Assessing the impact of a web-based comprehensive somatic and mental health screening tool in pediatric primary care.

OBJECTIVE: To evaluate how parents and physicians perceive the utility of a comprehensive, electronic previsit screener, and to assess its impact on the visit. METHODS: A mixed methods design was used. English-speaking parents were recruited from 3 primary care systems (urban MD and rural NY and VT) when they presented for a well-child visit with a child 4 to 10 years of age. Parents completed an electronic previsit screen, which included somatic concerns, health risks, and 4 mental health tools (SCARED5, PHQ-2, SDQ Impact, and PSC-17). Parents completed an exit survey, and a subset were interviewed. All primary care providers (PCPs) were interviewed. RESULTS: A total of 120 parents and 16 PCPs participated. The exit surveys showed that nearly 90% of parents agreed or strongly agreed that the screener was easy to use and maintained confidentiality. During interviews, parents noted that the screener helped with recall, validated concerns, reframed issues they thought might not be appropriate for primary care, and raised new questions. PCPs thought that the screener enabled them to normalize sensitive issues, and it permitted them to simultaneously focus and be comprehensive during the visit. Parents and PCPs agreed that the screener helped guide discussion, promoted in-depth exchange, and increased efficiency. Findings were consistent across quantitative and qualitative methods and between parents and PCPs. CONCLUSIONS: A comprehensive electronic previsit screening tool is an acceptable and practical strategy to facilitate well-child visits. It may help with problem identification as well as with setting agendas, engaging the family, and balancing attention between somatic and psychosocial concerns.

Use of inexpensive technology to enhance adolescent health screening and counseling.

OBJECTIVES: To describe the health issues reported using a personal digital assistant (PDA) to conduct screening at adolescent well visits, and to determine the effect of a PDA screening tool on the content and quality of the clinical interaction. DESIGN: The PDA screening tool was used to record adolescent health risk behaviors, and cross-sectional exit surveys were administered before and after PDA introduction. SETTING: Five primary care practices in New England. PARTICIPANTS: The PDA screening was completed by 1052 youth aged 11 to 19 years. In addition, youth seen before (n = 65) and after (n = 98) PDA screening implementation completed exit surveys. Intervention Adolescents completed the PDA screening immediately before the well visit. Branching questions explored risk behaviors in more depth, including motivation to change. Physicians viewed the summarized findings before the adolescent health visit. MAIN OUTCOME MEASURES: Health risk behaviors based on PDA data. Exit surveys assessed the quality of the visit and of any discussion of nutrition, exercise, screen time, tobacco use, alcohol and other drug use, and mood. RESULTS: Multiple risk behaviors (n = 3-9) were reported by 30% of 11- to 14-year-olds and 45% of 15- to 19-year-olds. Exit surveys showed that, with PDA use, the proportion of visits that included discussions of health risk behaviors increased for fruit/vegetable intake (60.4% vs 41.7% without PDA use; P =.03), tobacco use (54.9% vs 40.0%; P = .07), and alcohol use (53.9% vs 38.0%; P =.05). With PDA use, more adolescents rated the visit as confidential (83.7% vs 61.5%; P =.002), more thought they were listened to carefully (87.8% vs 64.6%; P <.001), and more were very satisfied (87.8% vs 63.1%; P < .001). CONCLUSION: Use of a PDA-based screening tool enhances physician counseling and improves adolescents' perceptions of the well visit.

Changing adolescent health behaviors: the healthy teens counseling approach.

BACKGROUND: Brief motivational interventions that have been provided in addition to routine primary care have changed adolescent health behaviors. Whether health screening and motivational-interviewing-based counseling provided by clinicians during routine care can change behaviors is unknown. METHODS: Healthy Teens was a primary care, office-system intervention to support efficient, patient-centered counseling at well visits. Healthy Teens utilized a personal digital assistant (PDA)-based screener that provided the clinician with information about a teen's health risks and motivation to change. Changes in adolescent self-report of diet and activity health behaviors 6 months later were assessed in two cross-sectional samples of teens from five rural practices in 2005 and 2006. Usual-care subjects (N=148) were recruited at well visits prior to the intervention, and the Healthy Teens subjects (N=136) were recruited at well visits after the Healthy Teens system was well established. RESULTS: At 6-month follow-up, the Healthy Teens group had significantly increased self-reported exercise levels and milk-product intake. In the models exploring covariates, the only significant predictors for improvement in exercise levels were intervention-group status (p=0.009) and post-visit interest in making a change (p=0.015). Interest in changing predicted increased milk intake (p=0.028) in both groups. When teens planned an action related to nutrition, physical activity, or both after a well visit, Healthy Teens participants were more likely to report multiple planned actions (68% Healthy Teens vs 32% usual care, p<0.05). CONCLUSIONS: Changes in office systems using low-cost technology to screen adolescents and promote patient-centered counseling appear to influence teens to increase exercise and milk intake.

The impact of an appearance-based educational intervention on adolescent intention to use sunscreen.

During adolescence, there is a steady decline in the use of sun protection and increased use of indoor tanning lights. Previous health education efforts have changed knowledge but not these behaviors. Middle school students (n=113) received a single educational class that included personal viewing of skin changes visible under ultraviolet (UV) filtered light. Pre-/post-surveys assessed past, current and future intent to use sunscreen, as well as sun benefit and sun risk attitudes. Prior to the session, 42% were sunscreen non-users and 21% were consistent users. At post-test, one-third of students who had not previously intended to use sunscreen in the next month now intended to use it. Among students who had seen skin damage, 59% reported intention to use sunscreen in the next month versus 35% who did not see skin changes (P = 0.04). Viewing sun damage was an independent predictor of intent to use sunscreen in the next month (OR 2.9, P = 0.04), as was older age (OR 2.6, P = 0.04) and previous consistent sunscreen use (OR 6.1, P = 0.004). A brief educational intervention that emphasizes risk-to-appearance and personalizes the risks of UV exposure has the potential to influence early adolescent sun protection. Long-term studies of this approach are needed.

Longitudinal retention of families in the assessment of a prevention program targeting adolescent alcohol and tobacco use: the utility of an ecological systems framework.

This study examined the association between ecological context (extrafamilial, familial, child factors) at baseline and longitudinal retention of families in the 36-month assessment of an adolescent alcohol and tobacco use prevention program that was conducted within a pediatric primary care setting. A total of 1,780 families were enrolled at baseline when the youth were in the fifth and sixth grades, and 1,220 of these families participated in the 36-month assessment. Findings indicated that familial and child, but not extrafamilial, factors were associated with the participation of families in the 36-month assessment. Clinical implications and future research directions are discussed.

Family socialization of adolescent's self-reported cigarette use: the role of parents' history of regular smoking and parenting style.

OBJECTIVE: To examine the main and interactive effects of parental history of regular cigarette smoking and parenting style on adolescent self-reported cigarette use. METHODS: Predictors of adolescent self-reported cigarette use, including parents' history of regular cigarette smoking and two dimensions of parenting behavior, were analyzed in a sample of 934 predominately Caucasian (96.3%) parent-adolescent dyads. Families were drawn from the control group of a randomized control trial aimed at preventing adolescent substance use. RESULTS: In addition to the main effects of parents' history of regular smoking and parental warmth, logistic regression analysis revealed that the interaction of these two variables was associated with adolescent self-reported cigarette use. Parental warmth was associated with a decreased likelihood of the adolescent ever having smoked a cigarette; however, this was true only if neither parent had a history of regular cigarette smoking. CONCLUSIONS: Findings suggest that adolescent smoking prevention programs may be more efficacious if they address both parental history of regular smoking and parenting behavior.

Costs of a smoking cessation counseling intervention for pregnant women: comparison of three settings.

OBJECTIVE: Although the rate of smoking among women giving birth in the United States has declined steadily from 19.5% in 1989 to 11.4% in 2002, it still far exceeds the Healthy People 2010 goal of 1%. The objective of this study was to estimate the costs of a recommended five-step smoking cessation counseling intervention for pregnant women. METHODS: Costs were compared across three settings: a clinical trial, a quit line, and a rural managed care organization. Cost data were collected from August 2002 to September 2003. Intervention costs were compared with potential neonatal cost savings from averted adverse outcomes using data from the Centers for Disease Control and Prevention's Maternal and Child Health Smoking-Attributable Mortality, Morbidity, and Economics Costs software. RESULTS: The costs of implementing the intervention ranged from dollar 24 to dollar 34 per pregnant smoker counseled across the three settings. Potential neonatal cost savings that could be accrued from women who quit smoking during pregnancy were estimated at dollar 881 per maternal smoker. Assuming a 30% to 70% increase over baseline quit rates, interventions could net savings up to dollar 8 million within the range of costs per pregnant smoker. CONCLUSIONS: Costs may vary depending on the intensity and nature of the intervention; however, this analysis found a surprisingly narrow range across three disparate settings. Cost estimates presented here are shown to be low compared with potential cost savings that could be accrued across the quit rates that could be achieved through use of the 5A's smoking cessation counseling intervention.

A longitudinal examination of the link between parent alcohol problems and youth drinking: the moderating roles of parent and child gender.

The unique and interactive effects of paternal and maternal alcohol problems on the drinking behavior of adolescent girls and boys were investigated. A prospective design was employed to examine changes in youth drinking behavior over a 3-year period in a community-based sample of 695 families. Results revealed that, as maternal alcohol problems increased, the likelihood of adolescent alcohol use increased. Paternal alcohol problems were associated with an increased likelihood of alcohol use for girls only. Findings point to the need for future research to investigate both maternal and paternal alcohol problems in community samples and with a sample size large enough to examine both parent and adolescent gender. Implications for preventive and interventive efforts are considered.

A pediatric, practice-based, randomized trial of drinking and smoking prevention and bicycle helmet, gun, and seatbelt safety promotion.

OBJECTIVE: To prevent early adolescent health risk behaviors and to maintain or improve safety behaviors, we compared the effects of 2 interventions, delivered through pediatric primary care practices. The interventions, based on an office systems' approach, sought to prevent early drinking and smoking or to influence bicycle helmet use, gun storage, and seatbelt safety for children who were followed from fifth/sixth grades through eighth/ninth grades. DESIGN: Settings and Participants. Twelve pediatric practices in New England were paired according to practice size and assigned randomly within pairs to deliver the multicomponent interventions, which built on pediatric primary care clinicians performing as counselors and role models during health supervision visits and other office encounters. INTERVENTION: One intervention arm focused on alcohol and tobacco use. The other intervention arm focused on gun safety, bicycle helmet, and seatbelt use. Office systems provided infrastructure that supported the clinician's role. Clinician messages encouraged family communication and rule setting about the issues of the middle school years. The intervention was initiated during a health supervision visit and continued for 36 months. Both child and parent received quarterly newsletters to reinforce the clinician messages. OUTCOME MEASURES: The primary outcomes were ever drinking alcohol, ever smoking, ever using smokeless tobacco, using a bicycle helmet in the previous year, using a seatbelt in the previous 30 days, and guns in the child's home in locked storage. RESULTS: The pediatric practices recruited 85% (N = 3525) of the practices' fifth/sixth grade children and their responding parents. We obtained 36 months' follow-up data on 2183 child-parent pairs. Chart audit verified that the intervention was implemented. Additional data from interviews and surveys showed that parents, children, and pediatric clinicians found the intervention useful. Despite this, comparisons between the 2 study arms show no significant intervention effects in the prevention of alcohol and tobacco use or gun storage or seatbelt safety. There was a negative effect in the alcohol arm. Only bicycle helmet use showed a positive outcome. CONCLUSION: With rigorous evaluation, 2 office interventions failed to produce desired outcomes. Coordinated multiple settings for prevention interventions are probably necessary.