Florida Department of Health in Duval County
Teen Health Centers in Collaboration with Duval County Public Schools
Duval County comprises close to 928 square miles located on the northeastern coast of Florida. It has a population approximately 935,476 residents (48% male and 52% female). Duval County's population is 59% White, 30% Black, and 11% other races, with approximately 9% having Hispanic ethnicity. Approximately 17% of Duval County's population is adolescent (between the ages of 13 to 24 years old).
STIs and HIV are serious public health issues. STIs are common, especially among teens and young adults. There are about 20 million new cases of STIs in the United States each year, and close to half of these are in people between the ages of 15 to 24. According to the Youth Risk Behavior Survey (YRBS, 2015), 37% of high school students in Duval County have engaged in sexual activity, with 40% reporting unprotected sex during their last sexual encounter. Adolescents have also been identified as a population in great need of improved access to health services. They have one of the lowest primary care usage rates and the highest under- or uninsured rates in the United States. In 2015, 15% of Duval County residents were uninsured and 7.4% of those individuals were under the age of 18.
A collaboration with internal and external stakeholders was developed in order to reduce the bacterial STI and HIV rates among youth in Duval County, and to improve access to key sexual health services. The Duval County Public Schools (DCPS) partnered with Full Service Schools of Jacksonville (FSSJ), the Florida Department of Health in Duval County (DOH-Duval), and the Jacksonville Area Sexual Minority Youth Network (JASMYN). This partnership is made possible by a grant from the CDC to DCPS that funds the provision of key sexual health services in teen friendly and accessible locations.
With reducing the bacterial STI and HIV rates among emerging adults in the Jacksonville area in mind, this model practice aims to bring key sexual health services to youth in high-risk areas of Duval County. The Teen Health Centers THCs are outreach programs offered in teen friendly and accessible locations that provide group education, free condoms, STI/HIV/Pregnancy screening, STI treatment, as needed, and referrals for related services. There are currently seven THCs located at FSSJ locations throughout Jacksonville. FSSJ provides a collaborative approach to serving the therapeutic, health, and social service needs of at-risk students and families in Duval County. Among these seven locations, JASMYN a community-based organization that operates a center for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth with comprehensive services including HIV prevention programs, support groups, and a teen-friendly health clinic that provides HIV/STI screening, treatment, and linkage services.
Several factors have contributed to the success of the THC initiative. Our partnership has allowed for grant partners to pool resources, share expertise, and create new insights into better ways to address the health challenges facing our youth. By providing key sexual health services in teen friendly and accessible locations, our dynamic partnership has brought much needed health services to the youth of Duval County. THC staff also provides community outreach to inform, promote, and educate the community on sexual health resources available to not only teens but their parents/guardians, as well. Monthly clinic collaboration meetings are held where partners and clinic staff meet to discuss strategies for implementation and improvement of services. Brief reports are shared following each THC to summarize activities and identify opportunities for improvement. Together these activities build the capacity of the THCs, improve communication, and streamline processes.
The partnerships' combined efforts during school year 2016-2017 enabled 538 youth to access key sexual health services during 946 THC visits on high school campuses.
THC staff provided 876 group education services, 190 HIV tests, 190 Gonorrhea/Chlamydia tests, and 38 pregnancy tests.
Of those screened for STIs, HIV and/or pregnancy, 21 tested positive for Chlamydia, one tested positive for Gonorrhea, and two tested positive for pregnancy.
All youth that tested positive for chlamydia or gonorrhea, were given treatment via Direct Observed Therapy (DOT) protocol that allows the THC staff to provide treatment.
During this time period, the JPPHEA collaboration also enabled 57 youth to access key sexual health services at 73 JASMYN THC visits. The staff at JASMYN provided 50 STI tests, 53 HIV tests, and five pregnancy tests. Of those screened for STIs, three tested positive for Chlamydia, five tested positive for Gonorrhea, and three tested positive for both Chlamydia and Gonorrhea. Of those screened for pregnancy, one tested positive.
Sexually transmitted infections (STIs) and HIV are serious public health issues. STIs are common, especially among young people. There are about 20 million new cases of STIs in the United States each year, and close to half of these are in people between the ages of 15 to 24. The state of Florida reported 131,238 cases of bacterial STIs to CDC in 2016. Duval County ranked number five out of Florida's sixty-seven counties with a reported 9,743 cases of STIs. Among Duval County's population, individuals between the ages of 15 to 24 represented 17% of the population but represented 57% of reported STIs in 2016. According to the Youth Risk Behavior Survey (YRBS, 2015), 13% of middle school and 37% of high school students in Duval County have engaged in sexual activity, and many of these students report multiple lifetime sexual partners. Condom use among youth in Duval County is low, with 40% of high school students reporting unprotected sex during their last sexual encounter. The high level of sexual risk behaviors among Duval County youth are complicated by alarming rates of STI infections.
Despite intervention efforts, in 2016 Duval County (3,868.4/100,000) remained above the state rate (2,440.4/100,000) for the number of STI cases in this age group. Duval County (11.7/100,000) also remains above the state rate (10.6/100,000) for the number of new HIV infections among youth. The goal of this project is to reduce the rates of STI and HIV infection among youth in Duval County, Florida. This project targets secondary school students enrolled in Duval County Public Schools. Duval County Public Schools serves approximately 62,000 middle and high school students in 48 schools. The student population at Duval County Public Schools is diverse: 61% of students are members of a racial/ethnic minority group, 3% report English as a second language, and 55% receive free or reduced lunch. Teens in low-income neighborhoods are less likely to have access to interventions that prevent unplanned pregnancies and STI/HIV transmission, such as sexual health education and teen sexual health services. The Teen Health Centers bring critical, developmentally appropriate, key sexual health services to school campuses, a location where youth spend most of their day.
Prior to the Teen Health Center's (THCs) opening, Duval County Public Schools only allowed abstinence only education for the students. FDOH-Duval was limited to providing sexual health information to the teacher's only. The current practice allows us to have one on one education to students and provide demonstrations on how to effectively have safer sex practices if and when they find themselves in that situation.
Youth served during THC outreaches are 13 to 19 years old from a wide array of backgrounds. This approach is innovative because in order to increase participation among the students at the THCs, we felt it was important to employ staff that the students could relate too. We currently have four full-time THC staff. Each of the Teen Health Center staff have had specialized training as a Disease Intervention Specialist (DIS). Two of the four THC staff are also Health Service Technicians that assist in providing medical care. The students have made connections with the staff because the staff resemble the students. The staff are able to connect with the students at school, as well as the parents because several of the staff are parents themselves. These staff have been trained to serve as a one stop shop for the students.
They are able to provide health education, STI/HIV testing, linkage to additional health and wellness services such as family planning and behavioral health provided by FDOH-Duval or other community organizations. Through our efforts, we have been able to provide our services to over 10,000 students attending DCPS and JASMYN in 2016.
The THC provides services in a safe, friendly, confidential environment. The Teen Health Center provides a safe place which offers key sexual health services and everyday life practices at the school campus where the youth spend most of their day. Females who come to the THC site for pregnancy testing are encouraged to get screened for STI/HIV because they are more at risk due to having unprotected sex. Delaying or avoiding health care can lead to an increased risk of transmitting STIs to others, as well as long term negative consequences, including infertility.
In working with youth, it is better to take a holistic approach. Having an STI can have a negative long lasting impact but through the Teen Health Centers we often encounter youth where having an STI is the result of other things that may be going on in that youth's life. So the THC staff engage the students in other topics that contributes to positive health outcomes and reducing sexual risk behaviors and the incidence of STI/HIV in the Jacksonville area community. These topics include but are not limited to:
Life practice skills
Decision making skills
Social skill building
Enhancing gender and ethnic pride
HIV in the U.S.|Teen Pregnancy
The Teen Health Centers aim is to reduce the rates of sexually transmitted infection (STI) and HIV among youth in Duval County by providing key sexual health services to youth in teen-friendly and accessible locations. The primary objective of this practice is to facilitate, educate, increase access to key sexual health services, including education, STI/HIV/pregnancy screening, and linkage to treatment, and provide tools to encourage youth and young adults to make healthy lifestyle choices in the early stages of their lives. To achieve this objective, the Department of Health in Duval County (DOH-Duval), in collaboration with Duval County Public Schools and other key partners, have established seven Teen Health Centers that provide key sexual health services to youth in teen friendly locations. This practice addresses some of the unique challenges faced by youth accessing key sexual health services by providing these services in a convenient and accessible environment that is sensitive to the unique needs of youth.
The Teen Health Center initiative has been underway since the fall of 2014. This program is funded (in-part) by the Duval County Public Schools, and includes Health Support Technicians, Disease Intervention Specialists and a Health Educator. The Teen Health Centers began in the 2014-2015 school year, with one site located in the North side of Jacksonville. Duval County is comprised of urban, suburban and pockets of rural areas. The county is divided into six health zones which differ demographically and economically. The location of the Teen Health Centers was determined through the use of Geographic Information Systems mapping of STI cases. High schools in closest proximity to cluster centers were selected as sites for the initial outreach implementation.
Coordinated efforts among partners contributes to the success of the Teen Health Centers. The design and implementation of the Teen Health Centers involved a number of important stakeholders including DOH-Duval Disease Control staff, Duval County Public Schools administration, and community partners. These community partners include the Full Service Schools of Jacksonville, which provides space and aids marketing, and the Jacksonville Area Sexual Minority Youth Network (JASMYN), which provides consulting and staff support for LGBTQ services and linkage.
Our partnership has allowed for grant partners to pool resources, share expertise, and create new insights into better ways to address the health challenges facing our youth. Our partnership has implemented a number of strategies to facilitate collaboration among grant partners. For example, biweekly Teen Health Center meetings are held to discuss barriers and facilitators of success, strategies for implementation, and opportunities for improvement of services. In addition, weekly and monthly reports that summarize clinic activities and identify opportunities for improvement are shared with all partners. To ensure consistency in procedures across sites, a toolkit was created to document Teen Health Center procedures. Together these activities build the capacity of the Jacksonville Teen Health Centers, improve communication among key stakeholders, and streamline processes.
We believe community collaborations are instrumental in the programs' success and the decision to maintain funding for the prevention program.
Staff are trained in cultural competency in order to appropriately address our youth. By building this capacity in our staff, they are able to engage with the youth and create a safe space for them to open up.
Trainings on stigma, related to race/ethnicity; sexual orientation and/or gender identity; and the exploration of how stigma places LGBTQ youth of color at risk for unsafe sex, violence, and substance abuse. The training explores strategies and principles of how to create inclusive programming for LGBTQ youth of color; community mobilization. Taking a focused approach that targets those areas of behavioral change that are both reasonable and feasible for adolescents to accomplish. This may result in outcomes that not only reduces adolescents' sexual risk behaviors, but lay the foundation for more sustainable sexual risk avoidance within our community.
Additionally, the THC staff have conducted multiple outreach activities this year to raise awareness of resources available within the community for sexual health services, via condom blast in high morbidity areas. These events included condom distribution, testing events, sexual health education, and marketing for sexual health services available for teens.
The Teen Health Centers aim is to reduce the rates of sexually transmitted infection (STI) and HIV among youth in Duval County by providing key sexual health services to youth in teen-friendly and accessible locations. The primary objective of this practice is to facilitate, educate, increase access to key sexual health services, including education, STI/HIV/pregnancy screening, and linkage to treatment, and provide tools to encourage youth and young adults to make healthy lifestyle choices in the early stages of their lives. The Teen Health Centers (THCs) are evaluated on an ongoing basis. To ensure the successful evaluation of the Teen Health Centers, the Office of Performance Improvement at the Department of Health in Duval County (DOH-Duval), in collaboration with grant partners, developed an evaluation plan and logic model, designed data collection tools, oversaw data collection efforts, and analyzed customer satisfaction and clinic data. The Teen Health Center data is used to produce monthly and annual reports that summarize clinic activities.
Evaluation of the THCs focuses on four main areas: the demographics of youth accessing services at the THCs, the number of services provided, positivity rates for pregnancy and STI/HIV screening, and customer satisfaction. Data to track the demographics of youth accessing services at the Teen Health Centers is collected using a patient intake form. The patient intake form was developed for this project and allows for the collection of data for grant reporting purposes. The patient intake form is completed when a student first arrives at the THC site and assesses demographics (e.g., age, grade, sex, sexual orientation, home zip code). The patient intake form is also used by Teen Health Center staff to track services provided during the appointment. For example, each intake form documents whether group education, Gonorrhea/Chlamydia screening, HIV testing, and pregnancy testing services were received. Test results and initiation of treatment are tracked through the electronic medical record system. Customer feedback is collected through the use of satisfaction surveys that are administered at the Teen Health Center appointment. To ensure consistency across sites, a toolkit containing Teen Health Center documents and procedures was created.
During Year 4 of the grant, the JPPHEA collaboration enabled 538 youth to access key sexual health services during 946 FSSJ Teen Health Center visits. Teen Health Center staff provided 876 group education services, 190 HIV tests, 190 Gonorrhea/Chlamydia tests, and 38 pregnancy tests. Of those screened for STIs, HIV and/or pregnancy, 21 tested positive for Chlamydia, 1 tested positive for Gonorrhea, and 2 tested positive for pregnancy. All youth that tested positive initiated treatment for STI. When youth tested positive for pregnancy, appropriate referrals were made to resources in the community.
Of the youth tested during Year 4 at the FSSJ Teen Health Centers, the majority were Black (77.7%) and non-Hispanic (76.0%). During this time period, more males (57.8%) than females (41.1%) were tested. Most youth that were tested were residents of Health Zone 2 (51.3%) and attended Jean Ribault High School (25.8%). Please refer to Table 3 for additional details regarding the demographics of youth tested at FSSJ Teen Health Centers during Year 4.
Data from the JASMYN THC was collected from July 2016 June 2017. During this time period, the JPPHEA collaboration enabled 57 youth to access key sexual health services at 73 JASMYN Teen Health Center visits. The staff at JASMYN provided 50 STI tests, 53 HIV tests, and 5 pregnancy tests. Of those screened for STIs, 3 tested positive for Chlamydia, 5 tested positive for Gonorrhea, and 3 tested positive for both Chlamydia and Gonorrhea (22.0%). Of those screened for pregnancy, 1 tested positive (20.0%). When youth tested positive for pregnancy, appropriate referrals were made to resources in the community. Of the 57 clients served during Year 4 at JASMYN, 35.1% were 18 years old and the majority were female (50.9%), Black (49.1%), and non-Hispanic (80.7%). Most clients were residents of Health Zone 2 (28.1%).
Customer satisfaction surveys are distributed to youth attending the Teen Health Centers. During school year 2016-2017, over 120 youth attending the Teen Health Centers completed a customer satisfaction survey. Of those completing a customer satisfaction survey, 98% indicated that they were either satisfied or very satisfied with their overall experience at the Teen Health Center.
In order for the Teen Health Centers (THCs) to be sustainable, we have to make sure the utilization of the centers is high. In order to increase participation with the centers, we have given incentives to students and those students that became ambassadors for the THC program were given $25 Amazon gift cards. We are continuously finding ways to keep this segment of our population engaged. In addition to keeping the students engaged, we have had involvement from parents, including parents wanting to get tested at our THCs.
Although the THCs aim to increase access to key sexual health services, many Duval County youth continue to experience significant challenges accessing these important health services. For example, students may be unable to attend the THCs after school if they rely on school buses to get home. To help minimize this potential barrier, bus tickets are now offered to students. In addition, FDOH-Duval is exploring ways to offer key sexual health services via a mobile unit. The goal of the mobile unit is to expand THC services to health zones that currently have an influx of STIs among youth but limited access to the key sexual health services that are offered at the other seven THC sites.
Although successful and challenging, the THC program has some limitations but through collaboration with other FDOH-Duval programs, we will be implementing the use of a mobile unit to expand our program to areas where we currently do not operate THC sites.
The goals of this unit will be to:
Identify neighborhoods where residents are demonstrably under-served, and screen for acute and chronic illnesses
Offer preventive care to areas with known health disparities
Provide disease intervention services with community partners
During the fall school year 2017-2018, the Department of Health in Duval County (DOH-Duval), in collaboration with Duval County Public Schools (DCPS), will implement an in-school STI/HIV screening program to educate students about STIs/HIV, provide testing, and treat, if necessary. During in-school testing days, students will attend a group education program on STIs/HIV, including risk factors and prevention methods. By providing STI/HIV testing and treatment during the school day, many of the known barriers adolescents encounter when seeking appropriate health care will be reduced.
Sustainability requires careful planning, goal setting, and continuous monitoring of policies, objectives, practices, programs, and services to address community needs, even as they evolve over time. Our goal is to develop a living sustainability plan that is re-visited regularly by DOH-Duval, DCPS, FSSJ, and JASMYN, as well as other interested organizations. As part of our grant requirements, many of these tools are in place.
Using DOH-Duval resources, as well as resources available to us through community partnerships, we will continue to:
Educate students about HIV and other STIs
Promote communication between parents and adolescents
Teach students how to find HIV counseling and testing services
Provide referrals to testing, counseling, and treatment services
Provide on-site testing for HIV and STIs at the THC or via FDOH-Duval clinics or via community bases organizations (CBOs) whom we have memorandum of agreements in place
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