Problem Addressed

• Significant health disparities: Latino youth face educational inequalities, poverty, unequal access to health care, poor environmental conditions, and language and acculturation barriers, all of which may adversely affect their health. Latino youth are more likely to be obese or overweight; less likely to be in excellent or very good health (as reported by their parents); and more likely to experience anxiety, delinquency, and depression than White youth.¹
• High rates of teen pregnancy: Pregnancy rates among Latina teens exceed those of all other demographic groups.² For example, in Minnesota, the birth rate among Latina females aged 15 to 19 years was 107.8 per 1,000 births in 2007, nearly six times higher than that of White females of the same age (18 per 1,000).³ Many of these teens have additional children before the age of 20 years—in fact, more than one in five (21 percent) Latina adolescents who gave birth in Minnesota in 2007 have more than one child.³
• Inadequate support for parents: According to a national survey, Latino teens report that their decisions about sex are most strongly influenced by their parents' input.⁴ However, at least 70 percent of Latino parents need more support and guidance in communicating with their teens about healthy sexual behaviors. This finding is particularly true among immigrants and those living in predominantly Spanish-speaking households, as language and cultural barriers often arise between parents and their more acculturated teenagers.⁴

Description of the Innovative Activity

• Clinic logistics: Aqui Para Ti operates on Monday and Thursday afternoons from 1:30 to 5:30 p.m. The program serves any Latino youth ages 11 to 18 and their families, along with young Latino adults up to age 24, with no geographic or financial restrictions. 
• Bilingual, bicultural multidisciplinary team: A multidisciplinary team staffs the program, including a board-certified physician (in adolescent and family medicine), health educator, case manager/behavioral health specialist, and program coordinator. All team members are bilingual and bicultural, creating a comfortable and welcoming environment for families.
• Initial office visit: Each participant completes an introductory office visit that typically lasts 2 hours. Parents are encouraged to attend this visit with their child. Key components are outlined below: 
  • Review of confidentiality policy: A team member meets with the youth and his or her parent(s) to go over the program's "Confidentiality Mantra," which ensures that no information shared between the teen and the program will be disclosed to parents without the teen's consent, with the exception of information about abuse or other threats to the teen's safety. This policy emphasizes the program's goal not to segregate the parent from the teen but rather to support the parent by acting as an "other significant adult" to help them raise their teen. 
  • Questionnaire and risk assessment: The youth completes a questionnaire designed to identify existing protective and risk factors, which in turn helps program staff determine the teen's level of risk and intervention needs. Parents complete a separate questionnaire to identify concerns about their child's behavior or development.
  • One-on-one meetings with providers: The youth meets individually with the physician and then with other members of the team as determined by the needs identified in the questionnaire. A youth with many risk factors may meet individually with all four team members during the initial visit, whereas someone with few risk factors may meet with just one or two. When parents accompany the youth to a visit, a member of the team, usually the coordinator or health educator, also meets with the parents to explore their concerns.
  • Development of treatment plan and next steps: Program team members and the youth discuss and prioritize treatment needs and agree on next steps, including subsequent visits.
• Ongoing, individualized care and referrals: After the initial appointment, youths follow their individualized treatment plans under the guidance of program staff. Treatment plans vary based on the needs of the individual and may include a combination of internal program services and referrals to outside agencies and other community partners. The program team meets weekly to review cases, discuss and further develop treatment plans, and ensure that each youth's needs are being met. Although the team does not share information with parents without the child's consent, the program encourages the youth to involve their parents in the process. Services provided as part of this ongoing care process include the following:
  • Primary and preventive medical care: The physician on the team becomes the primary care provider for most patients, providing full-service medical care, including physicals, treatment for common illnesses, vaccines, pregnancy testing, family planning services, and testing and treatment for sexually transmitted infections. For those youth who have another established primary care provider, the program provider may provide consultations on certain issues. The program physician also provides prenatal care for pregnant youth, as well as full medical care for any children the youth may already have.
  • Health education: The health educator provides the youth with health information concerning various lifestyle-related issues, such as family planning, pregnancy care, puberty, sexually transmitted diseases, diet, and healthy control of weight, all with an emphasis on prevention. Health education services supplement the message of the physician and serve to identify and address important issues the youth may be experiencing in greater detail. As needed, the health educator meets with parents to discuss adolescent health issues and the challenges involved in raising healthy children.
  • Behavioral health consultations: The physician and case manager meet with the youth for consultations on a variety of emotional and mental health topics, including depression, anxiety, anger, school issues, substance use and abuse, body image issues, relationships with family or friends, and communicating with their parents. Owing to limited capacity, those who require more than a few mental health consultations receive a referral to an offsite provider for ongoing therapy.
  • Referrals: Youth who require services that go beyond the scope of the program receive referrals to offsite community agencies, all of which have been vetted by program staff for cultural competency. Referral services include individual and family therapy, exercise programs, nutrition programs (e.g., the Federal Women, Infants, and Children or WIC program), housing programs, food pantries, and nurses who can provide home visits to those who are pregnant. 
• Parent education: Team members follow a formal curriculum developed in collaboration with the University of Minnesota for educating immigrant parents of Latino youth. This curriculum, delivered through onsite discussion groups, provides guidance to parents raising children in an unfamiliar culture, including how to improve parent-child communication so as to reduce the chance that the youth will engage in risky behaviors. Group sessions cover topics such as parenting styles, adolescent development, communication, discipline, conflict resolution, and parent and youth connectedness. In addition to hosting the onsite parenting group, program staff also use the curriculum to guide one-on-one visits with parents who request additional assistance.
• Free (or low-cost) services, financial assistance: Many program services are offered free of charge; whereas, for others (primarily direct medical services), families pay according to a sliding-fee scale based on income. Onsite financial counselors assist youth and their families in applying for health insurance and other types of financial assistance.

References/Related Articles

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Innovator Disclosures

Results

• Increased use of birth control: According to a review of patient charts, the proportion of youth reporting that they do not use any method of birth control fell from 47 percent to 13 percent after one or more office visits with the health educator. Half of all youth elected to use a highly effective method of birth control (e.g., intrauterine devices, injectable contraceptive, birth control pills, or patches) after meeting with the health educator, up from 7 percent at baseline.
• Improved self-reported health status: The vast majority (86 percent) of youth reported that their overall health had improved since initiating program services. Nine in 10 believed that the prescribed treatment plan addressed their needs, and all respondents reported that they trusted the doctor and other members of the program team.
• Positive clinic experience: The vast majority of youth surveyed (93 percent) reported feeling comfortable during clinic visits. In addition, 100 percent trusted program staff and believed they were responsive to their needs, and 87 percent found their experience much more positive than with other clinics.
• More communicative, aware, and confident parents: Focus groups with parents suggest the program has increased their ability to communicate with their children, improved their understanding of available community resources and how to access them, and increased their confidence in seeking guidance and support from providers on how to support their child's development.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Conducting community survey: West Side Community Health Services contracted with the Wilder Foundation, a local nonprofit organization, to conduct a survey identifying the service needs of the local Latino community. Parents consistently reported the need to receive guidance on how to talk to their children about healthy behaviors. Program leaders used this feedback to design a clinic-based intervention that emphasized parent and child connectedness as a vital factor in healthy youth development.
• Transitioning to new leadership: From 2002 through 2006, Aqui Para Ti operated as a program of West Side Community Health Services. After the program's Minneapolis clinic site closed in 2006 owing to funding issues, program leaders sought available clinic space from other community agencies. They eventually partnered with the Hennepin County Medical Center, which agreed to reopen and operate the clinic where the program was originally housed.
• Establishing network of partner agencies: Program leaders used existing contacts with community agencies as launching points for developing a network of Latino-friendly specialty and support services to which Aqui Para Ti clients could be referred (and from which referrals to the program could be encouraged). Program representatives also attended health fairs, community events, and conferences to network and connect with new service providers. Program leaders conducted site visits and/or met with representatives of each potential partner site to learn more about their services and eligibility requirements, develop a relationship, and ensure cultural competence.
• Developing parenting curriculum: The program collaborated with the University of Minnesota Program in Health Disparities Research, the Extension University of Minnesota, and other community partners to develop a risk prevention curriculum for Latino immigrant parents, which was piloted in parenting groups at Aqui Para Ti and other community organizations. Plans are under way for a second phase of the project, involving a companion curriculum for adolescents.
• Broadening partnerships to meet wider range of needs: Aqui Para Ti leaders are currently working to create a broader, more integrated network of partnerships to better meet the multiple needs of Latino youth and families. To that end, the program has partnered with Centro and La Conexion (two local organizations that support and provide resources to the Latino community in and around Minneapolis) on an initiative called "Todos Juntos," which seeks to integrate community and clinical services to improve the physical, emotional, and social health of Latino youth.

Resources Used and Skills Needed

• Staffing: The program employs a full-time program coordinator, full-time health educator, and part-time case manager. The program also employs a physician/medical director who dedicates roughly 20 hours a week to the program (although this individual sees program participants during other hours as well). Starting July 2011, the program will hire a youth mentor to work with youth and parents to help children complete their K to 12 education and get into college.
• Costs: The program's current annual budget is $300,000.

Funding Sources

Getting Started with This Innovation

• Recruit staff members who know the target population: Cultural competence, sensitivity, and a responsive attitude toward the needs of immigrant youth and families are essential qualifications for program staff. Front-line staff must speak the language of their clients and be well-versed in their community values and norms. Acknowledging and mirroring these values during interactions helps create a safe, welcoming space where youth and families feel recognized and respected.  
• Ensure that staff has experience in adolescent development: To best fit the team approach to working with youth, any physician working with the program should have an interest in—and understanding of—adolescent medicine. If community members recruited to fill other staff positions do not have similar expertise, provide training on the basics of adolescent medicine, development, and parenting. 
• Establish partnerships wisely: Search broadly for local partners that share the program's vision and priorities and have the means to support the initiative. For example, by partnering with Hennepin County Medical Center, Aqui Para Ti secured access to clinic space and supplies from an organization dedicated to making health care affordable and accessible to all.

Sustaining This Innovation

• Provide adequate staff support: Working on reducing health disparities for members of underserved communities can be an emotionally difficult job for front-line providers and staff. To avoid burnout, ensure that staff members have adequate support and dedicated time to debrief on difficult cases. 
• Secure sustainable funding and partnerships to meet growing demand: Programs that provide comprehensive and culturally competent care to specific minority populations often become referral centers for the entire community, which can create financial challenges and overwhelming demand as client volume grows. To meet these challenges, look for funding sources other than time-limited grants, and establish partnerships to support the provision and expansion of services over time. Developing close relationships with academia can help inform research targeted at the community served, which in turn can lead to additional sources of funding.
• Partner for program evaluation: As program demands grow, staff focus often falls increasingly on service delivery and patient care, with little time allotted to ongoing evaluation. Hire or partner with an outside entity to help with this critical function.
• Take systematic approach to providing care: A systematic approach allows providers to address all the variables that affect the health of Latino youth, including family relationships, school, and other cultural dynamics. Focusing only on physical symptoms will likely not result in a long-term, positive impact on the child's health.
• Share lessons learned: Program staff periodically share lessons learned by participating in various advisory boards and initiatives targeted to the Latino community, which helps to disseminate best practices in adolescent care and boost support for program activities.

Additional Considerations and Lessons

• In December 2010, National Multicultural Institute granted Aqui Para Ti the Leading Lights Award in recognition of being a role model for enhancing diversity and encouraging respect and inclusion within the organization and within the diverse communities it serves. More information is available at http://www.hcmc.org/Newsroom/pr2.asp?nrID=251.
• The National Alliance to Advance Adolescent Health has also recognized the program as exemplary; visit http://www.thenationalalliance.org/programs/program.cfm?programID=3 for more details.