Bullying (FY 2024 Application)

The percent of adolescents, ages 12-17, who are bullied or who bully others (NPM 9) was selected to address Michigan’s priority need to “Create safe and healthy schools and communities that promote human thriving, including physical and mental health supports that address the needs of the whole person.”

A variety of data sources point to why NPM 9, with a focus on the health of LGBTQ+ students, is a good fit for the current five-year cycle. Michigan saw a decline in overall bullying rates of high school students who reported in-school or online bullying from 27.7% in 2019 to 24.2% in 2021 (YRBS). However, LGBT students remain at significantly higher risk of being bullied than their non-LGBT counterparts (40.8% vs 21.3%).

Bullying is strongly associated with adverse mental health outcomes. Michigan students who reported any bullying in the previous year were significantly more likely than students who did not experience bullying to report: feeling sad/hopeless for 2+ weeks in the past month (1.9x as likely); considering suicide in the past year (2.7x as likely); attempting suicide in the past year (2.5x as likely); a suicide attempt requiring medical attention in the past year (3.1x as likely); and engaging in self-harming behaviors (2.4x as likely).

Students who identify as LGBTQ+ disproportionately and inequitably experience the harmful consequences of bullying. Compared with other students who report being bullied, who themselves report higher levels of adverse mental health outcomes, LGBT students are even more likely to report considering and attempting suicide. The 2021 Michigan YRBS found that LGBT students are more likely to report suicidal thoughts (3.5x more likely to consider suicide) and behaviors (4.0x more likely to attempt suicide) than their high school peers.

Multiple data sources point to school often being an unsafe place for LGBTQ+ youth in Michigan. According to the Gay, Lesbian and Straight Education Network’s (GLSEN) 2021 Michigan State Snapshot, 64% LGBTQ+ students experienced at least one form of anti-LGBTQ+ victimization (verbal, online, physical) at school. The State Snapshot also found that only 33% of LGBTQ+ youth had access to a Gender and Sexuality Alliance, or GSA. Only 8% of LGBTQ+ students attend a school with a comprehensive anti-bullying policy. Especially concerning is the finding that 55% of LGBTQ+ students heard school staff make homophobic remarks and 70% heard negative remarks from school staff about someone’s gender expression. Furthermore, when LGBTQ+ survey respondents reported victimization at school only 22% reported that it resulted in effective staff intervention.

The CDC’s 2021 Adolescent Behaviors and Experiences Survey (ABES) illuminates the ways in which COVID-19 impacted young people and especially LGB young people. The survey found that more than 25% of LGB students, as compared to 5% of heterosexual students, attempted suicide in the past year. Being confined to home during the pandemic proved more dangerous for LGB students as 20% reported physical abuse perpetrated by a parent or other adult in their home, compared to 10% of heterosexual students.

While COVID-19 created barriers for LGBTQ+ students to feel safe and supported in school, an additional threat involves the state and nationwide trend of exclusionary legislation and policies. Some school leaders are also becoming wary of implementing LGBTQ+ supportive policies due to political pressure against the work. This backlash against affirming policies and practices harms students and plays a role in creating a stressful environment in which teaching and learning are compromised.

Michigan’s CYSHCN population also experienced bullying at a higher rate, with 57.0% of CYSHCN being bullied compared to 23.8% of general population students in Michigan (2020-2021 National Survey of Children’s Health). During focus groups and listening sessions for the 2020 Title V Needs Assessment, youth and their parents described a need for activities and support groups to address a sense of social segregation and stigma within the community for CYSHCN. In response to the data and feedback, CSHCS utilized $150,000 of Title V funding to implement a bullying prevention initiative within the CYSHCN population to promote peer support and inclusion.

Objective A: By October 2025, 30 secondary schools will implement schoolwide bullying prevention initiatives emphasizing social emotional health (SEH) education and creating safe schools for LGBTQ+ students.

Focus group participants indicated that more progressive policies and innovative strategies for health education are needed to teach children healthy habits and the risks of dangerous health behaviors. Robust health education programs, in which social emotional health (SEH) is foundational, enhances the skills needed to prevent bullying behavior and helps to achieve equitable health outcomes. Addressing this need, efforts will center around bullying prevention through health education in the classroom with added supports for LGBTQ+ students. In FY 2024, Michigan will again select six schools to implement an approach to bullying prevention that includes teaching health education and creating safe schools for all students. All grade levels within selected schools will implement the social and emotional health skills module of the Michigan Model for Health™(MMH) curriculum. School teams will receive extensive training and customized support on creating safe schools for LGBTQ+ students. Schools will also receive training and support for the establishment, growth, and sustainability of Gender and Sexuality Alliance (or Gay-Straight Alliance) student clubs. This whole school approach will help move the needle on all students feeling safe and supported at school. Title V funding, via $5,000 stipends to each school, will fund curriculum implementation; cover costs associated with participation in workshops (sub costs, staff stipends, etc.); and costs to implement strategies related to creating safe and supportive schools for LGBTQ+ youth, including GSA support. Funds will also be used to support the consultants, employed by the Michigan Organization for Adolescent Sexual Health (MOASH), working directly with the school teams, facilitating workshops, and providing customized technical assistance.

The ESM for this NPM will be all classrooms in six selected schools implementing the MMH™ social and emotional health unit/module with at least 80% fidelity. Both the middle and high school modules focus on the development of social skills, including lessons that directly address bullying and cyber-bullying. Additional lessons addressing anti-bullying skills will be added from other curriculum units. Health teachers will complete fidelity lesson logs documenting the implementation of lessons.

The MMH™ is a K-12 comprehensive school health education curriculum that is evidence-based and culturally, linguistically, and age-appropriate. It is recognized by the Collaborative for Academic, Social and Emotional Learning (CASEL). Michigan’s 22 regional School Health Coordinators provide training and technical assistance for the MMH™ and other school health initiatives. They partner with schools on creating safe schools for all students, addressing the needs of LGBTQ+ students, and addressing the role of adults in an inclusive learning environment.

The second strategy involves intensive training and customized technical assistance for a team of staff members from each school focusing on creating safe schools for LGBTQ+ students and implementing schoolwide strategies to improve the school climate. This includes the establishment, growth, and sustainability of a GSA. A series of workshops, along with individualized technical assistance and networking with other schools, builds the skills of educators so they can lead the effort to improve the school climate for all youth, especially those who identify as LGBTQ+. The trainings/workshops, as well as the customized support, are facilitated by skilled consultants who have worked with schools and LGBTQ+ youth in a variety of settings. These consultants, employed by MOASH, work with the Michigan Department of Education (MDE) on the MDE LGBTQ+ Students Project.

The workshop series, offered by the MDE LGBTQ+ Students Project, includes sessions devoted to understanding the identities and experiences of LGBTQ+ students; recognizing and addressing barriers to supporting LGBTQ+ students and families; legal and policy issues; LGBTQ+ youth panels; the power of GSAs; safe, supportive and inclusive classrooms; practical strategies for affirming LGBTQ+ students; school-wide policies and best practices; and accurately reflecting student gender identities in student information systems. Two new sessions address supporting this population in athletics and physical education along with partnering with parents, caregivers, and families. The workshops include youth panels, and the training content is developed with input from youth through youth advisory councils facilitated by MOASH. Drop-in technical assistance sessions are regularly scheduled and open to all interested schools in Michigan.

Research indicates that school policies supportive of LGBTQ+ youth combined with the presence of a GSA help create school environments where not only LGBTQ+ youth experience peer and teacher support, but the entire student body experiences less bullying and a more supportive school environment. Project consultants affiliated with MOASH will provide school teams with training and support specifically related to GSA establishment, growth, and sustainability. MOASH has been helping to build the capacity of GSA clubs in schools across Michigan for years. MOASH has significant expertise in this area and working with youth via youth advisory councils. MOASH will partner with schools to lend expertise in moving through the five stages of GSA development and functioning: Initiation and Organizing, Establishment, Implementation, Recruitment and Participation, and Sustainability. The MOASH annual statewide summit for LGBTQ+ youth is well attended (375 participants, primarily youth, attended in 2022). GSA participants from these schools will be encouraged (and financially supported) to attend.

Partnering with MDE, MOASH, and School Health Coordinators will help schools receive the training and technical assistance needed for schoolwide MMH™ curriculum implementation; that youth voice will be centered; and that school teams will be provided with the training and support needed to create systemic change. The comprehensive and in-depth nature of these strategies, combined with the demonstrated expertise of our partners and the foundation of youth input supports schools in advancing the goal of creating safe and supportive environments for LGBTQ+ students.

Objective B: By October 2025, provide 1,050 schools with guidance on state laws and model policies on bullying prevention with protections for LGBTQ+ youth.

School districts benefit from guidance on Michigan’s laws and policies to better equip staff to appropriately address bullying. Most school staff members understand that it is imperative to intervene when bullying occurs, but surveys show that many feel ill-equipped to do so, resulting in unhelpful or even harmful staff response. Michigan’s Public Act 241 mandates that schools develop a district anti-bullying policy. The law includes multiple components, based on best practices, required to be included in the policy. However, many school districts neither fully understand the law nor fully implement it. Michigan’s State Board of Education (SBE) has a model anti-bullying policy in place to help school districts meet the law. The policy also has components that render it more comprehensive. While Michigan is a local control state—meaning the SBE Model Policy is a recommendation for schools rather than a requirement—the policy helps schools understand what should be included in a comprehensive bullying prevention policy.

For legislation to be effective as a means of decreasing bullying and cyberbullying, it is necessary for schools to adopt (and fully implement) policies. School Health Coordinators will work with their local schools to provide guidance on Michigan law and anti-bullying policies. Project partners will support their work to create awareness and understanding in the education community by facilitating professional development opportunities on the laws in Michigan and why adopting, and fully implementing, the SBE Model Anti-Bullying Policy is an essential component of bullying prevention efforts.

An additional strategy for promoting safe and supportive school environments for ALL students involves extending the learning opportunities on GSAs to school teams and staff members outside of the six project schools. Increasing the number of GSAs will help create school environments where not only LGBTQ+ youth experience peer and teacher support but the entire student body experiences a safe, supportive, and inclusive climate where all students can thrive. Project consultants will provide learning opportunities in a variety of formats: webinars, lunch and learns, workshops, and one-on-one technical assistance on the establishment, growth, and sustainability of GSAs.

Objective C: Explore bullying prevention campaigns for CSHCS and determine goals for bullying prevention initiatives in Michigan.

The Family Leadership Network (FLN), staffed by the CSHCS Family Center and the F2F, is comprised of parents of CYSHCN representing each of Michigan’s 10 Prosperity Regions. CSHCS utilizes feedback and participation from the FLN to keep family voices at the center of program decisions. The first strategy for this objective is to replicate a focus group with the FLN to document changes in the perception and occurrence of bullying for CYSHCN. The focus group is held at the annual meeting for FLN. Focus group results will inform changes in CSHCS bullying prevention activities.

The second strategy for this objective is to continue implementing the CSHCS Bullying Prevention small grants program. During focus groups with the FLN, parents of CYSHCN identified peer-to-peer support groups as one of the most helpful strategies to improve bullying for their children. In response to this finding, CSHCS launched the Bullying Prevention small grants opportunity in FY 2020. The Family Center co-coordinates this activity. Grants of up to $10,000 are available to schools and school districts to create or expand a peer-to-peer support program within their school. Peer-to-peer programs are evidenced-based and result in decreased anxiety, increased sense of belonging and confidence, increased level of engagement in the school community, and friendships that extend beyond the school building. CSHCS will continue to partner with the Statewide Autism Resources and Training (START) project to provide resources and support to grantees through monthly webinars and an annual in-person meeting. In FY 2024, CSHCS will evaluate the first three years of the grant program to identify additional areas to outreach with information about the grant, adapt the application to meet the needs of grantees, and identify data metrics to measure the success of the initiative. This information will be shared with the CSHCS Advisory Committee and other stakeholders.

In May 2021, some states from HHS Region IV (AL, FL, GA, NC, TN) and Region V (IN, MI, MN, OH, WI) expressed interest in creating a workgroup to share strategies for bullying prevention among CYSHCN. The Maternal Child Health Bureau facilitated quarterly meetings to discuss topics such as data capacity, youth advisory councils, and policies. The third strategy for this objective is for CSHCS to continue serving on the Region IV/V workgroup.

Immunizations – Adolescents (FY 2024 Application)

Based on the 2020 Title V five-year needs assessment, the state performance measure (SPM) created in 2015 was retained, which is the “Percent of adolescents 13 to 18 years of age who have received a completed series Human Papilloma Virus (HPV) vaccine.” The HPV vaccine has the potential to save thousands of lives from HPV-related cancers. While Michigan has made progress increasing the timely uptake of HPV vaccination for adolescents, more progress is needed. Further, the COVID-19 pandemic has significantly limited efforts to focus on improving HPV vaccination coverage, due to competing priorities within provider offices.

Data from the Michigan Care Improvement Registry (MCIR), as of December 2022, show that the HPV vaccine completion rate for 13-17-year-old females is 45.3% while the rate for 13-17-year-old males is 43.2%. One goal of the MDHHS Immunization Program is to encourage HPV vaccination at 11-12 years of age when it is routinely recommended, although it can be administered as young as 9 years of age. Further, data from the MCIR as of January 2023 show that only 32.7% of adolescents have received a completed HPV series by 13 years of age. This is short of the desired immunization level since it is routinely recommended at this younger age.

As seen in Image 1, HPV vaccination remains the lowest among all adolescent series vaccines, however, the disparity between males and females has decreased.

Image 1: Adolescent Vaccination Coverage, by Vaccine, 13-17 Years

Due to the impact of COVID-19 on all adolescent vaccinations, the Immunization Program plans to target all recommended vaccines for adolescents in FY 2024, with a focus on HPV vaccine. The pandemic has illustrated how diseases can severely impact the health of communities. Vaccines are developed to protect the health and well-being of individuals and minimize community spread. On-time vaccination of all recommended vaccines will lead to healthier Michigan adolescents.

As discussed in the SPM 2 Children’s Immunization narrative, the Division of Immunization operates the MCIR information system. MCIR data as of December 2022 show that 72.8% of adolescents 13-18 years of age who reside in Michigan have received the recommended 1:3:2:3:2:1 adolescent vaccine series. The 1:3:2:3:2:1 vaccine series represents 1 dose of Tdap vaccine, 3 polio doses vaccine, 2 doses of MMR vaccine, 3 doses of hepatitis B vaccine, 2 doses of varicella vaccine, and 1 dose of meningococcal vaccine. When a complete series of HPV vaccine is added to the same series, the rate drops to 42.8%. Image 2 indicates that the adolescent vaccine series 1:3:2:3:2:1:3 falls below the desired protection for all recommended adolescent vaccines.

Image 2: 13 through 17 years adolescent vaccine series coverage: 1:3:2:3:2:1:3 by MCIR Region, March 2020 – December 2022, MCIR

Specifically, two other adolescent-focused vaccines are concerning to the Immunization Program: influenza and meningitis B (MenB) vaccine. As illustrated by the COVID-19 pandemic, respiratory illnesses such as influenza are highly communicable and can be deadly. Every year Michigan’s vaccination rates for influenza are sub-optimal and leave the community susceptible to disease. According to MCIR, and data made available at www.michigan.gov/FLU, for the 2021-2022 influenza season the vaccination coverage for all Michigan residents was 30.48%. Current season estimates for the 2022-2023 influenza season indicate a statewide vaccination coverage of 28.79%. In addition, as of December 2022, adolescent vaccination coverage for 1+ MenB for adolescents 16-18 years was 25.9% (www.michigan.gov/immunize). It is critical to assess for all recommended vaccines and to collectively improve all adolescent vaccination rates.

The Immunization Program plans to use Title V funds to support program work in improving HPV vaccination uptake and working with internal and external partners to improve influenza and meningitis B vaccination rates as illustrated in the activities below. Receiving all recommended vaccines, on-time, protects the health and well-being of Michigan adolescents and their communities.

Objective A: By 2025, increase the percentage of adolescents who have completed the HPV series to 64%.

The Forces of Change assessment in the 2020 needs assessment revealed that for some racial and ethnic groups, cultural barriers (such as historical trauma, language, or norms) may impact accessing mainstream health care. The System Capacity assessment also indicated that the MCH system has an opportunity for improvement in working with providers to establish trust with patients, especially with families in minority populations. It is important to address these concerns related to health equity and access to care, including vaccinations. The Michigan Immunization Program will assess possible strategies for engaging families and communities in the vaccine dialogue. Seeking expertise from families and consumers can help MCH systems and providers identify barriers to vaccine uptake and create vaccination messages that are culturally sensitive and linguistically appropriate, which may include different messages targeted to different population groups or geographical regions.

Using this information, the Immunization Program will update current HPV materials to reflect up-to-date vaccine changes and effective communication strategies to promote vaccination and make the materials available for providers. The Program will work with the MDHHS Vaccine Equity Strategy Group so that materials are culturally and linguistically inclusive. The Program will also provide updated translations of HPV materials to promote a more equitable approach in addressing HPV vaccine hesitancy. Providers and the public will be able to review these materials on the MDHHS Immunization website, www.michigan.gov/Immunize, and order materials for free at the MDHHS Clearinghouse, www.healthymichigan.com.

The COVID-19 pandemic has contributed to an increase in vaccine hesitancy for all vaccines. The Program will work with national partners, including Centers for Disease Control and Prevention, as well as internal and external local partners to promote vaccine confidence among parents of this age group and adolescents themselves through resources, media, and presentations. MDHHS continues to be an active member in the Michigan HPV Alliance which includes partners from health systems, American Cancer Society, Karmanos Cancer Institute, local public health, and universities. The goal of this alliance to work collaboratively among the public and private sector to promote timely HPV vaccination, with the plan of hosting annual HPV Summits to provide education on HPV vaccine and HPV disease. While many parents choose to vaccinate their adolescents according to the recommended schedule, some parents may have questions about vaccines and getting answers they can trust may be hard. It is vital that the Program works with partners to address any questions or concerns parents, or adolescents may have about vaccinations and to promote vaccine confidence among this group.

Further, the Program has made it routine to provide data and information to local health department clinic staff on coverage levels for patients in their immunization clinics and coverage levels at the county population level with the Michigan Immunization Report Cards. The Immunization Report Cards are posted on the MDHHS website at www.michigan.gov/Immunize and provide population-based immunization coverage levels for each county with rankings compared to other counties in Michigan.

The Michigan Immunization Program will analyze the MCIR data to identify disparities between the adolescent vaccines and to monitor the uptake of HPV vaccine and the adolescent vaccine series. The Program will emphasize that providers who see adolescents for vaccine visits need to assure they are strongly recommending all recommended vaccines and not missing an opportunity to administer the HPV vaccine.

Finally, the Division plans to work more directly with the Alliance for Immunization in Michigan (AIM) Coalition to better engage families and communities through education and improvements to the aimtoolkit.org website. AIM is a partnership of public and private sector organizations which was formed in 1994 to focus on a broad spectrum of immunization issues in Michigan. AIM’s mission is to promote immunizations across the lifespan through a coalition of health care professionals and agencies. The AIM coalition continues its focus on improving all facets of immunization services in Michigan.

As a result of the COVID-19 pandemic, the AIM coalition was essentially put on hold. As immunization rates continue to drop statewide, it is more important than ever to re-ignite this coalition and work collaboratively with private and public stakeholders to address vaccine hesitancy and improve vaccine uptake. AIM’s website, aimtoolkit.org, provides education and promotes vaccination for both healthcare professionals and individuals and families. Utilizing the Division’s partnership with the AIM coalition will better connect the Division’s resources directly with consumers.

Objective B: Emphasize routine assessment of all recommended vaccines for adolescents to increase influenza and meningococcal vaccine rates by 5% among this age group.

As discussed above, due to the impact of COVID-19 on all adolescent vaccinations, the Immunization Program plans to target all recommended vaccines for adolescents, in addition to HPV vaccine. The pandemic has illustrated how diseases, especially respiratory illnesses, can be deadly and wreak havoc on the health of communities. Vaccines are developed to protect the health and well-being of individuals and to minimize community spread. On-time vaccination of all recommended vaccines will lead to healthier Michigan adolescents.

In FY 2024, the Immunization Program will work with internal and external stakeholders on a statewide influenza campaign to improve influenza vaccination coverage among all ages, including adolescents. Every year Michigan’s vaccination rates for influenza are sub-optimal and leave the community susceptible to disease. According to MCIR, and data made available at www.michigan.gov/FLU, for the 2021-2022 influenza season the vaccination coverage for all Michigan adolescents, 13-17 years of age, was 12.81%, below the statewide average of 30.48%. Current season estimates for the 2022-2023 influenza season indicate a statewide vaccination coverage of 11.17% among this age group, as illustrated in Image 3. This is extremely concerning to the Immunization Program and emphasizes that now is the time to target influenza vaccine, in addition to offering the COVID-19 vaccine, among this age group.

Image 3: Influenza Dashboard, Seasonal Influenza Vaccination Coverage, 13-17 Years

The COVID-19 pandemic has significantly impacted immunization rates at every age. The Immunization Program will produce a COVID-19 Impact Report to illustrate the impact the pandemic has had on childhood and adolescent immunization rates, while encouraging providers to catch Michigan children back up on recommended vaccines. The Immunization Program will continue to make the data available to local health departments so they can be better informed on areas for improvement as they work with immunization providers in their jurisdiction.

Using the data from this report, the Program will generate and distribute a letter to Michigan healthcare providers highlighting the importance of catching children and adolescents back up on routine vaccines that they may have missed due to the COVID-19 pandemic. The Program will work collaboratively with organizations such as Michigan Chapter of the American Academy of Pediatrics, and the Michigan Academy of Family Physicians to generate, distribute and promote this letter among healthcare personnel in the state.

Various studies and Michigan’s experience indicate that clinical staff tend to overestimate the immunization rates for their practice. Offering vaccination coverage feedback during annual quality improvement visits, based on MCIR data, is insightful to provider offices and enables staff to consider recommendations to improve how vaccines are promoted and administered. Simple changes could be ensuring that vaccines are assessed and offered at every visit. The Immunization Program will work with local public health to offer quality improvement visits to providers, emphasizing on-time HPV vaccination, and provide a comprehensive assessment of immunization rates and recommendations for practice improvements.

Finally, the Program will work with external stakeholders to conduct targeted outreach to improve meningitis B vaccination rates for adolescents 16 through 18 years of age. Although it is uncommon, meningitis B (MenB) is a serious infection caused by the bacterium Neisseria meningitidis group B, which can cause an infection of the membrane that surrounds the brain and spinal cord. It can also cause septicemia, a serious infection of the bloodstream. Although most people recover, even with appropriate treatment, up to 1 in 10 patients will die, sometimes within 24 hours after the onset of symptoms. Further, up to 1 in 5 survivors of meningitis will experience long-term consequences including hearing loss, skin scarring, neurological problems, or limb loss.

While most people are familiar with MenACWY vaccine, many are unaware that there are two meningitis vaccines needed to protect adolescents from all serotypes of meningitis. The Emily Stillman Foundation was founded by a Michigan mother who lost her daughter from meningitis B in 2013, 36 hours after being admitted to the hospital. The Emily Stillman Foundation has combined forces with the Meningitis B Action Project to raise awareness for meningitis B vaccine. The Immunization Program plans to work with these organizations to conduct targeted outreach to Michigan adolescents and their parents to improve meningitis B vaccination rates. As of December 2022, adolescent vaccination coverage for 1+ meningitis B for adolescents 16-18 years was only 25.9% (www.michigan.gov/immunize). In comparison, the vaccination rate for 1+ MenACWY for adolescents 13-17 years of age was 76.7%.

It is important to assess for all recommended vaccines and to collectively improve all adolescent vaccination rates. Michigan plans to use statewide quarterly immunization report cards to monitor vaccination uptake for HPV vaccine, adolescent series (1:3:2:3:2:1:3) vaccination coverage, 1+MenB and 1+ Flu (6 months – 17 years) to assess the impact of these strategies.