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A Call to Action Planning

Local Health Department and School Partnerships for Adolescent Sexual Health

Ritter, Samantha, MPH; Kelley, Kat, BS

Journal of Public Health Management and Practice: July/August 2019 - Volume 25 - Issue 4 - p 408–410
doi: 10.1097/PHH.0000000000001035
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National Association of County and City Health Officials, Washington, District of Columbia.

Correspondence: Samantha Ritter, MPH, National Association of County and City Health Officials, 1201 Eye St NW, Fourth Floor, Washington, DC 20005 (sritter@naccho.org).

The authors declare no conflicts of interest.

Adolescence is a period of significant physical, cognitive, and social development, during which young people explore their burgeoning independence, develop life and decision-making skills, and establish habits and behaviors that will endure throughout adulthood. Risk-taking is a natural part of adolescence, which provides young people with opportunities to develop competencies and skills needed for adulthood. However, these risks can also impact the health and well-being of adolescents. Young people aged 13 to 24 years account for half of the 19 million new cases of sexually transmitted infections (STI) each year and 1 in 5 new HIV/AIDS diagnoses.1,2 Adolescence is also a period of increased vulnerability to substance use; the use of tobacco products, alcohol, and marijuana, as well as misuse of prescription pain medicines, is common among teens, and most people who use high-risk substances such as heroin, cocaine, or methamphetamine start in late adolescence or early adulthood.3–5 LGBTQ+* youth and young people of color are less likely to receive culturally responsive health services and sex education and face greater risks for HIV/AIDS, STIs, and unintended pregnancy. The behaviors and health outcomes that arise during adolescence can have lifelong impacts; protective factors, such as family, school, and community support, are critical in mitigating these risks.

Local education agencies (LEAs), or school districts, play an important role in advancing adolescent health. Student health and academic achievement are closely linked—sexual and other risk behaviors are associated with lower grades, and health problems can contribute to absenteeism.6,7 However, LEAs are often overburdened and underresourced and may find it challenging to address students' health needs comprehensively in addition to their educational mandates. Through partnership, local health departments (LHDs) can support LEAs in implementing health promotion efforts, services, and education and promoting student health, well-being, and safety.

Recognizing the promise of public health and education partnerships to advance adolescent health, the National Association of County and City Health Officials (NACCHO), with support from the Centers for Disease Control and Prevention (CDC) Division of Adolescent and School Health (DASH), recently completed a 2-year project to support LHDs in establishing and strengthening partnerships with LEAs to implement school-based HIV/AIDS and STI prevention initiatives. As a result of this work, LHD-LEA pairs in 4 jurisdictions developed adolescent sexual health–focused action plans and garnered community support for school-based HIV/AIDS and STI prevention efforts.

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Project Overview

In August 2017, NACCHO funded 4 competitively selected LHD-LEA pairs to collaboratively develop and implement action plans for school-based adolescent sexual health initiatives:

  • Florida Department of Health in Pinellas County, with Pinellas County Schools (Florida);
  • Metro Public Health Department of Nashville Davidson County, with Metro Nashville Public Schools (Tennessee);
  • Monongalia County Health Department, with Monongalia County Schools (West Virginia); and
  • St Louis County Department of Public Health, with Normandy Schools Collaborative (Missouri).

Each jurisdiction prioritized one of the 3 CDC-developed approaches for school-based HIV/AIDS and STI prevention:

  • Health services: The provision of school-based or school-linked sexual health services, which mitigate common barriers faced by adolescents in seeking HIV/AIDS and STI prevention services.
  • Health education: The delivery of health education programs that provide students with developmentally and culturally appropriate and medically accurate information and critical skills to promote healthy behaviors.
  • Safe and supportive environments: Fostering a positive school climate by preventing bullying and harassment and promoting school connectedness and family engagement in schools, recognizing that adolescents who feel connected to their schools engage in fewer sexual risk behaviors.
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Partnership Building and Collaborative Action Planning

Relationship building is resource intensive, and the short-term benefits can be hard to quantify. This project was designed to provide LHDs with the support needed to build and nurture partnerships with their LEA and other local adolescent health stakeholders, convene the partnership group, and establish mechanisms for collaborative strategizing, planning, and program implementation.

NACCHO worked with each LHD-LEA pair to identify stakeholders within their community and invite them to a 1.5-day action planning meeting. Each site was encouraged to consider stakeholders that would have the authority, access, or ability to implement school-based sexual health programs and those who would be impacted by programming, including students themselves.

To kick off each action planning meeting, the LHD presented local data about adolescent sexual health, after which all participants were asked to share information about local trends, efforts, challenges, and opportunities to inform project priorities. Once the group had a shared understanding of the current state of adolescent sexual health in their community, NACCHO facilitated a series of consensus-building activities to develop a vision, identify and navigate obstacles, and determine strategic priorities to navigate these barriers and achieve their vision. Common themes for these strategic priorities included mobilizing partners, engaging young people, and establishing mechanisms for continued collaboration.

Once the sites established strategic priorities, they developed 1-year action plans, or road maps for achieving their goals. The collaborative process engendered buy-in from meeting participants, and the action plans enabled each LHD-LEA pair to monitor progress and mobilize additional partners, as needed.

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Successes

Each LHD strengthened its relationship with the LEA and established new partnerships with local stakeholders. The action planning meetings fostered a deeper understanding of the connection between adolescent sexual health and academic performance and increased buy-in for the project among LEA staff. Each site also achieved significant milestones in implementing its action plans:

  • Piloted a comprehensive sexuality education program in the ninth grade (St Louis County);
  • Increased the knowledge and capacity of sexual health competencies among school administrators, leading to an enhanced relationship between the LHD and the LEA and new funding from the CDC to support school-based adolescent sexual health programming (Nashville/Davidson County);
  • Developed a Web site to increase adolescents' awareness of and access to sexual and reproductive health services (Monongalia County); and
  • Increased STI testing rates in school-based health centers (Pinellas County).

For some sites, participation in the project also led to increased prioritization of adolescent sexual health by the LHD. All partners demonstrated commitment to sustain this work beyond the project period.

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Lessons Learned

This project revealed important lessons for LHDs seeking to partner with the education sector and mobilize community partners to advance adolescent sexual health. Each site faced challenges in determining who to invite to the action planning meetings and how to ensure their attendance. LHDs found that they could boost participation by clearly communicating about the purpose of the meeting and utilizing champions within the LEAs to encourage other school staff to participate.

LHDs found that the upfront work of preparing for the action planning meetings paid off—the collaborative process generated buy-in and mobilized partners. The diverse participation also ensured each group had the knowledge, capacity, and connections to develop an action plan that was responsive to local trends, leveraged community resources and opportunities, and adeptly navigated potential barriers.

Education and public health partnerships are powerful vehicles for advancing adolescent health and well-being, but they can be challenging to establish, as each sector has its own priorities, styles of communication, and methods for achieving its goals. Each LHD-LEA pair sought to understand one another, including their priorities, concerns, and even jargon, which ensured clear and effective communication. LHDs learned that building trust within the LEA and implementing new school-based programs can take time, but that incremental progress should be recognized and celebrated.

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Youth Role

Engaging adolescents as partners in youth-focused initiatives leads to positive outcomes for both the initiatives and adolescents.8 Each LHD-LEA pair engaged young people in the development and implementation of their action plan; high school students participated in all 4 action planning meetings, providing insight into the local adolescent experience to ensure the action plans were responsive and relevant.

Student participants also served as powerful advocates for adolescent health programming. Adult participants knew that adolescent sexual health was important but did not recognize how central it was to adolescent well-being and success; youth voices elevated the discussion and significance in a way that adult leaders could not do on their own.

Over the course of the meetings, participants saw firsthand the benefits of youth engagement and ultimately developed action plans that centered and leveraged the expertise of young people. Examples of activities included the following:

  • Establishing youth task forces or advisory boards;
  • Leveraging students as advocates during school board meetings;
  • Utilizing “health squads” of students to provide peer education;
  • Collecting youth input to inform efforts to increase awareness of sexual health resources; and
  • Training students to strengthen their leadership skills and school staff on positive youth development to facilitate youth-adult partnerships.

Student participants were critical to the success of the action planning meetings and should be key partners in any effort focusing on their health and well-being.

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Conclusion

Given current trends in substance use, HIV/AIDS, and STIs, LHDs must prioritize adolescent health interventions. LHDs and LEAs can use their collective knowledge, capacity, and resources to mobilize partners, identify priorities, and implement strategies to effectively advance adolescent sexual health. Through this project, NACCHO developed a number of resources to support such LHD-led, community-driven work to improve adolescent sexual health outcomes. The resources listed as follows can be accessed at http://bit.ly/nacchoash:

  • Action Planning for Adolescent Sexual Health;
  • Celebrating Success: Local Health Department and School Partnerships for Adolescent HIV/AIDS and STI Prevention;
  • The Role of Local Health Departments in Advancing Adolescent HIV/AIDS and STI Prevention Efforts Through School-Based Programs; and
  • Policy Statements: Comprehensive Adolescent Health, Comprehensive Sexuality Education.
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References

1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2017. Atlanta, GA: US Department of Health and Human Services; 2018.
2. Centers for Disease Control and Prevention. HIV among youth. https://www.cdc.gov/hiv/group/age/youth/index.html. Published April 20, 2018. Accessed March 1, 2019.
3. Miech RA, Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the Future National Survey Results on Drug Use, 1975-2017: Volume I, Secondary School Students. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2018. http://monitoringthefuture.org/pubs.html#monographs. Accessed March 1, 2019.
4. Kann L, McManus T, Harris WA, et al Youth Risk Behavior Surveillance—United States, 2017. MMWR Surveill Summ. 2018;67(8):1–144.
5. Lipari RN, Ahrnsbrak RD, Pemberton MR, Porter JD. Risk and Protective Factors and Estimates of Substance Use Initiation: Results From the 2016 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2017. https://www.samhsa.gov/data/report/risk-and-protective-factors-and-estimates-substance-use-initiation-results-2016-national. Accessed March 1, 2019.
6. Rasberry CN, Tiu GF, Kann L, et al Health-related behaviors and academic achievement among high school students—United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(35):921–927.
7. Centers for Disease Control and Prevention. Health and Academic Achievement. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/healthyyouth/health_and_academics/pdf/health-academic-achievement.pdf. Accessed March 1, 2019.
8. Zeldin S. Youth as agents of adult and community development: mapping the processes and outcomes of youth engaged in organizational governance. App Dev Sci. 2004;8:75–90.

* LGBTQ+ is an acronym designed to be inclusive of nonheterosexual and noncisgender identifies. It stands for lesbian, gay, bisexual, transgender, queer, and questioning. The “+” indicates a number of other ways people define their gender and sexuality, as the acronym is limited in its representation.
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For more information on the CDC-developed school-based approaches for HIV/AIDS and STI prevention and the role of LHDs in implementing these approaches, check out NACCHO's report The Role of Local Health Departments in Advancing Adolescent HIV/AIDS and STI Prevention Efforts Through School-Based Programs, available at: https://www.naccho.org/uploads/downloadable-resources/report_DASH-Workshop-Overview.pdf.
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