Needs Assessment Update

The District of Columbia (DC) Department of Health (DC Health) conducted the DC Title V Needs Assessment from February 2019 to March 2020, assessing the needs and strengths of its MCH population and infrastructure. The purpose of the Needs Assessment was to: 1) better understand the current health status of the District’s MCH populations; 2) ascertain current MCH needs through qualitative and quantitative methods; and 3) utilize the findings and Title V National Performance Measure System to identify top District priorities and determine the allocation of resources and strategies that would improve the health and wellbeing of each of the District's five MCH population health domains -women, infants, children, including children with special health care needs, and adolescents. Using a mixed methods approach (qualitative/quantitative), the capacity, accessibility, and quality of delivery of services for DC’s MCH populations was assessed. DC Title V received ongoing stakeholder feedback through both formal and informal channels. At the beginning of the needs assessment, the team engaged the MCH Advisory Council, comprised of representatives from government agencies, consumers and health care, and community-based organizations. Council members participated in key informant interviews where they provided input on unmet needs, systematic factors impacting the District’s MCH population, and positive protective factors that strengthened their health. The team also conducted a community Discovery Survey to collect the public’s perspective on MCH topics and a focus group with the Youth Advisory Council to solicit input and gain insight from middle and high school student representatives.

Partnerships and collaborations

The findings from the Needs Assessment highlight the importance of continuing collaborations and coordination with agencies that improve outcomes within the MCH population. The Title V team engages with internal and external stakeholders representing the various MCH population domains through various committees, and working groups highlighted throughout this application. Title V, through its partnership with the Office of the State Superintendent (OSSE) Division of Early Learning (DEL), works to implement the Strong Start Early Intervention Program (Strong Start). This statewide, comprehensive, coordinated, multidisciplinary system provides early intervention therapeutic and other services for children ages 0-5 with disabilities and developmental delays and their families. Title V additionally partners with the DC Help Me Grow (HMG) program. HMG provides services to District residents through a comprehensive and integrated system designed to address the need for early identification of children at risk for developmental and/or behavioral problems and to prenatal women. Title V funded the Office of Human Rights (OHR) to develop and complete a curriculum (El Camino Program) targeting bullying and help middle school students learn how to use technology and social media in a healthy and supportive way. DC Health’s Community Health Administration (CHA) actively participates with several District-wide MCH collaborative groups, including the State Early Childhood Development and Coordinating Council, Child Fatality Review Committee (CFRC) and Infant Mortality Review subcommittee, Department of Health Care Finance Perinatal Quality Improvement Collaborative, the Thrive by Five Coordinating Council, DC Home Visitation Council, DC Food Policy Council, CSHCN Advisory Council, Maternal Mortality Review Committee and the D.C. Healthy Communities Collaborative, among others.

Changes in the Health Status and Needs of MCH Population

Key findings resulting from the needs assessment highlighted the following priority areas: well-woman visits, breastfeeding; reducing perinatal disparities; mental health including grief and trauma-informed care; implicit bias/discrimination; positive youth development; early childhood developmental screening; medical home identification/place-based care; and addressing social and economic needs. The findings point to persistent health disparities by race/ethnicity, immigration documentation status, and socio-economic status. Furthermore, these findings emphasize the need to address social determinants of health such as housing, education, violence, and discrimination/implicit bias, among the top factors identified by community members as the biggest unmet needs of District women, children, and families. Factors identified through the Discovery Survey as positively influencing families to thrive within the District community were community support activities, access to public spaces, a safe environment, food access, social support, community-based services, public transportation, and quality education. As the unprecedented Covid-19 pandemic unfolded in 2020, during the 5-Year MCH Needs Assessment submission year, the impact of the public health emergency and the potential to exacerbate already identified MCH issues was included in the Needs Assessment Summary.

Women/Maternal Health

Women comprise the majority of the District’s population (52.48%), with more than a quarter being of reproductive age (15 – 44). The racial demographic of women in the District shows that 47% identify as Black or African American, 40% as White and 11% as Hispanic. In 2020, the first year of the COVID-19 pandemic, the top three leading causes of death among DC residents were heart disease, cancer, and COVID-19. Disparities in health for different age and racial/ethnic groups continue to exist despite high insurance rates (96.7%) for the maternal health population, which exceeds the national average (92.1%). Nearly 20% of women have income below the federal poverty level, with the highest concentration living in neighborhoods in Wards 7 (Twining, Stadium-Armory) and Ward 8 (Douglass and St. Elizabeth’s), followed by some neighborhoods in Wards 2, 5, and 6. The District’s priorities for Women’s/Maternal Health include addressing: well-woman visits, prenatal care, mental health, social and economic needs, and implicit bias/discrimination. Establishing a holistic form of care and a safe space to thrive is crucial.

Preventative Care Utilization: In 2020, the DC Behavioral Risk Factor Surveillance System (BRFSS) data showed that 79.2% of women ages 21-65 had a pap test in the past three years, a decrease compared to 81.3 % in 2018. There is a difference across race /ethnicity in utilization of care, and there are also clear disparities among wards among adult females who did not have a pap test within the past three years. Early initiation into prenatal care can reduce the risk of preterm births, low-birthweight babies, and overall improve birth outcomes. In the District, 86% of non-Hispanic white mothers, 53% of non-Hispanic Black others, 69.4% of Hispanic mothers, and 81.1% of non-Hispanic Asian/Pacific Islander mothers initiated prenatal care during their first trimester. Women across wards 7 and 8 have lower rates of first-trimester prenatal care initiation, ranging from 44.16% to 64.18%.

Chronic Disease Burden: In the 2020 BRFSS report, 29.1% of women in the District reported being obese. There are also clear racial disparities in adults who were classified as obese across the District: Black or African American residents reported being more likely to be obese (39.6%) compared to 20.8% for Hispanic and 11.5% for White residents. Wards 8 and 7 had the highest percentage of adult residents who were obese, 49.1% and 40.5%, respectively. The percentage of overweight or obese mothers prior to pregnancy for all births in the District was about half (46.8%). The highest percentage of overweight or obese pre-pregnancy weight was among non-Hispanic Black mothers (60.8%), which was significantly higher than non-Hispanic white mothers (27.2%) and Hispanic mothers (54.9%).

Substance Abuse: CDC data for 2020 revealed that 5.5% of pregnant women reported smoking at any time during pregnancy. The percentage of mothers who smoked cigarettes at any point during pregnancy decreased from 2016 to 2021, from 7.2% to 4.6%. The percentage of mothers who smoked during pregnancy declined across all maternal age groups between 2016 and 2021. According to 2020 BFRSS data, higher rates of tobacco use were reported among non-Hispanic Black (19.3% currently smoke) compared to non-Hispanic White (6.1%). Wards 7 and 8 had the highest percentage of adult residents who reported being current smokers. BRFSS also reported a slight decrease in the number of women in the District who binge drink in 2020 (20.8%) compared to in 2019 (22%), however, it is significantly higher than the national average (16%). Wards 2 had the highest percentage of adult residents who reported being binge drinkers.

Perinatal and Infant Health

Infant Mortality Rate (IMR): Infant Mortality Rate (IMR): The DC infant mortality rate has decreased by about half from 7.4 per 1,000 live births in 2011 to 4.5 per 1,000 live births in 2020. The average DC IMR from 2016 to 2020 was 6.4 per 1,000 live births. However, there has been a more significant decline in infant mortality in the last couple of years (2019 and 2020), with an IMR of 4.7 per 1,000 live births. The IMR is now below the DC Healthy People 2020 target of 6.0 per 1,000 live births. The ratio comparing infants of non-Hispanic white mothers and Hispanic mothers was 2.6 in 2020.

Preterm Births: The percentage of preterm births among all DC resident live births decreased significantly between 2011 and 2020, from 11.1% to 9.8%. The percentage of preterm births by maternal race and ethnicity varied from 2011 to 2020. In 2020, non-Hispanic Black mothers had higher levels of preterm births (12.4%) than non-Hispanic white mothers (7.0%) and Hispanic mothers (9.6%). The percentage of preterm births decreased between 2011 and 2020 in all wards, excluding wards 3 and 7. Wards 1 and 5 experienced the most significant decreases in preterm birth percentages between 2011 and 2020. Ward 8 had the highest percentage of preterm birth (13.8%), significantly higher than the percentage in all other wards except for Ward 7 (13.4%).

Breastfeeding: The 2020 Breastfeeding Report Card reports that 88.0% of infants in DC were initially breastfed. Duration of breastfeeding reduced as the infant's age increased, with 64.7% of women breastfeeding at six months and 39.3% at 12 months. From 2011- 2015, about 96% of White infants in DC were breastfed at birth versus 65% of Black infants.

Child Health

Developmental Delays: According to the American Community 5-Year Survey, 20.4% of children in the District under the age of 6 are living below the poverty level. 22.8% of all children in the District lived below the poverty level between 2017 and 2021.  A significant portion of infants and toddlers in DC live in low-income households (21.4% live less than 100% Federal Poverty Line (FPL), and 16.5% live 100-200% of FPL), a known risk for developmental delays. To ensure children have early and appropriate access to services, the American Academy of Pediatrics recommends that all children aged 9, 18, and 30 months receive a developmental and behavioral screening during their well-child visit. However, only approximately 32.2% of children in the District between 9 – 35 months were reported to have received a developmental screening using a parent-completed screening tool. Given that multiple points of access can serve as the opportunity to screen children for developmental delays (e.g., DC Early Intervention Program/Strong Start led by OSSE for children 0-3 and the DC Early Intervention Program led by DCPS for children three years and older), the developmental screening rate may be underreported. DC Health Title V team, along with its partners, continue to work on promoting efforts to create and implement the use of a centralized database (i.e., Ages and Stages Questionnaire (ASQ) Hub) for developmental screening to reduce the duplication of services and connect families to timely and appropriate services should continue.

Health Services:   According to the 2021 National Survey of Children’s Health, 17% of children aged 0 through 17 in the District had no preventive care visits in the past 12 months. 17.7% of Hispanic children received no preventive care visits in the last 12 months, 6.4% of white non-Hispanic children, and 22.9% of Black children had no preventive care visits in the past 12 months.

Obesity:  Between 2020 and 2021, 17.3% of DC children aged 10 through 17 were considered obese, which mirrors the national average (17.0%). This rate is a significant increase from 2019-2020 (14.2%).

Oral Health:   Between 2020 and 2021, 80.3% of children in the District ages 1 through 17 had one or more preventive dental care visits in the past 12 months. This is higher than the national rate (75.1%). In DC, 82% of Hispanic children, 79.4% of white non-Hispanic children, and 81.8% of Black children ages 1 through 17 had one or more preventive dental care visits in the past 12 months. Efforts must ensure that resources are equitably distributed to allow access to affordable dental care, particularly for Medicaid-eligible and under 2 years old.

Children with Special Health Care Needs

There is a shortage in the availability of data illustrating the needs and challenges of CSHCN in the District. However, access to rich qualitative data from partners in the field has allowed for an assessment of this population. In the 2020-2021 National Survey of Children’s Health, 18.3% of families in DC reported their child has a special health care need, and therefore, is vital to provide support for this population. Based on the report from the 2020-2021 National Survey of Children's Health,  18.2% of children with special health care needs, ages 0 through 17 do not have a medical home or the care does not meet medical home criteria. The District’s priorities for the CSHCN population include Medical Home and Transition.

Care Coordination:  The District of Columbia has a first-of-its-kind health system - Health Care System (HSC). This nonprofit healthcare organization is committed to serving people with complex healthcare needs and eliminating barriers to health services by providing the resources of a health plan, a pediatric specialty hospital, a home health agency, rehabilitative therapy centers, and parent foundation assistance. The District offers a Medicaid health plan for CSHCN through Health Services for Children with Special Needs, Inc. (HSCSN). HSCSN serves children and young adults up to age 26 who live in Washington, D.C., and receive SSI. A care manager helps ensure an individual or their child gets the care or services a physician prescribes. A healthcare system professional stated that additional work is required to increase the quality of services throughout the entire continuum of care. This includes helping CSHCN integrate back into their communities and allowing CSHCN to practice skills learned in speech therapy, developmental therapy, etc. to engage in social interactions, participate in physical activity, and live more independent lives. Despite the District’s improvements in expanding access to care, CSHCN continues to face challenges in accessing community-support services. According to the 2020-2021 National Survey of Children’s Health, among children who needed effective care coordination, 31.2% did not receive it.

Adverse Childhood Experiences: CSHCN may be at an increased risk of experiencing adverse childhood experiences (ACEs), which include witnessing violence towards a parent/guardian, experiencing violence themselves, living with someone who suffered from poor mental health, and more. Approximately 32.4% of CSHCN in DC were reported to have two or more ACEs, almost half the rate of children with no special health care needs (67.7%). Nationwide,37.0% CSHCN are reported to have two or more ACEs, and 63.0% of non-CSHCN are reported to have two or more ACEs. CSHCN are also at an increased risk for experiencing bullying, with 48.0% of CSHCN between ages 12-17 reporting a higher rate of experiencing bullying compared to 20.7% of children without a SHCN.

Adolescent Health

Sexual Health: In 2019, 44% of high school students in the District reported ever having sex, with 7.9% of youth engaging before age 13, a decrease from 2017(45.6% and 8.9%, respectively). Approximately one-quarter of currently sexually active students (20.8%) reported not using any method to prevent pregnancy, and 72.4% of the students reported that they had not been tested for a sexually transmitted disease. Teen birth rates have decreased steadily over the years, with the current rate at 19.3 in 2020, a decrease from the rate in 2019 at 21.0 per 1,000 females ages 15 to 19. However, the DC birth rate for mothers aged 15-19 is still higher than the national average.

In 2021, 28.5% of high school students in the District reported ever having sex, with 5.3% of youth engaging before age 13, a decrease from 2019 (7.9%). 9.8% of DC high school students reported being tested for an STD other than HIV, showing a significant decrease compared to 2019 (27.6%).

Obesity and Nutrition: The 2019 Youth Risk Behavior Surveillance System (YRBSS) reported 17.1% of high school respondents were obese and 17.6% were overweight. 28.4% of District high school students do not engage in recommended physical activity, with the female rates (32.4%) higher than the males (24%). DC was ranked 4th in the country for households with children experiencing food hardship (23.3%) by the Food Research and Action Center between 2016-2017.

The 2021 YRBSS reported that 16.3% of students in high school had obesity, and 16% of high school students were overweight. 32.2% of high school students in the District were physically active for 60 minutes per day on five or more days. 19.2% of female high school students were not physically active for at least 60 minutes on at least one day, which was higher than the rate for male high school students (12.4%).

Unintentional Injuries and Violence: About 20% of high school students reported riding in a car with a driver who had been drinking in 2019. Over a quarter of high school students (28.7%) were in a physical fight, with 14.1% reporting being in a physical fight on school property. 9.4% of the students were threatened or injured with weapons, such as a gun, knife, or club, one or more times on school property, and nearly 16% of high school students have reported carrying a weapon. 10% of students experienced physical dating violence, and almost fifteen percent of high school students attempted suicide at least once. In 2013, DC ranked 13th (8.9 per 100,000) among states for the rate of firearm deaths, decreasing to 26th (13.1 per 100,000) by 2017.

14% of high school students nationwide reported riding in a car with a driver who had been drinking in 2021. This number is consistent with the rate for the District. 4.7% of DC high school students have reported driving after drinking. In 2021, 18.3% of high school students had been in a physical fight, and 5.8% of students had been in a physical fight on school property. 6.6% of students nationwide were threatened or injured with a weapon on school property, and 3.1% of high school students reported carrying a weapon on school property. 9.7% of high school students experienced physical dating violence, with 15% of female students and 4% of male students experiencing dating violence. In 2021, 10.2% of students attempted suicide at least once.

Substance Abuse: In 2019, 13% of high school students used electronic vapor products, an increase from 10.9% in 2017. 29.2% of students reported current marijuana use. High school students in 2019 reported lower rates of “current alcohol use” and “lifetime cocaine use” (20.2% and 5.8%, respectively) than in 2017 (20.5%and 7.4%, respectively). However, higher initiation rates of alcohol use (17.8%) were reported compared to 16.1%in 2017.

Emerging Issues – Maternal Health

In the U.S., every year since 2012, syphilis cases have increased; there has been a 30% increase in all cases of syphilis infection in recent years.[1] Nationwide in 2018, there were 1,306 cases of congenital syphilis, 78 syphilis stillbirths, and 16 infant deaths, representing over 10 to 20 times increase in congenital syphilis since 2014. [2] This increase mirrors the increases seen among women in the District and nationwide experiencing heightened rates of primary and secondary syphilis. There have been significant increases in perinatal syphilis cases. It is important to note that a pregnant woman can transmit syphilis to her child at any stage of pregnancy and at any stage of syphilis. However, the risk for transmission is higher if the mother has been recently infected. In the last ten years, congenital syphilis in the US has increased eightfold. In 2019, the District of Columbia saw a sizable increase in early syphilis diagnoses, specifically among women of reproductive age. There are significant disparities in the rates of reported STDs, including syphilis. For example, 50.5% of reported cases of STDs were among adolescents and young adults.  disparities may reflect inequities in access to quality health care and differences in sexual network characteristics. In 2018, DC had the sixth highest rates of primary and secondary syphilis cases [3] Testing for STDs should be administered at the first prenatal visit or as early as possible in the pregnancy and in the third trimester. DC Health also recommends testing at delivery, particularly for high-risk patients who may not have a documented test or have not received prenatal care. DC Health and the Title V team will continue to utilize our strong partnerships to increase education and improve outcomes in the District.

Changes in Program Capacity or MCH Systems of Care/Organizational Structure

The District of Columbia is governed by the Mayor, who has the sole authority and responsibility for the daily administration of the District government. Within the Office of the Mayor, there are four Deputy Mayors representing various public sectors. The Deputy Mayor for Health and Human Services is a liaison between the Executive Office of the Mayor and the Health and Human service cluster, including the Department of Health (DC Health). DC Health has six administrations, including the Community Health Administration (CHA). CHA is responsible for administering the Title V grant.

Within CHA, the Deputy Director for Strategy, Programs and Policy Family Health Bureau Chief serves as the Title V MCH State Director.  The Family Health Bureau Chief, Title V Program Manager (vacant), and Title V team collaborates with the Title V MCH State Director to oversee Title V program activities and MCH collaboration throughout the Community Health Administration.  The Title V MCH director is responsible for the strategic direction of the program, while the Title V Program Manager (vacant) and team oversee the programmatic activities for the Title V grantees and MCH-related projects within CHA. The Grants and Budget Monitoring Unit within the Office of the Deputy Director for Operations provides grant support through fiscal monitoring of contracts and grant awards. All bureaus within CHA: Nutrition and Physical Fitness Bureau, Family Health Bureau, Cancer and Chronic Disease Prevention Bureau, and Health Care Access collaborate to facilitate Title V MCH programming to DC residents.

In FY23, the Mayor appointed an Acting Director of the Department of Health (DC Health), Dr. Ayanna Bennett. Dr. Bennett is a healthcare and public health executive with over 20 years of experience in clinical practice, clinical service design, system integration, and quality improvement. Dr. Bennett most recently served as Chief Health Equity Officer and Director of the San Francisco Department of Public Health’s Office of Health Equity, where she focused on quality improvements and sustaining systemic change through policy improvement. Please see [APPENDIX] for the organizational chart.

Agency Capacity

DC Health's capacity to promote and protect the health of the District’s maternal and child population is evidenced in its policies, programs, grants, and collaborations with government, health systems, and community-based organizations. The Community Health Administration (CHA) of the District of Columbia Department of Health promotes healthy behaviors and healthy environments to improve health outcomes and reduce disparities in the District's leading causes of mortality and morbidity. CHA focuses on nutrition and physical fitness promotion; cancer and chronic disease prevention, and control; access to quality health care services, particularly medical and dental homes; and the health of families across the lifespan and is organized into four respective bureaus: Nutrition and Physical Fitness Bureau, Cancer and Chronic Disease Prevention Bureau, Health Care Access Bureau, and the Family Health Bureau (see Supporting Document #1 for Office & Bureau descriptions). Each bureau addresses at least one of the six population health domains. CHA’s approach targets the behavioral, clinical, and social determinants of health through evidence-based programs, policy, and systems change.

MCH Workforce Capacity

The District of Columbia Title V staff includes 37 full-time equivalent staff. Senior level management includes Robin Diggs Perdue, Interim Senior Deputy Director, Community Health Administration and DC Title V State Director; ; Kafui Doe, EdD, MPH, Family Health Bureau Chief; Perinatal and Infant Division Chief (Vacant); Lori Garibay, MPH Child, Adolescent & School Health Division Chief; and Ifedolapo A. Bamikole, JD, MPH, Early Childhood Health Division Chief.

The MCH workforce has strong medical, public health, program planning, and evaluation capabilities and a core cohort of staff with several years of MCH experience. CHA anticipates expanding the MCH workforce capacity by supporting the MCH leadership development of mid-level managers for retention and transition into senior-level roles. In FY22, the Title V program hired two new additions to the Title V team (Lawryn Fowler, Public Health Analyst, and Chrycka Harper, Data Analyst) in addition to Simileoluwa Ekundayo, who was hired in FY21 as the Title V Data Analyst. Lashawn Robinson, Program Specialist, has been appointed State Youth Representative for the Title V program. Additionally, Ifedolapo Bamikole, the Early Childhood Health Division Chief, was appointed State Family Representative for the Title V program. Other Title V staff are embedded throughout CHA Bureaus and work on a variety of MCH programs referenced in this report.

Title V Program Partnerships, Collaborations, and Coordination

The DC Title V program partners with other District agencies to implement important MCH work. Title V, through its partnership with the Office of the State Superintendent (OSSE) Division of Early Learning (DEL), works to implement the Strong Start Early Intervention Program (Strong Start). This statewide, comprehensive, coordinated, multidisciplinary system provides early intervention therapeutic and other services for infants and toddlers with disabilities and developmental delays and their families. Title V and OSSE DEL also partner with DC Help Me Grow (HMG) program. CHA actively participates with several District-wide MCH collaborative groups, including the State Early Childhood Development and Coordinating Council, Child Fatality Review Committee (CFRC) and Infant Mortality Review Subcommittee, the DC Committee of Health Care Finance Perinatal Quality Improvement Collaborative, the Thrive by Five Coordinating Council, DC Home Visitation Council, DC Food Policy Council, CSHCN Advisory Council, Maternal Mortality Review Committee and the D.C. Healthy Communities Collaborative, among others.

Identifying Priority Needs and Linking to Performance Measures

DC Health has worked in partnership with communities, families, stakeholders, and public health professionals to better understand the needs of women, children, and families living in Washington, D.C. DC Health is continuing to focus on the nine priority areas and 11 NPMs from the previous report in addition to revised SPMs.

[1] https://dchealth.dc.gov/sites/default/files/dc/sites/doh/page_content/attachments/Health%20Notice%20-%20Syphilis.pdf

[2] https://www.pbs.org/newshour/show/u-s-sees-concerning-rise-in-stis-congenital-syphilis-with-no-signs-of-slowing

[3] Ibid