Adolescent Health: Annual Report
In 2018, there were 154,948 adolescents aged 12 to 17 residing in Idaho, which is 9% of the total state population. According to the 2019 Idaho Youth Risk Behavior Survey, teen alcohol use (34.2% to 26.6%) and tobacco use (26.1% to 12.5%) in Idaho have declined significantly over the past decade from 2009-2019. For 2019, 10% of Idaho teens reported a suicide attempt in the past year. The teen pregnancy rate for 2018 was 19.3 per 1,000 females aged 15 to 19 years old. The state’s high school graduation rate for 2017-2018 was 80.7%, which is lower than the national rate of 84.6%.
For the Adolescent Health domain, the MCH team selected “NPM 10: Adolescent Well-Visits.” Selection of this NPM is supported by the state’s Cross-Cutting/Life Course priority need of improving maternal and child health population access to medical homes. To assess progress of the proposed strategies, the MCH Program developed the objective of increasing the number of adolescents who receive information about the importance of regular well-visits by September 2020. Measurement of the objective will be based on programmatic and evaluation data. Strategies to address this objective and NPM are discussed below.
According to 2018 National Survey of Children’s Health data, Idaho adolescents are less likely than adolescents nationally to receive a well-care visit. In Idaho, 60.9 percent of adolescents had at least one preventive medical visit in the past 12 months compared to 64.8 percent nationally. The MCH Program collaborated with the Adolescent Pregnancy (APP) Program to use a phased approach to engage youth in determining the solution to increasing adolescent well-visits. The APP Program and the Title V Adolescent Health Coordinator are part of the Idaho Maternal and Child Health Section.
In 2016, to understand the barriers to seeking or receiving care among adolescents, the MCH Program collaborated with the state’s Title V Adolescent Health Coordinator and the APP Program to assess awareness of and the reasons why adolescents do or do not seek routine preventive care. The APP Program coordinates with agencies, educational organizations, and other partners throughout the state to provide adolescents with resources concerning their sexual health. Reducing the Risk (RTR) is a sexual health education curriculum for students ages 12-18, focusing on building knowledge of abstinence and contraception while providing a positive perception of sexual health and relationships. The RTR curriculum is delivered in all seven public health districts by coordinators across 15 sites. As part of the RTR class, a participant entry and exit survey is administered at the beginning and end of the course. For the 2016/2017 school year, the MCH Program collaborated with the APP Program to develop and add questions to the participant entry and exit surveys to assess awareness and barriers. The questions incorporated into the survey were tailored from the Oregon Healthy Teens survey to assess health issues (Oregon Health Authority, 2015). The goal of the questions was to determine if adolescents are partaking in wellness visits, whether they believe such visits to be important, and to identify barriers to engaging in an annual check-up or wellness visit. Conducting the survey served as the ESM for the 2016 Annual Report (yes/no measure).
During the 2016-2017 school year, there were 554 Reducing the Risk entry and exit survey respondents with ages of respondents ranging from 12 to 19 years old. Results revealed that 67% of adolescents reported attending an annual check-up or wellness visit in the past 12 months. Among those who did not receive an annual wellness visit, the most commonly reported reason was “I don’t need to see a health care provider.” Respondents were asked if they felt that having a check-up or wellness visit every year was important. Most respondents indicated that having an annual check-up or wellness visit was either very important or important. A significant association was found in the survey results revealing that those who considered annual well-visits to be important were much more likely to have attended such visits in the last 12 months than those who did not consider such visits important. Based on the results of the survey, the MCH Program will develop evidence-based strategies to address identified barriers and raise awareness for adolescent well-visits. According to the Centers for Medicare and Medicaid Services (2014), offering resources, training, and incentives to adolescents and families to encourage preventive care is a proven strategy for promoting adolescent well-visits. The MCH Program will likely explore developing education, tool kits, or social media campaigns to raise awareness about the need for adolescent well-visits.
Youth-Adult Partnership (YAP) groups are a Positive Youth Development (PYD) strategy focused on promoting the healthy development of all youth by creating learning experiences and providing access to adult mentors that enable youth to feel connected to others. It builds their capacity to meet personal and social needs, and enables youth to be engaged in meaningful activities. In YAP groups, youth and adults work together to accomplish common goals, with shared responsibilities, decision-making, and commitment. An essential principle of youth development/sexual health programming is that young people gain more from an experience when they are actively involved. Research also suggests that programs for youth which are developed through a partnership of youth and adults may be highly effective in building young people's skills and reducing their sexual risk-taking behaviors. Such programs benefit the youth who help to develop them and have a greater impact on the young people served. The Idaho public health districts implement YAP groups as a youth development strategy to complement RTR implementation. YAP groups plan and implement activities that promote adolescent sexual health and healthy choices in their schools and communities. In FY 2019, there were 212 youth that participated in 18 YAP Groups across the seven public health districts in Idaho.
During the 2017-2018 school year, YAP groups in five health districts across Idaho conducted youth-friendly clinic assessments. The Youth-Friendly Clinic Assessment Project was conducted at six local health clinics. Five of the six clinics assessed were health district clinics located in Hayden, Caldwell, McCall, Pocatello, and Idaho Falls. The non-health district clinic assessment was conducted at Community Family Clinic in Idaho Falls. A total of 42 youth participated in the youth friendly clinic assessment projects (ESM 10.2). This youth-led project complements strategies to address NPM 10 by encouraging changes in the clinic environment that will increase youth willingness to seek well-visits, and initiate dialogue with providers for future efforts that address this measure.
During the 2018-2019 school year, Phase II of the Youth-Friendly Clinic Assessment Project was completed. For this phase, the APP Program, in collaboration with local public health districts and local clinics, implemented recommended changes from the 2017-2018 Youth-Friendly Clinic Assessments. All six clinics that participated in the youth-friendly clinic assessment completed Phase II. The clinics created an implementation plan to evaluate recommendations received from the assessment, determined which recommendations to adopt, and created a timeline for implementing the improvements. Youth recommendations that have been or will be implemented include: fresh coats of paint, privacy walls in waiting rooms, free Wi-Fi, charging stations, gender neutral restroom signs, a brochure rack with resources specific to youth, enhanced privacy options on forms, launching a text reminder system for clinic appointments, and youth-friendly posters, art, and signage for waiting rooms. After the changes were made, four groups of youth were able to provide feedback to the clinic in their community. Positive changes have included the new signs on the clinic building to make it easier to identify, welcoming décor in the waiting rooms, and text systems for clinic appointments and reminders – youth have been successful at scheduling appointments and receiving reminders. One of the youth groups participated in the trial run of one of the text reminder systems and were able to provide feedback. Additional changes youth suggested included addressing the privacy barrier in the waiting room (it isolated that section and people didn’t sit there), having clinic hours at more convenient times for youth, and addressing transportation barriers since public transportation is not available to some clinics.
For 2019 through 2020, work to address adolescent well-visits shifted after the conclusion of the Youth-Friendly Clinic Assessment Project to strategies focused on capturing youth participation in health-focused, youth-led projects. Youth-led projects are currently part of the YAP groups supported by APP Programming. YAP groups plan and implement activities that encourage healthy choices in their schools and communities. This may include projects such as youth-friendly clinic assessments, action research or participatory evaluation, and other activities that promote reproductive health and APP Program goals. Research has shown the benefits of effectively incorporating youth voices into program activities include: increased self-esteem; sense of personal control and enhanced identity development; enhanced development of life skills including leadership, public speaking, and job responsibility; strengthened communication skills with adults, peers and family; and decreased involvement in risky behaviors (Scales & Leffert, 1997). Youth-adult partnerships can serve as a unifying factor when they include authentic decision making, natural mentors, reciprocity, and community connectedness (Zeldin, Christens, & Powers, 2012). Additionally, youth participatory evaluation has been shown to decrease youths’ feelings of alienation and increase understanding of their ability to affect change within their communities (Sabo, 2003). Data is still being collected on the number of youth participating in youth-led projects for FY20, however, twelve (12) YAP groups had been formed by the spring of 2020. Two of these YAP groups participated in focus groups for the MCH 5-year Needs Assessment, which is described in more detail below.
Other strategies that were implemented after the conclusion of the Youth-Friendly Clinic Assessment Project included raising awareness of adolescent health and building workforce capacity to incorporate best practices when working with youth.
Comprehensive Adolescent Health
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In May 2018, the Idaho Family Planning Program (IFPP) and the APP Program began working with the Youth Leadership Institute (YLI) to build workforce capacity to effectivity work with youth and young adults and incorporate best practices for doing so into the structure of the statewide Reproductive Health Advisory Group. This work included the formation of a task group that met regularly to map out an action plan, work together to draft group guidelines, recruit new youth members, and increase members’ ability for successful shared decision-making among youth and adults.
In May 2019, the IFPP and APP Program hosted a workforce training, “Adolescent Health Training for Public Health Professionals,” that was facilitated by YLI for public health staff and community partners. This training helped participants identify examples of youth development principles within the context of their work and assess their readiness to implement youth engagement strategies. Participants also had the opportunity to connect across programs within the Division of Public Health and find potential points of collaboration to reach youth more effectively.
The MCH State Adolescent Health Coordinator has partnered with the APP Program to continue efforts towards creating a workforce development plan for public health staff. Data from a 2018 Adolescent Health Survey that surveyed eleven programs within the Division of Public Health (DPH) was reviewed to lay the foundation for a plan that could have impact across multiple public health programs. Key points that will be included in the workforce development plan include: opportunities for collaboration with other DPH programs that reach adolescents, strengthening the level of adolescent participation within programs, internal and external training opportunities, and opportunities to develop knowledge and skills in a variety of topics related to adolescent health. Research into implementation strategies for these key points of the workforce development plan is ongoing, however, the creation of an adolescent health working group with a positive youth development focus has been identified as a key strategy. Another strategy that has been identified is the creation of a website to house workforce development content, such as trainings and resources, that can be accessed by all staff. A self-paced training, or resource review, would likely be another successful approach to address staff turnover and varying programmatic needs.
The MCH State Adolescent Health Coordinator attended the Region 8 Summit, Healthy Transitions -- Partnering with Youth and Young Adults, in Salt Lake City, Utah, on July 30-31, 2019. Workshop topics included health equity, youth-centered healthcare, engaging youth through social media and technology, and building effective networks of youth. Content from the summit was used to plan and conduct an adolescent health strategic planning session with MCH staff on August 20, 2019. The goal of the session was to map out how to approach and grow the MCH focus on adolescent health in the coming years. One step that has been taken is the renaming of the Reproductive Health team, which houses APP and IFPP, to Reproductive and Adolescent Health to give greater visibility to adolescents within public health.
In summer 2019, Reproductive and Adolescent Health staff participated in the planning of a small youth summit with other youth and adults from a variety of public health programs and community organizations. The planning committee, through partnership with YLI, hosted the youth summit in November 2019 and had over 60 youth in attendance from across the state. The goals of the summit were to provide an opportunity for youth to connect with one another, learn strategic planning skills, and lay the foundation for planning a larger youth summit in the Fall of 2020.
MCH partnered with the APP Program to conduct youth focus groups across the state to gather youth voice to inform the MCH 2020 needs assessment. Input from these focus groups provided essential consumer feedback to ensure the state action plan identifies those priorities that are most needed. In Fall 2019, six APP coordinators from regional health districts held focus groups with youth from local schools participating in established Youth-Adult Partnership Groups and other community youth groups. Seven youth focus groups were held, and a total of 89 youth participated. APP coordinators were provided a facilitation packet vetted by the DPH’s internal review board (IRB). The packets contained consent forms, a script to provide background information, facilitation and note taking strategies, focus group questions, ideas for a secondary activity to rank responses with the youth, and a general demographic survey. The results from the focus groups can be found in the 2020 5-year needs assessment summary.
The APP Program coordinates with the public health districts (PHDs), educational organizations, and other partners across the state to provide adolescents with evidence-based curricula and resources to empower their reproductive health choices. The APP Program currently supports five curricula in school and community settings: ¡Cuídate!, Reducing the Risk (RTR), Wise Guys, Draw the Line/Respect the Line, and Making a Difference. The APP Program also works with these partners to implement parent education opportunities and engagement through Bridging the Gap community dinners and the parent education curriculum, Families Talking Together. These programs are supported by Temporary Assistance for Needy Families (TANF), Personal Responsibility Education Program (PREP), and Sexual Risk Avoidance Education (SRAE) funding from HHS.
¡Cuídate!, which means, “take care of yourself,” is a cultural and theory-based pregnancy prevention and HIV sexual risk-reduction program designed specifically for Latino youth ages 13-18. ¡Cuídate! helps Latino youth develop the knowledge, attitudes, and skills to prevent unplanned pregnancy and reduce their risk for HIV. The program emphasizes risk reduction such as sexual abstinence and condom use through a variety of activities. ¡Cuídate! is unique because it addresses cultural beliefs related to sexual risk behaviors that are common among many Latino subgroups. Aspects of Latino culture, such as familialism and gender-role expectations, including machismo, are built into the program. ¡Cuídate! includes cultural beliefs related to abstinence and condom use in program activities, and shows these attitudes and beliefs in a positive way. For FY 2019, 127 students participated in ¡Cuídate!.
RTR: Building Skills to Prevent Pregnancy, HIV, and STD is an evidence-based curriculum for students ages 12-18. RTR includes 16 lessons that emphasize refusal skills to increase students’ ability to choose abstinence or to encourage protection from pregnancy and sexually transmitted infections. Activities include skill-building lessons in refusal skills, negotiation, and active communication. The goal of RTR is to prepare youth for their sexual future while reducing the incidence of unprotected sex. For FY 2019, 592 students participated in RTR.
Wise Guys: Male Responsibility Curriculum©, is an evidence-informed curriculum designed to engage males in the prevention of adolescent pregnancies. The 10-lesson curriculum was created by the Family Life Council of Greater Greensboro and was developed as a male involvement tool to engage young males, ages 10–24, in pregnancy prevention efforts. Additionally, the Wise Guys curriculum has been adapted to include the topic of statutory rape and include elements of Positive Youth Development (PYD). Contractors implement the curriculum as an after-school program, as part of a community-based program, in juvenile detention centers, vocational job trainings, and therapeutic programs for youth in crisis. Additionally, contractors implementing the Wise Guys curriculum conduct presentations to state and local law enforcement officials, individuals in the educational system, and relevant counseling services to provide education and training on statutory rape and sexual offenses against minors in Idaho. For FY 2019, 161 male students participated in Wise Guys.
Draw the Line/Respect the Line is a 3-year, evidence-based curriculum that promotes abstinence by providing students in grades 6, 7, and 8 with the knowledge and skills to prevent HIV, other STDs, and pregnancy. Using an interactive approach, the program shows students how to set personal limits and meet challenges to those limits. Lessons also include the importance of respecting others’ personal limits. For FY 2019, 122 students participated in Draw the Line/Respect the Line.
Making a Difference is an evidence-based, abstinence approach to teen pregnancy and HIV/STD prevention. The 8-module curriculum provides middle school students, ages 12-14, with the knowledge, confidence, and skills necessary to reduce their risk of sexually transmitted diseases, HIV, and pregnancy by abstaining from sex. In FY 2019, new subgrants with the public health districts were initiated to begin facilitator training and curriculum implementation. Participation numbers will be available in FY 2020.
Bridging the Gap community dinners provide an opportunity for parents and caregivers of middle-school aged children to visit with other adults during a catered dinner who are facing the challenges of raising children today. It is developed, promoted, and taught by high school-aged teens along with trained facilitators in their community. It provides them with an overview of adolescent pregnancy in Idaho, tips on how to discuss adolescent sexuality, and emphasizes how to keep the lines of communication open with their children. Parents are a critical part of teen pregnancy prevention efforts. Teens consistently report that their parents are most influential when it comes to their decisions about sex, and often state that they wish they could talk more to their parents, particularly about topics such as relationships. Research suggests that parent-child communication is a protective factor that reduces engagement in risky sexual behavior. Parent-child communication about sex can delay sexual initiation. As a result, many programs seek to engage parents in teen pregnancy prevention efforts. In recent years programs developed specifically for parents have been proven to change teens’ behavior related to their risk of pregnancy. For FY 2019, a total of 23 students, 6 staff, and 69 parents participated in Bridging the Gap community dinners.
Families Talking Together (FTT) is an evidence-based parent curriculum from The Center for Latino Adolescent and Family Health at New York University. The curriculum is a two-part intervention series that can be implemented in an individual or group setting. FTT focuses on reducing sexual risk behavior by; increasing parent communication skills, building parent-child relationships, teaching successful monitoring strategies, and encouraging parents to discuss sexual health topics with their child. The curriculum strengthens protective factors by increasing parent involvement in their child’s life. For FY 2019, a total of 15 parents participated in Families Talking Together.
The APP Program designs and purchases incentives which are used to recruit and retain adolescents in pregnancy prevention programming, to promote YAP group projects in their schools and communities, and to direct parents to APP resources at Bridging the Gap community dinners. The incentives change from year to year, however, popular items include water bottles, pens, flash drives, and sunglasses. The incentives use the APP Program’s logo and website address. The website has information on birth control methods, abstinence, and healthy relationships, and serves as a resource for adolescents and parents.
Youth Suicide Prevention
In FY 2018, the MCH Program contributed funds to the newly established Idaho Suicide Prevention Program (ISPP). The funds were used to enhance outreach for a 30-second public service announcement (PSA) focused on raising awareness about adolescent suicide and how to help. The PSA was shown across the state of Idaho and featured the Idaho MCH logo. This was a first step in collaboration with the ISPP to bolster suicide prevention and education efforts among children and adolescents.
In FY 2019, the MCH Program continued to develop its partnership with ISPP and expand suicide education in schools through the Idaho Lives Project (ILP). ILP is funded by the ISPP and the Idaho State Department of Education to provide training to Idaho schools on suicide prevention and wellness programs, along with support for program implementation and fidelity. The programs that ILP implements and supports include Sources of Strength™, PAX Good Behavior Game®, and Gatekeeper trainings.
Sources of Strength™ (Sources) is an evidence-based program implemented in a school setting as an upstream program that has been found not only to reduce suicide, but also to decrease other risky behaviors. Sources is one of the most robustly researched suicide prevention programs and is the only peer-based suicide prevention program listed on the National Registry of Evidence-based Programs and Practices. Between August 2019 and June 2020, a total of 21 middle, junior, or senior high schools participated in the program, and 467 adults received Sources training.
The PAX Good Behavior Game® (GBG) is a set of strategies to help students learn important self-management skills while collaborating to make their classroom a peaceful and productive learning environment. This universal preventive approach not only improves classroom behavior and academics, but also provides a lifetime of benefits for every child by improving self-regulation and co-regulation with peers. ILP had originally planned to offer GBG to elementary schools, but received feedback from schools indicating they would prefer a different program. In response, IFP is partnering with Sources to bring their new elementary curriculum to Idaho schools. Training and implementation will begin in FY 2020.
ILP has selected 15 elementary schools through a grant application process to receive Sources of Strengths Elementary training. This universal classroom curriculum is evidence-based and designed from a comprehensive, strength-based model that focuses on the development of protective factors to help students better understand themselves, their strengths, and their power to positively influence their world. The topic of suicide is explicitly addressed through a strength-based lens and in a developmentally appropriate and accessible way. Training for elementary school staff is scheduled for August 2020.
ILP also offers suicide prevention gatekeeper trainings to schools. Gatekeeper trainings are designed to raise awareness about suicide and suicide prevention. These prevention efforts target and benefit all citizens in a defined community, such as a school. The trainings provide basic information about suicide, the warning signs, and how to refer people to help. Between August 2019 and June 2020, a total of 1,236 adults received the Suicide Prevention Fundamentals Intervention (SPFI)™ Gatekeeper training. In April 2020, in response to the COVID-19 pandemic, ILP began offering online QPR Gatekeeper trainings. As of June 2020, a total of 405 adults have completed the online training.
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