AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
SALLY KERSCHNER: So we are continuing this work through this spring. I just kind of laughed, because at lunchtime we were talking about how we were doing this, and I think it was Audrey who talked about grounded theory and how we keep talking and the themes come around, and we discuss them more, and that refines the themes. And I really like that. This whole process has been very much like that. And, of course, I said to Audrey, "What we're really doing is we're making it up as we go along." And we've all been in that situation. That's how you survive at MCH.
But to anchor us, we went back to resiliency and assets. And I realize that many of us here have worked with this in one form or another, we use a lot of the Search Institute, which you folks are familiar with, but I'll explain that in a minute.
But I need to go back, Dick Aaronson , who many of you know and who is with the Bureau of Health in Maine and has been a long‑time member supporter of AMCHP, last summer delivered a speech on resiliency, and in that speech was this definition, "Resiliency refers to the ability to bounce back from adverse experiences and to avoid their long‑term negative effects. It describes the power of people to recover, heal, grow and succeed in the midst of stress, which is often overwhelming in nature."
And, of course, examples of this ‑‑ we got into this last night, bringing up the concentration camps and the survivors and who survived and who didn't. And that is a very extreme example, but yet we can go back to either inner city or go by geographic, go by individual resiliency, resiliency of communities, and then as we look at the Title V needs assessment, in my mind, that's starting to look at resiliency of populations and the strengths of populations and who is looked at that. So that's what we're floundering with and doing our processing about. So, again, talking about individuals, families, communities, and the application of the concept of resiliency, and then as we get into populations with Title V, how does that look?
Folks, too, I'm sure, are familiar with John McKnight , and his works, I guess starting back several decades ago in Chicago in community development and, in my mind, one of the first to really to come out with this idea of the strength of the community. And my understanding, he worked more with community and community development, but the concept that community development is based on capacity, skills, and assets of the people and their communities. And then we have all heard this criticism of service systems focus on community weaknesses instead of supporting strength which empower the communities. So I think we've all been guilty of that. We all have to really remember that. As we're looking at the end of our strength and needs assessment process, how do we implement what we've found?
Okay. So here's the Search Institute, which you folks knew we were going to get to sooner and later when we talk about assets and resiliency.
It hasn't come out ‑‑ there's the web site for the Search Institute, and if you Google search, you come up and get it. So if you've not been on their web site recently, it's a great place to go and look at how they've applied this concept of assets to research in individuals and groups of individuals.
And over the years they've done extensive research on assets that's resulted in 40 concrete positive experiences and qualities, the developmental assets of youth. These assets are powerful influences on adolescent behavior. They both protect you from problem behaviors and promote positive attitudes and behaviors.
And then their research also is showing the cumulative effect of assets as linked to a reduced likelihood of high‑risk behavior in teens, and now they're working ‑‑ there's some handouts over there on other age groups besides just adolescents that they've taken this 40 developmental assets and applied it to other subpopulations of different ages.
So, again, Val and I kind of hinted at some of this. Again, we have to stop and do this thinking about where are we in this as we're making it up? There's been much work done in assessing the strengths and needs of individuals, families, communities. How do we apply this concept of assets to populations? How is this reflected in a valid way in a population needs assessment? How to create a true assets‑based measure that reflects population health. And we're working on this through the learning collaborative. And then what's the continuing role of deficit‑based measures? How do we ‑‑ I mean, you can just measure assets. And for years we've measured just deficits, and that's not working, and so we have to do both. And how, as we start to more routinely measure assets, how do we view the deficit measures, and how do they show us the progress we're making in assets?
As we all sat around and talked about this, we were talking about people from education, people from early ed., people from health, people from population health. I had to go back to my Public Health 101 and figure out exactly what I've always been talking about all these years. So when you think Public Health 101, you think of Bernard Turnock . And so I opened him up, and here's just a couple definitions that I used to ground me.
Public health activities that a society undertakes to assure the conditions in which people can be healthy. Population‑based public health services is what we're talking about. Interventions aimed at disease prevention and health promotion that affect an entire population. We talk about systems and the public health system, that part of the larger health system that seeks to assure conditions in which people can be healthy. Then a lot of talk about communities, and the real short definition of community is a group of people who have common characteristics.
I'll talk about two ways that we've worked this concept in Vermont . And the first way is taking the assets and measuring a subpopulation of the risk behavior of youths. And, of course, that leads to the YRBS, the Youth Risk Behavior Survey, and how a group of researchers took the Search Institute philosophy and applied it to the YRBS. And you folks may know these folks, David Murphy, Kelly Lamonda is the YRBS data analysis person for Vermont , Jan Carney is at the University of Vermont , and she's been also our health commissioner for many years. She now is doing public health work at UVM. And Paula Duncan, who is a pediatrician. And many of you may know her work. She's done a lot of work nationally on assets and resiliency.
So in Vermont , we want to measure youth assets. We needed a brief measure of assets that could be incorporated into a preexisting tool such as the YRBS. The brief measure can be used to guide community‑based efforts, which I have an example of that. How can the community take YRBS results and use it in an assets‑based intervention? And, also, this brief measure can be adapted for a screening and intervention tool that healthcare providers can use in their offices in their clinical practices. And Paula Duncan has dot a lot of work on that. And that's, of course, a whole 'nother presentation, but it's really quite fascinating to see how this concept can be used in many different forms.
So as many people know, the Search Institute has 40 assets, and there were too many to put on the YRBS because the kids are going to get bored and not complete the survey, so the research team chose six.
Most folks know about the YRBS in Vermont , as many places it's administered every two years. In Vermont , all the schools except one participate, 153 schools. And this year they think this one school is going to participate too. It's peer pressure.
And so in Vermont , we're a rather small state, but that ends up to be about 31,000 students participating, and it has the traditional measures of risk‑taking behaviors such as tobacco use, sexual activity.
Then we added the six questions to the YRBS that reflect six assets. These six assets, the questions asking about the grades in school, asking the students about how often they talk with parents about school, representations, school decision‑making, their feelings about that, how often they participate in youth programs that are not sports based, volunteering in the community, and feeling valued by the community.
Quickly, the results showed ‑‑ I'll have some graphs. This article is ‑‑ was over there. Looks like people have pretty much found the copy of this article. But basically the results showed the association between the higher the number of assets, the lower the report of risk behaviors and the higher report of healthy behaviors.
And the other concept here that I really liked is that even if ‑‑ the student doesn't have to have all six assets to be doing well. The student just needs a couple of assets and you've got something to work with, either as a population of students or in individual therapy or something like that.
Then the usual limitations of the study. Even though ‑‑ I mean, this is student self‑report, and it's not a statistically representative sample, but when you get every high school in Vermont , you pretty much have a sample of all the students who attend public high school in Vermont . So it needs to be ‑‑ the results do need to be paid attention to.
Oh, good there ‑‑ these are my graphs. It's taking a minute.
What is that one?
All right. Well, luckily you have a hard copy of this in the article by Murphy, et al., and it shows that as the number of assets reported increased up to six assets, the risk behaviors declined, the risk behaviors defined as alcohol use, sexual activity, marijuana use, physical fighting, cigarette smoking, binge drinking, and planned suicide or thoughts of suicide. So these are ‑‑ I'm sorry this isn't coming out. These are lines that come down on the graph.
And then the ‑‑ it's coming in now. I figured that out. There we go. See? They're all down. That's good, right?
Then these are the healthy behaviors that increase with the number of assets. So it's a really great association. It's not causal, but it's an association that we need to pay attention to. And they're also coming out with some great graphs like this related to nutritional behavior.
Okay. So there's our YRBS. And then how we take the one school district in Vermont ‑‑ many school districts in Vermont are using the YRBS, as are school districts nationally, I'm sure. We have one school district that's 1,500 students, and it's in a whole community of about 8,000. There's three red lights in this community, to give you an idea that it's small, and people know everybody, which helps.
This school district used the Safe and Drug Free Schools money to do prevention programs. The administrators of the school district looked at the YRBS results, and I won't get into how they figured this out, but they used them to determine ‑‑ they wanted to increase communication connectedness between the parents and the adults in the community and the teens who live in the community.
So they decided ‑‑ they took ‑‑ they paid for 130 stars, which two are on display there, with asset‑based messages developed from the Search Institute's research, and they put these in windows in the businesses around the community. And it was really neat because then you'd drive around the community through the three red lights and see all these stars all over the place. And they put a lot on the school grounds. They decorated all around the school sign that has the time of the boys' varsity basketball team game tonight. And the neat part is, of course, everybody sees them, but then, also, as the woman who was putting these in the businesses, it took her 20 to 30 minutes every time to explain what this is all about. You know, the business owners say, well, sure, you can put a star in my window, but what does it mean? And so she talked about it. And it was a great way to engage people, and everybody, everybody, was very enthusiastic. We had no business that decided they didn't want that there.
And then it was fun to see the teenagers. They're looking at, oh, yeah, that's something the school's doing. And then they look at it again, and then they look at it again, and they kind of ‑‑ you could see, it was seeping in, what this means and what it was saying, and they liked it.
And I don't have a lot of qualitative data, focus group data to discuss that in a more research‑based way, but this was an example of one way a community took the assets and put it into implementation.
So how to create a strength‑based indicator. Val talked about this. I made up this little slide, and we're going to talk about it now in the work session. But basically start to describe what's in the community, even in the way of services or population strengths and needs, pull out what are assets and describe that connection between what is existing and what are the assets. And just even this process, like I was describing putting the stars in the signs of the bank and the gas station, that process can empower communities. And then by recognizing that by measuring and building the assets, communities and systems can prevent deficits. Again, how do you measure this, and what's the relationship between building assets and preventing deficits? And then back to John McKnight about how systems empower communities and not how they take care of them.
More thoughts on what we've been doing in creating a Strengths and Needs Assessment. We talked about the YRBS and the assets questions in Vermont . In Vermont , we're doing key informant interviews, and we're asking the key informants what's right and what's not right with the system, with the population, and not just saying ‑‑ going into the terrible teen pregnancy rates or something like that.
Tools for organizational capacity assessments such as the
Cast 5 you can use. In the Cast 5, many tools have the
SWAT analysis, which is the strengths/weaknesses. So there is another way to work in the strengths approach.
Identifying ten priority needs and describe them and discuss them within an assets framework instead of a deficit framework. Setting annual indicators using asset approaches, what we're going to be talking about in a minute. Then, overall, creating the Strengths and Needs Assessment ‑‑ first of all, calling it a Strengths and Needs Assessment ‑‑ and using guidelines that reflect assets.
So here we are in Region 1. We still have a lot of work to do. We're going to continue with our learning collaboratives, as Val talked about. We'll continue and get together in a more collaborative way, work more closely with our colleagues in school readiness and early childhood.
There's a sample that you folks have received about ‑‑ we took the guidance from April. It was written in April 2003 for the needs assessment, and we just played around in trying to rework it and putting in assets‑based language.
And then each state in Region 1 will obviously produce their own Strengths and Needs Assessment that reflects these overall concepts, but is specific to the strengths and needs of the MCH community in their state.
Okay. We'll talk about how we'll break up here.
As you can see, we don't have answers. We've had lots of good questions to stimulate discussion, and I think the thing that still I find challenging is there's research about how you look at assets in individuals and communities, but there's not anything in the literature that talks about looking at assets in systems. And wearing my Title V hat and thinking to the ‑‑ you know, Title V, and we're responsible for assuring that there are systems of services and care available to meet the needs of the maternal child health populations in our states, and how do we ‑‑ what are the indicators or the measures we use to assess those systems?
And nobody has been able to answer that question for me, and I'm getting comfortable with it. But I think it just challenges us to think a little bit differently about it, and particularly as we continue ‑‑ at least in my state, we're continuing with a budget shortfall, and I add on what's going on at the national level, and I presume my budget is going to be even less. And since I was maxed out before we got to the budget deficits, I know I'm going to have to make some tough choices in our state and I'm going to have to bring people together.
And how do we look at those systems to know what's really working well? Is it just looking at your infant mortality rate, is it looking at your prenatal enrollment? Does that tell you your systems are working well or doesn't it?
I think it doesn't fully tell you that. And have to make some choices about where are you going to continue to invest resources, both human financial, and where are you going to start stepping away from? We can't ‑‑ for 40, 50 years we can't keep funding, you know, certain specialty clinics or certain services and ‑‑ because we won't have the resources to say yes to some new emerging issues, and so needing to make those choices in an educated manner.
What we would like to have you do now ‑‑ as I said, we've started the conversation, and we're hoping that this helps also to stimulate some thinking for you, and maybe collectively we can come up with some answers. But I don't think that's going to be this month. I think it's going to be a little bit down the road. In moving toward that avenue, what we'd like to do is have everybody break up into some small work groups.