Health and Outreach Across Latin Ammerica, Guatemala and Peru by Megan Durham
THE DURHAM HEALTH NNOVATIONS PROJECTsites.duke.edu/durhamhealthinnovations/files/2015/...Sep 17,...
Transcript of 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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Adolescent
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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
Northern High School
Hillside High School
Riverside High School
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
Appendix E - Violence
21
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Southern High School
Northern High School
Hillside High School
Riverside High School
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
Rate
0% - 12.27%
12.28% - 14.27%
14.28% - 17.38%
17.39% - 23.28%
23.29% - 31.93%
0 2 4 6 81Miles
²
Appendix E - Violence
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
23
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§̈¦40
§̈¦540
§̈¦85
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tu70
tu501
tu15tu70
tu15
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
Appendix F - Pregnancy
24
§̈¦85
§̈¦40
§̈¦540
§̈¦85
§̈¦40
§̈¦85
tu70
tu501
tu15tu70
tu15
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
Appendix F - Pregnancy
25
§̈¦85
§̈¦40
§̈¦540
§̈¦85
§̈¦40
§̈¦85
tu70
tu501
tu15tu70
tu15
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
Appendix G - STD's and Risky Sexual Behavior DUHS
27
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tu15
tu15Neal Middle School
Southern High School
Northern High School
Hillside High School
Riverside High School
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 Risky Sexual Behaviors
#* DHA Communities
!( Schools
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
²
Appendix G - STD's and Risky Sexual Behavior DUHS
28
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tu15Neal Middle School
Southern High School
Northern High School
Hillside High School
Riverside High School
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 Risky Sexual Behaviors
#* DHA Communities
!( Schools
Patients
0 - 34
35 - 57
58 - 89
90 - 132
133 - 455
0 2 4 6 81Miles
²
Total Count = 11,708
Appendix G - STD's and Risky Sexual Behavior DUHS
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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tu15Neal Middle School
Southern High School
Northern High School
Hillside High School
Riverside High School
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 Substance Abuse
#* DHA Communities
!( Schools
Patients
0 - 21
22 - 40
41 - 65
66 - 95
96 - 186
0 2 4 6 81Miles
²
Total Count = 7600
Appendix H - Substance Abuse
31
!(
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¬«157
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¬«98 tu70
tu501
tu15
tu15Neal Middle School
Southern High School
Northern High School
Hillside High School
Riverside High School
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 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
Appendix H - Substance Abuse
32
!(
!(
!(
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!(
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¬«55
¬«147
¬«98
¬«751
¬«157
¬«54
¬«147
¬«98 tu70
tu501
tu15
tu15Neal Middle School
Southern High School
Northern High School
Hillside High School
Riverside High School
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 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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§̈¦85
§̈¦40
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§̈¦85
§̈¦40
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¬«55
¬«147
¬«98
¬«751
¬«157
¬«54
¬«147
¬«98 tu70
tu501
tu15
tu15Neal Middle School
Southern High School
Northern High School
Hillside High School
Riverside High School
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 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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!(
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!(
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tu501
tu15
tu15Neal Middle School
Southern High School
Northern High School
Hillside High School
Riverside High School
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 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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tu15
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Southern High School
Northern High School
Hillside High School
Riverside High School
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 Mental Health Issues
#* DHA Communities
!( Schools
Patients
0 - 35
36 - 59
60 - 78
79 - 122
123 - 295
0 2 4 6 81Miles
²
Total Count = 10,467
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
Appendix M – Collaborative Programs and Steering Committee Members
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
Appendix M – Collaborative Programs and Steering Committee Members
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
Appendix N – Steering Committee Self - Assessment
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:
Appendix N – Steering Committee Self - Assessment
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
Appendix N – Steering Committee Self - Assessment
Adolescent 46 !
Strongly Disagree Strongly Agree
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
Strongly Disagree Strongly Agree
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.
Appendix N – Steering Committee Self - Assessment
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
Strongly Disagree Strongly Agree
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.
Appendix N – Steering Committee Self - Assessment
Adolescent 48 !
Give an example of something the steering committee could do to better value differences.
Page 6 of 9
IV. Shares Power/Responsibilities
Strongly Disagree Strongly Agree
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.
Appendix N – Steering Committee Self - Assessment
Adolescent 49 !
Give an example of something the steering committee could do to better share power and responsibility.
V. Sound Decision-Making
Strongly Disagree Strongly Agree
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.
Appendix N – Steering Committee Self - Assessment
Adolescent 50 !
Page 7 of 9
IV. Leadership
Strongly Disagree Strongly Agree
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
Strongly Disagree Strongly Agree
1 2 3 4
Appendix N – Steering Committee Self - Assessment
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
Strongly Disagree Strongly Agree
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.
Appendix N – Steering Committee Self - Assessment
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
Strongly Disagree Strongly Agree
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.
Appendix N – Steering Committee Self - Assessment
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?
Appendix N – Steering Committee Self - Assessment
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.
Appendix O - Steering Committee Self-Assessment Results
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
Appendix O - Steering Committee Self-Assessment Results
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
Appendix P – Digital Story Telling Guide
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
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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.
1
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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."
2
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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
3
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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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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.
5
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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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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.
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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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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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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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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.
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HOW ARE WE GOING TO HOW ARE WE GOING TO
USE OUR STORIES?USE OUR STORIES?
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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HOW ARE WE GOING TO HOW ARE WE GOING TO
USE OUR STORIES?USE OUR STORIES?
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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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
6. Digital Storytelling Toolkit by the Llano Grande Center
http://captura.llanogrande.org/director.html
7. Digital Storytelling Toolkit by the Llano Grande Center
http://captura.llanogrande.org/editor.html
8. Digital Storytelling Toolkit by the Llano Grande Center
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 S – AHI Process
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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
Appendix T – Summary Findings Focus Groups
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.
Appendix T – Summary Findings Focus Groups
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]
Appendix T – Summary Findings Focus Groups
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."
Appendix T – Summary Findings Focus Groups
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"]
Appendix T – Summary Findings Focus Groups
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
Appendix T – Summary Findings Focus Groups
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
Appendix T – Summary Findings Focus Groups
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.
Appendix T – Summary Findings Focus Groups
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
Page 1
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
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No
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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
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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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have more school-based health centers and increase utilization and awareness of their services.
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?
4. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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).
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?
5. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have creative incentives for teens to decrease risk-taking behavior and engage in services (examples include food, money, or other rewards).
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?
6. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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).
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?
7. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have mental health providers assist teens in getting a physical health assessment as a standard part of care after their initial evaluation.
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?
8. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have more substance use and treatment programs for adolescents, including tobacco.
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?
9. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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).
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?
10. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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).
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?
11. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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.
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?
12. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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.
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?
13. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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.
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?
14. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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).
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?
15. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have free or low-cost services for the uninsured, underinsured, or those in need.
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?
16. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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.
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?
17. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have a clinic for adolescent parents and their children.
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?
18. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have more and improved community and school-based services for developmental delay and autism spectrum disorders.
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?
19. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have cultural competency training for adolescent service providers and bilingual services when appropriate.
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?
20. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have improved health education in schools (for example, nutrition and sexuality education, positive youth development interventions, training of school personnel to be nutrition educators).
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?
21. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have more afterschool, recreational and prosocial activities for adolescents such as free and accessible exercise and sports opportunities and mentoring opportunities.
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?
22. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have more obesity treatment and nutrition resources for adolescents.
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?
23. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have interventions focusing on improving school services that affect health (for example, improving the nutrition profile of school lunches, increasing physical activity at school).
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?
24. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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).
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?
25. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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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).
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?
26. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have interventions and programs to ease the transition to adult care.
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?
27. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have a group of providers committed to improving adolescent health meet regularly to build relationships and exchange information.
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?
28. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have health services that go to teens where they are (examples include traveling van, locating services in a church or mall).
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?
29. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have more residential programs for youth (extended-stay facilities such as group homes where teen go if need to be removed from home environment).
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?
30. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
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Have a comprehensive, "one-stop shop" adolescent health center with physical health, mental health and health education services.
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?
31. 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
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Appendix U - AHI Delphi Survey
116
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Adolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi Survey
Have more confidential reproductive health services for adolescents, including allowing contraception to be prescribed and distributed at school-based health centers.
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?
32. 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
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Appendix U - AHI Delphi Survey
117
Page 33
Adolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi Survey
Have a peer educator program aimed at decreasing adolescent risk-taking behavior.
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?
33. 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
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feasible
somewhat
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somewhat
feasiblevery feasible
absolutely
feasible
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Appendix U - AHI Delphi Survey
118
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Adolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi Survey
Have better access to and quality of mental health services for adolescents.
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?
34. 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
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somewhat
feasiblevery feasible
absolutely
feasible
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Appendix U - AHI Delphi Survey
119
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Adolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi SurveyAdolescent Health Initiative Delphi Survey
Have more services sensitive to gay/lesbian/bisexual/transgender youth.
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?
35. 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
Select one answer nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj
Appendix U - AHI Delphi Survey
120
Page 36
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Have more adolescent-specific training for trainees and providers (examples include on-line training, practice visits and quality improvement).
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?
36. 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
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feasible
somewhat
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feasiblevery feasible
absolutely
feasible
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Appendix U - AHI Delphi Survey
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Have mental health routinely incorporated into juvenile justice system; counselors should routinely educate clients about physical health, mental health and community resources.
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?
37. 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
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feasible
somewhat
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somewhat
feasiblevery feasible
absolutely
feasible
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Appendix U - AHI Delphi Survey
122
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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).
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?
38. 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
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feasible
somewhat
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absolutely
feasible
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Appendix U - AHI Delphi Survey
123
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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.
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?
39. 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
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somewhat
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feasiblevery feasible
absolutely
feasible
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Appendix U - AHI Delphi Survey
124
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Have transportation or transportation discounts for teens to attend appointments or clinic visits.
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?
40. 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
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feasible
somewhat
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feasiblevery feasible
absolutely
feasible
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Appendix U - AHI Delphi Survey
125
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Thank you for your time in completing the survey!
41.
Appendix U - AHI Delphi Survey
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).
Somewhat Feasible (some variety of
opinions)
Have free or low-cost services for the uninsured, underinsured, or those in need.
Somewhat Feasible (some variety of
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.
Somewhat Feasible (some variety of
opinions)
Have a comprehensive, "one-stop shop" adolescent health center with physical
health, mental health and health education services.
Somewhat Feasible (some variety of
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.
Somewhat Feasible (some variety of
opinions)
Have a clinic for adolescent parents and their children.
Somewhat Feasible (some variety of
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).
Somewhat Feasible (some variety of
opinion)
Have interventions and programs to ease the transition to adult care.
Somewhat Feasible (some variety of
opinion)
Have health services that go to teens where they are (examples include traveling
van, locating services in a church or mall).
Somewhat Feasible (some variety of
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.
Somewhat Feasible (some variety of
opinion)
Have mental health routinely incorporated into juvenile justice system; counselors
should routinely educate clients about physical health, mental health and
community resources.
Somewhat Feasible (some variety of
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).
Somewhat Feasible (some variety of
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
Appendix X – Site Visits Summary
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
Appendix X – Site Visits Summary
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? _____
Appendix X – Site Visits Summary
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
Appendix X – Site Visits Summary
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
Appendix X – Site Visits Summary
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
Appendix X – Site Visits Summary
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
Appendix X – Site Visits Summary
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?
Appendix X – Site Visits Summary
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?
Appendix X – Site Visits Summary
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
Appendix X – Site Visits Summary
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?
Appendix X – Site Visits Summary
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
Appendix X – Site Visits Summary
Adolescent 143 !
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Adolescent 144 !
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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
Appendix Y – Summary Findings Town Hall
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
Appendix Y – Summary Findings Town Hall
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
Appendix Y – Summary Findings Town Hall
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
!
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Potential Intervention
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Appendix Z - Community Health Assessment Map
159
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160
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161
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162
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Appendix AB – Hub-and-Spoke Model of Connected Care Phases Diagrams
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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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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