# Presentation: 824697

## Public Health 

- in the South West:
- Successes and Challenges
- in Maternal & Child Health

**Joyce Naseyowma-Chalan, MPH**
**Director, Public Health Division**
**New Mexico Department of Health**
**December 10, 2003**

**Notes:**
Joyce:  your opening statement ........

## Welcome to the South West		

- New Mexico, the land of enchantment
- Arizona, the Grand Canyon State

**Notes:**
Joyce: 

## Slide 3

## Slide 4

## Slide 5

## Slide 6

## Slide 7

## The Navajo Nation Across NM, AZ, UT

**Notes:**
Susan:  Here you see how the sovereign Navajo Nation crosses the states of New Mexico, Arizona and Utah

## New Mexico and Arizona

- 1.8 million in New Mexico
- 5.1 million in Arizona

## Racial & Ethnic Diversity Children <18 Years of AgeA Different Profile

- New Mexico
- 50.9% Hispanic

- Arizona
- 36.1% Hispanic

**Notes:**
Joyce’s Text ........ Write here Joyce, what you will say about the racial-ethnic, cultural diversity of the south west... its unique characteristics

## Challenges 	

- There are 32 counties in New Mexico with a high proportion designated as HEALTH PROFESSIONAL SHORTAGE AREAS
- 27 for PRIMARY CARE
- 13 for DENTAL CARE
- 32 for MENTAL HEALTH
- As many as 17% of New Mexicans report they cannot access preventive services due to distance and access issues

- Source: NM Health Policy Commission, 2002

## Rural areas, remote roads, issues of access

**Notes:**
For rural counties, the average time to get to primary care is >30 minutes; for some areas it can be 1-2 hours for the one-way trip.

## Meeting the Challenges 	

- New Mexico works to improve access to care for its rural and tribal communities:
- Indian Health Service
- Federally Qualified Health Centers
- State and Tribal WIC Programs
- Local Health Offices of the Dept Health serve as a “safety net”

**Notes:**
Joyce, please add to slide AND do your script for this one

## Arizona and New MexicoThe South West using 10 Indicators		

- The Kids Count 2003 featured 10 indicators of MCH well being
- These two states are challenged by 7/10
- There are successes or progress in 3/10

**Notes:**
The 2003 Kids Count Report of the Anna E. Casey Foundation features 10 indicators of MCH well-being.  These two states are challenged by 7 of the 10; and there are success or progress in 3 of the 10.  Many are predictive of health outcomes;  a few are health outcomes.  

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;

**Notes:**
The blue triangle is New Mexico.  The red diamond is Arizona.  Here you see that for the set of 10 indicators, NM and Arizona struggle within the 10 worst-ranking states for these indicators ... next slide

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
From 1990 to 2000, the percent of children under 18 living in poverty shows a net improvement in this slide with a scale from 16% to 32%; however the disparities between the nation and our two southwestern states is evident.  Poverty is predictive of many poor health measures:  preventable illnesses, injuries, risk-taking behaviors, hunger and poor nutrition, access to and use of health services.

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
The percent of families with children headed by a single parent is on the increase .... For South west states, associated in part with cultural aspects of childbearing among our Hispanic and Native American populations.

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
These two southwest states have a higher percent of unemployed families with children

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
And of teens who are high school drop outs, NM at about 11 percent and Arizona at 17%

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona; Green circle = US

**Notes:**
And of teens age 16 – 19 who are neither in school nor working

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
Low birthweight in these two states has often been at or better than the national figure; in all cases, there appears to be an increase in low birthweight .... An observation that deserves detailed analysis at the state and local level for there to be progress made.  The Perinatal Periods of Risk process can help to pin-point effective targeting of services

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
Easy access to firearms, youth drinking and speed limits over 70 miles per hour contribute to the disparities seen here between southwestern states and the US.  Child fatality review in both of these states works to understand factors that can reduce these higher rates.

- 7 of these measures Challenge
-  our two states3 are related to some of our
- successes

## Slide 24

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
Our 2 states are showing decreases in infant mortality.  In New Mexico, some of this sharp decrease was due to the 50-60% drop in SIDS events.  The Back to Sleep campaign and results from NM Child Fatality Review and NM PRAMS help to target SIDS prevention messages .. Not only sleep position for baby sitters, fathers, other family members and infant day care .... AND the risks of smoking as well.

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
Births to young teens are greater in these two states, again associated with cultural dimensions of young childbearing among Hispanic and Native Americans.  The disparity between the southwest and the US is great; yet a decline is apparent.  In NM PRAMS tells us that over 75% of these births were unintended pregnancies.  Although data cannot be linked ~ In New Mexico the Youth Risk Resiliency survey is helping to address teen sexuality and uses of evidence based strategies to meet needs of youth who need services and youth who need support through abstinence.  

## Slide 27

**Notes:**
Joyce, just show this photograph with brief narration “the majority of fatal injuries in children are preventable ...”

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
I am told to say “CAUTION, small numbers for each year” .... Nevertheless we see the downward trend in child deaths for ages 1-14, the majority of which are unintended injury.  The role of each state’s Child Fatality Review to identify risk reduction factors and systems improvement factors will be critical to more progress.

## Blue triangle = New Mexico; 

- Blue triangle = New Mexico;
- Red diamond = Arizona;       Green circle = US

**Notes:**
This final slide of the 10 indicators of childrens well being by Kids Count shows the continuum of injury across ages, teens 15-19.  While progress is evident, the role again for additional data to help our states determine how to target efforts is critical.

## Building on Success of WIC to work on the challenge of immunization coverage

**Notes:**
New Mexico is among the top 4 states for breastfeeding initiation ... at 80%.  NM WIC and Tribal WIC play a strong role in this success.  Yet our state has only 62-63% immunization coverage.  Here Rosalyn Carter visits with WIC staff ... WIC is the gateway for many pregnant women to enter care ... and now, a potential gateway to get children immunized.  We must take care to ensure that WIC can still do its job, resources are critical!

## Slide 31

**Notes:**
In NM, the WIC program is the first pilot for the Electronic Benefits Transfer (EBT) card ... it will ease the food purchase for mothers and grocers alike.  Down the road, our mothers and infants may use such a card to register immunizations, prenatal care, and other critical services.

## NM PRAMS generates data that is critical to reducing gaps among our tribal communities

- The PRAMS team is proactive, they go out into tribal communities to promote understanding and use of the data
- In turn, tribal communities use the data to prioritize resources

**Notes:**
The PRAMS survey is a success in NM; the PRAMS team works proactively with many community groups to promote understanding of the data, and ways in which the data can drive improvements in health programming

## PRAMS data is used

- by policy makers in
- Managed Care Organizations
- the US Mexico Border Area and its Healthy Start Programs
- The Department of Health’s Strategic Planning

**Notes:**
PRAMS data is actively sought by several of our Department of Health Partners.  Executive Directors of NM Medicaid Managed Care Organizations used PRAMS for the Family Planning Waiver, and more recently it contributed to expanding the medicaid benefit package for pregnant women.  As PHD Director, these active partnerships are an example of how our epidemiologists need to be working ... its is a significant part of the road to success 

## Challenges 	

- Political atmosphere ... where does health fit in political leadership priorities
- Style(s) of leadership
- Partnerships – many communities and tribal entities
- Diminishing resources – critical to have data to make good decisions
- Issues of gaps and disparities in access to care

**Notes:**
Joyce:

## Successes		

- Alphabet Soup Group
- Rocky Mountain MCH Training Partnership
- State and Tribal Data Advisory Group
- 10 Essential Public Health Services exercise
- Child Fatality Review
- Uses of qualitative data, our stories, to explain quantitative data

**Notes:**
There are many challenges in these large, rural states.  And, there are many successes.  In New Mexico we have a strong tradition of developing partnerships across the state to address issues.  
The Alphabet Soup Group, so-named because of the many acronyms in health, convenes monthly with executive directors of Medicaid Managed Care Organizations, leaders from Medicaid, the Dept. of Health, the Children Youth & Families Departments.  It is a data-driven group .... They are regular clients of PRAMS data
The Rocky Mountain MCH Training Partnership, across the southwestern and rocky mountain states, is an example of partnerships to address the need for MCH training in our MPH programs.  
I am proud that several working groups of epidemiologists are formed in NM; one example is the state and tribal data advisory group that meets every month to share data and information ... consultation and capacity building.
The state has sponsored several assessment exercises to build our capacity in the 10 essential public health services; our mch epidemiology team joins in these as do many other epidemiologists, they are critical to the process which builds relationships as well as capacity
Stories are significant to understanding and thinking about the data we collect .....

## Slide 36

**Notes:**
To begin:

"Hello, my name is ________________ (from ______ clan, if Navajo).  I’m here today to talk about some preconception health issues.  This means how to make our bodies strong BEFORE and DURING our pregnancy so that one day we can have a healthy baby.  Our elders teach us health habits by their actions.  If you are a parent, grandparent, uncle or aunt, you can share this information with young ones in your life."

"I'd like to suggest we do two things today:  first, talk a little about preconception health related to 5 issues:  drinking alcohol, smoking cigarettes, not getting enough folic acid in your diet, being overweight, and having diabetes.  Then I'd like to talk about what each of you makes of this information for yourself.  Would that be okay?" 

## Slide 37

## Slide 38

**Notes:**
As the Public Health Division Director, I will tell you a story ... First, this beautiful canyon is near my home at Cochiti

## Public Health Leadership in the South West	and MCH Epidemiology	

- Challenging profile of social determinants needs good epidemiology
- Traditions of consultation, partnership, working groups
- Public health leadership to strengthen capacity

**Notes:**
As we have seen, the south western states of Arizona and New Mexico have disproportionately high levels of poverty associated indicators.  
While we have fewer people and resources than states with larger populations, in NM we have learned to make the most of our resources.  This is achieved through fostering an environment of collaboration, working together.  Among the community of epidemiologists they strive to achieve conditions for sharing data, linking data.  Public health leaders work closely with epidemiologists (we in leadership are their data clients) .... 
While a Public Health Division Director has a broad portfolio of responsibility, a key one is to work to strengthen our MCH epidemiology capacity.  .......

## Acknowledgements

- Susan Nalder, EdD, MPH
- 	-  MCH Epidemiologist & MCH Epidemiology Program Manager, Family Health Bureau, Public Health Division

## Photo and Data Credits 

- Landscapes
- 	- www.nmmagazine.com/PHOYOTOURS
- 	- www.taospueblo.com
- Data Credits
- - Anna E. Casey Foundation, website with data tables (kidscount 2003) and census data 2000
- Art
- - B. Seutopka, Hopi 03

## Thank you MCH Epidemiologists

- for all you do to improve the health of mothers, children and families!

## Slide 43

## Slide 44

## Slide 45

## Slide 46

## Slide 47

## Slide 48