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Students for Public Health Policy and Systems Change

State: OR Type: Model Practice Year: 2020

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Crook County Health Department
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Students for Public Health Policy and Systems Change

Crook County Health Department (CCHD) is located in Prineville; the sole incorporated city in Crook County, Oregon with a population of approximately 10,000. CCHD serves a rural and frontier population of 23,123. The poverty rate is approximately three percent higher than the state, with 19.4 percent of persons living below poverty level, and 13.5 percent of the population unemployed. 94.8 percent of the population identify as white and the average annual household income is $41,777, which is $14,000 less than the state median.

Following the Great Recession, Facebook and Apple opened data centers changing the economy in Crook County to technology as much as natural resources. In response, Crook County schools have prioritized Career and Technical Education (CTE) programs. These help meet the growing need for skilled trade workers, especially in rural areas. CTE programs have an emphasis on experiential learning.

In Crook County, cigarette smoking among adults is higher than Oregon and the rest of the United States.

From 2016 to 2018, there has been an increase in emergency room admissions at St. Charles Hospital in Prineville relating to nicotine use for those 17 and under. In 2018, there was a 119 percent increase, with 25.4 per 1,000 nicotine-related visits. At Crook County High School from 2016 to 2018, disciplinary actions for Inhalant Delivery Systems increased by 96 percent.

According to the 2018 Tobacco and Alcohol Retail Assessment, 4 out of 5 Oregon youth who use nicotine products started with a flavored product. Additionally, 91 percent of tobacco retailers in Crook County sold flavored products.

Goal 1: Develop capacity for community mobilization and advocacy surrounding tobacco prevention policies.

  • Engage youth in training, team building, and presenting to elected officials
  • Conduct a two-day media advocacy training
  • Youth map out legislative strategies for use in Central Oregon
  • Youth leaders recruit and train 12 additional youth

Goal 2: Increase awareness among youth about tobacco industry tactics, effects of tobacco use, and resources available to prevent initiation and support cessation.

Goal 3: Adult Champions and Youth Leaders develop and deliver messages to community members and decision makers in order to limit the influence of tobacco in the retail environment.

  • Identify and deliver appropriate messaging to address predatory tobacco industry practices in the retail environment
  • Enact Tobacco Retail Licensing (TRL) ordinances in all Central Oregon jurisdictions

CCHD secured funding to hire high school students as Youth Liaisons (YLs). YLs received public health training and engaged student interns and volunteers through the CCHS Students Against Destructive Decisions (SADD) Chapter and the Chamber of Commerce.

Student training included coalition and action groups, regular meetings, leadership trainings, and state and national events, including Oregon Health Authority's Place Matters Conference, CADCA National Forum and the SADD National Conference.

The Youth Summit for Health provided advocacy training for policy and systems change related to the issue of nicotine marketing to youth. It also provided adult training to partner effectively with youth in advocacy work.

Youth advocates developed a Photovoice exhibit and conducted events in each County to educate community members about how students observe the effects of use and influence of the tobacco industry.

Students went to our state capitol for Public Health Advocacy Day and met with legislators about supporting policies that reduce tobacco industry influence. Locally, student advocates met with elected officials to educate on tobacco and advocate for policy.

Outcomes of our project include:

  • 40 adults and 54 adolescents trained and engaged in advocacy activities
  • 24 youth trained in tobacco prevention advocacy
  • TRL proposals drafted and/or advocated for in Central Oregon city and county jurisdictions
  • TRL currently considered by Crook County elected officials

All objectives were met except enacting TRL ordinances. However, we have made progress toward this objective and continue to work toward accomplishment.

Factors leading to the success of this practices are:

  • Employment of students as CCHD Employees demonstrates commitment to the value of youth engagement in public health.
  • Multiple levels of engagement supports students by fostering skill-building at a variety of levels, including students with busy schedules.  
  • Stakeholder engagement and funding support Multiple partners recruit students, provide meeting space, funding, and opportunities for outreach.
  • Shared value of youth engagement among all levels of LHA executive leadership, managers, and program staff all demonstrate commitment.

The Public Health impact of this practice is the reduction of tobacco use and associated health issues experienced by many Crook County residents. Increasing readiness for policy change assures that the most people possible benefit from protections against nicotine addiction, secondhand exposure, and the health effects of tobacco use.

https://co.crook.or.us/health

Historically, tobacco prevention policy proposals have been met with resistance in Crook County. The Health Department began conducting Key Informant Interviews with decision-makers and stakeholders to determine what new strategies could be more effective. Results of these conversations reaffirmed what we knew about our tightknit rural community. Community members and leaders don't want more government telling them what to do and they value freedom to live and conduct business however they choose. These interviews made it clear that the health and well-being of youth is a strong shared value among decision makers and community members alike. It was also apparent that youth in the community had valuable insight and energy to make change. With youth being the target population for substance use and prevention efforts, their meaningful engagement is critical.

The Crook County Health Department (CCHD) Prevention & Health Promotion Team utilizes several best-practice programs, strategies, and approaches to provide public health services to our community. With this particular topic of youth substance use, we know that comprehensive approaches are necessary to be most effective. Therefore, we use the Center for Substance Abuse Prevention Strategies as the framework for addressing this issue.

Our innovative use of this comprehensive strategy model lies in strategically combining the strategies of community-based process, education, and alternative activities; implementing them with core Positive Youth Development components: health, competence, confidence, connection, and service. Additionally, we are being responsive to community need by seeking to address the issue of generational poverty by offering paid positions and resources that support development of financial literacy and post-secondary education and/or training.  

The goals and objectives of this practice were as follows:

Goal 1: Develop capacity for community mobilization and advocacy surrounding tobacco prevention policies in Crook County.

  • Engage 15-25 youth throughout the Central Oregon region to participate in training, team building, and providing public presentations to elected officials
  • Engage 3-12 Adult Champions to train and present with youth to public officials
  • Conduct a two-day media advocacy training as a retreat for youth
  • Youth will map out legislative strategies for use in Central Oregon
  • Youth leaders will assist in recruiting and training 12 youth coalition members for the next biennium

Goal 2: Increase awareness among youth about tobacco industry tactics to target youth, effects of tobacco use, and resources available to prevent initiation and support cessation.

Goal 3: Adult Champions and Youth Leaders develop and deliver messages to community members and decision makers in order to limit the influence of tobacco in the retail environment.

  • Identify and deliver messaging that will appeal to adults and to youth in the region in order to address predatory tobacco industry practices in the retail environment
  • Enact Tobacco Retail Licensure ordinances in all Central Oregon jurisdictions

In order to achieve these goals, Crook County Health Department partnered with LHAs in two neighboring counties and a tribal government to apply for and secure funding from state public health and our regional Coordinated Care Organization. Each partner contributed to the outlining of work in proposals, and collectively committed to the practice of authentically and meaningfully engaging youth in all aspects of the work. Securing buy-in from all levels of each LHA was critical to the success of this project.

Activities:

Recruitment and outreach: LHA staff leveraged relationships with school groups (Students Against Destructive Decisions, leadership, health classes, et cetera) and local substance abuse prevention coalitions to garner feedback on the project, educate about the issue being addressed, and to recruit advocates.

Advocacy trainings and ongoing capacity-building: LHAs developed a robust advocacy training schedule that included customized skill-building for coalition members, engagement in state and national conferences (Oregon Health Authority's Place Matters, Oregon Public Health Association's Annual Conference, Communities Against Drugs Coalitions of America (CADCA) National Forum, and Students Against Destructive Decisions (SADD) National Conference). Each of these opportunities had emphasis on local policy and system changes that can support the health of communities. In between training events, local workshops were held to practice skills, including message drafting, public speaking, and media communications.

Youth Summit: The First Annual Youth Summit was collaboratively planned and coordinated by the three LHAs in Central Oregon. We subcontracted with the Youth Leadership Institute to provide staff training on effective youth-adult partnerships prior to the Summit, facilitate sessions for youth during the Summit, and evaluation of Summit objectives, which aligned with and supported the objectives for the project. More information on results of the Summit are described in the Evaluation section of this application. 24 middle and high school students attended the two-day Summit and received training on effective youth-adult partnerships; how to advocate with peers, community members, and elected officials; and interpretation and use of media.

Public Health Advocacy Day: Youth who attended the Summit from the four county and tribal jurisdictions in Central Oregon had the option to continue building their skills and travel with the group to the State Capitol for Public Health Advocacy Day. Youth met with their representatives to share their concerns about health issues they are facing, including mental health and e-cigarette use. 

Photovoice: Groups of students across the region participated in Photovoice workshops where they learned the process and went out in their communities to take pictures that could tell their stories of how tobacco affects their lives. They then developed messages to accompany their photos and chose a series of 24 displays to be included in exhibits across the region. Three community events were planned, promoted and held throughout Central Oregon. Community members, media, and decision-makers attended the exhibits.

Presentations to local elected officials: Youth advocates presented to city and county elected officials in two of the three county jurisdictions to educate about the issue of e-cigarettes among youth and advocate for local Tobacco Retail Licensing and expansion of the Indoor Clean Air Act.

Policy drafting and proposal: Based on responses to the presentations with elected officials, LHA staff worked with state public health, the Public Health Law Center, local legal counsel, and community stakeholders to draft a Tobacco Retail Licensing ordinance that has been proposed to county and city officials and is currently under consideration. The policy has been requested by and shared with neighboring Jefferson County. 

Sustainability efforts: Building capacity among our stakeholders is a major aspect of sustainability for this project, and is ongoing. Funding sustainability is also pursued on an ongoing basis by applying for grants, fundraising, and requesting sponsorships and in-kind donations or services. Since the conclusion of this project, we have continued the work for another six months and have secured additional funding to support the 2nd Annual Youth Summit for Health.

The specific steps taken to implement the program were:

  1. LHA staff and coalition members conducted Key Informant Interviews to inform policy strategies
  2. Coordinated with LHA partners to develop program plans
  3. Secured funding
  4. Hired Regional Project Coordinator
  5. Hired Youth Liaisons
  6. Recruited and engaged adult and youth community leaders in advocacy trainings
  7. LHA staff trained in effective Youth-Adult Partnerships and Positive Youth Development
  8. Worked with youth, the Youth Leadership Institute, and LHA partners to plan and coordinate the first annual Youth Summit for Health
  9. Development of legislative strategies for Central Oregon region
  10. Facilitation of Photovoice
  11. Organization of community education events (Photovoice Exhibits)
  12. Presentations to local elected officials
  13. Drafting and proposal of policy options for Tobacco Retail Licensing and strengthening the Indoor Clean Air Act

Most of this practice was open and available to all community members. Some of the roles within the practice had criteria for participation. Youth Liaisons and interns must: be current high school students, submit application and references via county job portal, and interview with a panel. Youth Summit participants must: be current middle or high school students in the Central Oregon region, express interest in learning about health issues and advocating for policy and/or systems change. Priority given to youth previously engaged in coalition and/or advocacy efforts in their community. Presenters to elected officials must complete advocacy training. Priority given to Youth Summit participants, engagement in message development and message delivery coaching and supports.

The timeframe for our practice was September 1, 2018 to June 30, 2019.

  • September – planning and funding proposals
  • October – hiring and training, volunteer recruitment
  • November & December – advocacy training, Youth Summit planning
  • January – Youth Summit and policy message development
  • February – state legislative outreach & education
  • March & April – Photovoice & community education
  • May & June – community outreach, local elected officials presentations, policy drafting

Our key stakeholders involved with this project include LHAs in the region (three counties and one tribal), schools (specifically health teachers, counselors, careers teachers, and administrators), youth, and the business community (Chamber of Commerce). Several of these stakeholders are engaged through local substance abuse prevention coalitions with 12 sector representation (business, media, youth, parents, school, youth-serving organization, faith, law enforcement, government, substance abuse organization, civic organization, and healthcare professional). Funders are also key stakeholders engaged in this project, and include Oregon Health Authority, our local hospital – St. Charles Health System, the Coordinated Care Organization for our region – PacificSource & Central Oregon Health Council, and a variety of business and community members who provide fundraising and sponsorship opportunities.

Stakeholders were involved from the inception of this project, in every step until completion, and into ongoing efforts. Youth, LHAs and coalition members conducted key informant interviews, focus groups, and other data collection to inform project development and funding requests. Funders have not only supported the project financially, but also provided technical assistance, evaluation support, and networking connections throughout the project. Schools partnered with LHAs to conduct surveys, recruit students, communicate with parents and staff, provided letters of support, and platforms for presentations and student outreach. The Chamber of Commerce has partnered with Crook County's LHA to recruit and support student interns. All stakeholders received presentations and/or reports of project results and continue to be involved in the ongoing work.

The LHA fosters community collaboration in a wide variety of ways. Essentially, try not ask our stakeholders to do anything that we would not do for them – OR – if what we are asking is outside our scope, we are sure to find other ways to reciprocate support. This means that LHA staff serve on steering committees, advisory boards, and work groups for stakeholders. We have regular attendance and engagement in Chamber of Commerce events and provide technical support for our local substance abuse prevention coalition.

Additionally, we work hard to connect the work to values held by our stakeholders. Our partnership with schools includes provision of training for teachers and staff; classroom presentations; and data collection, analysis and sharing. This is all framed within our shared value of student health and success. In order to stay connected with the values of our partners, we conduct regular surveys, listening sessions, and send out requests for review and input.

We have regular and ongoing collaboration with neighboring LHAs in order to best coordinate with state and regional stakeholders (Oregon Health Authority, hospital system, Coordinate Care Organization, Federally Qualified Health Center). These efforts also assure that we leverage each other's resources where it makes sense.

Expense Category

Description

Amt.

Subtotal

Staffing

Liaison wages & fringe

4

$10,820

Intern stipends

6

$1,800

Conferences & training

Registration

2

$1,500

Room & board

$8,050

Youth Summit

Program supplies


$1,200

Conference space, meals & lodging

24

$8,505

Trainers

2

$9,030

Office supplies

Binders, pens, markers


$250

Transportation

Charter bus to state capitol


$1,250

Total Expenses:

$42,405.00

In-kind Category

Description

Amt.

Subtotal

Staffing

Staff supervision & program support

2.0 FTE

$48,000

Work stations

Furniture, hardware, software, utilities

4

$5,000

Transportation

County vehicles & mileage


$2,500

Training

Advocacy, Public Health best-practice, Coalition-building, Media communications

36

$2,700

Meeting space

Weekly and quarterly conference room use


$4,600

Office supplies

Printing, paper


$500

Tobacco-Free Kids National Ambassador

Training, media & legislative connections, travel

1

$4,000

Total In-kind:

$67,300.00

Evaluation of youth engagement is done through a variety of assessments. The Youth Liaisons are evaluated by their overall work through exit interviews with the prevention supervisor upon completion of employment. This process evaluates student growth, the impact of the student's involvement, and perceptions about the impact of youth engagement overall on the community.

The Students Against Destructive Decisions (SADD) chapter is evaluated through surveys distributed at the beginning and end of each school year through SADD Leadership. This assessment evaluates the impact of the student's involvement in SADD and perceptions about the impact of youth engagement. Performance measures on the SADD survey included if students thought being involved in school activities and extra-curricular activities is important and questions assessing their personal risk and protective factors. According to surveys, student protective factors have increased, specifically connection to a trusted adult and participation in community service activities.  

The Youth Summit for Health was evaluated by retrospective post-tests from the Youth Leadership Institute (YLI) which determined the information learned and the overall effectiveness of the summit. Each student and adult participant is asked to complete this evaluation. Performance measures included how much participants knew before and after the training in regards to youth-adult partnerships, creating action plans, and getting messages out to the community. YLI analyzed all of the surveys and provided a full report of quantitative and qualitative data. All youth reported increased knowledge, with greatest improvement in knowing decision makers in their community (2.5 to 4.06 out of 5 point scale) and creating an action plan (2.75 to 4.21 out of 5 point scale).

Heath Department staff use Hart's Ladder of Participation as a quality improvement tool to determine the level of youth engagement and ensure meaningful participation. Staff use this tool frequently as a process measure to determine what the current state of participation is and work towards the desired state of meaningful participation. Prior to implementing this project, the Health Departments' level of engagement landed on rung 3 or 4 of the Hart's ladder of participation. Afterwards, the level of engagement increased to rungs 6-8 with the overall goal to achieve rung 8.

In addition to evaluating youth engagement, the Health Department uses the Policy Change Model as a continuous process measure evaluation tool to determine the phase of community readiness and to direct activities and objectives accordingly. With all the youth engagement activities and adult leader trainings, there has been increased community support, readiness and political will which reflect progress along the Policy Change Model.

Immediate modifications were not deemed necessary as a result of the data findings. However, the data did inform us of training topics that need ongoing support and ones that were not as impactful going into the next year of the project. One significant change going forward is that we will not be subcontracting with another entity to provide instruction at the 2nd Annual Youth Summit for Health. Instead, a local stakeholder panel (including youth) will choose training topics and local presenters.

Evaluation of our specific goals and objectives are as follows:

Goal 1: Develop capacity for community mobilization and advocacy surrounding tobacco prevention policies in Crook County.

  • Engage 15-25 youth throughout the Central Oregon region to participate in training, team building, and providing public presentations to elected officials 24 youth were engaged in training and teambuilding activities at the Youth Summit for Health and 11 students provided presentations to elected officials at the state capitol and/or in their local jurisdictions.
  • Engage 3-12 Adult Champions to train and present with youth to public officials 7 adult community members were trained in advocacy skills and 2 presented with youth to elected officials in their local jurisdictions.
  • Conduct a two-day media advocacy training as a retreat for youth This objective was completed with the Youth Summit for Health.
  • Youth will map out legislative strategies for use in Central Oregon Youth drafted legislative strategies for Central Oregon during the Summit
  • Youth leaders will assist in recruiting and training 12 youth coalition members for the next biennium 14 youth coalition members have been recruited and trained going into the next biennium.

Goal 2: Increase awareness among youth about tobacco industry tactics to target youth, effects of tobacco use, and resources available to prevent initiation and support cessation. 6 outreach events conducted by youth leaders increased awareness among their peers of tobacco industry tactics, the effects of tobacco use, and available prevention and quit resources.

Goal 3: Adult Champions and Youth Leaders develop and deliver messages to community members and decision makers in order to limit the influence of tobacco in the retail environment.

  • Identify and deliver messaging that will appeal to adults and to youth in the region in order to address predatory tobacco industry practices in the retail environment Youth and adult advocates identified messaging that would resonate with their respective peers about the tobacco industry's predatory nature in the retail environment. This messaging was delivered in person, via print media, and online.
  • Enact Tobacco Retail Licensure ordinances in all Central Oregon jurisdictions Tobacco Retail Licensure was advocated for in each Central Oregon jurisdiction, but has not been passed. It is currently under consideration by city and county officials in Crook County.

This is our fourth year building this practice of comprehensive, coordinated youth engagement. Each year has seen growth in funding and stakeholder engagement because youth continue to attain and share results with community stakeholders, decisions makers, and partners. 

Project sustainability is ongoing and relies heavily on building capacity among our stakeholders. Funding sustainability is pursued on an ongoing basis by applying for grants, fundraising, and requesting sponsorships and in-kind donations or services. Since the conclusion if this project, we have worked for another six months and have secured additional funding to support the 2nd Annual Summit for Health. This funding was granted through a Regional Health Improvement Plan (RHIP) workgroup with an emphasis on risk and protective factors related to teen pregnancy, substance use and mental health conditions.

In addition to funding, the youth involved in these projects have made it a priority to recruit and continue to engage other youth. The SADD chapter at the high school will be conducting outreach at the Middle School Health Fair and in Crook County High School classrooms to engage new students and increase participation in their current activities. Youth recruitment is critical in sustaining these projects and the relationship built with the Crook County School District has been an instrumental part in sustaining these efforts.

SADD students and the Youth Liaisons are continually working on fundraising. Each year they plan and host a community event called Popsicles in the Park where local stores donate popsicles and SADD offers a variety of activities such as a bag toss tournament, face painting, a dunk-tank, and raffle prizes, in addition to inviting community partners to join with games and resources. Community partners such as the Parks and Recreation Department, District Attorney's Office, Crook County Library, Law Enforcement, and the School District have continued to participate in this event and show their support.

Sustainability is also built by providing leadership and professional development opportunities for teens and adult leaders. Students raised enough money last year to have four students attend the SADD National Conference in Phoenix, AZ where they went through leadership training, team building activities, and SADD planning workshops. This gave underclassman students the tools they needed to support the SADD Chapter and recruit more students. Each of these components continue to be a part of our comprehensive sustainability plan.

We have found that flex and adaptability are critical to sustaining this work, but that there is a balance to be struck in order to stay on mission. We are committed to staying true to our mission and will not seek or accept funding that threatens to stray from community priorities just because money is needed. Rather, we have developed program adaptations to use if funding becomes an issue. These adaptations change structure, while maintaining the integrity of the project. For example, Youth Liaisons can become paid interns and the Youth Summit can be a day-long retreat, as opposed to overnight.

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