The cost of comprehensive preventive medical services for adolescents

Children's mental health as a primary care and concern: a system for comprehensive support and service

In response to the serious crisis in mental health care for children in the United States, this article proposes as a priority for psychology a comprehensive approach that treats mental health as a primary issue in child health and welfare. Consistent with the principles of a system of care and applying epidemiological, risk-development, and intervention-research findings, this approach emphasizes 4 components: easy access to effective professional clinical services for children exhibiting disorders; further development and application of sound prevention principles for high-risk youths; support for and access to short-term intervention in primary care settings; and greater recognition and promotion of mental health issues in common developmental settings and other influential systems. Integral to this approach is the need to implement these components simultaneously and to incorporate family-focused, culturally competent, evidence-based, and developmentally appropriate services. This comprehensive, simultaneous, and integrated approach is needed to achieve real progress in children's mental health in this country.

Prevention opportunities in health care settings

Psychologists have an opportunity to offer their expertise at a time when health care settings are beginning to recognize the importance of behaviorally based interventions for improving health and health care. The authors review the changing patterns of health and illness that have led to an increased interest in the role of patient and provider behavior and discuss the many advantages of using health care settings as prevention sites. Examples of successful behaviorally based prevention programs are presented, along with the evidence supporting the cost-effectiveness of such programs. Challenges presented by working in health care settings are described. Throughout, the authors emphasize the multiple opportunities for psychologists' involvement across a wide variety of health care delivery sites.

Physician weight counseling for adolescents

Adolescent obesity prevalence is increasing, with minimal study of physician weight counseling with youth. This study examines adolescents' (n=110) perceptions of physicians' weight counseling. Overweight adolescents (> or =85th percentile for body mass index, BMI) report receiving counseling more than nonoverweight adolescents. Physicians more often have counseled obese (> or =95th BMI percentile) than overweight but not obese adolescents (85th-94th BMI percentile). Prior counseling and adolescents' ethnicity were related to greater perceived physician concern and adolescent receptivity to future counseling. Overweight adolescents report attempting weight loss strategies at rates similar to recommendations, but recommendations for specific weight control behaviors do not increase the likelihood of adolescent attempts. Clin Pediatr. 2002;41:575-585

Screening measure for assessing dietary fat intake among adolescents

BACKGROUND

Clinical preventive guidelines recommend that health care providers counsel adolescents on nutrition. Brief, accurate, and reproducible dietary assessments are needed. The purpose of the current pair of studies was to develop a dietary fat screening measure for use with adolescents.

METHODS

Two measures were developed-a 21-item and a 4-category measure. The measures differed in the level at which fat consumption was assessed (food item vs food group). Study 1 (N = 231, age M = 15 years, 57% female, 41% Euro-American) evaluated reliability. Study 2 (N = 59, age M = 14 years, 63% female, 37% Euro-American) evaluated construct validity and correct classification rates.

RESULTS

Internal consistencies (alpha > 0.70) and test-retest reliabilities (ICC > 0.60) were adequate for both measures. Neither measure correlated with total fat assessed by a 3-day food record (P > 0.05). The 21-item measure correlated significantly with percentage of calories from fat (r = 0.36, P <.01). Correct classification rate (71%) and sensitivity (81%) of the 21-item measure were good. Specificity (47%) was lower, indicating some subjects with a low-fat diet were misclassified by the screening measure.

CONCLUSIONS

The 21-item measure is quick to complete and score, is inexpensive to reproduce, and has demonstrated reliability and validity. The measure could be clinically useful, but further improvements should be attempted to improve specificity.

Improving adolescent preventive care in community health centers

OBJECTIVE

To evaluate implementation of the Guidelines for Adolescent Preventive Services (GAPS) in Community and Migrant Health Centers (CMHCs).

DESIGN

Before and after comparison of health center policy, clinician and adolescent self-report, and chart reviews in 5 CMHCs.

PARTICIPANTS

Eighty-one preintervention and 80 one-year postintervention providers and 318 preintervention and 331 postintervention 14- to 19- year-old adolescent patients being seen for well visits at 5 CMHCs.

INTERVENTION

Health center staff were trained to implement GAPS and were provided resource materials, patient questionnaires, and clinician manuals.

MAIN OUTCOME MEASURES

Delivery of and receipt of preventive services and perceived access to care.

RESULTS

CMHC systems changes were related to stronger leadership commitment to adolescent care. Providers reported high levels of preventive services delivery before and after guideline implementation. After guideline implementation, adolescents reported increases in having discussed prevention content with providers in 19 of 31 content areas, including increased discussion of physical or sexual abuse (10% before to 22% after), sexual orientation (13% to 27%), fighting (6% to 21%), peer relations (37% to 52%), suicide (7% to 22%), eating disorders (11% to 28%), weapons (5% to 22%), depression (16% to 34%), smokeless tobacco (10% to 29%), and immunizations (19% to 48%). Adolescents were also more likely to report knowing where to get reproductive or mental health services and were more likely to have received health education materials. Implementation also increased documentation of recommended screening and counseling in 51 of 79 specific content areas assessed in chart reviews.

CONCLUSION

Implementing GAPS increased the receipt of preventive services at these health centers. Adolescents received more comprehensive screening and counseling, more health education materials, and had greater access to care after implementation. GAPS implementation may help improve the quality of care for adolescents.

Why adolescent medicine?

This article reviews the biologic, cognitive, and sociocultural changes that occur during adolescence. Providing appropriate health care to adolescents in an effective manner requires an in-depth understanding of these changes, both in terms of preventing the onset of health-risking behaviors and promoting a healthy lifestyle. As many chronic diseases of adults have their origins during adolescence, this approach holds promise for reducing morbidity and mortality in later life as well as during young adulthood. There is an emerging consensus regarding the scope and content of preventive services for adolescents. The approach to incorporating these services into the health maintenance visit for young people is reviewed.

Health counseling in adolescent preventive visits: effectiveness, current practices, and quality measurement

Most morbidity and mortality among adolescents results from their participation in health-compromising behaviors. Recent guidelines for clinical adolescent preventive services recommend that primary care clinicians routinely screen for and counsel adolescents about these behaviors, identify and address related social, psychological, and biologic factors. Office-based counseling can influence adult health behaviors, but little is known about the effectiveness of office-based counseling for adolescents. In this review we: (a) evaluate available information about the effectiveness of office-based health counseling to improve outcomes; (b) report what is known about the health counseling adolescents receive from primary care clinicians; and (c) critically review different approaches that have been, or might be, used to measure the content and quality of health counseling provided during adolescent medical visits. With the emphasis on accountability in the current health care environment, evidence supporting the effectiveness of counseling is needed to justify investment in this aspect of clinical adolescent preventive services. Challenges to studying the effectiveness of health counseling include the lack of well-defined theory-based models for adolescent office-based counseling, the complexity of measuring counseling quality, and the many factors that influence adolescent outcomes. Reliable and valid measures of counseling quality are needed both to study and to ensure the quality of counseling received by adolescents. No single measure can be expected to fully capture counseling quality, although patient self-report deserves further development.

Managed care, school health programs, and adolescent health services: opportunities for health promotion

The rapid expansion of managed care creates opportunities and dilemmas for those involved in school health and adolescent health promotion. Managed care organizations (MCOs), public health agencies, and school and adolescent health providers share certain common goals and priorities including an emphasis on prevention, cost-effectiveness, and quality of care--and a willingness to explore innovative approaches to health promotion and disease prevention. However, MCOs often face conflicting challenges, balancing the goals of cost containment and investment in prevention. In considering support for school health programs, MCOs will be interested in evidence about the effectiveness of services in improving health and/or reducing medical expenditures. Mechanisms for improving prevention efforts within MCOs include quality assurance systems to monitor the performance of health plans, practice guidelines from professional organizations, and the contracting process between payers and health care providers. Development of partnerships between MCOs and schools will be a challenge given competing priorities, variation in managed care arrangements, structural differences between MCOs and schools, and variability in services provided by school health programs.

GAPS: an opportunity for nurse practitioners to promote the health of adolescents through clinical preventive services

Today the leading causes of morbidity and mortality among adolescents originates in social and behavioral determinants. Thus much of adolescent death and disability can be attributed to preventable risk factors. In response, clinical preventive services have been developed by the American Medical Association to shift the focus of care to prevention. Guidelines for Adolescent Preventive Services recommendations address delivery of health services, health guidance, screening, and immunizations. Nurse practitioners are uniquely positioned to promote health and improve the quality of care delivered to adolescents. The purpose of this article is to describe the Guidelines for Adolescent Preventive Services model for clinical preventive services and the role of the nurse practitioner in implementation.

Integrating comprehensive adolescent preventive services into routine medicine care. Rationale and approaches

Relying on therapeutic interventions to address health problems after they occur has proven costly and does not address the need to reduce the number of youth who develop these health problems. Primary care physicians have an important role to play in promoting adolescent health through a strategy of providing health guidance to adolescents and parents, screening, and promoting immunizations. Reducing the health risk behaviors of adolescents is a challenge that is best accomplished with the support of other preventive initiatives. Clinical preventive services should complement and reinforce preventive efforts in schools (i.e., comprehensive school health programs) and communities (i.e., mass media campaigns and health regulations). GAPS recommendations developed by the AMA and recommendations from other groups provide a model for organizing the content and delivery of comprehensive preventive services for adolescents. Physicians and other primary care health providers may use these recommendations to expand the quantity and quality of preventive services they offer to adolescents. Additional information about preventive services and GAPS, including a complete list of the recommendations, dates for future GAPS training, a description of the materials developed to help implement preventive services, other national efforts in adolescent preventive services, and current articles in scientific literature, can be reviewed on the AMA web site (http:/(/)www.AMA-Assn.Org/Adolhlth/Adolhlth+ ++.htm).

Computerized health assessment and education for adolescent HIV and STD prevention in health care settings and schools

This report summarizes a number of computer applications from a decade of experience with computerized adolescent health assessments and automated health education in a large health maintenance organization, military adolescent clinics, detention facilities, health fairs, and public schools. Feedback from over 5,000 adolescents is given for patient responses to and acceptance of computerized health assessments and preferences for automated health education modalities, including multimedia. Implications of the computerized approach to assessment of adolescent health risk behaviors and the provision of automated health education and HIV/STD prevention are considered in terms of efficiency, reliability, and access to health screening and educational services.