Teens Increasing Preventive Services (T.I.P.S.)

Adolescent morbidity and mortality most often are associated with risky health behaviors such as substance use and abuse, unsafe sexual practices, and risky vehicle use. Accidents and unintentional injuries account for the greatest number of adolescent deaths, which often involve the use of alcohol. Sexually transmitted diseases are the most common infectious diseases among adolescents; among older adolescents, pregnancy and childbirth are the leading causes of hospitalization. Current trends in adolescent morbidity and mortality have turned greater attention to the preventive role of the health care system. Most adolescents visit a health care provider once a year, which provides an ideal opportunity to integrate prevention into clinical encounters. Although primary care providers often screen adolescents for some risky health behaviors, there is inconsistency in screening across various risk areas. Barriers to implementing screening and counseling guidelines include physician knowledge, physician attitudes, and external factors. Physician factors, such as knowledge and attitudes, may be linked to training. External barriers include lack of tools or reminder systems, which can affect a provider's ability to follow recommendations. Research indicates interventions that provide the major components of (1) training and (2) screening and charting tools may be particularly effective in increasing delivery of services to adolescents. 

Teens Increasing Preventive Services (T.I.P.S.) is a systems preventive services intervention for primary care providers to facilitate screening and counseling for risky health behaviors of adolescents at their annual health care provider visit. The intervention focuses on the targeted risk areas of tobacco, alcohol, drugs, sexual behavior, and safety (helmet and seatbelt use). T.I.P.S. is composed of clinician trainings in adolescent preventive services and the later implementation of customized screening and charting forms.

Based on social cognitive theory, the 8-hour training workshop for providers focuses on increasing clinicians' knowledge, attitudes, self-efficacy, and skills to conduct preventive services. The provider training workshop is conducted by an expert panel of adolescent medicine specialists and actors portraying adolescent patients in the demonstration and interactive practice role plays. The workshop focuses on adolescent health, confidentiality, screening, and conducting a brief office-based intervention that includes anticipatory guidance/brief counseling for the six risk behaviors. The workshop contains four components: (1) didactic presentations, (2) discussion, (3) demonstration role plays, and (4) interactive role plays.

In addition to the provider workshop, the T.I.P.S. intervention includes the implementation of an adolescent health screening questionnaire and a provider charting form. The adolescent health screening form includes questions about risk engagement in a broad variety of areas, including sexual behavior, tobacco use, alcohol and drug use, and helmet use. Prompts and cues in the target areas are also included to remind providers to screen and deliver brief counseling messages. Providers are cued to give adolescents positive reinforcement if they report they are engaging in healthy behavior. Examples of healthy behavior include not using tobacco or always using a bicycle helmet when riding. Providers are also cued to express concern to adolescents if they report engaging in risky behavior, such as using tobacco or alcohol. The primary care provider completes a charting form to document services provided to the adolescent. This form becomes a part of the adolescent's medical record. 

The Implementation Guide is a resource for implementing this program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the research-tested program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded in the Products page.

This program is an example of provider reminders with provider education (Tobacco), which is recommended by the Community Preventive Services Task Force, as found in the Guide to Community Preventive Services.

Time required to implement T.I.P.S. includes 8 hours for the provider workshop.  Screening and counseling are conducted within the time frame of the patient's well visit which lasted 20-30 minutes. 

The intended audiences for this intervention are primary care providers and the adolescents they serve.

The program can be implemented in outpatient pediatric clinics.

Required resources to implement the program include the following:

-TIPS: Teens, Increasing Preventive Services, provider training workshop manual
-Screening and Counseling Training Steps
-Workshop Demonstration Role-Plays
-Provider office screening form
-Provider office charting form
-Expert panel of adolescent medicine specialists
-Actors

The study was conducted in four outpatient pediatric clinics within a large health maintenance organization throughout Northern California; two clinics served as intervention sites, and two served as comparison sites. The comparison sites continued to deliver the usual standard of care. There were three separate assessments in each of the four clinics: (1) a pre-training baseline period; (2) a post-training period, which began immediately after the training; and (3) a post-tools full implementation period, which began immediately after the implementation of tools into the clinics. Providers' screening and counseling behaviors during adolescent well visits, as reported by adolescents who attended the visits, served as the basis for the evaluation of the intervention. These independent adolescent reports of provider behavior were obtained immediately after well visits in both the intervention and the comparison clinics during the three assessment periods. 

The provider sample consisted of 76 participants, 37 from the two intervention clinics and 39 from the two comparison clinics. In the provider sample, 63.2% were female and the mean age was 42.8. The majority of providers were either White (47.4%) or Asian-Pacific Islanders (35.5%). 

Adolescents completed the Adolescent Report of the Visit (AROV), an independent survey of provider behavior, immediately after well visits during each of the three evaluation periods in both the intervention and comparison clinics. The AROV is a 45-item, 3- to 5-minute patient-report measure that includes questions about whether clinicians screen and offer brief counseling messages for each of the six target risk areas. An example of a screening question is, "Did your doctor ask if you smoke or chew tobacco?" Items that assessed counseling differed by skip patterns, depending on whether an adolescent was engaging in a particular risk behavior and whether she or he had informed the clinician about engagement in the risk behavior. An example of a counseling question for adolescents who were not engaging is, "Did your doctor encourage you to remain a nonsmoker or nontobacco user?" An example of a counseling question for adolescents who were engaging in a risky behavior is, "Did your doctor express concern that you use tobacco?" The response categories were dichotomous: yes or no. Each adolescent questionnaire identified the provider who conducted the visit. A provider's score for each screening and counseling area was obtained by taking the average of the individual items for that area, summed across all of the adolescent questionnaires available for that provider. The resulting score for each item (e.g., screening for tobacco use) represented the percentage of time a provider performed screening or counseling in that area. Thus, each provider had a mean score representing his or her screening rate across adolescent reports for each behavior area and each time period. 

A total of 2,628 adolescents reported on their providers' behaviors. Adolescent reporters ranged in age from 13 to 17 with a mean age of 14.8. The sample was 55.1% female; 34.9% White, 24.0% Hispanic, 19.0% Black, 13.6% Asian-Pacific Islander, 4.6% Native American/Alaskan Native, and 4.0% other.

• Tobacco screening rates after implementation of the training workshop only (p<.01) and the full intervention (training plus tools; p<.001) were significantly higher in the intervention group than in the control group, controlling for baseline levels of screening and other covariates. Screening rates did not increase significantly in the intervention group, in relation to the comparison group, after the addition of the tools component. 

• Counseling rates after implementation of the training workshop only (p<.01) and the full intervention (training plus tools; p<.001) were significantly higher for tobacco use in the intervention group than in the control group, controlling for baseline levels of screening and other covariates. Counseling rates did not increase significantly in the intervention group, in relation to the comparison group, after the addition of the tools component.
  

Additional Findings

• The same pattern of results was found for the other five risky health behaviors: alcohol, drugs, sexual behavior, seatbelt use, and helmet use.

 

Ozer EM, Adams SH, Lustig JL, Gee S, Garber AK, Gardner LR, Rehbein M, Addison L, Irwin CE Jr. (2005). Increasing the screening and counseling of adolescents for risky health behaviors: a primary care intervention. Pediatrics, 115 (4), 960-968.

Lustig, J. L., Ozer, E. M., Adams, S. H., Wibbelsman, C. J., Fuster, C. D., Bonar, R. W., & Irwin, C. E. (2001). Improving the delivery of adolescent clinical preventive services through skills-based training. Pediatrics, 107 (5), 1100-1107.

Ozer, E. M., Adams, S. H., Lustig, J. L., Millstein, S. G., Camfield, K., El-Diwany, S., Volpe, S., & Irwin, C. E., Jr. (2001). Can it be done? Implementing adolescent clinical preventive services. Health Services Research, 36 (6 (Part 2)), 150-165.