- Email: [email protected]
Consultations with practice nurses may improve adolescent health behaviours slightly
EVIDENCE -BASED HE ALTH PROMOTION
Consultations with practice nurses may improve adolescent health behaviours slightly Abstracted from: Walker Z, Townsend J, Oakley L et al. Health promotion for adolescents in primary care: randomised controlled trial. BMJ 2002; 325: 524 ^530.
BACKGROUND Relatively few adolescents receive health promotion in general practice.There is little evidence about the e¡ects of general practice health promotion strategies for teenagers. OBJECTIVE To evaluate the e¡ect of inviting adolescents to discus health behaviours with general practice nurses. SETTING Eight general practices in Hertfordshire, United Kingdom;1999 to 2000. METHOD Randomised controlled trial. PARTICIPANTS One thousand, ¢ve hundred and sixteen people aged 14 to 16 years (mean 14.8 years); 51% female; 89% white. All were registered on the general practice lists of participating centres. INTERVENTION Invitation to discuss health concerns and develop plans for a healthier lifestyle with a practice nurse compared with no intervention or educational pamphlet. Consultations with practice nurses lasted 20 minutes.
MAIN RESULTS Forty-one percent of adolescents invited for a consultation met with a practice nurse. One-third of these were o¡ered follow-up care. Ninety-seven percent said they would recommend the intervention to a friend. Adolescents in the intervention group were more likely to report improved ‘stage of change’ for diet and exercise at 3 months, but this did not persist at12 months.There was a trend towards more positive change in reported behaviour in the intervention group (16% versus 12%, p=0.06). Mental health outcomes were improved in the intervention group at 3 and 12 months. AUTHORS’ CONCLUSIONS This brief health promotion intervention was cheap and well received. Change in behaviour was slight, but showed positive trends. Source of funding: NHS Executive - Eastern Region; HertNet (Hertfordshire Primary Care Research Network). Correspondence to: J Townsend, Health Promotion Research Unit, London School of Hygiene and Tropical Medicine, UK. Email: [email protected]. Abstract prepared by Bazian Ltd, London
MAIN OUTCOMES Mental and physical health; ‘stage of change’ for health related behaviour; use of health services. Questionnaires were completed at baseline, 3 months and 12 months.
14
Evidence-based Healthcare (2003) 7,14 ^17 doi:10.1016/ebhc.2003.0581
1462-9410/03/$ - see front matter & 2003 Published by Elsevier Science Ltd.
Commentary 1 Many organisations advocate screening adolescents for behaviours that may compromise their health.1 In the United States, the three leading causes of mortality among adolescents and young adults are motor vehicle accidents, homicide and suicide.2 Many young people will be affected by tobacco consumption, unprotected sexual encounters and poor diet. It is important to understand risk factors in these areas. The effect of screening on adolescents’ actions or intentions remains unclear. Studies with adults suggest that health promotion modestly reduces risk.3,4 Research with adolescents suggests that although young people may be aware of the adverse outcomes associated with certain behaviours and be able to assess their own risk, they often do not change their behaviour.5,6 This may be why many health providers do not routinely screen adolescents or remain sceptical of the benefit.7^10 This study by Walker and colleagues examined whether a structured interview consultation altered adolescents’ intention to change their diet, exercise, smoke or consume alcohol over a 12 month period. The consultation allowed nurses to assess an adolescent’s level of risk and provide targeted information. More teens in the intervention group reported positive change in health related behaviours, intention to change these behaviours at 3 months and knowledge about conf|dentiality and contraception facilities at 12 months. Seventy-f|ve percent of those interviewed asked to talk to the healthcare provider about other topics.This f|nding is consistent with other studies which suggest that adolescents want to talk to healthcare providers about a variety of issues.11,12 The paper makes a valuable contribution to the field of adolescent medicine. It suggests that a one-time interview to identify health risk behaviours and goal setting may have short term benefits. It is impressive that a brief intervention could influence attitudes about diet and exercise at 3 months and depression in some groups at 12 months. The strengths of the study include a well described random isation process, an appropriate sample size at baseline and follow-up, use of a validated instrument to assess depression and appropriate statistical analyses. The 50% response rate at 3 and 12 months is commendable, as it suggests a concerted effort to track a group who may not complete questionnaires without an obvious incentive to do so.The authors do not overstate their findings or generalise inappropriately. This is important because the results may not be applicable to a broader adolescent population.The participants were not demographically diverse in terms of ethnicity, socio-economic background or family structure. There was no demographic comparison between the control and the intervention groups. The study has several other limitations. First, it is unclear how many of those in the intervention arm who returned surveys at 3 and 12 months actually received an initial consultation. Second, an educational pamphlet was given to those who did not want a consultation.The authors could have provided more detail about the content of the pamphlet and whether or not participants read it. It might also have been useful to analyse individuals who received the pamphlet separately rather than include them in the ‘consultation’ group.Third, it may have been useful to provide examples of how nurses responded to the adolescent, depending on the particular behaviour and stage of change. There is likely to have been variability in the skills and motivation of the 12 nurses delivering the intervention.This could have been controlled for in the analysis. Fourth, although one-third of participants were referred for follow-up care, it is unclear how many of these attended follow-up.
& 2003 Published by Elsevier Science Ltd.
What do healthcare providers and policy-makers gain from this study? The findings suggest that nurses can screen, identify and intervene in health risk behaviours in teens. Benefits may persist beyond 3 months if follow-up were targeted to those with the most self-reported need. Adolescents may be relieved that someone has asked them questions about their health and may welcome the information and counselling provided. This study sets the stage for longer, more standardised interventions with follow-up care. R Michelle Schmidt, MD Baylor College of Medicine Department of Internal Medicine Adolescent Clinic, BenTaub General Hospital Houston, Texas, USA and Professor Albert C. Hergenroeder, MD Baylor College of Medicine Adolescent Medicine and Sports Medicine Texas Children’s Hospital Leadership Education in Adolescent Health (LEAH) Training Program Houston, Texas, USA Literature cited 1. American Medical Association. AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Baltimore, MD: Williams and Wilkins,1994. 2. Centers for Disease Control and Prevention. Surveillance summaries. MMWR 2002; 51: SS- 4. 3. Dowell AC, Ochera JJ, Hilton SR et al. Prevention in practice: results of a 2-year follow-up of routine health promotion interventions in general practice. Fam Prac1996; 13: 357^362. 4. Winleby MA, Taylor CB, Jatulis D, Fortmann SP. The longterm effects of a cardiovascular disease prevention trial: the Stanford Five-City Project. Am J Public Health 1996; 86: 1773^1779. 5. Diclemente RJ, Wingood GM, Sionean C et al. Association of adolescents’ history of sexually transmitted disease (STD) and their current high-risk behavior and STD status: a case for intensifying clinic-based prevention efforts. Sex Transm Dis 2002; 29: 503^509. 6. Johnston BD, Rivara FP, Droesch RM et al. Behavior change counseling in the emergency department to reduce injury risk: a randomized controlled trial. Pediatrics 2002; 110: 267^274. 7. Galuska DA, Fulton JE, Powell KE, et al. Pediatrician counseling about preventive health topics: results from the physicians’ practices survey,1998 ^1999. Pediatrics 2002; 109: E83^3. 8. Halpern-Felsher BL, Ozer EM, Millstein SG et al. Preventive services in a health maintenance organization: how well do pediatricians screen and educate adolescent patients? Arch Pediatr Adolesc Med 2000; 154: 173^179. 9. Ewing GB, Selassie AW, Lopez CH et al. Self-report of delivery of clinical preventive services by US physicians: Comparing specialty, gender, age, setting of practice, and area of practice. Am J Prev Med 1999; 17: 62^72. 10. McAvoy BR, Kaner EF, Lock CA et al. Our Healthier Nation: are general practitioners willing and able to deliver? A survey of attitudes to and involvement in health promotion and lifestyle counseling. Br J Gen Pract 1999; 49:187^190. 11. Ackard DM, Neumark-Sztainer D. Health care information sources for adolescents: age and gender differences on use, concerns, and needs. J Adolesc Health 2001; 29:170 ^176. 12. Klein JD,Wilson KM. Delivering quality care: adolescents’ discussion of health risks with their providers. J Adolesc Health 2002; 30: 190 ^195.
Evidence-based Healthcare (2003) 7,14 ^17
15
Commentary 2 Most research into the effect of preventive health advice from providers focuses on adults. These studies suggest that primary care interventions may have small benefits for reducing smoking1 and alcohol consumption2 and increasing physical activity.3 These findings may not apply to adolescents, who have different social and familial pressures than adults and are still developing cognitive skills. Although interventions targeting the behaviour of adolescents have recently been developed,4 ^7 there is less information about their e¡ectiveness. Preventive health initiatives are important because risky behaviours during adolescence can alter the likelihood of both acute and chronic health outcomes.8 For instance, the immediate risk of acute conditions such as injury, unplanned pregnancy and poor physical development may be reduced with seatbelts, contraception and adequate nutrition, respectively. The risk of chronic health conditions such as cancer and cardiovascular disease in adulthood may also be influenced by behaviours initiated during youth.Two risk factors for these conditions, smoking and obesity, have some origins in childhood. Eighty-two percent of adults who smoke tried their first cigarette before 18 years of age9 and 25% to 50% of children who are obese as children remain so as adults.10 Walker and colleagues’ study of health promotion for adolescents therefore addresses an important topic. Medical settings may be a good place to promote preventive health behaviours among adolescents. In the United States, approximately 80% of adolescents visited a healthcare provider over a 2 year period.11 Furthermore, adolescents believe that their provider should discuss health risks with them, even though youth may be unwilling to initiate these discussions due to embarrassment.12 Clinical and government organisations also believe that counselling adolescents is important. Numerous clinical guidelines include recommendations on adolescent health promotion. For example, guidelines developed by the US Preventive Services Task Force,13 Maternal and Child Health Bureau of the Health Resources and Services Administration,14 American Medical Association15 and the American Academy of Pediatrics16 all suggest that physicians should talk to adolescents about preventive health topics such as nutrition, tobacco use, physical activity, sexual activity and substance abuse. Currently, health promotion to adolescents is suboptimal in clinical settings.The proportion of US paediatricians who always counsel adolescents during routine visits ranges from 70% for alcohol and drug use to 25% for firearm safety.17 Whether physicians provide this type of counselling is influenced by a multitude of factors related to the patient, the physician and the physician’s environment.18,19 According to physicians, the perceived effectiveness of counselling is one determinant of their decision to offer advice.20 Thus, studies of the effectiveness of health promotion initiatives may encourage more providers to offer counselling. This study by Walker and colleagues is well designed.The intervention was based on existing models of self-efficacy and behaviour change. Consultations followed the model outlined by the American Medical Association to promote self-efficacy in healthy lifestyles for adolescents. The intervention was guided by teenagers’ attitudes toward general practices as well as their perceived needs during consultations. In addition, teenagers chose which behaviours to change. The investigators also proposed, a priori, the level of adolescent behaviour change expected and recruited a sufficient number of participants to detect this change statistically. A final strength is the use of an intention-to-treat analysis.This strategy provides a conservative
16
Evidence-based Healthcare (2003) 7,14 ^17
estimate of efficacy, but maintains the fidelity of the randomisation. There are also several limitations. First, baseline data was not available for a high proportion (32% of the treatment group and 37% of controls). If predictors of behaviour change differ between non-participants in each group, the results could be biased. Second, of 504 people in the treatment group who provided baseline data, only 304 received the consultation (60%). This low level of participation provides a conservative estimate of efficacy. It may also suggest that some adolescents are unwilling to attend preventive health consultations outside of scheduled visits with their provider. It would have been helpful to document the reasons that adolescents did not participate. Finally, the intervention was of relatively low intensity. It consisted of a single, relatively short consultation with no follow-up.This structure mimics what could be accomplished in typical office settings, given limited resources and time. Intense interventions may be more effective than minimal advice, however.1 It would be of interest to examine whether small variations in the intensity of the intervention, such as a follow-up telephone call, could produce more extensive changes in adolescent behaviour. Because research on this topic is sparse, reasonably well-designed studies, such as this, provide important information even if they suggest that an intervention is not effective. New interventions should be based on appropriate theoretical models, include the needs of both the adolescent and the healthcare provider, be evaluated using appropriate analytic methodology and include cost-effectiveness analyses. Since this intervention was not associated with large behaviour changes, widespread implementation does not seem warranted. Practitioners should recognise, however, that a similar intervention delivered in a different setting may have better outcomes (e.g. a school health centre or another country). Practitioners should also note that the treatment group had a modest improvement in the ‘stages of change’ continuum for at least one of four key behaviours. Most adolescents who attended the consultations also set goals for behaviour change. Thus, adolescents seem willing to try to change behaviours based on consultations. Deborah A Galuska, MPH, PhD National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Georgia, USA
Literature cited 1. Silagy C, Stead LF. Physician advice for smoking cessation. Cochrane Database System Rev 2001; 2: CD000165. 2. BienTH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993; 88: 315^335. 3. Petrella RJ, Lattanzio CN. Does counseling help patients get active? Systematic review of the literature. Can Fam Physician 2002; 48: 72^ 80. 4. Fidler W, Lambert TW. A prescription for health: a primary care based intervention to maintain the non-smoking status of young people.Tob Control 2001; 10: 23^26. 5. Patrick K, Sallis JF, Prochaska JJ et al. A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med 2001; 155: 940 ^946. 6. Saelens BE, Sallis JF, Wilfley DE et al. Behavioral weight control for overweight adolescents initiated in primary care. Obes Res 2002; 10: 22^32. 7. Paperny DM, Hedberg VA.Computer-assisted health counselor visits: a low-cost model for comprehensive adolescent & 2003 Published by Elsevier Science Ltd.
preventive services. Arch Pediatr Adolesc Med 1999; 153: 63^ 67. 8. Grunbaum JA, Kann L, Kinchen SA et al.Youth risk behavior surveillance ^ United States 2001. Morb Mortal Wkly Rp CDC Surveill Summ 2002; 51: 1^ 64. 9. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA.1994. 10. Serdula MK, Ivery D, Coates RJ et al. Do obese children become obese adults? A review of the literature. Prev Med 1993; 22: 167^177. 11. Hedberg VA, Byrd RS, Klein JD et al. The role of community health centers in providing preventive care to adolescents. Arch Pediatr Adolesc Med 1996; 150: 603^ 608. 12. Ackard DM, Neumark-Sztainer D. Health care information sources for adolescents: age and gender differences on use, concerns and needs. J Adolesc Health 2001; 29: 170 ^176. 13. US Preventive ServicesTask Force. Guide to Clinical Preventive Services, 2nd edn. Baltimore: Williams & Wilkins,1996. 14. Green M, Palfrey JS (eds) Bright Futures: Guidelines For Health Supervision of Infants, Children, and Adolescents, 2nd edn. Arlington: National Center for Education in Maternal and Child Health,1994. 15. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph, 2nd edn. Chicago: American Medical Association,1996.
& 2003 Published by Elsevier Science Ltd.
16. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health.Guidelines for health supervision, Vol. III. Elk Grove Village: American Academy of Pediatrics,1997. 17. Galuska DA, Fulton JE, Powell KE et al. Pediatrician counseling about preventive health topics: Results from the Physicians’ Practices Survey, 1998 ^99. Pediatrics 2002: 109: http:// www.pediatrics.org/cgi/content/full/109/5/e83. 18. Green LW, Eriksen MP, Schor EL. Preventive practices by physicians: behavioral determinants and potential interventions. Am J Prev Med 1988; 4: 101^107. 19. Walsh JME, McPhee SJ. A systems model of clinical preventive care: an analysis of factors influencing patient and physician. Health Educ Q1992; 19: 157^175. 20. ChengTL, DeWitt TG, Savageau JA, O’Connor KG. Determinants of counseling in primary care pediatric practice: physician attitudes about time, money, and health issues. Arch Pediatr Adolesc Med 1999; 153: 629^ 635.
Author’s response It was not possible to monitor individuals attending for follow up care, because adolescents were assured of anonymity and confidentiality. Dr JoyTownsend Health Promotion Research Unit London School of Hygiene and Tropical Medicine, UK
Evidence-based Healthcare (2003) 7,14 ^17
17
Consultations with practice nurses may improve adolescent health behaviours slightly Abstracted from: Walker Z, Townsend J, Oakley L et al. Health promotion for adolescents in primary care: randomised controlled trial. BMJ 2002; 325: 524 ^530.
BACKGROUND Relatively few adolescents receive health promotion in general practice.There is little evidence about the e¡ects of general practice health promotion strategies for teenagers. OBJECTIVE To evaluate the e¡ect of inviting adolescents to discus health behaviours with general practice nurses. SETTING Eight general practices in Hertfordshire, United Kingdom;1999 to 2000. METHOD Randomised controlled trial. PARTICIPANTS One thousand, ¢ve hundred and sixteen people aged 14 to 16 years (mean 14.8 years); 51% female; 89% white. All were registered on the general practice lists of participating centres. INTERVENTION Invitation to discuss health concerns and develop plans for a healthier lifestyle with a practice nurse compared with no intervention or educational pamphlet. Consultations with practice nurses lasted 20 minutes.
MAIN RESULTS Forty-one percent of adolescents invited for a consultation met with a practice nurse. One-third of these were o¡ered follow-up care. Ninety-seven percent said they would recommend the intervention to a friend. Adolescents in the intervention group were more likely to report improved ‘stage of change’ for diet and exercise at 3 months, but this did not persist at12 months.There was a trend towards more positive change in reported behaviour in the intervention group (16% versus 12%, p=0.06). Mental health outcomes were improved in the intervention group at 3 and 12 months. AUTHORS’ CONCLUSIONS This brief health promotion intervention was cheap and well received. Change in behaviour was slight, but showed positive trends. Source of funding: NHS Executive - Eastern Region; HertNet (Hertfordshire Primary Care Research Network). Correspondence to: J Townsend, Health Promotion Research Unit, London School of Hygiene and Tropical Medicine, UK. Email: [email protected]. Abstract prepared by Bazian Ltd, London
MAIN OUTCOMES Mental and physical health; ‘stage of change’ for health related behaviour; use of health services. Questionnaires were completed at baseline, 3 months and 12 months.
14
Evidence-based Healthcare (2003) 7,14 ^17 doi:10.1016/ebhc.2003.0581
1462-9410/03/$ - see front matter & 2003 Published by Elsevier Science Ltd.
Commentary 1 Many organisations advocate screening adolescents for behaviours that may compromise their health.1 In the United States, the three leading causes of mortality among adolescents and young adults are motor vehicle accidents, homicide and suicide.2 Many young people will be affected by tobacco consumption, unprotected sexual encounters and poor diet. It is important to understand risk factors in these areas. The effect of screening on adolescents’ actions or intentions remains unclear. Studies with adults suggest that health promotion modestly reduces risk.3,4 Research with adolescents suggests that although young people may be aware of the adverse outcomes associated with certain behaviours and be able to assess their own risk, they often do not change their behaviour.5,6 This may be why many health providers do not routinely screen adolescents or remain sceptical of the benefit.7^10 This study by Walker and colleagues examined whether a structured interview consultation altered adolescents’ intention to change their diet, exercise, smoke or consume alcohol over a 12 month period. The consultation allowed nurses to assess an adolescent’s level of risk and provide targeted information. More teens in the intervention group reported positive change in health related behaviours, intention to change these behaviours at 3 months and knowledge about conf|dentiality and contraception facilities at 12 months. Seventy-f|ve percent of those interviewed asked to talk to the healthcare provider about other topics.This f|nding is consistent with other studies which suggest that adolescents want to talk to healthcare providers about a variety of issues.11,12 The paper makes a valuable contribution to the field of adolescent medicine. It suggests that a one-time interview to identify health risk behaviours and goal setting may have short term benefits. It is impressive that a brief intervention could influence attitudes about diet and exercise at 3 months and depression in some groups at 12 months. The strengths of the study include a well described random isation process, an appropriate sample size at baseline and follow-up, use of a validated instrument to assess depression and appropriate statistical analyses. The 50% response rate at 3 and 12 months is commendable, as it suggests a concerted effort to track a group who may not complete questionnaires without an obvious incentive to do so.The authors do not overstate their findings or generalise inappropriately. This is important because the results may not be applicable to a broader adolescent population.The participants were not demographically diverse in terms of ethnicity, socio-economic background or family structure. There was no demographic comparison between the control and the intervention groups. The study has several other limitations. First, it is unclear how many of those in the intervention arm who returned surveys at 3 and 12 months actually received an initial consultation. Second, an educational pamphlet was given to those who did not want a consultation.The authors could have provided more detail about the content of the pamphlet and whether or not participants read it. It might also have been useful to analyse individuals who received the pamphlet separately rather than include them in the ‘consultation’ group.Third, it may have been useful to provide examples of how nurses responded to the adolescent, depending on the particular behaviour and stage of change. There is likely to have been variability in the skills and motivation of the 12 nurses delivering the intervention.This could have been controlled for in the analysis. Fourth, although one-third of participants were referred for follow-up care, it is unclear how many of these attended follow-up.
& 2003 Published by Elsevier Science Ltd.
What do healthcare providers and policy-makers gain from this study? The findings suggest that nurses can screen, identify and intervene in health risk behaviours in teens. Benefits may persist beyond 3 months if follow-up were targeted to those with the most self-reported need. Adolescents may be relieved that someone has asked them questions about their health and may welcome the information and counselling provided. This study sets the stage for longer, more standardised interventions with follow-up care. R Michelle Schmidt, MD Baylor College of Medicine Department of Internal Medicine Adolescent Clinic, BenTaub General Hospital Houston, Texas, USA and Professor Albert C. Hergenroeder, MD Baylor College of Medicine Adolescent Medicine and Sports Medicine Texas Children’s Hospital Leadership Education in Adolescent Health (LEAH) Training Program Houston, Texas, USA Literature cited 1. American Medical Association. AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Baltimore, MD: Williams and Wilkins,1994. 2. Centers for Disease Control and Prevention. Surveillance summaries. MMWR 2002; 51: SS- 4. 3. Dowell AC, Ochera JJ, Hilton SR et al. Prevention in practice: results of a 2-year follow-up of routine health promotion interventions in general practice. Fam Prac1996; 13: 357^362. 4. Winleby MA, Taylor CB, Jatulis D, Fortmann SP. The longterm effects of a cardiovascular disease prevention trial: the Stanford Five-City Project. Am J Public Health 1996; 86: 1773^1779. 5. Diclemente RJ, Wingood GM, Sionean C et al. Association of adolescents’ history of sexually transmitted disease (STD) and their current high-risk behavior and STD status: a case for intensifying clinic-based prevention efforts. Sex Transm Dis 2002; 29: 503^509. 6. Johnston BD, Rivara FP, Droesch RM et al. Behavior change counseling in the emergency department to reduce injury risk: a randomized controlled trial. Pediatrics 2002; 110: 267^274. 7. Galuska DA, Fulton JE, Powell KE, et al. Pediatrician counseling about preventive health topics: results from the physicians’ practices survey,1998 ^1999. Pediatrics 2002; 109: E83^3. 8. Halpern-Felsher BL, Ozer EM, Millstein SG et al. Preventive services in a health maintenance organization: how well do pediatricians screen and educate adolescent patients? Arch Pediatr Adolesc Med 2000; 154: 173^179. 9. Ewing GB, Selassie AW, Lopez CH et al. Self-report of delivery of clinical preventive services by US physicians: Comparing specialty, gender, age, setting of practice, and area of practice. Am J Prev Med 1999; 17: 62^72. 10. McAvoy BR, Kaner EF, Lock CA et al. Our Healthier Nation: are general practitioners willing and able to deliver? A survey of attitudes to and involvement in health promotion and lifestyle counseling. Br J Gen Pract 1999; 49:187^190. 11. Ackard DM, Neumark-Sztainer D. Health care information sources for adolescents: age and gender differences on use, concerns, and needs. J Adolesc Health 2001; 29:170 ^176. 12. Klein JD,Wilson KM. Delivering quality care: adolescents’ discussion of health risks with their providers. J Adolesc Health 2002; 30: 190 ^195.
Evidence-based Healthcare (2003) 7,14 ^17
15
Commentary 2 Most research into the effect of preventive health advice from providers focuses on adults. These studies suggest that primary care interventions may have small benefits for reducing smoking1 and alcohol consumption2 and increasing physical activity.3 These findings may not apply to adolescents, who have different social and familial pressures than adults and are still developing cognitive skills. Although interventions targeting the behaviour of adolescents have recently been developed,4 ^7 there is less information about their e¡ectiveness. Preventive health initiatives are important because risky behaviours during adolescence can alter the likelihood of both acute and chronic health outcomes.8 For instance, the immediate risk of acute conditions such as injury, unplanned pregnancy and poor physical development may be reduced with seatbelts, contraception and adequate nutrition, respectively. The risk of chronic health conditions such as cancer and cardiovascular disease in adulthood may also be influenced by behaviours initiated during youth.Two risk factors for these conditions, smoking and obesity, have some origins in childhood. Eighty-two percent of adults who smoke tried their first cigarette before 18 years of age9 and 25% to 50% of children who are obese as children remain so as adults.10 Walker and colleagues’ study of health promotion for adolescents therefore addresses an important topic. Medical settings may be a good place to promote preventive health behaviours among adolescents. In the United States, approximately 80% of adolescents visited a healthcare provider over a 2 year period.11 Furthermore, adolescents believe that their provider should discuss health risks with them, even though youth may be unwilling to initiate these discussions due to embarrassment.12 Clinical and government organisations also believe that counselling adolescents is important. Numerous clinical guidelines include recommendations on adolescent health promotion. For example, guidelines developed by the US Preventive Services Task Force,13 Maternal and Child Health Bureau of the Health Resources and Services Administration,14 American Medical Association15 and the American Academy of Pediatrics16 all suggest that physicians should talk to adolescents about preventive health topics such as nutrition, tobacco use, physical activity, sexual activity and substance abuse. Currently, health promotion to adolescents is suboptimal in clinical settings.The proportion of US paediatricians who always counsel adolescents during routine visits ranges from 70% for alcohol and drug use to 25% for firearm safety.17 Whether physicians provide this type of counselling is influenced by a multitude of factors related to the patient, the physician and the physician’s environment.18,19 According to physicians, the perceived effectiveness of counselling is one determinant of their decision to offer advice.20 Thus, studies of the effectiveness of health promotion initiatives may encourage more providers to offer counselling. This study by Walker and colleagues is well designed.The intervention was based on existing models of self-efficacy and behaviour change. Consultations followed the model outlined by the American Medical Association to promote self-efficacy in healthy lifestyles for adolescents. The intervention was guided by teenagers’ attitudes toward general practices as well as their perceived needs during consultations. In addition, teenagers chose which behaviours to change. The investigators also proposed, a priori, the level of adolescent behaviour change expected and recruited a sufficient number of participants to detect this change statistically. A final strength is the use of an intention-to-treat analysis.This strategy provides a conservative
16
Evidence-based Healthcare (2003) 7,14 ^17
estimate of efficacy, but maintains the fidelity of the randomisation. There are also several limitations. First, baseline data was not available for a high proportion (32% of the treatment group and 37% of controls). If predictors of behaviour change differ between non-participants in each group, the results could be biased. Second, of 504 people in the treatment group who provided baseline data, only 304 received the consultation (60%). This low level of participation provides a conservative estimate of efficacy. It may also suggest that some adolescents are unwilling to attend preventive health consultations outside of scheduled visits with their provider. It would have been helpful to document the reasons that adolescents did not participate. Finally, the intervention was of relatively low intensity. It consisted of a single, relatively short consultation with no follow-up.This structure mimics what could be accomplished in typical office settings, given limited resources and time. Intense interventions may be more effective than minimal advice, however.1 It would be of interest to examine whether small variations in the intensity of the intervention, such as a follow-up telephone call, could produce more extensive changes in adolescent behaviour. Because research on this topic is sparse, reasonably well-designed studies, such as this, provide important information even if they suggest that an intervention is not effective. New interventions should be based on appropriate theoretical models, include the needs of both the adolescent and the healthcare provider, be evaluated using appropriate analytic methodology and include cost-effectiveness analyses. Since this intervention was not associated with large behaviour changes, widespread implementation does not seem warranted. Practitioners should recognise, however, that a similar intervention delivered in a different setting may have better outcomes (e.g. a school health centre or another country). Practitioners should also note that the treatment group had a modest improvement in the ‘stages of change’ continuum for at least one of four key behaviours. Most adolescents who attended the consultations also set goals for behaviour change. Thus, adolescents seem willing to try to change behaviours based on consultations. Deborah A Galuska, MPH, PhD National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Georgia, USA
Literature cited 1. Silagy C, Stead LF. Physician advice for smoking cessation. Cochrane Database System Rev 2001; 2: CD000165. 2. BienTH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993; 88: 315^335. 3. Petrella RJ, Lattanzio CN. Does counseling help patients get active? Systematic review of the literature. Can Fam Physician 2002; 48: 72^ 80. 4. Fidler W, Lambert TW. A prescription for health: a primary care based intervention to maintain the non-smoking status of young people.Tob Control 2001; 10: 23^26. 5. Patrick K, Sallis JF, Prochaska JJ et al. A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med 2001; 155: 940 ^946. 6. Saelens BE, Sallis JF, Wilfley DE et al. Behavioral weight control for overweight adolescents initiated in primary care. Obes Res 2002; 10: 22^32. 7. Paperny DM, Hedberg VA.Computer-assisted health counselor visits: a low-cost model for comprehensive adolescent & 2003 Published by Elsevier Science Ltd.
preventive services. Arch Pediatr Adolesc Med 1999; 153: 63^ 67. 8. Grunbaum JA, Kann L, Kinchen SA et al.Youth risk behavior surveillance ^ United States 2001. Morb Mortal Wkly Rp CDC Surveill Summ 2002; 51: 1^ 64. 9. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA.1994. 10. Serdula MK, Ivery D, Coates RJ et al. Do obese children become obese adults? A review of the literature. Prev Med 1993; 22: 167^177. 11. Hedberg VA, Byrd RS, Klein JD et al. The role of community health centers in providing preventive care to adolescents. Arch Pediatr Adolesc Med 1996; 150: 603^ 608. 12. Ackard DM, Neumark-Sztainer D. Health care information sources for adolescents: age and gender differences on use, concerns and needs. J Adolesc Health 2001; 29: 170 ^176. 13. US Preventive ServicesTask Force. Guide to Clinical Preventive Services, 2nd edn. Baltimore: Williams & Wilkins,1996. 14. Green M, Palfrey JS (eds) Bright Futures: Guidelines For Health Supervision of Infants, Children, and Adolescents, 2nd edn. Arlington: National Center for Education in Maternal and Child Health,1994. 15. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph, 2nd edn. Chicago: American Medical Association,1996.
& 2003 Published by Elsevier Science Ltd.
16. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health.Guidelines for health supervision, Vol. III. Elk Grove Village: American Academy of Pediatrics,1997. 17. Galuska DA, Fulton JE, Powell KE et al. Pediatrician counseling about preventive health topics: Results from the Physicians’ Practices Survey, 1998 ^99. Pediatrics 2002: 109: http:// www.pediatrics.org/cgi/content/full/109/5/e83. 18. Green LW, Eriksen MP, Schor EL. Preventive practices by physicians: behavioral determinants and potential interventions. Am J Prev Med 1988; 4: 101^107. 19. Walsh JME, McPhee SJ. A systems model of clinical preventive care: an analysis of factors influencing patient and physician. Health Educ Q1992; 19: 157^175. 20. ChengTL, DeWitt TG, Savageau JA, O’Connor KG. Determinants of counseling in primary care pediatric practice: physician attitudes about time, money, and health issues. Arch Pediatr Adolesc Med 1999; 153: 629^ 635.
Author’s response It was not possible to monitor individuals attending for follow up care, because adolescents were assured of anonymity and confidentiality. Dr JoyTownsend Health Promotion Research Unit London School of Hygiene and Tropical Medicine, UK
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