I. Overview of Approach to Needs Assessment

In preparation for interim needs assessment from 2021 to 2025, the Bureau of Family Health (BFH) developed a plan and framework. Similar methods will be employed annually, and the cumulative results will serve as groundwork for the five-year needs and capacity assessment in 2025. Health equity remains the overarching framework of the BFH’s needs assessments.

 

Ongoing activities fall into three broad categories: 1) engagement of stakeholders to characterize maternal and child health (MCH) needs in the state, identify emerging issues, and inform development and implementation of strategies; 2) assessment of qualitative data collected through stakeholder engagement and available quantitative state data to further characterize the health status of the MCH populations and; 3) evaluation of the MCH system and the BFH’s capacity as the Title V administrator. Activities completed to date are described by category in the sections below.

 

II. Needs Assessment Update

 

1.         Stakeholder Engagement and Primary Data Collection

 

i.     Public Input Survey:

This was the third year that the BFH launched a public input survey asking respondents to identify unmet MCH needs and provide recommendations on strategies that would advance the state’s priorities for each Title V population domain. In 2023, three new strategies were implemented to improve the response rate to the public input survey. First, the links to the public input survey were disseminated using Constant Contact. This allowed the BFH to take a more active role in monitoring how many people were reached via email and clicked on the links. The second strategy was to remind current grantees and contractors receiving Title V funds that participating in feedback surveys is an expectation of their funding agreement; a question was also added to the survey to track vendor participation. Finally, the survey remained open for eight weeks in 2023. Despite these measures, the response rate was similar to that observed in previous years. Between March and May 2023, 94 responses to the survey were received, 63 from service providers and 31 from service recipients or caregivers. Statewide representation improved from last year as respondents represented all of Pennsylvania’s (Pa.) 67 counties, either as residents or by where they provided services. The questions included in the survey were predominantly open-ended and qualitative analysis consisted of categorization of text responses and subsequent identification of key themes based on the frequency with which responses in each category were identified.

 

ii. Focus Groups:

Stakeholders and service recipients were also engaged through meetings and focus groups. The BFH facilitated discussion at a virtual meeting with CYSHCN providers participating in the Leadership Education in Neurodevelopmental Disabilities (LEND) fellowship and at a site visit with adolescent health providers participating in the Leadership Education in Adolescent Health (LEAH) fellowship in April 2023. Providers were asked about emerging health needs, service gaps, and client engagement, and for feedback on the BFH’s plans for the upcoming 2025 five-year needs and capacity assessment.

 

Data resulting from these sessions contribute to understanding of the health status of MCH populations and help to inform the direction of Title V activities. Key takeaways are incorporated into the following section on health status under the corresponding population domain(s) and in the emerging issues section.

 

2. Assessment of Maternal and Child Health Status: Update

 

i.     Women/Maternal Health:

The existing Title V priority for the women/maternal health domain is reduce or improve maternal morbidity and mortality, especially where there is inequity. The most recent five-year rate available from the National Vital Statistics System suggests that there were 15.6 maternal deaths per 100,000 live births during 2017-2021 in Pa. and the rate of maternal mortality remained over three times higher among Black people (40.4) as it was among white people (13.3) in Pa. during 2017-2021. Similarly, state inpatient hospitalization data suggest that the rate of severe maternal morbidity increased again in 2020 to 89.5 delivery hospitalizations involving severe maternal morbidity per 10,000 delivery hospitalizations (up from 87.8 in 2019). The rate of morbidity remains nearly two times higher among Black people as compared to white people. As such, continued focus on this priority and the persistent racial disparity is imperative.

 

This priority and its associated strategies are linked to NPM 1, the percentage of women in Pa. who received a routine check-up or a preventive medical visit in the past year. The percentage of women who received a preventive medical visit decreased again from 74.3% in 2020 to 71.3% in 2021. Similarly, Pregnancy Risk Assessment and Monitoring System (PRAMS) data from 2021 suggest that the percentage of people with a recent live birth who received adequate prenatal care (71.9%), reached a new low in 2021. The percentage of people who received a postpartum check-up increased slightly from 87.2% in 2020 to 90.7% in 2021. Similarly, the percentage of people who received a teeth cleaning during pregnancy increased slightly from 43.9% in 2020 to 45.2% in 2021. Black birthing people remain less likely to have received adequate prenatal care or a postpartum check-up then their white counterparts. While the racial disparity in receipt of adequate prenatal care narrowed between 2020 and 2021, the disparity in receipt of a postpartum care visit widened. The newly available 2021 data suggest that birthing people have resumed routine care following the end of restrictions associated with COVID-19 but also demonstrate that inequities in care access were likely exacerbated by the pandemic and persist. Strategies that address these inequities in receipt of care and connect birthing and pregnant people to safety net preventive physical and mental health care services remain integral to the 2024 action plan.

 

Newly available data suggest that changes should be noted for several related indicators. A recently published national report suggests that maternal mortality rates significantly increased in 2021 across all age and racial groups, according to data from the NVSS. This change has been attributed to the COVID-19 pandemic. Annual data are not available at the state-level due to small numbers; however, multiyear estimates suggest that maternal mortality rates may have increased in Pa. in 2021 as well. These rates will be monitored closely, as new and provisional data become available, to assess whether the rate declines as the health impact of COVID-19 is lessened through vaccination and other treatment options. Previously published reports on maternal death in Pa. indicated that accidental poisoning, a category that includes drug-related overdose, is one of the leading causes of pregnancy-associated deaths in the state. In 2021, there was a three percent increase in overall drug overdose deaths as compared to 2020. While the impact on maternal mortality is yet to be established as the state’s Maternal Mortality Review Committee continues to review cases, continued focus on provision of adequate system-level supports for people with substance use disorder before, during, and after pregnancy is increasingly important. Approximately 16.5 per 1,000 delivery hospitalizations occurred among pregnant women with opioid use disorder in Pennsylvania in 2020. While this represents an increase from 15.5 in 2016, in recent years (2017-2020) this rate has fluctuated at or around 16.5. Associated strategies are and will continue to be encompassed within the existing strategy on preventing maternal mortality.

 

The percentage of people with a recent live birth who self-reported depression during pregnancy decreased from 17.7% in 2020 to 16.1% in 2021, per PRAMS survey data. Prevalence of self-reported postpartum depression also decreased to 11.7% in 2021, mirroring the prevalence last reported in 2019 (11.6%) and depression screening rates remain higher during postpartum visits (91.0% asked about depression per PRAMS) than prenatal care visits. Accordingly, behavioral health and depression screening and referral both before and during pregnancy also remain important and are strategies of the 2024 action plan. Finally, both NVSS and PRAMS data suggest a continued significant decline in the percentage of birthing people who smoke during pregnancy (7.3% of people smoked during pregnancy in 2021). While results from the 2023 public input survey (Table 1) further confirm a need for continued focus on access to preventive and specialty health care before, during, and after pregnancy respondents also highlighted the need for a culturally competent, unbiased workforce who can provide respectful, patient-centered care. Parental leave, access to affordable childcare, and the importance of meeting needs of families related to transportation and housing were also frequently cited in 2023

 

ii.            Infant/Perinatal Health:

The existing Title V priorities for the infant/perinatal health domain are reduce rates of infant mortality, especially where there is inequity and improve the percent of [infants] with special health care needs who receive care in a well-functioning system. The most recent available data suggest that the statewide infant mortality rate has stagnated around 5.5 deaths per 1,000 live births since 2020; preliminary estimates for 2021 and 2022 suggest minimal change (5.4 in 2021; 5.5 in 2022). However, the infant mortality rate is higher among infants born preterm and with a very low birthweight. Following a slight increase from 9.6% to 9.8% in 2021, preliminary 2022 data suggest that approximately 9.6% of infants were born preterm in Pa., consistent with prior years’ data. Additionally, the rate of infant mortality remains highest among Black/African American infants as compared to white infants. The black-white gap in infant mortality has persisted for decades and remained nearly three times higher among Black/African American infants as compared to white infants according to preliminary 2022 data (11.0 Black/African American infant deaths per 1,000 live births vs. 4.3 white infant deaths per 1,000 live births). A similar pattern is evident for preterm-related mortality, neonatal mortality, and postneonatal mortality. As such, addressing this racial disparity in infant mortality and preventing preterm birth remain important.

 

This priority and associated strategies are linked to two NPMs; NPM 4 measures the percentage of infants breastfed and NPM 5A-5C focuses on the percentage of infants experiencing safe sleep practices. Birth certificate data suggest a continued gradual increase in breastfeeding initiation. Preliminary data suggest that approximately 81% of infants were breastfed in 2022. PRAMS data indicate that the percentage of people with a recent birth who report any breastfeeding at six months remains near 50% (49.8% in 2020, 52.1% in 2021). Despite an overall increase in breastfeeding at the state-level the prevalence of breastfeeding initiation and duration remains lower among Black infants as compared to white infants. PRAMS data also suggest that continued breastfeeding remains less prevalent among young birthing people (≤19 years) and among individuals with lower income. Given the benefits of breastfeeding for birthing people and infants, and the association between breastfeeding and a potential reduction in postneonatal mortality and sudden unexpected infant death, strategies that aim to increase breastfeeding are encompassed within the existing priority that aims to reduce infant mortality.

 

Since 2016, there has been a statistically significant increase in the percentage of infants placed on a separate approved safe sleep surface (32.4% in 2016 to 42.6% in 2021). Similarly, the percentage of infants placed to sleep without soft objects or loose bedding has also significantly increased (46.1% in 2016 to 64.0% in 2021). However, differences still exist when evaluating safe sleep practices by maternal age and race/ethnicity; these practices are less common among birthing people under the age of 20 and birthing people of color. Additional work may be needed to advance the practice of placing infants on their back to sleep. While five-year estimates suggest a nominal increase in the practice, annual estimates demonstrate fluctuation around 82% and no consistent pattern since 2015.

 

The existing priorities are sufficiently broad to respond to the persistent unmet needs identified through analysis of statewide data. Respondents to the 2023 public input survey emphasized the importance of lactation support, parent/caregiver education and support, and renewed focus on meeting family needs related to childcare and transportation to promote infant health. While breastfeeding awareness activities are underway, additional strategies to better support parents and caregivers with needs identified in the 2023 public input survey (Table 2) will be considered.

 

iii.                Child Health:

The existing Title V priority for the child health domain is to reduce the rates of child mortality and injury, especially where there is inequity. The rate of hospitalization for nonfatal injury among children ages 0 through 9 has continued to decline from 152 deaths per 100,000 in 2016 to 132.5 in 2020. The rate of nonfatal injury hospitalization is highest among children less than 1 and is nearly two times higher among Black/African American children ages 0 through 9 as compared to white children. Recent data from the National Vital Statistics System suggest that the rate of mortality among children in Pa. between the ages of 1 and 9 has gradually increased from 15.1 deaths per 100,000 in 2017 to 17.9 deaths per 100,000 in 2021. Similar to the patterns apparent in hospitalization data, the child mortality rate is two times higher among younger children, between the ages of 1 and 4, as compared to the rate among children ages 5 through 9 and is also over two times higher among Black/African American children as compared to white children. The BFH remains committed to identifying additional strategies linked to the existing priority that may drive improvement in child mortality and address the disparities by age and race that persist among children for both mortality and injury hospitalizations.

 

Newly available two-year estimates from the National Survey of Children’s Health (NSCH), indicate that there was minimal change in the prevalence of physical activity or tooth decay. Approximately 31% of children ages 6 through 11 were physically active at least 60 minutes per day during 2018-2019 and 2020-2021 and the percentage of children ages 1-17 who had tooth decay or a cavity in the past year remained at 10% during both 2018-2019 and 2020-2021.

 

Data from 2020-2021 suggest a slight increase in the percentage of children reported to be in excellent or very good health (88.8% during 2018-2019 to 90.2% during 2020-2021). Additionally, a significant decrease in the prevalence of children ages 6 to 11 who were bullied at least once in the past 12 months was observed; the prevalence decreased from 32.0% during 2018-2019 to 29.0% during 2020-2021. However, bullying remains more common among children ages 6 to 11 than among youth ages 12 to 17. Data from 2020-2021 and national trends indicate that resumption of routine care, such as vaccination and preventive physical health and dental visits, continues to be slow following disruptions caused by the COVID-19 pandemic. For example, only three of every four children in Pa. received a preventive medical or dental visit during 2020-2021, per the NSCH. The need for access to preventive health care and resumption of routine care were again highlighted in responses from the 2023 public input survey (Table 3). The BFH will continue to coordinate with partners, such as the Bureau of Community Health Systems and the Bureau of Health Promotion and Risk Reduction, to boost Title V’s capacity to support the provision of direct, safety net services for children.

 

Data from the public input survey (Table 3) also reaffirm the continued importance of the existing priority to improve the mental, behavioral, and developmental health of children with and without special health care needs and suggest that supporting parents and caregivers with child mental health and providing education on child wellness to inform care decision-making may be warranted. Identification of additional related strategies will be ongoing in 2024.

 

iv.      Adolescent Health:

The existing Title V priorities for the adolescent health domain are to reduce rates of mortality and injury (especially where there is inequity), improve mental health, behavioral health, and developmental outcomes, and support and effect change at the organizational and system level by supporting policies, programs, and actions that advance health equity. The adolescent mortality rate increased again from 33.3 deaths per 100,000 in 2020 to 37.0, the highest rate of mortality among youth aged 10 to 19 since 2010 when it was 34.0. Three-year estimates (2019-2021) suggest that the mortality rate was twice as high among youth aged 15 to 19 (44.8 deaths per 100,000) as compared to youth aged 10 to 14 (20.3 deaths per 100,000). The mortality rate remains over two times higher among Black/African American adolescents as compared to white adolescents. While the overall mortality rate increased, a decrease was observed in the rate of adolescent deaths attributed to motor vehicles (8.0 deaths per 100,000 during 2019-2021 compared to 8.2 during 2016-2018) and in the suicide rate (8.4 suicides per 100,000 during 2019-2021 compared to 9.7 during 2016-2018). However, new data from the Youth Risk Behavior Surveillance System demonstrate a significant increase in the prevalence of high school aged youth who self‑reported depression (34.5% in 2019 to 43.7% in 2021) or suicidal ideation (17.2% in 2019 to 18.1% in 2021).

 

Notably, the rate of nonfatal injury hospitalizations among youth ages 10 to 19 also increased significantly from 204.7 hospitalizations per 100,000 children in 2019 to 226.4 in 2020, the first observed increase in five years. The percentage of adolescents who are active for at least 60 minutes per day on five or more days weekly significantly decreased from 48.1% in 2019 to 41.7% in 2021. Given the relationship between mental and physical health, several existing strategies linked to the mental health priority aim to build protective factors among youth (i.e., access to a mentor) while also promoting physical and mental/behavioral health.

 

Given the observed increase in adolescent mortality rates, persistent mental health challenges among youth, and disparities by race, the aforementioned priorities and associated strategies that aim to promote development of protective factors among youth remain an essential component of the Title V action plan, especially for improving adolescent mental health. Adolescent health service providers engaged during the LEAH site visit also highlighted the continued importance of mental health services and indicated that the lack of youth-serving providers is a significant challenge. Providers also emphasized the need for adults in the lives of youth, including parents and teachers, trained in mental health first aid and knowledgeable about how to talk to those youth when they need support. Other emerging issues identified by the LEAH fellows were access to birth control and reproductive healthcare, access to youth-oriented resources such as treatment for substance use disorder, and the impact of gun violence on youth mental and physical health. Responses from the public input survey (Table 4) align with the fellows’ observations regarding the importance of addressing mental and behavioral health needs among adolescents, facilitating access to routine healthcare, and ensuring that youth have non-clinical social support outside of their family unit.

 

v.                  Health of CSHCN:

The existing priorities for the CSHCN domain are improve the mental health, behavioral health, and developmental outcomes of CSHCN and improve the percentage of CSHCN, including infants, who receive care in a well-functioning system. In Pa., CSHCN are twice as likely to be bullied as compared to children who do not have a special health care need. As of 2020-2021, 48.2% of CSHCN aged 12 to 17 experienced bullying in the past 12 months as compared to 20.5% of children without special health care needs. The prevalence of experiencing two or more adverse childhood experiences also remains higher among CSHCN in Pa. as of 2020-2021 (29.0% among CSHCN; 11.2% among children without special health care needs).

 

The percentage of CSHCN who receive care in a well-functioning system in Pa. decreased slightly from 21.6% in 2018-2019 to 18.0% in 2020-2021. Given that less than a quarter of all CSHCN in the state receive such care, this remains an important priority that encompasses various factors at the system-level. As of 2020-2021, the percentage of CSHCN receiving care in a well-functioning system is lowest among CSHCN aged 12 to 17 (6.4%) as compared to CSHCN aged 6 to 11 (26.5%) or 0 to 5 (34.6%). Upon reviewing the well-functioning system’s component parts, the areas where improvements are most needed are still access to a medical home and transition services. The percentage of CSHCN aged 12 to 17 receiving preparation for adult transition increased slightly to 29.5% during 2020-2021 and the percentage of CSHCN aged 0 through 17 in Pa. with a medical home also nominally increased from 44.5% during 2018-2019 to 45.6% during 2020-2021. However, the proportion of CSHCN with a medical home in Pa. has remained at less than 50% for years.

 

The existing priorities around mental health, developmental outcomes, and well-functioning system are sufficiently broad to encompass strategies related to bullying, trauma, and care coordination. In 2021 and 2022, the BFH started assessing gaps in care and services related to these topic areas. Results from surveys and family/youth focus groups conducted in 2022 informed the identification of new strategies on bullying and safe relationships among CSHCN which are currently under development.

 

The newly available 2020-2021 data from NSCH also suggest change in several CSHCN indicators. The percentage of CSHCN ages 0 through 17 who are continuously and adequately insured decreased slightly from 72.1% during 2018-2019 to 68.5% during 2020-2021. Several other apparent changes include a decrease in the percentage of CSHCN ages 6-17 who were physically active for at least 60 minutes daily (24.8% during 2018-2019 compared to 20.5% during 2020-2021). Conversely, the percentage of CSHCN ages 1 through 17 who had decayed teeth or cavities in the past year decreased from 15.1% during 2018-2019 to 11.4% during 2020-2021. Physical inactivity and the prevalence of tooth decay/cavities also remain higher among CSHCN as compared to children without special health care needs.

 

LEND fellows engaged during the April site visit further emphasized how continuity of care, education, and opportunities for socialization and recreation among CSHCN were interrupted by the COVID-19 pandemic. While the fellows suggested that some families are working to reengage with services and social opportunities, this process has been slow, and some programs or services are no longer offered or have been restricted. These changes have had impacts on receipt of health care services among CYSHCN, mental well-being, development, and social life. Many of these needs including increased support for families of CSHCN in the education system and improved care coordination were also identified by respondents to the 2023 Public Input Survey (Table 5). Another challenge identified again this year was the continued in-home nursing care shortage. Associated strategies that work to improve care coordination and navigation can be encompassed within the existing well-functioning system priority. The BFH will continue to partner with sister agencies such as the Departments of Human Services and Education to identify opportunities to support families of CSHCN in navigating related services.

 

Given that infants are now included in the definition of CSHCN, the BFH is in the process of evaluating its existing services for infants with special health care needs and identifying gaps. One potential change that should be noted for infants with special health care needs is the rate of infants born with neonatal abstinence syndrome (NAS) per 1,000 live births. As of 2020, there were 14.0 NAS cases per 1,000 live births, an increase from 11.9 cases per 1,000 live births in 2019. Rates of NAS continue to vary markedly across the state with the highest rates observed in the northwestern region. Strategies that support infants born with NAS are linked to the well-functioning system priority.

 

Responses from the public input survey (Table 6) suggest that as the BFH continues to support a well-functioning system of care for CSCHN, including infants, additional focus on care navigation, non-clinical support for parents/caregivers, and coordination with Early Intervention to ensure early identification and referral of infants with special health care needs to available services may be needed.

 

3. Capacity Assessment

 

i. Changes in Organizational Structure and Leadership:

There have been several changes in the leadership of the Department of Health over the past year, with a change in administration effective January 2023. In January 2023, Dr. Debra Bogen was named the new Acting Secretary of Health, taking over the role from Dr. Denise A. Johnson. Dr. Bogen is a pediatrician and previously was a director for a county health department in Pa. The BFH’s Director (Tara Trego), Division Directors (Erin McCarty, Cindy Dundas, Kathy Jo Stence, and Jennifer Bixler), Title V Block Grant Coordinator and Manager (Morgan Williams-Fake and TaWonda Jones Williams) and MCH epidemiology staff (Nhiem Luong and Caryn Decker) continue to lead the planning, evaluation, and data analysis required to administer the Title V program.

 

ii. Title V Program Capacity:

The capacity of the Title V program to serve the MCH populations in Pa. remains robust due to its continued implementation of strategies and programs that support essential public health services and systems. Changes in program capacity for each domain, including CSHCN, are described further in the state action plan narrative by domain for the application year.

 

A component of program capacity is the tenure and experience of BFH staff supporting Title V. According to a recent workforce capacity survey conducted in 2023, approximately 36% of BFH staff have been in their current positions for less than three years. This percentage is lower than last year (47%), suggesting minimal turnover in the past 12 months. Among staff with a short tenure, most were program staff but there has been some change at the management level as well. Additionally, the percentage of BFH staff who report at least three years of public health experience continued to increase to 92% in 2023 (up from 84% in 2022, 82% in 2021, and 70% in 2020). Improved retention provides the program with continuity and a workforce that is increasingly experienced in public health is an asset. Additionally, the combination of seasoned management staff and new program staff remains a strength of the Title V program as it seeks to continually adapt to new perspectives and the ever-evolving MCH evidence base.

 

iii. Title V Program Partnerships, Collaboration, and Coordination:

See pp. 16-25 of the Needs Assessment Update in Supporting Documents.

 

iv. Preparation for Five-Year Needs and Capacity Assessment

Beginning in 2022, the BFH initiated an internal project to evaluate progress on current priorities and assess existing strategies with a health equity lens. As part of this project, the BFH developed a supplemental fact sheet which further clarifies the 2021-2025 priorities and sets the stage for a renewed focus on and commitment to health equity in the coming funding cycle.

 

Since the end of the current five-year funding cycle is approaching, the BFH has been actively preparing for the upcoming 2025 Title V Five-Year Needs and Capacity Assessment (5YNCA). To date, the BFH has developed a plan and timeline, convened an internal steering committee, and started raising awareness about the upcoming assessment through presentations at partner and stakeholder meetings. Epidemiology staff are also in the process of performing in-depth analyses of the NOMs, NPMs, and other key indicators, to identify specific inequities that could be addressed by Title V and to develop an initial priority list. For more information on BFH’s 5YNCA and anticipated activities, please see the overview and timeline.

 

v. Capacity to Address Emerging Issues

A common emerging need across population domains was the importance of meeting basic family needs such as transportation, housing, food security, and enhancing social support networks for families. While the Title V program does not have the capacity to resolve all of these systemic challenges, the BFH will continue to consider how it can best promote system and policy change to address the social determinants of health in collaboration with its agency and community-based partners. As the BFH prepares for its comprehensive five‑year needs assessment in 2025, it will also continue to assess its existing capacity and how that capacity might need built upon or enhanced to best meet the dynamic needs of the MCH populations.