the durham health nnovations projectsites.duke.edu/durhamhealthinnovations/files/2015/...sep 17,...

THE DURHAM HEALTH

INNOVATIONS PROJECT

______________________

ADOLESCENT HEALTH INITIATIVE

COMMUNITY CO-LEAD: Nancy Kent, LPC The Durham

Center

DUHS CO-LEAD: Kristin Ito, MD, MPH Duke University

Medical Center

TEAM MEMBERS

Core May Alexander, how’s that working?

Rebecca Greco-Kone, Durham County Health

Department/ Division of Community Health

Donald Hughes, Community Member

Evelyn Scott, City Office on Youth

Wendy Tonker, how’s that working?

Yvonne Wasilewski, Center for Child and Family

Policy

WORKGROUPS Communication/Community Engagement

Nadeen Bir, El Centro Hispano

Chimi Boyd-Keyes, NCCU

Jen Candon, Center for Child and Family Health

April McCoy, Durham County Health

Department

Jamie Magee Miller, Durham County Health

Department

Selena Monk, Durham County Health

Department

Channa Pickett, Office of Durham Regional

Affairs

Vanessa Roth, Planned Parenthood

Terry Smith, M-PowerHouse

Kendra Wood, Student NCCU

Data Heidi Carter, DPS School Board

Tamera Coyne-Beasley, UNC

Sue Guptil, Durham County Health

Department

Implementation Glenda Clare, Community Member

April McCoy, Durham County Health

Department

Rosa Solorzano, Duke University Department

of Nursing

Gail Yashar, Community Member * Special Thanks to Jennifer Park and Rose Wilson for their work on the SC self assessment survey, the

focus groups and the town hall survey.

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TABLE OF CONTENTS _____________________________________________________________________________________

HEALTH NEEDS & METRICS …………………………………………………………1

BUILDING THE TEAM & COMMUNITY ENGAGEMENT ……. ………………………………4

MODELS OF CARE FOR 10 EMPHASIS AREAS ……………………………………………7

KEY ELEMENTS OF A CONNECTED CARE MODEL FOR SUCCESS OF PROPOSED TEAM MODEL

OF CARE ……………………………………………………………………………..14

APPENDICES …………………………………………………………………………….15

Appendix A - Duke University Health Systems Data 16

Appendix B - Community Health Assessment – Durham Primary Care Practices 17

Appendix C - Community Health Assessment – Non-Medical Service Providers 18

Appendix D - Map – Mortality 19

Appendix E - Map – Violence-Related Arrests; Map – DUHS Violence-Related Visits 20

Appendix F - Map – Pregnancy, Public Data; Map – Pregnancy, DUHS Data 23

Appendix G - Map – STDs, DUHS Data; Map – Risky Sexual Behaviors, DUHS Data 26

Appendix H - Map – Substance-Related Arrests; Map – DUHS Substance Use Visits 30

Appendix I - Map – DUHS Obesity-Related Visits 33

Appendix J - Map – DUHS Non-Substance Use Mental Health Visits 35

Appendix K - YRBS Summit Summaries 37

Appendix L - AHI Organizational Structure 39

Appendix M - AHI Collaborative Programs and Steering Committee Members 41

Appendix N - Steering Committee Self-Assessment Survey 43

Appendix O - Steering Committee Self-Assessment Results 55

Appendix P - Digital Storytelling Guide 58

Appendix Q - Digital Storytelling Project

Appendix R - Logic Model 74

Appendix S - AHI Process Diagram 76

Appendix T - Summary Finding Focus Groups 77

Appendix U - Delphi Survey 86

Appendix V - Delphi Survey Results 127

Appendix W - Steering Committee Voting Results 129

Appendix X - Site Visits Summary 131

Appendix Y - Summary Findings Town Hall 154

Appendix Z - Community Health Assessment Map 159

Appendix AA - Hub-and-spoke Model of Connected Care Graphic 160

Appendix AB - Hub-and-Spoke Model of Connected Care Phases Diagram 161

Appendix AC - Summary of Proposed Solutions 164

Appendix AD - Adolescent Health Coordinator Job Description 165

Appendix AE - Implementation Conceptual Diagram 166

Appendix AF - Implementation Plan Waves 167

Appendix AG - Town Hall Media 168

REFERENCES ……………………………………………………………………………172

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HEALTH NEEDS AND METRICS

The Health Issue

Adolescence is a critical time for health promotion, prevention, and intervention. Many health-related behaviors, habits, and conditions are formed during the adolescent years and continue into adulthood with significant implications for both short- and long-term individual and societal health. If risk-taking behaviors and unhealthful habits are formed, the resultant chronic conditions lead to long-term financial and societal costs. If, on the other hand, healthy habits and behaviors are formed, there is a positive impact on the health and well-being of our community. The Centers for Disease Control and Prevention (CDC) has identified the following risk-taking behaviors established during adolescence (defined as age 10-24) that contribute to the majority of morbidity and mortality among youth and adults in the U.S: injury and violence to self and others, risky sexual behavior, tobacco use, alcohol and other drug use, poor nutritional habits and lack of physical exercise.1

Although many adolescents are considered healthy by traditional medical measures, many are engaging in risk-taking behaviors that jeopardize their current and future health. Risk-taking behaviors are often interconnected and intricately linked to school performance, community connectedness, and mental health concerns.2 Moreover, certain specific populations, such as those who live in poverty, experience school failure, or are involved in the juvenile justice system, may engage in more risk-taking behavior and have more chronic medical conditions than the overall adolescent population.3

The current health care system does not adequately address adolescent health needs for multiple reasons.4 Existing health services are not optimally designed to promote adolescent health and prevent disease. Most services are focused on the delivery of care for acute conditions or specific issues, rather than the promotion of healthy behaviors. As many as 69-80% of adolescent encounters with medical health care providers do not include counseling or screening.5 Reimbursement is inadequate for the extended time required to provide risk-behavior screening, health education, counseling, multidisciplinary care and coordination of services for adolescents. Existing services can also be difficult to access. In two large nationally representative surveys, approximately a quarter of adolescents report foregoing needed medical care.6,7 Additionally, many adolescents and young adults report having no usual source of care.8,9 More than one-third of adolescents with behavioral issues that require treatment or counseling do not receive mental health care.10 Among adolescents residing in an area with high adolescent pregnancy rates in Durham County, less than half knew where to receive services for mental health, substance use or reproductive health and among those who reported knowing where to receive services, only 30% could describe how to get to the locations identified.11 Many adolescents are uninsured or underinsured, including non-citizens, the working poor, and those ages 18-24 who have the lowest insurance rate of any age cohort.12 Confidentiality concerns and transportation barriers are additional issues that limit adolescent access to available healthcare resources. Finally, health care services that exist for adolescents are often fragmented and disconnected. Physical health, mental health, schools and community services operate in “silos", with a few notable exceptions, such as the System of Care philosophy which will be discussed subsequently.

Promoting adolescent health requires innovative, adolescent-centered models of care that address the specific health needs of this population. Services must attract and engage adolescents, provide a safe and confidential environment to screen for and counsel about sensitive health-related information, and provide interventions demonstrated to be effective in reducing risk behaviors and improving health outcomes in this population. Durham County provides a unique setting and opportunity to reform the model of delivery of care for adolescents because of its relatively small urban population and presence of only one large health and hospital system, Duke University Health System (DUHS), in addition to numerous smaller private and public healthcare providers.

Durham County has an estimated 49,494 residents age 10-24.13 Sixty-six percent of Durham County residents in this age group (32,840 unique patients) were seen by DUHS in 2008. Duke University Health System health providers for this population include primary care providers and affiliated practices

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(pediatrics, internal medicine, and family medicine), specialty care providers (includes obstetrics and gynecology), urgent care and hospital services, including Duke and Durham Regional Hospital Emergency Departments. Of the nearly 175,000 visits in 2008 by 10-24 year olds, there were 135,956 Outpatient visits, 27,693 Emergency Department visits, 4,506 Urgent Care visits, and 4,453 Inpatient admissions (Appendix A). The six large pediatric practices in Durham provide nearly 50,000 visits a year and include Duke Pediatrics, Durham Pediatrics, Regional Pediatrics, University Pediatrics at Highgate, Chapel Hill Pediatrics and Lincoln Community Health Center (LCHC) (Appendix B). LCHC is a safety-net provider, providing care to nearly 6,000 predominantly African-American and Hispanic adolescents a year, many of whom are uninsured. The five large family practices in Durham, including Duke Family Medicine and Duke-affiliated practices, provide an estimated 17,092 visits to this age group per year. Planned Parenthood and the Durham County Health Department (DCHD) provide family planning and STD clinic services for 1576 and 1814 visits, respectively. The two local high school based health centers located at Hillside and Southern High Schools together saw approximately 1350 unique individuals during the 2007-2008 school year. The Durham Center, the local management entity for Durham County mental health providers, received 1,607 unique calls in fiscal year 2008 for Screening Triage and Referral services for youth 10-24 or their families who were experiencing mental health or substance abuse issues. This number is low compared to the estimated 20% or nearly 10,000 youth in this population who experience mental health concerns.14,15 We identified 50+ organizations providing non-medical services to adolescents identified during our Community Health Assessment (Appendix C).

Health Needs

Current health indicators demonstrate the need to improve adolescent health in Durham.16,17 Injury and Violence to Self and Others: Injury and violence represent over 70% of mortality within this age bracket for both Durham County and the state of North Carolina (Appendix D).18,19 The top two leading causes of death in Durham County are assaults and other unintentional injuries, while in North Carolina motor vehicle injuries and other unintentional injuries top the list. 20,21 Rates of violence among adolescents are also higher in Durham County compared with the state: homicides accounted for 11.3% of deaths in those under age 20 in Durham compared with 4.7% statewide. Furthermore, almost half of Durham County high school Youth Risk Behavior Survey (YRBS) respondents reported being in a physical fight and 8.2% required medical treatment for an injury sustained in the past 12 months.22 One quarter reported carrying a weapon in the past month. There were 1,283 assaults, 352 weapons violations, and 27 homicides in 2006 in this age group (Appendix E). According to the 2007 Durham County Gang Assessment Report, there are approximately a thousand gang members in Durham, but not all fall within the adolescent age group. However, involvement in gangs more than doubles between ages 12 and 13 and youth are particularly vulnerable at the transitions from elementary to middle school and middle to high school. Additionally, gang members have elevated rates of serious school problems, being placed below grade level, needing a mental health assessment and having poor parental supervision compared with their peers.23 Risky Sexual Behavior: North Carolina has the 9th highest teen pregnancy rate in the U.S. and Durham County has a higher rate than the state average (48/1000 versus 23/1000 among 15-17 year olds) with an even higher rate among Hispanic youth (178/1000 among 15-17 year olds).24 There are approximately 200 pregnant teenagers under age 18 in Durham County yearly (Appendix F). Nationally representative samples demonstrate that adolescents have the highest prevalence of sexually transmitted infections.25 Nearly ninety percent of chlamydia reported to Durham County Health Department in 2007 occurred in this age group. Reported rates of newly diagnosed sexually transmitted infections in those under 20 in 2007 were higher in Durham County than statewide, including chlamydia (1957/100,000 versus 1321/100,000), gonorrhea (1079/100,000 vs 504/100,000), syphilis (13.5/100,000 versus 2/100,000) and HIV (22/100,000 versus 12/100,000) (Appendix G).26

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Substance Use: In the YRBS, 29%,16%, and 10% of Durham high school students report using alcohol, marijuana, and tobacco, respectively, in the last month. In addition, there were nearly fifteen hundred substance-related arrests per year among adolescents in Durham County (Appendix H).27 The developing adolescent brain may be particularly vulnerable to the harmful effects of substance use. Earlier initiation of substance use is associated with increased substance use into adulthood; approximately 40% of those who start consuming alcohol at or before age 15 develop dependence at some point in their lives.28 Poor Nutritional Habits and Lack of Physical Exercise: County-wide measures of obesity rates in adolescents are currently not systematically measured. However, nearly a quarter of Durham County young children served by the WIC nutritional program are overweight which is higher than statewide averages.29 Nationwide, 34% of children and adolescents are overweight or obese.30 Five-thousand adolescent outpatient encounters were coded as obesity and potential obesity-related complications (diabetes, acanthosis, etc) at DUHS, however, this greatly underestimates prevalence because obesity is often not used as a diagnosis code even if present. (Appendix I) Mental Health: YRBS data also suggests serious mental health concerns among Durham youth; 24% of high school respondents agreed that they feel alone in their lives, 27% reported feeling sad or hopeless, and 18% reported attempting suicide in the past year. Nearly four hundred visits to the Duke ED were for adolescent psychiatric evaluations that resulted in transfer to psychiatric facilities. Five and a half percent of outpatient visits at Duke among adolescents were for non-substance abuse-related mental health concerns (Appendix J). School Performance: Two-thirds of Durham Public School (DPS) students complete four years of high school. This rate is only slightly higher than the state of North Carolina rate of 63% and significantly lower than the national rate of 87.6%.31 Thirty seven percent of DPS students are short-term suspended at some point during their high school years and 23% are involved in violent acts.32 School suspensions are higher proportionately than many other cities, such as Baltimore, MD.33 Youth who are suspended are at increased risk of academic failure, school drop-out and incarceration and engage in more risk-taking behavior.34

Health Metrics

The goal of the Adolescent Health Initiative (AHI) is to decrease risk-taking behaviors and their consequences among adolescents in Durham County. The key metrics we have selected to measure these outcomes are the Youth Risk Behavior Survey (YRBS) and county and state level epidemiological data. The YRBS is a national school-based survey tool conducted by the CDC, state and local health departments, and state and local education agencies. In 2007, Durham County began administering its own YRBS every two years to assess risk-taking behaviors. The DCHD has been proactive in constant improvement of the sampling method and analysis of the data to ensure the results are representative of the population and is committed to continuing the YRBS biennially to monitor risk-taking behavior among adolescents in Durham. Results from the 2009 survey are pending at the time of this report. Publicly available epidemiologic data are available to monitor the consequences of certain risk-taking behaviors, for example risky sexual behaviors (STD and pregnancy rates reported to the County and State), substance use (substance-related arrests), injury and violence to self and others (mortality data, weapon and assault-related arrests), mental health (referrals to Durham Center, the triage center for mental health referrals), school performance (publicly available data on graduation and suspension rates). Obesity data are not currently collected systematically, although self-reported BMI (along with behaviors related to obesity) can be monitored through the YRBS at the high school level as is done currently at the state and national levels.35 We would also recommend the implementation of systemic screening and documentation of BMI in schools and throughout DUHS, in conjunction with the Durham Health Innovations (DHI) obesity team’s recommendations. Data on school attendance and performance are available from the North Carolina Education Data Center located at the Duke University Center for Child and Family Policy.

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BUILDING THE TEAM AND COMMUNITY ENGAGEMENT The origin of the Adolescent Health Initiative team is a result of the convergence and timing of

multiple efforts including systematic collection of community level data about adolescent health through the YRBS and the commitment of the Durham community, service organizations, and community leaders to address the concerns highlighted by this data. The DHI Request for Proposals (RFP) was published at a critical moment, providing an opportunity for the AHI partners to solidify their common goal and develop a plan to improve the health of adolescents in Durham and address health disparities in the community.

The DCHD, Partnership for a Healthy Durham (PHD), especially the Obesity and Chronic Illness subcommittee, and DPS were key players in the decision to collect county level YRBS data. Around the same time YRBS data report was released, a Gang Assessment for Durham County was also released which included information about violence-related risk behaviors in the community. The release of these two reports sparked county and city community leaders and agencies that serve youth to organize two Youth Summits in the spring of 2008. These summits brought together youth service providers in March to prioritize issues and identify gaps and assets in the community related to health. Then two months later, adolescents themselves came together for the same purpose (Appendix K). In an effort to act on the expressed priorities, the same community leaders and agencies met monthly as the YRBS Action Committee and began to develop action plans while engaging new partners. One of those action plans was for a subcommittee to pursue the DHI RFP to be used to continue the work of building partnerships, developing plans, and implementing positive youth development programs to reduce adolescent health-risk behaviors.

At the moment when the YRBS Action Committee decided to pursue this opportunity there were numerous stakeholders at the table including the DCHD, the Durham Center, Duke University Medical Center’s Division of Community Health (through the ACCESS program and the Southern High School School-based Clinic), El Centro Hispano, North Carolina Central University Women’s Center, DPS, the Center for Child and Family Health, Lincoln Community Health Center (through the Hillside High School-based Clinic), Planned Parenthood, DPS Board Member, Criminal Justice Resource Center, the City Office on Youth, the City Office of Economic and Workforce Development’s Youth Office, M-POWERHOUSE, Inc. of the Triangle, and others. With guidance and leadership from the DCHD, the YRBS Action Committee hosted an interest meeting targeting community service providers, community members, and Duke University and Duke University Medical Center (DUMC) faculty/staff interested in the health of adolescents. There were over 40 individuals who attended the meeting and at the end there was consensus in the room that a team should be formed to move forward and pursue this opportunity. After this meeting, the subcommittee continued to meet with other teams and individuals considering this opportunity. Through this process additional team members were added and partnerships were strengthened, including but not limited to DUMC Department of Pediatrics, DUMC Child Development and Behavioral Health Center, Durham’s Partnership for Children, DUMC School of Nursing’s Office of Global and Community Health Initiatives, Durham Crisis Response Center, the Duke University Center for Child and Family Policy, and the DUHS Domestic Violence program. This group then submitted an application.

A key component of the successful functioning of our team rested on the selection of the project manager. The criteria for this position included: knowledge of the community, an understanding of adolescent health, and experience managing a collaborative process. Through a review committee and interview process, the adolescent health team selected May Alexander and Wendy Tonker from how’s

that working? to be the co-project managers. They were key to the creation of a well-defined organizational structure Core Team, Steering Committee, workgroups (Appendix L), ground rules and governance. Additional key team members continued to join AHI throughout the planning process and will be discussed further on in this section.

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Most programs, resources, and partnerships in Durham relevant to our team’s primary focus are mentioned above, a more comprehensive but not exhaustive list including the Steering Committee Members is contained in the Appendix (Appendix M). Each of these groups provided extensive information about their program(s) or service they provided and the purpose or expected outcome of that program/service. Some of these groups and/or individuals have been working with youth in Durham for a long time and provided historical perspective about the trajectory related to adolescent services in the community. These programs, resources, and partnerships played a critical role in shaping the thinking of the AHI team through their hard work in gathering data and doing the work of the project, challenging the solutions proposed during this process, and providing active feedback on the direction of the model of care. Many of these program staff have significant experience working with the target population. Their insight about how a youth may access a service or how a proposed model of care would fit into the existing system has been integral to the development of the plan.

We conducted two internet-based Steering Committee Self-Assessment Surveys to gain feedback on how well our collaborative functioned and ways to improve (Appendices N, O). The Steering Committee and Core Team member respondents identified key areas related to the mission, leadership style and communication process that required additional attention in order to make our committee function successfully. We addressed these issues in subsequent meetings with the goal of improving trust within our partnership and brainstormed about potential solutions, which were then implemented by the Core Team and project management to improve AHI functioning.

Youth Advisory Group and Community Engagement Team

Recognizing the limited timeframe of the planning process and the desire to involve youth in the process, our approach was to further engage the community through two strategies: a Youth Advisory Group (YAG) that would be responsible for reaching out to their peers for input and feedback as they actively participated in the development of the plan and a Community Engagement Team comprised of respected and trusted community leaders or organizations who demonstrated an interest in improving adolescent health in Durham.

For the YAG, we identified a young leader in the community to facilitate the group over the eight month period. Three strategies were used to form this group: (1) developing a base through the Partnership for a Healthy Durham Youth Advisory Group (2) reaching out to existing groups in the community, such as the City of Durham Youth Council, El Centro Hispano’s Jovenes Lideres en Accion, Durham County Health Department’s TACT (Teens Against Consuming Tobacco) and (3) asking Steering Committee members to participate in recruitment.

The YAG consisted of nearly 20 young people ages 13-24 from across the County of Durham including traditional students from various DPS middle and high schools, at-risk students from Achievement Academy of Durham, and students from Durham Technical Community College and North Carolina Central University. The YAG worked to identify the community challenges that adolescents face in accessing physical, mental, and sexual health services and leading healthy lives in our community. Through a creative, digital story-telling project, we were able to engage the youth and ensure their sustained participation (Appendices P, Q). The YAG conducted street interviews of young people throughout Durham asking questions regarding recreation and physical activity, diet and nutrition, and transportation to grocery stores and doctor appointments. They compiled the footage into a short documentary-style film entitled, “Through Our Eyes: A Look at Adolescent Health in Durham, North Carolina” that was shown at the Town Hall meeting. The YAG also frequently provided feedback about the proposed solutions to improve adolescent health and played an important role in the development of our model of connected care.

The primary purpose of the Community Engagement Team was to provide consultation, planning and implementation services to AHI in the area of community engagement. Specific responsibilities included

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participation in the planning, recruitment, and implementation of focus groups and Town Hall meeting and ensuring that the AHI plan considers and complements existing services in the community.

As active members of the Community Engagement Workgroup, the Core Team and the Steering Committee, the Community Engagement Team worked to ensure that AHI developed meaningful and sustainable relationships with the Durham community. These relationships are anchored in respect for each other and a mutual concern for the health of Durham adolescents and are based on give and take – where we ask for and listen to people’s ideas, their wisdom, and their experience.

Initially, three partners were chosen for the Community Engagement Team with active support from the DHI Community Engagement TA Core, and included agencies that had also submitted proposal for the DHI RFP. However, two partners were not able to commit to the level of responsibility required due to other commitments. We approached Evelyn Scott from the City of Durham, Office on Youth who joined the team and along with El Centro Hispano became the Community Engagement leads.

In addition to these Community Engagement Team Partner positions, AHI developed an active Community Engagement Workgroup that met weekly and consisted of representatives from the Health Department, NCCU, the Duke-Durham Neighborhood Partnership, the Durham Center, the Center for Child and Family Health, M-PowerHouse, Inc and Planned Parenthood. This group also engaged Mayme Webb-Bledsoe, an experienced community organizer working with the Duke Durham Neighborhood Partnership, to provide guidance.

We learned many things from the community engagement process, including: • Short-term projects can build some community engagement through leveraging existing

relationships and more narrowly defining "the community" - ie. target specific neighborhoods and populations.

• Appropriately engaging a community takes significant time (sometimes years) and involves building trusting relationships

• Community members need to be involved from the beginning, not "brought along" as the professionals/service providers/advocates move forward.

• Meetings must take place at times/places accessible to community members • We must be willing to be responsive to the wants and needs of community members to the extent

of abandoning our plans if necessary. We also learned many important lessons about adolescent health issues in Durham such as:

• Adolescent health is in a different stage than some of the other DHI projects; it is a “grassroots” initiative and needs to be focused on different types of approaches to make change, including educating and informing decision makers about the burden of the problem, improving data collection systems, and creating an infrastructure to support the initiative.

• Adolescents, if organized and provided incentives and transportation, are willing and able to actively participate in the planning process

• This is a complex issue that needs to be addressed from a systems level approach, which takes time, commitment, and leadership

• The Adolescent Health Initiative needs a “home” or an infrastructure if it is going to be sustainable. The leadership is in place but without a simple infrastructure support, it will be unlikely to continue.

The Planning Process We used a community-based participatory research process to develop our plan. A Steering

Committee consisting of over 60 individuals representing the community was involved in every phase of the planning process. Guided by a Logic Model (Appendix R), the Steering Committee met monthly to identify and execute the steps needed to complete the planning process (Appendix S). These steps included 1) focus groups with adolescents, parents, and services providers to identify the health needs of adolescents 2) key informant and system stakeholder interviews to identify present services gaps and desired features of the new model 3) a Delphi survey of key informants and Steering Committee members

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and voting during Steering Committee meetings to attempt to reach consensus about recommendations 4) review and documentation of evidence-based models of adolescent health care to inform the design of the model 5) site visits to two existing Adolescent Wellness Centers and 6) a Town Hall conversation to get critical feedback on the model. Summary findings from the focus groups, Delphi survey, Steering Committee voting, site visits and Town Hall (Appendices T-Y). We also collectively analyzed data from Duke’s Data Support Repository (DSR) and conducted geospatial mapping of health care utilization and prevalence of illness and risk-taking behavior as measured by visit diagnostic codes to better enable us to plan interventions in this population.

THE HUB-AND-SPOKE CONNECTED CARE MODEL

A recurring theme of the service provider focus groups and key informant interviews was that “Durham is resource rich.” Our Community Health Assessment provides evidence to support the description that Durham has many resources devoted to health and well-being for youth (Appendix Z). However, these resources are scattered throughout Durham, uncoordinated and often unknown to youth and their trusted adults.

We propose a hub-and-spoke model of connected care to improve coordination and public awareness of services (Appendices AA,AB). The hub-and-spoke model is adapted from the business literature, most notably companies like FedEx, and conceptualized as a system of connections arranged like a chariot wheel. The model aims to improve efficiency by having a centralized, coordinating hub. At the center or hub of the hub-and-spoke is an adolescent coordinating infrastructure with spokes representing life domains (physical health, mental health, education, social/family, etc) of youth. The hub-and-spoke is a dynamic flexible, model that allows for evolution over time. We envision phases of the model with implementation of our proposed solutions (Appendix AC) embedded in each phase. Phase 1 Hub-and-Spoke Model

Phase 1 will have a “virtual hub” with services currently existing in Durham as the spokes. The virtual hub will initially consist of an Adolescent Health Coordinator (Appendix AD) who is a resource expert for service providers about adolescent services across the life domains and is available via phone, text, online or optimally, some combination of the three. The virtual hub will begin as an information and referral service in Phase 1 with gradual expansion to provision of referral and resource coordination in Phase 2 and 3.

The Phase 1 virtual hub will also include development of a website listing and describing all adolescent resources building on the information available on the Network of Care website.36 One suggestion from the service provider focus group and key informant interviews is to create a web-based format that includes reviews or evaluations of listed services, similar to the customer-created reviews on a service like Angie’s list with supervised oversight and monitoring.

In addition, the Adolescent Health Coordinator will assume responsibility for coordinating AHI and take initial steps toward implementation of our proposed solutions by identifying resources, continuing to build partnerships and compiling and creating protocols for implementation of 1) evidence-based programs to decrease risk-taking behaviors 2) quality improvement programs, including cultural competency training, for existing service providers to enhance existing care for adolescents 3) community health education through social marketing, including use of social media and 4) care coordination and teen (patient) navigation services as detailed in subsequent sections. Phase 2 Hub-and-Spoke Model

Phase 2 will contain additional innovative virtual service coordination. Data gathered from adolescent focus groups, the Youth Advisory Group, and Town Hall participants indicate a strong preference by adolescents for use of texting and social media to access services and pertinent health education. We propose creating an innovative, Durham-wide text messaging information and referral service based on similar projects conducted in the field of reproductive health.37 The service will be an opt-in service whereby youth will text a five-digit phone number and receive a phone tree with codes instructing them to

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text a chosen code from a menu to receive basic information and referrals for services available in Durham for face-to-face consultation. Examples from San Francisco’s reproductive health SEXINFO texting intervention include, for example, texting C3 “to find out about STDs,” E9 “if ur sexually active,” F10 “if someone’s hurting u,” or E5 if you “need to speak to someone now.” In addition to reproductive health information and referrals, we envision Durham’s texting intervention to include select physical and mental health information and referrals based on community needs identified through the planning process, such as those related to substance use, obesity, depression/anxiety and violence. Additionally, we propose building upon existing innovative community-wide social media interventions such as the Health Department’s Knowing IS Sexy (KISS) reproductive health information Facebook intervention and free-text texting advice line.38

This phase will include continued growth of the adolescent health program overseen by the Adolescent Health Coordinator and the beginning phases of implementation of evidence-based programs, quality improvement programs, and social marketing/health education based on available resources. An essential step in Phase 2 is development of care coordination services through care coordinators and teen (patient) navigators described in subsequent sections with expansion of the resource expert service provided only to service providers during phase 1. The expansion would include an “on-call” resource expert available directly to adolescents and their trusted adults with triage to care coordination and teen (patient) navigators based on need. Phase 3 Hub-and-Spoke Model

Phase 3 will include a gradual expansion of the virtual hub to include a non-virtual, site-based Adolescent Wellness Center. This center will include comprehensive physical health, mental health, and health education services as well as providing a connection to Durham’s non-medical service providers and offering youth activities. The rationale for this is three-fold. First, expert opinion in the field of adolescent health recommends the integrated health service provision “one-stop-shop” adolescent model of care provision where physical health, mental health and health education services are co-located. This is because of the unique health promotion and mental health needs of this population, barriers and lack of follow-through for multiple visits to access healthcare, and its ability to decrease the stigma related to mental health care.39 AHI fully recognizes the limitations of having a one-site center, including the challenges to community members in accessing services outside of the geographic boundaries of each neighborhood. However, a central Adolescent Wellness Center can act as an infrastructure hub (staffing, protocol/organizational, and billing/reimbursement-wise) for gradual creation of additional community- and school-based services including school-based health centers. Second, our Community Health Assessment, key informant interviews and youth, parent, and service provider focus groups identified the need for more adolescent-specific health services and demonstrated community support for the idea of an Adolescent Wellness Center. Third, having a physical location will provide an additional point of entry and means to capture those who may not access virtual service referrals and coordination. It may also help raise the level of awareness about adolescent health and services in the community. The services described in Phase 1 and 2 will likely be coordinated through this center with pre-existing community-based services remaining at sites throughout the community. Proposed Solutions: Arriving at an Adolescent-Centered Model of Care

Below is a brief summary of each of the proposed solutions (Appendix AC) we envision will enhance the hub and the life domain spokes of the proposed model of connected care. Each of these solutions was developed using Durham specific adolescent health data, data from adolescent health literature, and information gathered through informant interviews, the Youth Advisory Group, Town Hall, and focus groups with youth, parents and service providers. Starred items are common themes that have been articulated across other DHI projects.

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1. Create coordinating infrastructure*

Recommendations: (1)“On-call” resource expert; (2) User-friendly, interactive resource website with

hardcopy version; (3) Regular meetings for adolescent service providers to strengthen relationships See discussion of the virtual hub in hub-and-spoke model description above.

2. Enhance existing adolescent services

Recommendations: (1) Adolescent-specific training and quality improvement interventions for all staff;

(2) Cultural competency training for all staff*; (3) Teen (patient) navigator program*; (4) Teen-friendly

environments and decrease stigma Quality improvement interventions have been demonstrated in pre/post-studies and randomized

controlled trials in the primary care setting to improve adolescent receipt of comprehensive screening and counseling and STD testing.40,41 Tools from these evidence-based interventions could be easily adapted to use in Durham. Additionally, adolescent-specific provider training may increase creation of teen-friendly environments, including sensitivity towards confidentiality and privacy concerns. Adolescent health screening has been demonstrated to improve outcomes in many areas. For example, mental health screening with subsequent education and prevention counseling in the setting of a positive screen has been shown to decrease the rates of self-reported suicide attempts.42 Screening females for sexual activity and if sexually active, screening for chlamydial infection, results in decreased incidence of pelvic inflammatory disease.43 Screening for adolescent risk-taking behavior often does not occur because of perceived difficulty in accessing referral resources; increased accessibility of resources via the adolescent coordinating infrastructure may also help to increase risk-behavior screening. There was strong community support for providing cultural competency and awareness training for any staff interacting with adolescents.

Care coordination is an essential element of enhancing care for adolescents with health needs that cross the traditional “silos” of care. Durham’s System of Care offers care coordination through multiple service agencies for youth that have been triaged as high risk, however, there remains a need for care coordination among other youth. There is evidence that coordination of care using the System of Care philosphy improves outcomes.44 We envision creation of care coordinators specific to adolescents who are linked to and trained by the Adolescent Health Coordinator. They will serve as an “on-call” resource expert for adolescents, their trusted adults, and service providers and be able to take referrals for service coordination. Protocols will be developed to triage based on need to care coordinators and/or teen (patient) navigators. We envision teen navigators as a hybrid of the definitions of patient navigators and community/lay health workers or advisors: trained community members who use flexible problem solving to assist adolescents and their trusted adults in overcoming perceived barriers to care or accessing services (examples of functions include assisting with transportation to appointments, providing health education, or increasing awareness of and empowering use of services).45 Patient navigator and community/lay health workers and advisors are concepts borrowed from interventions in other age or disease-specific populations with promising results that have been used on a small scale in the adolescent population and by implication are transferrable the adolescent population.46 3. Increase adolescent-specific services

Recommendations: (1) Adolescent Wellness Center; (2) School-based Health Centers in all middle and

high schools An Adolescent Wellness Center would meet the need identified by community members, service

providers and the Community Health Assessment for increased adolescent-specific services. Comprehensive adolescent clinics have been shown to attract high-risk youth and to detect, document and treat a wider range of medical, behavioral and risky behaviors as compared with non-adolescent focused clinics.47 The receipt of health care in a medical home setting such as our proposed center has been demonstrated to improve health status, timeliness of care and improve family functioning.48

Adolescent 10 !

The expansion of school-based health centers both in number (to all middle and high schools) and awareness of/enrollment would increase access to healthcare system for adolescents and was the second most highly ranked proposed solution in the Town Hall conversation. School-based health centers have been demonstrated to reduce urgent and emergent care use, decrease Medicaid expenditures, and decrease hospitalizations and their costs.49,50,51,52,53,54 4. Support Positive Youth Development

Recommendations: (1) Peer educator program; (2) Continued youth engagement and youth advisory

group; (3) Evidence-based youth empowerment programs

Programs that take a peer-led approach with adolescents have been shown to have an impact on tobacco use prevention, increasing fruit intake, reducing sexual risks among adolescents reducing self-reported aggressive behavior, reducing alcohol consumption and improving self-management of asthma.55,56,57,58,59,60,61,62 Fewer studies have examined the impact of the peer–led approach on the peer-leaders themselves.63 However, increased self-esteem, and more positive health outcomes have been found in adolescents trained to be peer leaders.64,65,66 Characteristics of a successful peer-led program include: involvement of peers in all phases of the planning process, interactive training methods, and tailoring of the activities to the sociocultural characteristics of the group involved in the learning.67 Peer educator programs have strong community support and ranked as the third most popular proposed solution in the Town Hall.

The traditional approach to decreasing risk-taking behavior has been to focus interventions on risk-taking behaviors through a siloed approach (i.e. sexual risk behaviors, substance use, or suicide prevention). However, a newer approach to decreasing risk-taking behavior recognizes the often present common underlying factors related to risk-taking behaviors (including academic success) and aims to influence these using interventions focused on positive youth development, such as teaching life skills and connecting adolescents to the community. Our Implementation Workgroup reached consensus to prioritize programs that targeted multiple risk-taking behaviors, had strong evidence for effectiveness, focused on youth and/or their families at the lower spectrum of our age range, and were culturally translatable. In addition, cost and cost-effectiveness data (if available) was also considered when deciding which interventions to recommend. Through this process, we recommend initial evidence-based interventions in Durham to be positive youth development interventions focused on the younger adolescents age group (10-14), or for school-based interventions, those in middle school. We propose conducting these interventions in areas corresponding to areas of high risk-taking behavior and their consequences on our geospatial maps. Middle schools with populations living in these areas are potential intervention sites, however, nearly all of the Durham middle schools draw students from at least one high risk-taking area identified on our maps. Thus, we will continue to work in partnership with our initiative member DPS to identify schools willing to serve as pilot sites for interventions. We have identified the following evidence-based positive youth development interventions that we recommend as initial programs: Life Skills Training (a school-based program teaching personal and social skills to prevent substance use and violence), All Stars (a school-based program focused on youth development to prevent risk-taking behavior), Guiding Good Choices (family-based drug prevention curriculum to promote positive parental involvement), and Storytelling for Empowerment (school-based, bilingual intervention using cognitive decision-making and positive cultural identity to prevent substance use). Many of these programs are school-based but could be adapted to after-school programming. Most of these programs are focused on primary prevention, have been tested for effectiveness using at least one randomized control trial, and are identified as model or promising interventions by Blue Prints (The Center for the Study and Prevention of Violence at the University of Colorado) or SAMHSA’s National Registry of Evidence-Based Programs and Practices.

Additional specific programs recommended are the Columbia University TeenScreen and Olweus Bullying Prevention Program. We also propose an intervention in high-risk older youth, Reconnecting Youth (small group skills training to enhance personal competencies and social support resources that

Adolescent 11 !

reduces high-school drop out, substance use, violence, depression and suicide-risk behaviors). This intervention may be included as part of our ongoing collaboration with Durham’s System of Care application for a six-year $6 million SAMHSA grant focused on transition-age youth age 16-21.

All of the identified programs have outcomes that reduce multiple adolescent risk taking behaviors (usually between 3 to 5 risk behaviors) or to increase protective behaviors primarily focusing on the following: decreased substance use, risky sexual behaviors, violence and delinquency, symptoms of depression, anger and suicide risk factors; increased school bonding or connectedness; and improved parenting and family interactions.

The AHI process to identify and plan implementation of evidence-based interventions as described above has in essence utilized a modified Communities that Care approach. The Communities that Care approach involves a process of community mobilization and needs assessment with selection and implementation of evidence-based positive youth development interventions best fitting the identified needs of the community. In a randomized-controlled trial, the Communities that Care approach resulted in decreased alcohol and tobacco initiation and number of delinquent behaviors in intervention communities.68 5. Promote Community Education*

Recommendations: (1) Social marketing campaign for teens and parents; (2) After hours, community

located parent educational opportunities; (3) Evidence-based interventions in schools and community

sites; (4) Community health advisors

Adolescents and their trusted adults articulated a strong desire for education on adolescent health issues in our focus groups and Town Hall. Proposed solutions related to health education accounted for four of the top six most popular proposed solutions during our Town Hall conversation. Positive youth development interventions (as described above) provide one aspect of education for adolescents and their trusted adults. Community education via social marketing has been shown to be effective in changing behavior, a prominent example being the Truth Campaign.69 Parents also voiced support for after hours educational opportunities regarding adolescent issues. Community education activities are also part of the teen navigator and peer educator role. 6. Use Technology*

Recommendations: (1) Teleconferencing for counseling services (mental health, health education); (2)

eHealth and mobile media interventions (use social media and texting for outreach and to promote

behavior change; (3) Universally accessible, shared electronic medical records The use of technology is a critical component to the success of an adolescent health program.

Technology is a primary means of communication and personal interaction among young people who want to be able to take information with them and decide when and how to receive it. If providers or health advocates want their messages to resonate with adolescents, it is imperative that they use the appropriate means of delivering that message. eHealth and mobile media interventions are a developing, innovative field. Teleconferencing is a relatively low-cost method to increase availability and accessibility of scarce resources, such as adolescent mental health providers or health educators, that do not require physical examination for consultation. Universally accessible medical records increase the possibility for coordination of care, prevents duplication of services, and is especially useful for adolescents with chronic diseases or those accessing multiple “silos” of care. Economic Analysis and Model Stakeholders

Our proposed model of care requires a shift in financing, coordination of resources, and the prevention of risk-taking behavior and chronic illness rather than the treatment of disease. One reason this shift has not occurred in the market system is that the stakeholders for prevention and treatment often differ. Investment in adolescent risk-prevention by private insurers, for example, may result in improved long-term health outcomes, however, these insurers are unlikely to insure the same adolescent as he/she ages and thus will experience little direct financial gain from paying for these prevention services. Medical providers earn revenue from treating disease for insured patients, earn less for preventive services and

Adolescent 12 !

have no financial incentive to participate in community-level health promotion. The financial burden for deleterious health habits begun in adolescence and perpetuated in adulthood in the current health care system is on private health-care insurers, health care providers providing unreimbursed care, community members in the form of taxation to support publicly-funded safety net and social support services, including Medicaid, and the community as a whole in lost revenue and social costs of poor health and disability. While the exact economic impact of adolescent risky-behavior is difficult to quantify, one can gain an appreciation for the magnitude of the problem by looking at health care providers provision of unreimbursed care and social costs of poor health and disability.

The economic impact to DUHS of largely preventable illnesses among adolescents is significant. In reviewing hospital charges at Duke University Hospital and Durham Regional Hospital, among the uninsured adolescent population across common illnesses in four of the disease states (mental health, obesity, risky sexual behavior, violence and injury) there was over $8,100,000 in care that went fully unreimbursed (i.e. “write-offs”, self-pay/uninsured) in 2007.70 Similarly, in 2008 the number was nearly $9,700,000. These values do not reflect reimbursement from third-parties that was significantly below charges (for example, Medicaid reimbursing 33% of charges for mental health illnesses in 2007 resulted in about $450,000 in unreimbursed care; 26% or $850,000 similarly uncompensated in 2008) nor does it include unreimbursed professional charges across all payers. When considering this additional lost revenue, there is a compelling charge for DUHS to take interest in our model of care for adolescents in Durham County.

With respect to societal costs the evidence is equally compelling. Injury and Violence: Unintentional childhood illness and injury resulted in an estimated $14 billion in lifetime medical spending.71 There is an additional $1 billion in other resource costs, as well as $66 billion in present and future work losses. Risky Sexual Behavior: It is estimated that the U.S. spends more than $6.5 billion dollars a year on STD diagnosis and treatment.72 The estimated lifetime cost of a youth that contracts HIV is $199,800. It is further estimated that 181,026 years of potential life lost are due to HPV. Teen pregnancies cost the local, state and federal government $9.1 billion annually associated with increased costs for health care, foster care, and incarceration of children of teen parents.73 Substance Use: The data for substance use reveals that nationally, across all age groups, cigarette smoking and exposure to tobacco smoke resulted in at least 443,000 premature deaths, approximately 5.1 million years of life lost, and $96.8 billion in productivity losses in the United States.74 In 2001, it was reported that approximately 75,766 alcohol attributable deaths occurred along with 2.3 million years of potential life lost, or approximately 30 years of life lost on average per alcohol attributable death.75 Poor Nutritional Habits and Lack of Physical Exercise: Annual healthcare costs are about $6,700 for children treated for obesity covered by Medicaid and about $3,700 for obese children with private insurance. In general, children treated for obesity are roughly three times more expensive for the health system than the average insured child and are far more likely to be diagnosed with mental health disorders or bone and joint disorders than non-obese children.76 Mental Health: The national expenditure for mental health for children in the U.S. annually is $10.8 billion.77 In North Carolina in 2005, the medical and productivity costs from fatal youth suicides totaled $97,768,628.78 School Performance: High school dropouts are more likely to be unemployed, single parents, earn lower wages, have higher rates of public assistance, and have children at a younger age. A single 18-year-old dropout earns $260,000 less over a lifetime and contributes $60,000 less in federal and state income taxes. The combined income and tax losses for one cohort of 18-year-olds who drop out is $192 billion which is 1.6 percent of the GDP. If the male graduation rate was increased by only five percent, the U.S. could save an estimated $7.7 billion a year through reducing crime related costs and increasing earnings.

The application of much of this data in terms of real “savings” for local health care providers and Durham County requires a far more robust financial analysis, however, given the minimal expense

Adolescent 13 !

associated with Phase 1 and 2 of this proposal, the above data are compelling. For example, text-messaging information and referral is a relatively low-cost intervention: SEXINFO cost $20,000 to develop with $1500 in maintenance costs and $15,000 to market and evaluate. Recommended Policy Changes

Many policy-level changes will facilitate our proposed solutions, most notably changes in financial allocations and reimbursement related to adolescent health, education, and well-being. For medical and mental health care for adolescents, we recommend health insurance for all adolescents; improved reimbursement for primary care, mental health, nutrition services, school-based services and health education for adolescents; reimbursement for care coordination; reimbursement for non-face-to-face counseling and health education (such as using teleconferencing); increased funding for primary prevention interventions; and implementation of universal shared electronic medical records. North Carolina Medicaid is currently revising the adolescent health check requirements; this is a first step and we advocate for increased reimbursement for this service. We support the increased funding for school-based health centers and requirement that Medicaid reimburse school-based health centers on-par with federally qualified health centers that has been included in The Affordable Health Care for America Act that has passed the House (Subtitle B, Part 1, Sections 2511 and Subtitle C, Section 1730B). A potential innovative suggestion for providing lower-cost care in SBHC is to have registered nurses provide screening and protocol-driven care which would require a change in reimbursement policy. In the absence of universal health insurance, education regarding eligibility for government programs such as Medicaid and SCHIP, including criteria for determining disability which are met by many at-risk youth, should be increased. We also recommend increased funding for schools, afterschool programs, mentoring and pro-social activities. Evaluation

We will conduct process, impact, and outcome evaluation for each step in the implementation of the hub-and-spoke model of care and our proposed solutions. Process evaluation answers the questions: Is the program reaching the target group (adolescents, parents, service providers)? Is the program being delivered as intended? Is the program achieving the learning objectives (new knowledge, changed beliefs and attitudes)? Impact evaluation answers the questions: Has the program achieved intended changes in the behavior of adolescents, parents and service providers? Has the program changed the way service providers interact with adolescents and parents? Outcome evaluation answers the question: Were there improvements in the health status and quality of life of the target population?

Our long-term goal is to decrease risk-taking behaviors and improve the health markers for adolescents in Durham and as such we will measure the epidemiologic health data and YRBS data discussed in our measures section for our long-term outcome measures and compare it to matched communities in a quasi-experimental design. More immediate measures will include process and impact evaluations of programs such as the introduction of the virtual hub and youth development interventions. Each step in implementation of the model may entail assessment of the opinions and perceptions of at least four groups: adolescents, parents, service provider staff and the organization in which any intervention occurs. In addition to assessing these outcomes, we will continue to assess the community engagement process with members of the AHI collaborative. Implementation Plan

We have created an implementation plan conceptualized into approximate implementation years (Appendices AE, AF) rather than an exact timeline since timing relies on available funding mechanisms and partnerships. Year 1 activities involve creating an infrastructure to build and continue AHI and are currently underway. The absolute minimum needed to maintain the AHI is creating a “home” for infrastructure, institutionalized meetings, and accountability. We are actively in negotiations with the DCHD, the Partnership for Healthy Durham, and System of Care to provide a home for AHI. Our recommendation for the next step toward sustainability is having an Adolescent Health Coordinator who will be responsible for enacting the items in subsequent years of the timeline, including continuing

Adolescent 14 !

working with AHI, supporting its meetings, nurturing and expanding partnerships, and identifying and applying for funding opportunities for program implementation. KEY ELEMENTS OF CONNECTED CARE MODEL

Our hub-and-spoke connected care model detailed above relies on the development of a coordinating infrastructure or “virtual hub,” enhancement of existing adolescent services and development of additional adolescent-specific services and evidence-based interventions. Key elements that share themes common to all DHI projects are starred in previous sections and include: Themes Common across DHI Specifics for AHI

Continuation of project collaboratives Find “home” for AHI Continuation AHI regular meetings and leadership

Resource coordination Adolescent Health Coordinator Texting information and referral resource Resource website

Community health education Community-located education for adolescents/parents Social marketing, including texting and social media Peer educators

Evidence-based interventions Prioritize positive youth development interventions Patient navigators Teen navigators Care coordination Same Technology Teleconferencing/telemedicine Texting and social media use essential Electronic medical records Same

Cross-cutting programs (eg patient navigator program) can be created to address many of these shared themes but adolescent-specific training and personnel will be essential to effectively interact with the adolescent population.

Continued success for AHI requires continued engagement of stakeholders and the Durham community. Stakeholders for our connected care model include community members, Durham City and County government, public agencies such as DCHD and DPS, all service providers (both medical and non-medical), and Duke University Health Systems to both decrease unreimbursed care and invest in having a healthier workforce. It is essential that we continue the enthusiasm and excitement generated by the AHI project. Our Town Hall gathered community support, energized attendees and collaborative members, and was well received and publicized (Appendix AG). Our Community Engagement Workgroup is actively creating a plan to increase the strength of engagement of the community, which will be presented at our January meeting.

We look forward to moving toward the implementation phase of the project and thank DHI for the support we have received in creating AHI’s model of care to enhance adolescent health in Durham.

Adolescent 15 !

APPENDICES

Appendix A - Duke University Health Systems Data Appendix B - Community Health Assessment – Durham Primary Care Practices Appendix C - Community Health Assessment – Non-Medical Service Providers Appendix D - Map – Mortality Appendix E - Map – Violence-Related Arrests; Map – DUHS Violence-Related Visits Appendix F - Map – Pregnancy, Public Data; Map – Pregnancy, DUHS Data Appendix G - Map – STDs, DUHS Data; Map – Risky Sexual Behaviors, DUHS Data Appendix H - Map – Substance-Related Arrests; Map – DUHS Substance Use Visits Appendix I - Map – DUHS Obesity-Related Visits Appendix J - Map – DUHS Non-Substance Use Mental Health Visits Appendix K - YRBS Summit Summaries Appendix L - AHI Organizational Structure Appendix M - AHI Collaborative Programs and Steering Committee Members Appendix N - Steering Committee Self-Assessment Survey Appendix O - Steering Committee Self-Assessment Results Appendix P - Digital Storytelling Guide Appendix Q - Digital Storytelling Project Appendix R - Logic Model Appendix S - AHI Process Diagram Appendix T - Summary Finding Focus Groups Appendix U - Delphi Survey Appendix V - Delphi Survey Results Appendix W - Steering Committee Voting Results Appendix X - Site Visits Summary Appendix Y - Summary Findings Town Hall Appendix Z - Community Health Assessment Map Appendix AA - Hub-and-spoke Model of Connected Care Graphic Appendix AB - Hub-and-Spoke Model of Connected Care Phases Diagram Appendix AC - Summary of Proposed Solutions Appendix AD - Adolescent Health Coordinator Job Description Appendix AE - Implementation Conceptual Diagram Appendix AF - Implementation Plan Waves Appendix AG - Town Hall Media

Appendix C – Community Health Assessment –Non-Medical Service Providers

Adolescent 18 !

Mental Health

The Durham Center

Center for Child and Family Health

Duke Behavioral Health

Catholic Charities

Triumph

Carolina Outreach

Private Practitioners

Lincoln Behavioral Health

Faith Based Counseling

DCRC

El Fututro

DCA

Durham Regional ER/Duke ER

UNC Adoldescent Services

University/College Counseling Centers

Turning Point

Duke Women's Center

The volunteer Center

Towergate

AA/NA/Alanon/alateen

School based SW and Counselors

Community Service Providers

Durham Parks and Rec

Durham Housing Authority

Durham Public Schools

Durham Cooperative Extension

Communities in Schools

El Centro Hispano

DurhamTRY

Mpowerhouse

4-H

Boys and Girls Club

Proud

Durham Tech

Boy/Girl Scouts

SWOOP

Yo Durham

ACORN

Southside Community Center

Peace Ambassadors

Durham Congregations in Action

Vocational Rehabilitation

Women in Action

Seeds

Teen Court

WIA Youth Council

County Junior Commissioners

YMCA

Durham Legal Aide

PACs

Project build

Training for Success

TROSA

Children's Environmental Health Initative

(DUKE)

Good Works

Genisis House

Durham Rescue Mission

Duke/Durham Neighborhood Partnership

Exchange Club

LATCH

SEE SAW

Plain Talk

GED programs(YES, EDGE, Achievement

Academy)

Durham Interneighborhood Council

Emily K.

Lyon Park

Edison Johnson

Help Increase the Peace

Durham County Deaths, Percent of all Decedents Aged 10-24, 2000-2006

Public housing

Neighborhoods

%

0%

0.01% - 1.72%

1.73% - 2.99%

3% - 4.71%

4.72% - 19.35%0 2 4 6 81

Miles

Ü

Appendix D - Mortality

19

Public housing

Neighborhoods

Number of Homocides

0

1

2

3

4 - 8

Public housing

Neighborhoods

Number of Weapons Violations

0

1

2

3 - 5

6 - 85

Public housing

Neighborhoods

Number of Assaults

0 - 1

2 - 5

6 - 9

10 - 14

15 - 189

Durham County Arrests, 2006-2007, Persons Aged 10-24

Total Number = 1283 Total Number = 27Total Number = 352

Appendix E - Violence

20

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Southern High School

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Hillside High School

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Brogden Middle School

Chewning Middle School

C E Jordan High School

Rogers-Herr Middle School

Durham School of the Arts

Lowe's Grove Middle School

G Carrington Middle School

Shepard Magnet Middle School

Sherwood Githens Middle School

Duke Hospital and Durham Regional Patients Aged 10-24Seen for Violence and Injury

#* DHA Communities

!( Schools

Patients

0 - 52

53 - 82

83 - 131

132 - 179

180 - 485

0 2 4 6 81Miles

²

Total Count = 15,809


21

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12.28% - 14.27%

14.28% - 17.38%

17.39% - 23.28%

23.29% - 31.93%

0 2 4 6 81Miles

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22

Durham County Births, Percent of Births Born to Mothers 10-17, 2006

Public housing

Neighborhoods

%

0% - 1.16%

1.17% - 3.57%

3.58% - 6.25%

6.26% - 11.11%

11.12% - 23.53%

In 2006, there were 209 pregnancies reported in 10-17 year olds. Of these, 65 (31%) were terminated. 144 were live births.

White portions of the map had no birthsin 2006.

Appendix F - Pregnancy

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Duke Hospital And Durham Regional Patients, Percent ofPatients Aged 10-24 Seen for Pregnancy

Rate

0% - 1.12%

1.13% - 2.38%

2.39% - 3.98%

3.99% - 5.62%

5.63% - 9.42%²3 0 31.5 Miles


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Duke Hospital And Durham Regional Patients Aged 10-24 Seen for Pregnancy

Count

0 - 4

5 - 11

12 - 18

19 - 34

35 - 122²3 0 31.5 Miles

Total: 2626


25

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Duke Hospital And Durham Regional Patients, Percent ofPatients Aged 10-24 Seen for STDs

Rate

0% - 7.08%

7.09% - 8.9%

8.91% - 11.67%

11.68% - 16.08%

16.09% - 21.93%²3 0 31.5 Miles

Appendix G - STD's and Risky Sexual Behavior DUHS

26

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Duke Hospital And Durham Regional Patients Aged 10-24 Seen for Sexually Transmitted Diseases

Count

0 - 29

30 - 55

56 - 81

82 - 121

122 - 389²3 0 31.5 Miles

Total: 10,568


27

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#* DHA Communities

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Rate

0% - 7.59%

7.6% - 9.97%

9.98% - 13.13%

13.14% - 17.61%

17.62% - 23.35%

0 2 4 6 81Miles

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28

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Patients

0 - 34

35 - 57

58 - 89

90 - 132

133 - 455

0 2 4 6 81Miles

²



29

Durham County Substance Related Arrests, Ages 10-24,2005-2006

Public housing

Neighborhoods

Number of arrests

0

1 - 3

4 - 7

8 - 16

17 - 3740 2 4 6 81

Miles

Ü

Total arrests: 1540

Appendix H - Substance Abuse

30

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#* DHA Communities

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Patients

0 - 21

22 - 40

41 - 65

66 - 95

96 - 186

0 2 4 6 81Miles

²

Total Count = 7600


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Duke Hospital and Durham Regional Patients Aged 10-24Seen for Substance Abuse

#* DHA Communities

!( Schools

Rate

0% - 4.55%

4.56% - 7.52%

7.53% - 10.94%

10.95% - 15.95%

15.96% - 34.48%

0 2 4 6 81Miles

²


32

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Duke Hospital and Durham Regional Patients Aged 10-24Seen for Overweight/Obesity

#* DHA Communities

!( Schools

Rate

0% - 3.9%

3.91% - 5.13%

5.14% - 7.26%

7.27% - 10.18%

10.19% - 27.59%

0 2 4 6 81Miles

²

Appendix I - Obesity33

33

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Duke Hospital and Durham Regional Patients Aged 10-24Seen for Overweight/Obesity

#* DHA Communities

!( Schools

Patients

0 - 17

18 - 32

33 - 52

53 - 73

74 - 289

0 2 4 6 81Miles

²

Total Count = 6472

Appendix I - Obesity34

34

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Duke Hospital and Durham Regional Patients Aged 10-24Seen for Mental Health Issues

#* DHA Communities

!( Schools

Rate

0% - 8.84%

8.85% - 10.61%

10.62% - 12.12%

12.13% - 14.06%

14.07% - 34.48%

0 2 4 6 81Miles

²

Appendix J - Mental Health

35

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Duke Hospital and Durham Regional Patients Aged 10-24Seen for Mental Health Issues

#* DHA Communities

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Patients

0 - 35

36 - 59

60 - 78

79 - 122

123 - 295

0 2 4 6 81Miles

²


Appendix J - Mental Health

36

Appendix K – YRBS Summit Summaries

Adolescent 37 !

Violence/Unhealthy Relationships Provider Votes

1. Safe, diverse, culturally sensitive, recreational teen environments* – places

where teens can feel welcome; racially charged perceptions

74

2. Prevention of gang membership* – talking to young people about not joining

gangs, not existing gang members (too late); alternatives to gang activity

66

3. Relationship violence/dating violence* – anger with girlfriend is one thing

that leads to relationship violence

50

4. Domestic violence in the home – students can mimick what they see their

parents do at home

41

5. Substance abuse/violence link 22

Substance Abuse (including alcohol, drugs, and tobacco) Provider Votes

1. Psychological/social factors* 44

2. Home/family life* - the problems within the home can influence drug use 30

3. Activities – can be beneficial, but can also bring about peer pressure that

leads to substance abuse

25

4. Media influence – media glorifying drug use 11

Sexual Behaviors Resulting in Unintentional Pregnancy or Sexually

Transmitted Diseases

Provider Votes

1. Peer Influence* - peer pressure to talk about sex activities 72

2. Media influence* - media promotes sexual behaviors (makes it attractive) 41

3. Open communication – open communication between parents and students 33

4. Sex education – sex education for parents and students 25

Unhealthy Eating Habits and Physical Activity Provider Votes

1. Lack of participation in extracurricular activities/physical activity* 67

2. Overweight and obesity (body mass index (BMI))* 41

3. Using diet pills or something not prescribed by a doctor – vomiting and

taking laxatives

31

4. Trying to lose weight – self-esteem issues related to trying to lose weight 29

Mental Health Provider Votes

1. Self-esteem* – youths’ image of themselves has an impact on their health;

education will benefit others

54

2. Depression* - depression that is tied to self-esteem 30

3. Home life 24

4. Abuse 19

Appendix K – YRBS Summit Summaries

Adolescent 38 !

Sexual Behaviors Youth Votes

1. Strategies for improved coping behaviors in a variety of settings – addressing

internal and external behaviors *

85

2. Communication between parents and children* 75

3. Safer sex – skill building on abstinence and how to have safer sex in the heat of the

moment

63

Violence/Unhealthy Relationships Youth Votes

1. Violence in the home – domestic violence; kids witnessing violence; learned violent

behavior*

78

2. Gang violence – a result of a distressed community* 58

3. High crime neighborhoods – crime mapping; violence with a public and private face 47

4. School violence – bullying; kids coming to school feeling unsafe; transference of

violence from home to school

32

Substance Abuse (including alcohol, drugs, and tobacco) Youth Votes

1. Substance use and abuse awareness and education in schools and communities –

education, awareness and skill building*

88

2. Parental involvement – providing information to parent on treatment, environmental

and social use*

65

3. Reduce accessibility of substances coming into schools 41

Unhealthy Eating Habits and Physical Activity Youth Votes

1. Expansion of physical activity options – how can we think outside of the box for kids

that may not know about programs out there; how can other options be developed*

85

2. Start of the school day – children getting to school on time and getting enough sleep

the night before; environmental support *

58

3. Availability of breakfast – when is it available; when do children arrive to receive

breakfast

37

4. Coordination of students/parents/schools – education and accountability 24

Mental Health Youth Votes

1. Depression/suicide prevention* 95

2. Prevention and intervention – what is going on in the home; are people in the after

school programs that can effectively communicate with the parents; how do you help

the parent and support the parent to help the child; help children feel connected at

school*

76

3. General access to mental health services – funding, transportation, school social

worker to student ratio, getting the correct services, education of services/systems, co-

occurring with substance abuse

73

4. Fewer school-aged children gang involved 17

Appendix L – AHI Organizational Structure

Adolescent 39 !

Steering Committee Members of the Durham Community invested in improving the physical and mental

health of adolescents

Core Team Two Project Co-Leads,

Project Managers, Community Members,

Evaluator, Youth Group Advisor. They are responsible for the day-

to-day management of the planning process including the

initial review of the data, and development of the

business plan.

Community Engagement Team

Members from three community based

organizations and the youth leader. They are responsible for community involvement

and organizing the Town Hall meetings

Youth Advisory Group Youth from our target group (10-24) who meet together to discuss health issues and offer input into the planning

process. Led by the Youth Advisory Group Leader.

Workgroups: Members of the Steering Committee make up the following, with staff support from the Core Team. Communications,

Community Engagement, Data, Implementation & Sustainability, Technology

Appendix M – Collaborative Programs and Steering Committee Members

Adolescent 40 !

AHI Collaborative Programs

• Plain Talk (DCHD)

• Syphilis Elimination Program (DCHD)

• TEAS (DCHD)

• System of Care (county agencies collaborative effort/ guiding principles and philosophy)

• Partnership for a Healthy Durham (local collaboration to address the state Healthy Carolinians

initiative)

• Jovenes Lideres en Accion (El Centro Hispano)

• Joven a Joven (Planned Parenthood)

• ACCESS (Division of Community Health, Center for Child and Family Health, DCHD, Lincoln)

• Durham YES (City of Durham, Office of Economic and Workforce Development)

• Durham Youth Council (Durham City Office on Youth)

• School-Based Health Centers (Southern and Hillside)

• SPARCS (Center for Child and Family Health)

• Child and Family Support Teams (DPS, Social Services, Health Department, Durham

Center/Mental Health provider)

• Pediatric Practices (DUMC and Community providers)

• Family Medicine Practices (DUMC and Community Providers)

• Mental Health Providers (DUMC, Durham Center)

• DUMC School of Nursing

• Center for Child and Family Policy

• Community Based Health Clinics (i.e. Lyon Park, Waltown, and Holton School)

• Lincoln Community Health Center (i.e. physical health and some behavioral health)

• Clinical Services at Health Department (i.e. reproductive health, STD screening, school nurses,

prenatal care, dental care)

• Durham Public Schools (health-related programming, including substance abuse, violence/conflict

resolution, physical education, sexual health, etc.)

• School Health Advisory Committee

• CAARE, Inc.

• Durham At-Risk Youth Collaborative (PROUD, RIL, AAMLA, YO Durham)

• M-POWERHOUSE, Inc. of the Triangle

• Peacemakers

• Women’s Center, NC Central University


Adolescent 41 !

AHI Steering Committee Members Name Organization

Emily Adams Planned Parenthood of Central NC

Gail Aiken Bridges Pointe Foundation

May Alexander Hows that working

Nadeen Bir El Centro Hispano

Wanda Boone Durham TRY

Derric Boston Community Member

Glenna Boston Community Member

Chimi Boyd Women's Center, North Central Carolina Center

Mary Braithwaite Duke

Suzette Brown Duke

Vicki Burnett Duke

Faye Calhoun Biomedical/Biotechnology Research Institute (BBRI), NCCU

Annette Carrington DPHD

Heidi Carter Durham Public School Board

James Chavis PAC 1

Tiffany Chavis Durham Housing Authority

Glenda Clare Community Member

Tamera Coyne-Beasley UNC School of Public Health

John Curry Duke University Department of Psychiatry

Richard D'Alli Child Development and Behavioral Health

Juaneza Daniels DPS

Susan Denman Duke School of Nursing

Anne Derouin Southern HS Wellness Center

Mel Downey-Piper DCHD

Amy Elliot CJRC

Sionne George Duke Family Medicine

Terri Grant Durham Center

Rebecca Greco Kone DCHD_DUMC Division of Community Health

Sue Guptil DCHD

Gayle Harris DCHD

Carrie Hill PAC 1

Kristin Ito DUMC, Dept of Pediatrics

Fred Johson DUMC, Division of Community Health

Wilhelmenia Jordan DPS

Nancy Kent Durham Center

Alexandra Lightfoot UNC

Kathleen Loucks John H. Lucas Sr. Wellness Center at Hillside High School (LCHC)

Jamie Magee Miller DCHD

April McCoy DCHD

Evey McIntosh-Vick Lincoln Health

Selena Monk DCHD

Robert Murphy Center for Child and Family Health

Karen Odonnell Center for Child and Family Health

Yvonne Pena City of Durham

Channa Pickett Duke

Pilar Rocha-Goldberg El Centro Hispano


Adolescent 42 !

Vanessa Roth Planned Parenthood of Central NC

Kim Sage NECD Leadership Council

Aurelia Sands-Belle Durham Crisis Response Center

Evelyn Schmidt Duke

Evelyn Scott City of Durham

Tony Selton Community Member

Maria Small DUMC, Division of Maternal and Fetal Medicine

Terry Smith Mpowerhouse

Deborah Smith Duke

Rosa Soloranzo Office of Global and Community Health Initiatives (Duke SON)

Elizabeth Stern Duke University Health System

Rosa Tilley Planned Parenthood of Central NC

Katie Tise Center for Child and Family Health

Meshia Todd Duke Family Medicine

Wendy Tonker hows that working

Trish Vandersea Durham's Parternship for Children

Maureen Velazquez DUHS Immaculata School

Rachel Vinson Duke

Yvonne Wasilewski Center for Child and Family Policy

Richard Waters Duke

Elaine Whitworth Bridges Pointe Foundation

Jim Williams Peace Ambassadors

Kim Winton DUMC, Division of Community Health

Duncan Yaggy Duke Health System

Gail Yashar Community Member

Michelle Zechman Durham Center

Appendix N – Steering Committee Self - Assessment

Adolescent 43 !

Page 1 of 9

Welcome to the AHI Steering Committee Self-Assessment Tool!

Please click the "next" button to continue to the consent form.

AHI Steering Committee Self-Assessment Survey

Page 2 of 9

Consent Form

You are being asked to participate in a research study designed to identify strengths in the Steering Committee around trust and to help you think about ways to

build upon those strengths.

What am I being asked to do?

If you agree to participate in this study, we will ask you to complete a 15 minute survey on the web, after which you will be asked to participate in a 15 minute

follow-up group discussion at a later date to discuss ways to improve the group's functioning. After two months we will ask you to take the web-based survey again,

and conduct another 15 minute discussion with the group using the results to discuss ways to strengthen the partnership.

What are the potential risks and benefits of participation?

There are minimal risks to participation in this study. The most likely risk is that a question may make you feel uncomfortable. You can choose not to answer any

question for any reason and can discontinue participation at any time. There are no guaranteed benefits associated with participation in this study. You may be made

aware of ways to improve the way the Steering Committee functions as a result of participating in the study.

What about privacy and confidentiality?

All of the information that you give us in your responses to the surveys will be kept private. All data collected from the surveys will be collected by software that

runs on a secure computer at the Social Science Research Institute at Duke University. Your IP address will serve as an identifier for your responses. When your

participation in the study is complete we will delete this information. In addition, when the results of this study are published or discussed, no information will be


Adolescent 44 !

included that would reveal your identity.

Voluntary participation and withdrawal

Your participation in this study is completely voluntary. If you agree to be in this study, you may end your participation at any time without consequences of any

kind. You may end your participation by exiting this webpage, or by simply closing your web browser. You may also refuse to answer any questions you do not

want to answer and still remain in the study.

Who should I contact if I have questions?

If you have any questions please feel free to contact Dr. Yvonne Wasilewski , Project Evaluator at 919-668-3290.You can also call the Duke University Health

System Institutional Review Board at 919-668-5111.

*I have read this consent form. I understand the information about this study. All my questions about the study and my participation in it have

been answered. By selecting "Yes, I want to participate in this study" and clicking NEXT, I agree to participate in this study and will be taken

to the first question.

Yes, I want to participate in this study

No, I do not want to participate in this study

Page 3 of 9

INTRODUCTION

The Adolescent Health Initiative (AHI) Steering Committee Self-Assessment Tool has been developed in order to initiate discussions around trust within our

community/university partnership to address adolescent health in Durham. It is intended to be a discussion and trust enhancing tool for our partnership, rather than a

measurement tool. The goal is to facilitate open discussion among steering committee members with the hope of building and facilitating trust in these

relationships.

INSTRUCTIONS

1. Please rate the following questions in each area using the scale below:


Adolescent 45 !

EXAMPLE

Strongly Disagree Strongly Agree

1 2 3 4

This is an example item. Please select one of the four

options.

2. Provide an example of a time when you felt members of the Steering committee were very good at each component.

3. Provide an example of a time when you felt members of the Steering Committee could do better.

It is okay if you cannot think of an example for every component. In such cases, please focus on the most important components. However, it is important to note

that the more examples, the better prepared your group will be for the second part of the Steering committee Self-Assessment Tool--the Facilitated Discussion.

Page 4 of 9

What is your role in the Adolescent Health Initiative?

Check more than one response, if appropriate.

Core Co-leader

Steering Committee Member

Youth Advisory Group Member

Other

I. Shared Vision


Adolescent 46 !


1 2 3 4

There is a clear and shared understanding of the mission of

the steering committee.

Give an example of a time when you were working with the steering committee and you felt people demonstrated a shared vision.

Give an example of something the steering committee could do to improve its shared vision.

Page 5 of 9

II. Inclusive


1 2 3 4

Steering committee members represent a wide range of

people and groups (e.g. parents, faith, business, local

associations, etc.)

Steering committee meetings and materials are presented in

languages that are accessible to members and community

residents.


Adolescent 47 !

residents.

The membership of the steering committee reflects the

ethnic, racial, socioeconomic, and age diversity of our

community.

Steering committee members share responsibility and

workload so that the work of the AHI is accomplished.

Give an example of a time when you were working with the steering committee and you felt people were inclusive.

Give an example of something the steering committee could do to be more inclusive.

III. Values Differences


1 2 3 4

The steering committee takes into account race, power, and

class differences during discussions and decision-making.

Give an example of a time when you were working with the steering committee and you felt people valued differences.


Adolescent 48 !

Give an example of something the steering committee could do to better value differences.

Page 6 of 9

IV. Shares Power/Responsibilities


1 2 3 4

Decision-making power is shared and not concentrated in

the hands of a few.

Steering committee members have an opportunity to

participate in decision-making.

We are able to resolve conflict in order to reach decisions.

The steering committee collects information and data and

uses it to make informed decisions.

Give an example of a time when you were working with the steering committee and you felt people shared power and responsibility.


Adolescent 49 !

Give an example of something the steering committee could do to better share power and responsibility.

V. Sound Decision-Making


1 2 3 4

The steering committee has an agreed upon decision-making

process that is spelled out in writing and is understood by all

members.

Give an example of a time when you were working with the steering committee and you felt people demonstrated sound decision-making.

Give an example of something the steering committee could do to improve decision-making.


Adolescent 50 !

Page 7 of 9

IV. Leadership


1 2 3 4

Leadership is shared among members.

Capacities and skills of steering committee members are

recognized and used by steering committee leaders.

Give an example of a time when you were working with the steering committee and you felt people demonstrated leadership.

Give an example of something the steering committee could do to improve leadership.

VII. Open


1 2 3 4


Adolescent 51 !

Ideas of all members are heard and respected.

Give an example of a time when you were working with the steering committee and you felt people were open.

Give an example of something the steering committee could do to improve openness.

Page 8 of 9

VIII. Effective Communication


1 2 3 4

Information about steering committee activities and

decision-making is freely shared and easily accessible--there

is not a lot of "insider" information.

Our steering committee has a communication plan that

fosters communication among members and the larger

community (e.g. newsletters, meetings, community forums).

Information about upcoming events and activities received

via e-mail, fax, or post is communicated to all steering

committee members.


Adolescent 52 !

committee members.

Steering committee activities are conducted in language that

everyone can understand (e.g. no jargon, multilingual).

Give an example of a time when you were working with the steering committee and you felt people communicated effectively.

Give an example of something the steering committee could do to communicate more effectively.

IX. Information about adolescent health


1 2 3 4

I have adequate knowledge about adolescent health issues to

function effectively in the steering committee.

The steering committee has helped me learn more about

adolescent health issues.

Give an example of a time when you were working with the steering committee and you felt people demonstrated knowledge about adolescent

health.


Adolescent 53 !

Give an example of something the steering committee could do to improve knowledge about adolescent health.

Page 9 of 9

X. Please select the TOP THREE components of the Self-Assessment that you think are most important for the steering committee to discuss

during the facilitated discussion session.

Shared Vision (clear, shared understanding of mission)

Inclusiveness (ethnic, racial, socioeconomic, and age diversity)

Values Differences (race, power and class differences taken into account)

Shares Power and Responsibility (shared decision-making power, opportunities for all to participate)

Sound Decision-making (agreed upon, written decision-making plan understood by members)

Leadership (shared leadership, unique skills and experiences of members recognized)

Openness (ideas of all members are heard and respected)

Effective Communication (formal communication plan, information well communicated, no jargon)

Adequate Information about Adolescent Health

Do you plan to attend the facilitated discussion about the results of this survey that will take place at on September 17, 2009?


Adolescent 54 !

Yes

No

Unsure

Thank you for taking the Adolescent Health Initiative Steering Committee survey.

Appendix O - Steering Committee Self-Assessment Results

Adolescent 55 !

Objective: To evaluate the success of implementation of the planning process for the Adolescent Health

Initiative (AHI). Specifically, we evaluated the degree to which the partnership was able to establish trust

in order to carry out its objectives.

Procedures: Steering Committee participants completed a 15 minute survey on two occasions: during

August 2009 (month three of the planning process for the AHI), and during November 2009 (month

seven). Sixty members of the Steering Committee of the AHI were asked to complete the survey.

Immediately following the administration of each survey, data were analyzed in order to provide feedback

to steering committee members at their next meeting during a facilitated discussion. The discussions took

the approach known as appreciative inquiry i.e. a strategy for purposeful change that identifies the best of

“what is” to pursue the possibility of “what could be.” On both occasions, the IRB-approved surveys were

administered on the Web using the Checkbox survey tool, which runs from a secure server in the Social

Science Research Institute (SSRI) at Duke.

Survey Instrument: The surveys assessed respondents’ standing on a number of constructs related to

trust in the partnership using a four point Likert scale ranging from Strongly disagree = 1 to Strongly

agree = 4. Participants were also asked to provide examples of times when they felt that members were

very good at each element of trust, and an example of when they felt that members could do better. At the

end of the survey, participants were then asked to rate the top three areas of concern to the continuing

success of the partnership. The Steering Committee Self-Assessment Survey generated from the

Checkbox survey tool is attached (Appendix N).

Analysis: Responses were exported and converted to an excel file. Mean scores were calculated for

elements within each domain at Time 1 and Time 2 and are summarized in Table 1 below. Preferred areas

to discuss at the next steering committee meeting were calculated by summing the number of first, second

and third choices and dividing by the total number of survey respondents. Findings are found below in

Table 2. Mean scores and percentages were calculated using MS Excel 2007. Open-ended responses for

each domain were reviewed in order to identify comments that supplemented, clarified, or highlighted

quantitative findings.

Results: Table 1 shows the results of the at the Steering Committee self-assessment surveys for Time 1

and Time 2. Twenty five (42%) of steering committee members responded to the survey at Time 1. The

domains of collaboration that received the highest ratings (highlighted in green) were Open

Communication, specifically that all ideas are heard and respected and Effective Communication,

specifically that upcoming events and information are communicated to all. Areas cited for improvement

(highlighted in yellow) were the better sharing of the workload, the need for a written and agreed upon

decision-making process, and meetings and materials in an accessible language. Nineteen (32%) of

steering committee members responded to the survey at Time 2. The elements of collaboration that

received the highest ratings were the collection and use of data in order to make decisions, and as in Time

1, all ideas are heard and respected. An area that respondents continued to rate as in need of improvement

was sharing the workload. Other areas judged as needing improvement were the diversity of membership,

i.e. members represent a wide range people and groups as well as ethnic, race, SES and age diversity.

Table 2 shows the results of topics chosen by Steering Committee members to discuss at the next

meeting. During Time 1 and Time 2 members were primarily concerned with improving communication.

During Time 1 there was a greater desire to clarify the mission or the project’s vision. During Time 2 the

concern shifted to how leadership was shared and how to better recognize and use the unique skills of

group members. These topics were addressed during the first 15 minutes of each Steering Committee

meeting following the administration of the survey.


Adolescent 56 !

Table 1: Mean Scores Elements of Collaboration T1 and T2

Domain Element

T1 Mean

(N=25)

T2 Mean

(N=19) Change

I. Shared Vision Clear and shared understanding of

mission 3.20 3.47

!

Members represent wide range people

and groups 2.96 2.79

"

Meetings & materials in accessible

language 2.92 3.16

!

Reflects ethnic, race, SES, age

diversity 2.96 2.83

"

II. Inclusive

Members share workload 2.83 2.65 "

III. Values Differences Takes into account race, power, class

differences 3.13 3.22

!

Shared power and decision-making 3.32 3.00

"

Shared participation 3.32 3.37 !

Resolve conflicts 3.00 3.33 !

IV. Shares

Power/Responsibilities

Collects & uses data to make

decisions 3.33 3.78

!

V. Sound Decision-

Making Written agreed upon decision-making

process 2.56 2.89

!

Leadership is shared 3.22 2.94 "

VI. Leadership

Capacities/ skills recognized & used 3.28 3.17

"

VII. Open All ideas heard & respected 3.58 3.47 "

Information freely shared & easily

accessible 3.37 3.16

"

Has a communication plan with

members and larger community 2.95 3.00

!

Upcoming events & info

communicated to all 3.58 3.44

"

VIII. Effective

Communication

Conducted in language everyone can

understand - no jargon 3.37 3.37

#

I have adequate knowledge about

adolescent health issues. 3.26 3.32

! IX. Information about

adolescent health The SC has helped me learn more

about adolescent health issues. 3.26 3.33

!

1 = Strongly Disagree 4 = Strongly Agree


Adolescent 57 !

Table 2: Comparison Top 3 Areas of Collaboration to Discuss at Next MeetingT1 and T2

T1(N=25) T2 (N=19)

Element of Collaboration % %

Effective communication (formal communication plan, information

well communicated, no jargon) 26% 25%

Shared vision(clear, shared understanding of mission) 23% 14%

Leadership (shared leadership, unique skills and experiences of

members recognized) 11% 32%

Sound Decision-making (agreed upon, written decision-making plan

understood by members) 9% 26%

Values differences(race, power and class differences taken into

account) 9% 26%

Shares Power and Responsibility (shared decision-making power,

opportunities for all to participate) 7% 26%

Inclusiveness (ethnic, racial, socioeconomic, and age diversity) 5% 21%

Openness (ideas of all members are heard and respected) 4% 21%

Adequate information about Adolescent Health 7% 11%

Appendix P – Digital Story Telling Guide

Adolescent 58 !

The Adolescent Health InitiativeThe Adolescent Health Initiative

Youth Advisory Group (YAG)Youth Advisory Group (YAG)

Project ManualProject Manual

Adapted from the

Center for Digital Storytelling & The Digital Storytelling Toolkit by the Llano Grande Center


Adolescent 59 !

TABLE OF CONTENTSTABLE OF CONTENTS

Introduction to the Adolescent Health Initiative…………………………....................1

Intro to the Youth Advisory Group………………………………………………….....2

Digital Storytelling Project………………………………………………………...….3-4

Steps to project completion

Step 1: What does your community look like?...............................................................5

Step 2: Everybody has a health story, what’s yours?.....................................................6

Step 3: Illustrate your life…………………………………………………………….…7

Step 4: Your voice, your eyes……………………………………………………….....8-9

Step 5: Production- putting it all together………………………………………...…..10

Step 6: How are we going to use our stories?...........................................................11-13


Adolescent 60 !

INTRODUCTION TO INTRODUCTION TO

ADOLESCENT HEALTH ADOLESCENT HEALTH

INITIATIVEINITIATIVE

The Adolescent Health Initiative (AHI) is collaboration between the Durham community and Duke

University Medical Center to develop a plan to improve adolescent health services in Durham County.

Members of the collaborative include a wide range of individuals and organizations in Durham (including

youth) that have a vested interest in the health of adolescents. The AHI was one of ten projects sponsored

by Durham Health Innovations and funded by the Nation Institutes of Health and Duke Medicine aimed at

reducing death or disability from specific diseases or disorders prevalent in the community.

Risk-taking behaviors established in adolescence are a significant source of morbidity and mortality for

adolescents and adults. Decreasing these behaviors is critical for improving the health of communities.

Current health care for adolescents in Durham is fragmented; as a result, many adolescents with

modifiable health problems and risk-taking behaviors do not receive needed care at significant cost to the

community. The AHI aims to build on existing adolescent health infrastructure and develop a sustainable

plan for a comprehensive adolescent health center (AHC).

Our goal is to provide integrated medical and mental health care and multidisciplinary care coordination

based on protocols found to be effective in improving the delivery of services in an innovative,

technology-driven medical home setting for youth ages 10-24. The desired outcome is to decrease

morbidity and mortality by reducing adolescent risk-taking behaviors which will be measured by the

following outcomes 1) decrease in adolescent risk-taking behaviors as measured by the bi-annual Durham

County Youth Risk Behavior Survey 2) increase utilization of the AHC as a medical home with a

resultant decrease in use of non-primary care services and 3) reduce morbidity and mortality among

adolescents as measured by epidemiological statistics, such as pregnancy and sexually transmitted

infection rates, youth homicide rates, and violence and substance use-related juvenile offenses in Durham.

During the planning process, the AHI worked closely with stakeholders to devise the most appropriate

model of how to build on existing services and streamline resources in the development of a medical

home model of care for adolescents that currently do not have a medical home in hopes of providing long-

term cost-savings by decreasing risk-taking behaviors and their health consequences in adolescents and

adults, decreasing specialty referrals and ED expenditures, and improving chronic disease management.

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Adolescent 61 !

INTRODUCTION TO THE INTRODUCTION TO THE

YOUTH ADVISORY GROUPYOUTH ADVISORY GROUP

Recognizing the limited timeframe of the planning process and the desire to involve youth themselves in

the process, our approach was to engage the community through two strategies.: a Youth Advisory Group

(YAG) that would be responsible for reaching out to their peers for input and feedback as they actively

participated in the development of the plan and a Community Engagement Team comprised of respected

and trusted community leaders/organizations who had already demonstrated an interest in improving

adolescent health in Durham.

For the YAG, we identified a young leader in the community to facilitate the youth advisory group over

the eight month period. Three strategies were used to form this group: (1) the base was developed

through the Partnership for a Healthy Durham Youth Advisory Group (2) reached out to existing groups

in the community, such as the City of Durham Youth Council, El Centro Hispano’s Jovenes Lideres en

Accion, Durham County Health Department’s TACT (Teens Against Consuming Tobacco) and (3)

steering committee were asked to participate in recruitment.

The YAG consisted of nearly 20 young people ages 13-24 from across the County of Durham including

traditional students from various DPS middle and high schools, at-risk students from Achievement

Academy of Durham, and students from Durham Technical Community College and North Carolina

Central University. The YAG worked to identify the community challenges that adolescents face in

accessing physical, mental and sexual health services and leading healthy lives. Through the engagement

in the completion of a creative, digital story-telling project, we were able to ensure sustained participation

of the youth. Asking questions regarding recreation and physical activity, diet and nutrition, and

transportation to grocery stores and doctor appointments, the YAG conducted street interviews of young

people throughout Durham and compiled the footage into a short documentary-style film entitled,

“Through Our Eyes: A Look at Adolescent Health in Durham, North Carolina” that was shown at the

Town Hall meeting. The YAG’s participation in this project allowed the youth to play an important role

in the development of the model of care/plan. They will likely continue to act as leaders in the movement

to improve adolescent health in Durham

"Our mission is to engage young people across Durham in the process of addressing the health concerns

of our community. One of our first projects is to use technology to develop a multimedia/documentary

project about health issues in Durham based on personal experience or the experiences of family and

friends. The stories created and told by our youth group will help prioritize the kinds of health education

that will take place in our model and be the basis to advocate for issues that will improve the health of

adolescents in the Durham community."

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Adolescent 62 !

DIGITAL STORY TELLINDIGITAL STORY TELLIN G G

PROJECTPROJECT

The Youth Advisory Group will use digital story telling as a means of capturing/sharing the personal

health stories of youth ages 13 – 24, supporting its mission of engaging young people in the process of

addressing adolescent health concerns in the Durham community. The digital story telling project will

also train youth to effectively advocate for improved adolescent health in Durham.

The YAG digital story telling process is based on the following principals taken from the Center for

Digital Story Telling:

1. Everyone has many powerful stories to tell. The ritual of sharing insights and experiences about

life can be immensely valuable both to those speak and those who bear witness.

2. Listening is hard. Most people are either too distracted, or too impatient, to be really good

listeners. And yet anyone can be reminded to listen deeply. When they do, they create space for

the storyteller to journey into the heart of the matter at hand.

3. People see, hear, and perceive the world in different ways. This means that the forms and

approaches they take to telling stories are also very different. There is no formula for making a

great story -- no prescription or template. Providing a map, illuminating the possibilities, outlining

a framework – these are better metaphors for how one can assist others in crafting a narrative.

4. Creative activity is human activity. From birth, people around the world make music, draw,

dance, and tell stories. As they grow to adulthood, they often internalize the message that

producing art requires a special and innate gift, tendency, or skill. Sadly, most people simply give

up and never return to creative practice. Confronting this sense of inadequacy and encouraging

people in artistic self-expression can inspire individual and community transformation.

5. Technology is a powerful instrument of creativity. Many people blame themselves for their lack

of technological savvy, instead of recognizing the complexity of the tools and acknowledging that

access and training are often in short supply. But new media and digital video technologies will

not in and of themselves make a better world. Developing a thoughtful approach to how and why

these technologies are being used in the service of creative work is essential.

6. Sharing stories can lead to positive change. The process of supporting groups of people in

making media is just the first step. Personal narratives in digital media format can touch viewers

deeply, moving them to reflect on their own experiences, modify their behavior, treat others with

greater compassion, speak out about injustice, and become involved in civic and political life.

Whether online, in local communities, or at the institutional/policy level, the sharing of stories has

the power to make a real difference.1

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Adolescent 63 !

DIGITAL STORY TELLINDIGITAL STORY TELLIN G G

PROJECT PROJECT

What is constructivism?

Constructivism is an emerging theory that grounds our digital storytelling development, and at the same

time, is an outcome of the process. As we build digital stories we also witness the emergence of a new

theory for community change, which is rooted in the following elements:

• respect for the narrative form;

• building trust with others as a result of sharing stories;

• formation of deep relationships; and

• cultivating a renewed understanding of story as a personal asset for the self and for community

change.

If we accept that everyone has a story—and we do—then we understand that everyone has assets.

Respect, trust, relationships, and story are among our most deeply cherished assets, and digital

storytelling honors, cultivates, and celebrates each of those assets.

These assets coupled with digital storytelling are catalysts for personal and community change. To begin,

it is necessary to understand ourselves and open ourselves to change. Once we do so, we can approach

community change efforts from a position of greater strength. Our digital storytelling experience teaches

us that social change is as much about personal transformation as it is about community transformation2.

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Adolescent 64 !

WHAT DOES YOUR WHAT DOES YOUR

COMMUNITY LOOK LIKE?COMMUNITY LOOK LIKE?

The cycle of digital storytelling

Creating a digital story is a process of understanding the self through story. Because our stories are

influenced by our surroundings, digital storytelling often includes many components including family,

work, and community. Although these components may seem separate from personal identity, digital

storytelling helps us understand the interconnections between them.

By creating a digital story, we begin to understand ourselves in a circle of interconnections. This process

is best illustrated by the “cycle of digital storytelling”: our personal story becomes what inspires our

organizational work; our work becomes what leads community change; and community change creates a

new context for personal development.

Digital storytelling is useful for people dedicated to social justice. As we understand how our personal

story interacts with the organization or community we are trying to impact, we realize that our story is an

integral part of our community and our organization. Thus, we view our story as a powerful tool to enact

organizational and community change processes3.

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Adolescent 65 !

EVERYBODY HAS A HEALEVERYBODY HAS A HEAL TH TH

STORY, WHAT’S YOUR STORY, WHAT’S YOUR

STORY? STORY?

“I didn’t think I had a story. But then I was seriously probed by a group of people I had just met. I wasn’t

uncomfortable with the probing, not as much as I was with my own perception of lacking a story. Very

quickly, however, I found I owned some powerful experiences, which essentially became my stories.

Writing one particular story became easy, but only after I went through the exploration for that story4.”

-Ginger Alferos, Mi Casa Resource Center for Women, Inc

What is your story?

Most people feel as though they don’t have a story. The truth is, however, that we all have our own

unique and interesting stories. Here are a few questions to help guide you in thinking about what your

own unique personal health story will be:

! What are your first thoughts when you hear the word “health”?

! What has been a critical health moment in your life? Why?

! What is your family’s history?

! What do you know about your family’s health history?

! What is something that you are passionate about in life?

! What are you most proud of?

Remember, your story is just as important as any other story. Take a moment to think about and write

down your personal health story. You will be amazed at how empowered you will feel after getting your

story out.

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Adolescent 66 !

ILLUSTRATE YOUR LIFEILLUSTRATE YOUR LIFE

Drawing Out Critical Moments

One activity we have used to help people think about the story they want to share digitally involves an

activity we call “moment mapping.” During the moment mapping process, participants are asked to think

about critical moments in their lives, and then to “map out” or creatively represent those moments on

paper. Afterwards, everyone presents to the group their map and tells the story of their moments.

We find that this activity is helpful because it gives people a chance to think not only critically about a

particular story, but orally, as they think of how they will tell the story, and visually, setting them up to

think about how they will aesthetically represent their story in digital form.

Moment Map Tools:

• sketch pad paper

• art supplies (pencils, pens, crayons, markers, paints and brushes, construction paper, glue, wire,

scissors, magazines [for cutting out images], pipe cleaners, etc.)

• tape (to hang maps on the wall)

This activity starts off in a group setting, where participants are asked: “What have been critical moments

in your life?” Follow up questions to emphasize the critical moment aspect of this exercise can include

“What moments in your life helped to define who you are?” or “Which moments in your life do you think

have been important in forming who you are?” Participants are given a few minutes to think and reflect

about these moments quietly. It is important to emphasize that this question is open for interpretation in

any number of ways, since everybody has unique experiences, and that they have the freedom to think

about and answer the question however they see fit. After the quiet reflection time, each participant is

presented with their own piece of sketch pad paper which they will use to create their moment map.

Using the art supply materials, the participants are given 20-30 minutes of time alone to artistically

represent those moments in whichever way they see fit. Again, openness and creativity are stressed in this

process – they can draw, paste images, or use clay and pipe cleaners to give texture to the story of their

critical moments. Once the creative process is complete, participants are asked to tape their moment maps

onto the wall of a large room as a way to create a gallery of maps.

When everyone has completed their map, and all the pieces have been placed on the wall, the group

travels from piece to piece to listen to each person tell the story of their critical moments. As members of

the group listen to each story, they are encouraged to ask questions of the presenter as a way to draw out

and develop the story5.

7


Adolescent 67 !

YOUR VOICE, YOUR EYEYOUR VOICE, YOUR EYE S S

WORKING THE CAMERA

How to Get the Best Shot When You Begin Recording

At some point in the creation of your digital story, you will be required to begin the process of recording

with a video camera. Usually, this happens when you have completed your narrative and are ready to

record it for use in your digital story. Other times, you may find that someone else has information you

need, and so you want to record an interview with them for use in your digital story. Sometimes, it may

come down to needing a certain shot of an event or place that you want to capture.

The Hardware

As you prepare to begin shooting, there are several items along with your camera that are very important

to prepare. Using these items will help to insure that whatever you record will look and sound

professional, adding to the depth and impact of your digital story.

Of course, some of the initial and most important items you want to make sure to have are your digital

video camera, a charged camera battery and blank mini DV cassette tape(s). Without any of these pieces,

it will be nearly impossible to move forward with recording.

You want to make sure before you begin that you have your camera, a battery and a tape ready, and that

they are working properly – unfortunately, many digital story producers overlook this item, and end up

with no recording at all. Your camera battery should be fully charged, allowing you to maximize the

amount of time you have to record. Also, it is helpful to use a blank mini DV tape for recording, so that

you don’t accidentally lose any material from previous recordings by shooting over them on the tape.

A tripod is another important, yet often overlooked, part of the recording process that allows for a more

professional presentation. By taking the camera out of your hand, you also remove the shaky and moving

shots that come with natural human movement; tripods allow for stable, consistent shots, and create

recordings that look and feel solid. When in question, always use a tripod.

The Camera Setup

Once the camera is ready for recording, the next step is to have your camera mounted onto your tripod.

This is done by taking the tripod head (sometimes called tripod plate) off of the tripod and screwing it

onto your camera. Most video cameras now include a receiving end for tripod heads, found on the bottom

end of the camera body. Once the tripod head is connected to the camera, you can slide it onto the tripod

to secure it.

Once everything is connected, make sure all necessary items are powered on. At this point, you are ready

to begin recording. It is usually helpful to capture a 10-20 second test recording of someone speaking with

a microphone as a final measure of how well everything is functioning.

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Adolescent 68 !

YOUR VOICE, YOUR EYEYOUR VOICE, YOUR EYE S S

The Shot

With all the necessary pieces now in place and working properly, you are ready to capture the compelling

audio and video you need for your digital story. Several factors, including angle, lighting and background,

become important considerations at this point when figuring out how to “frame” your shot.

Framing your shot involves setting up the people and area in your camera lens in a specific way so that

what you record looks and sounds aesthetically pleasing and professional.

When interviewing someone, we recommend setting up the camera about 2-4 feet away from the person,

with the camera at about eye-level. This distance allows for optimal recording with the microphones, and

allows for the shot to include mostly the interviewee’s upper body and face. Recording someone’s entire

body during an interview is usually unnecessary, unless their body is directly related to their interview in

some way; the best shot for an interview usually only has the person’s head and shoulders centered in the

frame, allowing the audience to get a better view of facial expressions during the interview.

The space you record is the next important consideration, since lighting and background come into play.

You want to make sure to record in an area that has plenty of light that allows for the interviewee to be

seen clearly by the camera. Dark areas tend to become blurry, or even blacked-out, when recorded by the

camera, and you can lose video of an interviewee if there is little light. Outdoor light works very well, but

be careful not to record with the sun in the background, as this can cause items or people in the

foreground to become blacked out on your recording.

The background of your shot can be anything, but some backgrounds work better than others, especially

when recording an interview. Stable backgrounds, like curtains or a solid-colored wall, work well because

they bring more focus to the interviewee and do not distract the audience. Dynamic backgrounds that

include a lot of space or action – such as a busy room or an outdoor scene – work well to give context to

an interview; for instance, a digital story about nature may include an interview with someone that has a

forest in the background. These backgrounds, though, can also tend to distract the audience from what is

being said in the interview if they are too busy with action6.

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Adolescent 69 !

PUTTINPUTTIN G IT ALL TOGETHERG IT ALL TOGETHER

DELIVERING A MESSAGE

Putting the puzzle together

So you’ve shot on location, captured a powerful narrative, photographed the most interesting subjects, and

selected the music to drive your digital story. What’s next? Editing presents the most crucial step in

actually forming a digital story. Before the editing process begins, all you have is information— useful,

with little direction and impact. The editor has all the power to create a story that inspires anger at

injustices, empathy for the marginalized, honor for your community, or sensible solutions to an issue. To

simplify the process of editing, one must be mindful of logging and cataloguing essential footage,

organizing all media in the computer, and finally providing the artistry to make the story come to life.

The editing process is like putting together a complicated puzzle. After assessing the media you’ve

collected or generated, you can begin assembling the puzzle pieces in a fashion that will elicit the reaction

you hope to achieve in your intended audience. Within your computer are all the elements you need to

weave together a cohesive and impacting message. While a photo of a run down school yard might evoke

a particular reaction, a narrative explaining its budgetary causes along with an interview of a child

desiring a safe playground produce extra power and meaning for that image. In any story intended to lead

change, it is important to remember the human and emotional effect. For example, add a piano rendition

of a popular children’s song as background to the school yard story and viewers will connect in a deeper

way to the message.

As editor, your goal is to have your audience empathize with your issue. To achieve this, your editing

process should be driven by your own empathy with the subject; steer away from over sympathizing. For

all other productions, such as personal or oral histories, you’ll want to be mindful to treat your subject

with respect and understanding to convey a genuine connection to your audience.

There is certainly an artistry involved in editing when you consider the nuances of putting together a

meaningful story. At the same time, there are technical aspects of editing that can be learned and practiced

to simplify the editing process7.

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Adolescent 70 !

HOW ARE WE GOING TO HOW ARE WE GOING TO

USE OUR STORIES?USE OUR STORIES?

It is important to find the message you will craft. It can be helpful to ask yourself: What are you trying to do with your digital

story?

" Inform the public about the different sides of an issue?

" Learn more about yourself or others?

" Have others consider an issue differently?

" Celebrate the impact and success of your organization?

" Create discourse on a subject nobody has the courage to talk about?

Identifying the audience(s)

The audience is an important element to consider in a digital storytelling production. In searching for an

audience, important questions emerge: How can I capture an audience’s attention and who am I looking to

impact?

Delivering your message to an audience

The reason digital storytelling is so transformative in nature is that transformation happens internally for the one making the

film and externally where the audience is presented a meaningful message. Producers need to examine the scope of the change

they want to enact with a specific audience.

Yourself

We are afforded few deliberate instances to reflect on life’s critical moments, important lessons, and interesting people. Yet

doing so is an important part of digital storytelling and seems to jumpstart most personal narratives. As the first critical

audience of any production, you have the privilege of learning deeply about your place in the world and how you got there.

11


Adolescent 71 !



Delivering your message to an audience (continued)

Family

The majority of family folklore and history is handed down by oral tradition and inevitably gets lost or changed in the transfer

across generations. Moreover, most of that tradition is seldom captured or fully understood. Within each elder and family

member is an encyclopedia of great moments, customs, and perseverance that can be captured through interviews.

Organization

In doing community work, one finds themselves crafting messages about the strategies and stakeholders that make your

organization unique. Relaying this message to your clients, stakeholders, and grantors helps celebrate successes and

communicates exactly what the organization is all about.

Community

Any member of any community—whether it is comprised of your friends, neighbors, local youth, parents, schools or

government bodies—can benefit from a meaningful message to start dialogue or create awareness about what affects them.

Digital stories can either take a stand on one side of the issue, or expose what the issue is through the presentation of unbiased

information. Vocalizing concerns or needs to a decision makers bridges those who enact policies and those most affected by

them.

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Adolescent 72 !



Disseminating your digital story

Some of the media you may want to consider using for disseminating your project include:

DVD media— Nothing brings closure to a digital storytelling production like a DVD hot off the burner. Share it with your

family, friends, or people who would find interest in your message. This massively reproducible media is perfect for giving

away at meetings or mailing to a target audience. Either way, DVD players are ubiquitous and this media can likely be your

ticket to a large audience.

Video blogs — This outlet has undergone some revolutionary changes in the past two years and as it matures, the winner is

the small production company (you) with free uploads and dependable streaming. If you have a website or a blog that your

audience frequents, then a video blog is a logical next step in your online media literacy. Sites like youtube.com and

myspace.com offer such services. One caveat, besides this being a very public forum, is that some video hosting sites give

themselves the right to use (and reproduce) your video. Read these agreements carefully and consider publishing under creative

common licenses.

Your media contacts — Whether in the press or on public television, local media outlets are usually waiting for your stories

to drop into their laps. A quick press release about an event and public access airtime for your story can create instant

awareness in your community. Perhaps taking a few choice sound bites from your digital story will entice radio listeners to go

to a public viewing of your production.

Because you will be public with your digital story, you must be sure to collect consent forms from anyone featured in the story.

This will guarantee that you have permission to use their image and voice and will protect you legally.

A good plan of action before, during, and after creating a digital story will save you the grief of not seeing your story go silent8.

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Adolescent 73 !

REFERENCESREFERENCES

1. Center for Digital Storytelling- http://www.storycenter.org/principles.html

2. Center for Digital Storytelling- http://www.storycenter.org/casestudies.html

3. Digital Storytelling Toolkit by the Llano Grande Center

http://captura.llanogrande.org/introduction.html

4-5 Digital Storytelling Toolkit by the Llano Grande Center http://captura.llanogrande.org/writer.html


http://captura.llanogrande.org/director.html


http://captura.llanogrande.org/editor.html


http://captura.llanogrande.org/producer.html

Appendix R: Logic Model for

The Adolescent Health Initiative Planning Process

• Situation: Health care for adolescents in Durham County is fragmented or non-existent; multiple risk factors but silo approach presently taken to

address them

What is being

invested What the AHI Planning Process does and who it reaches What difference it makes

Inputs Key Activities. Outputs Outcome Impact Who does the AHI reach?

Key informants

System stakeholders

Adolescents in Durham

Parents of adolescents in Durham

Community members involved in adolescent health

Greater Durham community

What does the

project invest?

Core Team time,

experience &

education

University/medical

center resources e.g.

data core, GIS,

statistical and

business

consultation

Expertise in

evidence based

models of care

Expertise of

community

participants

Diversity of

community

participants

Expertise of youth

advisors and their

parents

Diversity of youth

advisors and their

parents

What does the AHI

do?

Evidence of reach:

• Key informant and stakeholder interviews regarding

present services, gaps, desired features of new model

• Focus groups with adolescents regarding present

services, gaps, desired features of new model

• Focus groups with parents regarding present services,

gaps, desired features of new model

• Site visits to existing adolescent clinics

• Data documenting and prioritizing adolescent health

issues in Durham

• Review and documentation of evidence-based models of

adolescent health care

• Successful collaboration with community members

involved in youth issues to develop plan

• Successful collaboration with adolescent youth in

Durham (Youth Advisory Group) to develop plan

• Critical community input on the new model from Town

Hall meetings

What are short-term results?

What are

Implementation

plan will

include:

Short medium

and long term

impacts on

individuals,

organizations and

the community

Assumptions

External Factors

Creation of a plan to improve

adolescent health in Durham by

coordinating and building upon

existing resources

• Health case

• Business case

• Alternative model

• Evaluation plan

• Sustainability plan

Identify existing

adolescent resources

Identify issues of

concern to

adolescents and

their parents

Identify current

adolescent health

indicators

Identify key

elements desired in

new health care

model

Identify gaps in

adolescent health

care services

Document

community-based

participatory

process

Document

community

response to plan

process

74

DEFINITIONS

! INPUTS/RESOURCES: Inputs are the human, financial, organizational, and community resources available to do the work. Certain inputs/resources are

needed to complete the AHI planning process.

! ACTIVITIES: Activities are the processes, tools, events, technology, and actions that are used to bring about the intended outputs, outcomes, and impact.

! OUTPUTS: Outputs are the direct products of program activities and may include types, levels and targets of services to be delivered by the program.

! SHORT & LONG-TERM OUTCOMES: Outcomes are the specific changes in program participants’ behavior, knowledge, skills, status and level of

functioning.

! IMPACT: An impact is the fundamental change occurring in organizations, communities or systems as a result of program activities. If these benefits to

participants are achieved, then certain changes in organizations, communities, or systems might be expected to occur.

! ASSUMPTIONS: Assumptions refer to beliefs about the program and the way we think it will work, the participants, the way the program operates how

resources and staff are engaged, the theory of action and principles that are guiding the program. Assumptions of the AHI include:

1.

! EXTERNAL FACTORS: These are the environmental/external conditions (e.g., politics, cultural milieu, demographics, economics, values, and policies)

that form the context within which the program exists and which influence the success of the program:

1. Extent of community comfort/trust of relationship with university/medical center

2. Extent of youth advisory groups comfort/trust of relationship with steering committee and university/medical center

3. Funding priorities related to adolescent health in Durham County.

4. Characteristics of Durham County (e.g., crime rate, level of poverty)

75

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Appendix T – Summary Findings Focus Groups

Adolescent 77 !

Transition questions: Existing Adolescent Services – Parent Focus Group

1. If your teen or a friend's teen

were physically sick or had a

concern about their physical

health what would you do and

where would you take them?

2. How do you decide

whether you take

them or they go by

themselves?

3. If your or a friend's

teen were ever in need of

a check-up or physical,

either for school, sports,

or just because , where

would you take them?

4. If your or a friend's teen

had a mental health

problem such as feeling

down or depressed or

anxious, what would you do

and where would you take

them?

5. What about

concerns or

questions

related to

smoking, drugs

or alcohol or

sexual health?

6. What makes it

hard to get care for

them or be seen by

someone fore their

health problems?

Spanish

Parent

The hospital (Durham

Regional, mentioned

that they were afraid of

taking children to

hospital due to

expensive bills), a

clinic, The Lincoln

Center (although with

Medicaid… it comes

out expensive)

Always accompany child

no matter what age; one

parent commented that

although her daughter is

18 she always asks for her

mother to be with her (if

she is asked to answer

question alone, she only

stays in fear)

Lincoln, or to Lion Park,

Carborro (children are

registered there), [after some

discussion about parents

situations with clinics, one

parent noted that it's better to

take the child to a family

doctor.], or the health

department.

Look for a counselor, Centro

Hispano (…here is where you

find everything], or with a priest

Talkdirectly with

child about

everything and/or

accompany them to

events, parents

need to

communicate

Difficult to join a

clinic, the cost,

transportation

Key Question 2: Feedback on Models of Care (1-6)– Parent Focus Group

1. What kind of services would

you want there to be at this

clinic?

2. Where would you

like a clinic like this

to be located?

3. Would you take your

teen or advise other teens

to go to this clinic?

4. Would you prefer if there

was one location for such a

clinic or if there were a few

different locations throughout

Durham?

5. What kinds of

things would

make it hard for

you to go to a

clinic like this?

6. What kinds of

things would make

it easier for you to

take or send your

teen to a clinic like

this?

"Close to where the

hospitals are, or new

other known places."

"Well, it would better if there

were more."

Spanish

Parent

Where there's

transportation: more

open to the public

"If they treat me well and I

get the attention that I

needed, or course."

"Because the more there are…

sometimes they don't put more,

there's fewer people in onep lace

and less money, so, because that

also counts


Adolescent 78 !

Key Question 2: Feedback on Models of Care (7-12) – Parent Focus Group

7. What time of day and day of

the week would you want to go to

a clinic like this if you needed to

be seen?

8. What do you think

about having health

services come to places you

and your teen are to see

your teen?

9. Where are good

places for something

like a traveling van to

come to see your or

your friend's teens?

10. How would you

ideally like to

communicate with your

doctor, nurse or health

counselor?

11. We are trying to find ways to help

the different doctors, nurses and

counselors you see be able to share your

teens records. What do you think about

whether you would be willing to create

a private record or your teen's health

online that you would give permission

to your doctor to see?

"When [he's] in

school, after

school…

Phone or talk in person

… if [he's] not in

school, in the

morning.

… [Good] because that way we'd waster less

time, ti would be faster if it was especially

only for they outh, because, for example

[child] is still in pediatrics, and there's… a

bunch of children thatp ass, and then [finally

older child.]"

Weekends, mainly

for men; "If it was

Sat - if they had

appointments on

Saturday - Woo!"

Spanish

Parent

"Have it be open

during the day, and

if it's an emergency,

maybe have there

be" [...have hours

available at night for

an emergency."

"If a doctor would come to see

me, it would be as if they'd

finally given me my

citizenship!"

"As I understand it, there are

those services, but for the

neighborhoods where

Afican American's live, over

by my street I see that they

pass by, minivans that take,

they say, dentists, and they

go, and I've seen that they

go and they park there, they

put up their little house in

front and they see people,

but unfortunately for us it's

a little more, more difficult."

[about texting,

telephone, or internet to

improve adolescent

health] "Well, at the

same tiem it's not good

because they are the ones

that are most on the

internet and the web…

[separate quote] they are

the ones that find out

about things more

quickly , and if it's

something that one

should know, will they

want us to know?"

Parent's discussed the embarrassment

adolescents face in that pediatric setting

because of their age and size.


Adolescent 79 !

Transition questions: Existing Adolescent Services – Adolescent Focus Group

1. What are common

health issues that

people your age

experience or worry

about?

2. Where do your

friends go if they get

physically sick or

have a concern

about their physical

health?

3. How about for a

check-up or

physical?

4. If you or a friend had a

mental health problem

such as feeling down or

depressed or anxious, what

would you or your friend

do for that?

5. How about

concerns or

questions related

to smoking,

drugs or alcohol?

6. What

about

concerns

or

questions

about

sexual

health?

7. What makes it hard

to get care or be seen

by someone for these

health problems?

Adolescent 13-

17

Primary care physician,

clinic (seeks

information from

parents, doctor, or

clinic), the internet

(whatswrongwithme.co

m) school wellness

center

Doctor, clinic, school

doctor (not all schools

have wellness centers),

or sports manager

Psychiatrist, school counselor,

parent or adult, friend, mental

health [professional], therapist

(mention of a mental health

facility in Chapel Hill with a lot

of therapists)

Unemployement (reference

to high health insurance

costs if job benefits are

unavailable), Medicaid

ineligibility, the economy

(recession affecting

healthcare costs), no free

care given (like in the past)

Doctor (in a nearby

clinic or doctor's

office), Duke, Durham

Medical Center &

Durham Pedicatrics on

Roxboro Road, Wake

Med In Raleigh,

primary care doctor

Go to a psychiatrist (like Dr.

Ramsey on 55/54), Butner,

Holly Hill, John Umstead, and

the psych ward of Duke [after

taking their friend to the

emergency room] Adolescent 16+

Emergency Room (for

those without Medicaid

and youth mentioned it

would also depend on

the severity of their

injury)

Mental health care providers

[The Right Direction, Triumph,

and Turning Point]

NA & AA meetings

[held in churchs or

at the Hayti Center

in Durham]


Adolescent 80 !

Key Question 1: Suggestions for Improving Adolescent Services – Adolescent Focus Group

1. What would make it easier for you or your friends to be seen for the health

concerns we just discussed?

2. Ideally, where would you or your friends like to get help with these

health issues?

Adolescent 13-17 Availability of a school wellness center, but they cannot do all the

doctors can do (permission needed to write prescriptions)

Africa (holistic approach to medicine where natural remedies are used to cure

illnesses, mention of the side effects of medication), [affordable] doctor's office, free

healthcare, also an emergency-kind of setting for getting health needs met.

Transportation (by Red Cross, DATA, Access Van, Cabs,

anything reliable)

Youth expressed concern with payment and bills for those that do

not have Medicaid, Social services (youth expressed no

confidence that social services would help)

Adolescent 16+

Youth stated, "Barack just signed the health care so I'm straight."


Adolescent 81 !

Key Question 2: Feedback on Models of Care (1-6) – Adolescent Focus Group

1. What would it be like? What kind of services

would you want there to be at this clinic?

2. Where would you

like a clinic like this to

be located?

3. Would you

go to this

clinic?

4. Would you prefer if

there was one location

for such a clinic or if

there were a few

different locations

throughout Durham?

5. What kinds of

things would make

it hard for you to go

to a clinic like this?

6. What kinds

of things would

make it easier

for your to go

to a clinic like

this?

Adolescent

13-17

A [affordable] doctor's office only for

teenagers and young people, older

individuals should have a separate facility

(like different levels of the hospital for

different ages, no one over 30); doctor

would be a pediatrician, but younger

children would be seen on a different floor

In the middle of Durham;

Not in an emergency

room type setting, [probed

to describe design] bright

non-primary colors, TVs

[channels like MTV or

BET], current magazines,

phones, younger doctors;

a full service facility

where you could receive

dental care as well

Should offer

physicals, basic

check-ups,

prescription pick-

up with doctor's

permission, iron

deficiency tests,

pregnancy tests

yes and no, it would be

a waste of gas; should

have one… hooked in

with the school a block

or so away

[reference to 24 hour

emergency room, where

the doors are open all

night but doctors have

certain hours; although

one would have to wait

for extended periods of

time if the individual

were not pregnant or in

an extreme emergency

situation]

Transportation,

their hours, the

number of doctors

on staff

Colorful and bright, wall décor, video

games & tv's available, opportunity to

participate in surveys/studies where

compensation is provided for time (to be

conducted while waiting for services),

prepared food available, food stamp cash

converter

Physicals, free pregnancy tests, nutritional

counseling, weight loss support, health

coaching, Medicaid or health insurance

aid, financial support ("like we can use

that to get abortions because abortions are

expensive"), family planning services, and

dental services

Adolescent

16+

Child services & support, childcare ["Say

like us teen parents it's hard on us… we

need help with pampers and stuff..], and

free supplies for newborns

Within the school,

nothing that looks like

if placed within the

projects (although

preferably not designed

like a mental facility -

youth expressed

anxiety about going to

hospital-like facilities)

A series of smaller

locations for

everyone

A shuttle service

between

facilities.

Key Question 2: Feedback on Models of Care (7-12) – Adolescent Focus Group

7. How about hour? What time of day and day

of the week would you want to go to a clinic

like this if you needed to be seen?

8. What do you think

about having health

services come to places

where you are?

9. Where are

good places for

something like a

traveling van to

come to you and

other people

your age?

10. How would

you ideally like

to communicate

with your

doctor, nurse or

health

counselor?

11. What do you

think about how you

could use texting,

phones or

online/computers to

improve your

health?

12. What do you

think about

whether you would

be willing to create

a private record of

your health online

that you could give

persmission to

your doctor to see?

Adolescent 13-17 Weekend hours (not

Sundays), 5 days a week,

open during school hours

Face to face

[ability to communicate

with your doctor

electronically via

email], something like

text [where a triage

method could be used

and you could receive

advice about care

instructions via text],

Twitter, Skype

[some say yes, others

say no], reminders

over email & phone

and x-rays in their

email [already

receiving them from

doctors]

Adolescent 16+

24 hours a day or 9am to

10pm (modified to 8am to

12am everyday), [when

about service hours youth

stated, "that's the whole

point it's not about having

a certain time."]

Facility needed in the

neighborhoods (especially in

the projects), something

similar to the Community

Family Life & Recreation

Center at Lyon Park

Local facility

["They should be

mobile… so then

they wouldn't have

to work all the time

so... they can be on

call"]


Adolescent 82 !

Key Question 3: Feedback on Models of Care – Service Provider Focus Group

Models 1. Let's start with Model A. What do you

think are the advantages and disadvantages

of this model? (Probed to discuss Model's B

& C)

2. Where do you think

would be the best

location for these models

and services?

3. What ideas do you

have for reaching out to

teens with technology

such as texting or the

web?

4. We would like to have

you vote anonymously

on your preferred model

of providing services,

Model A, B, or C.

(Combinations

accepted, additional

explanations also

accepted

ADVANTAGES DISADVANTAGES

Sophistication of the

model & services

included, also providers

would be able to

communicate more

easily and save on time

Although potentially

cheaper, concerns

regarding transportation

and a centralized

approach, inability to

provide needed security

"I honestly think that ultimately for

you to have a Hub Leader in A and

C, where you have a central location

as well as a mobile outreach."

Service

Provider

9/10 - 9/22

A

Adolescents can receive

a variety of services

within central location,

which decreases the

probability of patients

not following through

with a referrals.

Level of effectiveness of

service and ability to

provide a sustainable

level of personable

progressive care;

increased distance for

some and potential

parking issues

School-based clinic (like in

South Carolina where parents

can take a bus to the school

and see counselors), providers

expressed concern with

storage for equipment…

[ Other services mentioned

for models ] holistic health

program, acupuncture,

computers, day care. Center

hub for services - referral

desk, alternative clinic for

gangs, follow-up contact

center, recreational center -

staff on site every day, a

common area for different

agencies - like court &

social workers, case

managers...

Suggestions for Combined Services

- Dental, eye, mental health,

substance abuse, housing, family

counseling, counseling, recreational,

abstinence education classes, life

skills, academics, tutoring, diet and

exercise, cooking classes, flexible

open hours, a place for teens to hang

out, socialization, and computers

Health conscience

businesses, exercise

booth, or other health &

wellness activity booths

can be present, efficient

for money, inclusive –

with regard to age

If all adolescents are

directed to the same

facility, they may be

faced with stigmas

associated with certain

services - overall loss of

privacy with such an

inclusive environment

Barber shops with scripted

messages to spread awareness

about services within the

community - to speak to

adolescent males


Adolescent 83 !

Providing mental health

professionals will be on

staff - It would be

beneficial to have mental

health staff there a

couple days out of the

week as opposed to

every day, where

different services would

be provided on different

days

Would have everything

that Model A had, but it

would be much more

spread out and the size

would be smaller, where

the disadvantage would

be that each location

may not have all the

services needed.

Centrally located, Southpointe

beside the Food Court (put the

services where kids are) or in

Northgate Mall's unused

basement, churches that

operate during the day,

The schools or community centers -

traveling out in the community -

highest risk to our youth are the

ones not in school and unemployed

– up to age 24 - If they’re not in

school, not engaged, they’re the

most at risk

B

Geographic convenience

- services in multiple

facilities without heavy

transportation needed;

Creates more jobs, sense

of like community,

benefit of choosing

locations

"If you're operating

multiple sites, you're not

going to be able to have

a comprehensive care...

you can go to your local

neighborhood site and

get a referral to go here..

then there's that follow

up issue."

Block parties for health and

well-being during the summer;

Different sections in the

community could have

activities alongside health

services

Gender specific service days

- certain days would be

exclusively for young men

and certain days for young

women - in order to further

safeguard privacy

Conceptualize from

examples such as the

bookmobile and Duke's

MRI mobile screenings,

home visitation program

like Durham Connects

Fewer patients could be

seen, [Depending on

program structure,

efficiency of

communication and

maintenance of privacy,

there could be

limitations ]

There are mental health

services currently being

delivered in this way in an

effective and proficient

manner, but not for physical

health.

Community a adolescent

male only day -

basketball; activities to

encourage return visits

C

Flexibility to deliver care

where it’s needed;

Possibly home calls or

doctors on call instead of

a van; Allows you to

schedule appointments &

follow-up; Good for

those who don’t have

transportation

Possibly running out of

resources or a limitation

of services; also if

scheduling is by

location, people who

need to be seen might

miss before clinic leaves

another place - there

would need to be a

coordinator

"I know of that Calvary and

(Union) Baptist... [as] two

churches right now that are

building huge facilities… I'm

wondering if some of these

mega churches… might

consider their ministry as a

possibility [for this type of

outreach].

Duke and UNC – provide

internships allowing

younger interns to pose as

good role models for

community programs - (it

was noted by one provider

that ideally a combination of

all out-reach would be ideal)

"I think that this more intimate

setting approach is an advantage

and... as a parent... [if] the child has

an STD, [he or she] has a stigma

[attached], I wouldn't want to take

that child in because I might see

[familiar faces].

"… may be the model

that makes the most

sense…"

One thing to consider is

the waiting area and

dealing with security

issues


Adolescent 84 !

Key Question 4: Identifying Other Key Informants – Service Provider Focus Group

7. What time of day and day of

the week would you want to go to

a clinic like this if you needed to

be seen?

8. What do you think about

having health services come to

places you and your teen are to

see your teen?

9. Where are good places for

something like a traveling van to

come to see your or your friend's

teens?

10. How would you ideally

like to communicate with

your doctor, nurse or health

counselor?

11. We are trying to find

ways to help the different

doctors, nurses and

counselors you see be able

to share your teens records.

What do you think about

whether you would be

willing to create a private

record or your teen's health

online that you would give

permission to your doctor to

see?

CONCERNS: It

would be public

domain bringing

security issues, it

would be a new

introduction into a

small community,

more potential for

traffic, added safety

risks as people

come and go unless

monitoring is

enforced

CONs: Some may not be able to

reach those locations due to lack of

transportation PROs: If

schedule were advertised with

young people then they will

network… there again you could

have it stop in strategic locations

that the community would

regularly visit (possibly divided by

police substations)

Service

Provider

9/10 - 9/22

Adolescent’s hours

at least - From

2pm until about

11pm due to school

hours, 24/7

Taking the service to teens because

there is not always awareness that

services are needed, being more

visible out in the community builds

awareness about mental and

physical health

Malls, churches, schools - that

would have an open door policy so

that outside adolescents & parents

could receive services;

Mobile units – with the purpose of

going to the homes of those

who’ve missed several

appointments - to help reduce or

eliminate barriers (assuming that

barriers are the reason you didn’t

initially come…)

"The reality now is if we want

to grab adolescents we need to

Twitter,... Facebook,... blast it

on Youtube… And then... the

other thing too is just remove

the stigma, that if I choose to

show up at the clinic like it’s

not a bad thing. ... again it’s

back to the access. Where do

we… house these types of

things? I think one of the

smartest thing this community

did was to create the Safe

Haven concept at all of our fire

departments, but most of our

community doesn’t even know

that those exist and more

importantly, that it’s not just for

domestic violence. It’s for

even for young people.


Adolescent 85 !

Ending

1. Here is a magic wand. I am going to give it to each person and ask that you wave the

wand and wish for any change that would improve your health and the health of other

people your age in Durham. What would wish for?

2. What one or two things

would help YOU most in

providing services to

adolescents in Durham

County?

3. What else do I need to

know or ask if I really

want to understand how to

improve adolescent health

services in Durham?

English Parent N/A N/A N/A

Place especially for youth that is as much for health, employees treat us

cordially, offers counseling, a clinich where you would call & there's always

room for you child

Availability in the afternoons and

weekends N/A

"Well, since this is a magic wand, I'd like ot have small place where they see

specifically Hispanics, Hispanic youth, and that they'd help them a lot, but more

than anything that all the employees that work there speak 80% Spanish, and

more than anything they'll give the youth good service, right?"

Language services for only Spanish

speaking patients; Spanish speaking

personel

N/A Spanish Parent

"…I would also like a clinic where if one doesn't have social security number or

one doesn't have insurance, it can be a clinic that also has credit facilities to

accept payment according to the income of the family."

Legal and financial services N/A

Adolescent 13-

17

A privacy act for 16 and younger with the child having the choice to inform

parents or not, parents would be informed on medical issues; affordibility,

ability to sign for their own medicine at age 16

Contraceptives more readily

available for teens N/A

Adolescent 16+

Compensation for good health, teenagers to be more aware of STDs like HPV,

mandatory to visit physicians at least once a year, wish that Durham could clean

the system - no drugs, move homeless mission to Raleigh, etc

N/A N/A

The kid's motivation altered and that all services would work to strengthen

adolescents' connection with their families. Service Provider

9/10 - 9/22 Homes, housing, affordable housing, open door policy at the schools - that

resources could actually get into the school setting, social workers in a lot of

places to provide resources or slash counseling, mentoring programs

Coordination Deal with peripheral issues

Adolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi Survey

You are being asked to take part in a research study to help prioritize recommendations for how to improve adolescent health services in Durham.

What am I being asked to do?If you agree to participate in this study, we will ask you to complete a 20 minute survey on the web. After analysis of the data, we will send you another 10 minute online survey to re-rate recommendations if any did not reach consensus.

What are the potential risks and benefits of participation?There are minimal risks to participation. The most likely risk is that a question may make you feel uncomfortable. You can choose not to answer any question for any reason and can discontinue participation at any time. The recommendations to improve adolescent services gathered will be used to inform the Adolescent Health Initiative plan with the ultimate goal of improving health among adolescents in Durham County.

What about privacy and confidentiality?All of the information that you give us in your responses will not be linked to your name or email address. In addition, when the results of this study are published or discussed, no information will be included that will reveal your identity.

Voluntary participation and withdrawalYour participation in this study is completely voluntary. If you agree to be in this study, you may end your participation at any time without any consequences at any time by exiting this webpage. Please contact May Alexander at (919)768-3088 if you would like your email address removed from the list.

Who should I contact if I have questions?If you have any questions please feel free to contact our Project Manager May Alexander at (919) 768-3088 or Dr. Kristin Ito at (919)970-6560. For questions about your rights as a research participant or to discuss problems or concerns, contact the Duke University Health System Institutional Review Board (IRB) Office at (919)668-5111.

*I have read this consent form. I understand the information about this study. All my questions about the study and my participation in it have been answered. By selecting “Yes, I want to participate in this study” and clicking NEXT, I agree to participate in this study and will be taken to the first question.

1. I want to participate in this study

1. Consent Form

*Yes

nmlkj

No

nmlkj

Appendix U - AHI Delphi Survey

86


We have compiled a list of suggestions from interviews and discussions about how to improve adolescent services (age 10-24) in Durham.

Each suggestion listed below is followed by two brief questions to answer about the suggestion.

Thank you for participating. Your opinion is important and will help us prioritize our project goals!

Click next to get started.

2. Survey Questions


87


Have interventions that reach out to teens using technology such as texting and Facebook.

1. How relevant is the content of this suggestion to improving services for adolescents in Durham?

2. To what extent do you think the content of this suggestion is feasible to be implemented?

3. Suggestion

absolutely

not relevant

very not

relevant

somewhat

not relevantnot sure

somewhat

relevantvery relevant

absolutely

relevant

Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj

absolutely

not feasible

very not

feasible

somewhat

not feasiblenot sure

somewhat

feasiblevery feasible

absolutely

feasible



88


Have more school-based health centers and increase utilization and awareness of their services.



4. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



89


Have a group that advocates for adolescent health policy change (for example, making physical activity in schools mandatory, increasing reimbursment for medical providers for the longer visits required to see teens, etc).



5. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



90


Have creative incentives for teens to decrease risk-taking behavior and engage in services (examples include food, money, or other rewards).



6. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



91


Have parent education and support groups about adolescent issues and resources (examples include how to deal with the defiant teenager, how to identify mental health issues, gang intervention workshops, prevention education, etc).



7. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



92


Have mental health providers assist teens in getting a physical health assessment as a standard part of care after their initial evaluation.



8. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



93


Have more substance use and treatment programs for adolescents, including tobacco.



9. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



94


Have interventions in schools to identify and intervene in risk-taking behaviors and mental health concerns (for example, increase risk-behavior screening, train school personnel to better recognize and refer for mental health concerns, strengthen System of Care).



10. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



95


Have a social marketing campaign to increase awareness of adolescent health issues, adolescent resources and services, and decrease risk-taking behavior (for example, how to recognize mental health issues, need for yearly physicals, anti-tobacco advertising like Truth campaign).



11. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



96


Have a Durham adolescent health coordinator who is a resource about adolescent services, works to connect organizations and agencies serving adolescents, and takes referrals for assisting teens/families in accessing services.



12. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



97


Have a shared adolescent-trained health educator or social worker that all providers could access to travel to sites for patient education, care coordination, and practice education/quality improvement.



13. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



98


Have education that sports physicals should be done by primary care providers only so that risk-taking behavior assessments and continuity of care can occur.



14. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



99


Have interventions to increase adolescent risk-taking behavior screening by health providers (for example, give medical practices pre-printed risk-behavior screening forms for teens to complete while waiting for providers).



15. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



100


Have free or low-cost services for the uninsured, underinsured, or those in need.



16. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



101


Have website or "on-call" phone number to obtain up-to-date information about adolescent resources in Durham, their cost, quality, and how to access them.



17. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



102


Have a clinic for adolescent parents and their children.



18. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



103


Have more and improved community and school-based services for developmental delay and autism spectrum disorders.



19. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



104


Have cultural competency training for adolescent service providers and bilingual services when appropriate.



20. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



105


Have improved health education in schools (for example, nutrition and sexuality education, positive youth development interventions, training of school personnel to be nutrition educators).



21. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



106


Have more afterschool, recreational and prosocial activities for adolescents such as free and accessible exercise and sports opportunities and mentoring opportunities.



22. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



107


Have more obesity treatment and nutrition resources for adolescents.



23. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



108


Have interventions focusing on improving school services that affect health (for example, improving the nutrition profile of school lunches, increasing physical activity at school).



24. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



109


Have teleconferencing (videoscreen connections, skype) to provide counseling services not available at an onsite locations (for example, mental health counseling or health education for patients).



25. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



110


Have initiatives and programs that address the social determinants of health (for example, providing job training, increasing awareness of literacy rates, improving home ownership, focusing on educational outcomes and interventions, etc).



26. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



111


Have interventions and programs to ease the transition to adult care.



27. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



112


Have a group of providers committed to improving adolescent health meet regularly to build relationships and exchange information.



28. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



113


Have health services that go to teens where they are (examples include traveling van, locating services in a church or mall).



29. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



114


Have more residential programs for youth (extended-stay facilities such as group homes where teen go if need to be removed from home environment).



30. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



115


Have a comprehensive, "one-stop shop" adolescent health center with physical health, mental health and health education services.



31. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



116


Have more confidential reproductive health services for adolescents, including allowing contraception to be prescribed and distributed at school-based health centers.



32. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



117


Have a peer educator program aimed at decreasing adolescent risk-taking behavior.



33. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



118


Have better access to and quality of mental health services for adolescents.



34. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



119


Have more services sensitive to gay/lesbian/bisexual/transgender youth.



35. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



120


Have more adolescent-specific training for trainees and providers (examples include on-line training, practice visits and quality improvement).



36. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



121


Have mental health routinely incorporated into juvenile justice system; counselors should routinely educate clients about physical health, mental health and community resources.



37. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



122


Have program that hires and trains people from neighborhoods throughout Durham to provide educational and supportive services to overcome barriers to health care (also called community health advisors or patient navigators).



38. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



123


Have schools and other community sites (Park and Rec, faith-based sites, etc) be after-hours sites for services (examples include evening hours at school-based health centers, evening parent education) and/or for marketing services.



39. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



124


Have transportation or transportation discounts for teens to attend appointments or clinic visits.



40. Suggestion

absolutely

not relevant

very not

relevant

somewhat


somewhat


absolutely

relevant


absolutely

not feasible

very not

feasible

somewhat


somewhat


absolutely

feasible



125


Thank you for your time in completing the survey!

41.


126

Appendix V –Delphi Survey Results

Adolescent

127 !

We conducted 29 Key Informant Semi-Structured Interviews which resulted in 207 suggestions for how to

enhance adolescent health in Durham. Multiple reviewers jointly condensed the suggestions based on common

themes to 39 suggestions. These suggestions were sent in a web-based survey to Key Informants and Steering

Committee members to rank for relevance and feasibility. Response rate was >50%.

Relevance Feasibility

Absolutely Relevant

Have more adolescent-specific training for trainees and providers (examples

include on-line training, practice visits and quality improvement). Very Feasible

Have a peer educator program aimed at decreasing adolescent risk-taking

behavior. Very Feasible

Have interventions in schools to identify and intervene in risk-taking behaviors

and mental health concerns (for example, increase risk-behavior screening, train

school personnel to better recognize and refer for mental health concerns,

strengthen System of Care). Very Feasible

Have website or "on-call" phone number to obtain up-to-date information about

adolescent resources in Durham, their cost, quality, and how to access them. Very Feasible

Have more afterschool, recreational and prosocial activities for adolescents such

as free and accessible exercise and sports opportunities and mentoring

opportunities. Somewhat Feasible

Have more obesity treatment and nutrition resources for adolescents. Somewhat Feasible

Have interventions focusing on improving school services that affect health (for

example, improving the nutrition profile of school lunches, increasing physical

activity at school). Somewhat Feasible

Have more confidential reproductive health services for adolescents, including

allowing contraception to be prescribed and distributed at school-based health

centers. Somewhat Feasible

Have better access to and quality of mental health services for adolescents.

Somewhat Feasible (some variety of

opinions)

Have improved health education in schools (for example, nutrition and sexuality

education, positive youth development interventions, training of school personnel

to be nutrition educators).


opinions)

Have free or low-cost services for the uninsured, underinsured, or those in need.


opinions)

Very Relevant

Have interventions to increase adolescent risk-taking behavior screening by health

providers (for example, give medical practices pre-printed risk-behavior screening

forms for teens to complete while waiting for providers). Very Feasible

Have mental health providers assist teens in getting a physical health assessment

as a standard part of care after their initial evaluation. Very Feasible

Have a social marketing campaign to increase awareness of adolescent health

issues, adolescent resources and services, and decrease risk-taking behavior (for

example, how to recognize mental health issues, need for yearly physicals, anti-

tobacco advertising like Truth campaign). Very Feasible

Have parent education and support groups about adolescent issues and resources

(examples include how to deal with the defiant teenager, how to identify mental

health issues, gang intervention workshops, prevention education, etc). Very Feasible

Have cultural competency training for adolescent service providers and bilingual

services when appropriate. Very Feasible

Have a group of providers committed to improving adolescent health meet

regularly to build relationships and exchange information. Very Feasible

Have more services sensitive to gay/lesbian/bisexual/transgender youth. Very Feasible

Have a Durham adolescent health coordinator who is a resource about adolescent

services, works to connect organizations and agencies serving adolescents, and

takes referrals for assisting teens/families in accessing services. Very Feasible

Have interventions that reach out to teens using technology such as texting and

Facebook. Very Feasible

Have more school-based health centers and increase utilization and awareness of

their services. Very-Somewhat Feasible

Have program that hires and trains people from neighborhoods throughout

Durham to provide educational and supportive services to overcome barriers to

health care (also called community health advisors or patient navigators). Very-Somewhat Feasible

Have a group that advocates for adolescent health policy change (for example,

making physical activity in schools mandatory, increasing reimbursement for

medical providers for the longer visits required to see teens, etc). Somewhat Feasible

Have more substance use and treatment programs for adolescents, including

tobacco. Somewhat Feasible

Have teleconferencing (videoscreen connections, skype) to provide counseling

services not available at an onsite locations (for example, mental health

counseling or health education for patients). Somewhat Feasible

Have schools and other community sites (Park and Rec, faith-based sites, etc) be

after-hours sites for services (examples include evening hours at school-based

health centers, evening parent education) and/or for marketing services. Somewhat Feasible

Have transportation or transportation discounts for teens to attend appointments or

clinic visits.


opinions)

Have a comprehensive, "one-stop shop" adolescent health center with physical

health, mental health and health education services.


opinions)

Have a shared adolescent-trained health educator or social worker that all

providers could access to travel to sites for patient education, care coordination,

and practice education/quality improvement.


opinions)

Have a clinic for adolescent parents and their children.


opinions)

Have initiatives and programs that address the social determinants of health (for

example, providing job training, increasing awareness of literacy rates, improving

home ownership, focusing on educational outcomes and interventions, etc).


opinion)

Have interventions and programs to ease the transition to adult care.


opinion)

Have health services that go to teens where they are (examples include traveling

van, locating services in a church or mall).


opinion)

Have education that sports physicals should be done by primary care providers

only so that risk-taking behavior assessments and continuity of care can occur.


opinion)

Have mental health routinely incorporated into juvenile justice system; counselors

should routinely educate clients about physical health, mental health and

community resources.


opinions)

Appendix V –Delphi Survey Results

Adolescent

128 !

Somewhat Relevant

Have more and improved community and school-based services for

developmental delay and autism spectrum disorders. Somewhat Feasible

Have creative incentives for teens to decrease risk-taking behavior and engage in

services (examples include food, money, or other rewards).


opinion)

Have more residential programs for youth (extended-stay facilities such as group

homes where teen go if need to be removed from home environment). Less than somewhat feasible

Appendix W - Steering Committee Voting Results

Adolescent 129 !

Top Five Selected Solutions by the AHI Steering Committee 1. User-friendly, interactive resource website with hardcopy version county owned/SOC/ Network of Care

2. Evidence-based youth empowerment programs – to include panel discussions with real life stories from

community members

3. Adolescent Wellness Center – Comprehensive holistic services to meet physical, mental, social and spiritual

health needs of youth and families; Central location, community-based satellites and traveling services with

sustainability; Evidence-based, quality interventions

4. eHealth and mobile media interventions (use social networking and texting for outreach and to promote

behavior change) – webinars, web-based education for parents

5. Evidence-based interventions in schools and community sites

Complete results are below.

Create Coordinating Infrastructure

0 “On-call” resource expert – phone/text

11 User-friendly, interactive resource website with hardcopy version county owned/SOC/ Network of

Care

3 Regular meetings for adolescent service providers to strengthen relationships – begin with a ‘speed’

networking event

Enhance Existing Adolescent Services

5 Adolescent-specific training and quality improvement interventions for all staff

4 Cultural competency training for all staff ongoing, continuous

/sensitivity/awareness/humility/sensitivity/ Linguistic/make sure this doesn’t lead to over generalizing

0 Shared public health educator and social worker

0 Patient navigator program – increase LATCH for adolescents

3 Teen-friendly environments and decreased stigma

Increase Adolescent Specific Services

9 Adolescent Wellness Center - Comprehensive holistic services to meet physical, mental, social and

spiritual health needs of youth and families; Central location, community-based satellites and

traveling services with sustainability; Evidence-based, quality interventions

6 School-based Health Centers in all middle and high schools - Increase awareness and student

enrollment in school-based health center.

Support Positive Youth Development

3 Continued youth engagement and Youth Advisory Group

0 Peer educator program

11 Evidence-based youth empowerment programs – to include panel discussions with real life stories

from community members

Appendix W - Steering Committee Voting Results

Adolescent 130 !

Promote Community Education

2 Social marketing campaign for teens and parents

3 After hours, community-located parent educational opportunities – related to wellness (parent and

adolescent)

7 Evidence-based interventions in schools and community sites

0 Community health advisor/peer educator program – trained across life domains

Use Technology

0 Teleconferencing for counseling services (mental health, health education) – schools/colleges tech

resources/linguistically appropriate

8 eHealth and mobile media interventions (use social networking and texting for outreach and to

promote behavior change) – webinars, web-based education for parents

0 Universally-accessible, shared electronic medical records

Appendix X – Site Visits Summary

Adolescent 131 !

SITE VISIT SURVEY Name: TEEN HEALTH CONNECTION 08/26/09

I. CLINIC CHARACTERISTICS

1. What is the physical set-up in your clinic (number of examining rooms, conference room, counseling room, lab, etc?) __8___ Examining Rooms ___1__Lab __1___Conference Room __1___Consultation Room __1___Waiting Room “Every adolescent empowered to be healthy” History: Non-profit ; early 90’s; history is on website Collaborators: Junior league, hospitals , Good Old Girls Club, Health Dept, Volunteers Allied with health practices First located North Charlotte Teen advisory Board when first started; named it : Teen Health Connects; made video of benefits; 18 years of history Had peer educators in HIV prevention; had an Americore facilitator; 3 people 3 years in a row; went to the community; teen volunteers; Big Issue: honoring privacy not at the clinic don’t want to see their friends Program champion: Barbara Zeigler, MCAP– founder and health educator, executive director and advocate Kate B Reynolds support Duke Endowment support “you can’t be everything for everyone.” Zeigler Other services: Area mental helth Heads assessment Triage Psychologist – most visits Community inservice on adolescent development


Adolescent 132 !

2. What services does your clinic provide? (Check all that apply) Yes No IF YES: DESCRIBE

Medical Health

x

Accidents; suicides

Mental Health

x

5013C Status? Helps SAFETY WORKS WELL NEVER SAY NOT IF CAN AVOID IT.

Social Services

x

Allowed to do sexual health Next day mental health appointments School – political hot potato due to County commissioners stance

Health Education

x

Anger Management Group – didn’t wrok well

Health Behavior Counseling

x

At school

Programs in clinic or community (e.g. peer educators, for parents, prevention, obesity) Other

x Community Outreach


Adolescent 133 !

3. How do you integrate the various clinical services, especially medical and mental health services? How do you provide care coordination? We are not a stand alone system; a collaborative partnership. We have political movers and shakers! E.G. Lorrie Johnson of Planned Parenthood, Mecklenberg Medical Alliances; Junior League of charlotte, K.B. Reynolds. Worked together very carefully Old money; Charlotte money. Also we don’t complete with pediatricians – we send patients back after referral to us We got a contract with DSS; used ED figures to fortify our case Physical and Mental Health Center No silo. Partner Council for Childrens’ Rights a stellar agency also Center for Children Defense; matching social worker Having a PhD psychologist really helps; can supervise grd students 4. What are the hours/days of operation of your clinic? M-F 8-5? 5. Have you ever tried evening/weekend hours? __x___Yes _____No Tues and Thurs evening but discontinued 6. What are the benefits and challenges of evening/weekend hours?

I. PATIENT CHARACTERISTICS

7. Approximately how many patients have attended your clinic over the course of the last 12 months? _____ 8. Approximately how many visits on average does each patient make? _____


Adolescent 134 !

9. Do you have any idea what the breakdown is for reasons for visits/type of visit? 10. What is your clinic no-show rate and how do you deal with this? (I.e. what actions do you take to decrease no-shows, how do you factor no-shows into scheduling template?)

11. What is the insurance breakdown of the patients you see? (I.e. what % Medicaid, what % Health Choice/SCHIP, what % private insurance, what % uninsured?)

Percent

Medicaid

Health Choice/SCHIP

Private Insurance

Uninsured

12. How are appointments made? ___ Appointment only MOSTLY ___ Walk-in RARELY, BUT YES NOT PUBLICIZED ___Other (Please describe) 13. What would you estimate the percent of males and females to be?

Percent

Male

40

Female

60


Adolescent 135 !

14. What percent are in the following age groups?

Percent

Ages 10- 12

DK

3 YEARA AGO MAN AGE WAS 16 YEARSAges 13- 15

DK

Ages 16-18

DK

Ages 19-21

DK

Ages 22-24

DK

3 YEARS AGO THE MEAN AGE WAS 16 YEARS 15. What are the percentages of adolescents by race/ethnicity?

Percent

White (Caucasian)

70

African American or Black

25

Native American

Asian/Pacific Islander

Multi-racial

Hispanic

5

Use off site translators contracted with CMC “works better; called in advance. Just ethnicity 17. Do you keep records or are these numbers/percentages your best guess? ___x__Yes _____No, best guess 18. What is the age range (youngest and oldest) of the patients you have seen during the most recent year you have data for? ___ Youngest age _____Oldest age


Adolescent 136 !

19 Are you connected to the following organizations? Yes No IF YES: CAN YOU EXPAND ON

BENEFITS/CHALLENGES/LESSONS LEARNED?

School-based Health Centers

Are part of the health department They call us; undocumented citizens we will see them; but they may opt not to bec they will get a bill

School System

Health Department

Informal ; do not refer back and forth; the health educator does because she used to work there

Larger Health System

Pediatric Practices in your community

20. Do you provide services at any other sites? _____Yes __x___No 21. If Yes, What kinds of sites? (e.g.) juvenile justice services 22. How do your patients find out about your clinic? Who refers patients to you? Do you reach out to patients, for example with advertising? Do you utilize any electronic media or other creative communication methods to reach adolescents? WEBSITE


Adolescent 137 !

ORG MED PRC/ WE GIVE TALKS

MARKET OURSELVES TO PHYSICIAN AS SPECIALTY REFERRALS #1 DEPRESSION

ANXIETY,A DH D , DSS, CUSTODY; ADOLESCENT FRIENDLY

WE ARE PRIMARILY SEEN AS A PRIMARY CARE OFFICE

WE ARE ON THE BUS LINE; MORE DESIRABLE AREA/MORE CENTRALLY LOCATED 50% BY CAR; 50%BY BUS THIS IS A MEDICAL PRACTICE THAT SEES TEENAGERS, NOT A CLINIC BECAUSE OF MH AND EATING DISORDERS PROGRAM CEMENTED – NEW PERCEPTION; MEDICAL/MENTAL – NO OTHER PLACE IN TOWN LIKE IT 23. Are teens required to have parental consent for all visits? ___X__Yes _____No 24. Do you have an electronic medical record (EMR) and if so, which one do you use? __X___Yes _____No

III. PROVIDER AND STAFF CHARACTERISTICS

25. How people work at your clinic and what are their responsibilities? # RESPONSIBILITIES

Medical Providers

2 MDS 2 NPS

nurses

2NP

Others

1 LCSW; 1PHD


Adolescent 138 !

27. Do you provide special training to staff or community providers on working with adolescents? X _____Yes _____No

27. IF YES: Please describe the training. PHYSICIAN MARKETING DEPT

:

IV. Finances and Sustainability

28 History? 29. Can you explain to us how your clinic operates and whether it has any affiliations (e.g. hospital affiliated, independent non-profit, etc)? 30 Can you tell us a bit about the finances of your clinic? NONPROFIT SIDE FUNDS THE RX OF PEOPLE WHO CAN’T PAY 30. What is your revenue from patient visits/charges, your expenditures, and how you make up 8the remainder in a year? Do you know the average expenditure and revenue per patient visit?


Adolescent 139 !

30. How are you able to provide care to the uninsured? 31. What kind of grants do you have if any? 32. Have you had any issues maintaining the sustainability of your center over the years? How do you envision sustaining the center in the future?


Adolescent 140 !

V. ADOLESSCENT INVOLVEMENT

33. Are adolescents involved in any non-patient aspects of the clinic or function in any capacity as advisors to the colic (e.g. teen advisory board, peer educator group? _____ Yes _____ No

34. IF YES. PLEASE DESCRIBE:

VI. DATA AND OUTCOME MEASURES

35. Are you able to track data about health outcomes of your patients and your impact on the community?

_____Yes _____No

36. IF YES: PLEASE DESCRIBE


Adolescent 141 !

VII. OVERALL

37. In general how well would you say that you are meeting the demand for services from adolescents at your site? _____Very Well _____Somewhat well _______Not so well _____Not at all

38. What barriers do you think that teens and parents have in accessing your clinic?

39. What are the greatest challenges in running your clinic?


Adolescent 142 !

40. Is there anything else I should have asked if I want to understand the workings of your center/clinic? TIME 45 MINUTES FOR AP PHYSICAL 15 MINUTES FOR FOLLOW UP 30 MINUTES NEW PATIENT SUGGEST NO 15 MINUTE SLOTS


Adolescent 143 !

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!

Appendix Y – Summary Findings Town Hall

Adolescent 154 !

Town Hall Survey Results

1. How would you like to hear about services for adolescents?

% Yes

Texting 25

Website 47

Phone number you can call 27

TV 29

Radio 26

Newspapers 10

Flyers 16

Schools 31

Email 34

Facebook or Myspace 39

Friends of family 35

Your Doctor's Office 8

If yes, which (schools, stations, newspapers etc)?

! Fliers all over Durham

! School & Fliers - Northern & Radio - 97.3

! Schools - all of them, Radio - 9.75 all, TV - every channel

! Schools - all high schools

! Newspaper - N&O, Herald Sun

! Radio - 103.9, TV - channels 5-11-17-22-28-40-50

! Radio - 103.9, 97.5, 107.1

! TV - BET CW VH1 channel 14, Other - Bus stops, Retail Stores

! Fliers - all schools

! All middle/high schools, Urban radio stations, Local channels

! Herald Sun

! Northern High School, TV - News channel 14 & 6, Other - Everywhere around US

and other countries who really need it

! Chewing Middle School, TV - News channel 14 & 6

! All Durham Public Schools, Radio - 96.9 G105.1 97.5, TV - Channels Fox50

ABC11 Univision40

! School - all

! NCCU

! School - Southern High, Radio - 97.5, TV - Channel 4

! School - Southern High, Radio - 97.5, TV - Channel 14

! Library

! Middle Schools & City of Durham Newspaper

! All middle & high schools

! School - DSA, Radio - 97.5 & 107.4, Newspaper - around school & YMCA

! School - RHS

! Brogden Middle School

! Radio - La Ley 96.9, TV - Univision 40

! School - Neal, Radio 97.5, Fliers - Near my house, TV - The one's I watch


Adolescent 155 !

2. Do you think there should be?

% Yes

More recreational/ afterschool activities 86

More positive/ prosocial programs (mentoring, etc) 86

More adolescent-specific medical services 71

More adolescent-specific mental health services 78

3. How likely would you be to go to educational classes about teen issues if they were available?

4. Where would you like educational classes to be located?

% Yes

Parks/ Rec Center 29

Schools 57

Clinics 20

Websites/the Internet 33

My community 47

Apartment 24

If yes, which (community, complex, schools, centers etc)

! School - Achievement Academy, Parks/Rec Center - Doesn't matter

! School - Northern

! Schools - all high schools

! Other - Northgate & Southpoint Malls

! Community - Club Blvd, Apartment - Damar Court, School - Carter Community Ctr

! Schools - all middle & high on rotating schedules, P/Rec - target based upon

demographic profile, Other - churches

! Community - library on HWY 98, Holton

! Damar Court - Public housing

! All

! All schools

! Indian community

! Durham community, South Terrace Apartments, School - NCCU

! Any around Durham

! NCCU

! Community - Morreene Rd, Apartment - Damar Court, School - Riverside HS, Clinics -

Lincoln

! P/Rec - E.D. Mickle Park or Duke Park

! E. D Mickle Park or Duke Park

Not at all likely A little bit likely Some

what likely

Very likely

% % % %

27 55 68 11


Adolescent 156 !

! Community - Latino youth, Apartment - JaloA El Centro Hispano, Schools - Durham

School of the Arts

! Hillside High School

! School - Southern High, P/Rec - Lyon Park

! Southern High

! Apartment- Damar Court, School - Riverside High

! Clinics - Planned Parenthood

! Community - Eastway, Children's clinic

! Community - Durham

! Community - Fisher Heights & Durham Public Schools

! All of them

! Latino Complex Apt

! Community Ctrs

! Birchwood

! Community - Durham, School - NCCU

! Durham School of the Arts

! RHS

! Brogden Middle School

! Hispanic

! The park around the corner from my house

5. What day and time would you like educational classes?

% Yes

Weeknights 59

Weekend afternoons 25

Weekend mornings 37

6. How likely would you be to use the items below?

Definitely

not likely

Not Likely Likely Definitely

likely

% % % %

Phone number to call to learn about resources for teens 8 18 49 24

Phone number to call to learn about doctors/nurses for teens 8 22 45 20

Phone number to call to learn about counselors/therapists 10 22 41 22

Text number to learn about resources for teens 8 35 28 25

Text number to learn about doctors/nurses for teens 12 37 29 2

Text number to learn about counselors or therapists for teens 12 33 29 18

Website to learn about resources for teens 0 14 41 39

Website to learn about doctors/nurses for teens 8 12 47 29

Website to learn about counselors or therapists for teens 4 16 39 33

Community member trained to help you learn about

services

8 14 41 29


Adolescent 157 !

7. If there was a clinic that had doctors, nurses, counselors and staff specializing in taking care

of adolescents where would you like it to be located? (check all that apply)

% Yes

Downtown Durham 33

Church 16

Existing Clinic 22

Park/Rec Center 14

Mall 20

My Neighborhood 27

School 31

Mean Age of Respondents: 23.7 Years

Gender:

31% Male

69% Female

Race:

59% Black

5% White

5% Asian

22% Other

9% Unknown

Are you Hispanic?

25% Yes

Last grade of school completed?

25% Less than high school

14% Some high school

12% High school graduate

20% Some college

29% College graduate

1% Missing

Are you currently attending school?

51% Yes

If Yes, what program?

! Durham

! Associate Degree

! Graduate School

! NCCU Grad

! NCCU Bachelors

! NCCU

! NCCU

! NCCU

! Brogden Middle

! Northern High

! Chewing Middle

! NCCU

! Southern, TACT

! Southern, TACT

! GED

! Middle School

! CET

! Bachelor degree

! Montessori

! high school diploma

!

Appendix Y Summary of Town Hall Findings

Adolescent !

158

Town Hall Voting Results

SCORE Solutions

54 13. Using texting and social media (Facebook/myspace) to educate youth

47 2. Health Centers in all middle and high schools

39 5. Peer educator program (training teens to teach teens)

36 11. Train persons and organizations working with youth about cultural issues

35 14. Using media (TV, radio, print) to educate the community about health and services

34 9. Education for parents (trusted adults) on teen issues

33

1. Adolescent Wellness Center (youth focused doctors, nurses and counselors with

youth resources and activities)

31 3. Mobile health services in the community – traveling clinic or home visits

26 10. Health professional available by phone/text/online to answer health questions

24 8. Training community members to act as health educators

23 4. Programs that connect youth to the community and positive social activities

22 12. Website available with resources and reviews of youth services

17 6. Resource person available by phone/text/online to help find youth services

10

7. Training community members to help youth and their parents (trusted adults) access

and use the health care system

!

§̈¦40

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£¤70

£¤15

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5 0 52.5 Miles

Facility TypeMental

Physical

Physical/Mental

Potential Intervention

Schools

Appendix Z - Community Health Assessment Map

159

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160

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161

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163

Appendix AC – Summary of Proposed Solutions

Adolescent 164 !

Create Coordinating Infrastructure

“On-call” resource expert

User-friendly, interactive resource website with hardcopy version

Regular meetings for adolescent service providers to strengthen relationships

Enhance Existing Adolescent Services

Adolescent-specific training and quality improvement interventions for all staff

Cultural competency training for all staff

Teen (patient) navigator program

Teen-friendly environments and decrease stigma

Increase Adolescent-specific Services

Adolescent Wellness Center

School-based Health Centers in all middle and high schools

Support Positive Youth Development

Peer educator program

Continued youth engagement and youth advisory group

Evidence-based youth empowerment programs

Promote Community Education

Social marketing campaign for teens and parents

After-hours, community-located parent educational opportunities

Evidence-based interventions in schools and community sites

Community health advisor

Use Technology

Teleconferencing for counseling services (mental health, health education)

eHealth and mobile media interventions (use social media and texting for outreach and to promote

behavior change)

Universally accessible, shared electronic medical records

Appendix AD – Adolescent Health Coordinator Job Description

Adolescent 165 !

ADOLESCENT HEALTH COORDINATOR

Position Description

Essential Functions: • Coordinate the Adolescent Health Initiative (AHI).

o Determine the type and level of support needed to accomplish goals/responsibilities

indicated in the Strategic Plan.

o Use data to inform AHI’s Strategic Plan and current activities.

o Ensure AHI strategic plan and activities align with overall goals of community. o Develop effective methods of communication between groups, including an established

feedback loop/communication structure between committees.

• Act as a liaison and provide consultation, education, and presentations throughout agencies of the

Durham’s System of Care (hospitals/clinics, schools/colleges, courts/social services, and other support

services throughout the area).

o Assist in identifying opportunities and barriers to achieve a seamless SOC across all adolescent-

serving systems and among government departments to support positive outcomes for youth and

families.

o Strategically seek out, develop, and maintain relationships with key stakeholders to provide

recommendations, guidance, and technical assistance to ensure their internal organizational efforts

are culturally appropriate and relevant to adolescence and adolescent health.

• Participate actively as a member of the transition age youth Care Review Team.

• Present on adolescent health issues and participate in development and implementation of community and

state-based services and programs.

• Help create Adolescent Health forums f information sharing, policy discussions, and partnership building.

• Ensure representation on community coalitions and initiatives related to adolescent health.

• Develop and maintain relationships with a wide array of partners including individuals,

organizations, community groups, and schools. May include those with expertise in adolescent health issues (e.g. substance use, mental health, reproductive health, health care), populations of adolescents (e.g. immigrant youth, youth in foster care, homeless youth), and systems that address

youth issues (e.g. education, human services, juvenile justice, recreational facilities/services).

• Conduct in-service training and workshops related to adolescent health services and issues for

youth, parents and community professionals.

• Identify and organize adolescent health resources. Resources can include people with expertise,

organizations involved in adolescent health issues, print materials, training resources, etc.

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166

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Appendix AF – Implementation Plan Waves 167

Appendix AG - Town Hall Media

168

Appendix AG – Town Hall Media

Adolescent health tops forum talk

BY KEITH UPCHURCH, Herald Sun November 6, 2009 DURHAM -- The spotlight was on Durham's adolescents Thursday as parents, their children and others gathered at Hayti Heritage Center on Fayetteville Street to discuss ways to improve their health care. The "town hall conversation'' drew more than 100 people who heard and discussed ideas for better health and ways to take advantage of the resources in Durham. One mother, Shauntelle Evans of Durham, said she wants her two sons to develop good habits for a lifetime. "I'm interesting in learning different stuff for the adolescents, because they always focus on the adults and babies, but the adolescents seem to get lost in Durham. It's hard to get men into a clinic to get checkups, so I want to start them at an early age so they can keep on going with their health care.'' One of her sons, 11-year-old Marquise Evans, said he's more conscious about healthy eating. "I'm not eating a whole bunch of fried stuff,'' he said. "My blood pressure is excellent. I'm staying healthy.'' Another mother, Tewauna Patterson of Durham, has a 15-year-old son, Frankie. She said he's doing well in school, but she's concerned about peer pressure and the prevalence of gang violence in Durham. Participants watched a DVD of interviews with adolescents about health concerns in Durham. One youngster talked about how easy it is to opt for fast food instead of healthier fare. Another said trying to ride the bus to doctor appointments and to the grocery store can be a problem because the buses are often late or break down. And one teen suggested issuing vouchers to use the YMCA during certain periods, since many people can't afford to pay the monthly fee. Kristian Ito, a pediatrician who specializes in adolescent medicine and is the Duke co-leader for the Adolescent Health Initiative, said health services in Durham need to be better coordinated. "We can't have a healthy society without healthy youth,'' she said. "The habits that are established in adolescence continue into adulthood. So adolescence is a really crucial time for health promotion.'' Thursday's gathering was sponsored by the Adolescent Health Initiative, one of 10 teams given $100,000 planning grants to improve the health system. The grants are funded by Durham Health Innovations, a partnership between the Duke University Health System and the Durham community.


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100 attend health forum

Teens encouraged to make safe and healthy decisions

BY STANLEY B. CHAMBERS JR. The Durham News Shauntelle Evans has a brother who sees a doctor via ambulance, if he sees a doctor at all. With a family history of diabetes and high blood pressure, Evans, 36, doesn't want to see the same thing happen to her two sons. Her youngest, Marquise, 11, thinks cartoons may help keep him interested in healthy living. "I feel like TV is fun, plus the commercials give you information about what's needed and different places you never heard of," he said. Marquise, along with about 100 other people, attended a town hall conversation last week at the Hayti Heritage Center to suggest ways to improve adolescent health. The Adolescent Health Initiative, a group formed after a 2007 risk behavior survey, brought the mostly teenage crowd together. The survey led to a realization that local health services for teens are fragmented, said Dr. Kristin Ito, a Duke Medicine pediatrician specializing in adolescent medicine. The services are available, but people don't know how to access them. "Some teens don't go to their physicians," she said. "Medical providers are an important source of information, but we wanted to make sure teens can get information through other ways. The better educated folks are and the more they know about resources, they'll be able to make better health choices." When it comes to making safe and healthy choices, Durham teenagers are a mixed bag. With responses from 484 middle and 392 high school students, the report stated that 29 percent of the middle school students have carried a weapon, over half have been in a physical fight and 29 percent have been bullied or harassed on school property. Over a quarter of the high school students were depressed enough to stop their normal activities, 18 percent had attempted suicide and over 35 percent had used marijuana. The numbers regarding mental health and substance abuse were especially concerning, said Donald Hughes, the initiative's youth advisory group leader and recent City Council candidate. "We know that unhealthy young people often grow up to be unhealthy adults," he said. "And there's a social cost with having an unhealthy population. It affects our education system. It affects our health system. It affects our community at large." Through street interviews, the group found that most youth want to live healthier lives but: Fast food is easy and cheap It takes too long to get to a doctor or a supermarket via bus


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More in-school recreation activities are needed Attendees got $50 in "adolescent health bucks" to place into bags with suggestions taped to them. Ideas, which came from teenage focus groups, include listing health resources on a Web site, training residents to become health educators and mobile health centers. Alexandria Horne, 22, put $30 into teenagers being able to text questions to a health professional and $20 on having health centers in all middle and high schools. When she attended Jordan High School, Horne said the school nurse was available only two days a week. The wait was potentially embarrassing, especially when someone needed things like deodorant. "Kids are going though this awkward stage between middle and high school.," said Horne, now a N.C. Central University senior. "A nurse or a health center would be a really good place for them to feel comfortable and get the things that they need that they may not be able to afford." Shauntelle Evans, Marquise's mother, has seen teenagers with adult health problems. As a health adviser for the county health department, she has come across middle school students with obesity and high blood pressure. "It's harder nowadays for our kids to even eat healthier," she said. "If you're on a budget, the organic food cost too much. So it's harder for us to eat healthier than to eat fast food." Efforts using texting and social media were among the top votes, Ito said. The imitative plans to incorporate the suggestions into a plan to address adolescent health. "It was really wonderful to see so many adolescent and young adults and to hear their thoughts," Ito said.

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