Ask A Researcher

January 2016

Making change happen - Improving the health and well-being of all North Dakota infants, mothers, children, children with special health care needs and their families

The Title V Maternal and Child Health (MCH) Block Grant Program—the Nation’s oldest federal-state partnership—aims to improve the health and well-being of women, particularly mothers, and children. Every five years, legislation requires ND to develop a comprehensive statewide needs assessment for the MCH Services Title V Block Grant Program. This needs assessment is an ongoing collaborative process, one that is critical to program planning and development and enables the state to target services and monitor the effectiveness of interventions that support improvements in the health, safety and well-being of the MCH population. For this article, the North Dakota Title V/Maternal and Child Health leadership team, consisting of Grace N. Njau, Epidemiologist; Devaiah Muccatira, Research Analyst III; Kim Mertz, Director of Division of Family Health/Title V MCH; and Tamara Gallup Lelm, Director of Division of Children's Special Health Services, all of the North Dakota Department of Health, came together to share some of the highlights from the 2016-2020 MCH Services Title V Block Grant needs assessment.

Can you tell me a little about the Maternal and Child Health (MCH) Services Title V Block Grant Program?
Since 1935, the North Dakota (ND) Maternal and Child Health Services Program has been a major source of federal, state and local funds for pregnant women, mothers and infants up to age one; children and adolescents; and children and youth with special health care needs.

The Divisions of Family Health in the ND Department of Health (lead division for administration of the Title V/MCH funds), Injury Prevention and Control (IPC), Nutrition and Physical Activity (NPA), and Children’s Special Health Services (CSHS) within the Community Health Section of the North Dakota Department of Health administer Title V /MCH funds. Programs/services within the divisions of Family Health, IPC and NPA that are fully or partially supported by Title V/MCH funds include: Abstinence Education Program, Child Passenger Safety Program, Cribs for Kids Program, Family Planning Program, Infant and Child Death Services Program, Information Technology, Injury Prevention Program, MCH Epidemiology, MCH Nurse Consulting, MCH Nutrition and Breastfeeding, Newborn Screening Program, Optimal Pregnancy Outcome Program, Oral Health Program, School Health/ School Nursing, and Women’ Health Services.

MCH also awarded contracts for approximately $1.3 million to nearly all of the local public health units, along with four nonprofit agencies, and one American Indian program for the period of July 1, 2013 through June 30, 2015. Funding is used for activities such as maternal care, well-baby clinics, newborn home visits, car safety programs, school wellness activities, school nursing services, nutrition and physical education, injury prevention, immunizations, and oral health care.

The Division of CSHS is the designated Title V Children with Special Health Care Needs program for the Title V/MCH Block Grant in North Dakota. The purpose of CSHS is to provide services for children and youth with special health care needs and their families and promote family-centered, community-based, coordinated services and systems of health care.

The Division of CSHS supports cooperative administration of programs for children with special health care needs with 53 county social service boards. Support for communities is addressed through contracts with a variety of entities that provide multidisciplinary clinics and community-based care coordination services. In addition, CSHS supports medical home projects and provides state-level family information, training, and support services.

Programs/services within the Division of CSHS include: Autism Spectrum Disorder (ASD) Database, Care Coordination Program, Children with Special Health Care Needs (CSHCN) Service System, Information Resource Center, Metabolic Food, Multidisciplinary Clinics, Russell Silver Syndrome Program, Specialty Care Diagnostic and Treatment Program, and State Systems Development Initiative (SSDI).

How are the needs of the MCH population determined to improve the health and well-being of ND’s mothers, children, and their families?
Every five years, ND is required to develop a comprehensive statewide needs assessment for the MCH Services Title V Block Grant Program.

When developed, ND’s needs assessment process followed the conceptual framework outlined in the Title V MCH Block Grant Guidance. This framework helps the state in determining MCH program priority needs and in developing five-year action plans to strategize and address the prioritized needs.

The 10 steps in the needs assessment process framework include:
1.   Engaging stakeholders
2.   Assessing needs and identifying desired outcomes and mandates
3.   Examining strength and capacity
4.   Selecting priorities
5.   Setting performance objectives
6.   Developing an action plan
7.   Seeking and allocating resources
8.   Monitoring progress for impact on outcomes
9.   Reporting back to stakeholders
10. Reporting in the interim years of application and annual reports

Early in 2014, ND began planning the five-year needs assessment to select priorities for 2016-2020. The first step involved the MCH leadership team reviewing the draft Title V MCH Block Grant Guidance. The MCH leadership team included the director of the Division of Family Health/Title V, the director of the Division of CSHS, the State Systems Development Initiative (SSDI) coordinator, and the MCH epidemiologist. These four individuals were responsible for the planning and oversight of the MCH needs assessment process.

Needs of the MCH population were determined through effective use of both quantitative and qualitative methods and data sources that included the following:

MCH data (e.g., National Performance Measures, State Performance Measures, National and State Outcome Measures, Health Status Indicators, Health System Capacity Indicators)
U.S. Census Bureau data
ND Vital Statistics/Vital Records
ND Department of Health program data (e.g., sexually transmitted infections)
ND Department of Human Services, Medicaid Health Tracks Program
National and state surveys (e.g., YRBS, BRFSS, National Survey of Children with Special Health Care Needs, National Survey of Children’s Health)
Community health data (e.g., ND Early Hearing Detection and Intervention Program, WIC)
Input of families and consumers through a qualitative survey (MCH Survey of Perceived Needs and MCH Stakeholder Survey – Did we select the best MCH priorities for 2016-2020?)
Expertise from state MCH program staff

What were some of the strengths and challenges within the MCH population that rose to the top during the MCH needs assessment?
Initially, the MCH epidemiologist evaluated the state’s MCH data based on the demographic factors that currently define ND, and later evaluated the socio-economic factors in order to identify disparities and needs. This was achieved by reviewing ND census data to gather information on the states changing population, including racial distribution. Several key findings for the general population stood out.

Overview of the state’s demographic trends:

ND is the fastest growing state in the nation with an almost 10 percent population increase between the 2010 Census and the 2014 population estimate data, reaching a total of 739,482 residents. This has been primarily due to energy development activity, in addition to strong agricultural markets, and private sector growth.
Contrary to the national population shift towards an aging population as the youngest of the baby boom generation enters their fifties, ND’s population is becoming younger. The median age in ND is currently 36.9 years old, slightly younger than the national median of 37.2 years old.
Health disparities and poverty disproportionately persist in the American Indian reservation areas of the state. American Indians represent the largest minority population in ND (5.4%). ND has five federally recognized tribes and one Indian community; approximately 64 percent of American Indians in ND live on reservations.
ND’s communities are becoming more racially diverse. The ND population of color (i.e., non-White) experienced a 24 percent increase from 2010 to 2013. During the same time period, when comparing racial/ethnic groups, the Black population experienced the fastest growth (59% increase), followed closely by the Hispanic population (54% increase).

This shift in population and racial diversity brings along both opportunities and challenges that affect the health of the MCH population, the types of health care services needed, and the financial viability of health care systems.

Overview of the health status, strengths/successes and needs/challenges of the state’s MCH population.
The key issues facing the ND MCH population were assessed based on trends, program goals/objectives, publications, and comparison on the national platform. Consequently strengths, weaknesses and challenges of the state’s MCH population were identified across the three legislatively-defined population groups:

Pregnant women, mothers, and infants to age one
Children and adolescents
Children and youth with special health care needs

The state’s MCH data has been evaluated based on the demographic factors that currently define ND and socio-economic factors that helped identify disparities and needs. Several key findings follow.

Pregnant Women, Mothers, and Infants up to Age 1:
Strengths

High-risk pregnant women are delivering at appropriate facilities.
Decreased neonatal mortality from a high of 4.2 per 1,000 live births in 2010 to the current rate of 3.6 per 1,000 live births in 2014.
As a result of mandatory newborn screening, 100 percent of infants screened that receive a positive result receive timely definitive diagnosis and clinical management.
Increased rate of low-birth weight infants being delivered at facilities for high-risk deliveries, from 45 percent in 2008 to 75 percent in 2013.

Challenges

Obesity among women (only 37 percent of ND women ages 18 through 44 are at a healthy weight).
Historical high increased incidence of sexually transmitted infections in women ages 15-44, from 11.9 per 1,000 in 2008 to 17.4 per 1,000 in 2013.
Risky behaviors among mothers (about 15 percent of pregnant women in the state smoking at any point during their pregnancy).
Disparities in the American Indian population. In 2013, the mortality rate for all causes for American Indians, age birth through 44, was four times higher than the mortality rate for the White population. American Indians overall have a higher prevalence of conditions such as diabetes, substance abuse, unintentional injuries, and smoking – especially those residing in reservations. American Indian infant mortality rates show significant disparities with an almost four-fold incidence of infant deaths as compared to that of the White infant population.
Decrease of Medicaid enrollees less than one year of age who received at least one periodic screen, from 88 percent in 2011 to 71 percent in 2013.
Enrollees of Healthy Steps, the state’s Children Health Insurance Program, receiving at least one periodic screen steadily declined from a high of about 81 percent in 2009 to a low of approximately 72 percent in 2013.
Infants still breastfeeding at six months in 2011 was 45 percent, a proportion significantly below the national average of 50 percent.

Children and adolescents:
Strengths

In the child population, decreased the death rate from unintentional injuries attributable to motor vehicle crashes from a peak of 3.4 per 100,000 in 2009 to no deaths per 100,000 in 2013. Non-fatal injuries from motor vehicle crashes have also steadily decreased from 366 per 100,000 in 2010 to 316 per 100,000 in 2013.
Among the ND adolescent population, continued the decrease in teenage pregnancies among female youth, ages 15 through 17, from a high of about 13 pregnancies per 1,000 in 2010, down to a rate of about 10 pregnancies per 1,000 in 2013.

Challenges

Declining oral health care services utilization in Early Periodic Screening Diagnostic and Treatment (EPSDT) eligible children, with this proportion dropping from approximately 50 percent in 2010 to about 42 percent in 2013.
Obesity and overweight in the childhood and adolescent populations, ages 10 through 17, – with approximately 36 percent of this population being overweight to obese.
Bullying is also a concern for this population. According to the 2013 Your Risk Behavior Survey (YRBS), more than half (52%) of students in grades seven and eight had ever been bullied on school property. Cyber bullying is also becoming an issue, with more than a quarter (28%) of these same students reporting ever been electronically bullied, with a significant difference between females (39%) and males (17%). While the percentages are lower for high school students, bullying is also a concern for this population, with 25 percent of students in grades 9-12 reporting being bullied on school property during the past 12 months.
Motor vehicle crashes are the number one killer of teenagers, and young drivers are twice as likely as adult drivers to be in a fatal crash. The past three years in ND, unintentional injuries among youth, ages 15 through 24, due to motor vehicle crashes ranged from 27 in 2011 to 19 per 100,000 in the year 2013.
Disparities persist in this age group, with 2013 American Indian suicide rates for youth, ages 15 to 19, at much higher rates (21 suicides per 100,000) than the national rate (12 suicides per 100,000).

Children with Special Health Care Needs:
Strengths

In the 2009/2010 National Survey of Children with Special Health Care Needs (NS-CSHCN), it was reported that 48 percent of children, ages 0 to 18, received coordinated, ongoing and comprehensive care within a medical home, a higher percentage than the nation’s 43 percent.

Challenges

While ND is doing better than the nation in providing care to children with special healthcare needs, this percentage represents a decrease from 2005/06 (55%).
Transition into adulthood is cited as a challenge by families in the NS-CSHCN, with only about 47 percent of ND families in 2009/10 reporting having adequate resources for successful transition, down from about 51 percent in 2005/06.

From these findings, what was deemed as priorities for the MCH population in North Dakota for 2016-2020?
Based on this qualitative assessment of strengths/success and needs/challenges, along with utilizing the quantitative MCH survey data of perceived needs and the criteria-based ranking and weighting prioritization tool, 10 state priority needs were determined across the six population domains (i.e., Women’s/Maternal Health, Perinatal/Infant Health, Child Health, Adolescent Health, Children with Special Health Care Needs (CSHCN), and Cross-cutting/Life Course) and aligned with the national priority areas.

With the 10 state priority needs identified and aligned with the national priority areas, the MCH leadership team sought public/stakeholder input in the form of a survey – Did we select the best MCH priorities for 2016-2020? The purpose of this survey was to evaluate whether the state priorities and national priority areas selected represented the public perception of the needs in ND; and if not, what they felt should be included. Incorporating the feedback received, the final ND MCH 2016-2020 priority areas were selected. See the table below for priority areas and the rationale for selection.

North Dakota Priority/ Linkage to National Priority Area	Rationale for Selection
Reduce tobacco use in pregnant women/ Well women care	In ND, about 18 percent of women (1 in 5) reported smoking at any point during their pregnancy, compared to about 11 percent nationally (1 in 10). Smoking during pregnancy can cause a baby to be born too early, have low birth weight, and increases the risk of Sudden Infant Death Syndrome (SIDS).
Increase the rate of breastfeeding at 6 months/ Breastfeeding	In ND, about 45 percent of women report having breastfed their infants at 6 months, compared to about 50 percent nationally. Breastfeeding is associated with a reduced risk of SIDS, reduces a child's risk of becoming overweight as a teen or adult, and has been linked to decreased risk of breast and ovarian cancer in women.
Reduce disparities in infant mortality/ Safe sleep	In ND, the American Indian infant death rate (15 per 1,000) is about 4 times greater than that of the White infant death rate (4 per 1,000). Significant differences exist in infant deaths between races. Infants born to American Indian mothers are at much higher risk for poor birth outcomes, including being born too early, being born at low birth weight, and to die in the first year of life.
Reduce fatal motor vehicle crash deaths to adolescents/ Injury	In ND in the past three years, unintentional injuries among youth ages 15 through 24 due to motor vehicle crashes ranged from about 19 to 27 per 100,000. Motor vehicle crashes are the number one killer of teenagers; young drivers are twice as likely as adult drivers to be in a fatal crash. Motor vehicle crashes are preventable and proven strategies can improve the safety of young drivers on the road.
Reduce overweight and obesity in children/ Physical activity	In ND, about 36 percent of children and teenagers between the ages of 10 through 17 are considered overweight to obese, compared to 31 percent nationally. There are many reasons for childhood obesity including poor food choices and reduced physical activity. Children that are overweight have an increased risk for heart disease, diabetes, asthma, and low-self-esteem.
Decrease depressive symptoms in adolescents/ Bullying	In ND, about 25 percent adolescents (1 in 4) report having depressive symptoms (feeling sad and/or hopeless) and/or being bullied in the past 12 months. Mental/behavioral health conditions have been increasing among children. Bullying is a major public health problem that is linked to depression, antisocial behavior, suicidal thoughts, poor school performance, et cetera.
Increase the utilization of medical home/ Medical home	In ND, about 48 percent of families of children with special health care needs, ages 0 to 18, report having received coordinated, ongoing, comprehensive care within a medical home. A medical home means a child has a personal doctor or nurse as a usual source of care, gets needed referrals, receives effective care coordination, and assures families are actively involved in their child’s care. Children with a medical home are more likely to receive preventive care, are less likely to be hospitalized, and are more likely to be diagnosed early for chronic or disabling conditions.
Increase the number of children with special health care needs receiving transition support/ Transition	In ND, about 47 percent of parents of children with special healthcare needs report having adequate resources for their child's transition into adulthood. Transition to adulthood is a critical developmental period. Children who do not receive transition services are more likely to have unmet health needs as adults. Transition includes discussions about adult doctors, changing health needs, health insurance, and appropriate self-care and management.
Increase adequate insurance coverage to the MCH population/ Adequate insurance coverage	In ND, about 23 percent of all children did not have adequate health insurance to meet their complex needs, compared to about 28 percent of children with special healthcare needs. A benefit of health insurance is better access to care; however, individuals with continuous insurance coverage may still not be adequately insured. Inadequate insurance can lead to delayed or foregone care. Problems include cost-sharing requirements, benefit limitations, and inadequate coverage of needed services.
Increase preventative dental services to children/ Oral health	In ND, about 42 percent of Early Periodic Screening Diagnostic and Treatment-eligible children ages 6 through 9 reported having received any dental services. Oral health is an important component of overall health throughout life and is a great unmet health need among certain population groups within the state. People with limited access to oral health care are at greater risk for chronic diseases.

Additional areas of need that were examined, but ultimately not included as state priorities included home visiting programs, suicide, youth and adult smoking rates, the incidence of sexuality transmitted infections, obesity in adulthood, racial disparities, and American Indian mortality ages 0-44.

What were some successes and limitations of this need assessment?
ND’s five-year needs assessment process was successful in selecting state priorities and national priority areas; this success was due to several factors. First, having a core MCH leadership team leading the process increased the efficiency of moving the needs assessment process forward. In addition, by having a large body of data to support the process, the design and implementation of the needs assessment was for the most part comprehensive and representative of the needs of the MCH population. Finally, involving state MCH staff and stakeholders during all phases of the process assured that the findings of the needs assessment served as the “drivers” in determining MCH program priority needs and in developing the five-year action plans to address them.

Although the needs assessment process was successful, there were some limitations including under-representation of rural counties and tribal populations in the qualitative portions of the process; lack of a thorough program capacity assessment; and time constraints in conducting needs assessment activities with competing priorities.

The needs assessment is an on-going process and ND will continue to monitor and assess the successes and continuing needs of the MCH population.

Contributing authors:
Grace N. Njau
Epidemiologist/Maternal and Child Health/Oral Health
Division of Family Health
North Dakota Department of Health
Bismarck, ND 58505

Devaiah Muccatira
Research Analyst III
State System Development Initiative Coordinator
Division of Children's Special Health Services
North Dakota Department of Health
Bismarck, ND 58505

Kim Mertz, Director
Division of Family Health/Title V MCH
North Dakota Department of Health
Bismarck, ND 58505

Tamara Gallup Lelm, Director
Division of Children's Special Health Services
North Dakota Department of Health
Bismarck, ND 58505