Adolescent Health

Report for the application year: Oct 2021 - Sept 2022

NPM 10: The percentage of adolescents, ages 12-17, with a preventive medical visit in the past year

Strategy 10.1: Increase the number of youth friendly clinics (or number of clinics participating in a QI initiative).

During this reporting period, the WCFH Adolescent Health Program (AHP) was unable to sustain the youth-friendly clinic grant initiative due to limited provider and practice capacity for QI initiatives. This reduced capacity is likely an impact of the COVID-19 pandemic. Many partner clinics are unable to bring in new nursing staff. A study by the National Center for Health Workforce Analysis projected Alaska would lead the nation in nursing vacancies by 2030 with 23% unfilled positions.

The AHP staff did collaborate with national and state partners on the improvement of NPM 10. Program staff continued to participate in the NPM 10 workgroup with the National State Adolescent Health Coordinators and the Adolescent and Young Adult Health National Resource Center. The AHP maintained sharing of the resources generated during the pilot QI initiative, but will no longer maintain the AHI Coaches certification, due to financial challenges and limited partner capacity.

Strategy 10.2: Support the Alaska Coalition for Healthy Teens and Young Adults.

The Alaska Coalition for Healthy Teen and Young Adults met quarterly to maintain open communication with community partners on the intersectionality of violence prevention and sexual health promotion. Partnerships sustained through this group are essential for the support of comprehensive sexual health education and age-appropriate violence prevention education for adolescents in Alaska.

Strategy 10.3: Coordinate and provide continuing education and workforce development for providers working with adolescents.

The Title V-funded School Health Nurse Consultant provides continuing education for school nurses through online trainings and annual conferences. A School Nurse Orientation course was offered virtually, at no cost to participants, and included 30 continuing education credits for nurses. School Nurses statewide were advised of the course through school district School Nursing and Health Services Leadership. School nurses could start the course at any time to increase equity in accessing school nurse professional development state-wide.

Weekly School Health ECHO’s continued to take place weekly and concluded with the end of the school year in May 2022. Virtual learning sessions provided continuing education credits and were well attended. Participants included district and school staff and administrators statewide which included school nurses, school counselors, rural teachers responsible for student health, principals, and superintendents. Session topics included mental and behavioral health, chronic illness, violence prevention, healthy relationships, developmental health, environmental health, infectious disease, and health promotion, among others. The virtual School Health ECHO series for the 2022-2023 school year began in August 2022 and will take place twice per month and again offer continuing education credits to participants.

New rural school nurses were invited to participate in a weekly mentorship meeting where they were encouraged to discuss current school health office issues, concerns, and successes recently encountered. This community of practice style mentorship helped develop professional connections with other rural school nurses, allowed for discussion on how they handled the situation, provided an opportunity for feedback, all with the support of the State School Nurse Consultants and experienced school nurses in a mentoring role.

The School Nursing/Health Services Program’s (SNHS) State School Nurse Consultant’s prioritized all programmatic guidance and documents requiring review and revision updates. State guidance for school district’s related to medication administration training for unlicensed assistive personnel in schools was updated. After review and approval by the AK Board of Nursing, the guidance was published electronically and made available on the SNHS Program website. Work also began on updating the state emergency medication training for unlicensed assistive personnel in schools.

Title V Block Grant funding was used to support school nurse leaders to attend the School Health Nurse Advisory Committee (SHNAC) annual in-person meeting as well as the annual Alaska State Nurses Association (ASNA) Conference in April 2022. This funding has historically been provided to nurses from outside of Anchorage to increase equity and access to these professional development opportunities. The Section allocated funding for one-year ASNA memberships for school nurses statewide and included the cost of the state conference. The Section purchased school nursing textbooks for 12 rural school districts.

The School Nurse Consultant, along with the lead of the Office of School Health & Safety, presented at the All Alaska Pediatric Provider (A2P2) Symposium regarding fostering and expanding pediatric provider collaboration with school nurses to enhance the health of wellness of students through coordination of care and health services.

Strategy 10.4: Support school nurses and school-based health centers in encouraging all youth to establish a medical home and have consistent visits.

As in-person learning resumed during the 2021-2022 school year, school-based health centers were able to resume providing services for students. Using marijuana tax revenue funds, sponsorship funding was distributed to four school-based health centers: Anchorage, Bethel, Juneau, and the Lower Yukon Kusilvak Career Academy (KCA).

Anchorage School Based Health Centers provided comprehensive wellness exams (physicals) and implemented the Rapid Assessment for Adolescent Prevention Screening (RAAPS) validated screening tool for all students receiving a physical exam. They also Partnered with Alaska Behavioral Health (non-profit community health agency to provide mental health services new service provided). The percentage of students seen for a comprehensive wellness exam was 9.82%

Bethel Youth Center provided medical, dental, and public health services for four Bethel area schools. The funding supported clinic improvements and needed medical equipment which focused on promoting an atmosphere for “adolescent friendly care. The percentage of students seen for a comprehensive wellness exam was 26.2%.

Juneau Teen Health Center reported that the COVID-19 pandemic had significant impact on students, particularly in adolescent mental health. They also used funding to implement the Rapid Adolescent Prevention Screening (RAPPS) tool. Funding also supported hiring Teen Health counselors and collaboration with National Alliance on Mental Illness (NAMI)-Juneau, which resulted in increased mental health counseling services by 1.5 days and prompt readily available counseling support to students in need. The Juneau Adolescent Health Care Coordinator reported that the funding helped promote equity by delivering clinical care to all students, particularly those who can’t afford or who would otherwise be unable to receive counseling outside of the school setting. The percentage of students seen for a comprehensive wellness exam was 12.9%

Lower Yukon KCA School Based Health Center partnered with South Central Foundation to provide on-site services thereby reducing emergency room visits. This increased access to health care for students while promoting continuity of care and a health care provider home for students.

Strategy 10.5: Continue collaboration between school nurses, other healthcare providers and Division of Public Health programs.

The School Nurse Consultant initiated communication and collaboration with the Section of Public Health Nursing (SOPHN) to foster a partnership in support of school health screening for school districts that do not have a dedicated school nursing/health services program. She provided training to Anchorage-based Itinerant Public Health Nurses to perform school-based health screening (hearing, vision, biometrics) and collaborated on resources and topics for them to provide educational classroom presentations for youth including reproductive/sexual health.

Strategy 10.6: Promote preventative medical visits (whether through school nurses, the Fourth R, adult preparation skills curriculum, healthy life skills or with community partners) and education on youth health literacy, including education on the importance of a well visit and oral health.

School nurses continued to encourage families to seek medical homes, provide comprehensive well child visits, and ensure immunizations are up to date. During this reporting period, there continued to be a focus on COVID mitigation. Funding to school-based health centers increased the ability to provide comprehensive wellness visits in schools.

The “Navigating the Health Care System: Alaska” curriculum was completed in early 2022, and the additional fifth module, “Coaching Youth in Health Literacy: A Training for Providers,” content development was completed during the summer. WCFH staff worked on reviewing the fifth training module for edits and have planned pilot trainings with providers to receive direct feedback in winter 2022 and early 2023. The WCFH team plans to develop an online training of the curriculum for further reach and accessibility for providers to receive professional development training in late Spring 2023.

The oral health literacy education video targeted for adolescents was publicly posted, in partnership with the Alaska Dental Action Coalition. Accompanying this video, the State of Alaska continued to develop a collection of oral health education resources for youth, including provider introduction videos, insurance resources, and ‘sights and sounds of the dental office’ videos, in partnership with MPH candidates supporting the project through their program practicum. This campaign, ‘Your Mouth Matters’, supports adolescents in transitioning to management of their oral health care, and Children and Youth with Special Health Care Needs (CYSHCN) patients in familiarizing themselves and their families with their dental care home, and is scheduled to go live next year.

Strategy 10.7: Collaborate with Medicaid to increase adolescent preventive health visits, and to collect data for analysis and dissemination regarding adolescent healthcare visits.

In the past year, Child and Adolescent Health Unit staff joined the monthly pediatric team meeting with Medicaid to bring this topic forward and provide data. This team includes the Medicaid Medical Director, EPSDT Coordinator, and CHIP Director. Staff identified opportunities for more work on this strategy through Office of School Health and Safety and the promotion of well-child visits and school-based health centers. The Adolescent Health Program drafted a contract with the agency Facing Foster Care in Alaska, which was founded and is led by foster youth alumni and current young involved in the system. This partnership will provide resources and equipment to support independent living services, higher education, and other resources to educate and engage foster youth in their healthcare services and rights.

Strategy 10.8: Review all adolescent deaths through the Maternal Child Death Review (MCDR), generate actionable recommendations for all preventable deaths and increase awareness about the MCDR program among the public, clinicians, and policymakers.

MCDR reviews all deaths among adolescents through age 17 from all causes using a multidisciplinary process that includes diverse representation of cultures, regions and disciplines. During 2017-2021, there were an average of 46 deaths among adolescents age 15-19, corresponding with a five-year average rate of 100.4 deaths per 100,000 (Kids Count Data Center, 2023). This is substantially higher than the national mortality rate for this age group for this timeframe (54.2/100,000). Suicide remained the leading cause of death among Alaskan adolescents. MCDR has a pool of subject matter experts with diverse competencies that support rich discussion of factors in mortality for all causes of death. This is especially true for suicide deaths, as these panels include statewide suicide and injury prevention leaders from Tribal and state agencies, cultural representatives, suicidology, mental health, school counseling, healthcare providers, and child welfare.

Rates (per 100,000) of Adolescent Death by Accident, Homicide and Suicide, 2011-2021

Suicide rates are highest among older adolescents who are outside the age-range which the program covers. Alaska does not have a comparable multidisciplinary death review process for these cases, although the Alaska Violent Death Reporting System (housed in the Division of Public Health, but outside WCFH) completes an internal data abstraction and data capture process for all violent deaths including suicide. The AKVDRS process does not generate prevention recommendations for each case in the way that MCDR does, although its data is certainly useful for analysis and prevention planning. Program staff, committee members and partners agree that MCDR review of transition-aged youth would be beneficial for these deaths, but the program does not have capacity to review additional cases at this time. Although deaths from suicide are seen more frequently among older adolescents, MCDR often reviews suicide deaths among younger teenagers and sometimes children 12 or under. Through the program’s review of maternal deaths from all causes, MCDR has reviewed numerous deaths among adolescent and young adults who were either pregnant or within one year of the end of a pregnancy (regardless of the outcome of the pregnancy). Nationally, rates of mortality from homicide among females are higher for the maternal population than for females who were not pregnant or postpartum. This difference is amplified among young women, with pregnant and postpartum adolescents being at much greater risk of being killed by their partners than other maternal age groups. Although Alaska’s small population limits statistical analysis as well as reporting of stratified case counts, the available information suggests that these realities hold true for young women in Alaska.

MCDR reviewed 13 deaths among adolescents aged 12-17 during this report period, most of which were due to suicide. MCDR completes reviews on a rolling basis, based on availability of records and completion of abstracts. Most deaths reviewed during this period occurred during 2020. Facilitators worked with the committee and national partners to identify strategies to consistently and objectively address the impacts of the COVID-19 during review of cases which occurred during this time frame. Most reviews during this report period were held via HIPAA-compliant virtual platform. However, a preference for convening in person has been expressed by many case reviewers, particularly those who review deaths involving complex social factors and trauma, due to the quality of discussion and peer support that can be facilitated in person. Many hours go into preparing and reviewing each case, including approximately one full day of case abstracting after all records have been collected. The review itself typically takes about one hour per case, with in-person reviews typically being slightly more time-efficient. Virtual reviews do not exceed four hours, but in-person reviews may be held for a full day with a lunch break. One full-day in-person review was held during this report period, focusing on adolescent deaths from suicide, and all other reviews for this age group were held virtually. Below are sample prevention recommendations made by the committee during this review:

• Public health agencies should conduct active outreach to marginalized communities to share information about resources and supports that are open and available during emergencies including pandemic lockdowns.
• Alaskan behavioral health associations should advocate for culturally matched behavioral health services to better meet the needs of community members with primary languages other than English.
• Law enforcement should utilize professional interpreters during investigative contacts and interviews and should never place children in the role of interpreting.
• Schools should have community liaisons available who can be a point of contact for parents/caregivers and who can provide culturally and linguistically matched support about student attendance, progress and concerns.
• ROTC programs should provide education and support for youth on how they can respond when a peer makes suicidal threats or shows other warning signs of suicide risk.
• Health systems should provide LGBTQ+ competency training for healthcare and behavioral health providers and ensure queer youth are matched with competent, culturally matched providers.

MCDR maintains a database with the committee’s recommendations from all completed reviews, along with a wide range of case variables and identified factors in mortality. During this report period, information about deaths among adolescents was analyzed and disseminated through presentations and data requests. Presentations during this report period included the statewide Suicide Prevention Conference, the Primary Prevention Summit, and the Suicide Prevention Community of Practice. Recommendations for the prevention of adolescent suicide were the most frequently requested type of recommendations during the report period. Requests were received from internal and external partners for use in presentations and to support funding applications and prevention planning. Requestors have included Tribal Health, child welfare, the Alaska Division of Behavioral Health, individual healthcare providers and the Children’s Justice Act Task Force. They were also requested by other WCFH staff for various purposes, including provider training and sharing with community partners.

Although implementation will be reported in the women/maternal domain, an MCDR recommendation for provider training on strangulation identification and response came from the review of both maternal and adolescent cases, pursuant to identification of missed opportunities for screening and response. MCDR advocated for implementation of this recommendation and collaborated with a committee member and the AKPQC to plan for provider training during the report period. Strangulation has acute and chronic impacts on physical and mental health, including depression and PTSD. Although commonly associated with IPV homicides, MCDR has noted strangulation history during the review of some adolescent deaths, including deaths from suicide. This training is scheduled to occur during the next report period. and will be delivered by one of Alaska’s top forensic medical experts, Dr. Cathy Baldwin-Johnson, with the MCDR Program Manager co-presenting. Dr. Baldwin-Johnson advocated for the inclusion of pediatric and adolescent strangulation response in addition to the in-depth discussion of implications for perinatal patients. This is not only because some perinatal patients are in fact adolescent, but also to help prepare attendees to identify and respond to signs and symptoms which may be observed in their patients’ children and other household members who accompany them to medical visits. Dr. Baldwin-Johnson has delivered several strangulation trainings for a variety of audiences in the state, but this is the first training that will be tailored to the perinatal population with Alaska’s perinatal providers as the target audience that Dr. Baldwin-Johnson and MCDR leadership are aware of.

SPM 2: Percent of adolescents with three or more adults (besides their parent/s) who they would feel comfortable seeking help from.

Strategy 2.1: Develop a Fourth R and Healthy Relationships Plus Program online training that includes additional resources for parents and educators on facilitating healthy relationship conversations with youth.

During this reporting period, the Fourth R and Healthy Relationships Plus Program online training was not completed as planned due competing priorities and limited external staff to help develop the resources. The Fourth R and Healthy Relationships Plus Program online training is in the process of being built to be hosted on the State of Alaska Moodle training system and the voice over recordings are planned to be recorded in January 2023. The training is expected to go live in August 2023. In addition, during the reporting period the WCFH team provided three virtual Fourth R facilitator trainings for a total of 43 facilitators trained, and 37 facilitators were trained through the curriculum proprietor’s online training.

Strategy 2.2: Support statewide training and dissemination of Coaching Boys into Men (CBIM), a comprehensive violence prevention curriculum for coaches and the athletes they work with developed by Futures without Violence.

The WCFH Adolescent Health Program partnered with the Alaska School Activities Association to implement two statewide training of trainers’ program for Alaska’s athletic coaches. Coaching Boys into Men is an evidence-based prevention program that trains and motivates high school coaches to teach their young male athletes healthy relationship skills and that violence never equals strength. This comprehensive violence prevention curriculum for coaches and their athletes was developed by Futures without Violence. Athletes As Leaders™ is a program designed for high school athletes on girls’ sports teams. Student athletes are encouraged to be leaders in changing social norms at school to a culture of safety and respect. Both curriculums provide high school athletic coaches with the resources they need to promote respectful behavior among their players and healthy peer relationships. Both curriculums address anti-racism through conversations about harassment and respect. Both curriculums are designed to impact Alaska’s SPM and further connect youth to trusted adults. During this past year, trainings were held in Fairbanks with Tanana Chiefs Conference, in Juneau, and multiple statewide trainings were held in Anchorage. This work was grant funded by CDC Rape Prevention Education Program dollars.

Strategy 2.3: Maintain statewide dissemination of Teen Speak publications and adolescent-focused motivational interviewing skills training and resources for supportive adults, parents, caregivers, and clinicians.

During this period, two virtual cohort trainings were conducted with school personnel, nurses, supportive adults, and parent groups in Alaska, including school health nurses from Healy, Homer, Alaska and Wasilla Alaska. Two introductory sessions were offered at public conferences encouraging participation. A school health nurses college-level course was created in conjunction with the Matanuska Susitna School District but was postponed due to low registration. Reinitiating of this training will be offered in the winter of 2022-2023. The Adolescent Health Program closed out the fiscal year with 10 individuals trained in Adolescent-Focused Motivational Interviewing training. The new MITEY Change format for Clinicians was received with contact hours or CEUs by 12 individuals.

Strategy 2.4: Increase meaningful connection between youth and supportive adults through YAHA by collaborating on the programs and projects that target youth.

In the 2021-2022 Session, YAHA members worked alongside the My Best Alaskan Life (MBAL) team as youth participatory action researchers to ensure that tool created is addressing Alaskan youth's concerns. The tool integrates hope therapy and motivational interviewing elements to focus on youth identifying their desired outcomes.

From January through April of 2022, the MBAL research team completed a statewide pilot assessing the design and implementation of the tool, gathering feedback from over 600 survey responses (youth ages 14-20); 10 in-depth interviews (adult partners at community organizations and clinics); and two- youth-led design review sessions (Planned Parenthood's Teen Council and Bethel's Youth Against Violence). Questionnaire respondents were overwhelmingly positive about the tool (91% "liked or loved" the tool) and its potential applicability in their community (86% cited "very applicable").

YAHA and the MBAL team are working on revising and finalizing the MBAL tool to reflect the realities facing youth in Alaska and address barriers to implementation. These amendments will include new modules on substance misuse and mental health.

YAHA reviewed The Dental Action Coalition video aimed at improving youth dental health literacy. YAHA members provided feedback on the naming of the video: Your Mouth Matters. The Alaska Oral Health Program supports collaborative workforce development, data assessment, and access to care initiatives. The program is currently funded with a HRSA Oral Health Workforce Development grant. The program also provides administrative support to the Alaska Dental Action Coalition, a group of oral health, public health, and community health professionals representing organizations and facilities statewide.

The program partners with and is supported by other State sections and staff with awareness of, and interest in, oral health promotion and those mindful of oral health issues for policy and program development. Health literacy is a priority of the current program management, and outreach to adolescents is a passion project supported by the oral health program’s presence within the Adolescent Health Unit of WCFH.

Muhammad Khan, the college Intern incumbent, graduated from the University of Alaska Anchorage this past spring with a Bachelor of Science in Health Sciences with a minor in Medical Anthropology. He will attend the Columbia University Mailman School of Public Health this fall to pursue a Master's of Public Health in Sociomedical Science with a certificate in Global Health. He aims to use the skills and knowledge acquired at Columbia to work in global healthcare development and to improve healthcare infrastructure and delivery in underdeveloped and developing countries.

Mya Robinson joined as the new College Intern II on August 15th, 2022. Mya is a University of Alaska Anchorage student pursuing her Bachelor of Social Work with a minor in Speech-Language Pathology. She expects to graduate in May 2023 and plans to achieve a master’s degree in Speech-Language Pathology after graduation. She believes the bridge between Social Work and Speech-Language Pathology brings forth a powerful combination of understanding that can be utilized to assist others. She is passionate about providing help and resources to communities to see them succeed.

The last YAHA session had an overwhelmingly positive effect on its membership. Members felt more comfortable talking to their peers, expressing their opinions in group settings, and feeling like they mattered in their community. During COVID-19 had an adverse effect on members’ physical health.