ADOLESCENT HEALTH DOMAIN

Nebraska Annual Report for the 2021-2022 Year

 

In this section, Nebraska MCH Title V reports on the accomplishments and activities in the Adolescent Health Domain for the period October 1, 2021 to September 30, 2022. This represents the second year of activity in the Title V needs assessment cycle.  The numerical sequence of headings used to organize the narrative below correspond to the narrative guidance for the Annual Report year as found on page 42 of the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, OMB Number 0915-0172, Expiration Date 1/31/2024.

 

From the 2020 Needs Assessment, the Nebraska Priorities selected in the Adolescent Health Domain for 2021-2022, with NPM, SPM, and ESM statements for the period are as follows:

 

• Motor Vehicle Crashes among Youth.

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

ESM: The number of schools participating in the “Teens in the Driver Seat” program.

 

• Sexually transmitted disease among Youth.

SPM: The rate of chlamydia infections reported per 100,000 youth ages 15-19 years.

ESM: None.

 

• Suicide among Youth.

SPM: The death rate due to suicide per 100,000 youth ages 10-19 years.

ESM: None.

 

1. Context: The State of the Adolescent Population Domain

 

The Adolescent Health Domain dominated the Title V 2020 Needs Assessment in the respect that participants and stakeholders selected three population health priorities in this Domain, the most priority statements of any of the population domains.  Stakeholders are tuned into both the potential and the risks of this period, and are committed to producing more positive and equitable youth outcomes.

 

In selecting Motor Vehicle Crashes among Youth as a priority, stakeholders responded to the fact the MVC are the leading cause of death among youth, as well as evidence of existing disparities, with males, rural youth, and American Indian youth most disproportionately affected. Stakeholders also identified that effective intervention strategies exist, including Nebraska’s Graduated Drivers Licensing (GDL) laws; peer-to-peer education such as Teens in the Driver Seat (TDS); and the importance of parental involvement in their teen’s developing driver behaviors.  In 2015-2020 a priority in the Adolescent domain was Injury Prevention, with a focus on motor vehicle crashes. 

 

Sexually Transmitted Diseases among Youth was also a population health priority in the 2015-2020 Needs Assessment cycle in Nebraska, and stakeholders remained concerned about the prevalence, disparities, and life course implications of sexually transmitted diseases on youth and related risk behaviors. The issue brief created by stakeholders on this topic speaks to impacts on both physical and mental well-being of youth affected, particularly Black youth.  During the 2015-2020 period, Title V focused primarily on activities and strategies involving improved school referral systems for sexual health issues of youth at school; improved communication between youth and trusted adults on sensitive topics; and youth-friendly clinics.  In the 2020 Needs Assessment, stakeholders point to evidence-based teen pregnancy prevention programs that may have the secondary effect of also reducing STDs.  Youth-serving organizations working on Positive Youth Development (PYD) strategies, including the Teen Outreach Program (TOP), which is sponsored by the DHHS Adolescent & Reproductive Health Program in several sites, are identified as promising venues in which to engage with youth. Stakeholders also pointed to the role of schools in offering standards-based sexuality education curricula, and the role of effective parent-child communication in mitigating youth risk behaviors.

 

Suicide among Youth is trending upward and has been a top cause of death in Nebraska for young people.  Stakeholders bringing forward the issue brief for this priority expressed concern not only at the preventable loss of life represented by each suicide, but also at the magnitude of impacts secondarily occurring in families, among friends, and impacting schools and communities. At the time of the 2020 needs assessment, stakeholders worked with the most recently available data about youth suicide, compiled by MCH Epidemiology.  However, since that time, much more data and anecdotal evidence have emerged regarding escalating mental and behavioral health needs among youth, of which suicidality is only one.  The total effects of pandemic-related disruptions and losses on the well-being of MCH populations passing through critical and sensitive periods of the lifespan will not be known fully for some time.

 

Stakeholders noted the opportunity for Title V to align with and amplify the Nebraska State Suicide Prevention Plan developed collaboratively in the state for the period 2016-2020.  Funding for this work is increasing in Nebraska, allowing Title V to support this work by a) helping align and promote mutual reinforcement of efforts statewide and b) advocating for intentional efforts to disrupt disparities in suicide.  Stakeholders urged effective strategies through workforce development, such as training school personnel and enhancing training of mental and behavioral health professionals, as well as others including Community Health Workers.

 

For the 2020-2025 Needs Assessment, Title V worked with the Nebraska Association of Local Health Directors to bring forward a summary of current priorities identified through the Community Health Needs Assessment and Community Health Improvement Plans that local public health departments regularly undertake in their respective jurisdictions.  The summary allowed stakeholders to consider degree of alignment with local priorities when determining which issues should be included in the final list of Title V priorities for the upcoming five-year period.

 

Five of seventeen local health departments have prioritized motor vehicle safety, unintentional death, and injury prevention as priorities. One health department prioritized teen pregnancy prevention.

 

Noteworthy to the population domain priority of Suicide among Youth is the fact that fifteen of seventeen local health departments in Nebraska have identified Mental Health issues as a priority. Eight local health departments have identified access to preventive care and screenings as a priority as well.

 

Nebraska Title V addresses adolescent health priorities in the state through the combined capacity of the DHHS Adolescent & Reproductive Health Program, Injury Prevention, School Health, and STI/STD programs, all of which partner with a variety of external entities across the state to accomplish their goals. 

 

2. Summary of Programmatic Efforts and Use of Evidence-based or Evidence-informed Approaches to Address Priority Needs

 

Priority: Motor Vehicle Crashes among Youth.

2021-2022 Objectives and Strategies

 

Objective AD6a: By 2025, reduce the number of crashes among adolescent drivers ages 14-19 years to prevent injury and death by addressing disparities in minority and rural populations.

 

Strategy AD6a(1): The DHHS Office of Injury Prevention will expand the scope of the Teens in the Driver Seat survey to include non-participating schools, in order to enlarge the data and understanding of Nebraska youth driving behaviors.

 

Strategy AD6a(2): The DHHS Office of Injury Prevention will expand its distribution plan for safe driving materials including Graduated Drivers Licensing to community cultural centers and other non-school settings.

 

Summary of Programmatic Efforts

In 2020, planned strategies for this objective focused on the ongoing work of the Office of Injury Prevention at DHHS. The Office of Injury Prevention planned to expand the reach of the program by expanding the scope of the Teens in the Driver Seat survey to include non-participating schools in order to enlarge the available data set to better understand diversity in driver behaviors and better localize prevention strategies.  The Injury Prevention program also agreed to address the need for health-literacy and translations in prevention education materials in order to reach a wider and more diverse audience of families.  Third, the Injury Prevention Program planned a campaign to reach out to more community cultural centers and non-school settings, in order to reach a broader and more diverse audience of parents of teen drivers, some of whom might be quite unfamiliar with U.S. driving regulations and practices for adolescents.

 

In practice, the Injury Prevention Program (IPP) worked with a total of 16 schools, 12 participating in the Teens in the Driver Seat program, and 4 additional schools agreeing to participate in the survey.  The IPP expected differences between schools that had Teens in the Driver Seat programs compared to schools that did not have Teens in the Driver Seat programs, but the differences in the driving behaviors measured were not statistically significant. The schools that participated in the survey that did not have Teens in the Driver Seat programs also were not compelled to start new programs. Based on these results, IPP does not plan to continue surveying schools without Teens in the Driver Seat programs.

 

In 2020-2021, an informational card for parents about Nebraska’s Graduated Driver’s License requirements for teen drivers was translated into Spanish. The IPP considers this strategy completed and no activities for the strategy were completed in 2021-2022.

 

The IPP reached out to community cultural centers and non-school settings to reach a broader and diverse audience. They did not have much luck distributing materials to these organizations but did distribute materials to non-school settings, including driver education courses, law enforcement, and physician offices.

 

In April 2021, the Injury Program recognized a total of eleven schools with All Star and Outstanding recognitions. One non-school community program for youth joined Teens in the Driver Seat. In 2021-2022, a total of 9 schools were recognized.

Use of Evidence-based or Evidence-informed Approaches in this Priority

 

At the website, www.mchevidence.org, the evidence review for injury prevention does not focus on motor vehicle crashes to a useful degree to assess strength of evidence in interventions. In the What Works for Health Directory of County Health Rankings and Roadmaps, https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health the topic of Community Safety encompasses safe transportation, within which Graduated Drivers Laws are shown as being supported by scientific evidence of effectiveness. All other evidence-supported interventions are of a policy, not educational, nature.

 

According to the National Highway Traffic Safety Administration (https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812683) seat belt use is one of the most effective ways to save lives and reduce injuries in crashes for adults and older children (who are big enough for seat belts to fit properly). A total of 2,276 people were killed in crashes involving a teen driver (15-18 years old) in 2020.  52% of teen passenger vehicle drivers who died in 2020 were unbuckled (https://www.nhtsa.gov/road-safety/teen-driving).

 

For Teens in the Driver Seat as an intervention, the TDS website (https://www.t-driver.com/) cites the following: Teens in the Driver Seat® program surveys show risk awareness levels increasing by up to 200 percent. Cell phone use at Teens in the Driver Seat® program schools has been shown to drop by 30 percent, and seat belt use has gone up by over 14 percent.  A rigorous 20-county control group analysis for Texas indicates the program results in an average decrease of 14.6 percent in injury and fatal crashes (total) where the program has been sustained for three or more years.

 

Priority: Sexually transmitted disease among Youth.

2021-2022 Objectives and Strategies

 

Objective AD7a: By 2025, decrease the rates of chlamydia and gonorrhea among youth in Nebraska by addressing disparities among racial/ethnic and urban/rural groups.

 

Strategy AD7a(1): The DHHS STD Program will review and address needs for health literate, culturally and linguistically appropriate materials to educate the population, particularly disadvantaged groups.

 

Strategy AD7a(2): The DHHS Adolescent Health Program will continue the development, testing, distribution, and evaluation of the Conversation Starters Project.

Strategy AD7a(3): The DHHS Adolescent Health Program, in partnership with the DHHS STD program, will research and select an evidence-based or evidence-informed youth programming model that addresses STDs in youth.

 

Strategy AD7a(4): The DHHS Reproductive Health Program will identify project opportunities to promote sexual health among underserved, disproportionately affected groups.

 

Summary of Programmatic Efforts

In 2020, a robust slate of strategies was set, involving the DHHS STD Program, the Adolescent Health Program, and the Reproductive Health Program mirroring the robust intent of stakeholders in identifying this priority, especially considering disparities.  These were continued in 2021-2022.

 

During the 2021-2022 period, activities continued within the Adolescent Health and Reproductive Health programs. In the first few months of the period, the Reproductive Health Program Manager left her position, and the Adolescent Health Program Manager was promoted into the Reproductive Health Program Manager position. As the Adolescent Health and Reproductive Health programs have a long history of partnership, it made sense to combine the two programs into one program, with the new name of the Adolescent & Reproductive Health Program (ARH). While staff reshuffled, ongoing efforts were maintained on all activities supported by Title V.

 

Throughout the year, the ARH Program researched relevant adolescent health-related topic areas and drafted a set of Conversation Starter questions for parents, guardians, caregivers, trusted adults, and youth-serving professionals to engage in meaningful conversations with youth. Some of the questions are on sensitive topics that can be difficult for trusted adults to navigate without prompts, including sexual health, racism and bias. They hosted two two-hour workshops to pilot the drafted questions and received feedback from eleven youth-serving professionals and experts.

 

Title V has developed a strategy to select an evidence-based or evidence-informed model to address STDs among youth. ARH Program staff attended a training of educators with ETR for Making Proud Choices and Making a Difference (MAD), to learn more about which curriculum would be most appropriate for Nebraska to adopt. The ARH Program developed the Nebraska MAD program - a flexible evidence-based curriculum which can be implemented as an alternative to Teen Outreach Program (TOP) in some settings.  In Nebraska, MAD cohorts are required to complete nine modules that provide young people with the opportunity to learn about abstinence, puberty, sexually transmitted infections and HIV, pregnancy, healthy relationships, peer pressure, and refusal/negotiation skills. During the 2021-2022 period, Making a Difference was piloted with two providers serving 22 youth in three cohorts.

 

Title V continued to support the ARH as a vehicle to support the sexual health and well-being of adolescents, with Title V positioned to make subawards to youth-serving organizations.  Six subawards were again issued in April 2022 for adolescent & reproductive health projects to increase adolescent use of reproductive health services through outreach and education, youth-friendly clinic updates, and professional development for staff.

 

Due to COVID-19 pandemic impacts, Title V removed a strategy to expand the evidence-based Teen Outreach Program in the ARH Program with Title V support to increase presence in rural areas. The landscape and funding opportunities for TOP expansion changed because of the pandemic, and Title V will not be making an investment as proposed.

 

Staff turnover in the STD program curtailed any progress on the strategies identified. The STD program did not review materials to enhance cultural and linguistic appropriateness for diverse youth audiences and their caregivers and educators. 

 

Use of Evidence-based or Evidence-informed Approaches in this Priority

When considering the use of evidence-based practice in the priority area of reducing STDs among adolescents in Nebraska, the resource www.mchevidence.org offers evidence primarily focused on adolescent well-visits for preventive health care, which may or may not be a visit inclusive of, rather than specific for, reproductive and sexual health services.  The summary of evidence includes the following:

“The following trends emerged from analysis of peer- reviewed evidence...

• Expanded insurance coverage appears to be effective.
• Patient reminders appear to be somewhat effective.
• There is insufficient evidence of the effectiveness for school-based health centers.”

 

In the evidence review of the County Health Rankings “What Works” feature (https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies?search_api_views_fulltext=sexual%20health&items_per_page=10&page=1) there is strong evidence supporting the following interventions to promote sexual health of adolescents:

• Comprehensive risk reduction sexual health education (scientifically supported);
• School-based health centers (scientifically supported);
• Condom availability programs (scientifically supported);
• Behavioral interventions to prevent HIV and other STIs (individual, group, and community-level interventions to provide education, support, and training that can affect social norms about HIV and other STIs – scientifically supported);
• Extra-curricular activities for social engagement (scientifically supported); and
• School-based social and emotional instruction (scientifically supported);

 

A review of the scientifically supported interventions above suggest the use of Conversation Starters to promote behavioral interventions would be plausibly related to evidence-based practice.  The TOP curriculum as developed and adapted by Wyman is an evidence-based curriculum, see: https://wymancenter.org/top/

 

In the Adolescent Reproductive Health Subawards, subrecipients utilize a mix of approaches, some of which may be evidence-based. As mentioned above, the ARH Program issued a total of six awards in 2022, including rural and urban communities, for the purpose of increasing adolescent use of reproductive health services. Subrecipients were specifically asked to focus on outreach and education, youth-friendly clinic updates, and professional development for staff.

 

Priority: Suicide among Youth.

2021-2022 Objectives and Strategies

 

Objective AD8a: By 2025, reduce suicide rates among youth by increasing access to early intervention services and education, addressing stigma, promoting protective factors (resilience, asset-building, family engagement), and reducing risk factors.

 

Strategy AD8a(1): The DHHS School Health Program will work collaboratively with cross-sector partners to increase the capacity of schools to respond effectively to student mental health issues including suicidality and behavior issues, for students with and without special health care needs.

 

Strategy AD8a(2): Title V will participate with state-level, cross-systems partners to align and amplify suicide prevention efforts for all children, youth, and families.

 

Summary of Programmatic Efforts

Many Nebraska stakeholders are deeply concerned by youth suicide in the state.  The prioritization of youth suicide was underscored with a particular sense of urgency.  Strategies included working in the setting of schools, through the School Health Program, building on work begun previously to address the gaps and assets in screening and referral of students; training of school personnel; needs for health literate and culturally- and linguistically-appropriate materials and communications for diverse consumers; referrals to community resources; school-family partnerships; and trauma-informed/restorative practices.

 

As noted, Title V does not work alone in this space, but alongside numerous systems partners and resources.  Specifically in order to assure that Title V efforts would be mutually-reinforcing and complementary with other system leaders, Title V committed during this period to continuing to be an active and present member of the Nebraska Statewide Suicide Prevention Coalition, as well as taking a new spot as a member of Nebraska’s Garrett Lee Smith Suicide Prevention Grant project management team.  Through these collaborations alone, Title V has been able to advocate for statewide reach of efforts, as well as a greater equity-focus, including greater outreach to promote training for Community Health Workers in such areas as suicide prevention, mental health first aid, and motivational interviewing.

 

Aware that American Indian youth suffer significant disparity in this area, Title V also identified an intent to work more closely with the Society of Care in Nebraska.  https://societyofcare.org/ This was limited by staff turnover. Title V continues to collaborate with Society of Care, but a close project was not initiated in 2021-2022.

 

The experience of the School Health Program proved fruitful in planning ensuing activities.  There are several partners working at the systems level and at the local school level to reduce risk of suicide and build protective factors. The School Health Program identified that School Nurses were often not included in these projects yet interact with students with mental and behavioral health needs frequently. The School Health Program launched several educational events and communication activities for school nurses to improve knowledge of and communication about suicide prevention resources. The School Health Program worked with the Nebraska Statewide Suicide Prevention Coalition to disseminate information to schools on suicide prevention mini grants in January 2022.

 

Title V frequently issues subawards to local entities for maternal and child health promotion activities. In 2020-2021 four local subawards named suicide prevention as a priority concern in their workplans. These subawards were initiated in 2021 and renewed in 2022. Additionally, during this period in early February 2021, the nation’s Surgeon General released a Call to Action to Implement the National Strategy for Suicide Prevention.

 

Use of Evidence-based or Evidence-informed Approaches in this Priority

The website www.mchevidence.org does not provide an evidence framework for mental and behavioral health issues of youth, nor suicide prevention.  

 

Referring to County Health Rankings and Roadmaps, What Works feature, there is a category of strategies around the topic of Family and Social Support that are supported by evidence and pertain to socially and emotionally healthy youth.  These include:

• Youth peer mentoring
• Extracurricular activities for social engagement
• Outdoor experiential learning
• Youth leadership programs

 

At the same resource, Crisis Lines and Mental Health First Aid are also evidence-supported strategies.

 

Perhaps most significantly, the Suicide Prevention Resource Center is an important resource for evidence-based best practices in suicide prevention. Here, resources at use in Nebraska schools include Kognito online resources, QPR Gatekeeper Training, and SOS (Signs of Suicide). https://www.sprc.org/resources-programs

 

3. Assessment of Alignment of NPMs, ESMs, SPMs, and SOMs with Priority Needs

 

Priority: Motor Vehicle Crashes among Youth.

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

ESM: The number of schools participating in the “Teens in the Driver Seat” program.

 

Alignment:

In this priority, Nebraska makes use of traditional alignment between hospitalization for non-fatal injury by age group and the priority topic of motor vehicle crashes involving youth drivers.  For the ESM, Nebraska draws on the evidence-based model Teens in the Driver Seat, by collaborating with the DHHS Injury Prevention Program, and measuring the extent to which Nebraska schools are participating in the program in a given year.

 

Priority: Sexually transmitted disease among Youth.

SPM: The rate of chlamydia infections reported per 100,000 youth ages 15-19 years.

ESM: None.

 

Alignment:

Nebraska uses an SPM, or state performance measure, in the priority area of sexually transmitted disease, and measures the incidence of chlamydia infections in a period for an age group of youth, the majority of whom are female.  Nebraska’s strategies in this priority largely focus on behavioral interventions, rather than looking at youth entering a point of care.  There is no ESM associated with this priority. 

 

Priority: Suicide among Youth.

SPM: The death rate due to suicide per 100,000 youth ages 10-19 years.

ESM: None.

 

Alignment:  

Alignment between the priority and SPM in this area is starkly clear.  Missing is Nebraska’s disparities between racial and ethnic groups in this priority.  There is no ESM assigned to this priority.

 

4. Progress in Achieving Established Performance Measure Targets along with Other Programmatic Impact

 

Since 2015, Nebraska Title V has been writing and utilizing Results-base Accountability (RBA) measures in an effort to make annual impacts and achievements more discernable to front line staff and stakeholders.  In addition, use of RBA has specifically highlighted inclusion and equity-focused efforts that have been transforming Title V work.

 

Results Based Accountability (RBA) measures Motor Vehicle Crashes among Youth
	Proposed 2021-2022	Achieved 2021-2022
How much did we do?	How many schools and how many youth participated in the Teens in the Driver Seat survey?	10 schools with 1,715 youth and 6 middle schools with 556 youth
How well did we do it?	How many cultural centers participated and how many individuals were reached?	0
Is anyone better off?	What evaluation measures are in place for the cultural center project?	There are no measures in place, this activity was not very successful

 

Discussion – Other Programmatic Impacts

The Injury Prevention Program carries out activities with Title V as well as CDC funding.

 

Results Based Accountability (RBA) measures STDs Among Youth
	Proposed 2021-2022	Achieved 2021-2022
How much did we do?	How many consumers participated in testing/evaluating the Conversation Starters?	11 youth-serving professionals evaluated the Conversation Starters
How well did we do it?	How were the Conversation Starters revised based on input from diverse users and consumers?	Additional adolescent health-related topic areas were added to the conversation starters and some drafted questions were rephrased, added, and deleted.
Is anyone better off?	Have any curricula been adopted and implemented by the adolescent health program focused on STDs?	Yes, Nebraska Making a Difference has been piloted with two sites and 22 youth.

 

Discussion - Other Programmatic Impacts

The Adolescent & Reproductive Health Program carries out activities with Title V as well as Personal Responsibility Education Program (PREP) and Sexual Risk Avoidance Education (SRAE) funding from the Family and Youth Services Bureau (FYSB).

 

Results Based Accountability (RBA) measures Suicide Among Youth.
	Proposed 2021-2022	Achieved 2021-2022
How much did we do?	Measure of Title V participation in statewide suicide prevention meetings.   How many new suicide prevention training events did Title V help organize in rural and underserved regions? (Include School Health Program and CHW training.)	Six     0
How well did we do it?	What gap area is Title V helping address in statewide suicide prevention?	Working with school health staff, who are often overlooked as a provider of mental health resources for schools
Is anyone better off?	How many Community Health Workers have participated in QPR Suicide Prevention training, or other mental health education from Title V?	CHWs hosted in five cross-sector trainings. None of them were QPR suicide prevention, mental health first aid, trauma informed care, and/or motivational interviewing.

 

Discussion - Other Programmatic Impacts

The urgency of work in this area has escalated as a result of life course disruptions at critical and sensitive periods for many youth, children, and families during the pandemic.  Because Title V in Nebraska serves as lead agency for Nebraska’s Pediatric Mental Health Care Access Program (2021-2023) there has been opportunity to leverage additional resources and supports for the mental and behavioral well-being of children and families, while sustaining an equity-focus.

 

5. Challenges and Emerging Issues

 

Suicide, depression, and anxiety

Numerous sources speak to the impact of the pandemic and subsequent loss of social, educational, and economic supports for many families, on adolescents.  One of the sources unique to Nebraska is the NEP-MAP Family Survey. NEP-MAP is the name of Nebraska’s Pediatric Mental Health Care Access Program.  Families relate their concerns about the mental state of children during the pandemic.  See the report at www.dhhs.ne.gov/NEPMAP  

 

Consequences of limited access to STD and contraceptive services

Similarly, recent anecdotal evidence shows that STDs are on the rise among youth due to disruptions in access to health services, as well as increasing risk behaviors.  

 

6. Overall Effectiveness of Strategies and Approaches: Addressing Needs and Promoting CQI

 

The Youth-friendly clinic environments work has promising merit and has been built into subrecipient activities by the Adolescent & Reproductive Health Program.  The scale and scope of the intervention activity with six subawards is small and unlikely to have population impact.

 

In the case of Nebraska’s priority statement of suicide among youth, most advocates agree that saving of one life is a worthy impact, and that working towards zero suicide is the goal.  In Nebraska, efforts are continuously occurring at the systems, school, and individual levels.