Nurse-Led Home Visits, Group Counseling Reduce Risky Behaviors and Sexually Transmitted Infections, Improve Family/School Connectedness and Grades Among Sexually Exploited Runaway Girls

Service Delivery Innovation Profile

Nurse-Led Home Visits, Group Counseling Reduce Risky Behaviors and Sexually Transmitted Infections, Improve Family/School Connectedness and Grades Among Sexually Exploited Runaway Girls

Snapshot

Summary

The Minnesota Runaway Intervention Program is a nurse-led initiative to help sexually assaulted or exploited runaway girls reconnect to family, school, and health care resources. Through a combination of home visits and group counseling, the program aims to reestablish girls' positive development, reduce trauma, and improve health and coping behaviors. The program reduced sexually transmitted infections, trauma symptoms, and risky behaviors while improving family and school connectedness, grades, and protective behaviors such as contraception.

Evidence Rating

Moderate: The evidence consists of comparisons of self-reported data and screening results for a group of 20 early participants at baseline and 6 months after enrollment; key results from an evaluation of 68 participants enrolled during the first 2 years of the study; and annual comparisons of similar data and screening results for participants at baseline and after 3, 6, and 12 months in the program, over the past 8 years. The evidence also includes comparisons to nonabused and abused urban ninth-grade girls who participated in the 2004 and 2007 Minnesota Student Survey .

Date First Implemented

2003

Problem Addressed

A significant number of young girls run away from home, and these girls often face significant risk of sexual exploitation and assault, along with a number of other mental, emotional, and sexual health issues. Programs that connect runaways to support services can help, but young runaways often have difficulty accessing these programs.

  • Many runaways, facing significant safety risks: Ten percent of ninth-grade girls in Minnesota public schools have run away from home at least once in the past year. Young runaways face significant safety risks, with as many as 40 percent suffering sexual exploitation and assault, including gang rape, prostitution, and engaging in survival sex., Many runaway youth have already experienced prior familial abuse, putting them at even greater risk of sexual exploitation.,,
  • Many health issues: Runaway youth often experience a variety of mental and emotional health problems, including depression, posttraumatic stress disorder, self-harming behaviors, and suicidal thoughts and/or attempts. They also experience high rates of sexually transmitted infections and pregnancy.,,
  • Unrealized potential of support services: Runaway or abused youth with higher levels of support, such as connectedness to school, family, and other caring adults or friends with positive social values, are less likely to engage in violent or harmful behaviors and more likely to report positive health, school performance, and aspirations for the future. Yet, few resources exist to link runaway youth to these support services before they begin living full time on the streets, a key period in which intervention can reduce negative health outcomes.

Description of the Innovative Activity

The Runaway Intervention Program is a nurse-led initiative that helps sexually assaulted or exploited runaway girls reconnect to family, school, and health care resources. Through a combination of home visits and group counseling, the program aims to reestablish girls' positive development, reduce trauma, and improve health and coping behaviors. The program provides initial assessments to between 200 and 250 youth each year, and offers intensive services to up to 75 youth per year. Key program elements include the following:

  • Program referrals: Runaway girls can be referred to the program through a variety of sources, including schools, the court system, law enforcement, community outreach workers, social service agencies, and current or former participants.
  • Initial assessment: Those referred receive an initial assessment, both to determine eligibility and obtain an extensive history of runaway behavior and sexual exploitation. The assessment, conducted at the Midwest Children's Resource Center by an advanced practice nurse and a pediatrician, includes a thorough health care examination; a review of medical, family health, and social history; and questions to assess risks and protective factors. Runaway girls can participate in the program if they are between the ages of 12 and 15, have been sexually abused by more than one person outside of their family, and do not currently have an open case with child protective services.
  • Home/school visits: Each youth receives an intensive set of home or school visits from a nurse; participation requires the parent or guardian to sign a consent form and attend an informational conference with staff at the program office or in the home, depending on the family's preference. Once permission has been secured, each youth receives four visits from an advanced practice nurse at home or school during the first month of participation, followed by two visits per month for the next 2 months. Visits continue at a frequency of once every 3 or 4 weeks for up to a year. Key services offered during these visits include:
    • Immediate access to health care: To eliminate barriers to accessing reproductive and sexual health care, the advanced practice nurse provides teenagers with in-home access to screening for pregnancy and sexually transmitted infections. The nurse can also provide condoms, prescribe or initiate birth control, and help with changes to existing birth control prescriptions.
    • Education focused on building skills and self-esteem: Each visit focuses on building on an individual's strengths and reducing the potential for harm, using education to improve skills and self-esteem and help set and achieve personal goals. The youth chooses the topic (from a predetermined list) to be covered at each visit, such as safe sex and contraception, mental health issues, substance use and abuse, family conflict, nutrition, physical fitness, injury prevention, and skills for daily living (e.g., making appointments, using public transportation, and navigating the health care system).
    • Reestablishment of school connectedness: During each visit, the advanced practice nurse devotes a portion of time to issues related to school connectedness. This time includes discussions about school and any conflicts being experienced there, helping with homework or locating sources of homework assistance, and working with the school to identify someone, such as a counselor or caring teacher, who can help the youth become better connected within the school environment.
    • Assistance for parents: The advanced practice nurse also provides assistance to parents and guardians, helping them to access support and services from the legal, health, and social systems. The nurse works with parents to increase awareness of their child's traumatic experiences and how they can help in the child's healing process.
  • Weekly group counseling: All participants can participate in a weekly therapeutic empowerment group, which meets after school under the guidance of a therapist. The group deals with issues related to problem-solving, family and peer conflicts, and addressing and healing from trauma. Youth can attend this group for as long as they find it useful to do so. The program provides free transportation to the sessions for those who need it through a van service.
  • Services for nonrunaways: In 2008 and 2009, the program began offering an 8-week intervention for sexually abused teens who were not runaways. As part of this 2-year project, 92 girls received a combination of group cognitive behavioral therapy and health education each week. This program provided the teens with birth control and connected them to a community health provider. This extension project ended in 2009, when grant funding expired; it was started again with new grant funding in 2011.

Context of the Innovation

Housed at the Minnesota Children's Hospital in St. Paul, the Midwest Children's Resource Center is a regional evaluation and advocacy center providing coordinated, nontraumatizing services to children who are victims of abuse and neglect and their families. During the summer of 2002, a group of seven runaway Hmong girls between the ages of 12 and 15 (all of whom had been severely sexually abused) were referred to the center for care. In attempting to coordinate services for these youths, nurse Laurel Edinburgh became concerned that traditional “safety nets” (e.g., law enforcement and the school system) did not always effectively intervene with young runaways before they became involved in violence and sexual exploitation. In consultation with University of Minnesota colleague Dr. Elizabeth Saewyc, Ms. Edinburgh sought funding for a nurse-led program to address this service gap.

Results

The program reduced sexually transmitted infections, trauma symptoms, and risky behaviors while improving family and school connectedness, grades, and protective behaviors such as contraception.

  • Fewer sexually transmitted infections: An analysis of screening results from the first 20 participants found that the rate of chlamydia infections fell from 55 to 15 percent after 6 months of participation. Results from the first 2 years of the program (68 total participants) and subsequent annual evaluations are consistent with this pilot study.
  • Reduced trauma symptoms: Beginning in 2011, the program implemented the University of California, Los Angeles Posttraumatic Stress Disorder (PTSD) screen as an assessment at baseline and for regular followup at 3, 6 and 12 months. The annual evaluation reports since then have documented significant declines in overall trauma symptom scores and PTSD diagnostic thresholds for most participants who have been in the program for more than 3 months (updated May 2014).
  • Less risky behaviors: Multiple studies suggest the program has reduced risky behaviors, as outlined below:
    • Initial trend study: A study of 68 participants found that after 12 months in the program, condom use increased by 56 percent, while overall use of effective contraception increased by 46 percent. Suicidal ideation fell by 57 percent, while the number of days within the past month in which participants used alcohol and tobacco declined by 65 and 75 percent, respectively. Participants also reported a significant decline in number of sexual partners over the past 3 months.
    • Followup trend study: Subsequent studies (from 2008 through 2014) show consistent declines in self-reported risky behaviors after 12 months of participation in the program.
    • Comparison study: When compared with two groups of urban ninth-grade girls from the 2004 Minnesota Student Survey (one group reporting sexual abuse and a second group not reporting such abuse), program participants showed significantly lower rates of suicidal ideation and attempts after 12 months in the program. Participants reported similar levels of condom and drug/alcohol use as both comparison groups; before joining the program, participants reported significantly more alcohol/drug use and less condom use than did the other groups. More recent comparisons between program participants and girls who responded to the 2007 Minnesota Student Survey show similar findings.
  • Improved connectedness, better grades: After 6 or 12 months in the program, participants consistently report being significantly more likely to feel able to talk to their mother about problems (as compared with before enrollment). Participants also consistently report improved overall family connectedness (after 6 months) and significantly higher school connectedness and improved grades (both 6 and 12 months after enrollment). School-connectedness after 12 months in the program was found to be significantly higher than that of girls in comparison groups from the Minnesota Student Surveys.

Evidence Rating

Moderate: The evidence consists of comparisons of self-reported data and screening results for a group of 20 early participants at baseline and 6 months after enrollment; key results from an evaluation of 68 participants enrolled during the first 2 years of the study; and annual comparisons of similar data and screening results for participants at baseline and after 3, 6, and 12 months in the program, over the past 8 years. The evidence also includes comparisons to nonabused and abused urban ninth-grade girls who participated in the 2004 and 2007 Minnesota Student Survey .

Planning and Development Process

Key steps included the following:

  • Forming task force: Program leaders assembled a task force of community stakeholders invested in serving the unmet needs of sexually exploited runaway girls. The group initially focused on serving young Hmong runaways, as the Midwest Children's Resource Center experienced a rapid increase in cases of sexually exploited Hmong girls. As time progressed, the task force widened its focus to examine the needs of runaway girls in general. Comprised of a core group of 10 to 12 members, the task force included representatives from the public school truancy program, the county attorney's office, social service and public health agencies, the police department, and several local Hmong organizations. The group met monthly to brainstorm ways to improve community-wide services for sexually exploited runaways; many of these ideas informed the creation of the program.
  • Conducting needs assessment: The task force conducted a community needs assessment to determine strengths and weaknesses in existing services for young runaways. In addition to identifying needs in individual areas (e.g., a lack of overnight shelters to which youths could self-refer), this process revealed an overall need for better connectedness and care coordination among agencies serving sexually exploited runaways.
  • Creating protocol: The task force created a shared protocol of best practices for when and how to refer runaway girls to various service organizations, and developed formal agreements for sharing information across agencies. Agencies use this protocol when referring runaway youth to the program, as do the program's advanced practice nurses when making external referrals for clients.
  • Obtaining funding: Program leaders sought and received a $20,000 grant from the Children's Hospital Association to launch the initiative.

Resources Used and Skills Needed

  • Staffing: The program employs one full-time coordinator and two part-time advanced practice nurses who collectively represent 1.1 full-time equivalents. The program also contracts with an outside therapist who works approximately 3 hours per week planning and facilitating the group sessions. All pediatricians who assist with the initial assessment do so as part of their regular job responsibilities with Minnesota Children's Hospital.
  • Costs: The program has an annual budget of $160,000, which covers staff salaries and benefits, compensation for the contract therapist, and transportation to and from the group sessions.

Funding Sources

The evaluation component has been funded in part by a grant from the Canadian Institutes for Health Research (Saewyc, Research Chair).

Getting Started with This Innovation

  • Cultivate a community coalition: Bring together a variety of community members (with different areas of professional expertise) invested in sharing ideas and building strategies to improve the lives of young runaways. Both concerned citizens and representatives of service agencies can be valuable to this coalition.
  • Involve decisionmakers in early brainstorming: To move quickly in creating solutions for youth, early idea-generating sessions should include key leaders from participating agencies. Having decisionmakers at the table who are empowered to speak authoritatively on behalf of their respective organizations can make a big difference in transforming ideas into action.
  • Seek funding from variety of sources: Use the community and, if possible, the local legislature to generate interest in the problem being addressed, thus opening the door to possible funding sources.

Sustaining This Innovation

  • Work towards cultural competency: Ensure that advanced practice nurses have a comfortable knowledge of cultural group norms and the pressures facing runaway youth of various ethnicities. This knowledge allows them to build welcoming and trusting relationships with teenagers and their parents.
  • Ensure commitment from key stakeholders: Because grant funding can vary widely from year to year, work to maintain the commitment and support of several key stakeholders.
  • Use best-practice protocols: In times of limited funding, the program may not be able to serve as many youth as leaders would like. Having a best-practice protocol ensures that those youth served get the best care possible across the continuum of care, even in periods of financial instability.

Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Laurel Edinburgh, MS, PNP, RNC
Midwest Children's Resource Center
Minnesota Children's Hospital
347 North Smith Avenue,
Suite #401
St. Paul, MN 55102
Phone: (651) 220-6065
Fax: (651) 220-7637
E-mail: Laurel.Edinburgh@childrensmn.org

Elizabeth Saewyc, PhD, RN, PHN
University of British Columbia School of Nursing
T201 2211 Wesbrook Mall
Vancouver, BC
Canada V6T 2B5
(604) 822-7505
E-mail: elizabeth.saewyc@ubc.ca



Innovator Disclosures

Ms. Edinburgh and Dr. Saewyc reported having no financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Edinburgh LD, Saewyc EM. A novel, intensive home-visiting intervention for runaway, sexually exploited girls. J Spec Pediatr Nurs. 2009;14(1):41-8. [PubMed]

Saewyc EM, Edinburgh LD. Restoring healthy developmental trajectories for sexually exploited young runaway girls: fostering protective factors and reducing risk behaviors. J Adolesc Health. 2010;46(2):180-8. Epub 2009 Aug 3. [PubMed]

Saewyc EM, Solsvig W, Edinburgh L. The Hmong Youth Task Force: evaluation of a coalition to address the sexual exploitation of young runaways. Public Health Nurs. 2008;25(1):69-76. [PubMed]

Edinburgh L, Huemann E, Richtman K et al. The Safe Harbors Youth Intervention Project: Intersectoral collaboration to address sexual exploitation in Minnesota. Nursing Reports. 2012; 2(1):18-24. doi: 10.4081/171.

Footnotes

  1. Minnesota Department of Health. Minnesota Student Survey Statewide Tables. 2007. Available at:http://www.health.state.mn.us/divs/chs/mss/statewidetables/mss07statetablesfinal.pdf

  2. Edinburgh LD, Saewyc EA. A novel, intensive home-visiting intervention for runaway, sexually exploited girls. J Spec Pediatr Nurs. 2009;14(1):41-8. [PubMed]

  3. Smith A, Saewyc E, Albert M, et al. Against the odds: a profile of marginalized and street-involved youth in BC. Vancouver, BC: McCreary Centre Society, 2007. Available at: http://www.mcs.bc.ca/pdf/Against_the_odds_2007_web.pdf

  4. Saewyc EM, Edinburgh LD. Restoring healthy developmental trajectories for sexually exploited young runaway girls: fostering protective factors and reducing risk behaviors. J Adolesc Health. 2010;46(2):180-8. Epub 2009 Aug 3. [PubMed]

  5. Halcon L, Lifson AR. Prevalence and predictors of sexual risks among homeless youth. J Youth Adolesc. 2004;33(1):71-8.

  6. Saewyc E, Wang N, Chittenden M, et al. Building resiliency in vulnerable youth. Vancouver, BC: McCreary Centre Society, 2006. Available at: http://www.mcs.bc.ca/pdf/vulnerable_youth_report.pdf

  7. Edinburgh L, Huemann E, Richtman K et al. The Safe Harbors Youth Intervention Project: Intersectoral collaboration to address sexual exploitation in Minnesota. Nursing Reports. 2012; 2(1):18-24. doi: 10.4081/171.

Funding Sources

Office of Juvenile Justice and Delinquency Prevention
Children's Hospital Association
Charlson Foundation

Developers

Midwest Children's Resource Center, Minnesota Children's Hospital (St. Paul, MN)
Original Publication: 01/20/10

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 05/21/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 03/23/14

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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