HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Title V and Adolescent Health

ROBERT NYSTROM: Good afternoon, everybody. My name is Bob Nystrom. I'm the State Adolescent Health Coordinator from Oregon. I'm really happy to be associated with this group and proud to say I've been around for development of the number products, the conceptual framework and systems capacity tool.

I'm here to talk about taking this down to the local level. In some respects I'm known to be a little bit of a rebel, sometimes doing my own thing. And when working on this tool, I sort of had an aha at the state level in terms of wanting to better understand capacity to do adolescent health at the local level. So I'm going to take you through basically an adaptation of the tool and some of the early results that I have with it.

First off, just a little bit of framework for Oregon 's adolescent health program. As you've probably already noted, there are vast differences between states and in fact that root of even wanting to put together the states systems capacity tool was a real recognition that varying capacity amongst states was directly related to their ability to engage the population and work on health‑related outcomes.

Our program is in our Title V program. That's the Office of Family Health and Public Health Services. We started out with a coordinator in 1994, which was funded by a SPRANS grant and have grown considerably. Our Title V director, I felt, really saw the vision around focusing on adolescent health. I joined the program in '96 to work with the state school‑based health center program, which had been in existence since 1986 and became the first manager of our adolescent health section. She took adolescents and elevated it to an equal section comparable to any other Title V component within our office.

Right now we have a school‑based health center program, CDC coordinated school health program called Healthy Kids Learn Better. Some teen pregnancy prevention activities and nutrition and physical activity. And, of course, I link with a lot of other people within public health and other state agencies.

From that one person in 1994, and I think the vision of our director and a lot of hard work, I'm pleased to report, I have to revise this figure on resources, we're now up to 12 staff that are focusing in full or in part on adolescent health. I am still the manager. There are now ten program staff and one support staff.

Our combined budget probably need to revise this a little bit, too, is right around two and a half million dollars a year, which is 5 million per biennium. We're a biennium state, our Legislature meets and sets a budget every two years.

For those who need a picture of Oregon, some of you might recognize Portland on the left. Left part of the image. But what most people don't realize that more of the state actually looks like the image on the right.

And we do find adolescents in both places, in fact the image on the right is a real dangerous place for drinking and driving. A lot of fatalities actually associated with rural drinking and driving.

A quick snapshot from our population. Not different, but I like to remind people about the basic demographics, our adolescents, the proportions of adolescents are growing in our population, up to three‑quarters of a million. They are more racially and ethically diverse compared to the population as a whole, really reflecting the changing demographics of our state. Not unusual, as adolescents get older, they're less likely to have insurance. Nearly a third, between 18 and 24 have no type of health care coverage. They report a lot of foregone care, in other words, they have needs but they're not being met. And from a preventive services viewpoint, one in two did not see their primary care provider for well adolescent check in the last year.

The wild, wild west is really still there. That picture on the right, what you might be surprised is that 35 out of 36 Oregon counties actually meet the criteria for rural or frontier. The Portland Metro area, obviously, has the largest population, most diverse population, but the work in Oregon really is in more areas that are underserved both medically and have healthcare shortage providers, et cetera. That translates right down to how well we're able to work with adolescents.

So what I did was think globally, act globally. So I asked the same question: What are my local health departments capacity to engage adolescent health?

Quick description of what it looks like. We have a county‑based system: 36 counties, 35 public health authorities. Two counties, ourselves, sparse, actually combine their efforts. We have in place an adolescent health annual plan. A contract where we give out public health monies. We have an adolescent health component. That's an opportunity where I can ask some questions and there's 28 health areas that I ask about in terms of activities, work with teen pregnancy, nutrition, physical activity, immunization, programs, et cetera. I also ask about technical assistance requests. So I have some information on local health departments, and this is also the same mechanism conveniently that we funnel our money back out. So they have to do an annual plan. I have some assessment information. We have a defined element where we put all our guidance on what would constitute good strategies or activities, and it's a place where then we would actually attach any funding we have available to the local health department level.

So although I had a fair amount of expectation there, knew a fair amount about their activities, I really knew nothing about their basic capacity to do adolescent health on a local level.

So I really just reversed the question in an attempt to answer this question. Now, the problem was we weren't going to be able to use the tool that was developed for national state assessment. It's quite large. As people have mentioned, it can be, can consume a fair amount of time. Requires a very large number of partners. And so we had to slim this thing down.

First thing we did was put it on a bit of a project plan. These are the five phases we crafted out. And our goal was to turn this into a rapid assessment. We wanted to come out with a tool that could be done on a local level in under two hours and we wanted to create a tool and a package and put out a request that would get at least 80% of our local health departments responding with.

We pretty much got there. This is what the packet looked like that we ultimately developed. There was a one‑page cover letter explaining the request and the rationale. I did a little bit of footwork before that with some other partner groups. There's a single page of instructions.

The tool was a front and back tool that synthesized the basic elements or capacity areas that's found in the national document and has a five‑point Lichert scale attached to it. There's definitions to help them better understand each of the capacity areas. And then we packaged it up with some resources, a copy of the conceptual framework and a copy of the national initiative guide as an incentive to use the tool and perhaps pass it on to the focal point in the county for adolescent health if they had one. We also tried to help them understand the crosswalk between the essential services, Maternal Child Health for adolescents and the use of this tool and those capacity areas. So that's what the package looked like.

This is a process we went through, you can note where we are now that the final report is supposed to be done. I'm glad to say it is done. I missed it by a month. I finally finished up editing the other day. And in our earlier meeting in the spring with state adolescent health coordinators I reported some preliminary results and I've updated them here.

We took the information that they did, entered it into an Excel data template. The only stratification we did was to see what the correlation between county size was, basically a proxy for health department size, and, of course, any kind of tools like this have some real limitations around being a self‑report and then the local variability of teams.

We did not expect them to do a rapid assessment and to bring 15 or 20 people into the room. We asked for a minimum. There was one person associated with their public health department administration, one with their clinical services, and one that could represent health education that were familiar with the adolescent health programming within their local health department. So at a minimum three people did this rapid assessment. In many cases they did convene 10 or 12 people to participate in it.

We came close. We didn't get 80%. We got 77% of our counties responding. They reported back to us that their mean capacity to do adolescent health, 100 percent meaning they were excellent in every single area that the tool measured. It was 57%, quite a large range, from low of 17% to high of 87%. Some of our counties felt they were doing a really good job in this area. Others obviously reported they had very little capacity. About eight counties were 70% or more. Half the counties, 14, were 50% or less.

If you take a look of the sections, at the sections that the tool actually evaluated, the capacity areas are formal commitment, effective partnerships, ability to plan and evaluate, focus on policy and advocacy, data systems and technical assistance. And there's a couple of questions, two, three, or four for each one, and to the right then are the means that they reported back statewide.

You can see that their highest areas were in effective partnership and their ability to provide technical assistance in the area of adolescent health, and where they felt they were the weakest had to do with planning and evaluation and then sort of equal with policy and advocacy and data systems.

Just because they were high or low in one area didn't mean that there wasn't some real internal differences between questions. If we took a look at the actual individual questions, sort of simultaneously and the highest rated elements are at the top and the lowest rated elements are at the bottom, you can see the two areas of partnership they reported very good capacity. And this is their formal and informal partnerships with agencies and agencies that specifically served youth. But what's interesting is that the lowest element single question the entire tool was also in the area of partnership and it was involving youth and families directly. And this is probably one of the most interesting findings in taking a look at the data that the local health departments responded back on.

This shows you the variability just within that one area of partnerships and we think this is really important because there's been a lot of attention to the youth, positive youth development framework. Patty mentioned it as a foundation to her state adolescent health program. This is a place where we feel we can come back to local health departments, help them better understand positive youth development strategies, work with them, either training or technical assistance to improve this particular area of capacity in their local health departments. So we easily spotted some things that we could do to help them.

This is a representation, we just did one stratification, those counties we thought had the large test departments and likely would have the most capacity and then some of our smallest counties that had the least number of FTE and might have the least capacity.

Not surprisingly, that's the pattern you see. The five most populous counties that reported, all reported feeling much stronger than the five least populous, with the exception of one. And it seems like planning and evaluation is a challenge, whether you're in a big county with a lot of resources or in a small county with very few.

So, again, this is an area we might feel we'll be able to go out and target some technical assistance in.

I remember one comment that was scribbled onto the side of the sheet from one particular county that said: Strategic planning, I don't even have time to eat lunch. And I can identify with that.

So here are some potential outcomes from doing this exercise within the state. First off, now local health departments have a baseline to measure their capacity to work with this population. So as we work to try to help them, we'll hopefully be able to come back in two or three or four years and see if we've made any progress and they can see if they've made any progress. One of the most outstanding results has nothing to do with the data but all of the comment we got back to say this is the first time we ever sat down in our county and talked about adolescents as a population. They remarked that, you know, we talked about them but only in the context of our family planning program. We talked about adolescents but only within the context of immunizations. So this was the first time just getting them to engage in this tool, they started talking about adolescents as a population within their local health department. We now have new information hopefully to seek additional funding and to target that funding or plan those resources so that they're targeted at the highest needs for counties collectively or for individual counties.

So we're really hoping to plan our technical assistance and our involvement better. And we think all in all it was a good experience and good effort to better understand capacity in Oregon.

I always try to remember that whatever we're doing within our respective job, what it's really all about is the adolescents. That's where my heart is and I know that's where the heart is of the people up here at this table. So I think at this point I'm done and we're going to open it up to questions.

Thank you.