Workforce development as a promising approach to improving health disparities among young males.

Smith, Peggy ; Buzi, Ruth ; Abacan, Allyssa 等

While high-risk behaviors are common among adolescents, rates are higher among adolescent males, especially adolescent minority males (Paxton, Valois, Watkins, Huebner, & Drane, 2007). According to the 2011 Youth Risk Behavior Surveillance Survey (YRBSS), 19.9% of males had ever smoked cigarettes, 8.4% of males had ever used smokeless tobacco, 42.5% of males had ever used marijuana and 49.2% of males had sexual intercourse with at least one person within three months of the survey. However, only 66.7% reported condom use during last sexual intercourse (Centers for Disease Control and Prevention (CDC), 2012). Rates for females were five to ten percent lower than that of males. Moreover, approximately 11% of males in the United States father a child during adolescence and 5.8% of those 18 years old or older met the criteria for substance abuse (Martinez, Chandra, Abmam, Jones, & Mosher, 2006: SAMHSA, 2012). Health disparities, persistent within the US male population, contribute to males' poor health outcomes (Treadwell & Young, 2013).

Young minority males are also vulnerable for school dropout (Bloom, 2010; Tyler, & Lofstrom, 2009). African American and Hispanic students have a higher dropout rate than the national average of 22% to 25%, with males having a higher dropout rate than females (Leventhal-Weiner, & Wallace, 2011; Tyler, & Lofstrom, 2009). Out of the class of 2002 cohort, only 52% of Latino students and 56% of African American students eventually earned a high school diploma. Furthermore, only 20% of Latino and 23% of African American students in comparison to 40% of White students graduated with credentials to apply to a 4-year institution (Kahne, Sporte, Torre, & Easton, 2008). A 2009 study found 23% of African American males 16-24 years old who had dropped out of school were in a juvenile detention center, jail, or prison (Sum, Khatiwada, & McLaughlin, 2009).

Factors such as disinterest in classes, failing grades, the need to get a job, and the necessity to care for a family member increases the likelihood of dropping out of school (Bloom, 2010; Tyler & Lofstrom, 2009). Premature termination of high school participation is associated with adolescents' engagement in risky behaviors such as early initiation of sexual intercourse, multiple sexual partners, and low contraception use (Rashad & Kaestner, 2004). School dropout contributes to adverse reproductive health as well as overall health outcomes (Brennan Ramirez, Baker, & Metzler, 2008). For example, in 2006, adults with less than a high school degree were 50% less likely to have visited a doctor in the past 12 months compared to those with at least a bachelor's degree (Brennan Ramirez, Baker, & Metzler).

School dropout also influences workforce and career opportunities for young males (Leventhal-Weiner & Wallace, 2011). Adults with less than a high school education are three times more likely to be unemployed than those with a bachelor's degree (Cabus & Witte, 2011; Rumberger & Lamb, 2003; Tyler & Lofstrom, 2009). Young males failing to obtain a high school diploma or GED are less likely to enter the labor force. Additionally, those who complete a GED rather than a high school diploma earn less than both high school diploma and bachelor degree holders.

Current strategies used to address high rates of school dropout among young males include workforce development through employment-focused programs, comprehensive education such as curriculum redesign and GED courses, and youth development initiatives including participant monitoring and counseling (Bloom, 2010; Chen & Kaplan, 2003; Rumberger & Palardy, 2005; Tyler & Loftstrom, 2009). Thus, many "second-chance" programs provide youth with a combination of education, on-the-job training, paid employment, counseling, and social services (Bloom, 2010; Crime and Justice Institute, 2009; Weigensberg et al., 2012). Evaluations of these "second-chance" programs suggest such approaches may be effective in addressing multiple risk factors to re-engage and redirect disconnected youth.

Two "second-chance" programs that round positive results were the National Guard Youth ChalleNGe and Job Corps, both programs focused on employment, education and training (Bloom, Gardenhire-Crooks, & Mandsager, 2009; Schochet & Burghardt, 2008). Results from both programs indicated a large number of participants earned a GED or high school diploma, while others earned vocational or trade certificates. Some programs extensively screened applicants and only accepted those with visible motivation and commitment, which contributed to better results (Bloom, 2010; Millenky, Bloom, Muller-Ravett, & Broadus, 2011). Although having had positive results, long-term follow-up did not find lasting improvements in youths' economic outcomes.

Research examining the effectiveness of "second-chance" programs is limited, yielding mixed results. These programs were not usually embedded in a health care setting and tended to ignore the effects of racial, ethnic, cultural, linguistic, sexual, and socioeconomic factors on health outcomes (CDC, 2012). The purpose of the present paper is to describe Project Bootstrap, a program targeting at-risk young males. The program integrated workforce development activities in reproductive and family planning clinics.

METHODS

Program Description

The Bootstrap program targeted at-risk, young males and provided them with a stipend to pursue education and vocational training. Each male was eligible to receive a stipend of up to $1,150. The stipend was based upon duration and level of involvement of participating males in work activities along with satisfactory participation in required activities. Workforce development activities included job training programs, GED classes, and technical skill certification courses. Each participant signed a participation contract, which included a requirement to participate fully in work development program activities. Enhanced supportive services through case management were also offered to participating males.

Project Bootstrap initially started as a program for expectant fathers and provided services for young, low-income, non-custodial fathers to assist them in obtaining resources to become responsible parents (Schroeder, Looney, & Schexnayder, 2006). The results of the evaluation indicated participants had greater levels of participation in the workforce subsequent to program entry as compared to the comparison group.

Conceptual Framework

The Social Determinants of Health framework guided the development of Project Bootstrap (Brennan Ramirez, Baker, & Metzler, 2008). This framework recognizes that social factors such as environment, education, and employment play great roles in the health of individuals, especially of minorities and those living in poverty. Social determinants of health suggest disparities in the incidence and prevalence of health conditions among groups are often related to factors, which include but are not limited to, socio-economic status, geographic location, race and gender. Therefore, young minority males require a multifaceted intervention and involvement of organizations at every level--city, community, judicial system, businesses, school districts, and philanthropic and faith-based communities. Hence, Project Bootstrap comprised four components: health services, education and employment, community mobilization, and community initiatives and outreach.

Participants

From February 2010 to January 2012, 138 inner city males were recruited to enroll in Project Bootstrap. Most participants were racial minorities and living at 150% of federal poverty levels or below. Of these males, 110 remained active in the program. Project Bootstrap was located at clinics that provide low-cost to free comprehensive family planning and reproductive health services to indigent adolescents residing in a large city in the Southwest. Services provided included reproductive health screening related to puberty development, immunization status, abuse history, mental health, substance abuse history, sexual health risk assessment, screening and treatment for sexually transmitted diseases (STD), and risk reduction counseling. Males come to the clinic mainly for STD testing and treatment. Community and clinic personnel, public school staff, and other community agencies referred participants to the program. In addition, several males were mandated to attend Bootstrap through court order.

Measures

The program included an assessment of participants' behaviors and service needs at program entry. Evidence of program success and improved outcomes were measured via education and job attainment, legal issues, substance abuse, and subsequent pregnancies. Two open-ended questions queried participants about their short- and long-term goals. The Institutional Review Board (IRB) of the affiliated institution approved the project protocol for the protection of human subjects.

Procedure

Two male case managers facilitated recruitment to the program. The purpose of the program was explained to participants and informed consent was obtained before participants completed the program intake assessments. Parental consent for enrollment and participation of minors was not required, as adolescents receiving reproductive services are not required to have parental consent by state statutes. Both case managers distributed the questionnaire to participants and were available to clarify any questions. In order to be included in the study, participants had to complete an intake assessment, agree to participate in educational and job training activities and meet regularly with their case manager. Case managers were responsible for coordinating needed services, monitoring participants' progress, as well as for collecting follow-up assessments.

RESULTS

Demographic Information

A total of 138 males participated in the study. Eighty (58%) participants were African Americans, 53 (38.4%) were Hispanics, and 5 (3.6%) were White Non-Hispanics. Table 1 shows study participants were between the ages of 16 and 28 years old (Mean = 20.34, SD = 2.7).

Education and Employment Attainment

Table 2 shows low educational levels at program entry. Chi-square analyses were conducted to compare differences between intake and follow-up. The results indicated that the number of participants with a high school diploma increased (66.7% vs. 78.3%, respectively, [chi square] = 76.67, df = 1, N = 138, p = .000). The number of those employed also increased from initial intake to follow-up (54.3% vs. 75.4%, respectively, [chi square] = 49.55, df = 1, N = 138, p = .000).

Chi-square analyses were not conducted for GED completion due to low GED rates at follow-up. Only three males obtained a GED after intake with a trend of male preference for high school diploma versus a GED.

High-Risk Behaviors

Table 3 shows that at intake, 49.3% reported having problems with the law (misdemeanors, felonies, and/or drug use). Eighty-two percent of participants were either expecting or already caring for a child. At follow-up, only two participants reported a subsequent pregnancy, and only two participants indicated having problems with the law. Both participants that experienced problems with the law had previous misdemeanors or felonies at program entry. At follow-up, only 9.4% of participants acknowledged having engaged in high-risk behaviors such as smoking marijuana and/or cigarettes. Chi-square analyses were not conducted for high risk-behaviors between initial intake and follow-up due to small rates of high-risk behaviors at follow-up.

Open-Ended Responses

A total of 132 (96%) participants completed the question about short-term goals and 119 (86%) participants completed the question on long-term goals. The majority (97%) of the short-term goals related to educational attainment. Forty-eight percent of participants set a goal to obtain either a high school diploma or GED, while 45.3% of participants stated wishing to enroll in higher education.

Long-term goals related to securing employment, educational attainment, and family life. Fifty-nine percent of participants stated they wanted to have a job or career, specifically, 9.8% wanted to be an entrepreneur. Twenty percent of participants wanted to obtain a higher level of education. Twenty percent of participants stated wanting to be a better provider and person for their family. Three participants indicated goals of becoming more spiritual and closer to God.

DISCUSSION

This study's purpose was to assess the impact of a workforce development program embedded in a health clinic on reducing subsequent risk behaviors and enhancing educational and employment attainment among inner city males. Participants had a history of risky behaviors and low rates of education and employment at program entry. Most participants entered the program with a previous misdemeanor and/or felony, had low levels of employment and education completion, and reported engaging in high-risk behaviors.

The results of the study show significant increases in completion of a high school diploma and a slight increase in the number of GED completions. Additionally, there was a significant increase in the number of employed participants. Results also show a decreased engagement in risky behaviors such as drug use and smoking.

The findings of the study suggest a comprehensive approach is effective in improving outcomes among young males. Treadwell and Young emphasize the importance of a comprehensive scope of services to reduce health disparities among males (Treadwell & Young, 2013). Additionally, Bootstrap contained characteristics of successful workforce development programs outlined by Chapin Hall of University of Chicago (Weigensberg et al., 2012). This included support services (food at each session), flexibility (multiple sessions to attend per week), job quality (wage and earnings), and positive work place environment. Bootstrap also addressed behavioral health aspects influencing workforce development.

Responses to the two open-ended questions indicated participants had high aspirations related to employment, educational attainment, and family contributions. The results of the study also show males were motivated to make lifestyle changes to accomplish these goals. This supports the idea that vulnerable young males can achieve their goals by accessing support and resources in a health setting. It is important to note that the program did not screen for motivation and commitment of participants, and accepted referrals from the court system.

Despite its successes, Bootstrap faced challenges that had to be addressed. Recruitment and retention of male participants is a challenge for many programs (Bloom, Gardenhire-Crooks, & Mandsager, 2009). A criminal background makes it difficult to place enrolled males in employment opportunities. Young males' economic disadvantages are correlated with having a criminal record and low performance in academic and employment settings (Cook & Hirschfield, 2008). Case managers cited low motivation of young males at entry as a program challenge. Low motivation of young males is attributed to engagement in high-risk behaviors and a history of failing grades (Chen & Kaplan, 2003). Limited financial resources and lack of transportation were additional barriers faced by males, which created challenges to program success.

This study also has several limitations which should be noted. First, the participants' assessments relied on self-report. It is possible social desirability bias led to responses that may not accurately represent participants' experiences. Participants may have also developed trusting relationships with staff members and may have responded in a way that positively reflects the staff. Second, participants in these programs came from a single urban community. Thus, the findings may not be generalizable to populations in other geographical areas. Finally, due to the sample size of the data available for this assessment, statistical analyses were limited.

Despite these limitations, data from this exploratory study can contribute to limited information available about the role of social determinants in addressing male health care, employment needs, and behavioral risk reduction. Although lacking extensive evaluation evidence, the use of this approach with young males seems to be quite promising on the basis of its positive impact on participants. Given the enormous social costs associated with teenage pregnancy and school dropout, it is important to identify and invest in innovative strategies that improve the health and welfare of young males.

CONCLUSION

There are several lessons that were learned in Project Bootstrap. First, workforce development initiatives should develop work opportunities in partnership with community organizations. Bootstrap staff worked with a number of local businesses that were willing to provide work opportunities for participants despite their criminal background. Also, obtaining support of philanthropic organizations to support educational stipends helped young males in securing basic needs, which allowed them to invest in improving their skills. Second, the presence of consistent program evaluations provided feedback addressing specific needs of enrolled males through modifications in the program curriculum. Third, the support provided by case managers to participants was crucial to the success of young males. Case managers mentored participants in educational and employment pursuits by encouraging them to take small steps in order to experience success. Fourth, partnerships with the justice system and city courts increased the number of vulnerable youths enrolled in the program. Mandated participation provided opportunities to reduce high-risk behaviors. Lastly, a strategy used to reduce health disparities in this group was placement of the workforce development program in a family planning setting in order to reduce the stigma young male participants typically associate with accessing reproductive and family planning services. These findings can provide policy makers with more insight on how to integrate workforce development in a healthcare setting. This strategy may be helpful in the design and implementation of effective practices targeting vulnerable youth populations.

REFERENCES

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PEGGY SMITH *, RUTH BUZI *, and ALLYSSA ABACAN *

* Baylor College of Medicine Teen Health Clinic.

This work was supported by the Madison Charitable Foundation; the McGovern Foundation; and the Office of the Attorney General.

Correspondence regarding this article should be addressed to Peggy B. Smith, Baylor College of Medicine, Ben Taub Hospital, 1504 Taub Loop, Houston, TX 77030. Email: Peggys@bcm.edu.

DOI:10.3149/jms.2201.3

Table 1

Socio-Demographics of Participants

Age                                N (%)

  16                              3 (2.2)
  17                             23 (16.7)
  18                             19 (13.8)
  19                             16 (11.6)
  20                             11 (8)
  21                             21 (15.2)
  22                             14 (10.1)
  23                             11 (8)
  24                              7 (5.1)
  25                              9 (6.5)
  26                              2 (1.4)
  27                              1 (0.7)
  28                              1 (0.7)
Ethnicity
  Black                          80 (58)
  Hispanic                       53 (38.4)
  White                           5 (3.6)
Education
  8th grade or below              5 (3.7)
  9th                            32 (23.9)
  10th                           29 (21.6)
  11th                           30 (22.4)
  12th                           33 (24.6)
  HS Diploma                     30 (21.7)
  GED                            12 (8.7)
Employment                       33 (23.9)

Table 2

Educational and Employment Attainment at Intake and Follow-Up

              Initial
              Intake     Follow Up    Chi-    p-value
              N (%n)       N (%)     square

HS Diploma   30 (21.7)   46 (33.3)   76.66     0.000
GED          12 (8.7)    15 (10.9)    N/A       N/A
Employment   33 (23.9)   62 (44.9)   49.55     0.000

p < 0.05.

Table 3

Risk Behaviors at Intake and Follow-Up

                            Initial
                             Intake     Follow-up      %
                              N (%)       N (%)     Increase

Misdemeanor and/or Felony   68 (49.3)   68 (49.3)      0
Past Drug Use               10 (7.4)    13 (9.4)       2
Pregnancy                   82 (59.4)   83 (60.1)     1.2

p < 0.05.