Overview and context of population domain
Adolescence is a critical period for physical, mental, and emotional development. Reducing risk exposure and adapting health-promoting behaviors at this transitional stage can have life-long impacts on health outcomes. At the same time, experiencing trauma or adopting unhealthy behaviors during adolescence may have negative impacts on long-term well-being1. While certain adolescent health indicators have improved in Louisiana, significant concerns remain for safety, as well as social-emotional and behavioral support.
Adverse experiences in childhood can impact the mental and physical well-being of individuals throughout the life course. Louisiana’s Adverse Childhood Experiences
(ACE) rate is one of the highest in the nation. Nearly 20% of Louisiana children age 0 -17 have experienced two or more ACEs, compared to 14.8% nationally.2 Suicide is another concern for children and young adults. According to the American Foundation for Suicide Prevention, suicide was the 3rd leading cause of death for Louisianans aged 10-24 and 25-34 in 2020.3 Multiple risk factors related to suicidal thoughts and behaviors are on the rise across the state. Depression rates of Louisiana adolescents age 18-24 are increasing steadily.4 Environmental stressors including community and domestic violence, hurricanes and other natural disasters, and the ongoing stresses associated with the COVID-19 pandemic all contribute to this increase in mental health issues.
Adolescent health priority needs and performance measures
The 2020 Needs Assessment priority ranking process underscored the importance of improving adolescent health and reducing child injury. The 2021-2025 State Action Plan strategies for this population domain are aligned with the following population priorities:
To strengthen the systems and supports that shape these factors, Louisiana Title V continues to execute strategies that align with the following systems priorities:
- Ensure Title V strategies are outcomes-focused and rooted in essential public health services
- Partner with families, youth, and communities at all levels of systems change.
Throughout the FFY 2021-2025 strategic period, Title V investments in the adolescent health population domain in Louisiana will contribute to improvement of the following outcomes at both state and national levels:
- Child Mortality rate, ages 1 through 9, per 100,000 (NOM 15)
- Adolescent mortality rate ages 10 through 19, per 100,000 (NOM 16.1)
- Adolescent motor vehicle mortality rate, ages 15 through 19, per 100,000 (NOM 16.2)
- Adolescent suicide rate, ages 15 through 19, per 100,000 (NOM 16.3)
Recognizing the evidence of the strong linkages between the desired outcomes and interventions promoting adolescent injury prevention, Title V supported programs in Louisiana delivered strategies to improve the following performance measure(s):
- Rate of hospitalization for non-fatal injury per 100,000 adolescents, ages 10 through 19 (NPM 7.2)
The strategies implemented to promote adolescent injury prevention are evidence-based, and adapted to the unique context of the state of Louisiana. In FFY2022, LA Title V aimed to achieve the following objective(s) in relation to the adolescent health population domain:
- By September 2022, review findings from the Rapid Assessment for Adolescent Preventive Services (RAAPS) tool pilot and evaluate feasibility for scaling use of the tool in all Title V-supported school-based health centers
- By January 2022 and annually thereafter, publish an annual report on injury and violence in Louisiana
- Facilitate four Adolescent School Health Initiative Coordinating Council meetings annually
Summary of adolescent health interventions supported by Title V in FFY2022
Population Priority Needs: Improve adolescent mental health and reduce child injury and violence
The Title V State Action Planning sessions that occurred during the 2020 Needs Assessment provided BFH staff a chance to reflect on the state of adolescent mental health care in Louisiana. Searching for improvement opportunities, participants identified systemic gaps and cultural barriers to optimal behavioral health provision. Identified challenges included a persistent stigma associated with seeking help for mental health concerns and a tendency for public health agencies to set strategic priorities without consulting focus populations (e.g., youth in Louisiana), thereby limiting program uptake and impact. BFH staff also recognized the need to refine the Bureau's role in improving mental health outcomes, acknowledging that other organizations may be better positioned to reach priority populations. To this end, participants considered how BFH might support partner agencies already working to improve adolescent mental health. Similar themes emerged from the State Action Planning workgroup that focused on reducing child injury and violence. While the specific objectives in each workgroup varied, both workgroups elevated issues of consumer engagement, alignment of messaging, and complementing existing efforts as the basis of their proposed Title V strategies.
Over the past several years, BFH has significantly strengthened its injury prevention portfolio and capacity and is now positioned as the leader of the state’s injury and violence prevention efforts. Historically, Title V had funded the bulk of BFH’s injury prevention work; however, since the 2016-2020 grant cycle, BFH secured numerous discretionary grant awards to expand its injury prevention capacity. BFH’s injury prevention programs and initiatives are now largely funded through competitive federal grants, and the concurrent action planning processes clarified that Title V is currently best suited to play an active supportive, rather than leading, role in most of the Bureau’s injury and violence prevention efforts.
Actively support implementation of the State Injury Prevention Strategic Action Plan strategies addressing shared or related priorities: Concurrent with the Title V State Action Planning process, the BFH Injury program utilized the Centers for Disease Control and Prevention (CDC) Core State Violence and Injury Prevention Program (SVIPP) funding to spearhead the development of a five-year state Injury Prevention Strategic Action Plan with the aim of galvanizing agencies and resources into a comprehensive and coordinated effort to prevent injuries and violence across the state. The plan focuses on the connections between and causes of different types of injuries (shared risk and protective factors), evidence-based strategies already being implemented around the state, and existing and new critical priority areas for intervention and prevention. The plan also considers how interventions affect change at the individual, relationship, community, and societal levels to ensure maximum reach and impact.
While the Title V and Injury Prevention assessments and plans were developed separately and under different directives, there was significant overlap in the identified priorities and collaboration throughout the planning processes of each grant. The leader and coordinator of the State Injury Strategic Action Plan participated in the Title V planning sessions, and the Title V strategy manager and Title V coordinator actively participated in the injury prevention planning sessions. With a mutual upstream focus on shared risk and protective factors, both plans contained similar strategies related to consumer and stakeholder engagement, alignment of BFH and partner efforts, and strategic communications rooted in market research. In FFY2022, the Title V and Injury team continued to meet and identify opportunities for collaborative implementation of strategies.
Participate in third cohort of the Child Safety Learning Collaborative (CSLC) and support implementation of hospital-based and community interventions for Suicide and Self-Harm Prevention (SSHP): Since 2019, BFH has participated in the Child Safety Learning Collaborative (CSLC), an initiative jointly sponsored by the Maternal and Child Health Bureau (MCHB) and the Children’s Safety Network that aims to reduce fatal and serious injuries among infants, children, and adolescents. The first cohort ran from November 2018 - April 2020, and the second cohort ran from May 2020 - October 2021. The third and final cohort was November 2021 - April 2023.
While the CSLC team previously focused on buildling hospital emergency department capacities to screen and identify children and youth at risk of self harm, in FFY2021 the CSLC team shifted focus and began partnering with local agencies, including The Family Tree Jacob Crouch Suicide Prevention Services, to offer evidence-based gatekeeper trainings across Louisiana. In FFY2022, Family Tree trained over 250 people including mental health professionals, educators, child welfare professionals, and others.
The CSLC team also partnered with LivingWorks Start program, a 90-minute self-directed suicide prevention training that teaches trainees to recognize when someone is thinking about suicide and connect them to help and support. Through this training, professionals with busy schedules can complete the training in their own time. The training was offered to professionals from the Office of Aging and Adult Services, the Department of Children and Family Services and extended foster parents, and school-based health centers. Over 80 people participated in LivingWorks Start.
Support implementation of Comprehensive Suicide Prevention (CSP) program: In September 2021, BFH was awarded the CDC Comprehensive Suicide Prevention grant. This project focuses primarily on reducing and preventing suicide among youth and veterans. The BFH Injury team built on the partnerships and work resulting from the CSLC. Beginning in September 2022, the Emergency Department Surveillance of Nonfatal Suicide-Related Outcomes (ED-SNSRO) program was rolled into the CSP program to align suicide data tracking and to inform prevention efforts.
Build community awareness around Adverse Childhood Experiences (ACEs), trauma, and resilience science:
ACE Educator program: Research has shown that many ACEs are associated with an increased population risk for health and social problems such as injury and violence. Even if violence, substance use or mental health issues are only present prior to conception, traumatic experiences can still have negative implications for a woman and her future children. Research shows that child behavioral health problems are linked to higher Adverse Childhood Experiences (ACEs) scores by their parents, particularly their mothers5. Social service professionals across the country have leveraged their ACEs awareness to create innovative, trauma-informed programs and approaches. Throughout the FFY 2016-2020 block grant cycle, Title V funded a statewide ACE Educator program to build community awareness around ACEs, trauma, and resilience science. The program trains small cohorts of volunteers to become ACE Educators. Once trained, these educators offer no-cost presentations to agencies, organizations, and community groups across Louisiana.
In FFY2022, the ACE Educator program trained a total of 3,901 professionals from a diverse range of sectors. Following significant staffing changes in FFY2021, the ACE Educator program developed new training materials including tips and best practices for presenting on ACEs, as well as additional training modules for Trauma-Informed Education, Parenting and ACEs, and General Approaches to Trauma-Informed Care. A virtual option for the Trauma-Informed Education module was developed to meet Louisiana Department of Education training requirements for teachers and other school personnel. Efforts were made to re-engage with volunteer educators, and analyses were conducted to determine which regions and parishes were most in-need of ACE cohorts. These analyses used chronic disease burden as a proxy for ACEs burden, and found that the highest ACEs burden was located primarily in rural areas with very few ACE Educators. This data was analyzed and an internal report was published in September 2022. The ACE Educator Program is developing opportunities to promote cohort training for volunteer ACE Educators throughout these rural areas.
Trauma & resilience strategy: In FFY2020, Title V invested funds to develop a new position to support state- and local-level efforts to integrate trauma-informed strategies beyond ACEs training. The trauma & resilience strategy lead (TRSL) coordinates BFH’s efforts to develop strategic partnerships in state- and local-level systems to support integration of trauma-informed programming, policies, and protocols in settings impacting vulnerable youth and their families. The TRSL also provides support for state- and local- level efforts building cross-system infrastructure, integrated service delivery systems, and protective community environments that can reduce the prevalence of ACEs, trauma, and inequity.
In 2021, the TRSL provided support for Whole Health Louisiana, a coordinated effort spearheaded by First Lady Donna Edwards’ Louisiana First Foundation to develop a shared framework and state trauma-informed plan for child- and family-serving entities across the state.The TRSL worked with the Office of the First Lady and a consultant team to conduct a discovery process to identify existing resources, deficits and attitudes regarding trauma-informed practices in the state. The discovery process took place from September 2021 - August 2022 and gathered input from over 800 experts, advocates and community members. The discovery process culminated in the publication of the Whole Health Louisiana Statewide ACEs Discovery Report.
Rape prevention and education: Throughout the FFY 2016-2020 block grant cycle, BFH continued to oversee the CDC-funded Rape Prevention and Education (RPE) program. The RPE program works in collaboration with the Louisiana Foundation Against Sexual Assault (LaFASA) and their partners to implement comprehensive, evidence-based prevention strategies in 27 parishes. The RPE program delivers school-based primary prevention programs to educate youth about healthy relationships, as well as training for middle school to college-age students on how to safely intervene when they witness someone engaging in unhealthy behaviors. The RPE program also works with communities to implement social norms approaches that promote safe, stable and nurturing relationships and environments.
In FFY2022, the CDC encouraged grantees to begin prioritizing health equity as a fundamental part of programming. Louisiana RPE leadership contracted with Trepwise to conduct a community-centered discovery process to provide insights on health equity in rape prevention. In addition, the local prevention coordinators used the virtual Community of Practice meetings to present strategies listed in a CDC funded publication, A Health Equity Approach to Preventing Sexual Violence. The presentations led to rich conversations regarding how to infuse health equity in prevention work.
Support school-based health centers (SBHCs) with piloting a standardized validated risk screening tool that supports professionals in addressing the risk behaviors impacting health, well-being, and academic success in youth: Louisiana Title V strategies to improve adolescent health include improving the quality, relevance, and uptake of available services at school-based health centers (SBHCs) affiliated with the OPH Adolescent School Health program (ASHP). The legislatively-mandated charge of ASHP is to “facilitate and encourage the development of comprehensive health centers in Louisiana public schools.” Title V funds staff to manage ASHP and facilitates evidence-based quality improvement in Louisiana SBHCs by providing informational resources, technical assistance, strategic direction, and contract monitoring.
OPH affiliated SBHCs provide medical and behavioral health services and are charged with conducting risk screenings through use of sponsor-selected risk screening tools. In September 2018, ASHP offered each SBHC the opportunity to participate in a pilot study of Rapid Adolescent Prevention Screening (RAAPS), a validated risk screening tool. RAAPS is completed via a computer or tablet and allows programs to run analyses and generate reports to identify top risk behaviors and supports collaboration with partnering agencies to reduce risk behaviors.
Five SBHCs participated in the pilot and an additional three SBHCs have implemented RAAPs since the pilot’s end. In FFY2022, eight OPH-affiliated SBHCs used the RAAPS to screen 1,315 students. The majority of students screened (54%) were between 12 and 15 years of age. Screenings were conducted by both medical and behavioral health providers. Programs shared information regarding the top five risk behaviors evident in the screening results with school administrators. A summary of risk factors identified by RAAPs was provided in the Louisiana Adolescent School Health Initiative Annual Report.
ASHP continued to work with SBHC staff on data analysis and how to use RAAPS data to inform their practices. In FFY2022, the ASHP program coordinator continued to facilitate quarterly quality improvement (QI) meetings. The QI quarterly teams were developed based on their selected QI topic rather than by their respective sponsoring agencies. The program coordinator continued to provide individual and group support to the QI champions and SBHC teams. At the conclusion of FFY2022, QI champions reported a deeper understanding of the QI process and also expressed satisfaction with the process. Some QI champions shared that initially they found the QI process to be “just one more task” but as they saw changes in their processes that resulted in greater efficiency and outcomes they became invested in the process.
In addition to the support provided for QI through the QI quarterly meetings, ASHP also resumed site monitoring visits in FFY2022. The program monitor developed a site assessment tool that extended beyond a checklist of activities. SBHC staff were interviewed about their processes used to provide physical and behavioral health services. In addition to SBHC staff interviews, school administration, school nurse, school counselor and students were interviewed about their experiences with the SBHC. During the site visit, ASHP provided suggestions and identified potential QI projects.
System Priority Need: Ensure Title V strategies are outcomes-focused and rooted in essential public health services
Investigate and effectively communicate trends and factors related to injury hospitalizations and deaths:
Mortality and injury surveillance: Historically, Louisiana Title V’s primary investment in addressing youth suicide has been through the Louisiana Child Death Review (CDR). As described in other domain narratives, the CDR consists of state and local panels that meet to review unexpected deaths of children under age 15, identify risk factors, and provide recommendations for preventive action. Beginning in FFY2019, a specific section in the annual CDR report was included to bring extra attention to child deaths by suicide. According to the most recent CDR report, during 2018-2020 30 children under the age of 15 years old died from suicide in Louisiana and 43% of those deaths were completed using firearms.
Although CDR does not review deaths among adolescents 15 years and older, suicide fatalities for individuals of all ages are included in the CDC-funded National Violent Death Reporting System (NVDRS). BFH has participated in NVDRS since 2016 and began collecting statewide data in January 2018. Collection of NVDRS data enables enhanced monitoring of trends among suicides, as well as contributing factors for these fatalities among older adolescents.
In 2019, BFH partnered with the OPH Infectious Disease Epidemiology (ID Epi) program on a CDC-funded ED-SNSRO project to expand surveillance to include non-fatal suicide attempts as well as suicidal ideation. As of September 2022, the ED-SNSRO project was rolled into the current CDC Comprehensive Suicide Prevention program also held by BFH. In FFY2022, the team surveyed key suicide prevention partners to determine what data would be most useful to them and in what preferred formats. Since fatality data can be delayed by several years, partners identified the importance of assessing near-time suicide ideation and attempt data by demographics and region. The communications specialist and injury epidemiologist worked with a Tableau expert from the Office of Technology Services to develop a public-facing data dashboard that aligned with partners’ interests by utilizing syndromic surveillance data. The interactive data dashboard gives partners the ability to access and track nonfatal suicide-related trends over time and in their regions.
Supported state Child Death Review (CDR) panel: Since FFY2019, the state CDR panel has made safe firearm storage a priority focus area and created a workgroup to address and promote safe firearm storage to prevent child deaths. Title V-funded communications specialists and other Title V staff supported the CDR Firearm Safe Storage workgroup with the development of a social norms campaign targeting Louisiana gun owners with children who live in or visit their homes and store their firearms unlocked or otherwise unsecured. In FFY2020, the CDR Firearm Safe Storage workgroup partnered with the Every Town for Gun Safety’s national Be SMART campaign to create Louisiana-specific social marketing materials to help parents and other adults normalize conversations about gun safety and take responsible actions that can prevent child gun deaths and injuries. In FFY2021, BFH conducted audience testing of the draft materials with Louisiana gun owners and worked with the workgroup and Be SMART to adjust the materials in response to the audience feedback. In FFY2022, State CDR received funding from Louisiana Children’s Trust Fund in collaboration with the Louisiana Chapter of the American Academy of Pediatrics to print the materials for distribution. State and local CDR partners have actively distributed these materials in their communities. In FFY2022, 17,508 materials (posters, palm cards, and brochures) were distributed. Key audiences that received materials include gun retailers and ranges, faith-based organizations, law enforcement, childcare providers, pediatrician offices, and local governmental agencies.
Injury-Free Louisiana (IFLA): One of the first shared risk and protective factors (SRPF) collaborative initiatives spearheaded by BFH was Injury-Free Louisiana (IFLA). IFLA is a team of partners that works to address the common underlying factors influencing multiple forms of injury affecting Louisiana families and communities. IFLA facilitates shared learning opportunities through webinars and training and offers peer-to-peer support among organizations who work in different injury areas. Participants usually include law enforcement, sexual violence and domestic abuse prevention agencies, behavioral health practitioners, child welfare, mangaged care organizations, social services, and other nonprofit organizations. IFLA trains this workforce through an interactive, four-day training academy that increases knowledge of SRPF approaches and develops skills in primary prevention, program planning and implementation, and evaluating evidence-based strategies to prevent injury among diverse populations.
To support further growth of IFLA and the growing portfolio of injury prevention efforts, BFH partnered with LDH Bureau of Health Informatics (BHI) on their CDC-funded Overdose Data to Action (OD2A) Initiative. Through this new collaboration, BFH hired a designated IFLA coordinator and expanded the focus to include substance misuse and opioid overdose prevention. IFLA teams selected various SRPFs to address within their communities, including community support and connectedness, connections to caring adults, coordination of resources and services, and addressing cultural norms that support aggression.
Since partnering with OD2A and hiring the IFLA coordinator in 2020, IFLA facilitated an in-person IFLA Academy held in Baton Rouge and a webinar series focused on primary prevention and connections between ACEs, suicide, and overdose. The in-person Academy included fifteen participants, and the webinar series had over 150 participants. IFLA also created contracts with local agencies and IFLA participants so that attendees can hear presentations and have discussions with injury and violence prevention subject matter experts and past IFLA participants. IFLA will host one more in-person Academy by August 2023. There will also be a formal program evaluation to determine program outcomes since the inception of IFLA Academy.
System Priority Need: Partner with families, youth, and communities at all levels of systems change
Support the Adolescent School Health Initiative (ASHI) coordinating council: The Adolescent Health Initiative requires the Office of Public Health to convene and participate in an intergovernmental coordinating council composed of representatives from the departments of education, children and family services, health and other governmental entities or programs related to health services. The charge of the council is to assist in implementation, oversight and funding assistance for health centers in schools. Following the initial meeting in June 2021, two additional meetings were held (December 8, 2021 and March 9, 2022). In March 2022, it was determined that the legislation mandating the council was vague and ASHP began working with the BFH Policy and Legislative team to seek clarity on the legislation and to identify membership and meeting frequency.
To Top