Overview

The Adolescent Health unit of the Department of Health (DOH) works to ensure equitable opportunities for improved social, emotional, and physical health and wellbeing for adolescents and young adults. Program goals include providing access to quality age-appropriate health services, ensuring safe and supportive environments at home, school, and in the community, and increasing sexual health services and information.

 

Our state action plan for adolescent health focuses on the following priorities: sexual and reproductive health, access to appropriate health care services, support for pregnant and parenting teens, and sexual health education.

 

National Performance Measure 10 – Adolescent Well-Visit

Percent of adolescents, ages 12 through 17, with a preventive medical visit in the past year.

 

The latest data from the National Survey of Children’s Health (2016-2017) indicate that 81.3 percent of adolescents, aged 12 to 17, received a preventive medical visit within the last year.

 

Much of the work for this measure in the reporting year has focused on three areas:

 

1. Delivery of age-appropriate, evidence-based clinical services (“teen friendly services”).

Three times per year, the Adolescent Health unit provides a 60 to 90 minute presentation on sexually transmitted infections to nursing students at three community colleges across the state, in Yakima, Bellingham and Bellevue. The Washington State Personal Responsibility Education Program (PREP) implements a teen pregnancy, sexually transmitted infections [STI] prevention, and adult preparation curriculum at high schools, middle schools, juvenile rehabilitation facilities, and other youth serving agencies.

 

We also continue to encourage adoption of the Bright Futures Guidelines for clinical services and will include evidence-based practices for providing a culturally appropriate environment of care. Issues specific to adolescents addressed in Bright Futures include physical growth and development; social and academic competence; emotional well-being (coping, mood regulation and mental health, sexuality); risk reduction (tobacco, alcohol, or other drugs; pregnancy; STIs); and violence and injury prevention (safety belt and helmet use, substance use disorder and riding in a vehicle, guns, interpersonal violence [fights], bullying).

 

2. Support and promotion of School-Based Health Centers (SBHC). Our evidence-based strategy measure (ESM) for 2019 was to continue to measure the increase in the number of SBHCs able to bill for services rendered. We exceeded our goal of 80 percent of SBHCs able to bill for services rendered, with 85 percent now able to bill. We had the opportunity to address billing problems as a statewide issue rather than approaching it clinic by clinic.

 

The Adolescent Health unit worked to promote school based health centers across the state over the last year. In October, the Adolescent Health Coordinator, along with partners from the Health Care Authority (HCA); Office of Superintendent of Public Instruction (OSPI); and Department of Children, Youth, and Families (DCYF), met with the Governor’s Office to discuss potential models to expand SBHCs. The Adolescent Health Coordinator also participated on a state Senate workgroup around SBHC legislation. The 2020 legislative session had six SBHC-related bills introduced, all with the hope of expanding SBHC services for students. Although many of the bills did not pass, we hope to work with the Washington School Based Health Alliance to build on this momentum and increased interest in the upcoming year.

 

3. Reimbursement for eligible services. Collaboration with HCA has continued to address Medicaid billing issues and cost sharing. Additional training will expand this service.

 

The Title V-funded Adolescent Health Coordinator and Adolescent Health Program Manager have continued to participate on the Healthy Students, Promising Futures (HSPF) Learning Collaborative. This national collaborative is co-convened by the Healthy Schools Campaign and Trust for America’s Health. The purpose of this collaborative is to increase access to school health services through Medicaid reimbursement. The HSPF focuses on federal and state polices that impact school-based health services for children in Medicaid, models for delivering school-based health services and cross-state collaboration.

 

Washington is one of 15 states participating in this project and has cross-agency representation, including HCA, OSPI and DCYF, along with DOH. DOH’s role on this workgroup is to bring the experiences of SBHCs to the table as Washington works with other states to create strategies to expand school-based health services. Over the last year, the Washington State team has received technical assistance around telehealth and trauma informed care through this learning collaborative. The collaborative, cross-agency relationships created through this collaborative have helped leverage our work around SBHCs as well.  

 

National Performance Measure 7 – Injury Hospitalization

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

Rate of hospitalization for non-fatal injury per 100,000 adolescents, ages 10 through 19.

 

In 2018, the overall rate of hospitalization for non-fatal injury was 223.9 per 100,000 for adolescents aged 10 to 19, as reported in the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). The unintentional specific injury hospitalization rate was 123.6 per 100,000 for 10-19 year old adolescents. From the Comprehensive Hospital Abstract Reporting System (CHARS), the top five leading causes of injury-related hospitalization for Washington adolescents aged 10-19 are intentional drug poisoning - 479, unintentional motor vehicle injury - 296, unintentional fall - 244, unintentional unspecified – 112, and intentional cut/pierce - 109.

 

The 2019 Washington State Strategic Highway Safety Plan identifies impairment, distraction, speeding and unrestrained occupants as being the leading risk factors for road users in Washington. Young drivers in Washington, ages 16-25, make up 31 percent of all motor vehicle fatal injuries and 34 percent of all serious injury, but represent just 13.5 percent of all drivers. Among fatal injuries of young drivers, impairment is a factor in 61 percent of fatalities, speeding is a factor in 38 percent, distraction is a factor in 30 percent, and unrestrained passengers is a factor in 35 percent. Recommendations to address these issues for young drivers includes: improve the Graduated Driver’s License (GDL) Law; publicize and enforce the seat belt law; and improve driver training.

 

A small work group committee including the Department of Licensing (DOL), Washington Traffic Safety Commission (WTSC), and DOH was planned for both GDL and review of the driving training curriculum starting in March 2020. Due to impacts from COVID-19 responses of state agencies and transition to mobile workforce these committees being led by DOL have been put on hold, but are expected to start back between June and July 2020.

 

The Motor Vehicle Safety Child Safety Learning Collaborative (CSLC) for Washington State did work on developing a spread plan for Impact Teen Drivers and has started reviewing a pilot of the Alive at 25 curriculum in traffic court for teens. A pilot for Alive at 25 was conducted in Snohomish County with the traffic court there, and preliminary outcomes look promising. Thurston County is the next county planned to spread the Alive at 25 program for teen traffic offenses as a diversion strategy.

 

The CSLC team has reached out to the Impact Teen Drivers organization and is working with them to identify certified trainers to connect with communities and provide technical assistance to initiate the curriculum across the state. COVID-19 has impacted this work as well and placed a temporary hold on these efforts. The team will evaluate how to move forward and consult with OSPI on how future school and classroom structures and routines might require modification of how these curricula will be presented in schools once schools open back up.

 

Local Safe Kids Coalitions provide public health education and awareness at the community level and are the main vehicle for information dissemination at the local level for child safety information and resources. From the last report we had planned to provide training to all Safe Kids coalitions on Positive Community Norms to address motor vehicle injury prevention as well as other child injury mechanisms. Our partner WTSC, held one training in early March just before the shutdown for COVID-19 issued by the Governor. This training was to be followed with a workgroup session at our annual Safe Kids Coalition leadership conference held at the end of March. Unfortunately, due to already rising concerns around COVID-19 at the beginning of March and the following shut down coalition coordinators were not able to travel to attend the early March meeting and the leadership conference had to be canceled. To date we only have 25 percent, or 3 of our 13 coordinators trained. We will work with WTSC and their training contractors to find solutions and get the training to all our coalitions. We hope to reconvene our leadership conference for coordinators in 2021 if funds are available after any required redirection for COVID-19 response or recovery.

 

The Western Pacific Injury Prevention Network (WPIPN), based out of Washington’s DOH, provides technical assistance to state and local public health agencies on a variety of injury and violence prevention strategies and capacity building. WPIPN has had a focus on Shared Risk and Protective Factors (SRPF), working with members on addressing upstream factors to injury. There have been four meetings since October 1, 2019 to date addressing topics of SRPFs and Communications Planning.

 

Our ESM is the number of Teens in Cars safety campaigns held, which was one. We continue to work to promote teen driver education curricula in the local communities. We transitioned from the Safe Kids Teens in Cars curriculum to Impact Teen Drivers as there was greater statewide support through our partner WTSC to increase resources and reach through partnerships with Target Zero Task Force coalitions that cover areas we do not have active Safe Kids coalitions. With position changes at WTSC, a new focus and additional curriculum, Alive at 25, targeted toward a special population of adolescent drivers with traffic violations is being planned for implementation and spread along with Impact Teen Drivers.

 

State Performance Measure 2 – Healthy Weight

Our state performance measure (SPM) is the percent of tenth graders who have a body mass index (BMI) between the 5th and 85th percentile. The most recent data available are from the 2018 DOH Healthy Youth Survey, indicating 68.9 percent. This did not meet our 2019 goal of 70.5 percent.

 

Healthy eating is consuming a balanced diet that meets individual nutritional needs. A healthy diet includes a variety of vegetables, fruits, protein, and low-fat dairy while limiting excess salt, fat, and sugar. Healthy eating promotes growth and development, including brain development, oral health, and healthy body weight, and it reduces chronic disease over the life course. We encourage healthy eating by making these choices easy to understand, affordable, and accessible.

 

In the last year, the Healthy Eating Active Living (HEAL) program has worked with partners to implement fruit and vegetable incentives for Supplemental Nutrition Assistance Program (SNAP) participants in grocery stores and farmers markets, with the ultimate goal of increasing fruit and vegetable consumption. The program also provided technical assistance on adapting licensing regulations to integrate best practices in nutrition and contracted with OSPI to implement programs in seven school districts.

 

DOH staff worked with the University of Washington Center for Public Health Nutrition to host five free, state-accredited online training modules for child care providers on healthy eating, screen time reduction, active play, healthy eating environments, and breastfeeding. Starting with healthy weight in toddlerhood is associated with healthy weight in childhood and adolescence.

 

State Performance Measure 4 – Adverse Childhood Experiences in Adolescents

We have included an SPM that was intended to enable us to better understand the impact of Adverse Childhood Experiences (ACEs) at a critical point in development. We intended to track the percent of tenth graders who report adverse childhood experiences, using information self-reported in the state Healthy Youth Survey. However, we never fully developed a successful methodology for calculating this from the Healthy Youth Survey responses, and have determined to not continue with this SPM. A second ACEs-related SPM, social and emotional readiness among kindergarteners, is located in the Child Health Annual Report.

 

Other Work, 2019 to Present

Washington has made considerable progress in decreasing statewide teen birth rates, but there are significant disparities across geographic, economic, racial and ethnic lines. To address these disparities, a number of activities are under way. The Adolescent Health program has well-established and collaborative relationships with other DOH programs, other government agencies and community partners.

 

The state Family Planning program has focused on the use of long acting reversible contraception (LARC) and emergency contraceptives for teens. LARC methods provide continuous contraception for three to ten years; a time period that covers most if not all of the adolescent years, and is recommended for sexually-active teens by both the American Academy of Pediatrics and the American College of Gynecology.

 

One of our priorities and objectives in the adolescent health population domain is to promote tobacco cessation and reduce adolescent tobacco use. DOH has continued to: (1) support successful efforts to increase the minimum legal age of tobacco and vapor product purchase from 18 to 21 years, (2) promote and support tobacco cessation, and (3) work to reduce tobacco-related disparities among priority populations. Over the last year, the Adolescent Program Manager has discussed collaboration with the tobacco unit within DOH for upcoming years to best leverage resources to further our shared goals for youth prevention and cessation of tobacco use.

 

The Personal Responsibility Education Program has implemented several new sites during the current reporting year. PREP grants are part of the 2010 Affordable Care Act. The program works to lower teen pregnancy and STIs among 10- to 21-year-olds and prepare youth for adulthood using evidence-based curricula. Settings added in the past year include local health jurisdictions and schools, with specific efforts in tribal schools. Recruitment has focused on schools in counties with the highest teen pregnancy, STI, and poverty rates. In federal fiscal year (FFY) 2018, WA PREP served 2,511 teens; in FFY 2019, we served an additional 1,914 youth.

 

An interactive map of the state with information on STIs and teen pregnancy rates can be found on the WA PREP website. PREP focuses on youth and young adults that are homeless, in foster care, live in rural areas, live in areas that have high teen birth rates, pregnant and parenting youth, and minority youth (including sexual minorities). Consequently, five additional school districts are now implementing evidence-based curricula that are proven to increase good decision-making skills and help youth make healthy choices.

 

Facilitating Comprehensive Sexual Health Education (CSHE) effectively requires teachers to create safe and supportive environments and support student learning. One- and two-day training programs equip teachers with the skills to effectively implement CSHE in the classroom. Additionally, training is provided on a variety of evidence based/informed interventions, such as:

 

• FLASH, MS & HS
• Draw the Line/Respect the Line
• Native Voices, Native Stand and Native It’s Your Game
• Making Proud Choices
• Respect, Rights and Responsibility (3Rs), MS & HS

 

Other partners include OSPI, Department of Social and Health Services and Cardea Services.

 

The Adolescent Health program works closely with OSPI on a number of projects. Staff continue to participate on OSPI’s Exemplary Sexual Health Education steering committee and provide technical assistance for the review of sexual health education curricula for medical and scientific accuracy. The 2019 Washington State Operating Budget required OSPI to convene a workgroup to complete the following tasks related to sexual health education:

 

• Review provisions related to sexual health education in the 2016 Health Education K–12 Learning Standards.
• Review existing sexual health education curricula in use in the state for the purpose of identifying gaps or potential inconsistencies with the learning standards.
• Consider revisions to sexual health provisions in statute.
• Consider the merits and challenges associated with requiring all schools to offer comprehensive sexual health education to students in all grades by September 1, 2022.

 

The Adolescent Health Program Manager served as the DOH representative on this workgroup, which provided two reports to the State Board of Education and the education committees of the Legislature: Sexual Health Education Workgroup Recommendations and Comprehensive Sexual Health Education Data Survey.

 

The Expectant and Parenting Teens, Women, Fathers and Family (EPTWFF) project works with OSPI’s Graduation, Reality and Dual-role Skills (GRADS) program that focuses on work and family foundation skills of significance to these students. GRADS sites are located in specific communities to improve education and health outcomes of pregnant and parenting teens. EPTWFF also implements evidence-based programming intended to reduce rapid repeat pregnancies, and continues to support programming for teen fathers.

 

The Adolescent Health program received continued funding from the Health and Human Services, Office of Population Affairs, Pregnancy Assistance Fund (PAF) program. Our project implemented evidence-based and evidence-informed programs and services that are medically accurate to improve personal health, child health, educational and social outcomes among pregnant and parenting teens and young adults. During the federal grant year July 1, 2018 - June 30, 2019, PAF served 405 expectant and parenting young adults, 246 children of the expectant and parenting participants, and 22 additional extended family members. Since 2013, PAF programming has served more than 4,000 expectant and parenting participants and over 3,000 dependent children across Washington State.

 

Sub-awardees at the state level include OSPI, the Office of the Attorney General, and the Northwest Portland Area Indian Health Board, a tribal non-profit organization that serves the 29 federally-recognized tribes in Washington State. At the local level, our sub-awardees are Benton-Franklin Health District (Benton and Franklin counties), Columbia Basin Health Association (Adams and Grant counties) and Tacoma-Pierce County Health District (Pierce County). Implementation partners include Black Infant Health Ministers, Washington State Coalition Against Domestic Violence, LifeWire, Open Arms Perinatal Services, You Medical, Tulalip Tribe, Sauk-Suiattle Indian Tribe, Quinault Indian Nation, and 12 school districts with GRADS sites.

 

The implementation partners span several sectors, including faith-based organizations, social services, housing agencies, and tribes. They are able to effectively reach priority populations including survivors of domestic violence experiencing homelessness, justice-involved fathers, Latinx families, including immigrant families who are Mixteco-speaking, American Indian teens, Black/African American and multi-racial mothers, and pregnant or parenting high school students. The EPTWFF work is largely community-based and focused on outreach and delivering interventions that are relevant for and driven by the community.

 

The Adolescent Health program also continued work on the Teen Pregnancy Prevention (TPP) grant. This two-year grant began October 1, 2018 and has been an innovative and collaborative effort to test a program aimed at preventing teen pregnancy. We adapted and tested All Stars, a curriculum that improves adolescent health and addresses sexual youth risk holistically by increasing five key protective factors: (1) idealism, (2) positive norms, (3) commitment to avoid risky behaviors, (4) bonding to school and community, and (5) positive parental attention. For this project, DOH collaborated with The Health Center, a school-based health center based in Walla Walla, in rural Washington, to serve more than 35 high school students.

 

Our goal was to create a culturally-relevant curriculum for underserved youth in rural areas of our state through input from youth served by the project and instructors implementing the curriculum. An independent evaluator, Cardea Services, created a mixed-methods implementation evaluation plan that captured the impressions and experiences of the program, as well as local and contextual factors. The process evaluation focused on three key research questions: (1) How relevant, acceptable, and appropriate were the core curriculum components? (2) How did organizational components impact program implementation? and (3) How did external factors impact program implementation? Furthermore, we maximized the   process evaluation period and provided information to improve future activities and program processes, such as facilitator training techniques, program enrollment, and age-appropriate curriculum adaptations. This evaluation highlights the importance and necessity of considering organizational context and external factors when implementing school-based programs and has potential implications for schools and other organizations implementing prevention programs in a school-based setting.

 

The Adolescent Health team, in collaboration with our Surveillance and Evaluation unit, submitted two new grant proposals for the next round for TPP funding. One was funded – to establish and coordinate the Washington Youth Sexual Health (WYSH) innovation network to improve youth access to and experience with sexual health services holistically and, to learn about what works, how, for whom, and why. Most of the efforts will be focused on interventions within the clinic setting, but the network will also include partners from all sectors who have bi-directional impact on youth sexual health care.

 

We will encourage preventive health screenings for youth, including sexual health, and improve linkages between prevention programs and health service settings. Youth voices will be included across the project, including development of interventions and evaluation. The experience we bring with our team, and our commitment to equity will drive efforts toward improving optimal health, preventing teen pregnancy, and reducing STIs. DOH will partner with OSPI and the Northwest Portland Area Indian Health Board; and at the local level, we will partner with four to six tribal sites and six to ten non-tribal sites.

 

The second proposal was for a partnership with OSPI and the Education Resource and Data Center to conduct a rigorous evaluation GRADS program. The proposed study employs a quasi-experimental design that links de-identified GRADS data to birth records from 2010-2020 to determine the effectiveness of GRADS on reducing health disparities and improving health and systems outcomes across the reproductive life-span. The results of this evaluation will demonstrate that GRADS is an effective and cost-efficient intervention that decreases health disparities related to teen pregnancy and childbearing. Additionally, a rigorous evaluation of the program’s impact on repeat pregnancies in young parents, as well as other outcomes related to the optimal health of participants, will further sustainability efforts and have the potential to greatly impact support for the program at a policy level. Although not funded at this time, this concept may be adjusted to be a viable project in the future.

 

These projects demonstrate our commitment to developing programs that best address unmet needs for youth in our state, address gaps in services, improve the overall health and well-being of adolescents and young adults, and address inequities and disparities in order to increase equity in service delivery.