than the national average.
Since the pandemic, there has been an increase in mental health needs of adolescents, with more visits to the emergency room (ER) for acute care. A recent report found, in 2021, there were 2,273 ER treatment episodes for children and adolescents with a behavioral health diagnosis. 25% of them discharged with a suicidal ideation diagnosis and most went home without further treatment. Many of those seeking care in the ER did so because there were not lower-level behavioral health services readily available to them in their local community. A U.S. Department of Justice report into Alaska’s behavioral health system for children found that in 2020, the State of Alaska was the primary payer for 800 children, a third of whom were Alaska Native, placed in a psychiatric facility. During the pandemic, AI/AN children and youth were at greater risk for mental health needs. The lack of internet access was a barrier for them to access resources, their school, and friends. This was also true for children and youth living in rural and remote areas with limited internet access. Additionally, 55% of children are eligible for Medicaid. However, the Alaska Hospital and Healthcare Association 2022 report on child and adolescent behavioral health services found that of the 380 providers of behavioral health services identified in Alaska, only 11 indicate they accept Medicaid, which makes accessing care even more challenging.
The unintentional injury-related death rate for Alaska teens has been consistently higher than the national average and has been increasing for the past decade, to 33.4 per 100,000 population during 2019-2021. Alaska’s teen suicide rate has also been increasing and was almost 4 times the national rate in 2019-2021 (39.8 vs. 10.6 per 100,000 population). The most common mechanism of teen suicide is firearm, while motor vehicle crashes contributed to the largest proportion of unintentional injury deaths. Prior to the pandemic, Alaska’s adolescent suicide rate in 2016-2018 was 3.2 times higher than the national average, at 28.8 per 100,000 for those aged 12-19 years. Rates were highest for males (47.9 per 100,000) and American Indian/Alaska Native (AI/AN) adolescents (78.9 per 100,000), with the more rural and remote areas of the State seeing higher rates of suicide by Public Health regions.
The priority identified for the CYSHCN domain is to increase or promote equitable access to medical and pediatric specialty care and family supports for CYSHCN. The 2020-2021 NSCH estimated 20.4% of Alaskan children ages 0-17, or 30,496, have special health care needs. 41.3% of Alaskan CYSHCN have a medical home, while 22.4% of 0-11 year-olds and 4.7% of 12-17 year-olds received care in a well-functioning system. However, 20.8% did not have a usual source of care when sick or when a parent/caregiver needed advice about their health. Among parents of CYSHCN, 7.9% said they were usually or always frustrated in efforts to get services for their child in the past year. Of CYSHCN who received or needed specialist care during 2020-2021, 20.6% found it somewhat difficult to obtain, while 12.4% found it very difficult to obtain. Among CYSHCN ages 3-17 years, the number of those needing to see a mental health professional was 34.1, while 8.9% needed, but did not receive mental health treatment or counseling.
changes in program capacity and systems of care
From March - June 2023, the Title V Director and WCFH Section Chief served in acting status as the DPH Deputy Director while the MCH Epidemiology Unit Manager and CUBS Coordinator served as Acting Section Chief. The Section was significantly impacted by various vacancies in administrative support positions during the past year, with one office assistant position vacant for 9 months and a second for 5 months. The Accounting Technician III and Administrative Officer I positions were both vacated within a month of one another, just two months before the end of the state fiscal year. While the AO was filled fairly quickly, the Accounting Tech position was vacant for three months. Additionally, the Division and Department have experienced reduced capacity in many support services as a result of these units being split along with the Department in July 2022, including HR, IT, Grants and Contracts, and Finance/Revenue. Each of these vacancies substantially impacted the ability of program staff to efficiently conduct ongoing activities within planned timelines.
No positions were eliminated from WCFH in the Governor’s FY24 state budget. The Section did receive a one-time supplement of $250,000 to support the prevention and mitigation of ACES. It is yet to be determined how that will be implemented. Additionally, as part of the Governor’s Healthy Families Initiative, funding was added to the Medicaid budget to expand postpartum coverage from 60 days to 12 months.
In April 2023, WCFH was asked by Division of Behavioral Health (DBH) to apply for the new HRSA continuation grant for the Primary Care Mental Health Access line. The new CYSHCN Director will be the Project Director and will provide day-to-day management for this program. The DBH no longer had the capacity to lead this grant program and asked Title V to take over leadership. WCFH will continue to partner with the All Alaska Pediatric Partnership and Seattle Children’s Hospital to provide Alaska-based pediatric care providers working in primary care, behavioral health care, and integrated health care settings immediate access to psychiatric behavioral health consultation and whole-person resource navigation for children and adolescents.
Title V staff continue to partner with the Office of Children’s Services on implementation and evaluation of Plans of Safe Care (POSC) as outlined under the Child Abuse Prevention & Treatment Act. Juneau was the first community to pilot POSC. POSC is one component of the Substance Exposed Newborns initiative of the AKPQC. WCFH is hopeful the linkage between the AKPQC and POSC will foster momentum and have a positive impact on the service system for families affected by substances. Through the Substance-Affected Pregnancies Initiative (SAPI) of the AKPQC, WCFH has partnered with other agencies to enhance knowledge and awareness of the POSC in enrolled hospitals. This can be a challenging area for hospitals with already decreased staffing capacity due to the need for intensive collaboration and partnering with agencies outside the hospital. Additionally, there is not enough State funding to support implementation of POSC on a statewide level.
WCFH continues to lead efforts related to developmental screening, including partnering with state and community-based programs to promote the use of the online ASQ developmental screening tool and supporting the implementation of Help Me Grow (HMG) Alaska, which launched at the beginning of 2018.
Partnerships and collaborations
Key partnerships between WCFH and federal, tribal, state, and local entities are listed below, with upcoming or recent changes to the partnerships described.
WCFH administers federal grants from HRSA, CDC, and others that work collaboratively with Title V. In 2022, WCFH was awarded a new CDC grant to support the Alaska Perinatal Quality Collaborative.
WCFH collaborates with the Borough of Juneau to fund nurse practitioners to offer reproductive health and well child visits in 2 local high schools. Using marijuana tax funds, WCFH supports school-based health centers in Anchorage, Juneau, and Bethel.
In addition to the HRSA Pediatric Mental Health Access grant (PAL PAK), WCFH partners with the DBH on the Substance-Exposed Newborns Initiative. In 2022, WCFH also enhanced their partnership with the Office of Children’s Services (OCS) to expand evidence-based Parents as Teachers (PAT) home visiting services statewide. This doubled the amount of funding available for this model in Alaska. WCFH also continued collaboration with OCS on early childhood systems and prevention work, such as enhancing developmental screening.
The Department split in 2022 resulted in the assignment of the OCS to a different department from WCFH. However, data-sharing agreements and programmatic collaborations have continued uninterrupted. Within DPH, WCFH works with other sections on breastfeeding promotion, injury and cancer prevention, screening, school-based health centers, and the overdose death review. WCFH also supports Division-wide efforts such as Public Health Accreditation, the Quality Improvement team, Healthy Alaskans 2030, Workforce Development, Data Modernization, and the Scientific Review Team.
WCFH co-coordinates the Alaska Early Childhood Coordinating Council with DEED. WCFH and Medicaid organized a team to participate in a learning collaborative with the Center for Health Care Strategies, titled “Aligning Early Childhood and Medicaid (AECM).” The AECM team includes staff from DPH, OCS, the Alaska Medicaid Program, the Division of Behavioral Health, and the Commissioner’s Office. The team, led by the WCFH Early Childhood program manager, is working on a mapping project focused on substance use disorder during pregnancy in the Yukon-Kuskokwim region.
WCFH collaborates with Tribal Health in newborn screening, infant safe sleep, the AKPQC, home visiting, and pediatric clinics. In 2022, section staff began meeting regularly with staff from the ANTHC Tribal Epidemiology Center to begin planning for the spring 2024 MCH and Immunizations conference. Throughout the year, the Title V Director, MCDR, and PQC staff continued collaboration with the Alaska Native Birthworkers Community on an AMCHP learning opportunity related to anti-racism. Through a set of contracts established last year using funding from OASH focused on the prevention of maternal deaths due to violence, WCFH partners with four other Indigenous-led community-based organizations and service providers to deliver grant-funded services.
Collaboration with the Alaska Hospital and Healthcare Association (AHHA), through a contract with the AKPQC and MCDR, continued to support partnerships with birthing facilities around the state.
Operationalization of five-year needs assessment
In FY21, the following priority was added to increase strategic focus on health equity:
Promote health equity, improve social determinants of health, and identify and deconstruct systems of institutionalized oppression for maternal and child health populations.
Four strategies were added in the Cross-Cutting/Systems Building domain to address this priority. Staff have participated in numerous trainings and begun the process of translating theoretical knowledge into practice. Equity topics are emphasized at the annual AKPQC/MCDR Joint Summit and the MCH and Immunization conference. WCFH staff provided leadership in developing guidelines for inclusive language for the Division’s information products. The strategies are designed to promote deeper staff development and supervisory techniques, address equity impacts of current Title V strategies, promote equitable use of resources, and leverage data and information in partnership with marginalized communities to raise awareness and drive action.
changes in organizational structure and leadership
In 2021, the Governor proposed to bifurcate DHSS into the Department of Health and the Department of Family and Community Services. Public and stakeholder sessions were held to inform implementation, with the Title V Director serving as a department representative at these sessions. The proposal was resubmitted in 2022 as Executive Order 121. After no formal vote to reject the order was conducted by the legislature, the EO went into effect July 1, 2022. There are no major programmatic or leadership changes to DPH, however many support services staff were split between the two new Departments, leading to reduced capacity in the areas of procurement, IT, and human resources.
In fall 2022, the Commissioner of Health was named Commissioner of Revenue, and the Public Health Director was selected as the new Commissioner of Health. She was formally approved into this role during the 2023 legislative session. The DPH Deputy Director who oversees WCFH was asked to serve as Acting Director until a permanent Director could be found. She served in dual roles (as Director and Deputy) for several months. Due to the length of time it was taking to permanently fill the Director position, in March, she requested that the WCFH Section Chief take on Acting Deputy responsibilities. A permanent Director started in mid-June. Over the past year, multiple HR and Finance staff assigned to DPH have also continued to turn over.
Since 2021, the Department of Health and Department of Education & Early Development have been collaborating on the Office of School Health & Safety (OHSU). WCFH hired three new non-permanent positions to support enhanced work in these areas including a Health Program Manager III, a Nurse Consultant I, and Program Coordinator II. The Commissioners decided in June 2023 to not move forward with the implementation of a formal OSHS. While WCFH will keep the additional school nurse consultant on board, the other two positions will end in 2023. Despite the policy decision to not have a formal OSHS, the two departments are committed to collaboration and coordination on school health and safety.
emerging public health issues
Opioids and substance use continue to impact overall population health. In a May 2022 Bulletin, the Department announced a 71% increase in overdose deaths, with 75% attributed to fentanyl. Increased deaths and overdoses related to fentanyl have continued in the past year, with the Anchorage School District announcing 10 overdoses among high school students in less than a month in April 2023. The OSHS and WCFH School Nurse Consultants continued to distribute information related to the fentanyl crisis.
Alaska’s syphilis outbreak was first declared in early 2018 and case counts have continued to increase annually. In 2021, the Alaska CS incidence rate was 54 per 100,000 live births and increased to 119 per 100,000 live births in 2022. As part of the Governor’s Healthy Families Initiative, a key focus over the next year will be congenital syphilis. An increment of general funds was given to DPH to work on this important health issue. This will take a collaborative effort between the Sections of WCFH, Epidemiology, Laboratory, and Public Health Nursing. It is anticipated that WCFH will support efforts around provider education and enhancing linkages to timely prenatal care. In spring 2023, the Section of Epidemiology (SOE) reached out to the MCH Epidemiology Unit asking for assistance with documenting and responding to increases in cases of congenital syphilis. The CSTE fellow was lead author on an Epidemiology Bulletin describing the trend, and the MCDR Manager and MCH Epi Unit Manager are providing technical assistance to SOE staff in establishing a congenital syphilis case review team.
Rates of neonatal infant mortality (deaths at less than 28 days) in Alaska have historically been lower than the U.S. rate but were above the U.S. rate in 2020 and 2021. The neonatal mortality rate of 4.6 in 2021 was the highest Alaska has seen in 20 years. Although the rate dropped in 2022, WCFH will monitor this closely to determine whether increased efforts to address causes and contributing factors to neonatal mortality are needed.
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