The ADHS’ Office of Women’s Health (OWH) continued to prioritize and implement activities that young people need to thrive and address our priority for enhancing equitable and optimal initiatives that positively impact the emotional, physical, and social wellbeing of adolescents. In 2022, all activities under each priority have been categorized using Levels of Public Participation (Inform, Consult, Involve, Collaborate, Empower) and can be found in Appendix H. Levels of Public Participation under the Adolescent Health section. The Adolescent Health population domain continued its work in Health Equity and Family Engagement. The Health Equity activities are identified in italics throughout this section of the report and information about Family Engagement can be found in the Family Partnership narrative.

Adolescent Health 2022 activities are linked to NPM 7.2: Injury Hospitalization, NPM 9: Bullying, and NPM 10: Adolescent Well-Visits. A concerted effort was made in 2022 to integrate mental health into all adolescent health initiatives after several data sources – MCH needs assessment, YRBS, and the Child Fatality Review – showed an increase in suicides among youth. Mental health was interwoven in bullying prevention, teen pregnancy prevention projects, and direct mental health initiatives and partnerships.

The National Survey of Children’s Health 2021 data showed that 25.4% of youth 6-11 years of age had been bullied at least 1-2 times per month over 12 months, and youth ages 12-17 reported being bullied at a slightly lower percentage of 20.2% over 12 months. Regardless of the data, no one deserves to be bullied, and everyone has the right to feel safe. Therefore, Bullying Prevention, funded through Title V and state lottery dollars, continued to be an area of focus for Arizona’s Title V Program. The Bullying Prevention Stakeholder Workgroup continued to meet in 2022 and provided input on various projects, including developing a media campaign and improving the must stop bullying website. Taking the task force's advice and aligning our efforts with the Arizona Health Improvement Plan, the most current campaign focused on a mental health approach, broadening the message to a broader audience of young people. The “What Kind Are You” campaign targeted youth in grades 5-8 and focused on mental health, wellness, mutual respect for peers, being accepting of others, their choices, their lifestyles, and their bodies – to just simply be kind. The commercials aired in both English and Spanish and pointed audiences to the must stop bullying website for information and resources. The campaign ads were distributed statewide across various media channels, including social media platforms such as TikTok, Facebook, and Instagram, digital videos such as YouTube and Tremor, broadcast TV, connected TV, and out-of-home mall kiosks. Over the 6-month run period, there were a total of 23,257,052 impressions, with over 14,500 people accessing the MustStopBullying.org website. Out of the viewers who saw an ad via a digital platform, 25,607 engaged with the ad by clicking to learn more.

Additionally, the Stakeholders helped to identify and prioritize content to develop a school section on the must stop bullying website. The new section provides school staff with resources on what they can do when they see bullying, how to address bullying behavior, how to support students being bullied, and how to follow up on incidences of bullying. Since September, when the school section of the site went live, there have been 223 unique pageviews to the section, with an average of almost 3 minutes spent viewing the school section. Overall, the bullying prevention site received over 20,000 unique pageviews, with an average of a minute and a half spent on the site.

While there had been some success in providing training to schools, caregivers, and other professionals, despite the interference of COVID-19, there were also some weaknesses recognized in the approach. In seeking a diversity of trainees, past training recipients were turned away in favor of recruiting new recipients. This meant that certain stakeholder groups would go some time without receiving updated information. Furthermore, stakeholders wanted access to the latest research to keep their knowledge up-to-date, and they wanted to explore a variety of topics related to student health and mental health and stay engaged. Therefore, in lieu of the training, Brad Snyder, our resident bullying prevention and ACEs expert, was funded to produce a weekly podcast entitled, Talking about Kids, discussing the latest trends in bullying prevention and generally improving student well-being. In 2022, forty-five (45) episodes were produced and could be accessed on seven (7) channels. The podcast had over 4,400 downloads from the website and was in the top 50% of all podcast listenerships. Guests included multiple recipients of Lifetime Achievement Awards from the American Psychological Association; two members of the National Academy of Education; authors; globally-recognized experts on bullying, education, childhood trauma, and traumatic brain injury; and Directors and CEOs of respected agencies and organizations serving children and families.

ADHS continued to fund Youth Councils leveraging Title V and state lottery funding. This activity is in alignment with the 2021-2025 AZ MCH Title V overarching strategy of integrating Family Engagement to address health equity. The Office of Women’s Health, through the adolescent health initiatives, will continue to support youth councils as a way to incorporate lived experience into Title V activities. In 2022, four (4) councils were awarded in two rural counties (Gila and Santa Cruz County) and one urban county (Maricopa County). The councils, currently comprising 38 youth, used 2022 to recruit and prepare youth for participation. The ADHS OWH secured the Wyman Center to provide youth/adult partnership training to ensure quality youth engagement and leadership, as indicated on the top 2 tiers (steps 7 & 8) of the Hart’s Ladder of Participation, during project planning and implementation. In addition to implementing projects in their communities, the youth councils will also serve as the youth advisors for the ADHS OWH projects, as well as provide youth voice to the Arizona Alliance for Adolescent Health. Councils will begin implementing their projects in January 2023.

Data indicates that as teens enter high school, the annual well visit to their primary care physician or pediatrician is often substituted by the sports physical. If the youth are not involved in any school sport, then they do not have any sort of annual wellness check with a physician. In fact, according to the 2021 National Survey of Children’s Health, 36.7% of youth 12-17 years of age did not receive even one preventive medical visit. Therefore, 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 (U of M) Adolescent Health Initiatives (AHI), 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 Children and Youth with Special Health Care Needs (CYSHCN) “SPARK” training module, developed in coordination with BWCH’s Children and Youth with Special Health Care Needs Program, to help guide physicians and other healthcare professionals in meaningful engagement with this population. It also continued to incorporate the Adolescent-Centered Virtual Care training module, which addresses best practices when providing services to youth via telemedicine.

Though the pandemic continued to present some challenges with competing priorities, Cohort 3, with 10 participating clinics, concluded its 18-month implementation in November 2022. Final evaluation results are expected to be available in the spring of 2023. Cohort 4 began in May 2022 with 8 participating clinics. All ACM-participating health centers engage in continuous learning to maintain the ACM’s high standards of practice and receive professional development through Spark training, e-modules, and Summits.

In 2020, through a partnership with Phoenix Children’s Hospital (PCH), Phoenix Children’s Care Network (PCCN), and Affirm (previously known as Arizona Family Health Partnership (AFHP), ADHS funded the development and implementation of a Maintenance of Certification (MoC) Program geared toward increasing rates of adolescent well-visits within the PCH PCCN. This formal quality improvement module provided a significant number of practices the opportunity to positively impact adolescent health and enhance ADHS’ efforts to increase adolescent well-visits. It also contributed to a more formal relationship with the PCCN and a partnership regarding recruitment from their network for the ACM. While there was the hope of offering the MoC opportunity to current Champions and potential partners that were unable to commit to full-scale implementation of the ACM, there was not enough capacity to manage the implementation of the project to the scale required. The MoC remains available for practice improvement cohorts within the PCH PCCN.

Eligible Champions in the current cohort were provided the opportunity to participate in AHI’s Confidentiality MoC free of charge as an incentive for participation in the ACM. Eleven staff from 5 clinical sites completed AHI’s Confidentiality MoC in 2022. Additionally, 12 Summit participants received CEU/CMEs for attending Dr. Vinny Chulani’s presentation, Adolescent Consent and Confidentiality: Legal and Ethical Considerations in Caring for Adolescents in Arizona. The PCH MoC likely will not need to be incorporated into the current ACM as the U of M AHI is developing a well-visit MoC that will also be available through the ACM. At that time, ACM clinics will have the opportunity to complete either the AHI Confidentiality MoC and/or the AHI well-visit MoC.

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 funding through Arizona Proposition 207 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. The campaign began with conducting 10 focus groups statewide, in English and Spanish, to understand current attitudes towards and awareness of well-visits among parents of youth 14-17 years of age. There were also in-depth interviews conducted with high school coaches, primary care physicians, pediatricians, and pediatric nurse practitioners to gain their perspective on how parents and youth understand the importance of well-visits. The findings from all the focus groups will inform the direction of the campaign that will be launched in the spring/summer of 2023.

Overall, the perceived value by parents on the well-care visits was very low. Many viewed sports physicals and well visits as the same, though some saw well visits as more complete. In general, parents struggled to differentiate sports physicals from well-visits. Many felt it was redundant to attend both and would choose the sports physical because it is fast and required for sports participation. Some, however, saw the well-visit as a more holistic and complete approach to health and development monitoring as it “checks the broader spectrum” including mental health, which was a constant concern among participating parents. Many parents also substituted their well-care visits with quick visits to the Urgent Care or Minute-Clinic style of healthcare, specifically when all they needed was the sport physical, perceiving it as a lot less hassle or lower time commitment to just go to the minute clinic and get the paperwork signed. Parents shared the view that well visits grow less important and reduce well visits as their children grew older, and if scheduled, they did not prepare as much as they used to when their children were younger. For many, the well-visit became merely a box-checking exercise for sports participation or a visit they attended because they felt obligated.

The in-depth interviews with medical professionals corroborated several views expressed by the parent focus groups with doctors and nurses, citing that well-check frequency decreases with age and patients begin to visit only when sick, stating that only about 50% of parents understand what preventative care means. Sports physicals and well-visits mean the same thing for many doctors; if a youth comes in for a sports physical, they will perform well-visit tasks. However, when a youth is seen for a specific illness, they will not receive the same level of care but will schedule another appointment for a well-visit.

Coaches stated that they were invested in the well-being of their student-athletes and are concerned about their mental health; however, they do not have much face-to-face interaction with parents to have enough of an influence but did feel that the parents did not recognize the value of regular well-visits.

Therefore, to address some of the findings from the focus groups, messaging will target parents and will revolve around a tagline that parents felt contained important information, made them feel confident, and had a positive vibe, “Adolescent well-care visits: Keeping you informed and your child on the right track.” Creative development will include social media messaging, a website, and an informational flier that high school coaches can hand out.

With support from Title V funding, the ADHS provided funding to the Arizona Chapter of the American Academy of Pediatrics (AzAAP), who developed and hosted an ECHO project learning series targeting pediatric providers with the intention of increasing adolescent well-care. Project ECHO: Pediatric Learning Collaborative on Adolescent Health convened from September to November 2022 and featured three unique ECHO learning sessions. Each session featured a didactic lecture, case presentation, and discussion among participants. The series sessions included:

• Trauma Sensitive and Strength-based Care in Adolescents, presented by Dr. Ken Ginsburg;
• We Check Their Hearts, Why Not Check Their Minds? Addressing and Destigmatizing Adolescent Mental Health, presented by Dr. Terry Bravender; and
• Preventing Overdose in Adolescents: A Public Health Approach, presented by Dr. 'Andrew Terranella

Twenty-four (24) individual pediatric health care providers registered for the project, which showed positive outcomes. 83% of participants stated they planned to change the strategies they implemented in practice (e.g., how they manage patients, diagnose patients, and coordinate care) based on what they learned. 95% of participants stated what they learned through the project improved their confidence in evaluating patients. Qualitative data collected from participants indicated that participants learned new strategies to discuss the topic of confidentiality with adolescents and their caregivers, improved their knowledge of trauma-sensitive and strength-based care with adolescents, and participants were committed to using destigmatizing language when discussing concerns with adolescents.

The Arizona adolescent suicide rates for 15-19-year-old males decreased by 48% between 2009 and 2019; however, male adolescents committed suicide at two times the rate of females in 2019. Most recently, analysis from ADHS’ child fatality review program showed that in 2020 there was a 30% increase in adolescent suicides. While there are numerous risk factors that can contribute to suicide, the most commonly identified risk factors were relationship problems, access to firearms, history of maltreatment, and child mental health disorder. During 2022, the ADHS’ OWH worked on building programs to reduce youth mental health stigma and increase mental health awareness and training for youth-serving adults.

The OWH joined the second cohort of the Adolescent & Young Adult Behavioral Health Collaborative Improvement and Innovation Network (CoIIN) hosted by the Adolescent and Young Adult Health National Resource Center, AMCHP, and the National Improvement Partnership Network. The goal of the CoIIN was to increase depression screening and follow-up for young people through systems-level behavioral health integration in primary care and improvement of screening rates in clinical settings, using an age-appropriate standardized tool for young people 12-25 years of age. The ADHS OWH led the CoIIN public health project, and primary care was led by the National Improvement Partnership Network as the training arm for clinical partners and practices.

The AzAAP was a key partner in recruiting practices to participate in the clinical CQI component of the CoIIN, recruiting 10 clinics to participate in the 9-month CQI project. Participating providers administered the Patient Health Questionnaire (PHQ) to screen youth during telehealth and in-person visits and increased screening from 77% to 89% at well-visits and 23% to 66% at other visit types.

ADHS partnered with the Arizona Department of Education (ADE), which was leading its own Comprehensive School Mental Health CoIIN, to establish the ADHS/ADE Adolescent and Young Adult CoIIN. Since both CoIIN efforts had similar goals of improving screenings and referral pathways, it was found to be beneficial and complementary to both state agencies to combine the CoIIN partner groups and work together to achieve better outcomes. With this partnership, ADHS gained an additional 6 partners, for a total of 13 statewide partners, who assisted with developing several adolescent health-focused activities. Partners provided input and feedback to help ADHS and ADE accomplish 5 major activities:

• Conducted 12 focus groups statewide with youth in grades 6-12 to gauge awareness and understanding of mental health among youth; assess awareness, accessibility of, and use of available resources and treatment options; identify barriers and challenges to accessing resources; uncover ideal support needed; and test existing media messaging created by youth from Bring Change 2 Mind, a national nonprofit organization dedicated to encouraging dialogue about mental health and raising awareness, understanding, and empathy.
• Launched a youth stigma reduction campaign that included selected creatives from the youth participating in the focus groups and resulted in advertisements in mall kiosks and on social media sites.
• Developed a stigma reduction website, targeting primarily youth, providing tips for self-care and starting conversations about mental health with parents/guardians; various resources; and listing of therapists, among other resources. The website was developed for youth by youth.
• Developed social media messaging for Mental Health Month to allow for a coordinated state approach by ADE, ADHS, and AHCCCS, Arizona’s Medicaid system.
• Developed an application to identify and recognize a school or district as a school mental health champion.

The CoIIN workgroup agreed to continue participation beyond the CoIIN period of December 2022 and, in January 2023, formed the Youth Mental Health Steering Committee to help coordinate state initiatives to increase resiliency and improve mental health outcomes of youth, adolescents, and young adults. All participating CoIIN partners resumed their participation after the transition.

ADHS has committed to implementing Youth Mental Health First Aid (YMHFA) statewide. The training assists adults working with youth to identify, understand, and respond to signs of mental illness and substance use disorders in youth. The efforts began in 2021 with an initial certification training for Teen Pregnancy Prevention Program health educators. To make up for any turnover in county program staffing, the ADHS hosted another certification training in 2022. With funding from both Title V and Prop 207, the ADHS contracted programs continued to deliver training in their communities receiving $1,000 stipends for every training provided. Twenty-four (24) trainings were provided to 305 participants from 15 youth-serving organizations interacting with 21,717 youth throughout the year. To date, ADHS maintains 28 certified trainers. With COVID-19 restrictions still impacting programming, most training offered was delivered virtually or in a hybrid setting. Additionally, the ADHS entered into a contract with the Inter-Tribal Council of Arizona to deliver training in Arizona Tribal Nations. ITCA struggled to hire and maintain a program manager but, towards the end of the calendar year, was able to hire a qualified and passionate YMHFA-certified trainer.

The ADHS OWH funded Affirm to maintain activities of the Arizona Alliance for Adolescent Health and expand membership to create a statewide coalition of healthcare clinicians and social service providers. The Alliance was convened as a forum to connect and share best practices, identify common problems, and develop innovative strategies to overcome barriers to providing high-quality health and social services for adolescents. Much of the work conducted in 2022 focused on identifying best practices to strengthen the infrastructure of the Alliance, enhance projects, grow membership, and extend reach. Through the work of a steering committee, research and data were collected and analyzed in preparation for an Adolescent Health status report that will be released in 2023; working on the development of a Resource Hub to create an online clearinghouse of comprehensive, statewide resources; and reaching out to key states to obtain lessons learned in developing statewide coalitions. In the Fall of 2022, Affirm advanced a formal structure for the Arizona Alliance, securing key organizational partners as a backbone to provide leadership to the statewide coalition.

Though the teen birth rate continues to decline, from 41.6 per 1,000 females ages 15-19 years of age in 2010 to 17.0 per 1,000 females in 2020, it still exceeds the national birth rate of 15.3 per 1,000 females. Although birth rates for females ages 15-19 decreased between 2010 and 2020, major disparities among Arizona’s racial and ethnic groups persisted, and Hispanic, American Indian, and African American females 19 years or younger accounted for higher birth rates than the state rate. In 2020, the rate for American Indian youth was the highest at 34.5; rates for Hispanic/Latino youth at 30.0 and Black or African American youth at 28.4. Rates for White Non-Hispanics at 12.9 per 1,000 and Asian or Pacific Islanders at 6.4 per 1,000 are considerably lower than the state rate. Teen Pregnancy Prevention Programs (TPP) continued the delivery of evidence-based abstinence and abstinence-plus curriculum services with state lottery funding and federal Personal Responsibility Education Program (PREP) and Sexual Risk Avoidance Education (SRAE) funding. Program education is delivered in areas of the state with the highest rates and needs for teen pregnancy services and addresses teen pregnancy and sexually transmitted infections among youth. Models delivered are medically accurate, culturally relevant, and age-appropriate, delivered with a positive youth development approach. The TPP Program funded thirty-three (33) rural and urban programs statewide through County Health Departments and community-based organizations, including two (2) in American Indian communities. All TPP programming incorporated at least 3 of 5 Adulthood Preparation Subjects (APS) into the delivery of evidence-based program models to meet the unique needs of Arizona youth. APS aims to help youth avoid harmful behaviors and develop the necessary skills and knowledge needed to positively transition into adulthood and include lessons in (1) Healthy Relationships, (2) Healthy Life Skills, (3) Educational and Career Success, (4) Financial Literacy, and (5) Adolescent Development.

In 2022, 7,377 youth between the ages of 11-19 were served across all Teen Pregnancy Prevention (TPP) funding sources. There were 3,769 youth who received Abstinence Plus educational services, with 75% completing at least 75% of the curriculum delivered, and 3,608 youth who received Abstinence educational services, with 93% completing at least 75% of the curriculum delivered. Parent educational sessions provided information to help parents/ guardians facilitate conversations with their youth on sexual health topics and other topics, such as healthy relationships, were given to 390 parents, with 95% of parents completing them.

COVID-19 continued to have a varying degree of impact on program delivery during the beginning of 2022. Many schools exhibited hesitation in allowing outside visitors into the classroom to deliver TPP educational services in a continued effort to mitigate an increase in cases. Other schools prioritized core academics over dedicating time to TPP programming.

Unfortunately, as program delivery began gaining traction, HB2035 parental rights; sex education instruction, passed in September 2021, began to be enforced. The law requires a school district or charter governing body to approve all sex education curricula before its delivery, with a more stringent approval process. HB2035 negatively impacted TPP contractor delivery in schools, as several schools opted to no longer allow contractors to deliver teen pregnancy prevention curriculum and have refused to engage in any conversation around sexual health due to the backlash they received from parents and community members strongly opposing delivery of sexual health education in schools. With the pandemic and the parent’s rights law reducing access to youth in school settings, the number of youth served by TPP Contractors has been severely impacted. Each year prior to 2019, TPP programs served 33,000 youth compared to a little over 8,000 in 2022, and only 6,600 expected to be served in 2023. The Adolescent Health team has been supporting and encouraging contractors to change the status quo of curriculum delivery in schools by helping them to identify strategies that could overcome implementation challenges stemming from HB2035, including focusing delivery to youth outside of school settings and providing more parent education to equip parents/guardians with information on how to talk to their adolescents about sexual health.

ADHS continued to lead 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/El Rio 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 adaptable and scalable for reducing unintended pregnancy and improving sexual health outcomes among youth. The ADHS workgroup includes participants from Affirm, El Rio, Advocates for Youth, the ADHS Adolescent Health team, and the ADHS Bureau of Assessment & Evaluation team. In 2022, the workgroup developed a logic model to guide implementation and a review of strategies to identify where adaptations would be needed to make the model feasible for other clinics. A completed model is expected to be available for pilot implementation in the fall/winter of 2023.

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. Unfortunately, COVID-19 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 of the Office of Women’s Health and the Adolescent Health Program Supervisor participated in the ADHS Suicide Prevention Plan’s Adolescent Health Workgroup meetings. The original plan was developed in 2019, and when ADHS received funding to begin a Suicide Prevention Program, workgroups began meeting to identify updates needed to the current plan and begin working towards developing a new 5-year action plan.

Title V funds were allocated to each County Health Department via the MCH Healthy Arizona Families (HAF) Intergovernmental Agreement (IGA) which funds additional adolescent health initiatives such as bullying prevention, family planning, transition to adulthood, injury, and suicide prevention.

Alongside the Adolescent Health activities and work headed by the OWH team and collaborators, the Office of Oral Health (OOH) and Primary Care Office (PCO) continued in their cross-cutting activities relating to Adolescent Health.

The Office of Oral Health (OOH) worked with the Arizona Partnerships for Immunization (TAPI), a non-profit statewide coalition that was formed in response to the alarming fact that in 1993, only 43% of Arizona’s two-year-olds were fully immunized against preventable childhood diseases such as measles, mumps, polio, and whooping cough. TAPI reached another defining moment with the introduction of the HPV vaccine in 2006. A vaccine to prevent HPV-related cancers shined a spotlight on the high rates of cervical cancer and head and neck cancers in Arizona. After the vaccine had been in use for a few years, Arizona still had low rates of HPV vaccine coverage and responded to this problem by making a strong push to increase HPV vaccine uptake among Arizona preteens and teens. As part of that push, OOH was engaged to develop tools and resources for dental providers.

As part of these efforts, a workgroup was formed and resulted in the Protect Me with 3 campaign directed at parents of youth ages 11-12, providing parents with simple, actionable steps to protect their children from serious diseases including HPV-related cancers. The workgroup sought out input from local dental providers and dental schools that needed tools and resources to enable them to be better equipped to have conversations with parents of adolescent children. While dental providers cannot offer the vaccine in Arizona, they are now better equipped with having disease prevention discussions. The workgroup has also used continuing dental education and lunch-and-learn seminars to educate dental care professionals on the HPV vaccine.

The Chief of the Office of Oral Health also maintained her position by serving as the Secretary for the National Network of State Adolescent Health Coordinators Leadership team.

The Primary Care Office (PCO) within BWCH leads statewide efforts to improve access to care to all health services in Arizona’s rural and underserved communities through the State Loan Repayment Program (SLRP), the National Health Service Corps Loan Repayment Program (NHSC), and the Conrad 30 Waiver Program.

Additional information about the Primary Care Office and Access to Care activities can be found in the Women/Maternal Health 2022 Annual Report and Perinatal/Infant Health 2022 Annual Report section of the application.