Correction: Computer-Facilitated Screening and Brief Intervention for Alcohol Use Risk in Adolescent Patients of Pediatric Primary Care Offices: Protocol for a Cluster Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/55039.].

Computer-Facilitated Screening and Brief Intervention for Alcohol Use Risk in Adolescent Patients of Pediatric Primary Care Offices: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Alcohol and other substance use disorders usually begin with substance use in adolescence. Pediatric primary care offices, where most adolescents receive health care, are a promising venue for early identification of substance use and for brief intervention to prevent associated problems and the development of substance use disorder. OBJECTIVE: This study tests the effects of a computer-facilitated screening and brief intervention (cSBI) system (the CRAFFT [Car, Relax, Alone, Forget, Family/Friends, Trouble] Interactive System [CRAFFT-IS]) on heavy episodic drinking, riding with a driver who is substance impaired, or driving while substance impaired among adolescents aged 14 to 17 years presenting for a well visit at pediatric primary care practices. METHODS: We are conducting a cluster randomized controlled trial of the CRAFFT-IS versus usual care and recruiting up to 40 primary care clinicians at up to 20 pediatric primary care practices within the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings network. Clinicians are randomized 1:1 within each practice to implement the CRAFFT-IS or usual care with a target sample size of 1300 adolescent patients aged 14 to 17 years. At study start, intervention clinicians complete web-based modules, trainer-led live sessions, and mock sessions to establish baseline competency with intervention counseling. Adolescents receive mailed recruitment materials that invite adolescents to complete an eligibility survey. Eligible and interested adolescents provide informed assent (parental permission requirement has been waived). Before their visit, enrolled adolescents seeing intervention clinicians complete a self-administered web-based CRAFFT screening questionnaire and view brief psychoeducational content illustrating substance use-associated health risks. During the visit, intervention clinicians access a computerized summary of the patient's screening results and a tailored counseling script to deliver a motivational interviewing-based brief intervention. All participants complete previsit, postvisit, and 12-month follow-up study assessments. Primary outcomes include past 90-day heavy episodic drinking and riding with a driver who is substance impaired at 3-, 6-, 9-, and 12-month follow-ups. Multiple logistic regression modeling with generalized estimating equations and mixed effects modeling will be used in outcomes analyses. Exploratory aims include examining other substance use outcomes (eg, cannabis and nicotine vaping), potential mediators of intervention effect (eg, self-efficacy not to drink), and effect moderation by baseline risk level and sociodemographic characteristics. RESULTS: The AAP Institutional Review Board approved this study. The first practice and clinicians were enrolled in August 2022; as of July 2023, a total of 6 practices (23 clinicians) had enrolled. Recruitment is expected to continue until late 2024 or early 2025. Data collection will be completed in 2025 or 2026. CONCLUSIONS: Findings from this study will inform the promotion of high-quality screening and brief intervention efforts in pediatric primary care with the aim of reducing alcohol-related morbidity and mortality during adolescence and beyond. TRIAL REGISTRATION: ClinicalTrials.gov NCT04450966; https://www.clinicaltrials.gov/study/NCT04450966. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55039.

Adapting a Counseling-Plus-mHealth Intervention for the Virtual Environment to Reduce Sexual and Reproductive Health Risk Among Young Women with Depression.

MARSSI (Momentary Affect Regulation - Safer Sex Intervention) is a counseling-plus-mobile health (mhealth) intervention to reduce sexual and reproductive health (SRH) risks for women with depression and high-risk sexual behavior. Due to the COVID-19 pandemic limiting in-person care, we sought to develop the counseling and mhealth app onboarding for virtual implementation. A team with SRH, adolescent medicine, motivational interviewing, cognitive behavioral therapy, and technology expertise adapted the counseling through an iterative consensus process. We identified essential aspects of the counseling, specified the content so the counseling could be delivered in person or virtually with fidelity, and considered best practices for telehealth for the focus population. Virtual counseling retained key elements from in-person counseling while including enhancements with engaging visual and audio-video aids. Instructions and programming were developed to support virtual counseling delivery and onboarding for the mhealth app component of MARSSI. After testing the virtual format in mock sessions, we implemented a small-scale feasibility study in an adolescent medicine clinic with women with depressive symptoms and high-risk sexual behavior age 18-24 years (N = 9). Participants experienced minimal technical difficulties and expressed satisfaction with the virtual format, and all were able to complete app onboarding successfully. Expanding delivery options for SRH interventions to include virtual can improve access, particularly for populations with psychological and environmental barriers to care.

Application of the Toxic Stress Schema: An Exemplar for School Nurses.

For many children of color, the cumulative impact of pre-existing stressors, disparities, and pandemic-related losses has contributed to a toxic level of stress. Toxic stress can disrupt healthy brain development making children vulnerable to physical and mental health problems. School nurses are the primary health professionals who interact with children daily during the academic year, which positions them to identify risk factors within the social determinants of health that contribute to the development of toxic stress. The Toxic Stress Schema (TSS) provides a framework for assessment and care planning related to social determinants of health and potential sources of stress and/or buffering support for the physical and mental well-being of children. A case study approach is used to demonstrate the application of the TSS to school nursing and provide the basis for conceptualizing a plan of care and identifying resources to support the child's physical and mental health.

A Schema of Toxic Stress Informed by Racism, Transgenerational Stress, and Disadvantage.

INTRODUCTION: The Toxic Stress Schema (TSS) is an ecological framework with a social justice lens for identifying and alleviating stress and strengthening social determinants of health for children and families of color impacted by the COVID-19 pandemic and the cumulative effects of racism and generational, systemic inequities. METHOD: Relevant literature is reviewed, and examples were provided to illustrate the differential impacts of the "stress superstorm" of 2020 had on children of color based on their family's position on the advantage-disadvantage continuum. RESULTS: The utility of the TSS framework as a model for advanced nursing practice is demonstrated, and recommendations are formulated for the pediatric nurse practitioner's role in health policy. DISCUSSION: The COVID-19 pandemic elucidated the historical inequities experienced by children and families of color. The TSS framework provides a model for recognizing, organizing, and implementing.

Evaluation of a Tool to Measure the Demands of Immigration.

BACKGROUND: The Demands of Immigration (DI) scale consists of six subscales and is designed to measure demands that negatively affect emotional health of immigrants. PURPOSE: The purpose of this review is to (a) examine the DI scale's language versions and translation procedures; and (b) evaluate reliability and validity of the DI scale based on studies subsequent to its initial development. METHODS: Published studies were identified through CINAHL Complete, MEDLINE, Social Sciences Premium Collection and PsycInfo. RESULTS: Seventeen quantitative studies reported the DI scale's reliability (internal consistency and test-retest) and/or validity (content and construct). Correlations among the DI subscales and key variables (e.g., job satisfaction, acculturation, depression, perceived support, and resilience) support its construct validity. CONCLUSION: The DI scale is a reliable and valid tool for measuring demands or challenges that immigrants face.

Applying systems thinking and human-centered design to development of intervention implementation strategies: An example from adolescent health research.

Introducing innovative health interventions into clinic settings requires a comprehensive and creative approach to multiple implementation challenges. To optimize implementation of a sexual and reproductive health intervention for young women with depression, we applied systems thinking and human-centered design thinking methods to develop tools and strategies to address issues influencing intervention implementation in diverse clinics. We recruited staff from three clinics that provide sexual and reproductive health and behavioral health care to young women. Across five sessions (four video conference calls, one in-person workshop), we used systems mapping to identify key stakeholders and their relationships, processes, and challenges to care; formed clinic staff-investigator design teams; brainstormed about challenges that would influence intervention implementation and considered potential solutions; prioritized implementation challenges; and designed prototypes of solutions. Participants responded positively to the systems thinking perspective and collaborative design thinking process. Findings included generalizable considerations about solving implementation challenges for clinic-based interventions, such as forming a team of champions representing the diverse disciplines involved in and impacted by intervention implementation, and creating multiple tools and strategies for implementation that can be tailored to a given clinic's culture.

Development and pilot testing of a counseling-plus-mHealth intervention to reduce risk for pregnancy and sexually transmitted infection in young women with depression.

BACKGROUND: Depressed young women have elevated rates of unintended pregnancy and sexually transmitted infections (STIs). The objective of this study was to develop and pilot-test a counseling-plus-mHealth intervention to reduce sexual and reproductive health (SRH) risk in young women with depressive symptoms. METHODS: Using the Behavior-Determinants-Intervention logic model, we developed the Momentary Affect Regulation-Safer Sex Intervention (MARSSI) to address the challenges that depression imposes on SRH risk reduction efforts of high-risk young women: (I) in-person counseling using motivational interviewing (MI) to elicit motivation for safer sex and develop a behavior change plan, and teaching cognitive-behavioral skills to manage negative thoughts and affective states; (II) 4-week Ecological Momentary Intervention (EMI) on a smartphone to report momentary phenomena related to depression and SRH risk, and receive personalized, tailored messages prompting healthy behaviors and encouraging cognitive-behavioral skill use when risk-related cognitions and negative affect are reported; and (III) booster counseling to review behavior change goals and plans and teach a new cognitive-behavioral skill. We developed the counseling through iterative interviews with 11 participants and developed the EMI through a 2-week trial with three participants, then revised MARSSI to reflect participant feedback. We next conducted a pilot-test among depressed, high-risk female adolescent clinic patients age 15-24. Pilot participants completed mental health, motivation to change behavior, and SRH behavior assessments and provided feedback at baseline, post-EMI, and at 3-month follow-up. We analyzed participant retention, counseling duration, app engagement, intervention quality ratings, and participant feedback, and compared mental health and SRH risk behavior across the study. RESULTS: Seventeen participants completed the initial counseling session, 15 participated in the EMI, 14 returned for the booster session, and 14 completed the 3-month follow-up. App engagement was high for all 4 EMI weeks (≥1 report/day for median ≥6 days/week). Post-intervention, most or all participants agreed with each positive statement about the messages, reported "Excellent" MARSSI usefulness, and attributed improvements to MARSSI. Compared to baseline, post-EMI depressive symptoms, confidence to change self-selected risk behavior, and confidence to use the cognitive restructuring skill improved. At 3 months, depressive symptom scores remained lower and confidence to use cognitive restructuring remained higher, compared to baseline. Participants also reported lower frequency of sex, lower proportion of condom-unprotected sex events, and, among those using effective contraception, more consistent condom use at 3-month follow-up vs. baseline. CONCLUSIONS: MARSSI was feasible, acceptable, and engaging to young women with depression and SRH risk behavior, and was associated with increased confidence to reduce SRH risk, decreased SRH risk behaviors, increased confidence to use cognitive restructuring, and decreased depressive symptoms over 3 months. Future research is warranted to evaluate MARSSI's efficacy to improve motivation, skills, affect, and behaviors, as well as reproductive health outcomes in high-risk depressed young women.

Healthcare Clinician and Staff Perspectives on Facilitators and Barriers to Ideal Sexual Health Care to High-Risk Depressed Young Women: A Qualitative Study of Diverse Clinic Systems.

STUDY OBJECTIVE: This study identified clinician and clinic staff perspectives on facilitators and barriers to providing sexual and reproductive health (SRH) care to depressed young women, a population at increased risk for adverse SRH outcomes. DESIGN: We conducted in-person semi-structured qualitative interviews, which were audio-recorded, transcribed, and coded by two researchers. We used thematic analysis to identify themes pertaining to care facilitators and barriers within a socio-ecological framework. SETTING: This study was conducted in seven diverse clinics in the U.S. New England region. PARTICIPANTS: Participants were 28 clinicians and staff (4/clinic), including behavioral health clinicians (n = 9), nurse practitioners (n = 7), nurses (n = 3), medical doctors (n = 3), administrative associates (n = 2), practice managers (n = 2), family planning counselor (n = 1), and medical assistant (n = 1). MAIN OUTCOME MEASURES: We queried how clinicians and clinic staff identify and manage depression and sexual risk, and what they perceive as facilitators and barriers affecting provision of ideal SRH care to depressed young women. RESULTS: Themes represented facilitators of and barriers to providing ideal SRH care to high-risk depressed young women at five socio-ecological levels: individual (facilitator: trust in providers; barrier: stigma experiences), interpersonal/provider (facilitator: frequent patient-provider communication; barrier: lack of time during clinic visits to build trust), clinic (facilitator: integration of care; barrier: lack of scheduling flexibility), organization/community (facilitator: training for providers; barrier: funding constraints), and macro/societal (facilitator: supportive policies; barrier: mental health stigma). CONCLUSION: Optimizing SRH care to high-risk depressed young women necessitates attention to factors on all socio-ecological levels to remove barriers and bolster existing facilitators of care.

Engaging Youth (Adolescents and Young Adults) to Change Frequent Marijuana Use: Motivational Enhancement Therapy (MET) in Primary Care.

PURPOSE: To characterize information elicited from adolescent/young adults with frequent cannabis use in Motivational Enhancement Therapy (MET), and determine whether differences exist across stages of change (SOC) for reducing use. DESIGN AND METHODS: Primary care patients 15-24 years old using cannabis ≥3 times/week enrolled in a pilot randomized intervention trial. All youth were offered two 1-hour MET sessions. Content analysis was used to code and categorize main reasons for use, alternative behaviors, goals, values, pros and cons of change, and compared results between youth in Pre-Contemplation vs. Contemplation SOC. RESULTS: Fifty-six youth completed MET session 1, 46 completed session 2. Most reported their main reason for use was related to emotional coping, negative feelings were a top-3 trigger, and distraction was an alternative way to meet their needs. Youth most frequently described progress in education or career/job as 1-year goals. More than half identified family as a very important value. They most frequently reported pros of using less related to achieving goals, self-improving, and saving money, and a con related to stress/coping. Compared to youth in Pre-Contemplation SOC, those in Contemplation were more likely to identify relationships as both a pro and con of using less cannabis. CONCLUSIONS: MET can reveal developmentally appropriate goals, healthy values, and ambivalence about cannabis use that can be used to facilitate movement along the stages of behavior change toward reduction/cessation. PRACTICE IMPLICATIONS: Brief motivational therapy can be used in primary care to gather information important in helping youth to reduce cannabis use.

Predictors of HIV Risk Reduction in Adolescent Girls.

PURPOSE: The purpose of the study was to explore the associations among mastery, self-esteem, and HIV risk reduction behaviors in a culturally diverse group of adolescent girls. It is important to identify and assess psychological determinants of HIV risk reduction behaviors such as mastery and self-esteem so that healthcare interventions may be tailored to maximize an adolescent's preventive efforts. STUDY DESIGN AND METHODS: Black, Latina, and White adolescent girls were recruited from an urban primary care setting in a tertiary care center. A descriptive, correlational design was used. Measures included the Pearlin Mastery Scale, Rosenberg Self-Esteem Scale, and the Adolescent Problem Severity Index. Data were collected through written surveys completed anonymously. Data were analyzed using multiple regression analysis. RESULTS: There were 224 participants. Mastery and self-esteem, variables that commonly explain health-enhancing behaviors, were not associated with HIV risk reduction behaviors either in the entire sample or cultural subgroups. There was an inverse relationship between age and HIV risk reduction behaviors in all cultural groups. There were no significant differences in HIV risk reduction behaviors among the three cultural groups. CLINICAL NURSING IMPLICATIONS: Findings suggest HIV prevention efforts by nurses should be universal regardless of an adolescent girl's presumed level of mastery and self-esteem, and that these efforts need to intensify as they age.

Intimate Relationships and Sexual Behavior in Young Women withDepression.

PURPOSE: To better understand links between depressive symptoms and high-risk sexual behavior in young women. METHODS: We conducted semistructured interviews with young women from three primary care clinics who reported clinically significant depressive symptoms, had penile-vaginal sexual intercourse within the past 6 months, and met at least one sexual risk criterion (N = 16, age 16-23years, racially/ethnically diverse). We transcribed the interview recordings, organized and coded the data, and conducted a directed content analysis. RESULTS: Participants described a complex interrelation between depression and intimate relationships and sexual behavior. Depression had negative effects on relationships, sexual motives and experiences (including safety), and feelings about oneself in sexual situations. Participants reported difficulty in developing and maintaining intimate relationships. Although many participants reported less interest in and emotional energy for sex, several were having sex frequently to manage depressive symptoms. Generally, the young women described sex as unsafe (e.g., no condom) owing to impaired judgment, increased impulsivity, apathy, and alcohol. As a result, sometimes their efforts to feel better by having sex led them to feeling worse (e.g., ashamed and worthless). CONCLUSIONS: Depressed young women may limit intimate relationships, yet engage in frequent and unsafe sex to cope with their symptoms. Their efforts to feel better may provide only temporary relief or result in feeling worse. Depressed young women would benefit from tailored interventions that identify and counter unhealthy thoughts, attitudes, behaviors, and patterns related to sexual relationships and behavior; minimize factors that impair healthy decision-making; and foster development of alternative affect regulation strategies.

Pilot randomized trial of MOMENT, a motivational counseling-plus-ecological momentary intervention to reduce marijuana use in youth.

BACKGROUND: Ecological momentary interventions (EMIs) influence behavior in real time, in real life. We evaluated trial feasibility and preliminary efficacy of MOMENT, a counseling-plus-EMI to reduce frequent marijuana use in youth in primary care. METHODS: Primary care patients age 15-24 years using marijuana at least 3 times/week were randomized to MOMENT [motivational enhancement therapy (MET)/smartphone-based momentary assessment/responsive motivational messaging] vs. No-messages (MET/momentary assessment) vs. MET-only. In MOMENT, two MET sessions were followed by 2 weeks of momentary assessment of marijuana use and factors related to use, with motivational messaging displayed after report of marijuana triggers, desire, use, and effort to avoid use. We evaluated study feasibility (recruitment, retention, and response rates; feedback survey responses) and explored intervention effects on marijuana desire and use at three months with linear mixed effects modeling. RESULTS: Seventy youth [mean (M) =20.7 years, 60% female] were assigned to MOMENT (n=27), No-messages (n=15; assignment suspended to enrich other arms), or MET-only (n=28). Most attrition occurred during baseline, before MET. Of those completing MET session 1, 82% completed their assigned treatment and 79% provided 3-month data. Participants highly rated acceptability; comments reflected changing motivation and behavior. Across arms, participants reported significantly lower marijuana use, desire, and problems at follow-up vs. baseline. Momentary marijuana desire declined more in MOMENT vs. MET-only. Marijuana use following a targeted context or behavior was less likely in MOMENT and No-messages, vs. MET-only. CONCLUSIONS: The MOMENT intervention is feasible to deliver, acceptable, and potentially efficacious in reducing marijuana desire and use among adolescent and young adults in primary care. A larger randomized trial to evaluate efficacy is warranted.

A Qualitative Application of Diffusion of Innovations to Adolescents' Perceptions of Long-Acting Reversible Contraception's Attributes.

STUDY OBJECTIVE: Long-acting reversible contraceptive (LARC) methods are the most effective forms of reversible contraception but adolescents often opt for other, less effective methods. In this study we explored how adolescents viewed LARC as an innovation to be adopted or rejected, and how their assessment of innovation attributes affected their decisions about LARC. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Sexually active adolescents between 15 and 22 years old (n = 22) participated in semistructured qualitative interviews. The data underwent a content analysis informed by constructs of the diffusion of innovations and emergent interview themes. RESULTS: Data analysis indicated 3 subgroups of participants on the basis of their inclination to use LARC and the mutability of that position: positive/persuaded (n = 7), negative/low knowledge (n = 10), and negative/adamant (n = 5). Participants' perceptions of the relative advantage, compatibility, complexity, trialability, and observability of LARC cohered around subgroup membership. Perceived complexity entailed in obtaining LARC and fears about LARC were observed across all participants. All participants believed that one has to try LARC to know how it will work for her, personally. This led the positive/persuaded group to be undeterred by others' negative experiences with LARC and the negative/low knowledge and negative/adamant groups to decide LARC was too risky to try. CONCLUSION: Adolescents engage in nuanced evaluations of LARC, weighing competing information about LARC while receiving anecdotal and empirical information about LARC from various valid sources. To reduce the uncertainty about LARC that prohibits trying these methods, adolescents require straightforward information about LARC that directly addresses the advantages of LARC over other methods coupled with candid acknowledgement of the potential disadvantages of LARC.

Intensive behavioral treatment weight loss program in an adult primary care practice.

BACKGROUND AND PURPOSE: To evaluate a nurse practitioner (NP) led intensive behavioral treatment program for obesity implemented in an adult primary care practice. METHODS: The outcome variables for this study included weight loss as well as patient and provider ratings about program satisfaction, feasibility, and acceptability. Data sources were the patient medical records, patient satisfaction surveys, provider satisfaction surveys, and a provider focus group. Thirty-six eligible patients completed the program. CONCLUSIONS: The program was feasible and effective with statistically significant weight loss (mean weight loss 6.7 lbs after four visits and 10.7 lbs at 12 weeks) and clinically significant with 39% of patients losing 5% or more of body weight at 12 weeks, with a high degree of acceptance. IMPLICATIONS FOR PRACTICE: Obesity is a national epidemic with significant health and economic consequences. The Centers for Medicare and Medicaid Services recognizes intensive behavioral therapy for obesity treatment in primary care and the U.S. Preventive Services Task Force established evidenced-based program criteria. However targeted interventions to treat obesity are largely lacking in primary care. NPs with a focus on patient-centered and evidence-based care are well positioned to lead intensive behavioral therapy initiatives for obesity treatment.

"Counselor in Your Pocket": Youth and Provider Perspectives on a Mobile Motivational Intervention for Marijuana Use.

Previous interventions for marijuana use have been administered out of the real-life contexts in which use occurs. In 2010, we interviewed youth aged 15-24 years who use marijuana frequently (n = 8) and providers who treat them (n = 6) on the acceptability and utility of a mobile intervention involving momentary self-monitoring of use-related contexts and responsive motivational messaging following clinic-based brief motivational enhancement therapy. Thematic analysis was used to examine youth and provider perspectives on the mobile intervention. Results suggest that mobile technology is a promising tool for brief interventions to reduce youth marijuana use and warrants further development.

Understanding motivations for abstinence among adolescent young women: insights into effective sexual risk reduction strategies.

INTRODUCTION: Pregnancy and sexually transmitted infections pose a significant threat to the health and well-being of adolescent women. Abstinence, when practiced, provides the most effective means of preventing these problems, yet the perspective of abstinent young women is not well understood. The purpose of this investigation was to characterize female adolescents' motivations for abstinence. METHOD: As part of a larger, cross-sectional quantitative study investigating predictors of HIV risk reduction behaviors, qualitative responses from study participants who never had intercourse were analyzed in a consensus-based process using content analysis and frequency counts. An urban primary care site in a tertiary care center served as the setting, with adolescent young women ages 15-19 years included in the sample. RESULTS: Five broad topic categories emerged from the data that characterized motivations for abstinence in this sample: personal readiness, fear, beliefs and values, partner worthiness, and lack of opportunity. DISCUSSION: A better understanding of the motivations for abstinence may serve to guide the development of interventions to delay intercourse.