Primary and Preventive Services/Family Planning
Primary and preventive clinical services safeguard the health and wellness of all children and adolescents. LHDs have multiple programs targeting adolescents across KY. Adolescents are less likely to visit LHDs for annual preventive care, because more have established pediatric medical homes and insurance coverage, and the growth of retail-based clinics providing sports and camp physicals.
Immunizations are among the primary and preventive services accessed by youth at LHDs. The Kentucky Immunization Program distributes vaccines to LHDs and private providers enrolled in the federal Vaccines for Children Program. Family planning is another health service accessed by adolescents at LHDs. Services to adolescents for contraception, pregnancy, or childbirth can be accessed without parental consent per KRS 214.185. These visits may include diagnosis and treatment of sexually transmitted diseases or other conditions.
KY’s teen births continue to be higher than US teen birth rates. LHDs are responsive to addressing teen birth rate by providing family planning, engagement to HANDS, referral to WIC, and addressing alcohol, tobacco, or other drug (ATOD) use, or potential domestic violence. For many teens, they may first interact with a school nurse who provides communication with the LHD and community providers for linkage to early prenatal care. Teen birth rates for the Appalachian in KY Districts, illustrated below, continue to be higher than the state overall rate. This may be linked to other SDoH concerns for improving health behaviors in poverty-stricken areas of KY.
MCH collaborates with the Division of Women’s Health and their adolescent health programs such as Teen Pregnancy Prevention, the University of Kentucky Young Parents’ Program, and the Family Planning Program. The Adolescent Health Program receives federal funding to prevent teen pregnancy and promote positive youth development through the Abstinence Education Grant Program (AEGP) and the Personal Responsibility Education Program (PREP) Grant. The AEGP funds 34 sub-awardees who provide age-appropriate abstinence education to students in grades 5-8 in accordance with the KDE program of studies for sexual health education. Approximately 24,000 students and 3,500 parents of teenagers are educated each year with AEGP funding. The PREP Grant funds 23 sub-awardees to provide personal responsibility education with “ready for adult subjects” to middle and high school students. PREP targets disengaged youth at high risk for poor decision-making about health behaviors, academic failure, and poor adulthood outcomes. Approximately 7,000 students participate in PREP each year.
Obesity
Adolescent obesity is a priority for the adolescent health population domain identified from the 2015 Needs Assessment and continues to this day. To address this need, KY has chosen NPM # 8: Percent of children ages 6-11 and adolescents ages 12-17 who are physically active at least 60 minutes per day. According to the State Obesity Report, KY ranks 3rd in obesity with 19.3% of high school students considered obese. This draws a keen focus to the issue of teen obesity (Robert Wood Johnson Foundation, 2018).
Data from the 2017 KY Youth Risk Behavioral Surveillance System (YRBSS) reported youth activity level is below the national average. Physical activity continues to be a focus for all programs with less than half of high school students reporting exercise for greater than 60 minutes, 5 days per week.
The percentage of high school students who are obese increased from 16.5% in 2011 to 20.2% in 2017 (KY YRBSS). When the data was reviewed by gender, high school males were more likely to be obese than female high school students. The 2017 data also shown students in grades 10 and 12 were more likely to be obese than grades 9 and 11. Amidst all high school ages, Black high school students were more likely to be obese.
To reach all populations, KY must address obesity concerns from all levels. Strategies must begin at birth with breastfeeding promotion. Early childhood should lay the framework to establish healthy behaviors related to nutrition and activity. For the school age and adolescent population, the Whole School, Whole Community, and Whole Child (WSCC) model provides a wrap-a-round framework to continue encouraging this population to make healthy choices.
With the MCH Evidence Informed Strategy focusing on increasing physical activity and creating an overall healthier climate in school and community settings, local health departments have succeeded in providing outreach and supplemental health education to students in their local school districts. As previously mentioned in the Child Health Annual Report, LHDs that participated in Healthy People, Active Communities are also working to promote full community engagement with activity and nutrition.
To increase access to physical activity, LHDs collaborated with a number of communities that have a pedestrian plan. A Community Physical Activity Committee has representation from the Federal Highway Administration, Foundation for a Healthy Kentucky, Kentucky Association for Economic Development, KDPH, KDE, Kentucky Office of Adventure Tourism, KIPRC, KSPAN, Kentucky Office of the Americans with Disabilities Act, Kentucky Rails to Trails Council, Kentucky State Parks, Kentucky Transportation Cabinet, Kentucky Youth Advocates, National Park Service, and UK Cooperative Extension. Committee and local stakeholders identified assets, needs, and barriers through interviews and surveys of stakeholders and community members.
Information gathered helped develop the Access to Physical Activity Vision Document http://www.fitky.org/wp-content/uploads/sites/2/2015/04/PA-Vision-Slidedoc.pdf.
This document outlines three strategies needed to develop pedestrian plans: community engagement, easy to use resources, and training technical assistance and resources.
MCH has developed an Evidence Informed Strategy, the Healthy People Active Communities Package, to make healthy eating and physical activity safe and easily accessible. The strategy supports policies that make environmental changes that are sustainable within communities. In addition, this package will serve to increase community engagement with organizations and local community members. Together, the LHD, community organizations, and community members will define the issue, address the barriers to meeting the 5-2-1-0 evidence-based healthy behaviors, and engage possible solutions. A collaborative action plan was developed and implemented on one of the 5-2-1-0 behaviors. LHDs (24) engaged 97,254 local residents and stakeholders addressing safety in crosswalks for walking paths in urban areas, development of walking paths in the community, implementation of health education in the school system, development of farm to table initiatives, cooking classes, or engagement with local medical providers to promote 5-2-1-0.
The KDPH Health Promotions Branch and their state partners provide the training and technical assistance on access to healthy foods and physical activity, as well as resources including community engagement, Early Care and Education, Farmers’ Markets, and “Step It Up, Kentucky!”
One local health department used funding from the Healthy People Active Communities Package to collaborate with local community agencies to provide children's activities, including First Friday Community Field Day, to promote physical activity, health awareness, and nutrition in conjunction with a 5K walk/run. First Friday is a local market that occurs the first Friday of every month from June-Sept. Local merchants, farmers’ market stands, and artists set up. Another success from these funds includes a LHD collaboration with their local BRIGHT Coalition leaders. This collaboration increased promotion of “Step It Up Kentucky!” and access to fresh fruits and vegetables in vulnerable populations.
Other successful programs have included community walking programs, community wellness council meetings, and school and community collaboration to better support students and families in nutrition lessons and wellness initiatives.
Coordinated School Health (CSH):
One program that is significantly involved with physical activity strategies in KY is the CSH program. This program is an effort funded by the CDC’s 1801 Improving Student Health and Academic Achievement through Nutrition, Physical Activity and the Management of Chronic Conditions in Schools. The funding cycle will support this work through a five-year funding cycle ending in 2023. This new funding cycle awarded to Kentucky’s Department of Education (KDE) continues the work already established in prior school health funding. As a requirement of this funding, KDE has allocated a percentage of awarded funds to continue their partnership and collaborative school health efforts with the KDPH. These funds will be housed in MCH and continue to partially fund the KDPH Coordinated School Health Program Administrator. CSH is a major vehicle in schools and communities across the state, as well as the nation, to address obesity and the overall well-being of youth. CSH ties together adolescent services provided through the LHDs, schools, and school-based clinics. The traditional CSH model consists of eight components that recognize how health, wellness, environment, and learning are related. This traditional model expanded to include two additional and more specific components addressing the Social-Emotional Climate and Physical Environment. This expanded model integrates the components of CSH and the Whole Child tenets of the Association for Supervision and Curriculum Development (ASCD) Whole Child approach to strengthen a unified and collaborative approach to learning and health. The WSCC model includes the following ten components: health education, physical education/physical activity, nutrition environment and services, health services, counseling/psychological and social services, social and emotional climate, physical environment, employee wellness, family engagement, and community involvement. KY’s goal through using this model is to promote preventive best practices to support the needs of the whole child. KDE and KDPH work collaboratively to provide guidance to school districts and community partners to incorporate opportunities for students to create a healthier environment in which to live, play, and learn.
Among obstacles, the CSH team faces, is an effort to decrease adolescent obesity, and is the accountability core content outside of physical education and health education. Recently KY amended the Every Student Succeeds Act (ESSA) State Plan to eliminate the “Access and Opportunities” section that provided an accountability measure for physical education and health education. Without specific accountability, the CSH team is challenged to obtain administrative buy-in because of other priorities outlined in the state accountability system at the district level. Nationwide research is growing and shows additional research around the correlation between healthier children and higher academic performance; however, there is inconsistency in this message, the practices surrounding physical activity (PA) opportunities and enhancing nutrition settings in schools. In addition to academic success, we are seeing research on the benefits of PA in overall wellness including mental health. Addressing student mental health is a growing concern for school districts as we are familiarizing ourselves with the importance of addressing adverse childhood experiences (ACEs) and the long-term effect of exposure to trauma.
Suicide
In KY, suicide is the third leading cause of injury-related death among those 10-24 years of age, and the numbers are increasing. The number of childhood suicides nearly doubled from 2012 with 16 teen suicides to 25 reported in preliminary 2018 data. Preliminary information for 2019 suggest the the number of teen suicides could reach 30 or higher. Over half of childhood suicides involve the use of a firearm and is most prevalent among children 10-14 years of age. White children die at a disproportionate rate due to suicide (2.8/100,000) compared to black children (0.9 per 100,000).
The Kentucky Incentives for Prevention (KIP) Study published a report of information from a 2018 survey completed with students in grades 6,8,10, and 12. The survey is conducted bi-annually, on even numbered years, and has changed from the original intent of determining use of alcohol, tobacco, and other drugs to surveying students about handguns, bullying, dating violence, suicide, and mental health (KIP Survey, KY Dept. of Behavioral Health). (https://reacheval.com/projects/kentucky-incentives-for-prevention-kip-survey/). Per this report, while KY youth report bullying and cyberbullying has slightly declined, rates remain higher than national rates.
Suicidal ideation and reported suicide attempts was decreasing prior to 2009, but has been increasing since that time in all grades (see figure below). There was a significant increase among 6th grade respondents reporting they have seriously considered attempting suicide.
This warrants immediate prevention activities with families and schools. In 2014, the KY Youth Bullying Prevention Task Force was established by Executive Order to address bullying in schools and recommend practices/policies to provide safer, harassment-free schools. In the past year, MCH and DBHDID continued collaborative efforts using the Sources of Strength Curriculum as an integrative piece of outreach and prevention supported at the local level. Training programs across the state have been conducted with local school districts to promote peer-led youth resiliency programs.
The Kentucky Violence and Injury Prevention Program (KVIPP) staff produced “Self Harm Related Emergency Department Visits and Hospitalizations among Kentucky Adolescents 10-19 Years old, September 1, 2015-Aurgust 31, 2018” and presented this to the suicide prevention team at KDPH.
Nineteen LHDs partnered with schools and MCH in selecting the Bullying and Suicide Prevention MCH Package to provide reinforcement and link school districts with resources for prevention through regional treatment centers or grief counseling. In 2018, this package reached 19,457 students and community members and provided training for Sources of Strength with 50 school staff members. Anti-bullying messaging was placed on bulletin boards, with periodic changes throughout the year. Wedco District continued the Beautiful Minds Project in collaboration with University of KY Adolescent Health. This program provides on-site mental health screenings and, when possible, counseling on-site. This project has over 400 students self-referred or staff referred for have access to mental health screening and additional linkage to medical and mental health homes.
Teen Driving
MCH addresses teen driver deaths through collaborative efforts with KIPRC. LHDs had opportunity to implement strategies through a Teen Driving CFR package.
For the year 2017, 79 fatal collisions occurring in KY involved teen drivers. Teen drivers were involved in 8% of the state’s collisions (262,109). (Kentucky Traffic Collision Facts, 2017). Efforts, in KY to reduce the number of deaths of children related to young drivers or teens include the graduated driver’s license initiative, a cell phone ban for drivers under 18, and driver safety programs that address risk factors for youth drivers.
As part of child fatality and injury prevention, many health departments completed child passenger safety plans including car seat checks, Checkpoints™ Program, and the graduated licensure program. LHDs have been innovative in creating distracted driver videos, working with local high schools to provide education, and working with local police and first responders.
The Kentucky Violence and Injury Prevention Program (KVIPP), supported by CDC Cooperative Agreement Number, U17 CE924846, collaborates with the Kentucky Office of Highway Safety (KOHS), Kentucky Association of Counties (KACo), KIPRC, Kentucky Safety Prevention Alignment Network (KSPAN), and KDPH to address teen motor vehicle safety education. The Checkpoints™ Program is an evidence-based, parent-oriented teen driving intervention, originally developed by Dr. Bruce Simons-Morton of the National Institute of Child Health & Human Development, an agency of the US Department of Health & Human Services is being piloted for statewide implementation in KY. The program has been revised, including Checkpoints™ educational materials, to reflect KY’s Graduate Driver Licensing Program requirements and include KY injury data.
The Checkpoints™ Program provides parents and teens with information about:
- Risks teens face when first licensed (e.g., facts and myths about teen driving safety)
- KY’s Graduated Driver Licensing requirements
- Ways to improve the safety of the teen driver
- Ways to effectively communicate with teens about safe driving (video content)
- How to set Interactive Parent-Teen Driving Agreements that are customizable to the respective parent and teen, establishing clear guidelines, expectations, and consequences for their teens’ early driving and adaption as the teen progresses.
Checkpoints™ implementation was successful in 20 high schools in 14 counties in 2018. Participants were:
- Green River Area Development District (1 High School (HS) in Daviess County)
- Graves County Health Department (2 HS)
- Pennyrile District HD (2 counties - 2 HS in Livingston and Caldwell Counties)
- Lincoln Trail District HD (6 counties - 8 HS in Hardin, Meade, Larue, Marion, Washington, and Nelson Counties)
- Jessamine County HD, Safe Community (2 HS)
- Madison County HD, Safe Community (2 HS)
- Mason County HD, Safe Community (1 HS)
- Woodford County HD, Safe Community (2 HS).
Checkpoints™ is continuing into 2019 with an implementation goal of 20 counties with 35 high schools.
In addition, KVIPP is providing training and curriculum across the state to law enforcement officers on traffic safety Checkpoints™. The relevant components of the training to adolescent health are educating officers on the identification of impaired driving, human trafficking, improper restraint use, and any other obvious violations.
In November 2017, a specific Checkpoints™ Program strategy, website, and geographical review of data was completed and presented to KOHS officials and to the Governor’s Executive Committee on Highway Safety.
This information, highlighted in the annual child fatality report shows counties with high population density (Northern KY, Louisville, Lexington) have higher rates of teen motor vehicle driver at-fault crashes. However, some rural areas equally have higher rates of collisions.
When reviewing areas of teen driver collisions, it was anticipated higher population density would be a factor. The group also prepared a heat map of KY roadways to determine if any specific roadways or type of roadway had higher rates. Population density and travel (particularly in Central KY, between urban Lexington and Louisville) showed higher rates of teen collisions.
Teen Driving Challenges
With regard to teen driving, there are inadequate resources in districts that are experiencing the highest number of teen driving deaths. Personnel and training need to increase along with recruitment of additional community partners. The CoIIN and Teen Driver Package will allow us to reach some of these areas and provide education and resources. To address these challenges, KDPH will utilize Child Fatality Review (CFR) along with KIPRC, OHS, and Safe Kids in assuring that all motor vehicle deaths involving teen drivers receive reviews in CFR teams throughout Kentucky.
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