2007 Model Practice Application (Public)

Seen on da Streets

Minneapolis Department of Health and Family Support

Seen on da Streets targets adolescent and young adult African American males between the ages of 15 and 24 living in 5 Minneapolis communities with the highest rates of gonorrhea and chlamydia in the city. This racial/ethnic and age group was selected because of their high rate of sexually transmitted diseases (STDs) and teen pregnancies. Males are traditionally underserved by reproductive health services. The young men targeted is primarily disaffiliated individuals — those not likely to be engaged in activities at schools and faith-based institutions. This target audience includes individuals who have dropped out of school, are unemployed, belong to gangs, are homeless, or hang out on the streets. The goals of Seen on da Streets are:

• Increase knowledge and modify attitudes related to using condoms and other contraception and to STD testing.
  
  
• Increase self-reported use of condoms and other contraception and communication with partners about contraceptives.
  
  
• Increase STD testing, STD treatment, and other health clinic visits by the target population.

The objectives of Seen on da Streets are:

• Provide health education, risk assessment, and referrals through outreach to young males.
  
  
• Increase gonorrhea and chlamydia testing among young males utilizing in-clinic and off-site specimen collection.
  
  
• Provide treatment to those testing positive for chlamydia or gonorrhea.

Project outcomes include increased reproductive health services to young males, and lower rates of gonorrhea, chlamydia.

This project addresses the disproportionately high rates of chlamydia and gonorrhea among African American adolescents and young adults in Minneapolis. The relevancy of this effort is corroborated by the many organizations that work to decrease the burden of sexually transmitted diseases in Minneapolis. The Minneapolis Department of Health and Family Support has been involved in many of these efforts, supporting school-based clinics and neighborhood health care clinics, and educational campaigns. Additionally, reducing racial and ethnic health disparities is of great importance to the community. The Big Cities Health Inventory (City of Chicago, 2002) identified Minneapolis as having the highest rates of chlamydia and gonorrhea among African Americans among the 50 largest US cities, which further highlighted the need to address STDs in the African American community. Nationally, the federal Title X program has made expanding services to males a top priority. Locally, health practitioners were concerned about the dearth of males receiving STD testing and treatment, and the fact that many of the young women they treated were often reinfected, putting at risk for the potentially serious complications of pelvic inflammatory disease. Getting males tested and treated was recognized as a priority, but established models of care were not attracting young men, who had among the highest rates of disease.

This project provides services to males who are not affiliated with school, employment, church groups or other community providers. Street culture youth are not typically responsive to traditional health education and promotion messages, and often have health education, risk assessment and clinical sexual health services targeted at high-risk African American males using a peer outreach model. Off-site urine specimen collection through outreach has broken down many of the traditional barriers to care, and has been very appealing to the target population.

Literature review revealed that there were not many well-developed approaches to addressing sexually transmitted diseases from the perspective of male health. Testing males traditionally relied on male self-identification or partner referrals. However, the majority of STD cases among males are likely asymptomatic, and males typically procrastinate in seeking care even with symptoms. Female partners may be reluctant to identify partners, and males identified in this way may resist treatment. Innovations in male testing have made it more male friendly, yet high-risk street culture youth were not making use of these services. The peer outreach workers involved in project planning insisted that the most appropriate vehicle for expanding testing services was to provide off-site testing through peers. Peers can build the trust necessary for success, since urine sampling is often associated with drug testing and therefore avoided. The project is unique in targeting disaffiliated youth in the streets, local businesses, parks and other locations. This style of street outreach requires knowledge of and comfort with street culture. Outreach staff are from the community and familiar with the “hustling” mentality that sells a product on the street. While this type of mentality can be used negatively, the staff conducting outreach capitalize on this approach to sell other young men on the importance of sexual health practices. They do this in an engaging style that raises awareness and knowledge of their clients, and promotes self-empowerment in taking care of personal health issues. These staff have a diverse set of skills that allow them to be able to be effective in both clinical and street settings. One unintended outcome of this project is a group of trained peers who have developed job skills in health care settings who are viewed as leaders by their community, many of whom intend to pursue health careers.

The local health department was instrumental in the development and implementation of this project. The local health department identified the opportunity to serve males and approached the community clinical partners due to their expertise in serving adolescents. One of the partners had prior experience with providing peer outreach to young men. The experience of those peers was integral to the planning of the outreach protocols and off-site specimen collection plans for this project. The local health department provided expertise in developing the logic model and research protocol to provide systematic evaluation of this effort. The internal project team consisted of the Project Director, Project Coordinator, and Project Evaluator, who worked closely in developing and implementing the project. The Project Management includes the internal team, as well as administrators and male health educators form each project clinic. This teem meets biweekly to coordinate efforts, provide updates, and troubleshoot any problems.

During the course of the development of this project, STD experts in the state health department were also consulted. Once grant funding was received, a community advisory committee was established to provide assistance with making connections with community stakeholders working with young males and in sexual health. This group is made up of community leaders, and advocates, health and social service providers, and others. More targeted strategic partnerships that may involve coordination of activities, health education presentations, and targeted outreach have been fostered through direct meetings with many groups: alternative schools, other community clinics, police precincts, community agencies, and others. Project staff also met with local media outlets (radio and newspaper) to work out project marketing plans. The diverse group of organizations involved in the project has been essential to the success of reaching large numbers of young men.

Funding was provided by the US Department of Health and Human Services Office of Family Planning. Implementation costs totaled about $220,000 annually over 3 years. This covers outreach, supervisory, and administrative staff support, off-site testing costs, supplies and materials. Evaluation and research costs totaled $50,000. Additional costs include in-kind support for low-cost in-clinic STD testing.

This project is a collaboration between a local health department and two community clinics. The clinics provide clinical services and outreach activities, while the local health department is the fiscal agent and provides project coordination, evaluation, and administrative support. The tasks involved in this project are: providing outreach, health education, and risk assessment in community settings, including providing condoms and information on their use to sexually active males; and providing off-site specimen collection for chlamydia and gonorrhea testing during outreach. Outreach activities are conducted by teams of 4 peer outreach workers at each project clinic. These teams are supervised by a male health educator. Teams operate in groups of at least 2 for safety purposes, and each outreach worker has a cell phone.

Outreach is conducted in locations where younger men congregate, such as city parks, neighborhood store parking lots, and barber shops. Contacts are also made at alternative schools and community agencies. Most young men in the 15- to 20-year-old age group are reached in these locations, however, older men are not typically found in the same venues. The Health Educators and some Youth Advocates conduct outreach in local night clubs to reach older males; this activity is restricted to project staff at least 21 years old. During outreach activities, staff engage clients in a brief risk assessment covering sexual risk activity and receipt of health services. Project staff provide health education on the proper use of condoms to prevent STDs, STD information including testing and treatment, pregnancy prevention, and clinic information. Condoms and safe sex kits are distributed to sexually active males, and referrals for clinical services are also provided.

Off-site specimen collection for gonorrhea and chlamydia testing is provided to young men in outreach settings who may not otherwise come to the clinics for testing. During outreach, and in certain circumstances, outreach workers are able to obtain a urine sample for testing. During the specimen collection, detailed contact information is gathered, including the location of the test and what groups the client may be affiliated with to facilitate recontact. A preservative allows the urine to remain unrefrigerated for up to 24 hours after the test. The workers then return the specimen to the lab for processing. Once the result is known, the client is contacted with the results, often by cell phone but sometimes in person. Individuals with a positive result are highly motivated to obtain treatment, and treatment rates are above 95% for the project.

This project has been operational continuously since 2003. Outreach activities increase in the summer when there are more opportunities for providing services in community settings.

The primary funder for this project is a federal research grant through the Office of Family Planning, which provides funds for staff time (including male health educators, peer outreach workers, and administrative support), along with funds for testing associated with off-site specimen collection, marketing, and other costs. The project clinics provide a significant amount of support for the project in serving young males using free and sliding-scale fee structures. These commitments are an expression of their intention to expand services to men. Some of the testing services have been funded through the state health department, which provides support for walk-in testing services. Local foundations have expressed interest in helping to support aspects of this model. Relationships with other health providers, businesses and community organizations have been established to support the work of the project. Development plans for the future will rely on utilizing a range of resources from the local, state, and federal level and may involve partnerships across governmental, business, and non-profit sectors to help support the work of the project.

The goal of this practice is to reduce the rates of gonorrhea, chlamydia, and unintended pregnancies among the target population.

Objective 1: Provide health education and risk assessment through outreach.

Performance Measure: Reach at least 50 high-risk men per week.

Feedback: Data suggest that outreach effectively targets young males.

Outcome: Over the first three years, there were 8,822 contacts made, an average of 59 per week. 94% are sexually active.

Objective 2: Provide in-clinic and outreach testing to men between 15 and 24.

Performance Measure: Test 800 young men annually.

Feedback: Data suggest that outreach activities are effective in inducing young men to be tested for STDs.

Outcome: Over the first three years of the project, 2410 STD tests were administered, including 980 off-site tests.

Objective 3: Provide treatment to males who test positive.

Performance Measure: Treat at least 90 percent of positive cases.

Feedback: Data suggest that off-site specimen collection can result in successful treatment of infection.

Outcome: 97% of positive cases received treatment through project clinics. Other cases were referred to disease investigators.