Based on the findings from the 2020 Needs Assessment, Arizona’s Title V Program prioritized the need to enhance equitable and optimal initiatives to positively impact the emotional, physical, and social wellbeing of adolescents.

Bullying Prevention, funded through Title V, continued to be an area of focus for Arizona’s Title V Program. The Bullying Prevention Stakeholder Workgroup was reconvened in 2021, after a two-year hiatus. Through a series of meetings, stakeholders were guided through an idea-generating activity to identify needs and gaps that still existed in bullying prevention programming in four categories: youth, parents, schools, and medical professionals. Participation was overwhelming, which resulted in a plethora of ideas that will inform the bullying prevention plan for the next five years. As of fall of 2021, the workgroup will begin meeting quarterly.

To better prepare adults in developing safe and supportive relationships with adolescents, ADHS partnered with an internationally recognized expert on bullying to coordinate trainings with schools, school districts, and community organizations. The training provided guidance on explaining the science of bullying and bullying prevention, leveraging the science of bullying prevention to reinvigorate existing anti-bullying efforts/identify more promising practices, informing of state laws and policies, and instructing on how Must Stop Bullying materials can be used effectively. With the onset of COVID-19, and more schools moving to online instruction, trainings were offered virtually and incorporated a focus on creating positive home climates to promote learning, prevent stress, and protect youth against cyberbullying. Ten trainings were provided in 2021 with participation from 2,063 school administrators and educators, 51 community partners, and 108 parents.

ADHS entered into a partnership with the Phoenix Suns and Phoenix Mercury, Arizona’s NBA and WNBA basketball teams, to promote the bullying prevention youth bystander intervention messaging. The partnership included messaging on the Suns/Mercury digital banner, social media channels, and newsletters; on-court logo signage; and ads in home TV and radio game broadcasts in English and Spanish. With the Phoenix Suns rally to the National Basketball Championship in 2021, ADHS was able to extend message exposure past the regular season with a radio ad which played during every Suns playoff game.

To increase the percentage of adolescents with preventive visits, Arizona’s Title V Program continued to fund and focus efforts on implementing the Adolescent Champion Model (ACM) in Arizona. The ACM, created by the University of Michigan, transforms healthcare settings by improving high-quality services for adolescent patients, enhancing the health center culture and climate, impacting patient outcomes without increasing costs, and strengthening innovative interdisciplinary collaboration and practice. The ACM continued to offer the “SPARK” training module, developed in coordination with the Children and Youth with Special Health Care Needs (CYSHCN) Program, to help guide physicians and other healthcare professionals in meaningful engagement with this population. It also continued to incorporate the telemedicine practices training module, which addresses best practices when providing services to youth via telemedicine. No clinics in 2021 opted to participate in the Maintenance of Certification program geared toward increasing rates of adolescent well visits; however, it continued to be offered to practices as an alternative if a practice is not able to commit fully to the ACM. Though COVID presented many challenges and competing priorities, all seven clinics from the second cohort were able to complete all eleven requirements of the program. Even with COVID lingering, another ten clinics joined cohort three and began implementation of the model in June of 2021.

In response to the growing need for parents and youth to understand the importance of annual well visits, ADHS’ Office of Women’s Health (OWH) received one-time funding through Arizona Proposition 207 funds to develop a behavior change campaign differentiating well visits from sports physicals to create awareness around the importance of well visits and more clearly explain what a full well visit entails. ADHS is leading the development of the campaign and partnering with the Arizona Chapter of the Academy of Pediatrics (AzAAP), to piggy-back on their well visit campaign efforts targeting providers; to align messaging and feel of the campaigns, where possible. The campaign will begin with conducting focus groups statewide to understand current attitudes towards and awareness of well visits among parents of youth 14-17 years of age, high school coaches and primary physicians/pediatricians/pediatric nurse practitioners. The campaign will begin to be executed and launched in 2022. 

ADHS also provided Title V funding to the AzAAP to support pediatric infection prevention and control work through their COVID-19 Training Center. As part of this initiative, AzAAP participated in the Improving Immunization Rates for Adolescents (IIRA) Learning Collaborative, which began in October 2020, and aims to address adolescent vaccination rates within Arizona by helping pediatricians build confidence in their critical role and meet measurable goals. Four pediatric practices located in different parts of the state are working to utilize quality improvement techniques and clinical education/training to increase adolescent immunizations in their practices using the Model for Improvement, while receiving free CME and MOC Part 2 & 4 credit for their efforts. This project ended in August 2021 and the preliminary data showed an increase overall in adolescent well visits and increased immunization rates for Tdap and MenACWY. In 2021, the learning collaborative completed seven (7) IIRA webinars focused on the topics of: 1. Utilizing IIS Functionality, 2. Motivational Interviewing, 3. COVID-19 Vaccines for Adolescents, 4. Lessons Learned at the Practice Level: QI Communication and Flow, 5. Learning Session 4: Celebration Webinar, 6. Practice End-of-Project Value Survey for Practice Teams, and 7. Learning Session 4: Evaluation.

ADHS released a solicitation in September 2021 to establish statewide Youth Councils to work on various adolescent-focused topic areas as outlined in the 2020 Title V Needs Assessment; specifically, suicide prevention, bullying prevention, sexual health, promoting annual adolescent well visits, injury prevention, and/or promoting preventive dental visits. Utilizing a combination of Title V and state lottery funding, four councils were awarded in two rural counties (Gila with 2 councils and Santa Cruz Counties) and one urban county (Maricopa County). Three of these youth councils will be newly created and one is an existing youth council that will be enhanced with this funding. One of the awardees, Arizona Foundation for Human Service Providers plans to create and support a new youth council in order to highlight the voices, experiences, and health priorities of Arizona adolescents/youth that have been in kinship care through the Arizona Department of Child Safety.

The health needs and experiences of youth are often under-represented. By empowering youth through participation on youth councils, they will have an opportunity to gain leadership skills that will give voice to their health needs and be able to drive positive change within their peer group as well as in their communities. Additionally, these youth councils will serve as the family/youth engagement partners for other ADHS adolescent health programming and the Arizona Adolescent Health Alliance. ADHS will host a Youth/Adult Partnership Training for youth council members and their adult youth advisors to aid in their skill building and ensure councils are engaged in the top 2 tiers (step 7 & 8) of the Hart’s Ladder of Participation.

The 2020 Title V Needs Assessment showed high rates of suicide among young people in the state and a lack of resources to support their mental health and well-being. In response, ADHS has been working to focus more resources on youth mental health. ADHS’s Office of Women’s Health, which administers adolescent health programming, elected to participate in the second cohort of the Adolescent and Young Adult Behavioral Health (AYA-BH) Collaborative Innovation and Improvement Network (CoIIN), which began in April 2021. The CoIIN focuses on the impacts of the pandemic, including decreased access to healthcare and increased isolation and exacerbation of adverse mental health outcomes. Arizona’s AYA-BH CoIIN, led by ADHS, is composed of state agency representation from the Arizona Department of Education (ADE), Arizona State University, and AHCCCS (state medicaid agency), as well as rural community organizations and the AzAAP. In addition to participating in the prevention component of the CoIIN, the AzAAP served as the clinic champion; recruiting over 20 pediatric practices to participate in the quality improvement component. To reduce duplication of effort and align work which has similar goals, the ADHS-led AYA-BH CoIIN participants and the ADE-led School Mental Health CoIIN participants decided to work jointly and collaboratively; meeting monthly as a team, creating a Youth Empowerment team benefiting and informing the work of both CoIINs, and developing a stigma reduction campaign which will be launched in 2022. As part of the collaboration, all three state agencies (ADHS, ADE, AHCCCS) will contribute funding to the development of the campaign.

With Title V funding, ADHS hosted a certification training in Youth Mental Health First Aid (YMHFA) for teen pregnancy prevention (TPP) health educators. Thirty-two educators from all fifteen county-level TPP programs were certified to conduct trainings with other youth-serving organizations in their counties to assist them with identifying, understanding, and responding to signs of mental illness and substance use disorders in youth. Utilizing Prop 207 funding, the county-level programs will be paid a stipend for every training conducted. Additionally, the OWH entered into a contract utilizing Title V funding with the Inter Tribal Council of Arizona (ITCA) to hire staff to be certified and deliver trainings across Arizona’s Tribal Nations, which will include a supplement specific to American Indian populations that is being created by YMHFA. ADHS also collaborated with the Arizona Department of Education’s Project AWARE to provide technical assistance to YMHFA-certified educators around gathering and disseminating resources to youth-serving organizations that are trained.

At the recommendation of the bullying prevention stakeholders, ADHS will begin to look at bullying prevention from a mental health lens acknowledging the effect that bullying has on the mental health of youth.

Teen Pregnancy Prevention Programs (TPP) continued the delivery of evidence-based abstinence and abstinence plus curriculum services that were culturally relevant and age-appropriate with a positive youth development approach. Through state lottery funds and federal Personal Responsibility Education Program (PREP) and Sexual Risk Avoidance Education (SRAE) funding, the TPP funded 24 rural and urban programs statewide through County Health Departments and community-based organizations, including four in American Indian communities. All TPP programming incorporated at least three of the five (3 of 5) Adulthood Preparation Subjects (APS) into proposed evidence-based program models to meet the unique needs of Arizona youth. APS is designed to support youth’s successful transition to adulthood and include (1) Healthy Relationships, (2) Healthy Life Skills, (3) Educational and Career Success, (4) Financial Literacy, and (5) Adolescent Development.

In 2021, 6,443 youth between the ages of 11-19 were served across all Teen Pregnancy Prevention (TPP) funding sources. There were 3,593 youth who received Abstinence Plus educational services and 2,850 youth who received Abstinence educational services.

COVID-19 continued to have a varying degree of impact on program delivery. Many schools did not allow outside visitors into the classroom to deliver TPP educational services as an effort to mitigate rising cases. Other schools did not have the capacity to offer dedicated time to TPP programming prioritizing core academics instead. As a result, all programs ended prematurely or did not start at all. Youth participant retention and recruitment efforts were also impacted as most programs had to find new ways for engagement. Before COVID-19, contracted agencies provided services to over 30,000 youth each year; however, services from 2019 to 2020 decreased by about 52% and TPP experienced yet another 55% decrease in numbers of youth served between 2020 to 2021. The flexibility afforded to sub-recipients at the height of COVID-19 helped with reaching Arizona’s youth population, especially those at highest risk for becoming pregnant and/or contracting an STD. Contracted agency were able to focus on the delivery of APS to youth, as an adaptation, if the full core curriculum could not be delivered with fidelity. During the latter half of the year, implementation sites started to reopen their doors to TPP contracting agencies. Due to lessening of restrictive mitigating requirements enforced by schools in response to COVID-19, agencies, organizations, and schools have slightly generated an increased opportunity to serve youth and provide program delivery.

Despite challenges with COVID-19, 334 parents participated in educational sessions providing information to help parents/guardians facilitate conversations with their youth on sexual health topics as well as other topics, such as healthy relationships. 

ADHS is leading a workgroup to develop an adaptation model of the Advocates for Youth (AFY) Adolescent Reproductive Health Access Project (RHAP); currently being implemented by the El Rio Health Center, a local federally qualified health center in the state. The intention is to develop a model, adapted from the original AFY RHAP, that is feasible to replicate in other health clinics statewide and nationally. The model is expected to be designed as a peer-led intervention that is an adaptable, scalable, and evidence-based model for reducing unintended pregnancy and improving the sexual health outcomes among youth. The ADHS workgroup includes AFY, El Rio, and Arizona Family Health Partnership. The group began meeting monthly in the summer of 2021, but needed to regroup in the fall to reset direction by establishing expectations and guidelines and the inclusion of a professional facilitator to ensure true and efficient collaboration among participating stakeholders.

The strategies to decrease the incidence of childhood injury for adolescents included supporting ‘Battle of the Belt’. The initiative, led by the Bureau of Chronic Disease and Health Promotion, is a yearlong program that increases seat belt usage and good driving habits in school communities by providing resources to students to develop their own positive seat belt messaging. Yuma county conducted a survey among 108 driver’s education students to measure their responses on knowledge and attitudes on restraint use, and personal behaviors as a driver or passenger. Unfortunately, COVID presented challenges in program implementation with many schools closed or conducting education online for most of the school year. As a result, students were not driving onto school property and were not able to meet so the program could not be conducted. Though partners were eager to implement the program virtually, schools were overwhelmed with day-to-day activities and were not prepared to take on any outside programming.

The Chief for the Office of Women’s Health represents ADHS in the Arizona Adolescent Health Alliance (AzAHA), a steering committee of adolescent health and social service providers convened to identify priorities in the focus areas of medical care and services, mental health, oral health, social determinants, special populations, and reproductive health. The aim of the Alliance is to develop a forum to connect and share best practices, identify common problems, and develop innovative strategies to overcome barriers for providing high-quality health and social services for adolescents. The OWH began working with the Alliance to explore the possibility of expanding efforts to create a statewide adolescent health coalition. The existing steering committee offers the opportunity to institute a statewide coalition as participating stakeholders are inclusive of safety-net providers, such as medical professionals and general youth-serving organizations located in the Phoenix and Tucson area. In lieu of the OWH reconvening the Adolescent Wellness Stakeholder Workgroup, the OWH will work collaboratively with the AzAHA to serve as the body that will inform adolescent wellness efforts. 

The Chief for the Office of Women’s Health continued to participate in the Suicide Prevention check-in call led by the AHCCCS. The call reviews the progress both agencies are making in accomplishing the recommendations outlined in the 2020 Suicide Prevention Action Plan, projects being conducted, and any emerging issues in mental health. The calls have temporarily paused after the AHCCCS lead left the agency and while the Suicide Prevention Program transferred to the ADHS Office of Chronic Disease Prevention and Health Promotion.

The Chief also maintained her role as the lead of the Adolescent & Young Adults Behavioral Health CoIIN team which began in 2021. She also continued to serve as the Secretary for the National Network of State Adolescent Health Coordinators Leadership team.