Empowering Youth Aging Out of Foster Care
Condition: Health Behavior
Study type: Observational

Summary: 
      Improving the health literacy of adolescents and increasing the success of transitions to
      adulthood from foster care are two defined Healthy People 2030 public health priorities.
      Skills to promote health literacy and independent living are often lacking in adolescents in
      foster care and young adults who have aged out of care. Frequent placement changes, no
      permanent home, lack of trust in adults and systems of care prevent the development of a
      strong support system for transitioning to adulthood from foster care, which can result in
      lack of access to personal health information, complicated identity documents, and
      disconnected child welfare, health care and community resources. These factors limit the
      ability to transition to adulthood successfully, drive disparities in health outcomes, and
      may explain lack of educational attainment and career development for young adults formerly
      in care. Successful transitions to independent living are unattainable unless barriers are
      addressed with a multidisciplinary, community-based approach.

      The Rees-Jones Center for Foster Care Excellence at Children's Health and the Krissi Holman
      Family Resource Library at Children's Health recognized the unique needs of adolescents in
      foster care and young adults formerly in care (AYAFC) as they transition to independent
      living. We developed a partnership with community agencies (Empowering Youth Taskforce) that
      support these youth in the areas of child welfare (TX Department of Family and Protective
      Services), education (UNT PuSH Program), career development and housing support (TRAC at City
      Square, Zoie's Place), legal support (SMU Dedman Law School), and others, to increase AYAFC
      health literacy, access to health care, and awareness and use of available community
      resources. Frequent placement changes and unstable housing make it difficult for AYAFC to
      keep their health information, identity records and personal documents together, which is
      critical for accessing health services, enrolling in health insurance, and maintaining
      wellness. Since many have access to a smart phone, using technology is one way to promote
      adolescent health and wellness. An app is a possible solution to address many of the barriers
      that impede successful transition to independent living.

      The goal of this project is to engage AYAFC and stakeholders who support these young people
      throughout North Texas to collaboratively design an app to support the transition from foster
      care to adulthood. This project will utilize a mixed methods approach to inform the
      transition process while addressing both individual and systems level barriers to increase
      the success of AYAFC's transition to independent living. This project builds upon work done
      by a multidisciplinary community task force led by the Principal Investigator, and the
      development of an adolescent transition process at the Rees-Jones Clinic. Community partners
      are fully engaged in the design of the intervention and will be involved in AYAFC and
      stakeholder recruitment, data analysis, and interpretation of the results.
    

Detailed description: 
      This project is uniquely community-based as the only known digital information-sharing
      project that will solicit input directly from AYAFC and multiple community stakeholders.
      Prior studies had input from youth in care, child welfare personnel and health care
      providers; our project includes stakeholders involved in life skills and employment training,
      housing support, legal advocacy, and education for a more robust community perspective. Other
      information sharing resources have been web-based, which is more challenging to access, or
      resulted in a paper guidebook. Our innovative app maximizes ease of access and portability
      without requiring significant cellular data usage. Assessing the health literacy skills of
      AYAFC can inform future interventions to support transitions to wellness in adulthood while
      youth are still in foster care.

      This project is supported by the Region 3 Foster Care Consortium, a coalition of
      organizations and individuals committed to improving the lives of children involved in the
      foster care system. The Empowering Youth Task Force members are community partners who
      specialize helping youth in foster care successfully transition to adulthood. Each member
      organization contributes expertise on specific issues surrounding AYAFC they serve. They will
      engage in participant recruitment, app design and dissemination. Members of the Empowering
      Youth Task Force include:

      The Rees-Jones Center for Foster Care Excellence is a community leader in clinical care,
      policy and advocacy and research. Roles include project design; development focus group
      questions; focus group and survey data collection and analysis; expertise on adolescent
      transitions from the medical provider, behavioral health provider, foster parent, and
      caseworker perspective; stakeholder engagement, and information dissemination.

      The Krissi Holman Family Resource Library at Children's Health provide expertise in
      literature review and health literacy. Roles include project design; development focus group
      questions; survey and focus group and data collection and analysis. They will provide links
      to reliable health information and resources, and plain language educational materials that
      can be utilized through the app.

      The Transition Resource Action Center at City Square supports transition-age youth with
      employment, education and housing, providing perspective on the issues facing young adults
      aging out of foster care.

      The Southern Methodist University Dedman Law School Child Advocacy Clinic is a community
      expert on legal issues for youth aging out of foster care and will provide information
      resources (letter of support attached) The University of North Texas' Persevere UNTil Success
      Happens (PUSH) Program supports former foster youth and will provide additional perspectives
      on the needs of youth transitioning out of care.

      The Texas Department of Family and Protective Services and their Child Protective Services
      and Preparation for Adult Living Program contributes expertise in child welfare transition
      services available to youth.

      Superior Star Health Transition Services provides expertise in health insurance and support
      for AYAFC and will provide perspective regarding youth engagement in health insurance.

      Additional community partners include Dallas Court-Appointed Special Advocates (CASA) and
      Zoie's Place, who provide information as unbiased child advocates and perspective about needs
      surrounding life skills training, support and transitional housing for AYAFC, respectively.

      Study Design Most AYAFC have phones. An app is an ideal tool to help them manage reputable
      sources for health education and information, document storage, and access to community and
      child welfare resources. A community-engaged approach with AYAFC with first-hand knowledge of
      the foster care system will result in an app that is relevant and acceptable.

      4.1 Study Design: Aim 1: Using mixed methods, (survey and focus groups) conduct a needs
      assessment that measures health literacy and assesses health information, supportive care,
      and resource needs for AYAFC transitioning from foster care to independent living.

      Evaluation Methods: Survey of AYAFC to assess health literacy skills, assessment of knowledge
      of health and community resources, attitudes surrounding available resources and confidence
      in accessing digital information. Focus groups with AYAFC and community stakeholders to
      assess current needs surrounding health literacy, health information and community resources.

      AYAFC Inclusion Criteria for all focus groups and surveys: 1) AYAFC: English-speaking, ages
      18-24 who live in Texas Region 3.

      Community stakeholders Inclusion Criteria (focus groups): English-speaking adults (18+) who
      support AYAFC (e.g. caregivers, medical, legal, and social service professionals)

      Aim 2: App Development and Implementation: App development and implementation will use a
      user-centered design approach. This involves a needs assessment and targeted user feedback to
      develop an app framework. After legal approval, app infrastructure, capabilities and
      functionality are developed, design build-out and front and back-end integration occurs. User
      acceptability testing occurs at each step with testing and piloting before full roll-out.

      Evaluation method: (a) Survey of implementation outcomes. (b) 4 additional focus groups with
      AYAFC and community stakeholders to assess attitudes toward app content, design, and
      usability.

      Aim 3: By survey, reassess health literacy skills, and knowledge, attitudes, and confidence
      in accessing health information and needs for community resources.
    

Intervention name(s): Empowering Youth Aging out of Foster Care
Intervention type(s): Behavioral
Intervention description(s): App that allows storage of health information, and access to reputable health information and community resources.
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        At least 40% of adolescents in foster care have a chronic health problem or significant
        mental health diagnosis; many take medications daily. One third of adolescents in foster
        care do not have a permanent home prior to turning 18. They often have multiple placement
        changes, extended involvement in the child welfare system and substantial neglect, abuse
        and trauma histories. They may lack trust in adults, systems of care and ongoing support as
        they transition to adulthood. They also may lack access to their health information,
        identity documents and resources needed to successfully transition to adulthood. In 2019,
        over 1,100 children aged out of care in Texas. Almost 25% of children aging out of foster
        care had been in care before they were teenagers; many were in group homes or shelters and
        had multiple foster care placements. In Texas, youth who aged out of foster care are less
        likely to finish high school, go to college or be employed than youth not in care.