Adolescent Health Domain Annual Report

Please note, many activities were paused or slowed during 2020-2021 as a result of COVID-19 staff redirections and long-term staff vacancies. These activities are noted below by an asterisk (*) next to the activity. Where applicable, additional information is provided.

July 2020 – June 2021

Adolescent Health Focus Area 1: Improve sexual and reproductive health and well-being for all adolescents in California.

Adolescent Health Objective 1

By 2025, increase the proportion of sexually active adolescents who use condoms and/or hormonal or intrauterine contraception to prevent pregnancy and provide barrier protection against sexually transmitted diseases (STDs) as measured by the following:

• Increase the percentage of sexually active adolescents who used a condom at last sexual intercourse from 55% to 58%
• Increase the percentage of sexually active adolescents who used the most effective or moderately effective methods of FDA-approved contraception from 23% to 25%.

Objective baseline History

 

Story behind the baseline 

Sexual development is a critical and normal part of adolescent development. Support for young people's healthy sexual development is essential.1 Providing adolescents with access to high-quality sexual and reproductive health information and services, such as contraception provision, is critical to promoting healthy sexual wellbeing, and preventing unplanned pregnancy and STDs.2

Factors that impact the curve from the baseline include a variety of barriers adolescents may face when accessing sexual and reproductive health care services and information, including the following:

• Black, Indigenous, and other adolescents of color often experience inequitable health care coverage and social determinants of health shaped by systemic racism that negatively impact their sexual and reproductive health outcomes and care.
• Young people who identify as LGBTQ may be less willing to seek care if they feel their provider is unable to meet their needs or that their identity will not be respected.
• The health care system in the U.S. makes minimal accommodations for adolescents with disabilities.3

Both nationally and in California, few young people (ages 15 to 19) use the most effective types of contraception. The Centers for Disease Control (CDC) has reported that use of Long-Acting Reversible Contraception (LARC) is low, and even fewer use dual contraceptive method.4 To address this and similar issues, connecting youth with high-quality sexual and reproductive health education and services is core to the adolescent health program efforts put forth by the Maternal, Child, and Adolescent Health Division of the California Department of Public Health (CDPH/MCAH).

1. https://www.guttmacher.org/gpr/2021/02/adolescents-deserve-better-what-biden-harris-administration-and-congress-can-do-bolster

2. https://www.sciencedirect.com/science/article/pii/S2590151621000113

3. https://www.guttmacher.org/gpr/2021/02/adolescents-deserve-better-what-biden-harris-administration-and-congress-can-do-bolster

4. https://www.cdc.gov/vitalsigns/larc/index.html

Adolescent Health Objective 1: Strategy 1

Lead surveillance and program monitoring and evaluation related to adolescent sexual and reproductive health.

What Did CDPH Determine as Activities Necessary to Implement This Strategy? 

1. Lead in updating and utilizing the California Adolescent Sexual Health Needs Index (CASHNI) to implement adolescent sexual health programs.
2. Lead in updating and disseminating the Adolescent Sexual Health County Profiles.
3. Lead surveillance of California adolescent birth rates, with a focus on identifying inequities, and disseminate findings through a surveillance report and press release.
4. Lead monitoring and evaluation of the following MCAH adolescent health programs:

 

• CA Personal Responsibility and Education Program (CA PREP)
• Information and Education (I&E)
• Adolescent Family Life Program (AFLP)
• Provide data dashboards to locally funded agencies and disseminate findings through issue and data briefs, as well as programmatic and scientific abstracts and manuscripts.

How Did CDPH Accomplish the Chosen Activities?

1. CDPH/MCAH updated the CASHNI by analyzing the most recent available data for each indicator. The CASHNI will be used to identify eligibility for the Adolescent Sexual Health Education programs (i.e., CA PREP and I&E) and AFLP Request for Applications (RFAs) in 2022 and 2023. Using the CASHNI allows CDPH/MCAH to ensure that limited funds are distributed to areas with youth populations that face the greatest inequities in health and social outcomes. The CASHNI also serves as an important data source for Local Health Jurisdictions (LHJ), as it provides information at the Medical Service Study Area (MSSA) level and can be used to help identify service areas for adolescent health programs.
2. CDPH/MCAH analyzed data from multiple sources to update the Adolescent Health County Profiles to 2018 (report dissemination scheduled for release in 2022). The Adolescent Sexual Health County Profiles were updated and will be disseminated and used as a resource for RFAs and for counties across the state.
3. CDPH/MCAH analyzed California vital statistics and population data to update and release adolescent birth rate (ABR) estimates through 2018. The MCAH Adolescent Health team wrote a comprehensive report, “Adolescent Births in California: 2000-2018” (available here). In addition to this report, CDPH/MCAH attempted to lead surveillance of the ABR in the following ways:

• CDPH/MCAH started a data visualization project that will help to disseminate ABR trend data and crosstabs (e.g., race/ethnicity and age group) at the state and county level.
• CDPH/MCAH conducted a preliminary analysis of the 2021 provisional birth data to address questions regarding the impacts of the pandemic on the ABR. According to preliminary analysis, the number of births declined by 14% between January 2020 and January 2021. This may be a continuation of the historical downward trend observed annually in recent years.
• In collaboration with the Adolescent Sexual Health Work Group (ASHWG), CDPH/MCAH developed integrated data tables (IDTs) that include ABR, HIV/AIDS, and STD data for adolescents and young adults. These IDTs will be posted on the ASHWG website.

4. CDPH/MCAH continued to monitor and evaluate the MCAH adolescent health programs and provide data dashboards to local-funded agencies and disseminate the findings through issue and data briefs, as well as programmatic and scientific abstracts and manuscripts. Details from each program during the reporting period include the following:

• Adolescent Family Life Program (AFLP)
  • Released an annual data summary for the program in November 2020, providing a snapshot of characteristics of youth served and program implementation during the prior state fiscal year.
  • Provided data collection and entry training in December 2020 incorporating COVID-19 data collection adjustments for local agencies.
  • Began disseminating monthly data quality dashboards in March 2021, and provided a training webinar, FAQ, and ongoing technical assistance to support agencies using dashboards to improve data quality and program implementation.
  • Conducted a pilot program with four agencies in Spring 2021 testing several live data visual reports. Reports included key program implementation data that can be run on demand by agency staff. Pilot users provided key feedback to inform active reports as well as planned future reports.

• Adolescent Sexual Health Education (ASH Ed) Program
  • Convened a workgroup to develop and monitor participant survey procedures and submitted updated surveys for Institutional Review Board (IRB) approval; transferred paper surveys to an online platform, Qualtrics, and provided training and guidance for sub-awardees.
  • Updated the online data collection system (SharePoint) to capture data collection changes due to COVID-19; monitored data collection activities on SharePoint site/data system and provided technical assistance.
  • Updated the facilitation observation tool to account for virtual implementation and provided sub-awardees with training and data collection guidance.
  • Disseminated data templates and dashboards for data quality, program model implementation fidelity, and survey data for ongoing Continued Quality Improvement (CQI) efforts.
  • Analyzed and submitted aggregate data for CA PREP federal reporting requirements four times per year.

Updated Performance Measure Graph/Data Specific to This Strategy  

In California, the ABR continued to decline by 64% between 2010 and 2019. Each year since 2010, the ABR decline has ranged from 9% to 13%. However, the burden of STDs continued to be substantial, with the highest rates occurring among young people between the ages of 15 and 24. According to California’s Youth Risk Behavior Survey (YRBS), condom use among sexually active high school students remained at 55% in 2019, demonstrating no change from 2017. Combined YRBS data from 2017 to 2019 show that 31% of sexually active adolescents used the most effective or moderately effective methods of FDA-approved contraception. Dual contraceptive use (condoms and hormonal methods such as LARC or oral contraceptives) provides strong protection against both STDs and unintended pregnancy. California YRBS data show an increase in dual contraceptive use from 7% in 2017 to 12% in 2019.

Success Stories

Creating and releasing a comprehensive surveillance report with the ABR data was a major accomplishment for MCAH during this reporting period. The report was disseminated to local MCAH programs as well as local implementing adolescent health program agencies for CA PREP, I&E, and AFLP.

Challenges

Although the CASHNI provided data for assessing need at the sub-county level (California-defined Medical Service Study Area, or MSSA), not all areas collect the necessary youth demographic data. In addition, a main data source for the CASHNI (the California Birth Statistical Master File or BSMF) has a 2-year data lag. The COVID-19 pandemic also created a challenge in obtaining MSSA-level data for STDs; these data remain unavailable.

MCAH/AFLP planned to release the first phase of Tableau reports in Spring 2021, however due to contract staffing limitations that resulted from the COVID-19 pandemic, the Tableau pilot was delayed until Fall 2021. COVID-19 redirection for local agencies also delayed utilization of data quality dashboards to support program implementation.

Substantial staff changes delayed some evaluation activities and CQI efforts with local agencies. Additionally, some MCAH staff were redirected to the COVID-19 response during this period.

Adolescent Health Objective 1: Strategy 2

Lead to strengthen knowledge and skills to increase use of protective sexual health practices within MCAH-funded programs.

What Did CDPH Determine as Activities Necessary to Implement This Strategy? 

1. Lead in developing and disseminating a resource brief for public health professionals and parents/caregivers related to youth-friendly sexual and reproductive health information and resources.
2. Lead the review and update of the AFLP Positive Youth Development (PYD) Model to ensure integration of best practices related to protective sexual health behaviors and healthy relationships.
3. Lead trainings on protective sexual health practices.
4. Lead in promoting best practices for parent/caring adult engagement.
5. Partner with the CDPH Violence Prevention Initiative to reduce adolescent relationship violence.

Narrative section:

1. CDPH/MCAH developed and disseminated a variety of resource briefs related to youth-friendly sexual and reproductive health information and resources. Details from each of the division’s adolescent health programs include the following:

• Adolescent Family Life Program (AFLP)
  • CDPH/MCAH continued to share adolescent resources, helpful tools, and links to trainings with local AFLP agencies.

 

• Adolescent Sexual Health Education (ASH Ed) Program
  • CDPH/MCAH developed a guide with a list of resources for CA PREP and I&E Programs to assist local agencies to continue to provide virtual education, activities, and resources to youth, caregivers, and communities during the COVID-19 pandemic. The list included resources for professional development, youth engagement, telehealth and clinical linkages, community and parent engagement, curricula adaptations and quality improvement activities.
  • CDPH/MCAH developed and released the following four data briefs:
    • “Adolescent Dating Violence Among Program Participants”
    • “Access to Clinical Sexual and Reproductive Health Services”
    • “Overview of ASH Programs”
    • “Focus on the Information & Education (I&E) Program”
  • CDPH/MCAH developed an infographic called “Intimacy During COVID-19” for MCAH-funded local adolescent health program staff who work directly with youth. It was distributed to 16 local AFLP and 31 ASH Ed agencies. The infographic included health information about how COVID-19 is spread and tips for young people who want to engage in safer sex practices during the pandemic.

2. CDPH/MCAH created and implemented the “Adolescent Family Life Program Positive Youth Development Input Survey” to elicit feedback from AFLP local agencies regarding the implementation of the AFLP PYD model. Based on agency feedback, updates were made to the “Family Planning and Safer Sex” section of the “My Life Plan” booklet to ensure medical accuracy and gender inclusivity, using best practices to discuss reproductive goals and life planning. Additionally, updates were made in English and Spanish to the “My Goal Sheet” and “My Life and Me” tools to ensure medical accuracy and gender inclusivity. All new content was translated to Spanish.
3. CDPH/MCAH led trainings on protective sexual health practices within its adolescent programs.  Details from each of the division’s adolescent health programs include the following:

• AFLP

• CDPH/MCAH hosted a live virtual training on family planning and safer sex in January 2021 for local AFLP staff. The goal of the training was to support case managers in building skills, knowledge, and comfort in discussing family planning as a core program priority of the AFLP PYD program.
• CDPH/MCAH hosted a live virtual training primer on reproductive justice in April 2021 for local AFLP staff. The focus of this training was to create awareness of the reproductive issues that impact how youth engage in conversations about family planning and understand barriers to health care.
• CDPH/MCAH hosted a two-day virtual spring refresher training In June 2021 required for all AFLP coordinators, supervisors, and case managers. The training included an overview of the AFLP PYD program tool updates, including guidance for implementing the updated Family Planning & Safer Sex section and a training titled “Sexual and Reproductive Health (SRH) 201: Beyond the Basics.” The objective of this training was for local AFLP agency staff to be prepared to integrate the updated program tools into program implementation, and gain a greater understanding of advanced, medically accurate knowledge of the human reproductive system. 

• Adolescent Sexual Health Education (ASH Ed) Program
  • CDPH/MCAH hosted several virtual training opportunities for local ASH Ed agencies which included the following
    • Online Safety Messages for Youth
    • Navigating Conversations About Pleasure in the Classroom
    • Healthcare Delivery during COVID-19
    • Consent Counseling and Education
    • Innovative Strategies: Education Outside the Classroom
    • Agency Responses to COVID-19, Innovative Strategies: Parent Engagement
    • CA PREP Survey Data: Youth Participant Program Perceptions
    • Reproductive Justice and Rights for Young Californians
    • These virtual training sessions also included presentations by One Love, who provided trainings on these topics: Relationships, Health Education and Commercial Sexual Exploitation: Recognizing and Responding to Support Youth.

4. Local CA PREP and I&E agencies engaged parents and caring adults through various activities in the community to support youth in their sexual health education, and to build parents/caring adults’ confidence in engaging in medically accurate and open conversations. Some of the activities that took place in this reporting period include the following:

• Parents/caring adults were given a virtual preview of the evidence-based/evidence-informed curricula prior to implementation.
• Virtual health fairs, connection to community resources and referrals including California’s Family Planning, Access, Care, and Treatment (Family PACT), reproductive health service providers, domestic violence shelters, suicide prevention informational brochures, mental health clinics, information on child abuse prevention, and referrals to LGBTQ+ youth shelters. Resources were shared electronically via social media and agency websites. Agencies continue to build partnerships virtually with parent/community groups.
• The series “Sin Vergüenza” was produced by AltaMed to help reduce HIV stigma and shame, and increase awareness of the importance of safe sex practices, routine HIV testing, and seeking treatment.
• In the upcoming Request for Application (RFA) for State Fiscal Years 2022-2025, CDPH/MCAH will add the option to expand and enhance parent/caring adult program activities with funds from the I&E Program. CDPH/MCAH has approved three program models (“Parents Matter,” “Families Talking Together,” and “Talking Parents, Healthy Teens”) as evidence-based options for implementation to support parent/caregiver educational activities. The three models are cited by the CDC as having evaluation results showing improved parent/caring adult and adolescent communication about sex leading to better health outcomes.

5. CDPH/MCAH maintains participation in the Violence Prevention Initiative (VPI) Steering Committee and collaborates with/supports VPI partners on a variety of activities. During this reporting period, Intimate Partner Violence (IPV) was a key issue that was assessed by the group. CDPH/MCAH monitored data and research about the impacts of the pandemic on IPV and family violence. The team assessed key issues in California and began a process of strategizing on next steps for building capacity to address the growing needs related to prevention and early intervention. In addition, CDPH/MCAH coordinated a learning session between the MCAH Adolescent Health team and the Injury and Violence Prevention Branch to learn and share about the adolescent relationship education and rape prevention programs within CDPH.

Success Stories

CDPH/MCAH continued to host a variety of high-quality virtual training opportunities for local agencies implementing adolescent health programs, which was a major accomplishment given staffing restrictions and re-directions. The trainings were well-attended by local staff and provided a space for agencies to strengthen their skills and knowledge on a wide range of topics. The trainings also supported the ongoing process of adapting to a virtual environment for program implementation during the pandemic.

Challenges

The pandemic continued to impact staffing at the state and local levels as well as create challenges for implementation of programs and services and engagement of youth, families, schools, and other key partners.

Adolescent Health Objective 1: Strategy 3

Partner across state and local health and education systems to implement effective comprehensive sexual health education in California.

What Did CDPH Determine as Activities Necessary to Implement This Strategy?

1. Lead and fund implementation of CA PREP and I&E programs with diverse youth populations using evidence-based and evidence-informed curricula.
2. Lead in updating the selected evidence-based and evidence-informed PREP/I&E curricula.
3. Lead in coordinating the California Adolescent Sexual Health Work Group (ASHWG) and participate in the Steering Committee to strengthen the network of state health, education partners, and nongovernmental organizations (NGO) working to improve adolescent sexual and reproductive health.
4. Partner with ASHWG to develop and disseminate resources and best practices to local MCAH programs.
5. Support the Healthy Sexual Development workgroup led by the California Department of Social Services (CDSS) to ensure comprehensive sexual health education is provided to foster youth.

Performance Improvement Narrative

1. CDPH/MCAH funded and led the implementation of 22 local CA PREP and nine I&E programs. CA PREP is federally funded by the Family and Youth Services Bureau and I&E is state funded through the General Fund. ASH Ed contributed to the strategy in the following ways:

• CA PREP provided comprehensive sexual health education via effective, evidence-based program models to 8,526 California youth, nearly all of whom were between the ages or 10 and 19.
• The local CA PREP focused on how to prevent pregnancy and STDs. Services were offered in a range of settings, including schools, juvenile justice facilities, homeless shelters, and foster care group homes. CA PREP activities also included community engagement, adult preparation, and promotion of clinical linkages to youth-friendly reproductive health services.
• The local I&E agencies provided evidence-based/community-informed interventions to at least 3,328 young people, nearly all of whom were aged 10 to 19 years. These programs focused on adolescent pregnancy prevention and STD and HIV prevention and linkage to testing and treatment, as well as healthy relationships and life skills education.

2. In December, 2020 CDPH/MCAH shared the “California Healthy Youth Act (CHYA) Sexual Health Education Toolkit” developed by the American Civil Liberties Union, which provides a list of CHYA-compliant Curricular Materials & Resources. The toolkit supported CDPH/MCAH’s efforts to update the evidence-based and evidence-informed curricula used in the ASH Ed programs starting in State Fiscal Year 22/23.
3. CDPH/MCAH led in coordinating the ASHWG and participated in the Steering Committee to strengthen the network of state health, education partners, and NGOs working to improve adolescent sexual health and reproductive health. ASHWG is a collaborative group of key government and NGOs committed to working more effectively to address the sexual and reproductive health of California adolescents. CDPH/MCAH continued to fund the coordination of ASHWG, which included taking a lead role in maintaining the membership application process, coordinating quarterly membership and monthly steering committee meetings, and maintaining the workgroup’s guidance documents and work plan. CDPH/MCAH maintained leadership on the Data Integration Subcommittee and served on the Steering Committee. The ASHWG Steering Committee is in the second year of implementation of their strategic plan. The following are the three goals of the strategic plan:
   1. Identify and articulate the gaps, needs, and opportunities in adolescent sexual health education and services.
   2. Improve the quality and effectiveness of providers of sexual health education and services.
   3. Raise awareness about adolescent sexual health needs and services to a broad range of stakeholders.
4. CDPH/MCAH contributed to developing and disseminating data and analysis from the 2017 Youth Risk Behavior Survey (YRBS) to assess the prevalence of and the association between sexual violence and suicide attempts among youth in California. The resource was posted on the ASHWG website and disseminated to 61 local health jurisdictions and 47 local AFLP and ASH Ed agencies. Those same jurisdictions and agencies received the ASHWG-developed resource on Sexual Health Education and Policies in California Middle and High Schools: Results from the School Health Profiles Surveys and Compliance with the California Healthy Youth Act (CHYA).
5. CDPH/MCAH continued to participate in the CDSS Healthy Sexual Development workgroup, formed with the passage of Senate Bill 89, which requires social workers, caregivers, and other adults in the lives of youth in foster care to be trained in reproductive and sexual health issues. CDPH/MCAH shared expertise with regards to sexual health education for young people in the foster care system as well as best practices for engaging and empowering parents and caregivers.

Meeting frequencies decreased drastically in this reporting period due to COVID-19 and are picking back up with the passage of a new state law expanding financial benefits to expectant and parenting youth in foster care.

Success Stories

Due to the national declarations of racism as a public health crisis, the California ASHWG’s Steering Committee prioritized adopting and centering an anti-racist framework in its vision, mission, and strategic plan, and paused on some of its activities to focus on this. The Steering Committee conducted a climate survey to assess member experiences and learned they needed to first deepen their own understanding of racism and the historical traumas of reproductive health in our country. The ASWHG Steering Committee participated in a 21-Day Racial Equity Challenge led by the Office of Health Equity at CDPH to develop a stronger shared understanding of racism, its history, and current impacts on adolescent sexual and reproductive health. The committee is now planning how to move forward and center anti-racism in its adolescent sexual health work.

Challenges

During this reporting period, many members of the ASHWG Steering Committee and General Membership had their work altered by the COVID-19 pandemic due to staff redirections and reprioritization of projects. The varying levels of involvement among members delayed some of the collaborative’s activities.

Adolescent Health Focus Area 2: Improve awareness of and access to youth-friendly services for all adolescents in California.

Adolescent Health Objective 2

By 2025, increase the percentage of adolescents aged 12 through 17 with a preventive medical visit in the past year from 76.2% to 83.8%.

Objective Baseline history 

Story behind the baseline 

During preventive health care visits, adolescents get important screenings, health counseling, and interventions.1

The Bright Futures guidelines recommend that adolescents have an annual checkup from age 11 through 21. Preventive visits are especially important for this age group because behaviors that can affect long term health often start in adolescence.2

Receiving health care services, including annual preventive well visits, helps adolescents with the following:

• Staying healthy and avoiding health risks.
• Talking about and get help for mental health concerns.
• Getting immunizations to prevent cancer and infections and managing chronic conditions.3

Data demonstrate that a significant proportion of adolescents and young adults are not receiving the recommended preventative health services to address their behavioral and physical health needs. Services they do receive may not be youth-centered or align with their developmental stages.

Factors that influence the curve include whether the youth is enrolled in school, is housed, is in the foster care or juvenile justice systems, identifies as LGBTQ+, has access to health insurance, feels comfortable with health care providers, and has access to a network of supportive adults in their communities.

The COVID-19 pandemic has significantly impacted a young person’s ability to have a preventative health visit. A recent study showed that overall, 26% of US households reported that one or more children or adolescents had missed or delayed preventive visit because of Covid-194

Access to and coverage for telemedicine has the potential to increase preventive visits given the pandemic.

1. https://brightfutures.aap.org/Bright Futures Documents/BF4_AdolescenceVisits.pdf

2. https://health.gov/healthypeople/objectives-and-data/browse-objectives/adolescents/increase-proportion-adolescents-who-had-preventive-health-care-visit-past-year-ah-01

3. https://mchb.hrsa.gov/maternal-child-health-topics/adolescent-and-young-adult-health

4. https://journals.sagepub.com/doi/10.1177/00333549211061322

Adolescent Health Objective 2: Strategy 1

Lead to develop and implement best practices in MCAH-funded programs to support youth with accessing youth-friendly preventive care, sexual and reproductive health care, and mental health care.

What did CDPH determine as activities necessary to implement this strategy?

1. Partner to implement evidence-based screening tools or assessments to link adolescents to needed services.
2. Lead the development of resources and templates for local pathway maps to link youth to needed services.
3. Lead to ensure MCAH program participants are referred to California’s Family Planning, Access, Care and Treatment program.
4. Partner in the dissemination of recommendations for adolescent preventative care to local MCAH programs.

Narrative section

1. CDPH/MCAH partnered with several stakeholders to implement the following evidence-based screening tools or assessments to link adolescents to needed services:

• During FY 20-21, despite decreases in overall enrollment and monthly caseload (likely due to COVID-19) and challenges adapting to virtual services, local AFLP agencies continued to administer both baseline and follow-up assessments to youth. These assessments are utilized to learn about youth needs and strengths and are conducted using motivational interviewing techniques. Among 975 youth receiving services during 20-21, 88% received at least a baseline or follow-up assessment (Source: AFLP FY 20-21 Annual Data Summary).
• In 2020-2021, 90.1% of AFLP youth received primary preventative health care and 89.2% of pregnant youth in AFLP received prenatal care (Source: AFLP FY 20-21 Annual Data Summary).
• CDPH/MCAH is actively working with local agencies to increase the percentage of youth who are screened and referred for basic needs and who receive a comprehensive assessment of needs through quality improvement efforts, including monthly data quality dashboards released during FY 20-21.
• Some local AFLP agencies conducted supplemental mental health, substance use, and other screenings to support the well-being of youth and their families.

2. CDPH/MCAH paused this activity due to shift in priorities and low staffing, however, it will resume in the next reporting cycle and will consider linking efforts to the new work being done as part of the Adolescent and Young Adult Mental Health CoIIN.
3. CDPH/MCAH’s adolescent health programs ensured participants were referred to California’s Family Planning, Access, Care and Treatment program (Family PACT) in the following ways:

• Adolescent Family Life Program (AFLP)
  • CDPH/MCAH utilizes the program’s Comprehensive Baseline Assessment (CBA) and Youth Outcome Assessment (YOA), which are data collection tools that AFLP case managers complete with participants to assess needs and connect them to resources. The CBA is completed within the first two months of program enrollment and the YOA is completed every six months from the date of program enrollment. Both assessments include questions regarding family planning and contraceptive use, which based on youth responses may result in referrals to Family PACT.
  • CDPH/MCAH updated the policy and procedure (P&P) 100-20, requiring local AFLP agencies to develop a coordinated system of care focusing on adolescent health and supporting expectant and parenting youth and their families. Agencies must assess local needs and develop and maintain a collaborative service network of local providers to assist AFLP participants access comprehensive, youth-friendly, culturally appropriate, supportive, and necessary services. The collaborative service network established by agencies must include both a Local Stakeholder Coalition (LSC) and a referral network.
  • LSCs include representatives from various organizations including Family PACT and Medi-Cal providers (preventive, obstetrics/comprehensive perinatal services program).
  • All AFLP agencies identified Family PACT as partners in their implementation plan.

• Adolescent Sexual Health Education (ASH Ed) Program

• CA PREP and I&E agencies, as required in their CDPH/MCAH scope of work, established formal partnerships with their local Family PACT providers to increase adolescent access to reproductive health services.
• CDPH/MCAH requires all CA PREP and I&E to be trained and knowledgeable about Family PACT and reproductive health services in their communities to make timely referrals for youth. CA PREP and I&E health educators provided information to youth on the location, cost, and confidentiality of local sexual and reproductive health services, including Family PACT.

4. CDPH/MCAH paused this activity due to shift in priorities and low staffing, however, it will resume in the next reporting cycle.

Updated Performance Measure Graph/Data Specific to This Strategy

Due to questionnaire changes made in 2018, National Survey of Children’s Health (NSCH) data on preventive medical visits from that year are not comparable to those collected before or after. However, aggregated 2016-2017 and 2019-2020 NSCH data are comparable. From 2016-2017, 76.2% of adolescents aged 12 to 17 years had one or more preventive medical visit each year; from 2019-2020, 70.6% had one or preventive medical visit each year.

Success Stories

In this reporting period, CDPH/MCAH updated an important P&P for AFLP, requiring local AFLP agencies to develop a coordinated system of care focusing on adolescent health and supporting expectant and parenting youth and their families. This was a critical update to include new services and resources specifically aimed at supporting young people through the challenges of the COVID-19 pandemic such as accessing confidential telehealth services.

Challenges

Lack of staffing, due to a combination of Covid-19 redirections and other staff vacancies, has resulted in activities being paused, slowed, or shifted. Priorities have changed at the local level in the ongoing wake of the Covid-19 pandemic and activities will continue to evolve as CDPH/MCAH learns about the impact, emerging needs, and changes.

Adolescent Health Objective 2: Strategy 2

Partner with the CDPH Adolescent Preventive Health Initiative (APHI) to increase the quality of preventive care for adolescents in California.

What Did CDPH Determine as Activities Necessary to Implement This Strategy? 

1. CDPH/MCAH will partner with APHI to develop and disseminate a communications platform with a comprehensive set of resources for adolescent service providers.             

Narrative section 

1. While this activity was paused due to COVID-19 staffing challenges, CDPH/MCAH continued its participation in the Leadership Exchange for Adolescent Health Promotion (LEAHP) program, coordinated by the National Coalition of STD Directors, as part of the California state team. During this reporting period, the team developed a Google Map “How To” document with instructions for local organizations to populate a Google Map with sexual health resources in their communities on one side, as well as information about minor consent and confidentiality rights on the other side.

Success Stories

N/A

Challenges

Lack of staffing across CDPH, due to a combination of COVID-19 redirections and other staff vacancies, has resulted in the activity for this strategy being paused, slowed, or shifted.

Adolescent Health Focus Area 3: Improve social, emotional, and mental well-being and build resilience among all adolescents in California.

Adolescent Health Objective 3

By 2025, increase the percent of adolescents aged 12-17 who have an adult in their lives with whom they can talk to about serious problems from 77.2% to 79.7%.

Objective Baseline History 

Story Behind the Baseline 

Youth connectedness is an important protective factor for health and well-being. Youth who feel connected at school and home are less likely to experience negative health outcomes related to mental health, violence, substance use and sexual health risk.1

Connectedness refers to a sense of being cared for, supported, and belonging, and can be centered on a feeling connected to school, family (i.e., parents or caregivers), or other important people or organizations in their lives. Research demonstrates the powerful contribution of positive peer and adult relationships to healthy adolescent development and well-being.2 Adolescents are more likely to engage in healthy behaviors if they have a supportive and trustworthy adult in their life, leading to increased well-being in adolescence and contributing to improved social, emotional, and academic outcomes that have a lasting impact on health across the life course.3

Factors that influence the curve include whether the youth is enrolled in school, is housed, is in the foster care or juvenile justice systems, and has access to a network of supportive adults in their communities.

The impacts of the COVID-19 pandemic aggravated the mental health challenges of young people. Efforts to mitigate the spread of the virus led to social isolation and other disruptions in education, services, and social activities, even as mental health challenges were already increasing among youth before the pandemic.

It is critical to build resilience among youth, especially when they are faced with adverse experiences, and connect them to trusted and caring adults. Connecting youth with caring adult support is core to the CDPH/MCAH adolescent health program efforts.4

1. https://www.cdc.gov/healthyyouth/protective/youth-connectedness-important-protective-factor-for-health-well-being.htm

2. 7 Positive Childhood Experiences that Help Kids Grow into Successful Adults (youthranch.org)

3.https://health.gov/healthypeople/objectives-and-data/browse-objectives/adolescents/increase-proportion-adolescents-who-have-adult-they-can-talk-about-serious-problems-ah-03

4. https://developingchild.harvard.edu/science/key-concepts/resilience/ https://link.springer.com/chapter/10.1007/978-3-030-64537-3_14

Adolescent Health Objective 3: Strategy 1

Partner to strengthen resilience among expectant and parenting adolescents to improve health, social, and educational outcomes.

What Did CDPH Determine as Activities Necessary to Implement This Strategy?

1. Lead and fund implementation of Adolescent Family Life Program.
2. Lead the program start-up and orientation for the new AFLP cycle.
3. Lead trainings for local staff to implement the AFLP PYD Model.
4. Lead the development of a plan for AFLP PYD Model updates, further evaluation, and program expansion.
5. Lead implementation and analysis of data from evidence-informed/based assessment tools such as the AFLP Resiliency Scale.
6. Lead in updating and disseminating the physical activity and nutrition guidelines for adolescent parents

Narrative section

1. In Fall 2019, CDPH/MCAH released a Request for Applications (RFA) for AFLP, reviewed eligible applications and awarded 16 agencies funds to implement AFLP from July 1, 2020 – June 30, 2023. The total amount distributed among Awardees was $5.6 million in this reporting period. CDPH/MCAH provided funding, training, technical assistance, monitoring, and oversight to 16 Local Health Jurisdictions (LHJs) and community-based organizations (CBOs) to implement AFLP. These agencies implemented the evidence-informed, strengths-based Positive Youth Development (PYD) Model. During FY 20-21, 975 youth received AFLP services, which included the following:
   • 740 (76%) were in the program for at least six months.
   • 352 (36.1%) had enrolled into AFLP during the reporting period.

(Source: AFLP FY 20-21 Annual Data Summary).

2. In Fall 2020, CDPH/MCAH hosted a mandatory two-day AFLP Virtual Grantee Orientation for local program directors, coordinators, and supervisors. The two-day orientation covered topics such as a program overview, requirements, implementation, oversight, staffing, outreach, referrals, monitoring, evaluation, and quality improvement.
3. In Spring 2021, CDPH/MCAH hosted a three-day virtual AFLP PYD basic training in fall 2020 and a four-day virtual basic training. The training was required for all new AFLP directors, coordinators, supervisors, and case managers. The objectives of the training were for participants to develop skills and enhance their knowledge to implement the AFLP PYD program in its entirety, as well as learn about the strategies and tools to help intentionally integrate life planning and PYD approaches into case management.
4. CDPH/MCAH lead the development of a plan for AFLP PYD model updates, further evaluation, and program expansion.
   • All immediate and high-priority needs for AFLP PYD model updates were addressed in this reporting period.
   • CDPH/MCAH has a partnership with Mathematica who will work with local AFLP agencies that participated in the federal evaluation. Mathematica will work with the agencies to share evaluation results and get their feedback on ways CDPH/MCAH can improve program content and/or delivery of the AFLP PYD model.
5. CDPH/MCAH lead the implementation and analysis of data from evidence-informed/based assessment tools such as the AFLP Resiliency Scale.
   • As reported in last year’s annual report, CDPH/MCAH paused implementation of the AFLP youth resilience scale (YRS) in April 2020 due to the shift to virtual implementation resulting from the COVID-19 pandemic. The implementation of the scale remained paused through FY 20-21, which also allowed for final development of the scale.
   • CDPH/MCAH has drafted a finalized version (12 items) in both English and Spanish with accompanying protocol. The scale is expected to be resumed in FY 21-22.
   • CDPH/MCAH established a mechanism to integrate data collected from the YRS tool (completed via Qualtrics) into Penelope, the primary web-based data system for AFLP.
6. CDPH/MCAH led a workgroup to update sections of the Adolescent Nutrition and Physical Activity Guidelines as well as update language to be more gender inclusive and responsive to changing norms and behaviors.
   • The workgroup met through the summer and fall of 2021 to provide feedback on existing sections of the guidelines as well as one new section.
   • At the conclusion of the workgroup, this project was paused until a more significant update of the information could occur.
   • CDPH/MCAH removed the outdated guidelines from the website.

Updated Performance Measure Graph/Data Specific To This Strategy

According to National Survey of Drug Use and Health (NSDUH) data, 76.7% of California’s adolescents aged 12-17 years had an adult (mother, father, or other) in their lives with whom they could talk about serious problems. This indicator value has remained stable, showing only minor fluctuations (less than 1% change annually), over the last seven years.

Success Stories

By developing a new mechanism to integrate data collected from the YRS tool (completed via Qualtrics) into Penelope, the primary web-based data system for the Adolescent Family Life Program (AFLP), local AFLP staff now have direct and immediate access to youth data. CDPH/MCAH expects this will improve survey response rates and allow AFLP case managers to tailor services to better respond to youth needs.

Challenges

N/A

Adolescent Health Objective 3: Strategy 2

Partner to identify opportunities to build protective factors for adolescents at the individual, community, and systems levels.

What Did CDPH Determine as Activities Necessary to Implement This Strategy?

1. Partner with the Adolescent Sexual Health Work Group (ASHWG) to finalize the Positive Youth Development (PYD) Organizational Assessment and Toolkit and disseminate to other partners.
2. Partner to establish a CDPH youth advisory board.
3. Lead to ensure youth voices are reflected in local programs.

Narrative Section

1. The ASHWG Positive Youth Development (PYD) Toolkit was put on hold due to shifting priorities during COVID-19, including the development of an anti-racist framework in its vision, mission, and strategic plan.
2. CDPH/MCAH partnered with colleagues from the Office of Health Equity and STD Control Branch to conduct key informant interviews with other state health departments to learn about best practices for state level Youth Advisory Boards (YABs). This small planning team facilitated focus groups with internal CDPH programs who work with youth to assess their interest in a Department YAB. CDPH/MCAH co-developed a proposal for a YAB for Department consideration, which is under review.

CDPH/MCAH ensured youth voices were reflected in state and local programs in the following ways:

• Local AFLP agencies were given the opportunity to hire a youth advisor (YA) and include the position in their 2020 budget to support Quality Improvement efforts, assist the agency with addressing challenges, and inform decisions to best meet the needs of youth in the program.
• Five of 16 funded agencies budgeted for the YA position, and three of the agencies hired a YA. At the state level, the YA participated in stakeholder forums, including meetings with CDPH/MCAH, and provided input on state MCAH adolescent health projects such as AFLP PYD model development and program requirements.
• Twenty youth active in AFLP participated in semi-structured conversations about their experience with data collection in the program, including their understanding of confidentiality and data usage. Results were summarized and shared with local implementing partners and used to inform improvements in the data collection process for AFLP.

CDPH/MCAH plans to establish a mental well-being youth ambassador program to amplify youth voice in an 18-month Adolescent and Young Adult Behavioral Health Collaborative Innovation and Improvement Network (CoIIN) that aims to strengthen depression screening and follow-up through primary care quality improvement and public health strategies.

Success Stories

One AFLP YA at El Nido Family Centers in Los Angeles worked on creating a social networking space for program participants through two Instagram groups, one run in Spanish and another in English. The YA co-created and implemented a survey to assess the impact of the pandemic on program participants. They helped analyze responses and produced a summary report to improve program quality and services to better support participants. The YA contributed to the agency’s efforts to strengthen participant engagement in the virtual space.

Challenges

Lack of staffing, due to a combination of COVID-19 redirections and other staff vacancies, has resulted in activities being paused, slowed, or shifted. Priorities have changed at the local level due to the COVID-19 pandemic, and activities need to be re-examined and potentially revised.

Adolescent Health Objective 3: Strategy 3

Partner to strengthen knowledge and skills among providers, individuals, and families to identify signs of distress and mental health related needs among adolescents.

What Did CDPH Determine as Activities Necessary to Implement This Strategy?

1.  Lead in conducting an assessment of adolescent mental health.
2. Lead in promoting trainings and resources, including Mental Health First Aid, via MCAH communications platforms.

Narrative Section

1. CDPH/MCAH analyzed population-based data on suicide using the California Comprehensive Master Death File and California Department of Finance population data among adolescents and young people. CDPH/MCAH also analyzed Youth Risk Behavior Survey data to assess mental health, including suicide attempts, among California’s public high school students. Lastly, CDPH/MCAH analyzed the National Survey of Children’s Health data to assess relationships among adverse childhood experiences, family resilience, and neighborhood support. CDPH/MCAH conducted an environmental scan of other existing data related to adolescent mental health during the COVID-19 pandemic.
2. CDPH/MCAH provided oral presentations related to adolescent mental health, including suicide and suicide attempts, at three national conferences using data from the California Comprehensive Master Death Files, California Department of Finance population data and Youth Risk Behavioral Surveillance data. They are:

• The epidemiology of rising suicide among California youth aged 10 to 24, 2008-2017, CityMatch Leadership and MCH Epidemiology Conference, September 2020
• Sexual violence and attempted suicide among California’s high school students, American Public Health Association annual meeting, October 2020
• Rising suicide among California youth aged 10-24 years: Assessing the contribution of population subgroups, American Public Health Association annual meeting, October 2020
• The association between adolescent relationship violence and suicide attempt among California youth, 2019, National Conference on Health and Domestic Violence, April 2021. 

CDPH/MCAH started analyzing aggregated National Survey of Children’s Health to explore California data on adverse childhood experiences, resilience, and neighborhood support among adolescents aged 12 to 17 years.

The COVID-19 pandemic has raised concerns about mental health and well-being, especially among young people. To investigate the potential impact of the pandemic on the mental health and well-being of adolescents, CDPH/MCAH conducted an environmental scan related to this topic. Findings were presented at the California MCAH Directors meeting in the Spring of 2021.

CDPH/MCAH partnered with Dignity Health to present the Mental Health QPR (Question, Persuade, Refer) webinar, which was open to all AFLP, CA PREP, and I&E staff.  Approximately 59 AFLP, 44 CA PREP and 14 I&E staff registered to attend this training designed to teach lay and professional “gatekeepers” the warning signs of a suicide crisis and how to respond.

Success Stories

Partnering to provide local agencies with the Mental Health QPR training was a success. There is an ongoing and growing need to support caring adults in the lives of youth with the knowledge and skills to identify and refer when there is a mental health concern.

Challenges

N/A

Adolescent Domain Partners

Who are our partners?

CA Department of Education CA Department of Social Services CA Department of Health Care Services CA Department of Public Health, Office of Health Equity, Injury and Violence Prevention Branch, STD Control Branch, Immunization Branch and Office of AIDS California School-Based Health Alliance California Primary Care Association National Network of State Adolescent Health Coordinators State Adolescent Health Resource Center, University of Minnesota Association of Maternal and Child Health Programs National Improvement Partnership Network, University of Vermont Essential Access ETR University of California, San Francisco Gender Spectrum San Luis Obispo County Office of Education The Los Angeles Trust for Children’s Health American Civil Liberties Union of Northern California National Center for Youth Law Los Angeles School District Children Now CARDEA Barrios Unidos CAMI Health Health Connected