Needs Assessment Update

 

The Office of MCH Epidemiology (MCH EPI) is responsible for conducting needs assessment activities for Nebraska’s Title V Block Grant and MCH (Maternal and Child Health) populations. To that end they employ myriad activities to engage stakeholders, establish partnerships, monitor health, measure performance, and evaluate projects and programs. These activities include ongoing surveillance of births, health status, mortality, and social determinants of health.

 

Below is information regarding assessment updates and changes in Nebraska’s priority needs and health status along with various activities that MCH EPI have participated in or conducted. Assessment activities are largely driven by workforce capacity, stakeholder input and programmatic needs in a given year.

 

Women/Maternal Health Domain

   CVD Including Diabetes, Obesity, and Hypertension

Obesity is associated with serious health risks, including hypertension and diabetes. The Nebraska Behavioral Risk Factor Surveillance System (BRFSS) reports obesity at 33.3% for women over 18 years of age and a combined overweight obesity rate of 64% for 2020.  Further, the BRFSS reports that 31.1% of women have been told they have high blood pressure, 7.5% have been told they are pre-diabetic, and 9.3% have been told they have diabetes. The prevalence of each indicator increases with age, and there are disparities by race/ethnicity, income, and geography. These indicators have all increased since the 2020 Needs Assessment.

 

In 2021, the Office of MCH EPI conducted descriptive analysis of preterm birth to inform the Nebraska Perinatal Quality Improvement Collaborative’s review and recommendation process. The analysis highlighted the impact of CVD on preterm birth (more information below).

 

Perinatal/Infant Health Domain

   Premature Birth

 

In 2020, the Office of MCH EPI conducted descriptive analysis of preterm birth using birth certificate and Nebraska Pregnancy Risk Assessment Monitoring System (PRAMS) data to inform the Nebraska Perinatal Quality Improvement Collaborative’s review and recommendation process.  From 2015 through 2019, the overall preterm birth rate in Nebraska was 10.5%; the preterm rate for singleton births was 8.3%. Several chronic-disease-related risk factors were related to higher rates of preterm birth including maternal smoking, maternal obesity, pre-pregnancy diabetes, and pre-pregnancy hypertension. Also related to higher rates of preterm birth were previous preterm birth, young or advanced maternal age, use of fertility treatment, and relatively low maternal education.  A long-term approach should be implemented to address pre-pregnancy chronic disease to improve maternal health and reduce risk of preterm birth. In 2021, this effort concluded with a recommendation to address maternal tobacco use. MCH EPI worked with partners to publish “Call to Action: Improve Future Pregnancy Outcomes by Screening for Tobacco Use Now” in the Nebraska Medical Association Newsletter.

Data from the Nebraska PRAMS indicates that Nebraska parents have received the “back to sleep” message; in 2020 88.5% of respondents were placing infants in the supine position for sleep, this is an increase from 87% in 2017. Nonetheless, as the incidence of Sudden Unexplained Infant Death (SUID) in both the United States and Nebraska has decreased, the number of infants dying from accidental suffocation and strangulation in bed (ASSB) and other sleep-associated causes has steadily increased. Nebraska PRAMS data also indicates a slight decrease in parent/child sleep surface sharing, with 21.4% of respondents indicating sleep surface sharing in 2020 as compared to 23.7% in 2017.

 

Nebraska PRAMS updated the provider factsheets in 2020 and published social media posts for partners and stakeholders to share (https://dhhs.ne.gov/PRAMSDocuments/SafeSleepSocialMediaPosts.pdf).

 

Child Health Domain

   Access to Preventive Oral Healthcare

The Nebraska Department of Health and Human Services’ Office of Oral Health and Dentistry (OOHD) reports in 2015-2016 that 63.9% of 3rd grade children had decay experience, 32% of 3rd grade children had untreated caries, and 15% of children aged 1-17 years reported active oral health problems; all are higher than the U.S. averages. Although delayed by one year due to COVID-19, the Open Mouth Survey was conducted during the 2021-2022 school year. This survey was conducted among third graders as well as Head Start sites.

 

   Child Abuse and Neglect

 

Exposure to abuse and/or neglect as a child is considered an Adverse Childhood Experience (ACE). The presence of one or more ACE has been found to have negative, long-lasting effects on physical and mental health and well-being. According to the NDHHS 1,765 Nebraska children (aged 1-9 years) experienced substantiated abuse and/or neglect during 2021, a rate of 7.4/1,000. This is a significant decrease from 10.0 in 2020, which was most likely affected by the pandemic. The 2021 rate is inline with what Nebraska was reporting pre-pandemic (7.2 in 2019). Physical neglect is by far the leading reason for removal, and often is linked to a parent’s substance use. There are disparities that exist in both alleged and substantiated cases of child abuse/neglect.

 

Adolescent Health Domain

 

   Motor Vehicle Crashes

 

Motor Vehicle Crashes are the leading cause of unintentional injury related death for Nebraska youth aged 10 through 19 years. According to the Nebraska Department of Transportation in 2020, teen drivers aged 19 and younger were involved in 14% of all reported crashes but only represented 5.2% of all licensed drivers. This is an increase from 2019, when teens were involved in 13% of crashes, and represented 7.4% of all drivers.

 

Also in 2019:

• 78% of the 18 teen traffic fatalities (drivers and passengers) were NOT wearing seat belts.
• At least 31% of teen drivers involved in crashes were using a cell phone.

 

   Sexually Transmitted Diseases/Infections

 

Both chlamydia and gonorrhea rates among youth in NE are lower than national rates and have been stable since 2008. While chlamydia rates are not increasing for youth under age 19, they are increasing significantly for those over age 20 – demonstrating the continuing need for Title V to focus on this priority. 

 

According to the Centers for Disease Control and Prevention (CDC), young people (aged 15 through 24 years) acquire approximately half of all new STDs while making up only about one quarter of the sexually active population. Chlamydia is the most prevalent STD both nationally and in Nebraska. In 2021, the reported rate of chlamydia infections per 100,000 Nebraska youth aged 15 to 19 years was 1,805 for chlamydia. This is an increase from the 2020 rate of 1,776. Significant disparities by race and ethnicity exist.

 

Nebraska is seeing a rate increase in both syphilis among women of reproductive age as well as congenital syphilis. While the numbers remain small, the rate increase is of concern. Nebraska will begin tracking maternal and infant syphilis cases with SET-NET (Surveillance of Emerging Threats to Mothers and Babies Network) in FY 2022.

 

   Suicide

 

Suicide has been, and continues to be, a top cause of death in the state for young people. According to the Nebraska Vital Records in 2020 the rate of youth (aged 10 through 19 years) suicide deaths was 7.5 per 100,000; the national rate for 2020 was 6.7 per 100,000.  Further, the number of deaths due to suicide for youth (aged 10 through 19 years) in Nebraska has been steadily increasing since 2009.

 

CYSHCN Domain

 

   Behavioral and Mental Health in School

 

Students with disabilities are more than twice as likely to receive an out-of-school suspension (14.6%) than students without disabilities (6%). While students in Nebraska receiving special education supports make up only 14% of total students, they account for 32% of all school-related arrests. These practices lead to higher incarceration rates which are positively associated with academic failure, high school dropout, and involvement with the juvenile justice system, grade retention, and illegal substance abuse.

 

Cross-cutting or Life Course Domain

   Improved Access to and Utilization of Mental Health Care Services

Unmet mental and behavioral health needs significantly impact the MCH population.  One in five Nebraskans are reported to experience mental illness; a significant number of others also experience behavioral health concerns (Nebraska Behavioral Health Needs Assessment, 2016).  According to the Behavioral Health Barometer: Nebraska, Volume 6: Indicators as measured through the 2019 National Survey on Drug Use and Health and the National Survey of Substance Abuse Treatment Services:

• 13.6% of youth aged 12-17 years had a major depressive disorder in 2016-2019
• 39.7% of youth aged 12-17 years who had a major depressive disorder received depression care in the past year (2016-2019)

 

Emerging Issues

• Workforce

As the field of public health emerges from the pandemic, workforce issues are top priority. Morale is low, inflation is high, and Nebraska is recording the lowest unemployment rate in the county. This is impacting the NDHHS and the Division of Public Health. MCH EPI has enjoyed growth and is building capacity but has not been immune to staff turnover. Over the coming years MCH EPI will recruit a number of student interns each year in an effort to maintain a good pipeline of potential candidates for Nebraska’s MCH workforce. 

 

• Health Equity and Social Determinants of Health (SDoH)

The pandemic brought Health Equity and Social Determinants of Health (SDoH) to the forefront, renewing efforts to better integrate and achieve results. This has already affected MCH EPI as it investigates new and innovative ways to bring community, and individuals with lived experiences, into the data collection and interpretation (recommendation) spaces. As the pandemic brought to the surface and illuminated gaps in state-local service systems, we see the emergence of community-based organizations as key partners in addressing priorities, reducing disparities, and addressing root causes.

 

Changes in Title V Program Capacity

There have been a number of changes in Nebraska that have increased the capacity of Title V. The Office of MCH Epidemiology added a Master’s level Epidemiologist (December 2021) through the CDC Foundation, as well as a Health Surveillance Specialist and Community Health Educator (January 2022). These positions primarily staff SET-NET which was moved under the Office of MCH EPI in the fall of 2021.

 

Title V Partnerships and Collaborations

 

Nebraska’s MCH Epidemiology staff utilize a number of partnerships and collaborations to monitor the needs of the MCH population in NE, and to build relationships that allow for effective coordination.  Continued relationships include the Divisions of Behavioral Health, Children and Family Services, and Medicaid and Long-Term Care as well as multiple Division of Public Health programs within DHHS. External partners are UNMC’s/Nebraska Perinatal Quality Improvement Collaborative, Nebraska’s Department of Education, Nebraska’s Children and Families Foundation, local health departments (particularly Douglas County FIMR project), the four designated tribes (Omaha, Ponca, Santee, and Winnebago), the Great Plains Tribal Epi Center, Munroe Meyer Institute, PTI Nebraska, the PRAMS steering committee, the Child and Maternal Death Review Teams’ expert volunteers, the Title V steering committee and stakeholders.  

 

Operationalize the Needs Assessment Process and Findings

 

Nebraska’s Needs Assessment findings are fully operationalized.  NDHHS Title V is committed to honoring the involvement of stakeholders by ensuring that Needs Assessment priorities guide the majority of Title V work and remain visible to both internal and external partners on our website.  Not only does each annual Action Plan have strategies that correspond to one of the 10 priorities identified, but ongoing monitoring of MCH populations is aligned as well, often referring back to Issue Briefs developed by stakeholders during the Needs Assessment process that both describe the issue and identify what success might look like after 5 years of effort.

 

The process of the Needs Assessment is also operationalized.  Nebraska Title V staff utilize a wide range of data sources to monitor the health needs of Nebraska’s MCH and CYSHCN populations, including those related to NPMs, SPMs, and EPMs.  In addition to the Title V framework, there are a number of agency level assessments which support ongoing monitoring of maternal and child (including those with special health care needs) health, such as the MIECHV Needs Assessment, the State Health Improvement Plan (SHIP), and the Division of Public Health Strategic Plan. This ongoing monitoring ensures that the MCH EPI staff, and Title V, are well suited to initiate annual updates, as well as prepare for the next five-year Needs Assessment.

 

As part of the continued monitoring and readiness effort, the Office of MCH EPI has been working on a number of data capacity projects that will ultimately improve access to and quality of the data for MCH assessment and programmatic activities.  Most notably a PRAMS annual report, an inaugural report of the Maternal Mortality Review Committee, data linkage projects with the blood lead program and Hospital Discharge Data, and an analysis of Nebraska’s Immunization Registry as it relates to the MCH population.

 

Building team capacity as we integrate new staff has been a priority. At the end of 2020/early 2021 MCH EPI underwent a strategic planning process which resulted in a shared team vision: Generate high quality data to improve the health of families through partnerships. In addition, the following three goals were identified: develop and implement a streamlined process for data requests and products, improve office communication and participation with internal and external partners, and team development to build effective and efficient working relationships based on strengths and competencies. To further refine efforts to improve office communication, team development, and efficient working relationships, MCH EPI initiated a monthly review process to debrief on project and process looking for areas to improve or innovate.

 

Changes in Organizational Structure/Leadership

 

During 2021-2022 Nebraska Title V experienced turnover with key staff, but no organizational or leadership changes.  Rayma Delaney, Federal Aid Administrator III, who served with DHHS for 24 years retired on July 8.  Her successor, Jonathan Newcomb, started in his role on July 6 bringing internal audit experience and significant financial management skills which will serve him well in his new role.  Rayma’s contributions to Title V grant management in Nebraska cannot be understated, nor her ready assistance to colleagues across the Agency. 

 

Kathy Karsting, DHHS Program Manager II, also resigned with DHHS as of June 10.  Her successor, Jessica Seberger, began her new role on August 1, bringing a wealth of experience in maternal and child health issues as the previous manager of PRAMS.  Kathy also made significant contributions to the field of Maternal and Child Health in Nebraska, which culminated with a 2021 Title V Lifetime Achievement Award from HRSA MCHB. 

 

Andrea Riley, School Health Program Manager, resigned to take a new position helping the NE Department of Education revitalize its approach to school health issues, in partnership with Children’s Hospital.  A successor for this position has yet to be identified, as this period of transition will mean changes in how Title V approaches school health.

 

These are many and significant changes in the core staff of Nebraska Title V.  Transitions of course mean changes and often confusion, however for Title V, it is also an important opportunity to focus priorities and determine the right resource mix for ongoing efforts.  Additionally, it allows for fresh perspective and original ideas from the new teammates who are joining Title V.  The strong foundation in NE as well as the continued commitment of existing staff mean that Nebraska is well-situated to weather this transitional period and emerge as a different, but cohesive MCH team.