Think about the last time you thought you had an STD. How did you feel? Who did you tell? What did you do? Awkward, right? Maybe this hasn't happened to you personally, but each year over 20 million Americans contract a Sexually Transmitted Disease. Over 50% are youth and most go undetected and untreated. Just Health is a risk screen app being used in over 100 School-Based Health Centers and is the flagship tool of a National CDC Center for Technology Innovation that is focused on adolescent sexual health. Just Health works to improve patient-provider communication and reduce stigma around a range of topics from safety, substance use, mental health, and sexual health including the intersectionality of needs and gender identity and sexual orientation. Just Health is an example of ongoing evaluation in real-word conditions. Population-level data are improving understanding of these needs and risks from a system perspective.

1. Sexual Health is Just Health
findings from a
National CDC STD Prevention Training Center

2. National Center
for Technology Innovation

3. Session Objectives
1. Evaluation & Learning
2. Technology, Sex, & Humans: Bridge to stigma-free communication
3. Data, Context, & Meaning

4. Learning & Evaluation

5. On Learning
K = I∞ ⊗ TDSRP

6. On Learning
K = I ⊗ T

7. On Learning
Learning =△Knowledge
Knowledge = Information x Thinking
K = I⊗ T

8. On Learning
K ≠ I

9. On Learning
K = I∞ ⊗ T

10. Four Universal Patterns of Thinking
• Distinction-making: what it is and what it isn’t
• Systems - part-whole structures, zoom in and out, sort and group
• Relationships –cause and effect, compare & contrast
• Perspective – another view on the same point
Google: Derek Cabrera Cornell Systems Thinking

11. What is Learning
K= I∞ ⊗ TDSRP

12. What is Learning
K= I∞ ⊗ TDSRP
Metacognitive
Learning how to learn
Transfer

13. On Evaluation
Hypothesis
Question
Reality Test
MVP
Collect Data
Feedback
Interpret
Respond

14. On Evaluation
Hypothesis
Question
Reality Test
MVP
Collect Data
Feedback
Interpret
Respond
Can school-linked
services improve
access to healthcare
for adolescents?

15. Why:
Technology, Sex, & Humans

16. On Evaluation
Hypothesis
Question
Reality Test
MVP
Collect Data
Feedback
Interpret
Respond
How can
technology improve
patient-provider
communication to
improve adolescent
health.

18. People are having sex.
• Sexually Transmitted Diseases (STDs) are
on the rise with 20 million people in the
U.S. contract an STD each year.
• Over 50% were adolescents under the age
of 24 (even though they account for only
17% of the sexually active population).
• Most were asymptomatic at diagnosis and
CDC experts estimate there could be 2-3
times as many STDs that remain
undiagnosed.

19. It’s not only about sex.
• Mental Health and Trauma
• Alcohol and Drugs
• Intersectionality
• Adolescent Populations

22. The problem is
communication.
• STD and other health experts say their
biggest challenge is training healthcare
providers to collect comprehensive,
consistent, and accurate data on sexual
behavior via interview.
• Mental health, trauma, and substance use
carry similar stigma. They tend to get
glossed over, particularly when they are
not the primary or presenting concern.
• That’s why we created Just Health.

23. Just Health gets you through the difficult
questions so you can have a better
conversation about all aspects of your health -
free of stigma.
Just Health isn’t a substitute for the
conversation, it’s a bridge to it.
The solution is
communication.

24. On Humans and Technology

25. Just Health Overview
More Communication. Less Stigma.

26. Just Health is built on
evidence-based tools and
principles.
• Bright Futures Guidelines
• HEEADSSS Interview Protocol
• Home environment,
• Education and employment,
• Eating
• Activities
• Drugs
• Sexuality, Suicide/depression, and Safety
• PHQ-9 (depression)
• GAD 7 (anxiety)
• CRAFFT (substance use)
• CDC Sexual History Guidelines
• Motivational Interviewing Prompts

27. Quick Tour of Just Health

48. It’s Working
Just Health:
• is comprehensive
• promotes efficiency
• uncovers key sexual health and other issues
• opens space to discuss sensitive and vital patient information
• encourages more truthful patient history

49. Patient-Provider Communication
“We truly believe the [health screen] was a game changer. It has
allowed us to find and intervene with many issues that would not have
otherwise been revealed and addressed. The iPad has been so crucial in
allowing ‘the space between’ for the adolescent to open up and
mention their issues.”
“I get far more truthful answers with Just Health than I would asking the
questions face to face- especially related to anxiety and sexual health.
Love it!”

50. Quantity of Services

51. Quality of Services
“I think it gives us a great way to gather a LOT of information
quickly and then tailor our interventions/education to that
specific teen.”
“The answers we are getting are more complete and allow us
to address concerns at a deeper level than we previously
could.”

52. A Continuum of Support

53. Just Health Distinctives
Adolescents + Intersectionality + Communication

54. Plans for Improvement
• Interoperability
• Youth-Centered Design
• Decision-making and perception of harm
• Library of Counseling Messages

55. Invitation for Input

56. Data, Context & Meaning

57. Context gives meaning to data.
Data without context is meaningless.
Or worse, misleading.

58. What is context?
• More data
• Story behind the data
• Thinking:
• Distinction-making: what it is and what it isn’t
• Systems structure - part-whole, zoom in and out, sort and group
• Relationships –cause and effect, compare & contrast
• Perspective – shifting the point of view

59. What is context?
• How are distinct things related to each other?
• How are they the same for different people?
• How are they different for different groups of people?
• What new questions are raised?
• What more information do we need?

60. 32%
42% 39%
Hispanic American
Indian
White
34% of all students had
depressive/anxiety symptoms with
some variation based on
race/ethnicity, gender, and
significant differences based on
LGBT status.
Percent of Students with Depressive/Anxiety Symptoms
26%
38%
Male Female
29%
60%
Not LGBT LGBT
Depression and Anxiety

61. The main underlying issues
were abuse, problems at
home, and problems at school
69% of students with
depressive/anxiety symptoms
had at least one of these issues
In fact, most (63%) of students
with at least one of these
issues had symptoms
Percent of Students with Depressive/Anxiety Symptoms
75%
26%
Abused Not abused
77%
27%
Problems at
home
No problems at
home
62%
23%
Problems at
school
No problems at
school
Related Factors

62. One in four (24%) were
positive using revised CRAFFT
scoring (1+)
Substance Use

63. One in four (24%) were
positive using revised CRAFFT
scoring (1+)
22%
41%
Not LGBT LGBT
LGBT students were significantly
more likely to be CRAFFT1+ than
non-LGBT students
Percent of Students who were CRAFFT1+
Substance Use and LGBT

64. 44%
20%
Depressive
symptoms
No depressive
symptoms
42%
18%
Problems
at school
No problems
at school
The main underlying issues
were problems at school,
depressive symptoms, time in
jail, and abuse.
68% of students who were
CRAFFT1+ had at least one of
these issues.
However, 60% of students
with one or more of these
issues were not CRAFFT1+.
Percent of Students who were CRAFFT1+
70%
23%
Ever
in jail
Never
in jail
50%
20%
Abused Not
abused
Related Factors

65. 7.4%
13.5%
1.7%
Bisexual (108) Gay or Lesbian (37) Heterosexual (1547)
Sexual Orientation and Self-Reported Experience of Bullying
(N =1746)
Bullying and Sexual Orientation

66. 2.9%
1.2%
29.0%
Female (992) Male (765) Another Gender ID (14)
Gender and Self-Reported Experience of Bullying
(N =1791)
Bullying and Gender Identity

67. 74.4%
77.4%
11.1%
23.2%
22.2%
93.5%
Female
(997)
Male (780)
Another
Gender ID
(14)
Gender and Self-Reported Levels of Feeling Threatened
(N = 1791)
Low Moderate High
1.4
%
Safety and Gender Identity

68. 21.3%
29.7%
54.8%
24.1%
21.6%
24.8%
54.6%
48.6%
20.4%
Bisexual
(108)
Gay or
Lesbian (37)
Heterosexua
l (1547)
Sexual Orientation and Self-Reported Levels of Anxiety
(N =1746)
Low Moderate High
Anxiety and Sexual Orientation

69. 44.4%
61.7%
27.1%
23.1%
11.1%
28.5%
15.3%
92.8%
Female (997)
Male (780)
Another Gender ID (14)
Gender and Self-Reported Levels of Anxiety
( N = 1791)
Low Moderate High
Anxiety and Gender Identity

70. 52.8% 54.1%
33.7%
Bisexual (51) Gay or Lesbian (17) Heterosexual (1015)
Sexual Orientation and Self-Reported Sexual Activity
(N= 1729)
Sexual Activity and Sexual Orientation

71. 37.2%
29.5%
66.7%
Female (992) Male (765) Another Gender ID (14)
Gender and Self-Reported Sexual Activity
(N = 1771)
Sexual Activity and Gender Identity

73. One out of 5 of all Just
Health participants sext
73%
41%
Youth who sext Youth who don't sext
Self-Reported Sexual Activity
Youth who sext are more
likely to be sexually active
Sexting and Sexual Activity

74. Youth who sext are more likely to
have multiple partners
46%
34%
Youth who sext Youth who don't sext
Self-Reported Multiple Partners (2+)
Sexting and Sexual Activity

75. Youth who sext are more
likely to have multiple
partners AND never use a
condom
55%
40%
Youth who sext Youth who don't sext
Youth with Multiple Partners who Never Use a Condom
Sexting and Sexual Activity

76. 9%
of sexually active youth
engage in anal sex
33%
always use a condom
31%
never use a condom
Condom Use and Anal Sex

77. 9%
of sexually active youth
engage in anal sex
33%
always use a condom
31%
never use a condom
43%
LGBTQ
49%
Straight
Females
Condom Use and Anal Sex

78. Youth tend not to discuss past sexual history,
including STDs, with their partners
20%
30% 29%
Male Female Transgender
Percent of Sexually Active Youth who Discuss Past Sexual
History, Including STDs, with their Partners
Disclosure

79. Youth tend not to discuss past sexual history,
including STDs, with their partners
20%
30% 29%
Male Female Transgender
Percent of Sexually Active Youth who Discuss Past Sexual
History, Including STDs, with their Partners
Highest rate of discussion
was from youth engaging
in anal sex with multiple
partners and no condom
use
35%
Disclosure

80. Despite 4 out of 10 youth being
sexually active, few sexually active
youth are routinely
tested for STDs
22% 20%
Gonorrhea and Chlamydia HIV
Percent of Sexually Active Youth Tested for STDs
Highest rate of testing for
gonorrhea and chlamydia is
for those who have multiple
partners and do not use
condoms
Highest rate of testing for
HIV is for those with
multiple partners who do
use condoms
26%
29%
Testing

82. Session Objectives
1. Evaluation & Learning
2. Technology, Sex, & Humans: Bridge to stigma-free communication
3. Data, Context, & Meaning

83. Carlos Romero
c.romero@apexeval.org
www.apexeval.org
www.justhealth.org