I. Overview of Approach to Child Health Domain

Strategies in the child health domain focus on reducing childhood injury, improving developmental, behavioral, and mental health outcomes, and mortality prevention among children in Pennsylvania (Pa.).

II. Other Federal Funding and State-Funded Activities/Future Efforts

While the action plan does not address lead poisoning prevention activities and programming, Bureau of Family Health (BFH) staff participate in a variety of activities that support this important component of child health prevention and intervention. Lead exposure remains a concern for children. The major causes of elevated blood lead levels among U.S. children are lead-based paint and lead dust. Houses built before 1978 are likely to contain some lead paint which releases lead dust when it deteriorates or is destabilized during renovations. In 2024, the BFH will continue to explore and apply for additional funding to continue the mission of reducing injury and lead poisoning among the most vulnerable children in Pa. Using funding through the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Housing and Urban Development, the BFH, in partnership with local county and municipal health departments as well as other local governments and community organizations to implement primary and secondary prevention strategies to ensure blood lead testing and reporting, enhance blood lead surveillance, and improve linkages of lead-exposed children to recommended services. Ongoing efforts to support childhood lead poisoning prevention work continues following the passage of the Childhood Blood Lead Test Act (Act) on November 3, 2022. Requirements of the Act, which took effect on January 2, 2023, are anticipated increase blood lead testing rates and reporting. Additionally, $10 million in funds from the American Recovery Plan Act (ARPA) have been allocated for lead hazard control, lead training, and to build capacity among current lead programming in Pa. These funds will be administered through vendors who have existing lead hazard control programs in an effort to ensure the work is completed in the two-year period of this funding. Program staff have created flexibilities in program requirements that will enable vendors to serve families that may not be eligible through other funding sources.

The Bureau of Community Health Services (BCHS) oversees the School Health Program, which is the oldest program of public health services in Pa., with responsibilities predating 1895. The program serves all children of school age attending public, private and non-public schools in Pa. and is responsible for providing technical assistance, training and coordination of programs and services to schools, parents and the community at large regarding school health programs and services.

The Bureau of Health Promotion and Risk Reduction (BHPRR) discontinued funding Safe Kids Pennsylvania (Safe Kids PA) from the Preventive Health and Health Services Block Grant (PHHSBG) due to changing priorities in June 2023. The BFH determined that directly funding Safe Kids PA aligns with the Title V Block Grant child health priority and allows for continuity of vital injury prevention efforts throughout the state. Safe Kids PA is the designated Safe Kids organization to serve Safe Kids Coalitions and establish Safe Kids Partnerships throughout the state under an agreement with Safe Kids Worldwide and the American Trauma Systems Foundation Pennsylvania Division (ATSPA) which operated SKPA.

A one-year agreement to determine ongoing strategies is being pursued to allow for SKPA to fulfill their role as the state office for Pa. and BFH to identity strategies to support child injury prevention efforts. In addition to the current activities of the SKPA partner organizations and independent coalitions, support of the CDR program is being evaluated. Historically, the CDR program has faced challenges transforming findings into actionable prevention strategies. SKPA is poised to provide training and technical assistance to the local teams to transform the teams’ findings into evidence-based strategies.

BHPRR will continue to support injury prevention work through the PHHSBG. An RFA was released in March 2023 seeking applicants to address unintentional injury prevention services in three focus areas: falls prevention for older adults; reducing Motor Vehicle Occupant Injuries/Deaths in children, adults, and teen; and prevention of adverse childhood experiences.

III. Priorities

Priority: Improve mental health, behavioral health and developmental outcomes for children and youth with and without special health care needs

NPM 11: Percent of children with and without special health care needs, ages 0 through 17, who have a medical home

Strategy: Community Health Nurses will provide information about available medical homes to all families with children ages 0-17 without a provider during visits to the State Health Center (SHC)

Objective: Ensure that all SHCs are documenting and reporting all referrals of children ages 0-17, who do not have a provider, made to medical home within six months

ESM: Percentage of children without a provider referred to medical homes

BFH partners with the BCHS to provide maternal and child health services throughout the state. BCHS oversees the operations of SHCs, located in counties that do not have a local health department. Previously, Community Health Nurses located in SHCs documented and reported all referrals of children ages 0-17, who do not have a provider, made to a medical home. As of July 1, 2023, BCHS will no longer report data for purposes of the MCH State Action Plan. Referrals to medical homes will continue in the SHCs as appropriate.

Priority: Reduce rates of child mortality and injury, especially where there is inequity

As a result of the 2020 Needs and Capacity Assessment, the BFH identified a new priority which aims to reduce rates of child mortality and injury, especially where there is inequity. The BFH reviewed Pa. injury death, injury hospitalization, and injury emergency department data to identify the types of injuries as well as age, geographic, and racial and ethnic disparities that are injuring and killing young children. The types of injuries that children ages 0-9 years experience are preventable for the most part as the largest numbers fall into the unintentional category. As children age, the number of injuries that lead to death and hospitalization decrease and the most common types of injuries shift. Black/African American and Hispanic children were more likely to have an injury result in hospitalization than white children. Injury rates varied widely between counties with no clear causes.

NPM 7.1: Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9

Strategy: Use Child Death Review data to inform child safety programming

Objective: Annually increase the number of recommendations from CDR teams related to preventing child death that are reviewed for feasibility and implemented each year

ESM: Number of recommendations from CDR teams that are implemented (child health)

PA’s Child Death Review (CDR) program was developed to promote the safety and well-being of children by reducing preventable childhood deaths through review and exploration of the factors contributing to these fatalities. This is accomplished through systemic, multi-agency reviews of the circumstances surrounding the deaths of children 21 years of age and under. The BFH utilizes a combination of federal Title V and other federal funds to facilitate the review process, provide training and technical assistance to local teams, facilitate the State CDR Team, and make recommendations regarding prevention programs and policies. The BFH uses these data and team recommendations to inform program goals and interventions.

In 2018, the PA Department of Health (DOH) was awarded a grant by the CDC for the Sudden Unexpected Infant Death (SUID) and Sudden Death in the Young (SDY) Case Registry. The PA DOH was awarded the grant funds by the CDC based in part on the expectation that Philadelphia Medical Examiner’s Office would be receiving part of the funding award to implement the SDY component of the grant. Federal Title V funds will be used to supplement activities for this program and the SUID case registry. The SDY Case Registry gathers information to learn more about young people who die suddenly and unexpectedly. Babies, children, and young adults up to age 21 are included in the SDY Case Registry. The Philadelphia Medical Examiner’s Office has applied directly for the next round of funding from the CDC for the Sudden Unexpected Infant Death (SUID) and Sudden Death in the Young (SDY) Case Registry. As the Philadelphia Medical Examiner’s Office anticipates receiving the funding directly for this project, beginning in 2024, there will no longer be a need to support this work with Title V MCHSBG funds.  

In 2023, the BFH will continue to enhance and strengthen the CDR program through data quality and analysis for SUID, SDY and CDR cases. Pa. continues to seek to improve data quality for CDR, SDY, and SUID through training efforts at regional and statewide meetings and targeted technical assistance. COVID-19 mitigation efforts stalled BFH’s plans to facilitate trainings on death scene investigations, including doll reenactments, to improve the quality of death scene investigations for children who die suddenly and unexpectedly; however, the training will be held in June 2023. The response for this training was tremendous, especially from law enforcement. Moving forward, the BFH will work in consultation with leaders in the investigative agencies involved in child death reviews to develop a sustainable and permanent model for delivering death scene investigation and doll reenactment training that may include a train-the-trainer model, an asynchronous online training, or a combination of both.  The increased quality of the information available regarding a child’s death due to enhanced child death scene investigations will improve the review process and will provide more complete data.

Using the information learned during the assessment phase of the prevention recommendation framework process developed in 2021, the State CDR Team will brainstorm prevention strategies. The strategies will be assessed for effectiveness and feasibility and made actionable. The Team determines the target audience(s) for each white paper. Targeted entities should have the capability to implement or lead prevention strategies or already be involved in developing or implementing similar prevention strategies. The State CDR Team will develop a minimum of one white paper per cause of death. This process is being evaluated by the BFH and the State CDR Team in 2023. The evaluation will seek to streamline processes, assess effectiveness, and inform recommendations for improving the framework. Additionally, the BFH will continue to seek opportunities to share the CDR recommendations more widely, with a particular focus on prevention strategies that address identified social, economic, environmental, and structural factors influencing mortality rates, acknowledge the life course, and promote health equity. The goal is to increase sharing of data and findings with state and local partners to inform child fatality prevention and health promotion strategies, enhance policies and practices of systems serving children and families and promote support for concrete services and policies that help families thrive and expand community awareness of factors associated with fatalities.

Strategy: Reduce head injury amongst participants in school and non-school related sports

Objective: Annually increase the number of ConcussionWise trainings provided by the Safety and Youth Sports Program to athletic personnel by two per year  

ESM: Number of ConcussionWise trainings to athletic personnel

To ensure appropriate protections exist for youth athletes who participate in organized school and non-school sponsored sporting activities, the BFH will provide traumatic brain injury (TBI) education. TBI education will be provided through the Safety in Youth Sports Program, which will include in-person and web-based trainings. The program is designed to promote safe and appropriate removal from play in the event of a suspected concussion as well as evidence-based return-to-play protocol. These efforts help to ensure concussion symptoms are identified early and treated properly and reduce repeat incidence, which often cause more serious head injuries. Trainings will be provided to individuals affiliated with youth sports including coaches, parents, athletes, and school personnel. Multiple studies show that rural and urban areas suffer from health care disparities and lack of access to care and preventive care. According to the CDC, those living in rural areas are at a greater risk of dying from a TBI compared to people living in urban areas due to greater travel time to emergency medical care, less access to a Level 1 trauma center, and difficulty accessing specialized care. One of the most common ways children get concussions is through sports-related injuries. Contact sports, such as football, soccer and ice hockey, result in nearly twice as many TBI emergency department visits than noncontact sports and four times those associated with recreation-related activities. The program will continue to focus efforts on eliminating health disparities within its target population by ensuring equitable coverage throughout the state by prioritizing urban and rural areas.

In 2024, BFH will explore other options to increase the number of individuals served while reviewing the Department’s responsibilities outlined in the Safety in Youth Sports Act of Nov. 9, 2011, P.L. 411, No. 101.

Strategy: Provide in-home child safety education visits

Strategy: Provide home safety interventions performed as a result of needs identified during comprehensive in-home child safety education visits

Child injuries decrease when caregivers have positive well-being and low stress. Providing child safety information as part of larger parental supports, such as home visiting, positions the information to be better received, accepted, and implemented. Specific to unintentional injuries, education of caregivers shows increased use of safety equipment and safety practices. Most of the research on this type of education is associated with home visiting programs in the first two years of life. Home safety education provided one-to-one as face-to-face also showed increases in safety practices. These practices were enhanced when free, low-cost, or discounted safety equipment was provided as well as when education is delivered in the home.

By continuing to address factors contributing to injuries and death during early childhood in the home environment, the BFH anticipates a reduction in the child mortality rate and the rate of hospitalization for non-fatal injuries.

Objective: Annually increase the number of comprehensive in-home child safety education visits completed

Objective: Annually increase the number of home safety interventions performed as a result of needs identified during comprehensive in-home child safety education visits

ESM: Number of in-home child safety education visits completed

ESM: Number of home safety interventions performed as a result of needs identified during comprehensive in-home child safety education visits

The current Prevent Injuries in Children (PIC) program that began in July 2021 is scheduled to end in June 2024. During 2024, the PIC program will continue to be provided in association with other home visiting programs as an additional and separate component that provides education as well as interventions to families. PIC providers are required to complete motivational interviewing training to better engage with families as well as training on child injury hazards, prevention, and appropriate interventions. Low-cost interventions will be provided at no-charge to participating families based on their specific child safety needs.

The PIC program was designed to provide services in counites with the greatest health disparities in child injury. Counties were ranked for priority based on injury, death, race and ethnicity, and emergency department visits using both rates and numbers. Eight categories were used to establish the county prioritization with data calculated for the combined 0-9 age group and all given equal weight in the ranking and prioritization process. The service area of the PIC programs was designed intentionally to address health equity and serve those most in need without additional work or efforts at the local level.

As a prevention program, the immediate process measures track the work completed and potential for reduction in injuries and death. The number of in-home child safety education visits completed will measure the reach of the PIC program with the program seeking to annually increase the number of visits. Additionally, home safety interventions performed due to needs identified during comprehensive in-home child safety education visits represent potential injuries that are prevented.

Due to the enrollment challenges faced in several of the counties served by the PIC program, the outcome of the state fiscal year 2022-2023 activities will determine how the PIC program proceeds beyond July 1, 2024. It is likely that only some of the counties currently receiving funding will be renewed to continue providing services. The PIC program was established at the county level to better engage smaller trusted community partners in implementing evidence-informed child injury prevention strategies. The BFH attempted to streamline and simplify the application and implementation processes to support smaller and less resourced organizations. The PIC program has not resulted in the anticipated outcomes and, as such, the BFH is seeking alternative strategies.

As detailed above, the BFH is seeking to support the majority of child injury prevention strategies with SKPA going forward. The reach of SKPA is unparalleled, elevating the potential for long-term reductions in mortality and morbidity through evidence-based strategies. Safe Kids offers a wide array of child injury prevention strategies for children of all ages. Child passenger safety, bicycle safety, and drowning, large contributions to child injury, disability, and death that have typically been out of reach for the BFH strategies will now be possible. SKPA will be able to provide administrative support and technical assistance to smaller and less resourced community partners in harder to reach communities across the state. Collaboration with SKPA offers an opportunity for both statewide reach and with targeted strategies to meet local needs.