Introduction

The Title V Five-Year Needs Assessment was conducted in 2020 by the MCH section in the Division of Health Promotion with support from Program Evaluation and Performance Improvement in the Division of Health Promotion and the MCH Epidemiology Unit in the Division of Epidemiology within the Georgia Department of Public Health (DPH). This application year (FY 2022) is the second year of the FY 2021-2025 grant cycle. During the interim years of the grant cycle, DPH continues to monitor and assess the needs of the MCH population, as well as the capacity of the system to meet those needs.

 

The primary goal following last year’s application was to review and assess the priorities and objectives and refine the Evidence-Based or -Informed Strategy Measures (ESMs) for each of the eight National Performance Measures (NPMs) Georgia selected.

 

Ongoing Needs Assessment Activities

Title V program meetings were held regularly to review the state action plan within each priority to ensure that the progress was on target with the priority work. Objectives within each priority were reviewed and revised, as necessary and when possible, to ensure the development of specific, measurable, achievable, realistic and anchored within a timeframe (SMART) goals. A system was developed for ongoing assessment to measure and track progress and identify program responses. In addition, the Title V Analyst followed up with members of the team to ensure outstanding issues were addressed. Outstanding issues included identifying data sources and ensuring data from these sources would be available.

 

The new Title V State Plan reflects priorities and needs of the MCH populations statewide and requires commitment and shared responsibility among the state Title V program, partnering state agencies, families and consumers, and other valued state and local program partners. Success with advancing the plan lies in the strength of partnerships, and willingness to align efforts and collectively impact outcomes. Efforts to promote and increase awareness of the Georgia Title V MCH State Plan were increased and presentations to key stakeholder groups were delivered throughout the year.

 

MCH Title V continues work related to the Title V Needs Assessment and State Action Plan in partnership with many internal and external partners. The Georgia Maternal and Child Health (MCH) Advisory Council serves in an advisory capacity to the Title V program, monitors progress, and addresses specific needs for MCH populations. The MCH Council partners with Title V to improve the health of Georgia families and ensures that partners are engaged in program planning, evaluation, service delivery and policy development. The Council membership totals 50-55 individuals and is comprised of a multidisciplinary team of professionals with expertise in maternal and child health. The MCH Council also includes a family representative to ensure the needs of families are central to programming, initiatives, and special projects. The Title V needs assessment and State Action Plan are the guiding documents for ongoing work of the MCH Council. The MCH Section convenes the MCH Council bi-monthly and each meeting includes presentations and group discussion on Title V initiatives, such as fatherhood, improving birth outcomes, safe sleep, and bullying and suicide prevention.

 

The Improving Birth Outcomes Working Group works jointly with MCH to strengthen the priority to reduce infant mortality in all infants, and specifically in Black infants, through the development and implementation of innovative infant mortality prevention and community interventions. The Improving Birth Outcomes Working Group is comprised of research, medical, community and public health professionals and includes a family representative with lived experience. The Working Group meets quarterly with the objective to systematically improve Georgia’s overall infant mortality rate and reduce racial disparities. The Working Group facilitates cultivating strong partnerships to operationalize goals into tangible actions.  

 

To continue to assess needs and develop strategies to impact maternal and infant health outcomes, DPH is collaborating with the Mercer University School of Medicine’s Center for Rural Health and Health Disparities to conduct an environmental scan of rural Georgia to examine factors that influence infant mortality rates (IMR). More than 75 percent of Georgia’s rural counties do not have a birthing hospital, and racial and ethnic disparities in infant mortality persist in many rural communities throughout the state. From 2014-2018, half of the rural counties in Georgia had an IMR above the state average, 14 percent had an IMR at least 1.5 times the state average, and 3 percent had an IMR at least double the state average. There are 12 counties in Georgia which have an IMR among Black, non-Hispanic, babies at least five times higher compared to non-Hispanic White babies, 11 of which were rural.

 

The scan will assess socio-economic determinants of health including poverty, education, rural attitudes and culture, psychosocial risk factors, access to healthcare, employment, transportation, insurance status, and other risk factors, such as smoking rates, obesity, and safe sleep practices. The environmental scan will be conducted though focus groups, surveys, and key informant interviews and will create actionable recommendations to guide strategic planning and decision-making regarding rural infant mortality prevention in Georgia.

 

Changes in the Health Status and Needs of the MCH Population

Maternal/ Women’s Health

Maternal Mortality: From 2012-2016, the maternal mortality ratio was 66 deaths per 100,000 live births; the pregnancy-related mortality ratio was 26 deaths per 100,000 live births.

 

Well-Women Visits: The 2019 Behavioral Risk Factor Surveillance System (BRFSS) estimated approximately 70.1 percent of women, ages 18 through 44, reported visiting a doctor for a routine checkup in the past year.

 

Family Planning: From 2013-2018, the Pregnancy Risk Assessment Monitoring System (PRAMS) data show the percentage of women with a recent live birth who reported an unintended pregnancy increased from five percent to 10  percent. Among women who were not trying to get pregnant when they became pregnant, use of low-efficacy birth control methods (condoms and withdrawal) was most reported, followed by medium-efficacy methods (the pill, patch or injectables). Use of high-efficacy birth control methods was least commonly reported among women who were trying not to get pregnant when they conceived.

 

Early Prenatal Care: According to the 2019 National Vital Statistics System (NVSS), approximately 75.1 percent of pregnant women reported having their first prenatal care visit during the first trimester.

 

Postpartum Care: Available PRAMS data from 2013-2018 show the percentage of women who received a postpartum visit with a health care provider remained relatively constant around 90 percent.

 

Perinatal/ Infant Health

Infant Mortality: The NVSS estimated the rate of infant death in 2018 was 7.0 per 1,000 live births.

 

Breastfeeding: In 2018, the National Immunization Survey (NIS) approximately 83.5 percent of infants were reported by a parent to have ever been breastfed, while only 22.1 percent of infants were reported by a parent to have been breastfed exclusively through 6 months.

 

Safe Sleep Practices: There is federally available data for NPM 5: safe sleep. According to the 2019 PRAMS data, 72.2 percent of mothers report they most often place their baby to sleep on their back only. Almost a quarter of the mothers (24.4 percent) report that their baby always/often slept alone, usually in a crib, bassinet, or pack and play. Approximately 40.5 percent of women report their baby did not usually sleep with blankets, toys, cushions, pillows, or crib bumper pads. 

 

Evidence-Based Home Visiting Programs: According to PRAMS, seven percent of Georgia women with a recent live birth from 2017-2018 reported receiving a home visit from a health care worker since their infant was born to learn how to care for themselves and/or their new baby.

 

Congenital Syphilis: According to the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) AtlasPlus, there were 31 cases of congenital syphilis in 2018, with a rate of 23.8 per 100,000.

 

Child Health

Developmental Screening: The 2018/19 National Survey of Children’s Health (NSCH) estimated 40.2 percent of children, ages nine to 35 months, received a developmental screening using a parent-completed screening tool.

 

Medical Home: According to the 2018/19 NSCH, approximately half (47 percent) of non-CYSHCN children, ages zero to 17, received care that met the criteria for having a medical home. Non-Hispanic (NH) Black (43.5 percent) children were less likely to report having care that met the criteria for having a medical home than NH White (54.5 percent) children.

 

Childhood Immunization Rates: The 2017 Georgia Immunization Study (GIS) indicates that statewide, the up-to-date vaccination coverage at 24 months of age was 84 percent. The National Immunization Survey (NIS) estimates 65.9 percent of adolescents, ages 13 through 17, received at least one dose of the HPV vaccine, 92.5 percent received at least one dose of the Tdap vaccine, and 95.5 percent received at least one dose of the meningococcal vaccine.

 

Physical Activity: In 2018-2019, NSCH estimated 41.9 percent of children, ages six to 11, were physically active at least 60 minutes per day for 1-3 days per week, 26.9 percent were physically active at least 60 minutes per day for four to six days per week, and 26.7 percent were physically active for 60 minutes every day.

 

Non-Fatal Injury: From 2011 to 2019, “other” unintentional injury was the leading cause of emergency department visits for children, one to nine years of age. The emergency department visit rate due to unintentional injuries among children, ages one to nine, in 2019 was 6,077.8 per 100,000. The hospital discharge rate due to unintentional injuries among children, ages one to nine, in 2019 was 53.6 per 100,000 population.

 

Adolescent Health

Bullying: In the 2018/19 NSCH, 13.6 percent of adolescents, ages 12 to 17, were reported by a parent or guardian to have bullied others. The 2018/19 NSCH estimated approximately 40.7 percent of adolescents, ages 12 to 17, were reported by a parent or guardian to have been bullied, picked on, or excluded by other children. According to the 2019 Youth Risk Behavior Survey (YRBS), 14.5 percent of high school students reported having been bullied on school property in the last 12 months before taking the survey. In the same survey, about one in ten (10.6 percent) public high school students reported having been electronically bullied, including through texting, Instagram, Facebook, or other social media, during the 12 months before taking the survey.

 

Suicide: In the 2019 High School YRBS, 11.8 percent of Georgia high school students reported attempting suicide in the 12 months before taking the survey. Over one in ten high school students reported that in the 12 months before taking the survey, they (1) seriously considered attempting suicide, 18.5 percent and (2) planned about how they would attempt the suicide, 12.4 percent.

 

Transition to Adult Health Care: According to the 2018/19 NSCH, nearly 15 percent of non-CYSHCN adolescents, ages 12 to 17, received services necessary to make transition to adult health care. Parents and guardians of NH White adolescents (20.6 percent), ages 12 to 17, were more than twice as likely to report they received services necessary to make transition to adult health care than NH Black adolescents (8.2 percent).

 

Non-Fatal Injuries: From 2011 to 2019, “other” unintentional injury was the leading cause of emergency department visits for adolescents, 10 to 19 years of age. The emergency department visit rate due to unintentional injuries among adolescents, ages 10 to 19, in 2019 was 6,360.9 per 100,000. The hospital discharge rate due to unintentional injuries among adolescents, ages 10 to 19, in 2019 was 92.4 per 100,000 population.

 

Physical Activity: In 2018-2019, NSCH estimated 38.7 percent of children, ages 12 to 17, were physically active at least 60 minutes per day for one to three days per week, 26.7 percent were physically active at least 60 minutes per day for four to six days per week, and 19.9 percent were physically active for 60 minutes every day.

 

Children and Youth with Special Health Care Needs

Medical Home: According to the 2018/19 NSCH, approximately two in five (40.3 percent) children with special health care needs, ages zero to 17, received care that met the criteria for having a medical home. NH White CYSHCN (46.9 percent) were reported to have care that met the criteria for having a medical home than NH Black CYSHCN (38 percent).

 

Transition to Adult Health Care: In the 2018/19 NSCH, it was estimated that 22.7 percent of adolescents with special health care needs, ages 12 to 17, received services necessary to make transitions to adult health care.  

 

Access to Specialty Care: The 2018/19 NSCH estimated 33.4 percent of CYSHCN and 8.8 percent of non-CYSHCN, ages 0 to 17, received care from a specialist doctor (other than a mental health professional) during the past 12 months. Just under one in ten (9 percent) of CYSHCN needed to see a specialist doctor but did not receive care.  

 

Care Coordination Services: During 2018 and 2019, NSCH reported more CYSHCN (47.5 percent), ages 0 to 17, received needed health care coordination during the past 12 months compared to non-CYSHCN (34.9 percent). However, the reported percentage of CYSHCN (28.3 percent), ages 0 to 17, who did not receive needed health care coordination was also higher compared to non-CYSHCN (11.1 percent).

 

Cross-Cutting

Dental Visits During Pregnancy:  PRAMS showed approximately one in three women with a recent live birth from 2017-2019 had their teeth cleaned by a dentist or dental hygienist in the 12 months before pregnancy. Thirty-six percent of women reported having their teeth cleaned during their pregnancy. About nine in ten women reported they knew it was important to care for their teeth and gums during pregnancy, while 76 percent reported having insurance to cover dental care during their pregnancy. 

 

Childhood Dental Visits: According to the 2018/19 NSCH, 81.4 percent of CYSHCN and 79.3 percent of non-CYSHCN, ages one to 17, received a preventative dental visit in the past year.

 

Smoking During Pregnancy: The 2017-2018 PRAMS indicated 5 percent of women reported smoking cigarettes and over 1 percent reported using electronic nicotine delivery systems (ENDS) during the last three months of pregnancy. Among women who reported smoking during the three months before pregnancy, the most common reasons that made quitting difficult were cravings for a cigarette (67 percent), loss of a way to handle stress (56 percent), others smoking around them (55 percent), and worsening anxiety (39 percent). During pregnancy, women who smoked in the past two years were more likely to report allowing smoking inside their home than non-smokers.

 

Tobacco, or Nicotine, Use Among Children and Adolescents: The Youth Tobacco Survey (YTS) showed one in four Georgia high school students reported ever trying cigarette smoking. In 2017, 8 percent of high school students reported current cigarette use, 13 percent reported current electronic cigarette use, eight percent reported use of smokeless tobacco products, and 14 percent reported cigar use.

 

Mental Health Evidence-Based Screenings: During the three months before pregnancy, 10 percent of women with a recent live birth from 2017-2018 reported having depression. Among women who reported having depression during the three months before pregnancy from 2017-2018, 38 percent reported having a health care visit for depression or anxiety in the 12 months before getting pregnant. As compared to 2013, in 2018, a greater percentage of women reported feeling down, depressed, or hopeless since their new baby was born increased. Among women whose baby was alive and living with them, 4.4 percent reported using counseling services for depression or anxiety since their new baby was born.

 

Title V Program Capacity

There have been no noted changes in the state’s Title Program capacity or its MCH systems of care. MCH currently has the capacity to promote the health of all MCH populations through structural resources, data systems, partnerships, and competencies. The Title V program serves all 159 Georgia counties. Title V program managers monitor all aspects of program administration to ensure a statewide system of services, which reflect the principles of comprehensive, community-based, coordinated, and family-centered care.

 

Maternal/ Women’s Health

MCH uses Title V funds to provide services for women of reproductive age. Family planning clinics supported by Title V provide contraceptive counseling and preventive services. Cancer screenings and HPV vaccines are provided in the family planning clinics. MCH actively supports the MMRC and engages in various initiatives to promote maternal health. MCH has epidemiology staff to support programmatic efforts. Data sources used are PRAMS, Vital Records, BRFSS, and Family Planning program data. Women’s Health houses the data for the MMRC and identifies cases for review. MCH and Women’s Health have active partnerships with hospitals, private practice physicians, academic institutes, cancer and HIV screening agencies, the Chronic Disease Prevention Section, Healthy Mothers Healthy Babies (HMHB), Georgia Obstetrical and Gynecological Society (GOGS), and March of Dimes (MoD) to ensure a comprehensive system of services for women of reproductive age in Georgia.

 

Perinatal Health

Title V staff supports infant mortality prevention, newborn screening, breastfeeding initiatives, preterm birth initiatives, perinatal regionalization, and the Safe to Sleep campaign to promote perinatal health. MCH also participates in the Georgia Perinatal Quality Collaborative (GaPQC) to implement quality improvement projects in participating hospitals. Title V supports epidemiology staff to collect and analyze data on perinatal health. The primary data source used are PRAMS and Vital Records. MCH and Women’s Health has active partnerships with the RPC’s, birthing facilities, private practice physicians, Association of State and Territorial Health Officials (ASTHO), GOGS, HMHB, MoD, WIC, and Worksite Wellness.

 

Child Health

MCH supports child health through promoting developmental screenings among children, preventing injury, and promoting oral health. MCH state, district and local level staff are well-versed in developmental screening and the various tools used to assess developmental screening. The Child Occupant Safety Project (COSP) aims to prevent motor vehicle accident deaths among children. MCH utilizes the State Electronic Notifiable Disease Surveillance System (SendSS) and the Babies Information and Billing System (BIBS) to assess developmental screening data. To ensure comprehensive system of services among children, MCH has active partnerships with the Chronic Disease Prevention Section, Department of Early Care and Learning (DECAL), Department of Education (DOE), academic institutes, GA Chapter of the American Academy of Pediatrics (GA-AAP), GA Academy of Family Physicians (GA-AFP), Marcus Autism, and Emory Autism Centers.

 

Adolescent Health

The Adolescent Health program sits within the Chronic Disease Prevention Section and promotes adolescent health through programs targeting tobacco prevention, sexual violence prevention, teen pregnancy prevention, and positive youth development. Title V will partner with the Injury Prevention Program to identify the prevalence and existing prevention programs and legislation on bullying and facilitate improvements in bullying prevention efforts to schools that serve the target population.

 

Children and Youth with Special Health Care Needs

MCH supports several programs to provide services to Georgia’s CYSHCN. Children 1st acts as the access point for children with an identified special need. BCW provides services for children from birth to three. CMS is established and continues to provide on-going, comprehensive medical care for CYSHCN that are not eligible for state funded Medicaid and SCHIP programs. CMS promotes access to specialty care, care coordination, transition to adulthood, and medical homes for CYSHCN. Epidemiologists support data collections for CMS.

 

Oral Health

Title V, CDC, state, and private-donated funds support oral health initiatives. MCH has access to oral health data through PRAMS, NSCH, CMS, and the 3rd Grade and Head Start Basic Screening Surveys. The Oral Health program has an Oral Health Epidemiologist. To ensure a comprehensive oral health system of services, MCH has active partnerships with WIC, private practices, dental hygiene programs, academic institutes, schools, the Oral Health Coalition, and CDC.

 

Partnerships and Collaborations

Title V continues to be heavily focused on collaborative partnerships and demonstrates strong commitment to coordinating with others to address emerging and ongoing needs of MCH populations. Both formal and informal collaborative relationships exist that support Title V work. Georgia maintains partnerships to build the capacity of MCH services in the state.

 

MCHB Investments: Title V works collaboratively with other MCHB investments, including but not limited to: State System Development Initiative (SSDI), Maternal, Infant, and Early Childhood Home Visiting (MIECHV), and Healthy Start.

 

Other Federal Investments: Title V receives other federal investments through CDC funding, which includes PRAMS, Oral Health, perinatal quality improvement, USDA funded WIC, and Health and Human Services funded Head Start. Title V also works closely with Part C of IDEA and Early Hearing Detection and Intervention (EHDI).

 

Other HRSA Programs: District coordinators partner with Federally Qualified Health Centers.

 

State and Local MCH Programs: The state Title V program coordinates regularly with community organizations and local health departments to implement activities.

 

Other programs within the State Department of Health: MCH partners with the Office of Women’s Health, Adolescent Health, Chronic Disease Prevention, Immunizations, Injury Prevention, STD, and Vital Records.

 

Other governmental agencies: MCH has strong relationships with the Department of Community Health, the Department of Behavioral Health and Developmental Disabilities, the Division of Family and Children Services, the Department of Early Care and Learning and the Department of Education.

 

Public health and health professional educational programs and universities: MCH frequently partners with Emory University, Rollins School of Public Health, Georgia State, University of Georgia, Morehouse School of Medicine, Mercer University, Valdosta State University, and Augusta University.

 

Others: MCH has a contractual relationship with RPC’s to meet the needs of the perinatal regionalization system. GOGS is contracted to administer the MMRC. Relationships with Children’s Healthcare of Atlanta and Augusta University are critical to addressing transition, as these sites have transition clinics that DPH has assisted in establishing and promoting. Parent to Parent and GA-AAP are contracted to support services for CYSHCN. Emory University conducts follow-ups for the Newborn Screening program.

 

Title V Stakeholder Council: The MCH Advisory Council serves in an advisory capacity to MCH Title V Program; monitors progress; and addresses specific MCH population needs for MCH populations. The MCH Section serves as the lead agency for the Council. The Title V needs assessment and state action plan is the guiding document as it relates to the ongoing work of the Council. The Council is comprised of a multidisciplinary team of professionals with expertise in MCH.

 

Improving Birth Outcomes Working Group: An advisory group comprised of research, medical, public health, community organization professionals and family representatives to advise MCH on the Improving Birth Outcomes Initiative’s strategic plan to prevent infant mortality in all infants, and specifically in the Black population.

 

Operationalization of Five-Year Needs Assessment Process and Findings

Title V operationalized the Five-Year Needs Assessment process and findings by developing practices to better assess and monitor the status of process measures intended to advance the national and state performance measures. During the reporting year, the Title V team held monthly meetings with Title V programs outside of the MCH section, reviewed Title V program monthly Executive Status Summary reports for MCH sections programs, implemented quarterly status reports, and held quarterly ESM meetings to provide accountability for improving quality and performance related to the NPM/SPMs and the MCH public health issues for which they are intended. The MCH Fiscal representative is included in the monthly meetings to ensure that the Title V budget is aligned with Title V programming needs and activities to achieve goals.

 

A Quarterly Reporting process was implemented for Title V programs to provide a summary of program activities and achievements quarterly during the reporting period to assess strategies and progress in meeting goals. Title V programs report on program progress and accomplishments, new partnerships and collaborations, family engagement activities, funding opportunities, challenges and resources needed and any related legislation.

 

Monthly check-in meetings are held with Title V programs to review program activities and provide technical assistance. Quarterly ESM meetings with Title V program staff provide the opportunity to regularly assess the impact of developed strategies and activities contained in the State Action Plan. Accountability measures such as monthly meetings, quarterly review and assessment of ESM progress ensures that any issues or adjustments are identified timely, and strategies are reassessed to ensure that progress is made in the priority areas. Through regular and continued assessment of strategies and practices, improvements in structures or processes are expected, which will drive improvements in performance and, in turn, improve outcomes.

 

Organizational Structure and Leadership Changes                                                                                                

DPH is the lead agency in preventing disease, injury and disability; promoting health and wellbeing; and preparing for and responding to disasters from a public health perspective. The agency’s Commissioner reports directly to the Governor. The Health Promotion Division contains the MCH Section, WIC, Oral Health, and the Program Evaluation and Performance Improvement sections. The MCH section contains the following programs: Title V, Child Health, CYSHCN, and Family and Community Supports. DPH recently restructured and added the Clinical and Medical Services Division which includes Chronic Disease, Immunization, Infectious Disease, Nursing, Public Health Pharmacy, the Public Health Laboratory, Refugee Health, and the Office of Women’s Health. MCH has primary responsibility for the administration of the Title V Block Grant. The MCH Director serves as the Title V Director. The Title V MCH program sets program policy and monitors compliance with state and federal laws and rules and offers technical assistance to staff in district public health departments regarding Title V programs.

 

Emerging Public Health Issues

The capacity to address emerging public health issues is a continued focus of DPH. To reduce the burden and impact of COVID-19 among vulnerable populations and communities of color, DPH developed a four-prong approach for ensuring health equity.

 

1. Identify Vulnerable Populations

• Define populations adversely impacted by COVID-19
• Understand COVID-19 infection/case rates, vaccination rates, contact tracing outreach impact, and testing rates among vulnerable populations

 

2. Community Engagement and Outreach

• Recognize and address historical distrust, trauma, and broken relationships because of systemic inequities, racism, and medical harm marginalized groups have experienced
• Sponsor COVID-19 related events or “pop-up” sites to increase community access and testing
• Develop and leverage various platforms such as social media, print, and television to reinforce the importance of stopping the spread
• Ensure communications are culturally competent and linguistically appropriate
• Empower public ownership of COVID-19 vaccination to reduce hesitancy
• Provide language access services
• Communicate public health’s response to COVID-19
• Adapt messaging as the response evolves

 

3. Utilize Data and Technology

• Identify and leverage data to inform the health equity strategy and interventions
• Collect health equity data from community residents across the state to understand perceptions, preferred communications channels, trusted messages, and messengers

 

4. Identify and Engage Stakeholders

• Identify and partner with the Health Equity Council, local public health districts, employers, community partners and stakeholders to formulate and refine the strategy
• Serve as “trusted messengers” to ensure equity in the implementation of COVID-19 prevention and intervention strategies
• Enhance collaboration with providers who serve disproportionately impacted communities