GAPS (AMA Guidelines for Adolescent Preventive Services). Where are the gaps?

The AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale is a major breakthrough in the evolution of preventive health services in general and of adolescent preventive services in particular. GAPS is a comprehensive guide for adolescent health professionals that contains several pioneering elements. These elements include (1) providing a framework for the organization and content of "well-adolescent care," (2) offering guidance for parents and families as an essential part of adolescent health care, and (3) dealing with a wide range of adolescent health problems, with an appropriate focus on the behavioral, emotional, and developmental aspects.

Treating hypertension with a device that slows and regularises breathing: a randomised, double-blind controlled study.

OBJECTIVE: To examine the efficacy of a new device, which slows and regularises breathing, as a non-pharmacological treatment of hypertension and thus to evaluate the contribution of breathing modulation in the blood pressure (BP) reduction. DESIGN AND SETTING: Randomised, double-blind controlled study, carried out in three urban family practice clinics in Israel. PATIENTS: Sixty-five male and female hypertensives, either receiving antihypertensive drug therapy or unmedicated. Four patients dropped out at the beginning of the study. INTERVENTION: Self treatment at home, 10 minutes daily for 8 consecutive weeks, using either the device (n = 32), which guides the user towards slow and regular breathing using musical sound patterns, or a Walkman, with which patients listened to quiet music (n = 29). Medication was unchanged 2 months prior to and during the study period. MAIN OUTCOME MEASURES: Systolic BP, diastolic BP and mean arterial pressure (MAP) changes from baseline. RESULTS: BP reduction in the device group was significantly greater than a predetermined 'clinically meaningful threshold' of 10.0, 5.0 and 6.7 mm Hg for the systolic BP, diastolic BP and MAP respectively (P = 0.035, P = 0.0002 and P = 0.001). Treatment with the device reduced systolic BP, diastolic BP and MAP by 15.2, 10.0 and 11.7 mm Hg respectively, as compared to 11.3, 5.6 and 7.5 mm Hg (P = 0.14, P = 0.008, P = 0.03) with the Walkman. Six months after treatment had stopped, diastolic BP reduction in the device group remained greater than the 'threshold' (P < 0.02) and also greater than in the walkman group (P = 0.001). CONCLUSIONS: The device was found to be efficacious in reducing high BP during 2 months of self-treatment by patients at home. Breathing pattern modification appears to be an important component in this reduction.

Effect of otitis media on development: a community-based study.

Otitis media history until age 3 years were recorded for 233 children as part of the surveillance in a Community Program for Promotion of Growth and Development (PROD) conducted in a western neighborhood of Jerusalem. Recurrent otitis media (6 or more episodes) occurred more frequently among children who were of North African or Asian origin, of lower social class and maternal education, and whose duration of breast feeding was less than 26 weeks. Children with recurrent otitis media also failed the 7-month hearing test more frequently than other children. The mean Developmental Quotient score at 2 years and the mean Stanford Binet score at 3 years were statistically significantly lower among children with recurrent otitis media, even after controlling for maternal origin and length of breast feeding. These findings underscore the importance of early identification and early intervention for otitis media.

Concerns and risk behaviors and the association between them among high-school students in Jerusalem.

PURPOSE: To study the distribution, prevalence, determinants, and association between the health, social, and environmental concerns and risk behaviors of high school students in Jerusalem in order to provide a better basis for preventive and health promotion services. METHODS: 1078 tenth grade high school students, 15-16 years old answered an anonymous questionnaire including, perceived concerns and risk behaviors, (e.g., smoking, alcohol, drugs, and sexual activity). Concerns were grouped into six domains. RESULTS: The most frequently reported concerns related to school, weight, coping with aggression, fatigue, war, enlistment into army, and relationships with peers. Girls had more concerns in the domains of self-image, anxiety, and relationships with peers (p < .05). Adolescents with mothers who had less education had significantly more concerns in the domains of anxiety and relationships with peers and adults (p < .05). Forty-seven percent engaged in at least one risk behavior (boys 63% and girls 34%). The Guttman scalogram indicated the following sequence of risk behaviors: alcohol, cigarettes, sex, and drugs. There were statistically significant associations between concerns and risk behaviors in the domains of anxiety, sex, and relationships with adults and peers. CONCLUSION: Many adolescent concerns are universal, although the ranking and prevalence may vary based on different regional and population characteristics (e.g., in this population a high rate of concerns relating to aggression and war were identified). The results support the need to develop prevention and health promotion programs relating to the concerns and risk behaviors in the school and community, and individual counseling programs in primary care settings.

Evaluation of a community-oriented primary care workshop for family practice residents in Jerusalem.

BACKGROUND: A workshop on community-oriented primary care (COPC) has been integrated into Hebrew University's family practice residency program for several years. The participants of the first three workshops did an evaluation to assess subsequent application of the COPC approach. METHODS: The main objectives of the 45-hour workshop are: a) to learn the principles and practice of COPC as illustrated by the Hadassah Community Health Center programs, and b) to learn skills required in the COPC programs' various stages of development. In the workshop, physicians are required to work in groups of 5-6 to carry out the planning of COPC programs, which will be implemented in their practices. A structured questionnaire was sent 2-4 years after workshop completion to each of the 45 physicians who participated in these workshops. RESULTS: Thirty-six of the 45 physicians responded to the questionnaire. Of the 36 respondents, 75% reported that the content of the workshop was relevant to their daily work. Eighty percent of the physicians who were involved in intervention programs reported that participation in the workshop improved their ability to plan community programs. Fifty-five percent of the respondents reported the application of elements learned in the workshop to their current work, mainly in the performance of three COPC functions: definition of the community, identification of health problems, and planning community health interventions. Few (28%) were involved in evaluation measurements. CONCLUSIONS: A COPC workshop characterized by work groups of family physicians, epidemiological analysis of their practices' data, and the planning of a community program in their communities was positively evaluated according to the reported application of COPC functions by family physicians and residents in their daily work.

A school-linked health service for adolescents in Jerusalem.

This paper describes the Adolescent Health Service (AHS) and its multidisciplinary, school-linked, community-based adolescent health clinic located in a western neighborhood of Jerusalem. Files of the first 134 adolescents who completed or discontinued treatment in the clinic during the first two years of operation were reviewed for demographic data, referral source, number of visits, health concerns and clinical impressions. The clinic population included Jewish Jerusalem residents, ages 12-18, 75% of whom were female. Most referrals came from schools. The average number of visits per patient was five (range 1-20). The most frequent presenting concerns as well as the most frequent clinical impressions were in the psychosocial and nutritional domains. Concordance between presenting concern and clinical impression was 61% (k = 0.47). Health problems of Israeli high school students attending the clinic mainly were psychosocial and nutritional. The school-linked health service applied a comprehensive approach to the biopsychosocial needs of adolescents, not addressed at other health services.

PIP: In Jerusalem, Israel, a community-based comprehensive adolescent health center was established in 1989 to promote health among the students of 11 secondary and high schools; to provide multidisciplinary health care within a community-based, school-linked clinic; to serve as a professional training facility; and to establish a research database. The service is accessible during after-school hours, confidential, and free to adolescent residents of Jerusalem. To evaluate the service, data from the first 134 adolescents treated during the first 2 years of service were analyzed to determine demographic parameters, referral sources, presenting symptoms (nutritional, psychosocial, sexuality, somatic, or health maintenance), diagnoses, number of patient visits, management approach, duration of follow-up, and termination of contact. It was found that 75% of the patients were girls, and 75% were 14-17 years old. Referrals came from school professionals (60%), parents (11%), primary care physicians (4%), and the adolescents themselves (25%). The patients averaged 5 visits, with 35% being seen only once and 15% more than 10 times. The most frequent presenting complaints were psychosocial and nutritional problems (sexuality was named by only 4.5% of the patients), and concordance between presenting concern and clinical impression was only 61% (with most discordance among those who presented for health maintenance). Most of the youth who attended were from middle- and upper-class families despite the clinic location in a low-to-middle class neighborhood. It was concluded that the clinic had not yet had a major impact on access to health services for most of the teenagers in the city but that it provided a unique service with a multidisciplinary approach that has served as a model for adolescent "non-acute" health care in Israel. The clinic's high drop-out rate was attributed to ambivalent care-seeking behavior and accessibility of primary health care (which, however, fails to address many of the problems addressed by the adolescent clinic).

Symptom clusters among young adolescents.

This study examines recurrent psychosomatic symptoms and symptom clusters among 5th and 6th grade Israeli school children. A questionnaire which asked about the frequency of eight psychosomatic and eight organic complaints was administered to 259 students. The most frequently reported psychosomatic complaints were abdominal pain, experienced often by 21%, and headache, experienced often by 20% of the pupils. There were statistically significant differences between the sexes, girls having a higher prevalence than boys for eight of the symptoms, and with more girls than boys reporting more than one symptom in each category: 23% of the students had more than one psychosomatic symptom and 16% had more than one organic symptom. Multiple psychosomatic complaints were common, with 28% of those with back or limb pain and 27% of those suffering from "bad mood" reporting an additional three to five complaints. Abdominal pain and headache were each reported as an accompanying complaint in more than 40% of cases for almost every other psychosomatic complaint. The significance of these symptom clusters needs to be explored further as they may have important implications as markers for psychosocial stress.

Multiple family member visits to family physicians. Terminology, classification, and implications.

A study was designed to investigate "the family as the unit of care" in family medicine consultations from the patient's end of the physician-patient axis, unlike most previous related studies, which have concentrated on it from the physician's perspective. During 2 separate weeks in November 1987 and February 1988, nine Israeli family physicians collected demographic and family-related data concerning the spontaneous visiting patterns generated by 1156 persons (899 patients and 257 nonpatients) who attended 796 separate consultations at their clinics during this time. More than one patient attended 12% of the consultations, and more than one person, patient or nonpatient, was present at 36%. At 31% of the consultations children alone or children and adults were recorded as patients (child consultations), and at 69% only adult patients were present (adult consultations). Adults were recorded as second or third patients at 19% of the child consultations but at only 5% of the adult consultations. The child consultations alone yielded 86% of all the nonpatients documented. Basic terminology and methodology for investigating such multiple family member visits to family physicians is discussed as well as the composition of the different family units encountered and their possible significance.

[Community health services for adolescents in Israel--challenges for the next decade].

Adolescent health issues have become an increasingly important challenge for public health in Israel. Meeting this challenge is difficult because of the special needs of this age group, inadequate training of health professionals, reimbursement policies, and the need for multisectorial cooperation. The past decade has seen a proliferation of community-based health services designed to meet the needs of adolescents. These services are of four basic types: 1) primary care clinics; 2) school health services; 3) multi-disciplinary adolescent health centers; and 4) other services, including reproductive health clinics, mental health and eating disorder units, and informal youth counseling centers. This development has taken place without systematic public health planning, including prioritization and the design of an orderly, integrative network of primary and referral services. We present national health planning goals to meet these challenges. These goals include: 1) defining the roles of each health care sector; 2) providing professional training to meet these roles; 3) facilitating the development of a rational system of community-based health services; and 4) offering a more equitable distribution of services. Implementing these goals should aid in better meeting the unique health needs Israel's adolescent population.

Transmission of occupational disease to family contacts.

As recognition of occupational illness increases, the scope of health problems related to work widens. An important area of concern is the worker's family, which has been shown to be at increased risk of disease attributable to the hazards previously thought to be relevant only to the worker. Such "para-occupational" disease occurs particularly in spouses and children through transport by the worker of hazardous materials from the worksite into the home. The most common vehicle has been contaminated work clothing brought home for cleaning. Outbreaks of severe illness caused by lead, beryllium, asbestos, and other compounds have been traced to home contamination by industrial dust. In this review, we describe reports of "para-occupational" illness that demonstrate the importance of early recognition by medical professionals of this cause of illness and of strict control of the dissemination of hazardous materials outside the workplace.

A follow-up study of adiposity and growth of Jerusalem schoolchildren from age 6 to 14 years.

This study evaluated growth and change in adiposity from childhood to early adolescence in 587 Jerusalem schoolchildren examined in both the first and eighth grades. Mean body mass index, height, and weight were determined according to demographic variables and menstrual status and were compared to international reference populations. Menstruating females were taller and heavier than nonmenstruating females at both ages and were more overweight at age 14 years. Height and weight were positively correlated with social class for boys, and few differences were found among ethnic groups. Study subjects were shorter than reference subjects, and study girls were more overweight than reference girls at age 14 years. Our findings suggest that previously demonstrated ethnic differences in growth and adiposity among Israeli children are disappearing. Adolescent girls appear to be at greatest risk for developing obesity. The relationship of pubertal status to body size and obesity at and between the two ages is discussed.

Injury prevention program in primary care: process evaluation and surveillance.

OBJECTIVES: To carry out process evaluation and surveillance in a community oriented primary care program for injury prevention among children 0-2 years old (n = 306). SETTING: Mother and child health clinic in a defined area of Western Jerusalem. METHODS: An injury prevention program was integrated into the routines of the mother and child health clinic. The program consisted of injury surveillance and counselling using a developmental approach, regarding car safety and the prevention of falls, burns, suffocation, poisonings, cuts, drowning, and electrocution. Process evaluation and surveillance were based on records integrated into the child's personal file in the clinic. RESULTS: Process evaluation indicated that counselling coverage was 73% in the 0-5 month age group and decreased to 48% in the second year of life. The mean number of topics discussed with the parents was 6.6 (out of nine) for the 0-5 months age group, 13.6 (out of 18) for the 6-11 month group, and 15.7 (out of 18) for those 1-2 years old. Injury surveillance activities were complete for 66% of the children, incomplete in 32%, and not done in 2%. CONCLUSIONS: The results indicate that it is feasible to integrate an injury prevention program into primary care, and that process evaluation is important in detecting problems and improving performance of the program's activities.

The association between funding by commercial interests and study outcome in randomized controlled drug trials.

BACKGROUND: Previous studies limited to specific drugs or journal types have shown an association between the source of funding of research and the published results. OBJECTIVE: The aim of the present study was to determine the association between source of support of research and published outcomes of randomized controlled drug trials in general interest medical journals. METHODS: Randomized controlled drug trials (n = 314) published in five general interest medical journals over a 2-year period were reviewed. Study outcome was classified as positive or negative. Support was classified as pharmaceutical industry or non-industry. Association between source of support and outcome was tested with the chi-squared statistic. RESULTS: Positive findings were found in 77% of studies, negative findings in 20% and an uncertain outcome in 3%. Support from commercial sources was found in 68% of trials. Negative findings were found in 13% of industry-supported studies and in 35% of non-industry-supported studies (chi-squared = 18.36, P < 0.0001, odds ratio = 3.54, 95% confidence interval 1.90-6.62). CONCLUSIONS: An association was found between the source of study support and the published outcome. Though the reason for this association cannot be determined from the data collected, future studies may clarify the importance of this finding for readers concerned with the relationship of funding bodies to the publication of research outcomes.

Cardiovascular risk factors by ethnic group and menstrual status among 13- and 14-year-old Israeli schoolchildren.

BACKGROUND: Ethnic differences in cardiovascular risk factors have been demonstrated previously among Israeli children and adolescents. This study examines the prevalence of selected risk factors and risk factor clusters among 13- and 14-year old Israeli schoolchildren according to ethnic origin and other demographic variables, and takes into account the unique contribution of menstrual status of the girls to risk factor differences. METHODS: Demographic and menstrual status (for the girls) data were obtained for 299 West Jerusalem eighth grade students. Height, weight, and blood pressure were measured, and blood was obtained for total cholesterol, high density cholesterol (HDL), and triglyceride measurements. Differences in mean Body Mass Index (BMI), blood pressure, and lipids, as well as in the percentage of children with specific risk factors or total number of risk factors were tested for among the various demographic and menstrual status groups. RESULTS: BMI was statistically significantly greater among females (20.2 kg/m2) than among males (19.46 kg/m2), (p = .04) and among menstruating females (21.1 kg/m2) compared with non-menstruating females (17.9 kg/m2), (p = .000). Mean systolic blood pressure was higher among menstruating (109.8 mmHg) than non-menstruating (105.9 mmHg) females (p = .09). Statistically nonsignificant differences in mean systolic blood pressure and total cholesterol were found according to paternal country of origin. According to defined cutoff points, 8.7% of the students had elevated BMI, 2.8% had elevated systolic or diastolic blood pressure, and 13.0% had elevated total cholesterol. 17.5% of the students had one cardiovascular risk factor and 3.1% had two risk factors. CONCLUSIONS: The data demonstrate a high prevalence of cardiovascular risk factors without statistically significant ethnic differences in this population. Menstrual status exerted a unique effect upon BMI and systolic blood pressure. Pubertal status should be considered in the assessment of risk factors in early adolescents. Total-community-oriented intervention is recommended for this population.

Process and outcome evaluation of preventive care for infants in two types of practices.

Process and outcome of preventive and promotive infant care have been evaluated in a maternal and child health (MCH) service and compared with that of a comprehensive care family practice (FP), both serving a low middle class population in West Jerusalem. Both services are provided by the Community Health Center of the Department of Social Medicine. Community oriented primary care is integrated into the practices, including ongoing surveillance of the communities' health status. Preventive and promotive programs have been developed, implemented and evaluated. The process evaluation indicated a similar use of the preventive service in the MCH and FP services. Some of the routines were carried out to a lesser extent in the FP than in the MCH framework, such as growth monitoring, hearing tests and advice on iron supplementation. The small difference in compliance with routines did not affect a child's growth between birth and one year of age, but the anemia rate in the FP practice was higher than in the MCH practice. The high level of care and relatively small differences in process and outcome between the two types of services have been achieved by ongoing inservice training, a high level of personnel, similar protocols and supervision in both practices.

Reported health concerns of Israeli high school students--differences by age and sex.

Health concerns of high school students in the 10th grade and again in the 12th grade were studied. The students filled out an anonymous questionnaire that included a list of 73 concerns. At both ages their main concerns were reportedly related to school. Concerns relating to army service ranked high particularly in the 12th grade, among both sexes. Concerns relating to sexual relations were frequent among boys at both ages, whereas concerns about mood and loneliness were more frequent among girls. Reports on physical concerns were frequently related to height among the younger boys and weight and diet among girls of both ages. Concerns were grouped into 6 domains. In each of them, except for sexuality, girls had more concerns. A significant decline in the number of concerns was noted from the first to the second survey, indicating a partial resolution of the issues central to adolescent development. Knowledge about concerns of adolescents may help health care providers in counseling and health education program planning.

Adolescent preventive health visits: a comparison of two invitation protocols.

BACKGROUND: Adolescent health care in family practice at times creates conflicting responsibilities for parents and their teenagers. In the context of a new adolescent preventive health program in a family practice setting, we compared attendance rates using two invitation protocols, the protocols differing in their emphasis on adolescent autonomy vs parental responsibility. METHODS: One hundred six teenagers in the seventh and tenth grades were invited for preventive health visits with the family nurse and physician using two protocols. Protocol 1 involved obtaining parental consent before approaching the adolescent. With protocol 2, an invitation letter and parental consent form were mailed to the teenager, while a letter of explanation was sent concurrently to the parents. In each case, the letter of invitation was followed up by a telephone call for those who did not respond. The spontaneous response rate (a positive response after receiving the letter), agreement to attend rate (a positive response after receiving the letter or being telephoned), and the attendance rate were determined according to grade, sex, and protocol. RESULTS: The spontaneous response rate was 21%, the agreement to attend rate was 75%, and the attendance rate was 44%. Attendance rates were higher for the girls compared with the boys (54% vs 35%, P = .08) and for the seventh graders compared with the tenth graders (53% vs 31%, P = .03). The spontaneous response rate was lower among the tenth graders using protocol 2 (8% vs 37.5% with protocol 1, P = .04), while the agreement to attend rate and attendance rate did not differ for the two protocols. CONCLUSIONS: Nearly one half of this population of adolescents attended preventive health visits at the family nurse's and physician's initiative. A follow-up telephone call after the initial written invitation resulted in increased participation, while approaching the teenager or parent initially did not make a difference in attendance. This pilot study shows the potential for initiating an adolescent health program in the family practice setting.