Massachusetts has three Adolescent Health priorities for 2020-2025:
- Strengthen the capacity of the health system to promote mental health and emotional well-being.
- Promote equitable access to sexuality education and sexual and reproductive health services.
- Prevent the use of substances, including alcohol, tobacco, marijuana and opioids, among youth and pregnant people.
Priority: Strengthen the capacity of the health system to promote mental health and emotional well-being
The 2020 COVID-19 Community Impact Survey (CCIS) showed that almost half (48%) of all MA youth reported feeling so sad or hopeless almost every day for 2 weeks or more that they stopped doing some usual activities. This was 21% percent higher than the Youth Risk Behavior Survey (YRBS) (27% in 2017). LGBQA youth, youth of trans experience, and youth with disabilities experienced the greatest inequities related to mental health concerns during the pandemic: 78% of youth of trans experience, 83% of non-binary youth, 84% of queer youth, 78% of youth with a cognitive disability, and 81% of youth with a mobility disability reported feeling sad or hopeless every day for 2 weeks or more.
Key strategies to address this Title V priority among adolescents include offering mental health assessment, brief intervention, and referrals to treatment within school settings; training mental health clinicians, community organizations, and school personnel on youth suicide screening, assessment and treatment; and using positive youth development (PYD) and racial justice principles in MDPH-funded programs to foster protective factors among youth. Measures for tracking progress on this priority relate to adolescent social connectedness and protective factors, reducing depressive symptomology among middle and high school students, and reducing consideration of suicide among middle and high school students. The latter two measures were added during FY21 due to the significant impact of the COVID-19 pandemic on the mental health of young people.
Objective 1. Increase the percent of high school students who report having a teacher or other adult in school they could talk to about a problem to 77% from baseline (75%, 2017 YRBS).
School-Based Health Centers (SBHC)
In FY22, MDPH funded 15 agencies (hospitals, community health centers [CHCs], and local health departments) that operated 33 SBHCs, which function as satellite outpatient primary care clinics located in school buildings. The SBHC program assesses students on a range of risk and protective factors, including presence of a trusted adult. In FY22, the program transitioned to a new data vendor. Since it was a transition year and sites were adapting to the new system, most sites were not yet reporting their screening results to MDPH, including protective factors such as presence of a trusted adult.
The SBHC Program hosted a three session professional learning series with the Bridge for Resilient Youth in Transition (BRYT) Program called Healing is in the Return to increase the capacity of all SBHC staff (nurse practitioners, behavioral health providers, and community health workers (CHWs) to foster resiliency for students and the school community and promote connection during the transition back to in-person learning. Main topics that were centered in this learning series included:
- COVID-19 as a collective slow-moving trauma
- How mental health symptoms show up in the classroom, especially around learning
- Adults struggling to help others regulate when they are not regulated themselves
- Awareness of who is included and excluded within the school community and actively working to shape a sense of belonging for students
- Strategies around moderation, hope, and validation
- SBHC role in challenging school norms and what they can do to support students in healing from collective trauma.
A former CSHS performance measure objective was to achieve an annual 10% increase in the percent of students who report having at least one adult at school they can talk to if they have a problem. Feedback from school health staff is that they rely on student surveys (such as the YRBS and the Youth Health Survey [YHS]) to collect this information, and the data collection in the CSHS grant reporting is redundant. Additionally, school health is just one opportunity for students to connect with adults at school. Therefore, the School Health Unit eliminated this performance measure and data collection element from the CSHS performance measures in FY22 and will instead rely on YRBS and YHS data.
Data from the 2019 YRBS indicate that many high school students have adults they can talk to, and this has been a consistent finding since 2009. A majority (74%) of high school students report having a teacher in school they could talk to about a problem. Most (81%) high school students report having a parent or adult family member they could talk to about things important to them. However, further exploration of the data revealed that far fewer Hispanic and Black students report having an adult they can talk to than do their White, Asian, and Multiracial peers. The 2021 YHS did not collect this measure but found that despite the influence of the COVID-19 pandemic, 2021 rates of protective factors have remained similar to 2019 rates. However, in 2021, Black and Hispanic/Latino students were less likely than White students to report engaging in many protective factors, including volunteer/community work, organized activities, and sitting down to dinner with their families. All other racial/ethnic groups were less likely than White students to report feeling that their neighborhood was safe from crime, feeling safe with their parents/caregivers, and feeling that they belong at school. In addition, students who identified as LGBTQ were less likely to sit down to dinner with their families and to feel like they belonged at school than their straight, cisgender counterparts.
School nursing staff continue to ensure that they are available as a trusted resource to all students in the school. In FY22 the MDPH School Health program and their training vendor, Boston University School Health Institute for Education and Leadership Development (BU SHIELD), provided professional development to school nurses around responding to disclosures of sexual abuse/assault and providing culturally responsive health services to students who are refugees. They also developed and delivered a nine-part series on Supporting Mental Health in Schools, which is now an enduring offering on the BU SHIELD website. Health screenings (vision/hearing, height/weight, postural), including Screening, Brief Intervention and Referral to Treatment (SBIRT), are one opportunity for health services staff to connect with students they might not otherwise meet, and school health staff are encouraged to use the skills they have developed in these trainings to build trust and connection.
Office of Sexual Health and Youth Development (OSHYD)
In FY22, OSHYD provided trainings to increase the capacity of youth-serving professionals to support the mental health needs of adolescents. These trainings were instrumental in a dual strategy to prevent burnout of the youth-serving professionals and to strengthen their ability to provide safe spaces for adolescents during the COVID-19 pandemic.
- In September 2021, the OSHYD provided “Question, Persuade, Refer” training to providers. The goal of this training was to teach skills on how to identify the warning signs of suicide and provide three simple steps that participants can take to respond to individuals at risk for suicide.
- In November 2021, the OSHYD convened Adolescent Sexuality Education (ASE) & Personal Responsibility Education Program (PREP) providers for a Fall Provider meeting, led by Advocated for Youth, on Engaging Parents and Caregivers as Partners in Health Education. The goal was for providers to discuss benefits of and strategies for engaging parents/guardians as partners in health education.
- In May 2022 ASE & PREP providers attended a workshop titled Techniques to Create an Inclusive and Affirming Learning Environment led by Advocates for Youth. The goal of this training was for providers to learn strategies to create a more affirming space for LGBTQIA+ students in school and during out-of-school programming.
- In May 2021, OSHYD consulted with Aida Manduley, LCSW, to host a 2-day mental health training for providers. Aida is an award-winning Latinx activist, international presenter, and trauma-focused clinician. They provided a 2-day training titled “Beyond Staying Afloat: Recognizing, Addressing, Preventing the Stress Spectrum REDUX.” This training, attended by 79 providers, focused on ways providers can take care of their own mental health as they support youth and their families, in addition to tools and strategies for self and community care in an agency setting.
School-Based Health Centers
Throughout FY22, MA schools returned to full-time in-person learning. SBHC providers quickly shifted back to in-person services and learned to integrate lessons learned from providing telehealth services into the in-person SBHC models to help expand access opportunities and improve engagement. SBHC providers continued to note an increase in behavioral health needs of students as they transitioned back into the classroom with their peers after many months of virtual learning. In response, the SBHC Program collaborated with the BRYT Program to offer training on the transition back to in-person learning to support resilience and foster connection.
In FY22, SBHCs provided three-tiered behavioral health services related to prevention and promotion and early identification. The first two tiers are described below and a third tier of behavioral health services – clinical intervention – is described under Objective 3.
Tier 1: Prevention and promotion: This level of service is tailored to school community needs. The school faculty and principal are engaged in identifying priority topics, including social emotional skills, school climate, and early recognition of mental health symptoms. Based on identified topics, the SBHC behavioral health provider works with school staff to develop classroom sessions and staff professional development aimed at providing universal education for the entire school community.
Tier 2: Early identification: This level of service includes developing and improving structures for early intervention for students with behavioral health needs with advisories, student support teams, and individual education plans. The SBHC behavioral health provider is available onsite to assess students who are referred by school staff for a preliminary evaluation. The outcome of this evaluation may include consulting individually with school staff on classroom management strategies to address inattention, discipline, and truancy. In FY22, primary care clinicians in SBHCs continued to screen for behavioral health concerns.
School-Based Telebehavioral Health Pilot Program
In early FY22, MDPH selected the Brookline Center for Community Mental Health to coordinate a new telebehavioral health pilot program in schools. The objectives of the program are to 1) reduce barriers to access for critically needed behavioral health services for school-age children with a specific focus on racial justice and 2) demonstrate the feasibility and elements necessary for success to replicate this program in other schools. Expanding access to telebehavioral health will provide referral and support resources for students struggling with substance misuse, as well as students with other mental and behavioral health needs. The Brookline Center will design the pilot program; select, fund, and support pilot sites; evaluate the program; ensure sustainability of the provision of services; and produce a replication guide that will assist other schools in starting their own telebehavioral health programs.
During FY22, the Brookline Center convened an Interagency Working Group to advise the overall pilot program, including various bureaus within MDPH and local universities. The Brookline Center has also contracted with the Schneider Institutes for Health Policy and Research within the Heller School for Social Policy and Management at Brandeis University to evaluate the school-based TBH pilot initiative. In FY22, the Brandeis evaluation team completed an initial School-Based Telebehavioral Health Pilot Project Needs Assessment and identified 43 schools that are high priority for implementation of the pilot.
School Health Services
According to data from the MA YHS, the mental health needs of MA youth continue to increase post-pandemic: the rate of both high school and middle school youth who intentionally injured themselves increased in 2021 compared to 2019: 21% of high schoolers reported intentional self-harm in 2021 compared with 15% in 2019; middle school rates were higher with 27% reporting intentional self-harm in 2021 and 21% in 2019. However, the rates of youth feeling sad or hopeless and those considering suicide remained similar in 2021 compared to 2019 (although the rates show slight differences, the differences were not statistically significant). Additionally, in 2021, females and LGBTQ students were more likely than male and straight/cisgender students to report intentional self-injury, feeling sad or hopeless, and seriously considering suicide. Hispanic/Latino students were more likely than other racial/ethnic groups to report feeling sad or hopeless and considering suicide.
School health staff provide mental health assessment, brief intervention, and referrals to treatment for youth. Activities in our funded programs focus on vulnerable populations of youth and performance objectives include the following:
- Increase the percentage of students who are identified as experiencing symptoms of depression and/or anxiety, or suicidal ideation, and are not currently receiving behavioral health care, that are referred for mental health services by school health/counseling staff (Target – increase referrals by 10% annually). In FY22, 47% of districts met the target.
- Increase the percentage of students who are homeless or marginally housed that are assessed for unmet health needs by nursing services (Target – increase assessments by 10% annually). In FY22, 62% of districts met the target, compared to 42% in FY21.
- Increase the percentage of students with special health needs that have an individualized healthcare plan (IHP) developed (target – 100% IHPs developed). In FY22, 54% of nonpublic schools met the target and 42% are in process to meet the target.
- Increase the percentage of ELL students assessed for unmet healthcare needs by nursing services. (Target – 90% seen). In FY22, 58% of districts met the target.
In addition to services provided to students with CSHS grant funds, the School Health Unit also provided support to school health staff, who have been dramatically impacted by the COVID-19 pandemic. School health staff report high levels of burnout, and the Commonwealth has seen an increase in school health staff turnover, including chronically unfilled positions. To address these issues, CSHS has implemented several workforce training and development activities. During FY22, CDC awarded MDPH a two-year public health workforce development grant with 25% of the grant ($10M) specifically intended for the school health workforce. Forty-two schools and school districts received $100,000 per year for two years to retain and hire school health staff. Many schools identified a need for additional staffing to support unmet behavioral health needs among their student populations, and some of these schools hired licensed behavioral health clinicians and nursing case managers to meet this need. The School Health Unit has also worked with their professional development vendor (BU SHIELD) and other agencies to provide school health staff with workshops around self-care, managing difficult conversations, and an entire school mental health series, which is now an enduring offering on the BU SHIELD website. Additionally, MDPH partnered with the DMH, which helps funds health care workers, to provide a weekly virtual drop-in support group for school health staff.
Office of Sexual Health and Youth Development (OSHYD)
In response to increased mental health challenges experienced by youth, ASE providers were allowed to bill for one-on-one mental health supports or “Wellness Checks” for youth during FY22 using the billing rate for youth development. Providers implemented check in calls to youth and mentoring and additional supports as needed. Providers expressed that this opportunity allowed them to develop and foster relationships with the young people in their programs.
In March 2022, OSHYD conducted a provider focus group with ASE- and PREP-funded agencies to understand the landscape of issues currently impacting youth, brainstorm opportunities for innovation, and learn from providers' best practices for retaining and reaching youth. Common themes from this discussion were as follows:
- Mental health is one of the biggest challenges experienced among youth and there is a need for more support to meet this need in schools.
- Partnerships with schools makes curriculum delivery easier due to having a “captive audience.”
- The importance of having a trusted adult and creating a supportive environment for peer connections.
- There are challenges to implementing curriculum in community groups due to not having a captive audience, attrition, and scheduling conflicts with partner organizations.
OSHYD used this programmatic feedback to make changes to the structure of MDPH-funded sexuality education programming for youth. This includes:
- Continuing to allow providers to bill under the ASE youth development unit rate for Wellness Checks. ASE providers were also given flexibility on projects to complete with youth under the youth development rate. Providers reported delivering activities such as mentoring, career development, college preparation, and mental health supports.
- Collaborating with the MA Department of Elementary and Secondary Education (DESE) to release a 3-tiered procurement that includes an option school districts may apply to in partnership with community-based organizations (CBO). The CBO will act as an implementation partner and support the school to prepare to implement an evidence-based sexual health curriculum.
- Providing continued technical assistance (TA) on parent and family engagement and a training on creating inclusive and affirming environments for LGTBQ+ youth.
School-Based Health Centers
In addition to Tier 1 and Tier 2 behavioral health services described previously, SBHCs also provide clinical intervention (Tier 3). In students with higher acuity (substantial clinical functional impairment), the SBHC behavioral health provider is responsible for providing appropriate referrals. The behavioral health provider can provide immediate clinical assessment for students experiencing a mental health crisis or onsite individual psychotherapy. The provider collaborates with school staff to develop and implement school-wide crisis response protocols, including for violence and suicide. Students with serious mental health disturbance require crisis response plans tailored to their individual needs. SBHC behavioral health providers were in increased communication with school staff in this fiscal year to help identify, stabilize, treat and/or refer students with increased acuity noted during the return to in-person learning.
Suicide Prevention Program
In FY22 a hosting issue arose that made the “S” Word: The Role of Schools in Preventing Suicide training unavailable. The training was developed to fulfill an unfunded mandate requiring two hours of suicide awareness and prevention training every three years to all licensed school personnel. The program team began to formulate and discuss what re-developing this training would entail.
Child Fatality Review
In FY22, the Injury Prevention and Control Program (IPCP) collaborated with the Suicide Prevention Program to support Local Child Fatality Review in their review of suicide cases. IPCP staff encouraged local teams not already doing so to review cases with a particular cause or manner—including suicide—together in a single meeting to improve teams’ understanding of risk and protective factors common across cases. One team adopted this approach at IPCP’s recommendation and convened a meeting to review several cases of suicide. For three local team meetings, IPCP staff facilitated the attendance of Suicide Prevention Program staff, who provided insight around individual suicide cases.
Priority: Promote equitable access to sexuality education and sexual and reproductive health services.
Objective 1 (SPM 2). By 2025, decrease the Latinx teen birth rate of 26.0 per 1,000 Latinx women aged 15-19 to 16.0 per 1,000 to reduce the inequity between Latinx and White youth.
Objective 2. By 2025, decrease the gap between the Black and White teen birth rates to less than 2 times higher.
Office of Sexual Health and Youth Development (OSYHD)
The 2020 MA teen birth rate was 6.1 births per 1,000 women aged 15-19 years, a 64% decrease from 17.2 in 2010. The 2020 Hispanic teen birth rate was 25.5, a 48% decrease from 49.2 in 2010. Racial and ethnic inequities in teen birth rates persist, as rates for non-Hispanic Blacks and Hispanics continue to be 3 and 9 times higher, respectively, than the rates for Whites. Over the last decade, MDPH has continuously targeted its prevention efforts on Black, Latinx, and LGBTQ youth because these populations bear the burden of unintended teen births and have historically had limited access to age-appropriate, medically accurate sexuality education. Prevention strategies have included using evidence-based sexuality curriculum that reflects young peoples’ experiences, peer leadership, and strengthening referrals to local sexual reproductive health clinics.
During FY22, OSHYD continued to operationalize its core values of racial justice, health equity, reproductive justice,[1] trauma-informed care, sustainability, youth development, and evidence-based/data-driven programming to support efforts to close the gaps described above. OSHYD identified several shared priorities across programs and has been working to address equitable policy change, improve program sustainability, and create opportunities for meaningful youth development and leadership.
OSHYD community-based programs use the Massachusetts Life Plan tool with young people aged 12-24 years. This tool provides an opportunity for CHWs to facilitate discussions with young people around health and goal setting, including in the domains of education, work, self-care, relationships, and sexual health. The Life Plan tool serves as a guide for community providers to engage youth in one-on-one or group interactions and in tracking their progress toward making positive changes in their lives. Community health providers use motivational interviewing to work with youth toward developing and making progress in youth-driven goals.
PYD is the foundation of public health interventions for adolescents. However, there is a lack of shared language and measurable outcomes for PYD programming. To address this gap, OSHYD and The Posse Foundation developed the Valuing Our Insights for Civic Engagement (VOICES) curriculum. VOICES provides a space for youth to understand their personal experiences and identities. Through various experiential learning activities, youth strengthen their critical analysis and recognize the power of their voices for community change. The VOICES curriculum can be adapted and used in both school and community settings. VOICES allows participating youth an opportunity to explore topics such as identity, stereotypes, power, advocacy and how they can be a part of change in their communities. In FY22, 410 youth participated in the VOICES curriculum.
Key challenges across OSHYD programs include recruitment and retention of both program participants and staff, program sustainability, and how to authentically integrate youth voice into programming. OSHYD continues to work with funded agencies to plan for sustainability at the beginning of program delivery and examining how community assets and resources can contribute to program sustainability on a local level. To address participant recruitment and retention challenges, direct service staff make frequent contact with program participants using a variety of means (phone, text, and social media). Incentives, such as assistance with transportation, graduation events, and gift cards for program milestone completion also support program retention. To reach youth completion goals, staff over-recruit for planned program cohorts and strive to provide programming in settings easily accessible and often frequented by youth. OSHYD staff also worked with vendors to manage staff turnover and provide training as new staff are onboarded.
In FY22, planning for the Youth Advisory Board (YAB) began with collaboration from internal partners and Health Resources in Action (HRiA), an external consulting agency. The goal of the YAB is to engage youth to partner with OSHYD to redesign existing programs so that they best address the needs of the adolescent population in MA. Interested participants will be recruited from a pool of youth-serving agencies that deliver ASE, PREP, and STRIVE programming. While the board was not able to be launched in FY22, planning activities continued.
Additional efforts of specific programs within OSHYD to address this priority are described below.
Sexual and Reproductive Health Program (SRHP)
SRHP providers offer comprehensive sexual and reproductive health (SRH) services to decrease unintended pregnancy and sexually transmitted infections (STIs). Contracted agencies, including CHCs, free-standing SRH clinics, hospital-based clinics, and SBHCs operate in communities with higher rates of teen births and STIs, and focus on providing services to low-income, uninsured, adolescent, and refugee and immigrant populations. Agencies provide clinical sexual and reproductive healthcare on site and may provide education and outreach to promote SRH services, and/or supportive services to assist priority populations to access other types of social support services or clinical care.
In FY22, 17 agencies reached 1,140 young people through peer education programs and over 18,000 people through community-based education, many of whom were adolescents. Social media activities exceeded over one million impressions. All of these programs employed a combination of traditional in-person outreach, virtual outreach, and social media to alert and inform adolescents of the availability of services.
In FY22, 24% of female MDPH-eligible clients aged 13-19 years reported using long-acting reversible contraception (LARC), a slight increase compared to FY21 (22%). Clinics worked to reduce barriers, such as high upfront costs for supplies, provider lack of awareness about the safety and effectiveness of LARC for teens, and lack of training on insertion and removal. In FY22, the COVID-19 pandemic continued to be the biggest challenge for funded agencies. To adjust, the contracted SRHP clinics created hybrid in-person and telehealth access to services. While the transition to telehealth was imperative for the continuation of many clinical services, periodic prohibitions against in-person visits may have limited access to LARC services. Clinicians worked closely with adolescent clients during that period to ensure continuity of care and access to clients’ preferred contraceptive methods.
In FY22, MassHealth and SRHP entered their fourth year of oversight of two organizations (Upstream and Partners in Contraceptive Choice and Knowledge (PICCK)) funded to provide five-year, statewide comprehensive training and TA on contraceptive counseling and service delivery. Upstream addresses outpatient care service delivery, with a focus on CHCs, while PICCK targets hospitals and hospital-based clinics. In FY22, Upstream and PICCK pivoted from a COVID-informed virtual model to a hybrid model. They included some lessons learned and best practices from FY21, such as Zoom check-ins and train-the-trainer models of service delivery and re-introduced in-person precepting and cross-agency partnership projects.
Personal Responsibility Education Program (PREP)
PREP aims to increase positive reproductive health outcomes and life opportunities for youth in MA through sexual health and adulthood preparation education. Through a partnership with DESE, youth in both MDPH-funded community-based programs and DESE-funded school districts receive high quality, age-appropriate, and medically accurate comprehensive sexuality education. PREP programs are grounded in PYD principles and program facilitators are expected to be a trusted adult for the youth they serve. During FY22, PREP partnered with DESE to serve youth at the Salem and Springfield School Districts. The Springfield School District was not able to implement PREP programming because of staff turnover and challenges with recruiting teachers. The Salem School district served 22 youth during FY22. In addition to the partnership with DESE, MDPH directly supported five CBOs which served 444 youth with sexual health education. Both school and CBOs experienced a decrease in the number of clients served. This decrease can be attributed to navigating the impact of the COVID-19 pandemic from an institutional perspective (for example closures and re-opening) as well as youth recruitment and retention challenges.
Adolescent Sexuality Education (ASE)
In FY22, ASE programs served 3,683 youth with evidence-based or evidence-informed sexuality education curricula in 15 communities. ASE provides access to evidence-based and comprehensive sexuality education in communities with higher burdens of teen birth and STIs, and where such education might not otherwise be available. This program has served a lower number of youth than in previous years. This decrease can be attributed to recruitment and retention challenges, “Zoom fatigue” among potential participants, and navigating re-opening policies in school and CBOs. The numbers have been slowly increasing; however, some challenges remain with programs’ ability to reach youth, such as program staff turnover and vacancies at the agencies.
Massachusetts Pregnant and Parenting Teen Initiative (MPPTI)
MPPTI aims to increase life opportunities and enhance family stability among young families. Programs are implemented in communities with high teen birth rates and serve predominantly young families of color. In FY22, 405 participants, including 316 adolescent parents, were served by MPPTI. Fifty-nine percent (59%) of non-pregnant participants reported the use of a contraceptive method at program intake, and MPPTI-funded case managers worked to provide connections to clinical services for contraception, overall health, and well-child health services.
Successful Teens: Relationship, Identity, and Values Education Initiative (STRIVE)
The goals of the STRIVE Initiative are to increase life opportunities for youth by delaying the onset of sexual initiation, thereby preventing adolescent pregnancy and STIs/HIV; increasing youth connections to caring and trusted adults in their community; and increasing internal and external developmental assets through promoting PYD programming. In FY22, STRIVE worked with 181 youth aged 10-15 years, reaching them prior to initiation of sexual activity and risk for unintended pregnancy and STIs. STRIVE programs were also required to complete at least one family engagement event during the fiscal year. The primary challenges the STRIVE programs faced during FY22 were recovering from the impact of the COVID-19 pandemic and staff turnover and capacity.
Objective 3. By 2025, provide training to 75% of ASE and SRHP grantees on the integration of reproductive justice principles into delivery of sexuality education and/or sexual and reproductive health services.
Office of Sexual Health and Youth Development
In FY22, OSHYD hired a consultant to conduct key informant interviews to understand programmatic barriers for organizations or communities that could prevent integration of reproductive justice principles into delivery of sexuality education and sexual and reproductive health services. This information will help providers prepare for implementing a Reproductive Justice Curriculum Addendum for birth control lessons, which will have the primary goal of framing and providing historical context to birth control’s complicated development.
In June 2022, OSHYD providers attended a workshop entitled “From the Root to Reality: Connecting the Dots from History to Health Outcomes” focused on racial equity and led by Jannah Bierens, MPH, MA. Jannah is the founder and principal owner of PHREEEDOM LLC (Public Health Racial Equity through Exploration and Engagement to Dismantle Oppression for Movement). The goal of the workshop was to ground providers in root cause definitions and equity concepts and reflect on the historical influence of racism and oppression that has shaped our society and culture. OHSYD required agencies to send at least one staff member in a leadership position to attend this workshop. Overall, 42 providers attended. In August 2022 OSHYD disseminated a survey to help identify learning topics that providers will have an opportunity to further explore in the late Fall/early Winter.
Objective 4. By 2025, 85% of females under age 25 are screened for chlamydia at SRHP-funded clinics.
Sexual and Reproductive Health Program
Among the 15 agencies that reported chlamydia testing information, 44% of females under age 25 received a chlamydia test in FY22 (12,012 females tested for chlamydia, out of 27,499 females served in the SRHP). Staff monitor and provide TA during monthly oversight meetings to increase chlamydia testing in clinics. The impact of COVID-19 and the uptake of telehealth services impacted STI screening rates. In FY22, we began to see a return to pre-pandemic productivity levels and improved learning regarding the provision of comprehensive telehealth services that incorporate laboratory testing. We anticipate that this along with increased monitoring will result in higher chlamydia screening rates for females under 25 in the future.
Objective 5 (NPM 10). By 2025, increase by 2% from baseline (90.9%, NSCH 2016-2017) the percent of adolescents who have a preventive medical visit in the last year.
According to the 2020-2021 NSCH, 69.6% of adolescents received a preventive medical visit in the last year, a decrease from the 2016-2017 baseline. This decrease is expected, as CCIS findings showed that the COVID-19 pandemic disrupted healthcare capacity even for people who normally face few barriers to care and impacted people’s ability and willingness to access critical and essential healthcare services.
School-Based Health Centers
SBHCs offer onsite primary care and behavioral health services to all students, regardless of their ability to pay, while school is in session and is staffed by nurse practitioners. Research has shown SBHCs increase access to care and quality of care for underserved adolescents.[2],[3] SBHCs are important in reducing both financial and non-financial barriers to health care: lack of insurance, lack of confidentiality, inconvenient office hours and locations, inability of working parents to leave their jobs to get children to care, lack of transportation, and apprehension and discomfort discussing personal problems affecting health. An explicit goal of the SBHC program is that all children and adolescents obtain health insurance and are connected to a medical home. SBHCs also support students to develop the skills they need to navigate the health care system upon graduation from high school. Because young men are less likely than young women to receive care from SBHCs, the evidence-based strategy measure for NPM 10 tracks the percentage of SBHC clients who are male, with the goal of reaching a proportion more similar to the student population in the state. In FY22, of 10,705 total SBHC clients, 42.7% were male.
In FY22, MDPH SBHCs provided a total of 11,687 primary preventive visits, which made up 25.6% of total visits. As we transition data collection systems, we are working on improving accuracy of our visit counts. We expect this number is an undercount of both total visits and preventive visits.
While SBHC clinicians transitioned back to in-person learning, they worked to re-connect with students and provide in-person care upon their return to school. SBHCs continued to use telehealth to connect with students who were experiencing increased absence after the return to in-person learning to provide ongoing medical and/or behavioral health services and support during this challenging transition. SBHC clinicians engaged in a three session training series with the BRYT Program titled Healing is in the Return to help staff feel equipped with skills to foster connection and engagement with students upon the transition back to in person learning.
Sexual and Reproductive Health Program (SRHP)
In FY22, through state and federally (Title X)-funded SRH clinics, MA continued to promote the Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP). These recommendations expand family planning to include preconception and other preventive health services, including screening for obesity, smoking, diabetes, violence, mental health, reproductive life planning, and screening for and treating STIs. Additional preventive health services include breast and cervical cancer screening, immunizations, and other services based on nationally recognized standards of care. Clients seeking contraceptive services at SRH clinics often do not have another source of primary health care. SRH visits are opportunities for clinicians to offer broad preventive health services beneficial to overall health as well as to reproductive health. In FY22, as a central quality assurance/quality improvement activity, SRHP conducted virtual program reviews of its contracted agencies. This review included a comprehensive chart review to confirm and assure delivery of quality services and where necessary, provide TA. SRHP developed a participatory model where clinicians reviewed a sample of their own records and then worked with the program’s Clinical Advisor to develop action plans based on the findings. This strategy was well received and allowed for a robust dialogue regarding both the SRHP Program Standards as well as the QFP. Training and TA on the new standards were provided to contracted agencies during monthly oversight meetings and during state-wide provider meetings.
In FY22, SRHP launched its first year of programming with the new SRH training center and learning management system. MDPH selected a nationally recognized training and technical assistance (TTA) organization, JSI Research and Training Institute, Inc., to provide comprehensive SRH TTA to clinical providers, including specialized skills for serving adolescents. Year one activities included creating and launching the website (MASRH.org), delivering several webinars, and developing two e-learning trainings, one titled Racial Equity in Sexual and Reproductive Health Services and the other titled MDPH Sexual and Reproductive Health Program Core Values and Program Standards.
Priority: Prevent the use of substances, including alcohol, tobacco, marijuana, and opioids, among youth and pregnant people.
According to 2020 CCIS, MA youth living in rural areas were significantly more likely to report increased substance use since the pandemic began compared to youth living in urban areas. More than 2 in 5 Black youth reported using more substances since the pandemic began, and Hispanic/Latinx youth reported twice as much substance use (17%) as American Indian/Alaska Native (8%) and Black (8%) youth. Alcohol and marijuana were the most common substances used. The substance use prevention and treatment resources youth reported needing most were in person therapy and peer support.
School Health Services
Screening for substance use disorder in all MA public schools, in at least one middle school and one high school grade, is now mandated through the STEP Act of 2016 (An Act Relative to Substance Use, Treatment, Education and Prevention)[4]. This is done via SBIRT using a validated screening tool and has been implemented collaboratively by the MDPH School Health Unit and Bureau of Substance Addiction Services (BSAS). The tool uses the standard six-item CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) questions along with four validated pre-screening questions, which improves the sensitivity of the screening to identify individuals with substance use issues. The CRAFFT is designed for youth aged less than 21 years. Screening provides an opportunity for school nurses to develop deeper relationships with students, particularly students at risk for alcohol or substance use disorders, and equips nurses to listen and respond appropriately to behavioral health issues. Aggregate screening data are reported to MDPH annually, which include outcomes of screenings.
In FY22 the MDPH School Health Unit added another public health nursing advisor who works specifically with non-public schools, and the entities they interface with, in order to increase adherence to medication administration regulations and support implementation of screening regulations/statute including SBIRT screening.
In the Spring of 2022, the School Health Unit, BSAS, BU SHIELD and the Massachusetts SBIRT – Training and Technical Assistance program (MASBIRT-TTA) updated the approved SBIRT screening tool from the CRAFFT-2 to the CRAFFT-2N, including updating all associated trainings, in order to include screening questions and brief interventions that address nicotine use and vaping. This effort is intended to reduce youth vaping in MA and mitigate the negative health outcomes of vaping. In FY22, 72% of school districts with students in grades 7-12 implemented SBIRT screening.
School-Based Health Centers
In FY22, the SBHC program transitioned to a new data vendor. Since this was a transition year and sites were adapting to the new system, most sites were not yet reporting their screening results to DPH. Therefore, at this time we cannot report on the proportion of students visiting SBHCs that received SBIRT screening
Additional activities to prevent the use of substances among youth:
MassCALL3
In July 2021, the BSAS Prevention Unit began a new initiative called the Massachusetts Collaborative for Action, Leadership, and Learning 3 (MassCALL3). The goal of MassCALL3 is to prevent substance misuse (e.g., alcohol, nicotine, cannabis) among youth in middle and high school (approximate ages 12-17) through the implementation of comprehensive evidence-based substance misuse prevention programs, policies, and practices across multiple levels of the socioecological model (e.g., individual, peer, family, school, community). Emphasis is being placed on the application of a Restorative Prevention approach with a focus on race and health equity to address inequities in access to services, utilization of services, and substance misuse outcomes among historically marginalized populations. At present, the MassCALL3 initiative is supporting 41 grantees covering 178 of the 351 municipalities in the Commonwealth.
During the first 12 months of the MassCALL3 initiative (July 1, 2021 – June 30, 2022), all grantees were required to: (a) conduct an assessment of needs and resources within their catchment area, (b) identify areas for improvement within the local prevention infrastructure system, (c) prioritize substance misuse prevention intervening variables and outcomes of focus – including populations and settings of focus, (d) identify a comprehensive set of evidence-based programs, policies, and practices to be implemented, and (e) create a comprehensive strategic prevention plan – including a detailed one-year workplan for FY23. Each comprehensive strategic prevention plan is being reviewed by a Prevention Contract Manager within BSAS, a representative from the state’s prevention TA center , and the cross-site evaluation team for the MassCALL3 initiative. Upon approval of the plan, MassCALL3 grantees will proceed to implement the specifications outlined in the strategic prevention plan. We anticipate final plan approvals for the majority of grantees early in FY24 and expect that these grantees will then progress to providing direct and indirect prevention services with the population(s) identified in their approved plan.
[1] SisterSong defines Reproductive Justice as the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.
[2] Allison, Mandy A., et al. "School-based health centers: improving access and quality of care for low-income adolescents." Pediatrics 120.4 (2007): e887-e894.
[3] McNall, Miles A., Lauren F. Lichty, and Brian Mavis. "The impact of school-based health centers on the health outcomes of middle school and high school students." American Journal of Public Health 100.9 (2010): 1604-1610.
[4] Bill H.4056. Available at: https://malegislature.gov/Bills/189/House/H4056
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