# Presentation: 081451

## Teen’s Perceptions of Own Health Risks Mismatch Their Actual Behaviors

** **
**Cecelia Gaffney, MEd**
**Ardis L. Olson, MD****  **
**Pamela W. Lee, PhD**
**Clinicians Enhancing Child Health (CECH) ****Network**
**Departments of Community & Family Medicine and Pediatrics, **
**Dartmouth Medical School**

- Funded by The Robert Wood Johnson Foundation, Prescription for Health Program

## Hammer Metaphor

** **When we have only been trained to use hammers (give health information
- & advice), we tend to see every risk behavior as a nail.

**Notes:**
And that is what we were all taught in medical school – advice, medical information.  If you tell them, they patient will make an intelligent and informed choice. 

## Healthy Teens System Project

**Develop new approaches to health counseling in the preventive health visit for adolescents**
**Comprehensive health history/screening **
**Readiness to change cues for counseling four health behaviors : Nutrition, Exercise/TV, Alcohol/Drugs and Tobacco**
**Utilize technology to optimize time for clinician to discuss behavioral issues**
**Motivational interviewing tools for patient centered counseling**

**Notes:**
Northern New England PBRN
Pediatric & Family Medicine practitioners
Focus on child and family health issues
Adolescent health, parental depression, obesity prevention

Wide range of psychosocial and health risk behaviors exist in adolescence

Adult disorders related to nutrition, sedentary life styles, mental health, 
tobacco, alcohol and substance use have roots in adolescence

Too many issues to cover with interview

Paper questionnaires are difficult to implement

## Study Design

**Self-administered paper survey at end of visit**

- _Clinician Training_: **Use of PDA screener and MI counseling**
**     *****Clinician Baseline Survey***
- _Staff training and systems design_: **Assign tasks to complete screening and recruitment**

- Consented cohort
- Mailed surveys at 3& 6 months

**PDA screening and behavior change counseling for all patients aged 12-19 years presenting for well care  *****[Anonymous screening data]***

***Clinician ***
***follow-up survey***

**Patient Exit Survey:**
**Self-administered paper survey at end of visit**

- Consented cohort
- Mailed surveys at 3& 6 months

**Study Design**

## Implementation Design

**Pre-visit Assessment**

**Assess: use PDA screener**
**  ****-- health concerns**
**   ****-- behavioral risks**
**      ****--readiness**

**PDA Summary Report**
**       ****(for Provider)**

**Visit with Clinician**

**ADVISE – identify important risks**
**AGREE – patient centered negotiation**
** ****of health goal **
**ASSIST – counsel changing behavioral **
**risk**

**Resource Handout**

**ARRANGE**
** ****--referral as appropriate**
**--follow-up visit as appropriate **
** ****-- reinforce at future visits**

**Teen presents **
**for well visit**

**Intent to change**
**risk behavior**

**Patient’s **
**Chart**

- Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions:
- an evidence-based approach.  Am J Prev Med 2002 May;22(4):320-3

**Implementation Design**

## Pre-Intervention Exit Surveys

**Patients presenting for well-care aged 12-19 years old**
**Self-administered surveys**
**Baseline exit survey  N= 158**
**3 month follow-up survey  N= 110  [70%]**
**Assessed **
**Self-reported risk behaviors for nutrition, sedentary behavior, and substance use [combo measures] **
**Self-reported change for risk behaviors since visit**

## Cohort Demographics

**Gender**
**	****50.3%  Male****	****	**
**	****49.7%  Female****	**
**Age**
**    ****48% ≤  14 years**
**	**** ****29% 15- 16 years**
**	**** ****18%  17-18 years**
**	****  ****5%  ≥ 19 years**

## Nutritional Risk Behaviors

**< 5 Fruit/vegetables daily         ****	****70%  **
**< 3 milk products****	****  ****	****	****66%**
**> 1 soda****	****	****	****	****	****15%**
**> 1 sweeten beverage****	****	****	****30%**

## Sedentary Behaviors

**> 2hr TV                  ****	****	****32%**
**Computer >1 hr        ****	****	****48%**
**Exercise 30 minutes < 3x****	****26%**
**Exercise 60 minutes < 3x ****	****31%**

## Cigarette Smoking

**Ever Tried ****	****18.2%**
**Current Smokers  5%**
**PDA****	****	****	****     ****11-14 yr     15-19yr**
**Ever smoke                   9%         30%**
**Current smoker****	****	****21%****	****      45%**

## Alcohol Use

**Ever drink ****	****	****	****24%**
**Drink past month ****	****15%**
**Binge in past month****	**** 4%  **
**PDA****	****	****	****     ****11-14 yr     15-19yr**
**Ever Drink****	****	****	****10%****	****      34%**
**Drink past month****	****	****29%****	****      50%**

## Exploring the Health Behavior Change Process

**Teens presented with a continuum of responses corresponding to readiness to change each health behavior they discussed with their provider**
**(1) Doing well, no need to change**
**(2) Not interested in changing**
**(3) Thinking about changing**
**(4) Willing to try changing**
**(5) Already trying to change**

## Perception vs. Reality

| Doing well, no need to change.... |  | However they were wrong...
  |
| --- | --- | --- |
|  | 
Exercise - 66.4%
 | 25% were physically active for at least 60 minutes on 3 or less days in a typical week |
|  | TV/videogames – 58.4% | 
34.1% of these teens reported they watched 2 or more hours of TV and 36.4% said they play 1 or more hours of videogames daily |
|  |  |  |

## Perception vs. Reality

| Doing well, no need to change.... |  | However they were wrong...
  |
| --- | --- | --- |
|  | 
Fruits & veggies - 59.6%
 | 
61.5% of these teens reported eating less than 5 servings of fruits/vegetables daily |
|  | 
Drinking milk – 68.5%
 | 55.4% of these teens reported drinking less than 3 glasses of milk per day |
|  | Sweet beverages – 50.9% | 
37.7% of these teens were drinking 3 or more sweetened beverages and 9% were drinking 3 or more sodas per day |
|  |  |  |

## Nut and Bolt Metaphor

**   **
- Hammers do not work very well with a nut (risk behavior) rusted to a bolt (patient).
- Hammering away at patients may make things worst, and even damage the threads of the bolt so the nut never comes off.

**Notes:**
I However, we need to be careful about what we say and how we say it, or our patients/ parents may get defensive or counterargue.  Giving nonthoughtful advice is a bad idea.

## Support for Healthy Change

**Half of teens who were trying to make a healthy change indicated that their parents were “a lot” or “a great deal” of help**
**Types of help: encourage/motivate; participate in the change; provide a healthy environment; give reminders**
**Only 14% indicated that friends were a similar source of support**
**More often, friends were seen as “no help” or “not much help” (50.6%)**
**√ ****Types of help: encourage; participate in the change**** **

## Barriers to Healthy Change

**When teens identified barriers to healthy change, four major themes emerged:**
**Temptation**
**Having junk food in the house**
**Holidays**
**“****Bad foods” easily accessible at fast food restaurants or school cafeteria**
**Busy schedules**
**Appeal of junk food**
**Old habits are hard to break**

## Gardener Metaphor

- We are most effective in
- helping patients change
- when we work as gardeners...
- cultivating the soil, planting seeds, and fertilizing the ground.

**Notes:**
So I give you another metaphor (the last one, I promise) – that perhaps we would be most successful with behavior changes if we act as gardeners.