Massachusetts has three priorities for Adolescent Health for 2015-2020:

1. Promote safe, stable, nurturing environments to reduce violence and the risk of injury.
2. Promote equitable access to preventive health care including sexual and reproductive health services.
3. Promote emotional wellness and social connectedness across the lifespan.

 

Priority: Promote safe, stable, nurturing environments to reduce violence and the risk of injury.

Performance on this priority is measured by the rate of injury-related hospital admissions among youth aged 10-19 years. Key MDPH programs addressing this priority include the Suicide Prevention Program, Injury Prevention and Control Program, Child and Youth Violence Prevention Services, and School Health Services.

 

NPM 7: Rate of injury-related hospital admissions per population ages 10-19 years

Injuries are the leading causes of morbidity and mortality for adolescents. In 2017, the rate of adolescent injury-related hospital admissions was 162.1 per 100,000, a decrease from 174 per 100,000 in 2016.

 

Suicide Prevention Program (SPP)

Zero Suicide is a commitment to suicide prevention in health and behavioral health care systems through evidence-based strategies and practices that can be implemented system-wide, such as risk assessment training for health care staff, screenings to identify those at risk for suicide, and follow-up care of patients who present at an emergency department (ED) with suicidal ideation or an attempt.[1],[2],[3] Through the Garrett Lee Smith Suicide Prevention Grant funded by SAMHSA and administered by the SPP, Zero Suicide was piloted in two health care systems – Heywood Health Care in Gardner, MA and Berkshire Health System (BHS) in Pittsfield, MA. The SPP established and led a Learning Collaborative to support health and behavioral healthcare organizations interested in implementing Zero Suicide. From FY16 to FY18, the first cohort of the MA Zero Suicide Learning Collaborative consisted of representatives from MDPH, the Department of Mental Health, four health care systems, three behavioral health systems and one payer. This grant is ending in September 2020.

 

Two ESMs track progress on NPM 7: 1) the percent of ED patients aged 10-24 years in two Zero Suicide grant sites that receive a suicide screening and 2) the percent of ED patients aged 10-24 years identified to be at risk and who receive a same day assessment in two Zero Suicide grant sites. Studies have found that ED interventions for suicide prevention improve linkage to outpatient mental health treatment.[4]

 

BHS and Heywood Hospital both aimed to 1) screen 100% of ED patients aged 10-24 years for suicide risk using a standardized screening tool, regardless of presenting medical concern, and 2) provide 100% of patients at risk for suicide with a same-day (within 24 hours) comprehensive assessment by an Emergency Service Provider. Policies, procedures and a standardized screening tool for universal screening in the ED and follow-up assessments were implemented at the beginning of FY18. In FY19, Heywood reported a 97% screening rate and 6% were found to be at risk of suicide. Of the patients identified to be at risk, 96% received a same-day assessment. BHS reported a 100% screening rate for ED patients ages 10-24 years and 7.1% of patients were found to be at risk of suicide. Of patients identified to be at risk, 95% received a same day comprehensive assessment by a provider. In both health systems, patients also receive brief interventions while in the ED, such as safety planning, and are connected with the Behavioral Health Navigator (a social worker embedded in the ED) for follow-up and case management services.

 

Injury Prevention and Control Program (IPCP)

Motor Vehicle Safety:

In FY19, the MDPH Office of Emergency Medical Services launched a Mobile Integrated Health and Community EMS program. This project will produce an online toolkit for EMS professionals to educate their community members about child passenger safety, taking into account the specific opportunities and challenges they may encounter. FY19 was spent planning and understanding the data around these injuries, including assessing for racial inequities. The toolkit will be launched in FY20.

 

IPCP staff continued to co-chair the MA Traffic Safety Coalition, along with the director of the Highway Safety Division of the Executive Office of Public Safety and Security and a member of the Public Affairs team at AAA Northeast. These quarterly meetings included educational presentations, legislation tracking and member updates.

 

IPCP also continued to support the MA Department of Transportation’s Strategic Highway Safety Plan. IPCP staff led two working groups (Impaired Driving and Young Drivers) and provided data and expertise to a number of other working groups, including pedestrian safety and motorcycle safety.

 

Sports Concussions:

MDPH sports concussion regulations provide standardized procedures and guidance to schools with children in grades 6-12 in the prevention and management of sports-related head injuries in all public schools and other schools that are members of the MA Interscholastic Athletic Association.

 

The Sports Concussion Learning Collaborative (SCLC), a pilot program for the Sports Concussion Initiative, ran from September 2018 to January 2019 with nine schools. The goals for the SCLC were to 1) improve participating schools’ written sports concussion policies and their implementation, and 2) share lessons learned, approaches, and tips across schools. Topics included annual concussion training, pre-participation requirements, report of head injury, graduated return to play, and communication within the school. Monthly SCLC sessions were conducted virtually through Webex, increasing the ability to bring schools together from different locations across the state. The SCLC allowed schools to learn from and support each other in facing challenges and sharing best practices.

 

MDPH developed and distributed to approximately 800 middle and high schools a booklet titled “Returning to School After Concussion: Guidelines for Massachusetts Schools.” Return to learn focuses on developing policies and instructional materials for teachers to support students who are recovering from concussion and who may have difficulty in the classroom processing information, keeping up with assignments, concentrating, taking tests, and may be sensitive to light and noise. This booklet was developed in partnership with members of the Return to Learn Workgroup consisting of school nurses, advocates and hospital staff from sports concussion programs. 

 

Submission of Year End Reports on concussions enables measurement at the school level of awareness and compliance regarding the sports concussion regulations. The number of Year End Reports received from schools increased from 203 schools in school year 2011-2012 to 580 in school year 2017-2018 (out of approximately 719 public and private schools with extracurricular sports), suggesting that an increasing number of schools are compliant with the concussion regulations. School districts are also required to submit letters of affirmation to MDPH every two years stating they have updated and reviewed their sports concussion policies. The most recent collection of letters of affirmation (due September 2017) yielded a 73.5% return rate (275 letters of affirmations from 374 school districts).  

 

A Youth Concussion Advisory Work group continued to meet quarterly in FY19 and consisted of school nurses, school athletic trainers and directors, and representatives from hospitals, MA Concussion Management Coalition, and Concussion Legacy Foundation. Barriers to implementation of the sports concussion regulations were discussed, as well as opportunities for training and collaboration, and updates on programs and data.

 

The Clinical Expert Concussion workgroup meets every six months to provide guidance to MDPH regarding implementation of the regulations. In FY19, this group simplified and revised the MDPH mandated medical clearance form to improve compliance by medical providers. The revised form was rolled out to medical providers and schools in fall 2019. As a result of this group’s recommendation, an email was sent in September 2018 to 18,000 physicians in partnership with Board of Registration of Medicine reminding them of the medical clearance and training requirements of the MA sports concussion regulations and training opportunities in sports concussion treatment and management.

 

In FY19, a new collaboration was formed between the Sports Concussion/Traumatic Brain Injury (TBI) program, the MDPH Sexual and Domestic Violence program, and the MA Rehabilitation Commission State Head Injury Program to survey knowledge of TBI by domestic violence shelter staff. Survey results will guide future work such as trainings for Domestic Violence Shelter staff that could lead to better identification of TBI in survivors, resulting in access to additional support services. 

 

Child and Youth Violence Prevention Services

In FY19, CYVPS managed three program components to address violence among youth aged 10-24 years: Primary Violence Prevention, Youth at Risk, and Safe Spaces for LGBTQ Youth. These components work collaboratively to address the needs of young people in the Commonwealth through a positive youth development (PYD) strategy that ensures that youth learn skills such as conflict resolution, resiliency, and self-esteem building. These programs also contribute to reducing youth violence due to their long-term commitment to prevention services targeting youth at earlier ages (as young as 10 years old) and the collaborations between local police departments and MDPH-funded community-based organizations, which help to break down decades-old silos in services.

 

The Primary Violence Prevention program serves areas that are not necessarily identified as “hotspots,” but show a need based on local data and other health indicators. Providers primarily work with youth at the younger end of the 10-24 year age range. These upstream prevention initiatives, using the PYD model, may include but are not limited to leadership development, mentoring programs, sanctuary programs, academic supports, job training, arts expression, and outdoor learning. In FY19, 20 agencies reached an estimated 21,145 youth through group sessions, street outreach, community events, dances, social media, and other group gatherings.

 

The Youth at Risk Program serves youth in neighborhoods that have elevated rates of violence and works with youth at the older end of the 10-24 year age range. Prevention initiatives include programming such as gang intervention, outreach, job readiness, life skills, arts, and behavioral health supports. In FY19, contracted agencies reached an estimated 10,776 youth through group sessions, street outreach, community events, dances, social media, and other group gatherings. 

 

The Safe Spaces for LGBTQ Youth program provides opportunities for gay, lesbian, bisexual, transgender and queer/questioning youth to develop their full potential in a safe and supportive environment. LGB youth face issues of bullying, isolation, homelessness, domestic violence, partnership violence and general homophobia. According to the 2017 MA YRBS, 13% of LGB youth attempted suicide in the past year compared to 3% of heterosexual students. LGB youth are also significantly more likely than heterosexual students to skip school due to feeling unsafe (11% vs. 3%) and to experience bullying at school (26% vs. 13%). While many youth consider their home a safe haven from a difficult school or community environment, LGBTQ youth may find continued criticism and hate in their home environment. Given the myriad issues facing LGBTQ youth, the services provided to this population are constantly evolving. Safe Spaces for LGBTQ Youth supports community-based organizations to provide services that are trauma-informed, founded in PYD, culturally appropriate, and specific to LGBTQ youth. In FY19, six agencies reached an estimated 8,224 youth through group sessions, street outreach, community events, dances, social media, and other group gatherings. 

 

A core principle of the PYD model is to hire previous program participants as staff or peer leaders to mentor younger members. No one understands what a young person faces daily more than another young person who has experienced the same traumas. Young staff become role models for others to follow. Another core principle of PYD is active involvement and ownership of one’s own community and neighborhood. An additional benefit to hiring youth as staff is the continued development of these young people as leaders in their communities. A strong sense of belonging to one’s community is a significant protective factor in violence prevention. In FY19, 630 youth under the age of 24 were employed as direct care staff by CYVPS programs.

 

CYVPS activities continue to engage families as assets to youth violence prevention through family-specific programming. Because many of the youth served are primary providers for their families (they report giving the majority of their paychecks back to their families) it is imperative that MDPH continue to explore new and innovative programming to allow these youth to access services in the context of their roles as providers for their families.

 

Despite the successes of these programs in FY19, challenges to preventing and responding to youth violence continue, as does the need for better and more comprehensive data collection and analysis. The National Violent Death Reporting System does not include many MA towns. The YRBS only surveys in-school youth, which may miss more vulnerable youth, and survey sampling methodologies may not cover areas that have acute outbreaks of violence. Effectively measuring the impact of PYD approaches is difficult due to the nature of the approach/curriculums. Many aspects of PYD (e.g., resiliency skills, leadership, community buy-in) cannot be easily measured. A longitudinal approach is most effective; however, with funding changes from year to year, programs do not remain funded for a long period of time.

 

Furthermore, youth employment opportunities and behavioral health services are still inadequate to meet the current needs. In response, MDPH supports programs for job readiness and youth employment and programs that provide behavioral health services in non-traditional spaces. The significant increase in opioid use among MA teens has been an alarming and ongoing trend. CYVPS staff continued collaborating with the MDPH Bureau of Substance Addiction Services (BSAS) to develop a PYD model for substance use prevention and treatment work with young people.

 

Another key focus in FY19 across CYVPS programs was promoting racial equity. All CYVPS staff attended racial equity trainings provided by MDPH, to understand and address racial inequities that many young people served by the program experience. Traditional violence prevention programming is not always appropriate for or inclusive of youth of color. CYVPS continues to adapt its PYD curriculum and funding review process to assure that all populations are well represented and reflected in the work of these three programs.

 

Priority: Promote equitable access to preventive health care including sexual and reproductive health services.

In the Adolescent Health domain, this priority is measured by the percent of adolescents aged 12-17 years with a preventive services visit in the last year (NPM 10) and is addressed by School-Based Health Centers, School Health Services, and the Office of Sexual Health and Youth Development.

 

NPM 10: Percent of adolescents with a preventive services visit in the last year

Data from the 2016-2017 National Survey of Children’s Health indicate that 90.9% of youth aged 12-17 years had a preventive health visit in the past year. The evidence-based strategy for addressing this NPM is centered on increasing visits at School-Based Health Centers (SBHCs). This priority is also aligned with the MA State Health Improvement Plan, which includes strategies to link people to needed personal health services and health care through the support and expansion of school-based health clinics that provide preventive service visits. Other strategies include supporting the implementation of the Quality Family Planning Services Recommendations from the Centers for Disease Control and Prevention (CDC) and the Office of Population Affairs in clinical settings and tracking referrals to preventive health care visits in educational and community-based settings.

 

School-Based Health Centers

MDPH funds 16 agencies (hospitals, community health centers and local health departments) that operate 34 SBHCs, which function as satellite outpatient clinics located in school buildings. SBHCs offer onsite primary care to all students, regardless of their ability to pay, while school is in session. SBHCs are staffed by nurse practitioners who are authorized to prescribe medications and are supervised by a medical doctor. SBHCs offer both comprehensive primary care and behavioral health services within schools, where children and adolescents spend most of their time. Research has shown SBHCs increase access to care and quality of care for underserved adolescents.[5],[6]  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 be connected with a medical home in their community. SBHCs also support students to develop the skills they need to navigate the health care system upon graduation from high school.

 

In FY19, the ESM for this NPM was the percent of annual projected SBHC visits completed across all SBHCs. The target is 1,085 medical provider visits per school year (727 visits for SBHCs funded part-time). These include any visit to the medical provider/nurse practitioner for immediate onsite care and referrals to community providers for specialty services/medical home linkages. MDPH invested considerable energy in conducting site visits to ensure that all SBHC staff are properly trained in the strengths-based Comprehensive Risk and Resiliency Assessment methodology. As a result of these efforts, SBHCs completed 121.9% of the annual projected visits in 2019, reflecting more visits by adolescents to the medical provider/nurse practitioner than MDPH had originally aimed to complete.   

 

A key strategy of the SBHC program to maximize engagement in preventive visits is professional development opportunities for staff to foster welcoming, inclusive, and supportive environments for all students. In FY19 the SBHC program hosted professional development sessions on the following topics associated with enhancing and preserving access for adolescent preventive services: sharing stories that ignite belief in the SBHC model; understanding and addressing the issues behind school absenteeism; and re-finding joy in practice to foster sustained enthusiasm and prevent clinician burnout. The sessions, presented by SBHC primary care and behavioral health clinicians, covered topics such as using technology to reach students/deliver care; strengthening the school community through the SBHC Youth Advisory Council, and self-care in the workplace.

 

To fully address the priority of preventive care among adolescents, SBHCs also increased efforts to screen for substance use. In FY19, the SBHC program provided mandatory trainings for behavioral health clinicians and nurse practitioners through a collaborative agreement with the BSAS Office of Youth and Young Adult Services. In a session on Enhanced Adolescent Community Reinforcement Approach (A-CRA) for school delivery, clinicians learned strategies and skills related to youth engagement, conducting functional analyses of substance use behavior, teaching drink/drug refusal skills to youth, referrals to treatment, and developing connections with local substance use treatment providers to enhance the warm referral.  

 

During FY19, 81.3% of students aged 12-18 years seen by the medical provider in 30 SBHCs were assessed at least once for substance use using the CRAFFT screening tool, a tool designed for youth aged less than 21 years to identify risky use of alcohol and other drugs. This is a significant increase from 63% of clients assessed in FY14, and well exceeds the original objective of 73% by 2020. Among those students who were screened, 96.7% received a brief intervention, which included at least one of the following options: 1) give praise/encouragement for making good decisions or revealing use; 2) develop action plan for addressing risk; 3) schedule follow up with SBHC medical provider or 4) make a referral to an A-CRA provider in the community. The goal is that 100% of students screened will receive a brief intervention.

 

School Health Services

School Health Services collects information related to preventive care through school nurse referrals in response to screening for vision, hearing, posture, body mass index, and substance use (SBIRT). Students are referred to their primary care providers for further examination and intervention. Without screenings by school nurses, many of these referrals would not occur. These screening efforts were successful in identifying a large number of students in need of further assessment or treatment. For example, in response to vision screening there were 108.3 referrals per 1,000 enrolled students. Of these referrals, 35% were completed, meaning that the school nurses became aware of the outcome of referral (for example, a child received glasses).  

 

Referral completion rates ranged from 13% (BMI screening) to 68% (SBIRT). Although this is below the target (85%), obtaining referral completion data remains a challenge. In many cases, unless parents report referral results to a school nurse, referral completion data are not recorded. Therefore, current referral completion rates are likely a significant undercount, and efforts will be made to improve data collection.

 

The SBIRT in Schools program is a collaboration between the School Health Unit and BSAS. SBIRT is an evidence-based screening tool for prevention and early identification of substance use and has been a priority for School Health Services. The tool uses the standard six-item CRAFFT questions along with four validated pre-screening questions, which improves the sensitivity of the screening to identify individuals with substance use issues. Screening provides an opportunity for school nurses to develop a deeper relationship with the students, particularly for students at risk for alcohol or substance use disorders, and equips the nurses to listen and respond appropriately to behavioral health issues. In FY18, SBIRT screening was expanded statewide, and in FY19, 93,983 students in grades 7 through 11 were screened. The percentage of students at high risk of developing a substance use disorder varied by grade, ranging from 0.4% in grade 7 to 3.7% in grade 10. Per the SBIRT protocol, those students whose screening indicated a considerable risk of developing a substance use disorder were referred for counseling outside of school.

 

Office of Sexual Health and Youth Development

During FY19, the Office of Sexual Health and Youth Development (OSHYD) continued to operationalize its core values of health equity, racial justice, reproductive justice, trauma-informed care, sustainability, and data-driven programming. 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. These synergistic efforts will continue; many specific objectives are described in FY21 plans.

 

OSHYD includes both clinical and non-clinical programs. The Sexual and Reproductive Health Program (SRHP) provided clinical family planning care at approximately 90 locations throughout the state in FY19. Clinical family planning providers are a source of primary care for many adolescents, providing preventive health visits, blood pressure screening, BMI screening, testing for sexually transmitted diseases, physical exams, immunizations such as HPV, and referrals for specialty care. Of all clinical visits the SRHP funded in FY19, 20.3% of those visits were made by youth aged less than 20 years, and 87.3% of those visits were made by females.

 

Non-clinical programs that provide preventive services referrals for the youth that they serve include the Massachusetts Pregnant and Parenting Teen Initiative (MPPTI), Personal Responsibility Education Program (PREP), the Adolescent Sexuality Education Program (ASE), and Successful Teens: Relationship, Identity, and Values Education (STRIVE). In FY19, referrals were made to community health centers, MDPH-funded sexual and reproductive health programs, school-based health centers and private providers. 

 

OSHYD also plays a vital role in connecting with HRSA technical assistance centers that support adolescent health and disseminating resources to other MDPH adolescent-related programs. OSHYD actively participates in monthly calls and webinars with the Adolescent and Young Adult Health National Resource Center. In FY19 the MDPH Adolescent Health Coordinator served as the President Elect to the National Network of State Adolescent Health Coordinators. This leadership role allows for communication and collaboration across State Adolescent Health Coordinators in the nation to leverage expertise to address common challenges in meeting the health needs of adolescents, including preventive visits. The State Adolescent Health Coordinator also participated in the AMCHP and HHS Office of Adolescent Health’s annual meeting of State Adolescent Health Coordinators. During this meeting states discussed successes and challenges with youth engagement and how to leverage existing resources to support adolescent wellness. The partnerships with the State Adolescent Health Resource Center and the Adolescent and Young Adult Health National Resource Center are integral to aligning efforts and resources to support healthy adolescents in the Commonwealth.

 

Additional activities to promote equitable access to preventive health care including sexual and reproductive health services

Other MDPH activities to improve access to sexual and reproductive health services that are not specific to the performance measures are discussed below.

 

Office of Sexual Health and Youth Development

In FY19 OSHYD community-based programs continued to use the MA Life Plan tool with young people aged 12-24 years. This tool provides an opportunity for youth workers to facilitate discussions with young people around health and goal setting. The Life Plan tool assists youth to set goals in 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 used motivational interviewing and the Life Plan tool to work with youth toward developing and making progress in youth-driven goals. PYD is considered 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 experimental 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. In FY19 VOICES became an integral component of the STRIVE initiative discussed below. VOICES allows youth who participate in the STRIVE initiative an opportunity to explore topics such as identity, stereotypes, power, advocacy and how they can be a part of change in their communities. In FY19, 273 youth participated in the VOICES curriculum.

 

During FY19 OSHYD also partnered with Sister Song, a national reproductive justice organization, to train over 30 clinical and non-clinical programs on the reproductive justice framework. This training was a fundamental aspect of continuous efforts to support funded providers to integrate reproductive justice practices in service delivery. In addition, over 40 ASE and PREP program staff were trained on strategies for integrating racial justice into sexuality education programming.

 

Key challenges across OSHYD programs include program sustainability, recruitment, retention and how to authentically integrate youth voice into programming. The OSHYD is working 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 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. In order 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. The integration of youth voice and power in OSHYD programmatic services has been a consistent challenge. Current organizational structures do not allow for easy access to and recruitment of youth to be a part of program planning processes. Additional barriers include transportation of youth to meetings at MDPH, a system to compensate youth for their expertise, and a plan for management of the youth leaders.

 

The programs within the OSHYD also engaged in specific activities to address this priority and are described below.

 

Sexual and Reproductive Health Program (SRHP):

In FY19, only 8.3% of female MDPH-eligible clients aged 13-19 years were using long-acting reversible contraception (LARC). Challenges to providing LARC to teens include lack of information among youth; some teens mistakenly think they cannot use LARC because of their age or parity. Clinics also report barriers such as high upfront costs for supplies, and providers may lack awareness about the safety and effectiveness of LARC for teens and training on insertion and removal. In FY19, MassHealth and SRHP co-launched program oversight of two organizations (Upstream and PICCK) funded to provide five-year, statewide comprehensive training and technical assistance on contraceptive counseling and service delivery. Upstream focuses on outpatient care service delivery, with a focus on community health centers, while PICCK (Partners in Contraceptive Choice and Knowledge) targets hospitals and hospital-based clinics. Both organizations sub-specialize in LARC training for clinical staff and address the specialized care required for the adolescent client.

 

SRHP-funded agencies also provided sexual and reproductive health education to adolescents. In FY19, 17 agencies reached 2,500 young people through peer education programs, 3,000 young people through school-based education programs, and 12,000 people through community-based education, many of whom were adolescents. Most of these programs included explicit instruction on all contraceptive methods, including LARC.

 

Adolescent Sexuality Education (ASE):

The 2018 MA teen birth rate was 7.2 births per 1,000 women aged 15-19 years, a 64% decrease from 20.1 in 2008. Racial and ethnic inequities in teen birth rates persist, as rates for non-Hispanic Blacks and Hispanics continue to be two and eight times higher than the rates for Whites, respectively. While these are still unacceptable inequities, they do represent a narrowing of the racial gaps in teen birth rates. 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. In FY19, ASE programs served 5,922 youth with evidence-based or evidence-informed sexuality education curricula in 15 high-need communities.

 

Personal Responsibility Education Program (PREP):

The Personal Responsibility Education Program aims to increase positive reproductive health outcomes and life opportunities for youth in the Commonwealth through sexual health and adulthood preparation education. Through a partnership with the Department of Elementary and Secondary Education (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 founded in PYD principles and program facilitators are expected to be a trusted adult for the youth they serve. During FY19, the PREP partnership with DESE served 2,168 youth in schools and community-based programs. There was an increase in implementation sites for community programs as inter-agency collaborations among youth-serving agencies continue to strengthen each year.

 

Massachusetts Pregnant and Parenting Teen Initiative (MPPTI):

In FY19, 495 participants, including adolescent parents and their children, were served by MPPTI. Seventy-six percent (76%) of non-pregnant participants reported use of a contraceptive method.

 

Successful Teens: Relationship, Identity, and Values Education Initiative (STRIVE):

The goals of the STRIVE Initiative is 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 positive youth development programming. The STRIVE initiative works with youth between the ages of 10-15, reaching them prior to initiation of sexual activity and risk for unintended pregnancy and sexually transmitted infections. In FY19, STRIVE served 325 youth.

 

School Health Services

In FY19, nurses in Essential School Health Services (ESHS) districts provided 33,495 reproductive health interventions, a similar number to interventions performed the prior year. They referred 386 students for follow-up for reproductive concerns, a 57% decrease from the previous year (673). The decrease in referrals is likely caused by school nurses increasingly managing the interventions without the need for referrals. Another factor possibly impacting referral rates are increasing numbers of school health services providing condoms in schools, notably among them Springfield, the third-largest school district in the state. A significant drop in the student birth rate in funded districts was also seen in FY19; 63 students gave birth in FY19, compared to 241 the previous year. Overall, teen birth rates across the country continue to decline, and MA continues to have the lowest teen birth rate in the nation. Access to education and family planning services, as well as supportive services from school nurses, have all contributed to this decline.

 

School-Based Health Centers

SBHC clinicians regularly assess clients for sexual behaviors, including those that would put them at risk for STIs and pregnancy. In FY19, 5,395 clients aged 11 years and older were assessed for sexual risk-taking behaviors at least once at 30 SBHCs serving middle and high schools. When risks were identified, clinicians provided interventions ranging from education/counseling to developing concrete action plans for addressing risk. In communities with disparately high teen birth rates, SBHC clinicians continued to work to implement protocols for ‘clinic collaboratives’ to ensure that young women at risk of becoming pregnant could be sent via warm referral to partnering clinics to obtain effective contraceptive methods, including LARC, as quickly as possible.

 

As a part of routine primary care in SBHCs (and more specifically during reproductive health visits) all students were provided with universal education and anticipatory guidance on healthy relationships. They were also assessed for adolescent relationship abuse and reproductive/sexual coercion. Depending on the nature of the visit, clients were also assessed and counseled for birth control sabotage and pregnancy pressure and coercion.

 

Priority: Promote emotional wellness and social connectedness across the lifespan.

This priority has been discussed previously in the Women’s/Maternal Health and Child Health domains. MDPH also promotes emotional wellness and social connectedness among adolescents, driven by the work of School Based Health Centers, School Health Services, and the MA Pregnant and Parenting Teen Initiative.

 

School Based Health Centers

SBHCs offer comprehensive behavioral health services within schools, where children and adolescents spend most of their time, and are an important model of care for reducing barriers to care. Nationally, mental health concerns are the leading reasons for visits to SBHCs. While students usually present with somatic complaints, SBHC clinicians are skilled in assessing underlying emotional problems. The SBHC model is strengths-based and its clinicians are primarily concerned with promoting the emotional wellness of the students they serve.

 

The SBHC program assesses students on a range of risk and protective factors, including two measures of social connectedness: presence of a trusted adult and school connectedness. In FY19, 65.4% of students aged 11 years and older seen at 30 SBHCs were assessed for the presence of a trusted adult. Providers determined that 96.6% of students assessed had at least one positive trusted adult (a resiliency factor). School connectedness is the belief held by students that adults in the school care about their learning as well as about them as individuals. Extensive research has shown that young people who feel connected to their school are less likely to engage in many risk behaviors including early sexual initiation, alcohol, tobacco and other drug use and violence/gang involvement. In FY19, 60.4% of students 11 years and older were assessed for school connectedness. Providers determined that 96.8% of students assessed responded positively to at least one school connectedness question.

 

While the SBHC program has continually promoted a strengths-based and emotional wellness approach, there has been equal importance given to working with children and youth who exhibit emotional challenges. The behavioral health services provided in SBHCs are divided into three tiers that are similar to the well-respected multi-tier system of support. In FY19, SBHC behavioral health clinicians completed activities in all three tiers.

• Tier 1: Prevention and promotion: This level of service is tailored to school community needs. The school faculty and principal are engaged in identifying priorities, including social emotional skills, school climate, and early recognition of mental health symptoms. The SBHC mental 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 with advisories, student support teams, and individual education plans. The SBHC mental 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.
• Tier 3: Clinical intervention: In students with higher acuity (in which there is substantial clinical functional impairment) the SBHC mental health provider is responsible for providing appropriate referrals. The mental 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.

 

In order to provide more equitable, culturally competent, and developmentally appropriate care in response to youth mental health trends, in FY19 SBHC nurse practitioners received hands-on, interactive training via the Boston Children’s Hospital Leadership Education in Adolescent Health (LEAH) partnership. LEAH’s goals include: 1) develop and improve youth-centered/family-involved, culturally competent care for adolescents through the efforts of interdisciplinary faculty and fellows working in partnership with Title V and 2) work toward improved health status of adolescents, reduced health disparities, improved quality of care, and progress toward Healthy People 2020 objectives through partnerships with health and other agencies, providers, youth, and families. FY19 training topics related to this priority included evaluating mental health, diagnosing anxiety and depression, conversations with adolescents about SSRIs, prescribing antidepressant/anti-anxiety medication therapy, and conducting a suicide assessment.             

 

Recognizing the need for staff to be highly trained to address the needs of clinically high-risk students, the SBHC program also sponsored a full day session in FY19 on responding to sudden, unexpected loss. This topic was identified as a priority by SBHC clinicians in schools where students had died by suicide. The training covered topics such as risk and protective factors for suicide, responding to signs of suicide screening results, the role of the media in promoting suicide contagion, impact for survivors, and postvention tasks. SBHC clinicians expressed a high level of satisfaction with the quality and content of the training, describing higher self-efficacy related to their perceived capacity to respond to suicidal students and in the aftermath of a loss by suicide. They felt the training was especially relevant in the context of serving the clinically high-risk students who were receiving Tier 3 services and were more vulnerable to suffering from complicated grief and potentially being impacted by suicide contagion.

 

In FY19, the SBHC program also responded to a rural community with concerning suicide screening results. In addition to 10 suicide deaths in the region in the past 18 months, 47.7% (n=21) of 7th grade students and 29.3% (n=12) of 10th grade students who were screened for suicide were found to be at risk. MDPH responded immediately by collaborating with the Suicide Prevention Program to develop community linkages aimed at increasing service capacity in this school community. Additionally, SBHC clinicians and a large number of school staff were trained on Psychological First Aid in which participants were presented with an overview of the human stress response and how it affects the choice of interventions used with distressed individuals. The Posttraumatic Stress Management continuum and the core functions of Psychological First Aid were discussed and applied to the situation in this school community.

 

School Health Services

School nurses provide mental health counseling and interventions across all age groups. Nurses conduct an assessment, brief intervention, and plan for further intervention or referral as needed. Mental and behavioral health interventions fall into the following five categories:

• Coping enhancement/reassurance check-in/self-calming (e.g., allowing the student to rest in a quiet room and listen to music or play with stuffed animals)                    
• Stress/anxiety reduction/de-escalation (e.g., teaching stress reduction activities)
• Monitor for self-harm/suicide ideation (e.g., counseling depending on the type of harm)                   
• Social skills support (support provided to students with autism, e.g., teaching activities of daily living or assistance with self-advocacy)                                                                                
• Relationship guidance (e.g., focusing on making and keeping friends in kindergarten and on dating relationships and dating violence concerns in high school)

 

Schools nurses reported 5,390 interventions for relationship guidance, 149,084 interventions for coping enhancement, reassurance check-ins, and self-calming strategies to assist students who feel unsafe in school, and 69,130 interventions for stress/anxiety reduction and de-escalation.  These all represent decreases in the number of interventions compared to the previous year. However, in FY19, school nurses reported a significant increase in the number of interventions for social skills support (48,747) from the previous year (23,447). This may reflect a recent increase in mental health clinicians in schools where nurses are able to act as partners in plans to enhance social skills, rather than delivering direct care.

 

In FY19, there were 3,466 encounters in school districts where nurses monitored K-12 students for self-harm or suicidal ideation. There were 567 calls to emergency medical services for behavioral health issues, and 413 calls to mobile crisis units.  These numbers are similar to the previous year and most of these encounters were related to depression and suicidal ideation in the school setting.

 

Massachusetts Pregnant and Parenting Teen Initiative

MPPTI provides services including support groups and counseling to its participants to support emotional wellness and social connectedness for adolescent parents. This is an important opportunity to connect with this population outside of the school system. In FY19, MPPTI implementation partners directly provided parenting education and resources to 162 participants; healthy relationships education and skills building to 157 participants; housing support to 118 participants; academic support to 160 participants; and assistance with childcare to 136 participants.

 

 

 

[1] Asarnow, Joan Rosenbaum, et al. "An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment." Psychiatric services (2015).

[2] McNiel, Dale E., et al. "Effects of training on suicide risk assessment." Psychiatric Services (2015).

[3] Wintersteen, Matthew B. "Standardized screening for suicidal adolescents in primary care." Pediatrics 125.5 (2010): 938-944.

[4] Wintersteen, Matthew B. "Standardized screening for suicidal adolescents in primary care." Pediatrics 125.5 (2010): 938-944.

 

[5] 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.

[6] 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.