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

Predictors of Booster Engagement Following a Web-Based Brief Intervention for Alcohol Misuse Among National Guard Members: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Alcohol misuse is a major health concern among military members. Reserve component members face unique barriers as they live off base with limited access to behavioral health services. Web and app-based brief interventions are a promising means to improve access to treatment for those who misuse alcohol, with the use of booster sessions to enhance effectiveness, solidify gains, and reinforce changes. However, little is known about who will engage in booster sessions.

OBJECTIVE

This study aims to evaluate booster engagement across booster delivery modalities (Web and Peer) and identify participant-specific factors associated with booster session engagement.

METHODS

Following a brief web-based alcohol misuse intervention in National Guard members (N=739), we examined engagement in a series of three booster sessions. Using unadjusted and adjusted models, demographic and clinical characteristics that may serve as predictors of booster session engagement were examined across the 2 arms of the trial with different types of booster sessions: peer-delivered (N=245) and web-delivered (N=246).

RESULTS

Booster session completion was greater for Peer than Web Booster sessions, with 142 (58%) service members in the Peer Booster arm completing all three boosters compared with only 108 (44%) of participants in the Web Booster arm (χ²₃=10.3; P=.006). In a model in which the 2 groups were combined, socioeconomic factors predicted booster engagement. In separate models, the demographic and clinical predictors of booster engagement varied between the 2 delivery modalities.

CONCLUSIONS

The use of peer-delivered boosters, especially among subsets of reserve members at risk of lack of engagement, may foster greater uptake and improve treatment outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02181283; https://clinicaltrials.gov/ct2/show/NCT02181283.

Electronic Health Risk Behavior Screening With Integrated Feedback Among Adolescents in Primary Care: Randomized Controlled Trial

BACKGROUND

Health risk behaviors are the most common sources of morbidity among adolescents. Adolescent health guidelines (Guidelines for Preventive Services by the AMA and Bright Futures by the Maternal Child Health Bureau) recommend screening and counseling, but the implementation is inconsistent.

OBJECTIVE

This study aims to test the efficacy of electronic risk behavior screening with integrated patient-facing feedback on the delivery of adolescent-reported clinician counseling and risk behaviors over time.

METHODS

This was a randomized controlled trial comparing an electronic tool to usual care in five pediatric clinics in the Pacific Northwest. A total of 300 participants aged 13-18 years who attended a well-care visit between September 30, 2016, and January 12, 2018, were included. Adolescents were randomized after consent by employing a 1:1 balanced age, sex, and clinic stratified schema with 150 adolescents in the intervention group and 150 in the control group. Intervention adolescents received electronic screening with integrated feedback, and the clinicians received a summary report of the results. Control adolescents received usual care. Outcomes, assessed via online survey methods, included adolescent-reported receipt of counseling during the visit (measured a day after the visit) and health risk behavior change (measured at 3 and 6 months after the visit).

RESULTS

Of the original 300 participants, 94% (n=282), 94.3% (n=283), and 94.6% (n=284) completed follow-up surveys at 1 day, 3 months, and 6 months, respectively, with similar levels of attrition across study arms. The mean risk behavior score at baseline was 2.86 (SD 2.33) for intervention adolescents and 3.10 (SD 2.52) for control adolescents (score potential range 0-21). After adjusting for age, gender, and random effect of the clinic, intervention adolescents were 36% more likely to report having received counseling for endorsed risk behaviors than control adolescents (adjusted rate ratio 1.36, 95% CI 1.04 to 1.78) 1 day after the well-care visit. Both the intervention and control groups reported decreased risk behaviors at the 3- and 6-month follow-up assessments, with no significant group differences in risk behavior scores at either time point (3-month group difference: β=-.15, 95% CI -0.57 to -0.01, P=.05; 6-month group difference: β=-.12, 95% CI -0.29 to 0.52, P=.57).

CONCLUSIONS

Although electronic health screening with integrated feedback improves the delivery of counseling by clinicians, the impact on risk behaviors is modest and, in this study, not significantly different from usual care. More research is needed to identify effective strategies to reduce risk in the context of well-care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02882919; https://clinicaltrials.gov/ct2/show/NCT02882919.

Promotion of Preconception Care Among Adolescents and Young Adults by Conversational Agent

PURPOSE

Preconception care is important for all women to improve infant and maternal health outcomes and may be especially important for adolescents and young adults. This study assesses the acceptance, usability, and use of an automated intervention to screen women on 108 preconception care risks and address them over the course of a year via a Web-based virtual animated health counselor and compares these measures for the adolescent and young adult users aged 18-25 years with those of users aged 26-34 years. We hypothesize that the younger cohort will have significantly greater use of and satisfaction with the online intervention.

METHODS

A randomized controlled trial involving a national sample of 528 women was conducted. We present a secondary data analysis on the system use and self-reported usability and satisfaction of the 79 women aged 18-25 years randomized to the intervention group, compared with the 183 women aged 26-34 years in the intervention group. Participants were required to self-identify as female, black or African American, aged 18-34 years, not pregnant, and English-speaking and were recruited through a variety of advertisements and outreach activities.

RESULTS

Of the adolescent and young adult participants (aged 18-25 years) enrolled and randomized to the intervention, 20.25% of participants accessed the system 0 times; 29.11%, 1-3 times; and 50.63%, >3 times over the course of a year. At the end of the year, almost all (96.4%) indicated they had either acted on recommendations made by the agent or planned to. Most (75.0%) said they would recommend the system to someone they knew. There were no significant differences between the two age groups on intervention use or satisfaction.

CONCLUSIONS

Web-based conversational agents are a viable medium for delivering longitudinal preconception care counseling to adolescents and young adults.

A Mobile Health Contraception Decision Support Intervention for Latina Adolescents: Implementation Evaluation for Use in School-Based Health Centers

Background

Health care providers are a trusted and accurate source of sexual health information for most adolescents, and clinical guidelines recommend that all youth receive comprehensive, confidential sexual health information and services. However, these guidelines are followed inconsistently. Providers often lack the time, comfort, and skills to provide patient-centered comprehensive contraceptive counseling and services. There are significant disparities in the provision of sexual health services for Latino adolescents, which contribute to disproportionately higher rates of teenage pregnancy. To address this, we developed Health-E You or Salud iTu in Spanish, an evidence-informed mobile health (mHealth) app, to provide interactive, individually tailored sexual health information and contraception decision support for English and Spanish speakers. It is designed to be used in conjunction with a clinical encounter to increase access to patient-centered contraceptive information and services for adolescents at risk of pregnancy. Based on user input, the app provides tailored contraceptive recommendations and asks the youth to indicate what methods they are most interested in. This information is shared with the provider before the in-person visit. The app is designed to prepare youth for the visit and acts as a clinician extender to support the delivery of health education and enhance the quality of patient-centered sexual health care. Despite the promise of this app, there is limited research on the integration of such interventions into clinical practice.

Objective

This study described efforts used to support the successful adoption and implementation of the Health-E You app in clinical settings and described facilitators and barriers encountered to inform future efforts aimed at integrating mHealth interventions into clinical settings.

Methods

This study was part of a larger, cluster randomized control trial to evaluate the effectiveness of Health-E You on its ability to reduce health disparities in contraceptive knowledge, access to contraceptive services, and unintended pregnancies among sexually active Latina adolescents at 18 school-based health centers (SBHCs) across Los Angeles County, California. App development and implementation were informed by the theory of diffusion of innovation, the Patient-Centered Outcomes Research Institute’s principles of engagement, and iterative pilot testing with adolescents and clinicians. Implementation facilitators and barriers were identified through monthly conference calls, site visits, and quarterly in-person collaborative meetings.

Results

Implementation approaches enhanced the development, adoption, and integration of Health-E You into SBHCs. Implementation challenges were also identified to improve the integration of mHealth interventions into clinical settings.

Conclusions

This study provides important insights that can inform and improve the implementation efforts for future mHealth interventions. In particular, an implementation approach founded in a strong theoretical framework and active engagement with patient and community partners can enhance the development, adoption, and integration of mHealth technologies into clinical practice.

Trial Registration

ClinicalTrials.gov NCT02847858; https://clinicaltrials.gov/ct2/show/NCT02847858 (Archived by WebCite at http://www.webcitation.org/761yVIRTp).

Epic Allies, a Gamified Mobile Phone App to Improve Engagement in Care, Antiretroviral Uptake, and Adherence Among Young Men Who Have Sex With Men and Young Transgender Women Who Have Sex With Men: Protocol for a Randomized Controlled Trial

Background

In the United States, young men who have sex with men (YMSM) and transgender women who have sex with men (YTWSM) bear a disproportionate burden of prevalent and incident HIV infections. Once diagnosed, many YMSM and YTWSM struggle to engage in HIV care, adhere to antiretroviral therapy (ART), and achieve viral suppression. Computer-based interventions, including those focused on behavior change, are recognized as effective tools for engaging youth.

Objective

The purpose of the study described in this protocol is to evaluate the efficacy of Epic Allies, a theory-based mobile phone app that utilizes game mechanics and social networking features to improve engagement in HIV care, ART uptake, ART adherence, and viral suppression among HIV-positive YMSM and YTWSM. The study also qualitatively assesses intervention acceptability, perceived impact, and sustainability.

Methods

This is a two-group, active-control randomized controlled trial of the Epic Allies app. YMSM and YTWSM aged 16 to 24 inclusive, with detectable HIV viral load are randomized 1:1 within strata of new to care (newly entered HIV medical care ≤12 months of baseline visit) or ART-nonadherent (first entered HIV medical care >12 months before baseline visit) to intervention or control conditions. The intervention condition addresses ART adherence barriers through medication reminders and adherence monitoring, tracking of select adherence-related behaviors (eg, alcohol and marijuana use), an interactive dashboard that displays the participant’s adherence-related behaviors and provides tailored feedback, encouragement messages from other users, daily HIV/ART educational articles, and gamification features (eg, mini-games, points, badges) to increase motivation for behavior change and app engagement. The control condition features weekly phone-based notifications to encourage participants to view educational information in the control app. Follow-up assessments are administered at 13, 26, and 39 weeks for each arm. The primary outcome measure is viral suppression. Secondary outcome measures include engagement in care, ART uptake, ART adherence, and psychosocial barriers to engagement in care and ART adherence, including psychological distress, stigma, and social support.

Results

Baseline enrollment began in September 2015 and was completed in September 2016 (n=146), and assessment of intervention outcomes continued through August 2017. Results for primary and secondary outcome measures are expected to be reported in ClinicalTrials.gov by April 30, 2018.

Conclusions

If successful, Epic Allies will represent a novel adherence intervention for a group disproportionately impacted by HIV in the United States. Adherent patients would require less frequent clinic visits and experience fewer HIV-related secondary infections, thereby reducing health care costs and HIV transmission. Epic Allies could easily be expanded and adopted for use among larger populations of YMSM and YTWSM, other HIV-positive populations, and for those diagnosed with other chronic diseases such as diabetes and hypertension.

Trial Registration

ClinicalTrials.gov NCT02782130; https://clinicaltrials.gov/ct2/show/NCT02782130 (Archived by Webcite at http://www.webcitation.org/6yGODyerk)

Assessing the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, to reduce health disparities in unintended pregnancies among Hispanic adolescents: study protocol for a cluster randomised control trial

INTRODUCTION

Teen pregnancy rates in the USA remain higher than any other industrialised nation, and pregnancies among Hispanic adolescents are disproportionately high. Computer-based interventions represent a promising approach to address sexual health and contraceptive use disparities. Preliminary findings have demonstrated that the Health-E You/Salud iTu, computer application (app) is feasible to implement, acceptable to Latina adolescents and improves sexual health knowledge and interest in selecting an effective contraceptive method when used in conjunction with a healthcare visit. The app is now ready for efficacy testing. The purpose of this manuscript is to describe patient-centred approaches used both in developing and testing the Health-E You app and to present the research methods used to evaluate its effectiveness in improving intentions to use an effective method of contraception as well as actual contraceptive use.

METHODS AND ANALYSIS

This study is designed to assess the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, on its ability to reduce health disparities in unintended pregnancies among Latina adolescent girls. This study uses a cluster randomised control trial design in which 18 school-based health centers from the Los Angeles Unified School District were randomly assigned, at equal chance, to either the intervention (Health-E You app) or control group. Analyses will examine differences between the control and intervention group's knowledge of and attitudes towards contraceptive use, receipt of contraception at the clinic visit and self-reported use of contraception at 3-month and 6-month follow-ups. The study began enrolling participants in August 2016, and a total of 1400 participants (700 per treatment group) are expected to be enrolled by March 2018.

ETHICS AND DISSEMINATION

Ethics approval was obtained through the University of California, San Francisco Institutional Review Board. Results of this trial will be submitted for publication in peer-reviewed journals. This study is registered with the US National Institutes of Health.

TRIAL REGISTRATION NUMBER

NCT02847858.

Effect of an iPad-Based Intervention to Improve Sexual Health Knowledge and Intentions for Contraceptive Use Among Adolescent Females at School-Based Health Centers

OBJECTIVES

The use of effective contraception can decrease the incidence of unplanned pregnancy among adolescents. This study aims to examine the effectiveness of an iPad-based application (app) on improving adolescent girls' sexual health knowledge and on its ability to influence their intentions to use effective contraception.

STUDY DESIGN

This was a prospective study of girls aged 12 to 18 years recruited from 3 school-based health centers in California.

RESULTS

A total of 120 racially/ethnically diverse participants used the iPad app; 54% were sexually active, with only 26% using effective contraception at baseline. The average score on baseline sexual health knowledge assessment was 58%. After using the app, 68% of the sexually active participants reported intention to use effective contraception in the future, and sexual health knowledge improved significantly to 79% ( P < .001).

CONCLUSIONS

This iPad-based app is a promising intervention to educate adolescents about sexual health and support them in selecting an effective contraception method.

Testing the feasibility of a briefer school-based preventive intervention with aggressive children: A hybrid intervention with face-to-face and internet components

This study describes the results from a feasibility study of an innovative indicated prevention intervention with hybrid face-to-face and web-based components for preadolescent youth. This intervention includes a considerably briefer set of face-to-face sessions from the evidence-based Coping Power program and a carefully integrated internet component with practice and teaching activities and cartoon videos for children and for parents. The Coping Power - Internet Enhanced (CP-IE) program introduces a set of cognitive-behavioral skills in 12 small group sessions for children delivered during the school day and 7 group sessions for parents. Eight elementary schools were randomly assigned to CP-IE or to Control, and six children at each school were identified each year based on 4th grade teacher ratings of aggressive behavior. Path analyses of teacher-rated disruptive behavior outcomes for 91 fifth grade children, across two annual cohorts, indicated Control children had significantly greater increases in conduct problem behaviors across the 5th grade year than did CP-IE children. This much briefer version of Coping Power provided beneficial preventive effects on children's behavior in the school setting similar to the effects of the longer version of Coping Power. The website materials appeared to successfully engage children, and parents' use of the website predicted children's changes in conduct problems across the year.

Sexually Transmitted Diseases and Managed Care: An Inquiry and Review of Issues Affecting Service Delivery

To understand the potential role of managed care organizations (MCOs) in prevention and control of sexually transmitted diseases (STDs), we conducted a systematic review of articles on STDs and managed care and sought qualitative information from MCOs on STD-related activities. The review focused on prevention, risk assessment, patient education, counseling, screening, and costs of care, but revealed relatively few published articles. Barriers to STD service delivery included competing priorities, lack of time or supporting organizational structures, and differing mandates of health departments and MCOs. Facilitators included collaboration between health departments and MCOs, regulatory and performance incentives, buy-in from key stakeholders, availability of infrastructure to support data collection, and inclusion of chlamydia screening in the Health Employer Data and Information Set to monitor plan performance. Because of the shift of STD service delivery from the public to private sector, incentives need to maximize interest and cooperation of patients, clinicians, and MCOs in STD prevention.

The Future of Health Promotion: Talkin™ Technology Blues

Talking about the future often means talking about technology. Does the future of health promotion lie in technology? This article offers a user’s perspective on this issue. By returning to core values in which health education practice is rooted, it raises basic questions we ought to ask as we apply technology to meet the challenges we face.

The promise of multimedia technology for STI/HIV prevention: frameworks for understanding improved facilitator delivery and participant learning

There is increasing excitement about multimedia sexually transmitted infection (STI) and HIV prevention interventions, yet there has been limited discussion of how use of multimedia technology may improve STI/HIV prevention efforts. The purpose of this paper is to describe the mechanisms through which multimedia technology may work to improve the delivery and uptake of intervention material. We present conceptual frameworks describing how multimedia technology may improve intervention delivery by increasing standardization and fidelity to the intervention material and the participant's ability to learn by improving attention, cognition, emotional engagement, skills-building, and uptake of sensitive material about sexual and drug risks. In addition, we describe how the non-multimedia behavioral STI/HIV prevention intervention, Project WORTH, was adapted into a multimedia format for women involved in the criminal justice system and provide examples of how multimedia activities can more effectively target key mediators of behavioral change in this intervention.

eHealth interventions for HIV prevention

The rapidly changing media landscape and proliferation of new technologies creates vast new opportunities for HIV prevention. The fast growth of the relatively new eHealth field is a testament to the excitement and promise of these new technologies. eHealth interventions in HIV prevention tested to date include computer- and Internet-based interventions; chat room interventions; text messaging interventions; and social media. The current article provides a brief review of these types of interventions in HIV prevention, including their unique advantages and evidence of efficacy. Implications for future research in the eHealth HIV prevention field are discussed.

From questionnaire to conversation: a structural intervention to improve HIV test counseling

OBJECTIVE

We describe the effects of structural intervention to enhance the quality of HIV test counseling interaction with men who have sex with men (MSM) in San Francisco.

METHODS

Audio recordings of 28 rapid HIV test sessions by seven counselors were collected in two phases: before and after implementation of a waiting room intervention prior to the session. The sessions were analyzed using sequence maps to visualize and compare the sequence and distribution of four activities: counseling, information delivery, data collection, and sample collection.

RESULTS

Prior to the intervention, counselors and clients often oriented to data collection about the client's past risk as if it were a survey. In sessions recorded after the intervention, questions about past risk were dispersed throughout the session and embedded within an elaborated discussion of the client's particular life circumstances.

CONCLUSION

Direct observation with the aid of sequence maps illuminates the ways that counselors and clients collaboratively orient to various tasks.

PRACTICE IMPLICATIONS

We demonstrated the feasibility of a structural intervention that improved the quality of both counseling and the accuracy of client risk data without requiring additional session time or counselor training.

Sexual practices, barriers to condom use and its consistent use among long distance truck drivers in Nigeria

Among the long distance truck drivers in Nigeria, a major group that transmits HIV, the use of male latex condoms is generally low and erratic. To effectively promote their consistent use, it was necessary to understand the drivers' sexual practices, experience of barriers to condom use and HIV/AIDS-related attitudes. Four hundred and twelve long distance truck drivers were selected and interviewed in major truck stops along the country highways. The interview explored the drivers condom use barriers, their demographic characteristics, HIV/AIDS-related attitudes and practices. The drivers noted that their major barriers experienced were that condoms reduced their sexual satisfaction, caused health problems for them, and hindered their sexual interest. About 70% of the drivers knew about condoms HIV preventive measure, but only 9% consistently used them. The drivers that acknowledged that they always used a condom, had secondary education, were less likely to report that a condom was inconveniencing or caused health problems, rarely used local decoctions to improve sexual energy, and frequently listened to the radio. In conclusion, it is necessary to intensify condom education for the drivers through the radio, establish counselling centres, tailor counselling to reduce the barriers, and provide free condoms for the drivers.

Adolescent access to online health services: perils and promise

PURPOSE

Many health care institutions provide online health services to adult patients and proxy access to parents of young children. Many of the benefits and barriers to providing such services to adolescent patients remain unclear.

METHODS

The present work is based on a literature review and expert opinion synthesis.

RESULTS

Potential benefits of providing online health services to adolescents include improved health care access, health literacy, and ongoing care. Potential barriers include information complexity, confidentiality concerns, legal issues, and management priorities.

CONCLUSIONS

Although barriers exist to implementing adolescent access to online health services, the potential benefits are significant. Overcoming these barriers will involve invoking legal and policy strategies and refocusing priorities on adolescent health.

Depressive symptoms and interpersonal victimization among African American women attending an urban STD clinic

OBJECTIVES

This study evaluated the association of depressive symptom levels and interpersonal victimization. The sample was comprised of 455 African American women attending an urban sexually transmitted disease clinic. Interpersonal victimization was defined as whether a woman was forced to have sexual intercourse and whether a woman was ever hit, slap or physically hurt by a boyfriend, girlfriend, or spouse in the past 12 months.

METHODS

Using audio computer-assisted self-interviewing (ACASI), women responded to questions regarding interpersonal victimization and depressive symptom levels (e.g., depression, sadness, loneliness and crying in the past week).

RESULTS

Results indicated that women with a history of interpersonal victimization were more likely to experience higher levels of depressive symptoms when compared with women who did not. Statistically significant differences were found for being forced to have sexual intercourse (all p's <0.0001) and ever being hit, slap or physically hurt by a boyfriend, girlfriend, or spouse in the past 12 months (p's range from 0.012 to 0.0003) with regard to each depressive symptom item.

CONCLUSION

Behavioral women-focused interventions need to address mental health issues associated with risky sexual behaviors in order to be more efficacious.

Adolescent Satisfaction with Computer-Assisted Behavioural Risk Screening in Primary Care

BACKGROUND: This study measures patient satisfaction with a computerised mental health and risk-behaviour screening tool and predictors of satisfaction. METHOD: Youth, aged 11-20, were recruited to use a laptop-based screening system in nine primary care clinics. The study assessed correlations between satisfaction with the system and selected predictors. RESULTS: Most users were satisfied with their experience. Multivariate logistic regression found perceived ease of use, perceived usefulness, and trust to be significantly associated with high satisfaction. Satisfaction was not related to computer experience or risk behaviour status. CONCLUSIONS: Adolescent patients, even those at risk, accept computer-assisted screening in primary care. KEY PRACTITIONER MESSAGE: Screening adolescents for behavioural and mental health issues in the primary care setting is time consuming. Computer assisted screening has the potential to improve screening. This study finds that youth will accept computerised screening if the system is perceived to be useful and easy to use.

Trial of computerized screening for adolescent behavioral concerns

OBJECTIVE

Injury risk, depressive symptoms, and substance use are the leading causes of adolescent morbidity and death. The goal of this randomized, controlled trial was to determine whether computerized screening with real-time printing of results for pediatricians increased the identification of these adolescent behavioral concerns.

METHODS

A total of 878 primary care patients 11 to 20 years of age participated in computerized behavioral screening (the Health eTouch system) in waiting rooms of 9 urban clinics. These clinics all served predominantly low-income patients. The clinics were randomly assigned to have pediatricians receive screening results either just before face-to-face encounters with patients (immediate-results condition) or 2 to 3 business days later (delayed-results condition).

RESULTS

Fifty-nine percent of Health eTouch respondents had positive results for >/=1 of the following behavioral concerns: injury risk behaviors, significant depressive symptoms, or substance use. Sixty-eight percent of youths in the immediate-results condition who screened positive were identified as having a problem by their pediatrician. This was significantly higher than the recognition rate of 52% for youths in the delayed-results condition.

CONCLUSION

Immediate provision of an adolescent's self-report of behavioral concerns to a pediatrician increased recognition of those problems, compared with the delayed provision of results.

STD/HIV prevention practices among primary care clinicians: risk assessment, prevention counseling, and testing

OBJECTIVE

To describe current practices of primary care (PC) clinicians for STD/HIV control services: risk assessment, prevention counseling, and offering tests.

STUDY DESIGN

We identified clinical strategies through qualitative interviews. We then surveyed by mail a random sample of Washington State family physicians, general internists, obstetrician-gynecologists, nurse practitioners, and certified nurse midwives. We identified characteristics of clinicians and their practices associated with each strategy and universal provision of each service.

RESULTS

We report on 519 clinicians (80% adjusted response rate). Clinicians provided services to selected patients they considered high risk. Universal practices were less common: risk assessment (56%), prevention counseling (60%), STD tests (30%), and HIV tests (19%). Universal services were more common among nurses, those recently trained, and those seeing more STD patients.

CONCLUSION

Different types of PC clinicians use widely differing clinical strategies and many use selective rather than universal approaches to STD/HIV control services. Further research is needed to develop tailored interventions to improve provision of these services.

Providers' perceived barriers to sexually transmitted disease care in 2 large health maintenance organizations

GOAL

To identify providers' perceived barriers to sexually transmitted disease (STD) care in 2 health plans and plan-, clinician-, and patient-level factors that were associated with these barriers in order to inform quality improvement interventions.

STUDY DESIGN

Surveys were mailed to a stratified sample of 1000 physicians, physician assistants, and nurse practitioners at 2 large health plans in 1999-2000. Of the 743 (82%) providers who received questionnaires and responded, data were analyzed from 699 with complete specialty information.

RESULTS

Ninety-five percent of providers identified at least 1 barrier to STD care. The most commonly cited barriers in both plans related to insufficient time and staff to address STDs, to counsel patients or manage sex partners, to keep current with managing high-risk patients, and to monitor patient adherence to recommendations to abstain from sex or use condoms during treatment. Nurse practitioners and specialists in obstetrics and gynecology were more likely to cite these barriers. Providers in staff models were more likely to cite the most common patient-level barriers. Few cited barriers related to diagnostic and treatment services.

CONCLUSIONS

Interventions in health plans are necessary to address constraints related to time and staff performing STD related care, keeping current with managing high-risk patients, and supporting patient adherence to provider recommendations.

How to write health dialog for a talking computer

Automated dialogue systems delivered over the telephone offer a promising approach to delivering health-related interventions to populations of individuals at low-cost. Over the past two decades, an automated telephone system called Telephone-Linked Care or TLC has been successfully designed and evaluated by the authors and their colleagues. This work has resulted in over twenty systems for various health-related conditions and lifestyle behaviors. This paper describes our approach to developing and writing dialogue for these automated telephone systems, including determining the program objectives, defining the target population, and selecting a theory of behavior change to guide the intervention. Both macro and micro issues are considered in constructing dialogue systems that are engaging for the target population, easy to use, and effective at promoting positive health behaviors and outcomes.

Preventing Alcohol Abuse among Early Adolescents through Family and Computer-Based Interventions: Four-Year Outcomes and Mediating Variables

III-timed and excessive use of alcohol is associated with multiple and irreversible disabilities. The relationship between perinatal alcohol use and developmental disabilities, including fetal alcohol syndrome, is well documented. Empirical evidence also links alcohol use to a host of other developmental and physical problems among the offspring of drinkers and among drinkers themselves. Toward advancing the science of how to reduce alcohol abuse risks, this study developed and tested family and computer-based approaches for preventing alcohol use among a community sample of inner-city minority youth. Original findings from 4-year follow-up data obtained from over 90% of the study sample document continued positive program outcomes and shed light on cognitive problem solving, peer, and family mediators of alcohol use risk and protective factors among target youth.

Computerized HIV preventive intervention for adolescents: indications of efficacy

We tested the hypothesis that a computerized intervention would be as efficacious as an in-person, small-group intervention in reducing sexual risk behaviors. The sexual behavior of high-risk adolescents in 3 intervention conditions was examined: (1) computer based, (2) small groups, and (3) control. Adolescents in the computerized intervention were significantly less likely to engage in sexual activity and reported significantly fewer partners. For some youths, computers are a viable way to deliver prevention information and promote skill development.

Gender-specific computer-based intervention for preventing drug abuse among girls

This study developed and tested a gender-specific intervention for preventing substance abuse among adolescent girls. Delivered on CD-ROM by computer, the program was compared with a conventional substance abuse prevention program delivered live in a group setting. Seventh-grade girls in New York City middle schools completed pretests, and, by school, were randomly assigned to receive either gender-specific computer intervention (GSI) or conventional intervention, and were posttested. Analyses of pretest to posttest gain scores showed GSI girls compared to girls receiving conventional intervention to possess a larger repertoire of stress-reduction methods, to report lower approval of cigarettes, alcohol, and drugs, to identify more unhealthy ways to deal with stress, to report lower likelihood of cigarette use or alcohol consumption if asked to do so by best friends, and to hold stronger plans to avoid cigarettes, alcohol, and drugs in the next year. These modest findings lend credence to the promise of gender-specific, computerized interventions for substance abuse prevention among adolescent girls.

A review of computer and Internet-based interventions for smoking behavior

This article reviews studies of computer and Internet-based interventions for smoking behavior, published between 1995 and August 2004. Following electronic and manual searches of the literature, 19 studies were identified that used automated systems for smoking prevention or cessation, and measured outcomes related to smoking behavior. Studies varied widely in methodology, intervention delivery, participant characteristics, follow-up period, and measurement of cessation. Of eligible studies, nine (47%) reported statistically significant or improved outcomes at the longest follow-up, relative to a comparison group. Few patterns emerged in terms of subject, design or intervention characteristics that led to positive outcomes. The "first generation" format, where participants were mailed computer-generated feedback reports, was the modal intervention format and the one most consistently associated with improved outcomes. Future studies will need to identify whether certain patients are more likely to benefit from such interventions, and which pharmacological and behavioral adjuncts can best promote cessation.

Reducing the risks of alcohol use among urban youth: three-year effects of a computer-based intervention with and without parent involvement

OBJECTIVE

This study tested a CD-ROM intervention with and without a parent involvement component to reduce risk of alcohol use among an urban sample of early adolescents.

METHOD

Youths (N = 514, mean age 11.5 years at recruitment) were assigned randomly by community site to receive the CD-ROM intervention, the CD-ROM plus parent intervention, or no intervention. All youths completed pretest, posttest and three annual follow-up measurements. After pretesting, youths and parents received their respective interventions.

RESULTS

Main effects of the intervention and for measurement occasion as well as interaction effects of the intervention by measurement occasion were seen for substance use and related outcomes. Over time, youths in all 3 groups reported increased use of alcohol, tobacco and marijuana; youths who received the interventions reported smaller increases than control youths. At 3-year follow-up, alcohol use was lower for CD-ROM plus parent intervention youths than for CD-ROM only youths, who, in turn, reported less use than controls. Cigarette use was lower for youths in either intervention group than in the control group at posttest and at 1-, 2- and 3-year follow-ups. Marijuana use was lower for youths in either intervention than for controls at 1-, 2- and 3-year follow-ups. Youths in both intervention groups outperformed control youths at posttest and at 1- and 3-year follow-ups on levels of negative and peer influence toward substance use. Finally, at the 3-year follow-up, youths in the CD-ROM plus parent intervention group reported more family involvement in their alcohol use prevention efforts than did youths in the CD-ROM group, who, in turn, reported more positive levels of family involvement than youths in the control group.

CONCLUSIONS

Study findings modestly support the CD-ROM intervention with and without the parent intervention to reduce alcohol use risks among urban early adolescents.

Methodological challenges in research on sexual risk behavior: II. Accuracy of self-reports

Assessing sexual behavior with self-report is essential to research on a variety of health topics, including pregnancy and infertility, sexually transmitted infections, and sexual health and functioning. Recent methodological research has provided new insights regarding the accuracy of self-reports of sexual behavior. We review these studies, paying particular attention to a promising new development: the use of computer-assisted assessments. The collection of sexual risk behavior data with computers has increased dramatically in recent years, but little is known about the accuracy of such assessments. We summarize the evidence, discuss methodological issues that arise in studies evaluating the accuracy of self-reports, and offer recommendations for future research.

Collecting behavioural data using the world wide web: considerations for researchers

OBJECTIVE

To identify and describe advantages, challenges, and ethical considerations of web based behavioural data collection.

METHODS

This discussion is based on the authors' experiences in survey development and study design, respondent recruitment, and internet research, and on the experiences of others as found in the literature.

RESULTS

The advantages of using the world wide web to collect behavioural data include rapid access to numerous potential respondents and previously hidden populations, respondent openness and full participation, opportunities for student research, and reduced research costs. Challenges identified include issues related to sampling and sample representativeness, competition for the attention of respondents, and potential limitations resulting from the much cited "digital divide", literacy, and disability. Ethical considerations include anonymity and privacy, providing and substantiating informed consent, and potential risks of malfeasance.

CONCLUSIONS

Computer mediated communications, including electronic mail, the world wide web, and interactive programs will play an ever increasing part in the future of behavioural science research. Justifiable concerns regarding the use of the world wide web in research exist, but as access to, and use of, the internet becomes more widely and representatively distributed globally, the world wide web will become more applicable. In fact, the world wide web may be the only research tool able to reach some previously hidden population subgroups. Furthermore, many of the criticisms of online data collection are common to other survey research methodologies.

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

BACKGROUND

Adolescents are at high risk of sexually transmitted disease (STD)/HIV infection, and one vulnerable subgroup is African American females. The association between adolescents' previous experience of STD and recent sexual risk behaviors has been ill-defined.

GOAL

The goal was to examine the associations between adolescents' self-reported history of STD diagnosis and current sexual risk behaviors, prevention knowledge and attitudes, and STD infection status.

STUDY DESIGN

This was a cross-sectional survey. Recruitment sites were in low-income neighborhoods of Birmingham, Alabama, characterized by high rates of unemployment, substance abuse, violence, and STDs. Participants were sexually active adolescent females (N = 522) 14 to 18 years of age. Information on STD history and current sexual behaviors (within the 30 days before assessment) was collected in face-to-face interviews. Less sensitive topics, such as STD prevention knowledge, attitudes about condom use, and perceived barriers to condom use, were addressed via self-administered survey. DNA amplification of vaginal swab specimens provided by the adolescents was performed to determine current STD status. Outcomes associated with past STD diagnosis were determined by means of logistic regression to calculate adjusted odds ratios (AORs) in the presence of observed covariates.

RESULTS

Twenty-six percent of adolescents reported ever having an STD diagnosed. Although past STD diagnosis was associated with increased STD prevention knowledge, it was not associated with increased motivation to use condoms. Compared with adolescents who had never had an STD, adolescents with a history of diagnosed STD were more likely to report not using a condom at most recent intercourse (AOR = 2.54; 95% CI = 1.64-3.93; = 0.0001), recent unprotected vaginal intercourse (AOR = 1.79; 95% CI = 1.15-2.79; = 0.010), inconsistent condom use (AOR = 2.27; 95% CI = 1.46-3.51; < .0001), sexual intercourse while drinking alcohol (AOR = 2.09; 95% CI = 1.33-3.28; = 0.001), and unprotected intercourse with multiple partners (AOR = 3.29; 95% CI = 1.09-9.89; = 0.034). Past STD diagnosis was associated with increased risk for current biologically confirmed gonorrhea and trichomoniasis (AOR = 2.48; 95% CI = 1.09-5.23; = 0.030; and AOR = 2.05; 95% CI = 1.18-3.59; = 0.011, respectively). Past STD diagnosis was not significantly associated with increased risk of current biologically confirmed chlamydia (AOR = 0.78; 95% CI = 0.45-1.37; = 0.38).

CONCLUSION

Among this sample of female adolescents, past STD diagnosis was an indicator of current high-risk sexual activity and increased risk for two common STDs: gonorrhea and trichomoniasis. Although adolescents may gain factual knowledge from the experience of having an STD diagnosed, they are not applying that knowledge to their current sexual behaviors. Thus, these adolescents remain at risk for subsequent STD infection. Therefore, the findings suggest that there is a need to intensify clinic-based prevention efforts directed toward adolescents with a history of STDs, as a strategy for reducing STD-associated risk behaviors and, consequently, the likelihood of new STD infections.

Risk among men who have sex with men in the United States: a comparison of an Internet sample and a conventional outreach sample

This study compared the demographics and risk behaviors of two samples of men who have sex with men (MSM), using cross-sectional data that were collected via the Internet and through conventional bar-based outreach. The Internet sample was significantly older, more likely to identify as "bisexual," and less educated than the bar sample. After controlling for age and education, few differences were observed between the samples. However, three variables that markedly differentiated the samples were history of sexually transmitted disease infection, HIV serostatus, and sources utilized to obtain health information. No difference in Internet use was found. Based on the possible decreased social desirability promoted by the use of electronic data collection methodologies, these findings provide preliminary evidence that Internet and bar respondents are similar and that the Internet may serve as an expedient as well as reliable methodology to increase understanding of risk among MSM.

A low-cost approach to public health education using multimedia packages

The effect of health education programmes depends on the number of people exposed to the messages, as well as the method and style in which the information is transmitted. We conducted a pilot project to encourage healthier lifestyles by presenting culturally sensitive information using a variety of media. Material intended to provoke discussion was shared with a range of audiences in Barbados and Montserrat in the West Indies by a series of lecture discussions, which were videorecorded for local television and sound recorded for local radio. The lecture was also disseminated by newspaper articles, a special magazine and by publication on the Internet. The aim of the project was to achieve maximum effect for minimum effort, thus making optimum use of resources. The feedback obtained at the lecture discussions and in response to the radio broadcasts and newspaper articles provided a needs assessment on which to base a definitive programme, and confirmed that radio and television are the most effective media for health education.

Efficacy of a touchscreen computer based family cancer history questionnaire and subsequent cancer risk assessment

OBJECTIVE

A computer based touchscreen family cancer history questionnaire was developed and implemented to facilitate the provision of cancer risk assessments for the ambulatory and outpatient populations of a free standing cancer hospital.

METHODS

A questionnaire consisting of a series of branched point decision making screens was developed which enables the participant to enter demographic data, personal cancer history, and cancer histories for first and second degree relatives. A freestanding touchscreen computer kiosk system was used to place the questionnaire in public areas of the cancer hospital and clinic. Genetic professionals analysed the data received, using published criteria, and provided a basic cancer risk assessment and surveillance recommendations within 10 business days. A survey was completed by a small random group of users (n = 59) three to six months after receipt of their risk assessment.

RESULTS

After 11 months, 1440 people had entered information and received a written communication. Only 2% of completed questionnaires contained insufficient information to provide a basic risk assessment. Of the small group of participants surveyed, almost all (95%) felt "very comfortable" using the system, 93% remembered receiving the risk assessment letter when queried three to six months later, 42% felt their perceptions about cancer risk had changed, and 20% had made changes in their or their family's cancer surveillance practices.

CONCLUSION

The touchscreen computer family history questionnaire allows easy collection of family history information, provision of risk assessments to a broad population, and promotes increased awareness of familial risk and appropriate surveillance.

Computer-based approaches to patient education: a review of the literature

All articles indexed in MEDLINE or CINAHL, related to the use of computer technology in patient education, and published in peer-reviewed journals between 1971 and 1998 were selected for review. Sixty-six articles, including 21 research-based reports, were identified. Forty-five percent of the studies were related to the management of chronic disease. Thirteen studies described an improvement in knowledge scores or clinical outcomes when computer-based patient education was compared with traditional instruction. Additional articles examined patients' computer experience, socioeconomic status, race, and gender and found no significant differences when compared with program outcomes. Sixteen of the 21 research-based studies had effect sizes greater than 0.5, indicating a significant change in the described outcome when the study subjects participated in computer-based patient education. The findings from this review support computer-based education as an effective strategy for transfer of knowledge and skill development for patients. The limited number of research studies (N = 21) points to the need for additional research. Recommendations for new studies include cost-benefit analysis and the impact of these new technologies on health outcomes over time.

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.

Using behavioral theory in computer-based health promotion and appraisal

This article explores how behavioral theory can facilitate the development, implementation, and evaluation of health promotion software packages intended to influence personal health practices and/or assess health risks. Current behavioral theories and models are reviewed, and their relevance to developing health promotion software is discussed. A series of six steps is suggested for developing and evaluating health promotion and appraisal software within a behavioral theory framework. These steps should help to facilitate direct application of the theory-based process to health promotion software development.