MCAHD continued to strive towards improving adolescent health and wellbeing during 2021-22 even though COVID-19 new variant pandemic waves kept PR schools and workplaces changing from face to face to virtual mode with each surge. Adolescent domain’s planned activities have been adapted to overcome the service limitations and to continue youth projects and services.  SISA continues to be vigilant to unexpected events as the Orthopox/monkeypox outbreak. The 1st PR case was confirmed in June 29 and in July 15, 2022, there were 4 confirmed cases and 2 persons under investigation (DOH PR Monkeypox Outbreak 2022 - Situation Report #002). Trainings to identify and refer possible affected individuals as well as information about safety measures to prevent its spread will be offered in 2022 to SISA staff and youth.

NPM 10: Percent of adolescents, ages 12 through 17, with a preventive medical visit in the past year

1. Empower youth to adopt healthy behaviors through Positive Youth Development (PYD) initiatives

Youth Health Promoters Project (YHPP): In August 2021, SISARCs were available to implement YHPP in three modalities, virtual, face to face or combined. DOE issued an endorsement letter and a total amount of 50 schools were selected; 37 started Year 1 (6th grade) and 13 in “hybrid” specially designed curriculum (Years 2 & 3 combined) to finish the project they had started in 2019. All groups received “Vamos a conectarnos” (Let’s Connect”) welcoming meeting to identify events and ventilate emotions due to 2020-21 pandemic and to acquire tools to manage stress and anxiety. 

Although schools started face to face, they adopted COVID-19 Prevention Protocols and designed ways to provide effective distancing. Each classroom was separated into Groups A & B, alternating three times a week until noon (30 minutes classes). This schedule changed to regular groups by October when spreading diminished. In 2022, omicron variant surges forced schools to change again to limited groups or virtual mode. In the meantime, schools affected by the earthquakes were closed to do special repairs and students were transferred to nearby schools with “interlocking” class schedules. And in March, DOE experienced general turmoil due to proposed government decrease in retirement benefits that moved school personnel to do public demonstrations around PR and led to early retirement of personnel that, in many cases, were YHPP DOE liaisons. All these changes affected schools’ schedules and classes, but SISA RCs kept adapting YHPP meetings accordingly, either by changing to virtual mode or selecting new dates. Some 1st year groups were not able to complete their 15 meetings as scheduled. These groups will receive those meetings with additional dates before beginning their YHPP 2nd year. 

YHPP Initial Profile was finally approved, printed, and offered to two pilot groups with positive comments and evaluation. They finished it faster and liked the new format. It is expected to be offered to all groups (Years 1 & 2) in 2022.

Although three SISA RCs positions became vacant in 2021, MCAHD recruited new personnel with the required SW licenses and skills and received workforce development trainings to implement YHPP in 2022-23 among other duties.

 Youth Advisory Council (YAC)

On August 13, 2021, the transition meeting to welcome 22 new members alongside 3 advisors from 2018-20 YAC was held face to face and in virtual mode. Advisors from 2016 and 2018 YAC participated in the activities which included a mindfulness exercise, YAC  2016 to 2021 timeline, parent to parent & youth to youth dialogues, YAC 2018-21 Certificates and welcoming “stones” ceremony.

YAC 2021-23 began monthly meetings in September 2021. Due to COVID-19’s outbreaks, most of the meetings had been virtual. Those done face to face, also provided the virtual option. A committee was created to update YAC Bylaws, discuss them with all advisors and was approved by consensus on February 2022. YAC’s social media, adolescent campaign and friendly health visit committees were continued, and a logistics one was created to work in alliance with YAC Facilitators to evaluate meetings and plan next ones. Each committee scheduled bi-weekly meetings.

YAC continued to provide feedback to MCAHD annual plan initiatives, and two advisors participated as observers in 2021 Title V BG review. YAC received an MCAHD workshop directed to promote the use of “Mi agenda de Salud” planner among 10-21 y/o and their input was used to develop a dynamic new one. One advisor participated in the video to promote “Mi agenda…”. YAC also collaborated to provide input to DOH Folic Acid Awareness Education activities, reviewed a video directed to teens by the Suicide Prevention Commission, and participated in the development of the Adolescent Health Visit Campaign, among others.

They designed their space in DOH webpage (Consejo Asesor Juvenil (CAJ) (salud.gov.pr)) and created publications that were posted in YAC social media about multiple sclerosis, types of cancer, health visit promotion during the International Adolescent Health Week (IAHW) and a special series to introduce themselves and their role as YAC advisors. Their participation in PR Tobacco Free Coalition, HIV Community Mobilization and CSHCN Healthcare Transition Committees continued.

Workshops were provided to increase YAC knowledge about MCAHD programs, YRBSS data, health literacy, stress, mental wellness, among others. Two advisors participated in AMCHP 2022 virtual annual conference “Reflecting on our Past, Shaping our Future”.

The Secretary of Health held a special activity to meet YAC 2021-23 in June 2022. Advisors asked him about mental health, the decrease in healthcare professionals, DOE health classes at schools and other issues youth confront. They shared their ideas about the importance of checking out their health through the annual visit, screening questionnaires and stressed their availability to provide their input to DOH.  

During 2022-2023 YAC will continue to provide their input about youth policies and initiatives to DOH, MCAHD and other entities as requested.

2. Establish collaborations with MCAHD stakeholders to implement PR Youth Health Literacy Toolkit (YHLT) to provide knowledge about how to use the health care system

YHPs that began in 2019 had the opportunity to continue meeting with SISA RCs in 2021-22 with the “Hybrid” special curriculum developed. It included Year 2 meetings 8 to 12 about youth health literacy, annual healthcare visit and the pre/post questions that are used to assess ESM 10.1 Results gathered and analyzed will be reported in next year annual report.

The virtualization of YHPP included YHLT meetings 8 to 12 in YHPP. YAC received the virtual version of those meetings in April 2022 monthly meeting and their input will be included in YHLT virtual mode to be offered to non YHPs The Protocol and Guide for its implementation in non YHPs settings with stakeholders will be developed.  Then, youth serving stakeholder entities will be reached to establish collaborations to implement it.

3. Increase awareness of youth health and wellbeing issues including the annual healthcare visit through educational activities and multimedia campaign

PR Pediatric Preventive Healthcare Services Guideline approved in 2021 by DOH Secretary was shared with MCAHD stakeholders and published in DOH webpage. Efforts by MCAHD to increase its use by healthcare professionals will continue.

Nivel Máximo Multimedia Adolescent Mass Media Campaign: In August 2021, MCAHD contracted the new Advertisement Agency (AA) to work with the adolescent health campaign. The meetings with AA included MCAHD/SISA staff, and YAC members to discuss ideas. Besides promoting the annual health visit, advisors suggested the following themes: respect and diversity, bullying prevention, express your feelings, mental health, healthy relationships, communication with parents, vaping, and safe driving. Scripts for a series of short videos were developed by AA and advisors from all YACs were invited to an open casting for filming. In February 2022, the new “Vive al Máximo [saludable]” campaign was launched which included 8 short (30 secs.) videos for social media with accompanying messages, two longer videos (45 secs), social media banners and a QRCode link to DOH webpage. The minivelmaximo.salud.gov.pr  adolescent health campaign’s webpage had 7,337 views by April 2022. The following photos show three campaign posters with photos and messages about safe driving, annual health visit and exercise.

Vaping has increased in PR youth as revealed in youth surveys (YRBSS & “Consulta Juvenil”). ”). A short video and a poster directed to vaping prevention by AA for the campaign brought up concerns from YAC and DOH staff about the age of youth portrayed in them and the messages. A questionnaire to collect YHPs (10-14 y/o) understanding and opinions after viewing the video, poster, and message was developed by MCAH evaluator and offered in 2022.

Education activities directed to youth and adults about adolescent health and wellbeing by SISARCs, CHW, and HE were held in available schools during 2021-22 following the protective measures to prevent COVID-19. YHPs were not able to do their usual health promotion activities to their peers at schools but instead practiced and offered them within their classrooms. All education and health promotion activities will be reestablished in accordance with DOH & DOE protective protocols.

Immunizations and adolescent health and wellbeing: Messages about the importance of adolescent’s immunizations will continue by MCAHD personnel to dispel myths and educate youth and parents. Dengue vaccine (DEN4CYD) for 9 to 16 y/o was included in PR DOH immunization updated schedule and signed by DOH Secretary in March 2022. Accurate information about Dengue vaccine, HPV’s two doses requirement and COVID-19 vaccines will be emphasized in MCAHD personnel continued education. A collaboration between MCAHD, Immunization Program, and PRDOH Office of Communication began to develop coordinated education messages to promote immunization schedules and services to adolescents, through DOH webpage and social media.

Sexual and reproductive health/wellbeing education efforts directed to youth and their parents will continue through YHPP’s health promotion education activities, YAC committees, Nivel Maximo’s webpage, and MCAHD regional personnel. PR-Personal Responsibility Education Program (PREP) and Sexual Risk Avoidance Education (SRAE) ACYF grants will continue face to face and virtual implementation of their EBPs to youth and parents. A video recording of PREP stage-play “El Código” (Life Code) with its short guide for conducting youth dialogues will be distributed to reinforce pregnancy prevention message to PREP participants and other entities. PR SRAE will continue implementing Relationship Smarts Plus 4.0 in three new PR municipalities.

MCAHD secondary TPP efforts will continue with in-person visits, telephone calls or virtual mode implementation of HV and MIECHV programs as protective measures allow. The virtual prenatal Course will be continued and included in “Encuentro de mi vida” MCAHD webpage. Parenting Courses for 1-5 and 6-11 will be continued face to face by CHW and HE with protective measures.  

4. Implement PR Youth Friendly Healthcare Services Guidelines in a pilot project in a FQHC.

YAC 2021-23 Youth Friendly Health Visit (YHFV) committee began meeting in November 2021. They continued working with the guide for a youth friendly healthcare service that YAC 2018-21 began. YHFV committee will be working alongside SISA staff and MCAHD Curriculum Consultant to design the plan to implement a friendly youth health clinic to pilot in a FQHC.

5. Collaborate with CYSHCN Transition to Adult Healthcare Services Committee to assist all youth as they transition from pediatrics to adult centered care services in PR

YAC advisors and SISA staff’s collaboration with CYSHCN Transition Committee will be continued. The new Got Transition toolkit for all youth will be analyzed to determine its feasibility in PR and pilot if deemed appropriate.

NPM #9: Percent of adolescents, ages 12 through 17, who are bullied or bully others

The range of emotional and psychological effects of bullying, which affect those who are bullied, those who bully others and those who witness bullying (bystanders), extend beyond the physical, and the recognition of them has elevated bullying into a public health issue. It can result in physical injury, social and emotional distress, self-harm and even death. But bullying is preventable, there are many factors that may increase or decrease the risk for perpetrating or experiencing bullying. MCAHD’s SISA Program will continue its efforts to understand and address the factors that put young people at risk for or protect them from violence. The following strategies will continue:

1. Review Youth Health Promoters Project (YHPP) curriculum to incorporate additional strategies/ activities related to bullying prevention and mental health/wellbeing

To increase SISA staff capabilities, CE workshops will be continued with accurate information about bullying/cyberbullying and youth mental health with MCAHD mental health consultant. Also, a collaboration with Rutgers University Mental Health Technology Transfer Center Network (MHTTC) that was established in 2022 will be continued to offer mental health workshops about stress, anxiety, cutting, trauma informed care and others.

Three questions about bullying and cyber bullying were incorporated in YHPP Initial Profile questionnaire to be used to assess ESM 9.1 Percent of Youth Health Promoters (YHP) who report not being bullied in Puerto Rico by September 2021-2025. Profile was approved, printed, and offered to two YHPs groups as a pilot in May 2022. Youth response was positive to the new format and questions. Changes in schools’ schedules limited the amount of 2021-22 face to face meetings and it was not possible to offer it to Year 1 groups. Initial Profile will be offered to all groups in September-October 2022, to those starting in Year 1 and the ones in their 2nd Year continuation. This data will be reported as ESM 9.1 baseline in next year report.

2. Increase awareness about mental health/wellbeing and bullying/cyberbullying prevention in youth and adults, including parents and caregivers and healthcare providers

SISA and MCAHD MEU continued collecting and analyzing PRYRBSS and ASSMCA’s “Consulta Juvenil” (similar survey to Monitoring the Future) data, related to bullying/cyberbullying, safety in schools, suicide ideation and plans and other mental wellness indicators to study analyze and share with YAC, SISA and interested entities.

A collaboration with PR Legislature Citizens Participation Office was established to compile laws directed to bullying prevention, identification, and response. The recent Law #21 of May 24 was issued to establish the third Friday of April as the official day against bullying with the theme “United against bullying”. A proposed bill about street bullying is under consideration at PR Legislature.

The list of government agencies, health professionals’ organizations, NGOs that work with youth and youth groups (including LGBTT+) will continue to be updated each year. It will be used to invite youth to listening sessions to compile their voices and proposals to promote respect, inclusiveness, and safe spaces to all youth to eradicate discrimination and bullying. It will also be used to convene and develop an alliance or collective impact workgroup of entities (youth included) to address bullying/cyberbullying prevention and promote youth mental health and wellbeing.

The topics of bullying and mental health were included in “Vive al Máximo [saludable]”, adolescent health campaign as suggested by YAC and SISA staff.  The campaign ran on digital platforms and social media from February to June 2022. It is expected to continue until December 2022 through an extension of AA contract.

3. Develop a comprehensive project that incorporate youth, parents and school communities that promote school connectedness, respect, healthy relationships and equity to eradicate bullying, to be implemented in a YHPP school in collaboration with DOE

A National Academies of Science, Engineering, and Medicine report concluded that “bullying behavior is a major public health problem that demands the concerted and coordinated time and attention of parents, educators, school administrators, health care providers, policy makers, families and others concerned with the care of children.”

In accordance with this, an extensive review was done to identify initiatives with a comprehensive approach to prevent bullying/cyberbullying at schools and communities. Besides Sources of Strength, Brain Wise, Green Dot, and Welcoming Schools the National Council for Mental Wellbeing’s teen Mental Health First Aid (tMHFA) was identified but none was available in Spanish or had been used in PR. Communication with SAMHSA Region 2 was established to help us identify Spanish language projects or a means to translate and culturally adapt those identified. A meeting with The Youth Latina Project in NY for suicide prevention will be conducted through SAMHSA to assess its possible use. The communication with UPR Medical Sciences Campus’s PR EBP Committee will continue to identify culturally and linguistically competent promising or evidenced initiatives that could be piloted and used to prevent bullying/cyberbullying in PR.

The doctoral study “An Analysis of Public Policies and Practices of Education Leaders to Prevent Bullying in PR” was identified and a think-tank taskforce group of experts will be convened by SISA staff to continue developing this strategy. It will include the referred study investigator, DOE school health director, MH experts, Commission to Prevent Suicide and SISA staff among others.   

A meeting with new DOE school health education administrator was held to continue dialogues to develop and pilot an identified bullying/cyberbullying prevention initiative in a YHPP school.

4. Develop Youth Intervention Guides to promote resilience and reduce youth trauma after stressful events

 “YHPP Intervention Guide after a Hurricane and Guide after an Earthquake” developed by SISA were reviewed to develop “Vamos a conectarmos” (“Let’s Connect”) meeting that was offered to YHPs in August 2021. It was designed to be implemented virtually or face to face. Its purpose was to address COVID-19 pandemic effects on youth to reduce trauma and promote resilience after such an unprecedent event (See YHPP in 2021 annual report) and its analysis will be done in 2022-23. In collaboration of MH MCAHD Counselor, SISA will develop a Basic Intervention Outline Guide to be used to develop new ones directed to other unexpected events such as, epidemics or emerging issues to implement at schools or other settings. It will be shared with entities that work with youth.

5. Develop and disseminate an Emergency Preparedness and Response Guide that takes into account the needs of adolescents and young adults

The list of Emergency Preparedness Guidelines developed by government and NGOs will continue to be updated and evaluated by SISA for youth inclusion. The communication with DOH Emergency Preparedness Division will be established to include essential YAC’s voice and participation in the development of an Emergency Preparedness and Response Guide directed to youth.