PCORI funds implementation projects to increase awareness and promote the use of PCORI-funded research findings to improve healthcare practices and health outcomes. This project focuses on implementing findings from the following completed PCORI-funded research project: Using an iPad App in School Health Centers to Support Latina Teens Making Choices about Birth Control -- The Health-E You/Salud iTu Intervention.
1. What were the results from the original PCORI-funded research study?
Health-E You/Salud iTu is an innovative, interactive, individually tailored mobile health application (app). Accessible to patients in English and Spanish, the app was developed, in partnership with adolescents and clinicians, to address disparities in Latinas’ access to comprehensive contraceptive information and services, and to improve the delivery of patient-centered contraceptive care. As a clinician extender, Health-E You provides a risk assessment and personalized patient sexual and reproductive health (SRH) education. Informed by social cognitive theory, the app supports adolescents’ ability to select a contraceptive method that’s right for them with individualized contraceptive recommendations prior to the clinician encounter. We evaluated the effectiveness of Health-E You using a cluster-randomized control trial with 18 school-based health centers (SBHCs) and 1,360 Latina adolescents from Los Angeles County, which is home to the second-largest school district in the nation. Health-E You significantly increased adolescents’ sexual health knowledge and helped prepare them to select a contraceptive method.
Compared with controls, Latinas who used the app had greater increases in self-efficacy in talking with doctors about birth control and had more information to help them choose birth control and use it correctly between baseline and both three- and six-month follow-ups. The program also increased adolescents’ use of effective contraception by 119 percent. Clinicians and adolescents reported high satisfaction with the app and higher quality and efficiency of the visit. Thus, Health-E You promotes the delivery of patient-centered contraceptive decision-making support, improves uptake and adherence of effective contraception over time, and is a powerful tool to address SRH disparities. We are now poised to conduct an implementation study of the app over time in an expansive network of SBHCs. Due to COVID-19, many schools, and consequently SBHCs, have increased their reliance on telehealth. Because the app is designed on a web-based platform that can be accessed from any laptop, smartphone, tablet, or desktop PC with internet connection, it can be readily integrated into telehealth. The primary adaptation is the communication of information from the app to the clinician. Instead of sharing information from the app via a printer, as was done in our original study, we have created a dashboard for report access so this can be readily integrated with telehealth.
2. Why is this research finding important?
Despite declines in adolescent pregnancy in the United States, rates continue to be higher than in all other industrialized countries. There are also significant disparities by race/ethnicity and geography. Most (>80 percent) of sexually active adolescents want to avoid a pregnancy, but we, and others, have found that only 30 percent were using an effective method of contraception. Clinical guidelines recommend all adolescents have access to accurate, comprehensive, and confidential sexual health information and services. However, many clinicians lack time, comfort, and/or skill, and adolescents’ knowledge of contraception is poor. Stigma/discomfort with sexual health are additional barriers to care. The number and types of contraceptive options can be overwhelming, and selecting a method is confusing for adolescents. When contraception is offered to adolescent female patients, the decision is often driven by providers. Patient-centered preference and choice is critical to enhancing method satisfaction, and ultimately use over time so that adolescents are better equipped to achieve their pregnancy prevention goals. While several contraceptive decision support tools exist, Health-E You is the only one to date that improved knowledge, attitudes, and actual use of contraception. Clinicians and adolescent patients also reported high satisfaction with the app.
3. What is the goal of this project?
The primary objective of this study is to facilitate and evaluate the implementation of the Health-E You/ Salud iTu app in a vast network of SBHCs serving adolescents from diverse backgrounds in multiple states across the nation. We will assess patient outcomes, including improvements in adolescents’ knowledge, attitudes, and use of contraception; clinician–adolescent communication; and perceived visit quality among a sample of 1,080 sexually active adolescent females. We will also evaluate the app’s sustainability post–study implementation.
4. What is the project team doing?
The study team has engaged the leadership of state and national alliances of SBHCs, as well as the leadership of individual SBHC sites, in the development of this proposal. Once funded, we will host an interactive online orientation to the project. We will conduct interactive trainings for each of the SBHCs (one month prior to their scheduled implementation date). Trainings will provide information on using the app, implementation manuals, clinic flow, quality improvement (QI) protocols on how to use site-specific data generated from the app to inform QI efforts, and data collection protocols.
Upon implementation, Adolescent Care Teams will meet quarterly with members of the research team. We will roll out app implementation over time to 27 SBHCs across 10 states and the District of Columbia. Annually, these sites together serve over 16,000 adolescent females from diverse backgrounds. Given the range and diversity of SBHCs included in this study, the expanded adolescent population, and the engagement of stakeholders representing both SBHC systems and other healthcare delivery models, findings will inform subsequent dissemination efforts to the national network of over 2,000 SBHCs, and, potentially, to other healthcare settings. These efforts will promote equity in access and delivery of patient-centered contraceptive care for adolescents at risk of unintended/unplanned pregnancy. Ultimately, this technology aims to reduce disparities in unintended pregnancies and associated adverse outcomes for adolescent mothers and their offspring.
5. How is the team evaluating this project?
Our team is conducting a rigorous, multimethod evaluation design. Using Proctor’s Implementation Framework, we will assess the following implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, reach/penetration, and sustainability/maintenance of the intervention. We will roll out the intervention using a stepped-wedge design and recruit intervention and control participants during its rollout. We will conduct baseline and three-month follow-up surveys of adolescents and semistructured one-on-one telephone or Zoom interviews with clinic staff prior to implementation, midimplementation, and postimplementation. These surveys will provide in-depth information about the implementation from various perspectives of clinic staff. We will also include objective measures utilizing log data from the app and clinic records to assess utilization, reach, and provision of contraceptive services.
6. How is the team involving patients and others in ensuring the findings reach people who can use them?
This proposal builds on the successful dissemination and implementation efforts of Health-E You in the original study. We continue to engage a strong partnership of SBHC staff and providers, as well as adolescent SRH experts, in the development of this proposal. We have formed an Implementation Advisory Committee comprising representatives from our original partners from the L.A. Trust for Children’s Health, Youth Advisory Board, members from the Los Angeles County school district, and affiliated SBHCs, along with new formalized partners from the School Based Health Alliance, clinic system representatives (from SBHCs, FQHCs, and University Health), and the California State Maternal, Child and Adolescent Health Coordinator. All these partners have provided letters of support and commitment to engage in this study.
7. How will this project help ensure future uptake and use of findings from patient-centered outcomes research?
The app is designed to be easily integrated into clinical practice and has the potential for sustainability as part of routine care. Further, because it is being implemented both in person and in telehealth, information gathered from this study will inform the integration into the 2,584 SBHCs across 48 states, the District of Columbia, and Puerto Rico, providing access to 6.3 million students. Many SBHCs are managed by Federally Qualified Health Centers, Community Health Systems, and Universities, which positions us to expand beyond SBHCs into other clinical settings.
Implementation Project Details
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.
Initial PCORI-funded Research Study
This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Using an iPad App in School Health Centers to Support Latina Teens Making Choices about Birth Control -- The Health-E You/Salud iTu Intervention