iDecide Detroit: Engaging Youth to Reduce Unintended Teen Pregnancy

State: MI Type: Model Practice Year: 2019

The Detroit Health Department (DHD) is mandated by the State of Michigan to safeguard the health and wellbeing of the City of Detroit and has done so for over 100 years. Its mission is to work in partnership with Detroiters to protect and promote their health, well-being, safety and resilience, and to respond to every public health need with exceptional leadership, policies, programs and services. The Detroit Health Department serves 673,104 residents in the City. Under new leadership, the Detroit Health Department is in the midst of both growth and reorganization aiming to integrate services and programs and develop comprehensive, collaborative strategies to address challenging public health issues. The Detroit Health Department recently launched a new initiative entitled iDecide Detroit, which is aimed at reducing the unintended teen pregnancy rate in the city. Each year, there are over 1,600 teenage pregnancies in the City of Detroit, which is two and a half times the rate of the rest of the state of Michigan. The disparity contributes to Detroit's high infant mortality rate and unintended teen pregnancy increases a woman's health risks and can stymie her academic potential. To reduce unintended teen pregnancy across the entire City of Detroit, three interconnected and mutually reinforcing strategies drive our initiative. These strategies are to reduce barriers to accessing adolescent-friendly reproductive health care including long-acting reversible contraception (LARCs), increasing knowledge in the community around adolescent reproductive health, and strengthening the existing healthcare system within Detroit. This three-prong approach is imperative because public acceptance of LARCs must be established to make clinical engagement or access points worthwhile. Similarly, without access through clinicians and/or unconventional access points (including a clinic in a recreation center), demand for these services cannot increase LARC use. Planning and implementation was a two year process, emphasizing youth engagement and inclusion. We held focus groups with youth across the city of Detroit, then used that feedback to shape the standards for those we selected as healthcare partners as well as impact our own clinical practice. Additionally, the youth not only shaped the messaging of the campaign but also serve as the faces in the campaign and are the initiative's youth ambassadors. Recognizing the importance of understanding and addressing barriers to healthcare from a provider perspective, we also conducted focused interviews and surveys of medical providers in Detroit, to understand their attitudes and behaviors towards adolescent reproductive health. We learned there were challenges with being able to provide services to underinsured and uninsured patients, and that availability was often limited to regular business hours. To reduce barriers and align already existing partners, we convened and established a network of 23 healthcare partners across the City of Detroit, all who agreed to provide adolescent-friendly, high quality, low barrier care based on best-practice and youth feedback we received. This iDecide network creates a coordinated system of care for our youth, and also allows sharing of best practices and problem solving across providers in a supportive environment. Data sharing MOUs for providers in the network ensure we will be able to track progress and align goals and strategies. To circumvent traditional barriers and expand access, the Detroit Health Department established a new clinic inside a city recreation center that offers services during non-traditional hours, walk-in appointments and same day LARC placement. In addition, DHD has a central phone number to navigate young people to our clinic or a network provider near them, and we have partnered with a transportation service in order to provide free transportation to and from appointments. While our program is in its early stages of implementation we have already seen success and the necessity of this program within the City of Detroit. We have diagnosed and treated many sexually transmitted infections, placed same-day LARCs for young women seeking them, navigated a positive HIV patient to care within 24 hours and provided education to adolescents and their families facilitating important conversations across the community. Our project exemplifies a useful strategy for successfully engaging youth in health initiatives, aligning healthcare providers, and addressing social determinants of health and barriers to healthcare. For more information,
Currently there are approximately 45,000 young people in the City of Detroit between the ages of 15-19. Over 1,600 Detroit teens ages 15 to 19 become pregnant annually, which is two and a half times the rate in the rest of the state of Michigan (1). This disproportionate burden is driven by several factors, including poor awareness of contraceptive options and lack of access to reproductive health care services (2). The disparity contributes to Detroit's high infant mortality rate; compared to all babies, those born to teen mothers are more likely to die before the age of 1. Unintended teen pregnancy increases a woman's health risks and can stymie her academic potential. Only 50% of teen mothers graduate from high school by the age of 22, and only 10% of teen mothers graduate from college. Based on 2017 YRBS data Detroit teens are sexually active at a similar rate as teens across the United States. Although sexually active Detroit teens reported that they did not use any method of contraception to prevent pregnancy during last sexual intercourse at a significantly higher rate in comparison to sexually active teens across the country, making them at much higher risk to experience a pregnancy (3). Our goal is to reduce the unintended teen pregnancy rate in the City of Detroit by utilizing three strategies that are interconnected and mutually reinforcing. This goal is based off of proven results from models in Colorado and Baltimore, which are similar to what the Detroit Health Department has implemented. Our model is innovative for multiple reasons which were all formed on the foundation of engaging adolescents and other community stakeholders in order to shape a program that would best meet their needs. Through this process we identified that there is a gap in services for young people in the city of Detroit. In order to address this barrier to care we collaborated with twenty-three established healthcare practices across the City of Detroit to create a network of adolescent-friendly providers who will consistently offer comprehensive reproductive health services. A unique challenge of Detroit is the lack of reliable public transportation and that was a critical need that was addressed as this model was implemented. We have partnered with a transportation service to offer young people free transportation to and from appointments for any provider within the iDecide Detroit Network. In order to facilitate appointments for young people we offer a single phone number that the community can call and a DHD representative will assist them in making appointments at our own clinic or one of our network providers. Additionally, during this phone call we can schedule transportation in real time as needed. Our effort to provide comprehensive navigation for young people starts when they call our phone number and continues as they visit our DHD clinic. Each patient in our clinic receives a risk assessment and opportunity for referrals from a social worker, this allows us to meet as many needs for each young person during their visit as possible and aligns with the over-arching mission of the Detroit Health Department to work in partnership with our community. Finally, we have taken an innovative approach in our city-wide campaign. We are utilizing all forms of traditional media across the City of Detroit including radio, street level billboards and bus advertisements. Given our target adolescent population it was essential to understand how they consume media and how we can best tailor our message to them. During our focus groups we asked young people about their consumption of social media, streaming radio, and other digital media. With this information we developed a digital marketing strategy as a component of our larger campaign. Strategic placement of our information helps further community acceptance of our program; and knowledge of this new community resource in a different way than traditional public health approaches. (1) (2) (3)
From the initial planning of this program it was essential that the community drove the overarching strategy. We involved teens, community leaders, and healthcare providers from various fields across the City of Detroit in order to inform our approach for this program. Based on community feedback and evidence-based models for reducing unintended pregnancy our overarching goal for this program is to reduce the unintended teen pregnancy rate in the city of Detroit by 30% over three years. In order to reach that goal we determined that we needed to engage approximately 9000 teens within the city. Given the three pronged approach to our initiative there are a variety of steps that were taken to help us reach these goals. Initially we mapped unintended teen pregnancy rates within the city by zip code. This allowed us the opportunity to understand high burden areas and strategize our approach to expand care. Given the size of the City of Detroit and the barriers with public transportation we identified the need to engage established providers across to the city to fill the gap in service that community members identified. We took time over several months to meet with leadership within all of the major healthcare systems and federally qualified health centers to bring together a network of providers who have committed to providing teen-friendly services with rapid appointment scheduling through our central phone number. Additionally we have engaged providers that focus on special areas, such as LGBTQ care, special healthcare needs, and HIV prevention, so that we are able to meet the needs of any young person who reaches out to us. Additionally, we wanted to establish a clinic that is operated by the health department within an alternative location to further reduce barriers to care. We were able to secure space within a strategically located recreation center in the city and renovate the space to make our clinic a teen-friendly, private space for our residents. Our clinic serves people regardless of their ability to pay on a walk-in basis. Finally, we developed a city-wide campaign featuring real Detroit teens with a message shaped by our community. Our campaign is featured in all types of media and is continually evolving as we elicit feedback from our young people and families on an on-going basis. On-going collaboration with our community partners is essential in the success of this program. We formalize the collaboration with key stakeholders in a few ways. First, as we aim to serve our adolescents we established a youth advisor committee to help us develop key priorities and action items as well as further the outreach of our program through community events and a social media presence. Additionally, we established an iDecide Detroit Provider Advisory board. This consists of our network providers as well as other community members and resident physicians. This groups serves as experts within the medical field and also allows us to share information related to care that is being provided to young people in the City of Detroit on a quarterly basis. The City of Detroit made a significant commitment to this program as we initiated it. Throughout the planning and start up phases of the program there were several unique costs. In order to renovate the clinic space for this programs unique needs the city committed $180,000 for renovation and clinic preparation. Additionally new vendors were established for laboratory services, clinical supplies, and medication needs. We hired seven new staff members for this program including two advance practice nurses to provide the clinical services. Finally, our city-wide campaign has a commitment of $400,000 for our first year. This allows us to reach people through all types of media and community engagement with a special emphasis on digital media to reach young people effectively.
Given that iDecide Detroit is still in its early phases of our efforts our evaluation practice is still in process. During the planning phases of this program we set goals for the number of young people that we wanted to serve as well as our goals for LARC uptake among our network partners and within our own clinic. As we work towards our goal of reducing unintended teen pregnancy we wanted to establish objectives for the care that young people would receive. As we implemented the program our goal was to establish at least fifteen network provider sites. As we met with providers we were able to successfully achieve that goal and connect with more providers than we initially set out, this connection allows us the ability to have further reach within the community. Additionally, we successfully renovated and opened a reproductive health clinic within a city recreation center, which allows us the opportunity to circumvent traditional barriers to care by offering services directly within the community. We hope to further explore this idea through partnership with other community organizations or existing clinical spaces within neighborhoods that might have gaps in reproductive healthcare services. In order to monitor our progress towards our goal of reducing the unintended teen pregnancy rate we track our clinical and outreach activity on a monthly basis. We review all of our clinical visits for the reason for the visit, the contraceptives given, as well as how each patient was connected to our program. Furthermore we receive the same clinical metrics from our network partners on a quarterly basis. We will review this data and adjust our outreach strategy to reach more young people within the community as needed. To further support our own data we also receive quarterly data from the state of Michigan related to teen pregnancy rates within the City of Detroit. We will use this data and our own primary data to track progress and effectiveness of our program. Finally, in the spirit of community partnership and the importance of adolescent voice in this work; on an ongoing basis we elicit feedback from our patients about their experience and track successes related to the care that is provided within our clinic.
iDecide Detroit was established to provide a key service to the community of Detroit under the Detroit Health Department's programming. Given the need for access to reproductive health services these goals have been incorporated into the broader Maternal and Child Health strategy within the department. Additionally, in an effort to create sustainable practice we engaged existing healthcare partners to strengthen the assets already established within the community. By reducing barriers to care iDecide Detroit fills a critical care need for young people in the City of Detroit. We have also made an effort to ensure that young people's voices are sustained throughout our programming. Through teen advisory board meetings we will develop teaching guides, trainings, and community action items that can be distributed and used by our community partners. The aim of this aspect of the overall project is to continue to let our youth direct this work and prompt change in the community conversation around adolescent reproductive health.
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