The Effects of Receiving Adolescent Clinical Preventive Services on Adolescent Behavior Elizabeth M. Ozer, Ph.D. Division of Adolescent Medicine, Department of Pediatrics University of California, San Francisco Sixth Annual Child Health Services Research Meeting San Diego, CA June 5, 2004

Colleagues: Sally Adams, Ph.D. 1, Joan Orrell-Valente, Ph.D. 1, Julie Lustig, Ph.D. 1, Susan Millstein, Ph.D. 1, Charles Wibbelsman, M.D. 2, Charles E. Irwin, Jr., M.D. 1 1 University of California, San Francisco, Department of Pediatrics, Division of Adolescent Medicine 2 Kaiser Permanente, California

Supported by: The AAMC through a cooperative agreement with the Centers for Disease Control and Prevention (CDC) & Agency for Health Care Research and Quality (AHRQ) & The California Wellness Foundation & Maternal & Child Health Bureau (MCHB)

BACKGROUND  Majority of adolescent morbidity/ mortality is preventable

Leading Causes of Mortality in Adolescents Ages 10-19, 2001

MORBIDITY/MORTALITY  Accidents and injuries leading cause of death for both males and females  Many of these accidents involve alcohol and other substances

 Sexually transmitted diseases are common infectious diseases among adolescents  Among adolescents ages 15-19, pregnancy and childbirth are the leading causes of hospitalization MORBIDITY/MORTALITY

 Risky behaviors co-occur  Behaviors responsible for leading causes of morbidity/mortality during adulthood are initiated during second decade of life (e.g., smoking, substance use, physical inactivity, risky sexual behavior) BACKGROUND

 Requires participation of  Adolescents  Families  Schools  Communities  Federal, state & community policies PROMOTE ADOLESCENT HEALTH

 Health care system  Most adolescents see a primary care provider at least once a year PROMOTE ADOLESCENT HEALTH

ADOLESCENT CLINICAL GUIDELINES Recommend that primary care providers screen & counsel adolescent patients for risky health behaviors  MCHB - Bright Futures  AMA/GAPS  AAP/AAFP  USPSTF

ADOLESCENT CLINICAL GUIDELINES  National Committee for Quality Assurance (NCQA) Guidelines (HEDIS) have Adolescent-Specific Measures:  Screening for alcohol use  Annual visit to provider  Immunization status  Screening sexually active females for Chlamydia trachomatis (Over 15 years old)

 Despite guidelines, current delivery of preventive services below recommended levels  Limited research on how to implement adolescent preventive services ADOLESCENT CLINICAL GUIDELINES

UNANSWERED QUESTION If primary care providers screen adolescents for risky health behaviors… Does it have any effect on adolescent behavior?

 No published studies on the behavioral/ health effects of adolescents receiving clinical preventive services across multiple risk areas  Research on behavioral interventions focus on changing a specific risk behavior (e.g. smoking) EFFECT ON ADOLESCENT BEHAVIOR

RESEARCH GOALS 1. Develop and evaluate a system intervention to increase the delivery of adolescent clinical preventive services 2. Evaluate the effect of preventive screening and counseling on adolescent behavior

ADOLESCENT HEALTHCARE  Most adolescents receive health care through a managed care system  Utilize Pediatric clinics within Kaiser Permanente, N. CA to conduct research

RISK AREAS  Risky behaviors associated with major morbidity and mortality in adolescence:  Tobacco  Alcohol  Drugs  Sexual Behavior  Seatbelt  Helmet

SYSTEM IMPLEMENTATION OF PREVENTIVE SERVICES Increased Screening Increased Counseling IMPLEMENTATION OUTCOMES INTERVENTION IN KAISER SYSTEM ADOLESCENT BEHAVIORAL OUTCOMES INCREASE PREVENTIVE SERVICES TO ADOLESCENTS SEXUAL BEHAVIOR Increase condom use Delay onset SUBSTANCE USE Decrease initiation Decrease use TOBACCO Decrease initiation Decrease smoking SEATBELTS Increase seatbelt use HELMETS Increase helmet use

RESEARCH GOAL 1  Develop and evaluate a system intervention to increase the delivery of adolescent clinical preventive services

SYSTEM INTERVENTION TO INCREASE DELIVERY OF CLINICAL PREVENTIVE SERVICES CURRENT DELIVERY OF PREVENTIVE SERVICES IMPROVED DELIVERY OF PREVENTIVE SERVICES Provider Training Tools Health Educator

TRAINING  8-Hour Training for Pediatric Primary Care Providers  Adolescent Health and Development  Effective Communication with Adolescents  Gave Clinicians Targeted Specific Messages about Risk Behaviors

TOOLS  Adolescent Health Screening Questionnaire  Provider Charting Form  Provides information from the Adolescent Health Screening Questionnaire to indicate health behavior of the patients  Provides prompts and cues for provider intervention

GUIDELINES FOR PROVIDER INTERVENTION  Not Engaging in Risky Behavior –Confirm questionnaire response –Reinforce positive behaviors

 Engaging in Risky Behavior –Confirm response –Express concern about risky behavior –Provide key messages GUIDELINES FOR PROVIDER INTERVENTION

KEY MESSAGES Key Messages for Sexual Behavior Message 1 Avoiding sex is the safest way to prevent pregnancy and sexually transmitted diseases or AIDS.

Message 2 If you choose to have sex, be responsible. Use a condom every time you have sex. If you don’t have a condom, don’t have sex. To ensure you don’t get pregnant or get your partner pregnant, and as a backup to a condom, use another form of birth control such as oral contraceptives or Depo Provera. KEY MESSAGES Key Messages for Sexual Behavior

HEALTH EDUCATOR  Additional clinic staff  Reinforces provider preventive health messages  Focuses on each adolescent’s primary risk areas  Facilitates referrals

HEALTH EDUCATOR  Consistent with Social Cognitive Theory:  Specific area of behavior change  Focusing on the expected outcomes of the behavior  Setting an achievable goal  Building skills and confidence to change behavior

INTERVENTION PROCEDURE  Adolescent Health Screening Questionnaire prior to well-visit  Provider well-visit  Utilizes Charting Form to deliver preventive services  20 to 30 minutes  Health Educator visit  15 to 30 minutes

SUMMARY OF IMPLEMENTATION RESEARCH - GOAL 1  Demonstrated the efficacy of providing training, tools and additional health education resources as a method for improving preventive screening and counseling with adolescents  Screening rates increased from an average of 47% to 94% across multiple risk areas (Ozer, Adams, Lustig et al., 2001, Health Services Research)

SYSTEM IMPLEMENTATION OF PREVENTIVE SERVICES Increased Screening Increased Counseling IMPLEMENTATION OUTCOMES INTERVENTION IN KAISER SYSTEM ADOLESCENT BEHAVIORAL OUTCOMES INCREASE PREVENTIVE SERVICES TO ADOLESCENTS SEXUAL BEHAVIOR Increase condom use Delay onset SUBSTANCE USE Decrease initiation Decrease use TOBACCO Decrease initiation Decrease smoking SEATBELTS Increase seatbelt use HELMETS Increase helmet use

RESEARCH GOAL 2  Evaluate the effect of preventive screening and counseling on adolescent behavior

INCREASE ADOLESCENT PREVENTIVE SERVICES LONGITUDINAL INTERVENTION SAMPLE (6 Months) (Fall ) (Fall ) (Fall ) 14 yo15 yo16 yo Training Tools Health Educator Adolescent Risk Behavior (N = 1,233) DESIGN ACROSS 3 PEDIATRIC CLINICS

LONGITUDINAL INTERVENTION SAMPLE  Adolescents recruited from scheduled well- visits in 3 large Pediatric clinics within Kaiser Permanente, N. CA ( )  N = 1,233  14 Years of age  51% female  Agreed to return to clinic at ages 15 & 16 for well-visits

Ethnicity of Adolescents

COMPARISON SAMPLES

PRE-INTERVENTION COMPARISON SAMPLE  Adolescents recruited from scheduled well-visits in the same 3 Pediatric Clinics PRIOR TO preventive services intervention (Fall 1998)  N = 633  Cohort sample of adolescents ages 14, 15, & 16  50% female  Did not enroll in longitudinal component of study

PRE- INTERVENTION COMPARISON SAMPLE IMPLEMENTATION LONGITUDINAL INTERVENTION SAMPLE (Fall 1998)(6 Months) (Fall 99-00) (Fall 00-01) (Fall 01-02) 14 – 16 yo14 yo15 yo16 yo Adolescent Risk Behavior (N = 633) Training Tools Health Educator Adolescent Risk Behavior (N = 1,233) STUDY TIMELINE ACROSS 3 CLINICS

COHORT COMPARISON SAMPLES  Population-based CA sample  Kaiser Permanente, N. CA  Non-Intervention Pediatric Clinics

RESULTS Health Behavior Rates for Intervention and Comparison Samples

Pre-Intervention Comparison Fall 1998 Longitudinal Intervention Year 1 Fall Longitudinal Intervention Year 2 Fall Risk Behavior: Age 14 (n = 240) Age 15 (n = 219) Age 14 (n = 1233) Age 15 (n = 956) Tobacco use (past 30 days) Alcohol use – ever Drug use – ever Sexual Intercourse – ever Seatbelt use -100% Helmet use -100%

SUMMARY OF PRE-INTERVENTION COMPARISON SAMPLE  At age 14, behavior rates in the pre- intervention and intervention samples were similar, suggesting that risk levels were comparable  At age 15, intervention adolescents report significantly lower rates of risky behavior in every area except drug use, compared to those in the pre-intervention sample

COHORT QUESTION  While results are promising, potential problem of cohort effects: Did all adolescents in N. CA decrease risky behavior in the years 2000 to 2001 (between ages 14-15)?

COHORT QUESTION  To address this question, we utilize additional cohort comparison groups from N. CA to compare engagement in risky behaviors

COMPARISON DATA SETS  POPULATION-BASED SAMPLE CALIFORNIA HEALTH INTERVIEW SURVEY (CHIS) –State-wide health survey of California’s adults, adolescents and children –Randomly selected household telephone survey –Utilized data from adolescents who said that they had a well-visit within the past year

 N. CA KAISER PERMANENTE Well-visits in non-intervention Pediatric clinics  Shafer, Tebb, Pantell et al., 2000  Irwin & Ozer, COMPARISON DATA SETS

COMPARISON OF CHIS VS. INTERVENTION **p <.01 CHIS 2001 Longitudinal Intervention Age 14 N = 963 Age 15 N = 971 % CHANGE Age 14 Year N = 904 Age 15 Year N = 904 % CHANGE Tobacco Use Ever ** Alcohol Use Ever Drug Use Ever

COMPARISON OF N. CA KAISER VS. INTERVENTION N. CA. Kaiser Longitudinal Intervention Age 14 Age 15 % CHANGE Age 14 Year N = 904 Age 15 Year N = 904 % CHANGE Sexual Intercourse Ever (n = 46) 13.8 (n = 119) 8.5 † Seatbelt Use 100% ** Helmet Use 100% ** †p <.10 **p <.01

SUMMARY OF COHORT COMPARISONS  Tobacco: lower smoking rates in intervention group  Alcohol & Drug Use: N.S. difference

 Sexual Behavior: delayed initiation of sexual intercourse in intervention group  Seatbelt & Helmet Use: higher rates of use in intervention group SUMMARY OF COHORT COMPARISONS

DISCUSSION  Intervention may be less successful in influencing substance use: –Data reflects initiation of behavior “experimentation” –In our intervention, drug use was “add on” to alcohol use

 Intervention appears to have most dramatic effect in the area of safety (seatbelt and helmet use) –Screening rates were lowest pre-intervention in the area of safety. Possibly the least clinically sensitive and easiest behaviors to change (e.g., not addictive)  Results in the area of both tobacco use and sexual behavior are promising DISCUSSION

STUDY LIMITATION  Lack of longitudinal comparison group

SUMMARY OF GOAL 2  This was the first study to assess the behavioral impact of a clinic based intervention across multiple risk areas.  While further evaluation is necessary, initial longitudinal results show promise that screening and counseling adolescents may favorably influence adolescent behavior.

FUTURE DIRECTIONS  Extend behavioral/health outcome research using longitudinal comparison groups –How does this influence recommended guidelines? –What additional interventions might be necessary?

 Translating research into practice  Practical level – gratifying that implementation research results strong enough that Kaiser has Made changes to tools distributed throughout Region Plan to integrate training throughout N. CA 70,000 adolescents a year make at least 1 visit to a N. CA Kaiser clinic FUTURE DIRECTIONS

 Translating research into practice (cont.)  Research questions Translating research intervention: maintain integrity of intervention, other issues such as sustainability FUTURE DIRECTIONS