Can a medical clinic for youth provide a social determinant portal for employment? A pilot report from the field

Sixty-six minority low-income male and female post-secondary adolescents and young adults (AYA) were recruited to participate in a pilot job training program via a medical portal at their primary preventive care clinic located in a large metropolitan city in southwestern United States. Of this group 33 youth entered into the program. Following program enrolment, characteristics associated with success were qualitatively identified and monitored, prevalence of risk factors during participation were tracked and individuals were asked to identify program components that facilitated this transition to successful employment. Feedback from these youth suggests that a clinic can be a safe and successful portal to a multifaceted job training program in allied health professions and have the added value of being their medical home. In addition, this relationship provided easy access to primary care services which were a pre-requisite to job placement and advancement. *Correspondence to: Peggy B Smith, Population Program, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA, Tel: 713-873-3603; Fax: 713873-3608; E-mail: Peggys@bcm.edu


Introduction
During the 20 th century the field of public health was credited with adding 25 years to the life expectancy of the population in the United States [1]. Surprisingly for this longevity it was estimated that only 15% of cases were driven by medical interventions. Areas diverse as motor vehicle safety, the availability of effective family planning, and water purity had a larger and more profound impact on the quality and length of life. Still for most communities and their associated interventions most individuals were unaware of how non-medical initiatives or social determinants of health improved their daily lives especially for fragile groups. Ahonen, et. al. [2] have suggested that part of the problem lies in the fact that few researchers have incorporated such non-medical factors into the analyses of health disparities in general. These authors also suggest that such a dilemma is often created by the complexity of these factors. One such item is the concept of work, the interconnectedness of work and socioeconomic status and the lack of precise data on which to explore the relationships between work and health. As the majority of people spend most of their time either looking for work or working, it can be intuitive that a relationship exists between what people do and how well they are. Some [3] have gone so far as to say that bad working conditions are directly related to bad health. Even though few would argue with the importance of work, ironically, the validation of such suggestions is only as successful as the adoption and integration of evidenced-based practices albeit nonmedical through partnerships with local community members and their organizations.
A growing body of evidence suggests that one social determinant of health related to work, meaningful employment, may be one of the most significant factors in the well-being of individuals seeking employment. The World Health Organization suggests that employment plays an important role in the establishment and maintenance of health. Such a determinant has far reaching impact from providing economic livelihood and, in some cases, to accessing health insurance through the workplace.
One group of individuals may especially benefit from access to employment opportunities. For at-risk adolescents and young adults (AYA) work prospects, when appropriately tailored, can provide a living wage as well as mediation of risk factors which occur early and shape the subsequent health outcomes throughout the lifespan. Although employment has been cited as significant social determinant, emerging data in Harris County, Texas, for example, found that over 111,000 youth with qualified secondary achievement credentials had been unable to find and retain career-based employment. The lack of employment opportunity may indirectly influence youth and their subsequent behaviours which lend themselves to involvement in the juvenile justice system. This is especially true for status offenses such as truancy, running away and curfew violations which become impediments to meaningful employment. For example, from 1994 to 1998 while felony offenses dropped, arrests rose for simple assault, disorderly conduct, drug possession and curfew violations. Targeting AYA through the employment portal is important as they need access to health and employment opportunities that promote positive behaviour which can also mitigate such problems with the law. As most youth and young adults will eventually look for workforce opportunities to enter the workforce as contributing adults, the challenge is to develop an approach that also provide economic and health protective factors.
Traditional programs in the past have targeted high school drop outs to reduce sexual risks and future incarceration or encourage high school completion and access to birth control [4]. Recently, initiatives have targeted the specific needs of young males who dropped out of school such as education, training, and employment [5]. Previous research suggested that for males who dropped out of high school and participated in a GED program, initial employment occurred but effectiveness for females or the path to upward employment opportunities could not be documented. It is proposed that the longterm effectiveness of such work force initiatives can be enhanced if there is a re-focus on both male and female high school graduates. In addition, one could speculate that their career potential could be improved especially in the health care professions in large medical centers via access to a trusted portal, in this case a preventive primary care medical home. Secondary benefits to such an approach is that participants have access to an affordable medical home using a health navigator which includes but is not limited to reduction of negative health behaviours, increase in immunizations, management of BMI behaviours, receipt of STI screening and contraceptives including long-acting reliable contraception.
For example, Project Bootstrap [6] was a male initiative for high school dropouts that focused on preventing pregnancies and other related risk behaviours which offered work force training and educational stipends. Moreover, researchers are now suggesting that such programs for at-risk youth could also enhance a variety of protective factors such as positive values, social abilities, and positive identity in addition to reducing risk behaviour which maximizes employment retention [7][8][9].
The present paper provides a description of a pilot program for a cohort of post-secondary young men and women with the objective to recruit, enrol and provide career advancements in allied health professions using a medical home as a portal. The preliminary results of this initiative attempt to address the following questions. First, can a job portal located in a medical home facilitate employment outcomes including hiring, retention and advancement for post-secondary youth and young adults? Second, what components of innovative models of job acquisition are most successful with this cohort of disconnected high school graduates? Third, does participation is such a model provide protective factors which reduce behavioural risks and improve physical health? Finally, for those who participated in the clinic-based portal, can they access and maintain meaningful jobs in health-related professions? Such insights can provide useful guideposts on how to effectively and efficiently integrate this disconnected group into productive jobs.

Program description
The theoretical model used to guide this project was the Social Determinants of Health framework. This approach [10] suggests that health is also determined in part by access to social and economic opportunities; resources and supports available in our homes, neighbourhoods, and communities. Social determinants are often clustered into two components and include conditions (e.g., social, economic, and physical) and setting or place (e.g., school, church, workplace, and neighbourhood). These resources for purposes of our initiative include an economic strategy which was implemented via participation in preventive primary care health services. Understanding the relationship between how population groups experience work and its impact on health is fundamental to evaluating this approach. Core components in the program included case management, peer support groups, mentoring, community service activities, and life skills training.
The program was conducted at a primary preventive care clinic in an inner-city area in the Southwest United States. This clinic was selected for the program because youth in this area were defined as disconnected or high-risk based on indicators of and high unemployment rates and health disparities. The study protocol was approved by the Institutional Review Board of the affiliated medical school. In the first six months a total of 66 adolescent and young adults (AYA) 18 to 24 years of age were recruited to the program. Assistance with post-secondary education was available to all program participants. Of this initial group 1 male and 32 females showed an interest and were then enroled in the program.

Subjects
The sample for this program was comprised of all AYA who had completed post-secondary education and were enroled via the clinic portal into job training project. Of this group, 15% were African American and 85% Hispanic. No Anglo or Asian clients chose to be in the program. The majority of the participants resided in inner city neighbourhoods. Their mean age at entry to the program was 20.28 years.

Instrument and Procedures
At program initiation a group of enrolees were invited to participate in a group discussion to reflect on various aspects of program effectiveness. At the completion of the first six months in post-secondary job recruitment, all participants were assessed on what factors were most important to program completion following a group discussion, they were asked to respond in writing to four questions examining their experience with the program. These questions are used by the research team as an evaluative instrument to obtain participants' input on program implementation.

Data analysis
For qualitative information obtained through personal interviews and focus groups, thematic analysis techniques were employed. Two members of the research team, who were not involved in conducting the individual or group discussion, independently summarized the themes that emerged in the written responses. They then compared the themes and reached a consensus. The research team member who was involved in the group discussion reviewed and verified the themes based on notes taken during the group discussion. An aggregate of 14 participants across 3 cohorts during the months of January, February and March 2019 answered the questions in a group setting.

Qualitative results
The results are organized around the four questions which were embedded in a social determinants framework.
Question 1: Can a job portal located in a medical home improve employment outcomes including hiring, retention and advancement for post-secondary youth and young adults?
Most of the participants came to the clinic seeking medical care and were pleasantly surprised that the clinic could also provide a portal for job training in allied health professions as well. The recruited clients felt safe and appreciative of the pre-employment support that was available to them and was provided by staff whom they trusted and knew. "I always wanted to be a nurse, but I did not have much support from those around me; being in Ascend gave me the courage to pursue my dreams and believe that I can better myself" (JB).

Question 2:
What components of innovative models of job acquisition are most successful with this cohort of disconnected high school graduates? A variety of activities that were provided to participants prepared them for future employment. This included tours of academic campuses including the medical school and participation in mock interviews off the property. Enrolees were also taught the technical aspects of resume writing and on-line job search which gave them confidence to try new employment opportunities. "I really enjoyed the simulation of a job interview. It helped me to understand what I was getting into and it gave me courage" (ML).

Question 3:
Does participation in such a model provide protective factors which reduce behavioural risks and improve physical health? Several risk factors were identified and tracked which include lack of basic necessities as well individuals who experienced test anxiety related to taking a certification examination. The employment process for participants also often required a physical examination coupled with a variety of immunizations. Having the opportunity to access these services through their medical home provided a seamless access to required services. Some of our enrolees were not current clients so participation also provided access to initial clinical care at no cost to the participant. "I was happy to access immunizations that I could not afford that were conveniently located at the same place as the trainings" (JB).

Question 4:
For those who participated in a clinic-based portal, can they access and maintain meaningful jobs in health-related professions? An interesting perspective reported by male participants was that allied health employment for a variety of positions, even though the pay was competitive, was perceived as occupations that were appropriate only for women. This is supported by the fact that of 33 enrolees only one was a male.
"I never could see myself wearing scrubs, but now I could get used to them" (BS).

Discussion
With emerging data suggesting that social determinants have a direct relationship to health, linking access to those social factors with clinical care may enhance the impact of both concepts. For our cohort of patients, meaningful employment may be one of the most significant factors in supporting their well-being especially among youth who have high school diplomas but lack an upwardly mobile job. The purpose of this pilot was to build on this approach by initially identifying ways to strengthen the link between the clinic portal and training, job opportunities and ultimate long-term employment.
In addition to the suggestions of participants, several factors became apparent to staff which were predictory as to whether or not recruited participants would successfully enrol in training that led to job opportunities. First, social determinants whether positive or negative did not exist in a vacuum and usually co-varied. For example, the lack of child care and transportation affected employment readiness and sustainability. Staff had to accommodate these factors before employment options could be implemented. In addition to these factors' items such as social support and counselling from our clinic therapist also supplemented the training process. Second, for this cohort of youth, even though they lived in a city with an enormous medical complex with a high demand for medically trained employees, they were unaware of opportunities in the allied health fields. This could be a function of employment experiences which had traditionally been in retail, food or hospitality services. Staff in some cases had to market allied health opportunities and their benefits. Third, many employment programs subtly target males. Our experience suggests that young women can also benefit from workforce training activities in allied health. The first cohort of recruits were primarily minority females who desired upward mobility and stable employment.
We acknowledge that our pilot sample was small and was not randomized. However, our data suggest that disconnected adolescents and young adult men and women can benefit from an employment portal embedded in their medical home, when appropriate support is given. We predict that in the long-term, consistent follow up, support services and opportunities provided by their clinical home portal will be key elements facilitating employment for this group. Such insights can provide useful guideposts on how to initially integrate this adolescents and young adults into productive jobs. This work also encourages future research to determine whether such initiatives can sustain longterm career paths. In addition, the assessments of our participants provide useful suggestions on how to maintain the participation of minority low-income minority youth which will help their transition to sustainable wages and upward career mobility. Finally, given our unequal numbers of male versus female enrolees, staff may need to develop creative strategies to encourage males to enrol in these ancillary but well-paying medical professions.