Elizabeth M. Ozer, Ph.D. Division of Adolescent Medicine, Department of Pediatrics

1. THEORY & PLANNING FOR BEHAVIOR CHANGE: INTEGRATING ADOLESCENT PREVENTIVE SERVICES INTO PRIMARY CARE Elizabeth M. Ozer, Ph.D. Division of Adolescent Medicine, Department of Pediatrics University of California, San Francisco EPI 246 UCSF May 13, 2010

2. COLLEAGUES Charles E. Irwin, Jr., M.D., Sally Adams, Ph.D., Julie Lustig, Ph.D., Susan Millstein, Ph.D., Andrea Garber, Ph.D University of California, San Francisco Department of Pediatrics Division of Adolescent Medicine

3. KAISER PERMANENTE COLLEAGUES Charles Wibbelsman, M.D. – PI Scott Gee, M.D. - PI Chiefs of Pediatrics Louise Addison, M.D., Gordon Isakson, M.D., James Makol, M.D., Paul Phinney, M.D., Michael Rehbein, M.D., Charito Sico, M.D., Gail Udkow, M.D. Champions & Trainers Robert Bonar, M.D., Karen Camfield, M.D., Seham El-Diwany, M.D., Daniel Fuster, M.D., Silvana Volpe, M.D.

4. SUPPORTED PRIMARILY BY: The AAMCthrough a cooperative agreement with theCenters for Disease Control and Prevention (CDC)&The California Wellness FoundationAdditional support from:Maternal & Child Health Bureau (MCHB)&Agency for Health Care Research and Quality (AHRQ)

5. WHY PREVENTIVE SERVICES? • Majority of morbidity/mortality during adolescence is preventable

6. WHY PREVENTIVE SERVICES? • Accidents and injuries leading cause of death • Many of these accidents involve alcohol and other substances

7. Leading Causes of Death: Ages 10-19 & Ages 25-44, 2006 Adolescents Adults Source: National Center for Injury Prevention & Control, WISQARS database, 2009

8. Health Risk Behaviors RISKY Behaviors are responsible for >70% of adolescent morbidity/mortality: Arrows denote trends in prevalence over past decade

9. WHY PREVENTIVE SERVICES? • 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)

10. PROMOTE ADOLESCENT HEALTH • Requires participation of • Adolescents • Families • Schools • Communities • Federal, state & community policies

11. PROMOTE ADOLESCENT HEALTH • Health care system • Most adolescents in developed countries (70-90%) seek primary care services at least once a year

12. What Are Clinical Preventive Services? • Services delivered by a provider in a clinical setting - a medical office or health center • Services designed to avert/delay the onset of various health and mental health disorders or to identify problems (or assets) early in order to minimize (maximize) their impact

13. WHY PROVIDE ADOLESCENT CLINICAL PREVENTIVE SERVICES? • Adolescents/parents view clinicians as credible resources for information • Clinicians have been successful in reducing alcohol and tobacco use & increasing seat belt use with office-based ADULT interventions • Some evidence, though mixed, that office-based interventions improve adolescent behavior

14. Timing Of Interventions • Window of opportunity in adolescence: • Emergence of emotional health problems & risky behavior • Reinforcement of emerging independence and taking responsibility for one’s health • Establish relationship with provider & learn to navigate health care system – TIME ALONE

15. YOUTH FRIENDLY HEALTH SERVICES WHO framework to guide development of youth friendly services: • Accessibility • Point of delivery of care • Appropriate services • Effectiveness of services

16. ADOLESCENT CLINICAL GUIDELINES Recommend that primary care providers screen & counsel adolescent patients for risky health behaviors, as well as remind adolescents & families about strengths • MCHB - Bright Futures • AMA/GAPS • AAP

17. Why Provide Clinical Preventive Services? • NCQA Guidelines (HEDIS) have 4 Adolescent-Specific Measures: • Annual visit to provider • Screening for alcohol use • Immunization status • Screening sexually active females for Chlamydia trachomatis (over 15 years old)

18. Implementation of Guidelines

19. Recent Studies Examine Preventive Screening and Counseling for Children/adolescents • Rand et al., JAH, 2005 • Ma et al., JAH, 2005 • Hambidge et al., APAM, 2007 • Perry & Kenney, Pediatrics, 2008

20. Summary of Literature • Rates of preventive screening and counseling are low • Very little information about disparities • No study presents screening/counseling rates for subgroups of adolescents • Most data for adolescents is from physician records

21. CONTENT OF INTERVENTIONS Recent U.S. Population-based data: • Low rates of delivery of preventive services nationally by caregiver report - 10% across 6 broad areas (Irwin et al, 2009) • Disparities in delivery across content areas and population by teen report (Adams, Zahnd, Husting & Ozer, 2008) • < ¼ of teens asked about emotional distress (Ozer et al., 2009)

22. IMPLEMENTATION OF GUIDELINES • Barriers include: • Clinician Factors – Knowledge, attitudes, skills • External Factors – Tools, reminders, resources (Cabana et al., 1999)

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

24. EFFECT ON ADOLESCENT BEHAVIOR • No published studies on the behavioral/ health effects of adolescents receiving clinical preventive services across multiple risk areas • Research on office-based behavioral interventions focus on changing a specific risk behavior/area (e.g. alcohol or safety)

25. RESEARCH GOALS • Develop and evaluate a system intervention to increase the delivery of adolescent clinical preventive services • Evaluate the effect of preventive screening and counseling on adolescent behavior Adolescent Medicine@UCSF

26. RISK AREAS • Risky behaviors associated with major morbidity and mortality in adolescence: • Tobacco • Alcohol • Drugs - Sexual Behavior - Seatbelt - Helmet Adolescent Medicine@UCSF

27. ADOLESCENT HEALTHCARE • Most adolescents in the U.S. receive health care through a managed care system • Utilize Pediatric clinics within Kaiser Permanente, N. CA to conduct research • Delivers care to the greatest number of teenagers in CA • 3 of the largest Pediatric Clinics • 70,000 adolescents a year make at least one visit to a Kaiser clinic in Northern California Adolescent Medicine@UCSF

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

29. RESEARCH GOAL 1 • Develop and evaluate a system intervention to increase the delivery of adolescent clinical preventive services Adolescent Medicine@UCSF

30. CURRENT DELIVERY OF PREVENTIVE SERVICES • Current Screening • Current Counseling TRAINING TOOLS HEALTH EDUCATOR • Predisposing Factors: • Knowledge • Attitudes • Self-Efficacy • INCREASED DELIVERY OF PREVENTIVE SERVICES • Increased Screening • Increased Counseling • Enabling Factors: • Skills • Prompts & Reminders • Materials & Resources • Reinforcing Factors: • Feedback • Monitoring TRAINING TOOLS HEALTH EDUCATOR

31. SYSTEM INTERVENTION TO INCREASE DELIVERY OF CLINICAL PREVENTIVE SERVICES CURRENT DELIVERY OF PREVENTIVE SERVICES IMPROVED DELIVERY OF PREVENTIVE SERVICES Provider Training Tools Health Educator Adolescent Medicine@UCSF

32. TRAINING • 8-Hour Training Workshop for Pediatric Primary Care Providers • Conducted by Pediatricians and Psychologists from the University of California, San Francisco and Kaiser Permanente, CA

33. TRAINING INTERVENTION MODEL • SOCIAL COGNITIVE THEORY • Enhance knowledge • Increase perceived self-efficacy • Enhance skills

34. TRAINING INTERVENTION MODEL • Self-efficacy/perceived competence • Related to delivery of preventive services to adolescents (Ozer et al., 2005) • Training increases provider self-efficacy (Buckelew et al., 2008)

35. TRAINING WORKSHOP COMPONENTS • Didactic • Discussion • Demonstration Role Plays • Interactive Role Plays

36. TRAINING CONTENT • Adolescent Health and Development • Effective Communication with Adolescents • Gave Clinicians Targeted Specific Messages about Risk Behaviors

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

38. KEY MESSAGESKey Messages for Sexual Behavior 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.

39. TRAINING: GOALS FOR THE ADOLESCENTS • Increase adolescents’ competence to take responsibility for their health • Keep Themselves Healthy • Successfully navigate the health care system

40. TOOLS • Adolescent Health Screening Questionnaire • Provider Charting Form • Provides prompts and cues for provider intervention Adolescent Medicine@UCSF

41. GUIDELINES FOR PROVIDER INTERVENTION • Not Engaging in Risky Behavior • Confirm questionnaire response • Reinforce positive behaviors

42. GUIDELINES FOR PROVIDER INTERVENTION • Engaging in Risky Behavior • Confirm response • Express concern about risky behavior • Provide key messages

43. GUIDELINES FOR PROVIDER INTERVENTION • Engaging in Risky Behavior • Build on teen’s success experiences • When have you been able to …? • Understanding what circumstances enable her/him to be successful

44. X X X X X 20 4

45. HEALTH EDUCATOR • Additional clinic staff • Reinforces provider preventive health messages • Focuses on each adolescent’s primary risk areas • Facilitates referrals Adolescent Medicine@UCSF

46. 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

47. INTERVENTION PROCEDURE • Adolescent Health Screening Questionnaire prior to well-visit • Provider well-visit • 20 to 30 minutes • Health Educator visit • 15 to 30 minutes Adolescent Medicine@UCSF

48. COLLABORATION: RESEARCH TO PRACTICE • Each Intervention Site & System: • “Study Champion” in each site • Monthly meetings with working committee of 5-10 M.D.’s and other staff • Collaborate on development of recruitment, screening & charting forms, training, patient flow • Training for staff on youth friendly care • Attend other relevant meetings within broader health care system

49. EVALUATION OF INTERVENTION TO INCREASE DELIVERY OF PREVENTIVE SERVICES Adolescent Medicine@UCSF

50. EVALUATION PHASES (3 clinics) T1: Pre- Implementation 3 MONTHS T2: Post- Implementation 6 MONTHS T3: Follow-Up 18 MONTHS Baseline Sample 14 Y.O. N = 104 Post- Implementation Sample 14 Y.O. N = 211 Follow-Up Sample 14 Y.O. N = 998 Provider Training Tools Health Educator