Promoting resilience among expectant and parenting youth in California during the COVID-19 pandemic

The purpose of this study is to showcase some of the challenges experienced with the transition to and implementation of televisits and to identify strategies both in terms of practice and policy that enhance case managers’ ability to connect, engage and continue to support expectant and parenting youth (EPY) during the COVID-19 pandemic. A total of 83 program staff (case managers and supervisors) from each of the 20 programs across California provided information on their experiences in serving EPY youth during this challenging time, especially as they transitioned from traditional face to face visits to online televisits. They report that COVID has exacerbated the challenges facing expectant and parenting youth and identified a number of challenges in conducting televisits. Case managers provide critical support for EPY, understanding the needs of and providing ongoing support for these front-line staff is essential during this pandemic.

Background

The California Maternal Child and Adolescent Health (MCAH) Division, within the California Department of Public Health, developed the Adolescent Family Life Program Positive Youth Development (AFLP PYD) Model which provides comprehensive case management services to Expectant and Parenting Youth (EPY) [1]. AFLP PYD case managers are to meet with their clients in-person twice per month (over the course of a year and in many cases, longer). With youth-centered support, EPY and their children can draw on their personal strengths and community services and supports to achieve positive social, educational, health and economic outcomes. Case managers support youth in developing a sense of purpose, positive identity and skills, such as resourcefulness and problem solving, to build resilience [2-4].

On January 30, 2020, the World Health Organization declared the Coronavirus outbreak (COVID-19) a public health emergency [5] and subsequently on March 19, 2020, California (like many other states) issued a ‘stay at home’ order [6]. Home-visiting programs across California serve over 5,000 participants with nearly 30,000 home visits yearly (HRSA, 2020) [7].

This statewide shutdown had a significant impact on these programs across the nation, including California’s AFLP PYD program, requiring them to shift immediately from in-person visits to televisits with youth. The purpose of this study is to showcase some of the challenges experienced with the transition to and implementation of televisits and to identify strategies both in terms of practice and policy that enhance case managers’ ability to connect, engage and continue to support EPY during the COVID-19 pandemic.

Methods

A total of 83 representatives (53 case managers, 26 Supervisors and 4 both case managers and supervisors) from each of the 20 AFLP PYD programs across the state (Figure 1) were asked to describe how they were being impacted by COVID-19 and talk about challenges and strategies for engaging and working with youth as operations were being shifted to a virtual platform. Four, 1-hour group discussion sessions were held between April and June 2020, in which representatives from the 20 AFLP PYD programs across California discussed both their own experiences and that of their youth in transitioning to televisits. Inductive qualitative methods was used to analyze the data [8]. Two members of the research team were responsible for carefully reading the transcripts and developing a coding scheme that captured the main themes from the participants’ statements. The first coder then read the transcripts and coded the data. The second coder repeated the coding procedure independently. The two sets of coded transcripts were compared and agreement was reached on all of the coded segments. The researchers then categorized the data into key themes and identified quotes that represented each theme. The other members of the research team were then asked to review the transcripts, themes and quotes to ensure it accurately represented the data.

Results

The 83 AFLP PYD staff who participated in this study were serving an active caseload of 1,736 EPY at 20 different program sites across California. See Table 1 for youth program participant demographicS.

The following themes emerged

Meeting basic needs: Most case managers and supervisors expressed that helping EPY meet basic needs was a top priority. Case managers shared that youth were unable to purchase basic supplies such as food, diapers and wipes due to vast shortages, fear of exposing themselves or their infant to COVID by going to stores, and a loss of household income. According to case managers, many youth in these counties were already suffering scarcity and difficulty accessing resources and would rely on schools to access some of their daily meals.

“Youth were at first, ‘I need food, toilet paper, baby wipes…’ all that kind of stuff… I made sure that youth had addresses for all the places where we had food drives, where they could get diapers, wipes, items and made sure to give youth the info for information for all the free breakfasts and lunches at schools that were closest to them” (Representative 1).

Case managers stated that youth were having to wait in increasingly longer lines to receive food from food banks, and as stores' supplies were being rapidly depleted, they found it more difficult to use their food vouchers. Most case managers reported that they were able to connect youth to food banks, emergency distribution centers, mental health services, and some online parenting classes. This is in large part due to their knowledge of the resources in their community. As one case manager said.

“I have 19 years of case management experience. Right away we went into lock. I’m very involved in our county. I make sure to always have a person in every type of agency: hospital, food agency, industry, so I have contacts in place to support my clients” (Representative 2).

While some case managers were no longer permitted to travel, a few were able to drop-off diapers and other supplies at their client’s doorstep.

Health and mental health of youth: Navigating the health system has posed significant challenges for many youth. Many case managers were unable to reschedule canceled appointments due to language barriers and/or busy or disconnected phone lines. Youth continued to have health care needs, but case managers reported disruptions in care from changes in their health insurance status and shifts to telehealth visits. Case managers also reported that youth experienced additional anxiety in going out, whether it be for essential trips to the store or to the doctor, over potential exposure to COVID-19 for them, their baby and other family members. Those with uncertain immigration status expressed an additional level of fear in leaving the house. Some reported that they, or someone they know, had been stopped by police and questioned about where they were going. While no citations were reported, this contributed to stress they were already experiencing. Overwhelmingly, case managers reported youth had concerns about uncertainty with their job status, difficulty in assessing what is an essential service and when to leave the house, living in unsafe neighborhoods and how a sudden sense of isolation has made it difficult to manage their depression and anxiety.

“They are overwhelmed by being in the house. They don't feel like they are getting time to relax/unwind” (Representative 3).

“Not being able to go shopping for their baby, canceling their baby showers, losing their jobs, getting their ultrasound appointments canceled” (Representative 4).

“Stressed due to uncertainty regarding graduation and graduation ceremony” (Representative 5).

“Not having one on one interactions with teachers, counselors, and peers to discuss their concerns and for support” (Representative 6).

“Fear of taking child to a medical facility due to COVID-19” (Representative 7).

“Issues with applying for Medi-Cal through parents due to being a minor.” “Relationship issues with partner while in isolation” (Representative 8).

“Lapse in healthcare insurance coverage” (Representative 9).

Case managers also mentioned that youth were grieving the absence of social connection and gathering with friends and family to celebrate important milestones, making their accomplishments feel meaningless. Some adolescents in AFLP PYD, have overcome enormous challenges and were able to successfully graduate in 2020, though many experienced a sense of loss over the cancelation of graduations. Case managers shared how important it was to honor and celebrate these accomplishments, even if it meant a less desirable, on-line platform.

“Youth are feeling like their accomplishments mean nothing since they can't celebrate with their support system” (Representative 10).

Case managers in several regions stated that county mental health phone lines were overwhelmed by the increased volume of incoming calls, making it difficult for youth to access help.

“I had a youth who recently had a baby 2-3 months ago. There’s domestic violence in the home and she was able to get treatment. But her counselor was at a school-based site. Our mental health wellness line was overly impacted…I was able to connect her to the California peer warm line through Mental Health Association of San Francisco… She’s been doing really good” (Representative 11).

Several case managers noted the importance of talking about mental health with youth and doing their best to be a consistent presence in their lives – especially during this time. As one case manager said:

“I have a 13 yr old male, he had a very difficult time talking about his life. He had a lot of negative self-talk and a very difficult time even looking at me. I reminded him that mental health is emotional well-being and with stay-at home order, it was really important to show consistency and concern about his overall well-being, that’s going to be important going forward” (Representative 12).

Opportunities and challenges with televisits: A few case managers reported that COVID-19 created a crisis in which youth who would otherwise not reach out, were now contacting AFLP programs in search of help and resources. Case managers were able to use televisits to connect with youth new to the program. Benefits of telehealth also included the ability to stay connected with youth when face-to-face visits were no longer possible and, in some cases, increased case managers’ ability to reach youth in rural regions. Despite these benefits, many expressed a range of challenges. Some youth lacked reliable internet or phone services and a number of youth lacked access to laptops, tablets, or smartphones, making connecting with and video-calling youth more difficult.

“It is really difficult adapting to the new methods of working such as technology and helping others understand the need for technology” (Representative 13).

Case managers also reported it was challenging to discuss important and/or emotional topics through a screen as it was harder to interpret body language and nonverbal communication. Case managers felt they had a harder time connecting with youth.

Maintaining youth privacy and confidentiality, in the context of televisits, especially when in crowded living conditions, posed additional challenges for case managers. In particular, a lack of confidentiality made it nearly impossible for case managers to discuss mental or emotional health needs, especially in households where these issues are considered “taboo” topics or highly stigmatized.

“Challenges include lack of privacy in current location to discuss mental health/socio emotional health needs” (Representative 14).

Staffing/Redeployment of county staff: While many case managers were able to transition to working remotely, given the different funding structures of each individual program, many were redeployed from AFLP PYD to respond to COVID-19 emergency related issues in their community. In one county, if case managers would have to be emergently redeployed, the AFLP PYD program would be shut down as a whole given the lack of human resources and funding.

“Trying to balance everything required at work in conjunction with additional responsibilities from COVID 19 is challenging” (Representative 15).

Resilience: Case managers reported that the teamwork and support from their co-workers and supervisors allowed for them to stay connected to their youth and to more easily adapt to the new changes and challenges brought forth by COVID-19. For youth who were able to stay engaged (via telehealth), case managers expressed joy and gratitude in being able to support youth in accessing critical resources, and in helping youth stay on track to graduate and work toward achieving other goals they set for themselves as part of the AFLP PYD Model.

“What is working well for me is engaging with clients, having excellent communication with my boss, and seeing the resiliency of my clients” (Representative 16).

Conclusion

The COVID-19 pandemic is a rapidly evolving public health crisis and as case managers were forced to transition to televisits some were also redeployed to address COVID-19 emergencies in their communities. This study found that AFLP PYD staff experienced a significant strain on their available time and physical resources. They reported COVID-19 exacerbated challenges already facing this population of EPY. While telehealth enhanced the ability of some case managers to contact hard to reach youth, many reported challenges with internet connectivity, privacy and that it was often difficult to communicate and read social cues in a virtual environment.

We also identified some variations in the structure and resources across the programs in various counties, which had differential impacts on case management practice. Teamwork and support from their co-workers and supervisors allowed for them to stay connected to their youth and to more easily adapt to the new changes and challenges brought forth by COVID-19.

While the progression of the COVID-19 pandemic remains uncertain, the predicted devastating economic impact has already been identified [9], and the needs of these high risk youth will likely increase. The AFLP PYD Program and system of case management is an integral part of the fabric of these communities, providing the support and resources necessary to guide this vulnerable population to develop positive health, social, academic and economic outcomes. MCAH has been dedicated to understanding the successes and challenges experienced by case managers and EPY to provide appropriate guidance as the situation continues to unfold. Case managers hold a vital role in supporting vulnerable youth in these communities. It is critical to understand their needs in order to better to support them implement case management practice in a virtual context as COVID cases continue to rise. Investing the necessary funding and resources in these frontline workers can make a positive difference in the present and future lives of these youth.

We are grateful for the support of the leadership and staff at the California Department of Public Health, Maternal Child and Adolescent Health Division, Adolescent Family Life, Positive Youth Development (AFLP PYD) Program. This project would not be possible without their contributions. We also extend our sincerest appreciation to the case managers and supervisors across all of the AFLP PYD programs in the state for their commitment to the youth they serve and for sharing their experiences during the COVID-19 pandemic.

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© 2020 Toofan Y, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.