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Strengthening Maternal and Infant Health Data in the U.S. Territories ASTHO, association of state and territorial health officials, maternal and infant health data, U.S. territories, public health, surveillance programs, pregnancy risk assessment monitoring system, improving the health, live births, health problems, reproductive health, federal government, toggle the centers for disease control and prevention cdc, risk assessment monitoring system, assessment monitoring system prams, pregnancy risk assessment monitoring, maternal and infant health, information collected, table of contents, population based, health status, supreme court, prams data, toggle the table, risk factors, prenatal care, collecting information Stephany Strahle The U.S. territories—Puerto Rico (PR), U.S. Virgin Islands (USVI), Guam, Commonwealth of the Northern Mariana Islands (CNMI), and American Samoa—are largely excluded from most statistical data systems in the United States. This gap leaves island health leaders, national partners, and federal agencies without the surveillance necessary to inform timely and robust public health programs and policies. This is also seen in critical maternal and child health surveillance programs like the Pregnancy Risk Assessment Monitoring System (PRAMS), Maternal Mortality Review Committees, and the Pregnancy Mortality Surveillance System, which either do not include or only recently included territories in their scope of coverage. This incomplete information creates challenges in identifying the aspects health systems need to address to reduce adverse maternal and infant health outcomes. Applying a life course perspective to maternal and infant health data reveals gaps in public health systems that impact outcomes before, during, and after birth. PRAMS provides vital insights into these lived experiences and pregnant people’s interactions with health care services. PRAMS data can also be linked to other administrative datasets, such as Medicaid, child welfare services, and Community Healthy Start programs, to provide a broader understanding of determinants of health across the life course for both the birthing parent and their child. With the breadth of contextual experiences that PRAMS captures in its data and the potential for data linkage projects to explore outcomes and their contributing factors, U.S. territories can leverage this wealth of information to assess the needs of their pregnant communities and their children. Despite its development in 1987, PRAMS has been implemented in only two territories, PR and CNMI, within the past decade. This brief highlights the work of these two islands and the potential to gain further insights into maternal and infant health outcomes using data linkage methods. Island Expansion of Maternal and Infant Health Surveillance Using PRAMS Since beginning PRAMS data collection in 2017, PR has made considerable strides in providing their communities with comprehensive reports on various topics. In 2021, one in eight live births was preterm in PR—the U.S. average is one in 10 live births. This outcome is one example of a potential research area in PR that could leverage PRAMS linkages to clinical administrative data sources to investigate contributing factors. In a special project conducted from 2016 to 2018, PRAMS served as an avenue for assessment of Zika awareness among pregnant people and their partners. Moreover, PRAMS informed numerous reports and educational materials on topics ranging from dental care to lactation and opioid use during pregnancy. Linking PRAMS to other administrative datasets could illuminate more information about health care utilization and access among pregnant people in PR. Although limited research exists on maternal and infant health outcomes in CNMI, available evidence reveals disparities in preterm birth among the territory’s indigenous Chamorro and Carolinian communities and Asian and Pacific Islander groups. Since CNMI started administering PRAMS in 2021, strong relationships with entities outside the territory (e.g., the Hawaii Department of Health) have facilitated PRAMS implementation by helping navigate Internal Review Board regulations and applications—both of which are necessary to conduct PRAMS collection and potential research using PRAMS data, like data linkage projects. Moreover, the CNMI PRAMS team’s deep familiarity with their communities could help identify local administrative data sources that, when linked to PRAMS, capture priority areas for improved health care and social service delivery. Considerations for Future Maternal and Infant Health Data Exploration With the existing gaps in surveillance data available for maternal and infant health, this recent implementation of PRAMS and the potential for data linkages to other data sources could provide enhanced insights for U.S. territories. The following considerations can inform best practices to optimize this data. Building Partnerships to Support a Linked Maternal and Infant Health Data Network To build capacity for further data exploration, building partnerships with other agencies and PRAMS jurisdictions can facilitate the information-sharing necessary to navigate data use agreements and other considerations before successfully linking data. Leveraging these connections can also supply more avenues to administer educational tools about PRAMS and perinatal services, linking their pregnant populations to the services they need. A robust web of partnerships can create a network of linked data capturing the life course perspective to inform high-quality programs for the ongoing care of pregnant people and their infants. Leveraging Community Input and Data on Social Determinants of Health Territories are uniquely positioned to leverage closer community ties to examine how data linkages can inform initiatives that improve experiences surrounding pregnancy and the life course after birth. As with PR, integrating the voices of pregnant people, their families, and the people providing their care into their advisory committees allows for better identification of what communities need. Active engagement ensures agencies can be efficient with their linkage efforts by tailoring their projects to high-priority maternal and infant health outcomes. Moreover, to foster community awareness about PRAMS and possible linked data sources, territories could create dashboards such as those created by Washington D.C.’s PRAMS program to provide a comprehensive and interactive view of the data. Data on social determinants of health collected through PRAMS—such as insurance coverage throughout pregnancy and postpartum as well as access to social support and a wide range of services—can also be leveraged for potential data linkage to identify inequities in health outcomes and the delivery of care. website yes

Heart disease and stroke are the leading causes of death in Guam, Palau, and the Commonwealth of the Northern Mariana Islands. These jurisdictions are taking innovative steps to reduce hypertension among their populations.

Poster used as a visual to summarize Commonwealth of the Northern Mariana Islands' (CNMI) project. Target audience includes community members, public health programs, other jurisdictions, funders, and partners.

Agreement form that includes information about the program for patients to review before enrolling.

Questionnaire for weekly phone interview with participants enrolled in the peer coaching program.

Collecting and sharing data are crucially important to improving health equity, because those datasets inform effective policymaking. Despite having some of the most challenging population health outcomes, the U.S. island areas are often absent within federal public health datasets.Federal, island, and nonprofit partners should prioritize efforts to increase their inclusion.

Learn how increasing the use of indirect cost rates in the territories and freely associated states can help improve public health financing in these jurisdictions.

This ASTHOReport serves as a primer for state and territorial health agencies seeking to assess the public health impacts of lead exposure in drinking water.

This report aims to highlight the unique vector-borne disease challenges faced by Island Areas and to dive into the key components of a mosquito control program, that are relevant to these unique jurisdictions.

This toolkit is designed to support public health leaders in leveraging the policy development process to achieve health equity in their jurisdiction.

As COVID spread through the country and infection rates rose in every state, many of the the U.S. Affiliated Pacific Islands (USAPI) received media attention for remaining relatively COVID-free. The USAPI’s unified response in the face of a global pandemic is a history-making tale of collaboration, communication, and partnership. The successes of public health leaders provide important lessons for preventing, preparing for, and responding to future public health emergencies.

The 2020 holiday season is coinciding with a nationwide surge of COVID-19 cases. With great concern that holiday travel to see loved ones may exacerbate community spread of the virus, many states are increasing public health measures before the winter holiday season. As of November 16, 2020, 13 states and D.C. had a quarantine requirement for out-of-state travelers. The U.S. territories also have instituted travel restrictions to limit the spread of COVID-19.

Get insight into the successes and challenges of integrating race/ethnicity data in public health and future directions in this field.

This blog describes public health legislation introduced during the Island Areas’ 2024 legislative sessions.

Learn how CNMI and Palau successfully "planned to plan" in an effort to update and develop new public health plans—developing readiness assessments, team charters, and sequencing plans.

Strengthening Leadership, Risk Communications, and Preparedness in the Islands Strengthening Public Health Preparedness in the Islands Sidnie Christian, Alyssa Boyea Key strategies in on leadership, risk communications, and preparedness, can help island jurisdictions prepare for and respond to emerging public health threats. ASTHO convened a two-day, in-person workshop in Honolulu from June 25 – 26, bringing together public health preparedness staff from American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, Hawaiʻi, the Republic of the Marshall Islands (RMI), and Palau, as well as federal partners from CDC, the Department of Homeland Security, and the Administration for Strategic Preparedness and Response. The workshop focused on leadership and workforce development, risk communications, administrative preparedness, and more to support island areas as they prepare for and respond to natural disasters and other emerging public health threats, of which emerged key learnings that can benefit all island jurisdictions. Leadership and Workforce Development Leading through change requires transparency, trust, and collaboration. Planned change involves assessing readiness for change, identifying resources needed, securing buy-in, and determining a path forward. However, sometimes change can leave little to no time for preparation. Island jurisdictions have encountered challenges in the face of change, with many workshop participants sharing firsthand challenges around retaining institutional knowledge, infrastructure, and receiving assistance from the mainland United States in a timely fashion. As such, change readiness, succession planning, and effective change management practices are of utmost importance in the islands. Key recommendations and takeaways include: Utilizing a reputable framework, such as Kotter 8-Step Change Model, is pivotal for improving change readiness and change management. Change management frameworks and methods can assist with different types of change including structural change, strategic operational change, people-centric change, etc. Trust is hard to build, but easy to lose. Participants spoke about characteristics of high trust relationships including open communication, consistency, good judgement or expertise, and cultural sensitivity, while low trust relationships characteristics include lack of communication, inconsistency, and lack of teamwork. Succession planning is important to ensure institutional knowledge and capabilities remain in the wake of staff turnover or retirement. Identifying the necessary expertise, skills, and capabilities for each role is vital in the case of unplanned changes in staffing. Promising practices include annual review of critical positions, conducting talent calibration sessions, defining action plans, and obtaining buy-in from leadership and relevant partners. Risk Communications The island jurisdictions face emergencies that require creative response efforts. Both Hawaiʻi and RMI demonstrated innovative approaches in risk communications during COVID-19, finding success in forming critical partnerships, utilizing trusted voices within the community, and bridging communication gaps: Hawaiʻi utilized social media to showcase individuals such as doctors, pastors, social media influencers, and even local sports teams getting vaccinated, and utilized trusted voices to deliver messages. Additionally, they translated their materials into three languages (Marshallese, Samoan, and Hawaiʻian), modeling that no one gets forgotten, the true meaning of “ohana.” RMI created a working group with a mix of partners that curated press releases, educational materials, and sitreps, and served as a liaison between RMI Ministry of Health and Human Services and the community. It also partnered with several media outlets (e.g., radio stations, local papers, and other private sectors) and utilized mass text messaging to spread information quickly. The latter proved to resonate with most island jurisdictions who struggle with staying connected to hard-to-reach populations, namely those in more rural and disconnected communities. RMI was able to connect with these populations through WhatsApp to keep them updated throughout the COVID-19 response. Administrative Preparedness Improving administrative preparedness plans and processes ensure timely and efficient access to needed resources for a public health response. Most workshop participants are currently in the process of updating existing administrative preparedness plans, while some are working with other departments to create and implement new plans. Attendees discussed key partnerships for collaboration including other departments, Medical Reserve Corps, and other volunteer organizations. One common key challenge that emerged was around staffing (e.g., finding qualified people to fill vacancies, hiring process issues, making sure positions are competitive, etc.). To address this issue, island jurisdictions can work closely with other departments or jurisdictional agencies to streamline current processes, establish memorandums of understanding with different partners/facilities to assist with emergency procurement, and ensuring staffing vacancies are competitive and match public health classifications. Disease Forecasting A survey on state and territorial expertise and needs for infectious disease forecasts, models, and other outbreak analytic techniques—implemented by ASTHO with support from CDC’s Center for Forecasting and Outbreak Analytics—revealed that respondents from island jurisdictions experienced several barriers that led to limited use of infectious disease forecasts to inform communication and decision making. Challenges noted include limited software access, limited disease modeling capacity or skills, and lack of uniform reporting systems. Through a discussion-based exercise, workshop participants shared their challenges and considerations for ASTHO and CDC to assist with disease forecasting in the island jurisdictions moving forward. Challenges include but are not limited to: Delays with sending samples to labs and receiving results in a timely manner. Without timely results, it is challenging to take swift action. Lack of staff / staff wearing many hats with limited capacity. In most cases, there is no specific communication plan for disease forecasting within the departments. Communication can be challenging without clear processes and channels. Participants noted the desire for additional disease forecasting training and opportunities for collaboration. They suggested an integrated training session with island epidemiologists and other relevant staff to enhance disease forecasting knowledge and communication, as well as strengthen collaboration. Preparing for and Responding to Climate Events From hurricanes to typhoons to volcanic eruptions, the island jurisdictions are no strangers to the effects of changing climate. Willliam “Brandon” Aydlett, science and operations officer at the National Weather Service, and Shelbi Davis, Senior Analyst on the Environmental Health team at ASTHO, offer the following recommendations to island jurisdictions for preparing and responding to unprecedented climate events, as discussed with workshop participants: Create or update standard operating procedures for various climate related responses unique to the island. Always prepare for a category higher storm than is expected. Consider conducting regular vulnerability assessments to better understand areas where the island or its people may be most susceptible to adverse health impacts from climate events. Jurisdictions can learn from one another and find a sense of camaraderie in their preparedness efforts, much like the workshop participants. For example, one island jurisdiction noted that they currently do not have a warehouse to store equipment but are working on a plan to secure one; another jurisdiction, having recently revamped their warehouse, noted that they could assist their island neighbor in this endeavor and provide lessons learned as well as strategies to help secure a warehouse that will fit their needs. Looking Toward the Future Sharing lessons learned with one another and reflecting on how to apply those learnings in respective communities is crucial. Workshop participants shared their intent to share and utilize resources and information shared throughout the workshop with their leadership and team to begin implementing in their jurisdictions, as well as using strategies and skills learned to enhance partnerships. To all the participants and our Hawaiʻian hosts, we say mahalo. Related Resources Modernizing Infrastructure and Facilities for Readiness and Response | ASTHO PH-HERO Workforce Resource Center | ASTHO ASTHO STAR Center | ASTHO Evidence-Based Strategies to Enhance Public Health Emergency Preparedness and Response | JPHMP article yes

ASTHO Awards Public Health Leaders and Agencies for Service BETHESDA, MD—The Association of State and Territorial Health Officials (ASTHO) presented several awards during its 2019 Annual Meeting and Policy Summit this week to commend public health leaders and agencies for their service and dedication to improving our nation’s health. “We’re pleased to recognize this distinguished group of health professionals and agencies,” says Elke Shaw-Tulloch, state health officer at the Idaho Department of Health and Welfare, past ASTHO president, and chair of ASTHO's Nominations, Awards, and Membership Committee. “The excellence we highlight today touches millions of lives and represents just a small sample of our nation’s dedicated public health professionals, who continuously strive to promote the public’s health and well-being.” The 2019 ASTHO awardees include: John Wiesman, DrPH, MPH, Secretary of Health, Washington State Department of Health Arthur T. McCormack Award Dr. Wiesman has served as Washington state’s health official since 2013 and currently co-chairs the Presidential Advisory Council on HIV/AIDS. Under his leadership, the Washington State Department of Health is spearheading the End AIDS Washington program, developing the Healthiest Next Generation initiative, identifying and funding foundational public health services, implementing the governor’s executive order to reduce suicide and prevent firearm injuries and deaths, and addressing the public health impacts of climate change. Stephanie C. Williams, RNP, MPH, Senior Deputy, Arkansas Department of Health Noble J. Swearingen Award As deputy director for public health programs at the Arkansas Department of Health, Ms. Williams oversees and guides the work of the agency’s four operational centers: Health Advancement, Health Protection, Local Public Health and Public Health Practice. She also oversees the state public health laboratory and the state offices of Health Communication and Minority Health. Ms. Williams also advises and assists the state health official in setting policy and programmatic direction for the department and serves as state health official in his absence. Janae Price, MPH, Senior Epidemiologist, Illinois Department of Public Health State/Territorial Excellence in Public Health Award Ms. Price served the Illinois Department of Public Health from April 2016 to March 2019 as a member of the U.S. Public Health Service Commissioned Corps. She led or co-led more than five nationally-funded statewide projects, ten committees or workgroups, and numerous complex multi-year projects. Price’s contributions led the health agency to strengthen its chronic disease epidemiology capacity by integrating evaluation and performance monitoring for chronic disease programs, developing critical partnerships, improving data collection and reporting quality, and using innovative methods to assess public health needs. Paul K. Halverson, DrPH ASTHO Alumni Award Dr. Halverson served as the state health official for the Arkansas Department of Health from 2005-2013. He oversaw the development of Arkansas’ statewide trauma system, which has become a model for other states, and he greatly enhanced the effectiveness of the Arkansas Public Health Preparedness Program and the Arkansas Public Health Laboratory. As a state health official, Dr. Halverson was a mentor to many new state health officials and a trusted colleague to his peers. After transitioning to his position as founding dean of the Indiana University Richard M. Fairbanks School of Public Health, he has remained active as an ASTHO alumnus, serving as president of the ASTHO Alumni Society. Increasing Immunization Capacity in Texas Emergency Responder Facilities—Texas Department of State Health Services ASTHO Vision Award, First Place, Category A (Programs ≥ $250,000) ASTHO recognizes Texas Department of State Health Services for its work raising immunization rates for Texas emergency responders. Implementation of the New York State Prevention Agenda 2013-2018—New York State Department of Health ASTHO Vision Award, Second Place, Category A (Programs ≥ $250,000) ASTHO recognizes New York State Department of Health’s for its work developing a six-year state health improvement plan, which aims to make New York the healthiest state. Developed in collaboration with the Ad Hoc Committee to Lead the Prevention Agenda and more than 140 statewide organizations, the plan identifies New York’s most urgent health concerns and recommends ways statewide organizations and local health departments, hospitals, and partners from the health, business, education, and nonprofit sectors can work together to address them. Office of Grants Management—Northern Mariana Islands Commonwealth Healthcare Corporation ASTHO Vision Award, First Place, Category B (Programs less than $250,000) ASTHO recognizes the Northern Mariana Islands Commonwealth Healthcare Corporation for establishing the Office of Grants Management to improve coordination of the administration of all of the health agency’s federal programs and external funds. The office was created to oversee the financial and record keeping aspects of the annual grant-making process for the corporation and its divisions for all grants received or awarded. It also collaborates closely with all program managers to streamline and improve grant applications, implementation, administration, compliance, performance, and reporting requirements on all grants. Local and Tribal Public Health System Improvement Program—Montana Department of Public Health and Human Services ASTHO Vision Award, Second Place, Category B (Programs less than $250,000) ASTHO recognizes Montana Department of Public Health and Human Services for its efforts to improve Montana’s local and tribal public health infrastructure. As part of this work, the health agency has strengthened partnerships between the healthcare sector and public health agencies; accelerated the use of the Public Health Accreditation Board’s national standards for public health practice by state, local, and tribal public health agencies; and strengthened local boards of health. ASTHO Press Release Boilerplate website yes

Guam, Palau, and CNMI PHIG teams leverage diverse expertise to advance data modernization assessment, planning, and implementation strategies.

The bill provides $27.1 million to address shortfalls in Medicaid funding in the Northern Mariana Islands and extends critical autism-related programs.

For Emman Parian, Strong Partnerships Are at the Heart of Public Health Strong Partnerships Are at the Heart of Public Health Anya Groner Learn about Immunization Program Manager Emman Parian's approach to public health success: strong partnerships and collaboration. As immunization program manager for the Commonwealth Healthcare Corporation (CHCC) in the Commonwealth of the Northern Mariana Islands (CNMI), Emman Parian and his team work closely with a range of organizations: school systems, government agencies, private businesses, other Pacific Island jurisdictions, and national partners including ASTHO and the Association of Immunization Managers. Maintaining relationships through effective and regular communication sustains those networks and the communities they serve. Thus, the immunization program meets with partners regularly, basing the meeting frequency on partner’s roles and preferences. They also encourage off-island partners to visit in person so they can better understand the CNMI context. According to Parian, they rely on each other for their successes — a lesson he has learned throughout his public health career. Developing a Knack for Community Engagement In less than a decade, Parian has built an impressive career in public health. His journey began in 2018 as a student intern in public health at CHCC. Though he initially planned to become a nurse, his role offering support to community members with hypertension identification and control changed his trajectory. He was able to support people trying to navigate which services they could utilize to improve their health. When his internship ended, participants reported that his calls helped them manage their blood pressure and inspired them to make changes in their nutrition, medication compliance, and regular clinical visits — demonstrating Parian’s impact and providing him with fulfillment.   The Commonwealth Healthcare Corporation Immunization team attend a professional development workshop.   Discovering the Power of Collaboration The power of personal interactions inspired Parian to pursue a bachelor’s degree in health care management and a master’s degree in public health. When the COVID-19 pandemic began, he was shadowing CHCC’s CEO, Esther Muña, and corporate quality and performance manager, Halina Palacios, getting a front row seat as the organization’s leadership team developed their initial response to the pandemic. From this position, he learned effective strategies for addressing public health crises, like leveraging partnerships and building community trust, as well as approaches for successful workforce development. Eventually, he landed a permanent position as a vaccine specialist, managing storage, handling, and distribution of vaccines for the jurisdiction, then becoming the vaccine program coordinator overseeing the COVID-19 vaccination program for several years. Parian attributes his success to the supportive culture at CHCC where program managers and leadership regularly collaborate to align their missions for the benefit of the community. Making Advancements Through Outreach These days, Parian is a leader at CHCC, working as the immunization program manager for CNMI. Post-pandemic, vaccine hesitancy is on the rise. Parian’s team is responding by building trust through relationship-building activities and education. Emman Parian 1 - Strong Partnerships Are at the Heart of Public Health The team regularly visits villages, schools, health programs, and community centers, and even runs Saturday clinics/outreach events to ensure that all community members have the opportunity to get vaccinated. Efforts like these are particularly important given CNMI’s geography, which includes 14 islands, with three populated islands (Saipan, Tinian, and Rota). Even so, CNMI is in a better position to respond to future public health emergencies post-pandemic due to their expanded and improved partnerships and collaboration.   Parian attends a regional meeting with other Pacific Island managers and staff in Saipan.   Leading with Open Communication As a manager, Parian emulates the leadership models that he encountered early in his career. Open communication enabled Parian’s rise in the field, and he encourages discussion among his team. Whether feedback is positive or negative, Parian takes it into consideration. For him, leadership doesn’t mean dictating what your team does but instead working alongside them and being open-minded. That approach resonates. Emman Parian 2 - Strong Partnerships Are at the Heart of Public Health Building a leadership approach that works is important, as turnover can hinder programs due to lost institutional knowledge and a constant need to retrain employees. But lately, there’s less turnover. Parian notes that young people are increasingly invested in health care careers, a shift he attributes to recent health crises. Like him, they have a drive for outreach work and find fulfillment in it. Positioned for Future Public Health Success Strong collaboration builds the sustainability and infrastructure necessary for CHCC to succeed in their public health efforts. Should a new health crisis emerge, CHCC will be able to coordinate with partners to quickly identify resources, technical assistance, and subject matter experts. With strong teams and partnerships in place, Parian believes CHCC is ready for the future. article yes