Bullying (FY 2021 Application)

The percent of adolescents, ages 12-17, who are bullied or who bully others (NPM 9) was selected to address the 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.” Michigan’s needs assessment data points to multiple reasons why NPM 9 is a good fit for efforts over the next five-year cycle.

Needs assessment data for Michigan strongly support this selection. During adolescent focus groups and listening sessions, participants indicated that bullying is a recurring issue across Michigan. Students in Michigan schools experience bullying at an alarming rate. Michigan’s 2017 YRBS data indicate that the rate of high school students who experienced bullying in the past 12 months remained steady at 29.6% but for some subsets this number has increased. And with 19.6% of high school students reporting being electronically bullied in the past 12 months, Michigan is above the national average of 14.9% for cyber-bullying.

Additionally, the mental health needs of adolescents are not being met. The 2017 YRBS results showed a 43% increase since 2011 in students reporting sad or hopeless feelings for two weeks or more. The link between bullying and suicide has also illuminated the need to recognize the damage that bullying inflicts. A marked increase was found in the percentage of Michigan high school students who report considering suicide (15.7% in 2011 to 21.3% in 2017). Further, the mortality rate per 100,000 young people ages 15-19 years has jumped an alarming 34% since 2013. Because bullying can lead to suicidal ideation, it is imperative that Michigan addresses this need through more robust bullying prevention strategies.

One subset of the adolescent population experiencing the harmful consequences of bullying is students who identify as LGBTQ. The percentage of high school students who identify as LGBTQ or have had same-sex sexual contact (2017 YRBS) has steadily increased from 13.6% in 2013, when this question was added to the survey, to 29.5% in 2017, an increase of 53%. The YRBS 2017 data further indicate that LGBTQ adolescents are more likely to report two or more ACEs, more likely to consider or attempt suicide, try illicit drugs and engage in high-risk sexual behavior. Focus groups and listening sessions in Michigan found that LGBTQ adolescents struggle with anxiety and depression that is tied to their experiences with peers, families and community members. This population of young people also reported not feeling respected by their teachers and the education system. A theme in these focus groups included the need for respect and inclusion within educational settings. LGBTQ youth and their allies are asking for more policies and education that specifically addresses safe schools for sexual minority youth because they do not feel supported at school.

Michigan’s Forces of Change Assessment indicated that a lack of respect for and understanding of others increases stress, violence and trauma. Robust health education programs, in which social emotional learning (SEL) is at the forefront, enhance the skills needed to prevent bullying behavior. Adolescent focus group participants indicated that more progressive policies and innovative strategies for health education in schools are needed to teach children age-appropriate information on healthy habits and risks of dangerous health behaviors. The Michigan Model for Health™(MMH) is a K-12 comprehensive school health education curriculum that is evidence-informed and culturally, linguistically and age-appropriate. School officials throughout Michigan are recognizing the need for more robust education on SEL. The MMH can help meet this need as SEL is the foundation of the curriculum. Some Michigan state legislators recognize this need and are working to pass legislation requiring schools to implement the MMH as a key component of suicide prevention efforts.

These strategies align with a number of MDHHS and MDE priorities and initiatives related to creating safe and healthy school environments: a Whole School, Whole Community, Whole Child (WSCC) approach (addressing the health needs of the whole child and every child); comprehensive school health education through the MMH; creating safe schools for LGBTQ youth; several SEL programs and initiatives; and a variety of assessment/survey tools available at no cost to Michigan schools, including the Bully-Free Schools survey.

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 within a schoolwide SEL process.

A comprehensive approach to bullying prevention combines three components that, when implemented together, prove to be more effective than one alone. This whole school, universal approach will include health education in the classroom, social and emotional learning initiatives throughout the entire school community and added supports for students who identify as LGBTQ. The whole school approach will help move the needle on all students feeling safe and supported at school. Title V funding will go directly to selected schools to fund these schoolwide efforts.

Michigan’s regional school health coordinators are housed throughout Michigan in local school districts and Intermediate School Districts. They provide training and technical assistance for the MMH and a myriad of other school health initiatives. They are the local representatives for school health in Michigan. These school health coordinators report a need for a more comprehensive approach to bullying prevention through the implementation of social and emotional learning (SEL). They further indicated that the most pressing needs involve creating safe schools, addressing the needs of LGBTQ students, and addressing the role of adults in the SEL learning environment.

In FY 2021, Michigan will partner with regional school health coordinators to select six schools to implement a comprehensive approach to bullying prevention that involves SEL curriculum, schoolwide SEL initiatives, and training on creating safe schools for LGBTQ youth. Schools will implement the evidence-informed Michigan Model for Health™ social and emotional health skills module of the curriculum in all classrooms. The Collaborative for Academic, Social and Emotional Learning (CASEL) Guide to Schoolwide Social and Emotional Learning will be utilized to implement schoolwide initiatives in SEL. A school level team will also be trained on creating safe schools for LGBTQ students.

SEL has been shown to be an effective component in bullying prevention. Foundational to social and emotional learning is the teaching of social skill competencies, which include skills in the areas of self-awareness, self-management, social awareness, healthy relationships, and responsible decision-making. The ESM for this NPM will be all classrooms in six selected schools implementing the evidence-based Michigan Model for Health™ Social and Emotional Health unit/module with a minimum of 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. Health teachers will complete fidelity lesson logs documenting the implementation of lessons. Teachers will also conduct pre- and post-tests to measure student improvements in knowledge, skills, and attitudes related to SEL and bullying.

The second strategy is for selected schools to implement a schoolwide SEL process based on the CASEL Guide to Schoolwide Social and Emotional Learning. Each school will fully engage in the process outlined in the guide. The process will include an assessment of the entire school environment so schools will be addressing the needs evident within their unique school setting. Student input is an integral component of this assessment process as youth voice and engagement is a key indicator of schoolwide SEL.

The third strategy involves each school training a team of staff members in creating safe schools for LGBTQ students and implementing schoolwide strategies to improve the school climate for this subset of students. The training workshop is designed to help educators understand, assess, and improve school climate and safety for all youth, especially those who identify as LGBTQ. The workshop includes youth panels and youth-driven content. Participating schools commit to schoolwide approaches that include LGBTQ youth in planning, development and implementation. This strategy helps to target inequitable health outcomes among LGBTQ students related to bullying and depression. The training is facilitated by an expert in this area who also provides follow-up support to schools as they move forward in their efforts. Both the workshop and accompanying guidebook are entitled, A Silent Crisis: Creating Safe Schools for Sexual Minority Youth.

To strengthen protective factors against bullying and suicide, schools are working to improve their school climate, increase school connectedness and bolster efforts at addressing the needs of the whole child. School health professionals throughout Michigan are promoting use of the whole child approach through the Whole School, Whole Community, Whole Child (WSCC) framework. Through this lens, schools address the multi-faceted health needs of all students in order to become humane places for everyone, which leads to equitable outcomes. This approach acknowledges the effectiveness of a comprehensive approach in which multiple components work together to address bullying prevention on a more global, whole school level in order to create effective change throughout the entire school system.

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.

Michigan’s Public Act 241 of 2011, or Matt’s Safe School Law, mandates that schools develop a district policy and submit that policy to the Michigan Department of Education. The law includes multiple components, based on best practices, required to be included in the policy. However, many school districts do not have a full understanding of the law and, as a result, do not fully implement it or understand its importance. Regional school health coordinators work with every district in their region and are aware of districts that need further education and support on Michigan’s laws and model anti-bullying policy. They report that many schools do not understand the state laws related to bullying in schools and that many are not aware of the importance of having and implementing a local, district level anti-bullying policy. Policies are often in place, as required by law, but not fully implemented. The school staff response to bullying and staff role modeling remains varied and too often unhelpful and even harmful. School staff understand that it is imperative to intervene when bullying occurs, but surveys show that many feel ill-equipped to do so.

For legislation to be effective as a means of decreasing student exposure to bullying and cyberbullying, it is necessary to ensure that the requirement for schools to adopt (and fully implement) policies at the local district level is being met. Regional school health coordinators will receive training to prepare them to work with their local schools to provide guidance on Michigan law and policy related to anti-bullying. Coordinators will be supported with follow-up technical assistance from both MDHHS and MDE staff.

Michigan’s State Board of Education (SBE) has a model anti-bullying policy in place to help school districts meet the law, as well as add components to their policies to make them even more robust. While Michigan is a local control state—meaning the SBE Model Policy is a recommendation for schools rather than a requirement—the policy is in place to help school districts understand what should be included in a comprehensive bullying prevention policy.

To further create awareness and understanding in the education community and among stakeholders a session at the Child, Adolescent and School Health (CASH) conference will be provided on bullying prevention in Michigan. The session will focus on the laws in Michigan and why adopting, and fully implementing, the complete model anti-bullying policy is an essential component of anti-bullying efforts. Participants will be guided in the process of fully implementing each component of a model policy. This session is now planned for October 2021 since the CASH conference, originally scheduled for October 2020, was postponed one year due to COVID-19.

An additional strategy for promoting knowledge and understanding of PA 241 and the SBE Model Anti-Bullying Policy will involve collaboration with MDE on dissemination of guidance through existing work groups, committees, coalitions and contacts with stakeholders.

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

According to the 2018 National Survey of Children’s Health, 66.9% of CSHCN with more complex health needs in Michigan reported being bullied compared to 43.2% of non-CSHCN youth. For these CYSHCN, bullying creates stress which can impact their physical and mental health. The first strategy for this objective will be for the CSHCS Division to create a subcommittee consisting of CSHCS staff, Family Center Staff, other family representatives, and the Family Center Youth Consultant. This committee will be responsible for identifying bullying issues specific to CYSHCN, prioritizing identified issues, and developing initiatives to address these issues. The CSHCS Advisory Committee (CAC) will provide oversight to the subcommittee. The second strategy for this objective will be to conduct a focus group with CYSHCN and their parents. Results from the focus group will help to identify issues and prioritize initiatives. CSHCS will engage multiple partners, including the Family Leadership Network (FLN), Developmental Disabilities Institute, Behavioral Health and Developmental Disabilities Administration and others to provide input on documents and resources that are developed by the subcommittee. Once initiatives are finalized, the FLN, CSHCS, CAC and Family Center will help to share the resources across the state.

Immunizations – Adolescents (FY 2021 Application)

Based on the 2020 Title V 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.” In the 2020 needs assessment, when asked “Which of the following healthcare-related needs are most often unmet among the families you serve?” 37.8% of respondents across population domains identified immunizations as an unmet need. The need was identified as highest among respondents who serve CSHCN (46%) and children and adolescents (40.6%). The forces of change assessment identified an increasing focus on individual choice versus community benefits (including vaccine refusal) as a factor that impacts population health. However, the health status assessment identified positive progress: Michigan has improved the percentage of adolescents receiving at least one dose of the HPV vaccine almost every year since 2012 (NIS-teen, 2012-2017). Additionally, the gap in vaccination rates between male and female adolescents is shrinking as the HPV vaccination rate for both groups improves. The Title V Program therefore felt it was important to retain this SPM to continue building on the state’s progress.

The HPV vaccine has the potential to save thousands of lives from HPV-related cancers. Yet parental vaccine hesitancy persists, as evidenced by the fact that Michigan continues to have some of the highest vaccine exemption rates for children in the country. Michigan has made progress increasing the uptake of HPV vaccination for adolescents, but more progress is needed. Since 2014, Michigan has increased the coverage rate 25%; however, only 52.4% of adolescents between the ages of 13 and 18 years of age currently have completed the HPV series. The Healthy People 2020 goal is at least an 80% HPV vaccine coverage rate for adolescents in this age range. Data from the Michigan Care Improvement Registry (MCIR) show that the completion rate of females in the same age group is 53.9% while the rate for males is 51.0%. One goal of the MDHHS Immunization Program is to encourage the HPV vaccination at 11-12 years of age when it is routinely recommended. Data from the MCIR show that only 39.7% of adolescents have received a completed HPV series by 13 years of age. This is far short of the desired immunization level since it is routinely recommended at this younger age.

As discussed in the Child Health section, the Division of Immunization operates the MCIR. MCIR can forecast needed doses of vaccine for all children in the system. Data from the MCIR show that 76.9% of adolescents 13-18 years of age who reside in Michigan have received the routinely recommend 132321 series. The 132321 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 43.1%.

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

In 2014, the Immunization Program received grant funding to increase HPV immunization rates for adolescents in Michigan. At the beginning of the grant period, the HPV coverage rate was 18% for all adolescents (male and female) 13 to 18 years of age. The Division of Immunization used most of the funding to distribute notifications to parents of adolescents 13 to 18 years of age who were overdue for one or more doses of HPV vaccine. Given the impact of this strategy, in FY 2021 the Immunization Program will continue to seek funding for and use this strategy to increase adolescent HPV immunization rates.

In Michigan, 68.5% of the adolescents 13-18 years of age have initiated the HPV series but only 52.4% have completed the series as illustrated in Figure 1. The Immunization Program plans to send out notices to each adolescent who has initiated the HPV series to encourage them to complete the vaccination series. It is anticipated that approximately 40,000 notices will be sent to the parents of these adolescents.

Figure 1. HPV Initiation and Completion Rates for Adolescents

Data from Figure 2 show that adolescents are seeking other routine immunizations as rates for Tdap and MenACWY are nearly 95% but one dose coverage for HPV vaccination is only 68.5% for males and females combined. This is nearly a 30% difference between vaccination rates which indicates a missed opportunity to vaccinate. Immunization providers see adolescents for vaccine visits and assure they are receiving other recommended vaccines and are therefore missing the opportunity to provide all needed vaccines, including HPV vaccine.

Figure 2. Adolescent Vaccination Coverage

The Immunization Program is also partnering with the American Cancer Society to form a stakeholder group. This stakeholder group is made up of representatives from several organizations including the Michigan Pharmacist Association, Karmanos Cancer Center, Michigan Cancer Consortium, and representatives from some health systems. The group is tasked with creating a plan to increase awareness about the importance of HPV vaccine in an effort to reduce cancers by increasing vaccination rates in Michigan. The group will meet on a quarterly basis with the intent to expand the group to include a broader set of partners. These larger groups will meet semi-annually.

MDHHS has partnered with several large health systems to increase awareness and vaccination levels for HPV vaccine. An HPV summit is planned in 2021 to bring together large immunization practices that have low immunization rates along with the partnering health systems. MDHHS plans to continue to work with the health systems throughout 2020-2021 to solidify plans that health systems can put in place to increase HPV rates.

An additional strategy for the Immunization Program is to continue partnering with the cancer programs working toward a common goal of increasing HPV coverage rates and decreasing the incidence of cancers caused by HPV. The Division of Immunization has partnered with these programs to promote the message about cancer prevention using social media and public advertising.

Objective B: Increase outreach to adolescent immunization providers with low immunization rates.

In FY 2021, the Division of Immunization epidemiologist will generate a monthly list of all immunization providers submitting data to MCIR that are vaccinating adolescents. The list will show how many adolescents are being seen by the practice and how many adolescents are receiving all needed vaccines. MDHHS staff will review this list and identify the largest providers with the lowest immunization rates and reach out to those providers. Follow-up will include providing comprehensive Quality Improvement reports and working with the practice to develop a plan to increase immunization rates. Through direct outreach to the provider, MDHHS will have the opportunity to customize a practical quality improvement plan to help improve immunization rates as well as the quality of care. The data will also be used to identify providers that are doing outstanding work on assuring all their adolescent patients are receiving the HPV vaccine. The Division of Immunization will recognize those practices achieving high immunization rates by providing Certificates of Excellence for their successful work. The Immunization Program will also educate providers on the importance of HPV vaccination and the HEDIS measures. These measures will assess a) the number of adolescents who have completed the HPV series by 13 years of age and b) the number of adolescents who have completed the vaccine series according to the schedule which is to vaccinate at 11-12 years of age.

The Division of Immunization is changing the focus for how it evaluates completion of HPV vaccinations when educating provider offices. Rather than focusing on the completion rates for 13-18 years of age, more focus will be on adolescents who are complete at 13 years of age. This focus is to bring awareness in the provider office on timely vaccinations since all children should have completed the HPV vaccination series by 13 years of age.

Past experience indicates that clinic staff within provider practices tend to overestimate the immunization rates for the practice. Feedback to provider practices based on MCIR data to identify actual immunization rates is insightful and enables the practice to consider ways to improve how vaccines are promoted and administered. It may be as simple as making sure vaccines are assessed and offered at every encounter. The Immunization Program has made it routine to provide feedback to local health departments on their immunization levels using county report cards. Report cards are posted on the MDHHS website and provide immunization rates by county along with rankings. In the upcoming year, the Immunization Program will extend this concept to Vaccine for Children enrolled providers to create report cards for each of the larger practices in Michigan.

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 minority families. To address these concerns related to health equity and access to care (including vaccinations), in FY 2021 the Division of Immunization will focus on working with providers in the Detroit area, where overall immunization rates lag state rates. The Division will assess possible strategies for engaging families and communities in the vaccine dialogue. As discussed in the child health domain, 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.