Results Summary
What was the research about?
Risky behaviors, including eating poorly, not getting enough sleep or exercise, using drugs, and not wearing a helmet or seatbelt often emerge during the teen years. By talking with teens during clinic visits, doctors may help to reduce these behaviors.
In this study, the research team created a program about risky behaviors that had two parts:
- Doctors took a training on talking with teens about risky behaviors.
- Teens took an online survey that asked about risky behaviors. The survey gave them feedback to encourage healthy choices. It also gave doctors personalized recommendations for their patients.
The research team compared teens who were and weren’t in the program.
What were the results?
Teens who were and weren’t in the program didn’t differ in
- How satisfied they were with their clinic visits
- How satisfied their parents were with clinic visits
- How empathetic they said their doctors were
After three months, compared with teens who weren’t in the program, teens who were in the program reported fewer risky behaviors. But after 6 and 12 months, the two groups no longer differed.
Compared with teens who weren’t in the program, teens in the program said they received counseling about risky behaviors more often during their initial clinic visits. The two groups didn’t differ in
- How often they received follow-up care for risky behaviors
- How ready they said they were to change their behavior
Who was in the study?
The study included 302 teens who received care at six clinics in Seattle and their parents. Of the teens, 70 percent were white, 9 percent were Asian, and 15 percent were other races; 6 percent were Hispanic. The average age was 15, and 52 percent were girls.
What did the research team do?
The research team assigned a program start date by chance to the six clinics. In the first 10 weeks of the study, doctors had clinic visits as they normally would. Teens filled out a survey about risky behaviors before their visit for data collection only. After 10 weeks, doctors completed training on talking about risky behaviors. In the next 10 weeks, clinics started giving teens the program’s online survey before clinic visits. Doctors received a summary of each teen’s risky behaviors and suggestions for next steps for their care before the visits.
One day after their clinic visits, teens and parents filled out a survey about the visit. Teens filled out follow-up surveys about their risky behaviors 3, 6, and 12 months later.
Teens, parents, and doctors gave input to the research team throughout the study.
What were the limits of the study?
The study took place in one city, and 70 percent of teens were ages 13–15. Result may differ in other settings or with older teens.
Future studies could test the program with older teens or add other programs to address specific risky behaviors.
How can people use the results?
Health clinics can use the results when considering ways to reduce risky behaviors among teens.
Professional Abstract
Objective
To compare the effectiveness of a program, consisting of an online interactive training for clinicians and an electronic screener for teens, with usual care in increasing teen engagement during clinic visits and reducing risky behaviors
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 302 teens receiving care within a practice-based research network and their caregivers |
| Interventions/ Comparators |
|
| Outcomes |
Primary: teen and caregiver satisfaction with clinic visit, teen perceptions of clinician patient-centeredness, teens’ risky behaviors Secondary: risky behavior counseling rate, risky behavior follow-up care |
| Timeframe | 1-year follow-up for primary outcomes |
This stepped-wedge cluster randomized controlled trial assessed the effectiveness of a program to increase teen engagement during clinic visits and reduce risky behaviors. The program included interactive training for clinicians and an electronic screener for teens to identify poor nutrition, low physical activity, inadequate sleep, and other risky behaviors.
Researchers randomly assigned a study start date to six clinics within a practice-based research network. In the first 10 weeks of the study, clinicians conducted teen clinic visits as they normally would. Teens completed an assessment about risky behaviors prior to their visits. After the 10-week period, clinicians received online interactive training about motivational interviewing and engagement skills centered on reducing teens’ risky behaviors. In the 10 weeks after training, the clinics implemented an online electronic screener, which teens completed prior to their visits. The screener assessed teens’ risky behaviors and then provided personalized feedback to motivate them to reduce these behaviors and encouraged discussion with clinicians. Clinicians received a summary of screening results and recommendations for next steps.
The study included 302 teens from Seattle and their caregivers. Of the teens, 70% were white, 9% were Asian, and 15% were other races; 6% were Hispanic. The average age was 15, and 52% were female.
Teens and caregivers completed a survey about their clinic visits one day later. Teens completed surveys about their risky behaviors 3, 6, and 12 months later.
Teens, parents, and pediatricians provided input to the research team throughout the study.
Results
Teen and caregiver satisfaction with visits and teen ratings of clinician patient-centeredness did not differ significantly between teens in the program and those who received usual care.
After three months, compared with teens who received usual care, teens in the program had greater reductions in risky behavior scores (p<0.05). At 6- and 12-month follow-ups, risk behavior scores for the two groups no longer differed significantly.
Compared with teens who received usual care, teens in the program reported receiving risk behavior counseling more often during their initial visit (p<0.05). The two groups did not differ significantly in other secondary outcomes.
Limitations
The study took place in one city, and 70% of teens were ages 13–15. Results may differ in other locations or for older teens.
Conclusions and Relevance
The interactive training for clinicians and the electronic screener for teens increased health risk behavior counseling during initial clinic visits and produced a short-term reduction in risky behaviors among teens but did not result in long-term reductions in risky behaviors.
Future Research Needs
Future research could test the program with different teen populations or add interventions to address specific risky behaviors.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked for more details on how patients influenced the study. The researchers explained that the patient advisory board did not influence the study design but offered other feedback and input over the course of the four -year project, for example in helping to develop the clinician training and in interpreting findings. The researchers also engaged the patient advisory board to help develop the project’s public-facing website and to help plan the social media strategy that will be used when the study’s results are published.
- The reviewers said the quantitative study design was unclear and that the study may not have been a stepped-wedge design as described. The researchers added details about the study design to their report and asserted that the quantitative study was indeed a stepped-wedge cluster randomized trial (SW-CRT) because it fit three criteria: randomization at the level of clusters; all clusters transitioned from control phase to intervention phase; and the point of randomization was the order in which clinics transitioned to the intervention condition, rather than whether or not clinics received the intervention. The researchers noted that the open cohort design by which patients entered treatment in the clinics still fell under the SW-CRT model.
- The reviewers questioned the value of the researchers’ use of a summary risk variable that grouped together different types of health behaviors for analysis. The researchers responded that most studies have examined highly limited outcomes, but primary care clinicians address a wide range of behaviors in a short amount of time. There has been no evidence if this kind of wide-ranging advice makes any difference in the health of youth. The researchers said that everyone involved in the study was very interested in understanding how to improve the value of primary care visits. They also noted that the first step in doing so is to measure the impact of screening and feedback in a structured way, which is what this study did.
- The reviewers pointed out that with five clusters to compare and little room for improvement among the adolescent participants, the researchers should consider the study to not have met its objectives or at least state that there were no meaningful differences between intervention and comparison groups. The researchers disagreed, noting that although the number of significant outcomes was small, these outcomes were important clinically. The researchers did revise the report to acknowledge some of the limitations to the interpretation of results, including the larger number of outcomes that did not show significant differences, and the questionable validity for the summary health risk measure.