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The Rapid Assessment for Adolescent Preventive Services (RAAPS): Providers’ Assessment of Its Usefulness in Their Clinical Practice Settings

      Abstract

      Introduction

      The purpose of this study was to evaluate health providers’ use of the Rapid Assessment for Adolescent Preventive Services (RAAPS) screening tool to identify adolescent high-risk behaviors, its ease of use and efficiency, and its impact on provider/patient discussions of sensitive risk behaviors.

      Method

      This mixed methods descriptive study used an online survey to assess providers’ use of the RAAPS and their perspectives on its implementation and effect on adolescent-provider communication. The survey was completed by providers from a variety of settings across the United States (N = 201).

      Results

      Quantitative and qualitative analyses indicated that the RAAPS facilitated identification of risk behaviors and risk discussions and provided efficient and consistent assessments; 86% of providers believed that the RAAPS positively influenced their practice.

      Discussion

      Adoption of the RAAPS in practice settings could lead to more effective adolescent preventive services by giving providers a tool to systematically assess and identify adolescents at risk. Implementation of RAAPS offers health providers an efficient, consistent, and “adolescent friendly” way to identify risky behaviors and open the discussion needed to tailor interventions to meet their needs.

      Key Words

      Most health problems among adolescents are due to risky behaviors rather than biological dysfunction (
      • Centers for Disease Control and Prevention
      The youth risk behavior surveillance system—United States 2011.
      ). In fact, almost 75% of the primary causes of death in the adolescent population are preventable (
      • Centers for Disease Control and Prevention
      The youth risk behavior surveillance system—United States 2011.
      ). Addressing adolescents’ risky behaviors in health care visits is therefore essential to reduce their morbidity and mortality. Current American Academy of Pediatrics (AAP) and National Prevention Council (NPC) guidelines recommend routine risk behavior screening for all adolescents and the use of brief intervention techniques, as indicated, on an annual basis (
      American Academy of Pediatrics, Committee on Adolescence
      Achieving quality health services for adolescents.
      ;
      • National Prevention Council
      National prevention strategy.
      ).
      Despite national recommendations and positive intentions, primary care providers report many barriers to implementing routine risk screening. The most frequently reported concern has been insufficient time (
      • Cheng T.L.
      • DeWitt T.G.
      • Savageau J.A.
      • O’Connor K.G.
      Determinants of counseling in primary care pediatric practice: Physician attitudes about time, money, and health issues.
      ;
      • Henry-Reid L.M.
      • O’Connor K.G.
      • Klein J.D.
      • Cooper E.
      • Flynn P.
      • Futterman D.C.
      Current pediatrician practices in identifying high-risk behaviors of adolescents.
      ;
      • Van Hook S.
      • Harris S.K.
      • Brooks T.
      • Carey P.
      • Kossack R.
      • Kulig J.
      • Knight J.R.
      New England Partnership for Substance Abuse Research
      The “Six T’s”: Barriers to screening teens for substance use in primary care.
      ;
      • Yarnall K.S.
      • Pollak K.I.
      • Ostbye T.
      • Krause K.M.
      • Michener J.L.
      Primary care is there enough time for prevention.
      ). Although the vast majority of physicians believe it is their responsibility to educate patients about risk factors, provide support regarding risk behavior issues, and help patients adhere to recommended regimens (
      • Schaeuble K.
      • Haglund K.
      • Vukovich M.
      Adolescents’ preferences for primary care provider interactions.
      ;
      • Wechsler H.
      The physician’s role in health promotion revisited: A survey of primary care practitioners.
      ), only a few believe they have time to provide such interventions (
      • Henry-Reid L.M.
      • O’Connor K.G.
      • Klein J.D.
      • Cooper E.
      • Flynn P.
      • Futterman D.C.
      Current pediatrician practices in identifying high-risk behaviors of adolescents.
      ). In fact, other research studies confirm that health care providers rarely ask adolescents specifically about their health risk behaviors and little time is spent delivering preventive care (
      • Adams S.H.
      • Husting S.
      • Zahnd E.
      • Ozer E.M.
      Adolescent services: Rates and disparities in preventive health topics covered during routine medical care in a California sample.
      ;
      • Beebe T.
      • Harrison P.
      • Park E.
      The effects of data collection mode and disclosure on adolescent reporting of health behavior.
      ;
      • Henry-Reid L.M.
      • O’Connor K.G.
      • Klein J.D.
      • Cooper E.
      • Flynn P.
      • Futterman D.C.
      Current pediatrician practices in identifying high-risk behaviors of adolescents.
      ;
      • Irwin C.E.
      • Adams S.H.
      • Park J.
      • Newacheck P.W.
      Preventive care for adolescents: Few get visits and fewer get services.
      ;
      • Schaeuble K.
      • Haglund K.
      • Vukovich M.
      Adolescents’ preferences for primary care provider interactions.
      ). Furthermore, gender of the health care providers has been shown to affect risk behavior screening, with female health care providers more likely to identify and respond to risk behaviors reported by adolescents than their male counterparts (
      • Epner J.E.
      • Levenberg P.B.
      • Schoeny M.E.
      Primary care providers’ responsiveness to health-risk behaviors reported by adolescent patients.
      ;
      • Torkko K.C.
      • Gershman K.
      • Crane L.A.
      • Hamman R.
      • Barón A.
      Testing for Chlamydia and sexual history taking in adolescent females: Results from a statewide survey of Colorado primary care providers.
      ). Misperceptions of risk status and/or incomplete elicitation of risk information by health care providers leads to missed opportunities for screening and prevention activities.
      This situation highlights the need for an efficient screening tool to help busy health care providers obtain more complete and systematic risk assessments during adolescent visits. Research has shown that health care providers can facilitate adolescent communication during health care visits through use of a tool composed of questions designed to elicit responses (
      • Boekeloo B.O.
      • Bobbin M.P.
      • Lee W.I.
      • Worrell K.D.
      • Hamburger E.K.
      • Russek-Cohen E.
      Effect of patient priming and primary care provider prompting on adolescent-provider communication about alcohol.
      ). Such a tool would allow providers to focus their limited time more effectively on discussion and counseling of identified risks (
      • Frankenfield D.L.
      • Keyl P.M.
      • Gielen A.
      • Wissow L.S.
      • Werthamer L.
      • Baker S.P.
      Adolescent patients—healthy or hurting? Missed opportunities to screen for suicide risk in primary care setting.
      ;
      • Olsen A.L.
      • Gaffney C.A.
      • Hedberg V.A.
      • Gladstone G.R.
      Use of inexpensive technology to enhance adolescent health screening and counseling.
      ;
      • Yi C.H.
      • Martyn K.
      • Salerno J.
      • Darling-Fisher C.S.
      Development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS) questionnaire in school based health centers.
      ).
      The Guidelines for Adolescent Preventive Services (GAPS) questionnaire developed by the American Medical Association (
      American Medical Association
      Guidelines for adolescent preventive services (GAPS).
      ) has been considered the gold standard screening tool to identify adolescent risk behaviors (
      • Gadomski A.
      • Bennett S.
      • Young M.
      • Wissow L.S.
      Guidelines for adolescent preventive services: The GAPS in practice.
      ;
      • Levenberg P.B.
      GAPS: An opportunity for nurse practitioners to promote the health of adolescents through clinical preventive services.
      ). However, the length of this comprehensive tool (four pages) and the time needed to complete and review it have been barriers to its use for many health care providers. Additionally, differential screening of adolescents based on their age, gender, racial affiliation, socioeconomic level, or perceived risk behavior status has been identified as a barrier to identifying and addressing adolescent risk behaviors (
      • Bethell C.
      • Klein J.
      • Peck C.
      Assessing health system provision of adolescent preventive services: The young adult health care survey.
      ;
      • Wiehe S.E.
      • Rosenman M.B.
      • Wang J.
      • Katz B.P.
      • Fortenberry J.D.
      Chlamydia screening among young women: Individual- and provider-level differences in testing.
      ).
      The Rapid Assessment for Adolescent Preventive Services (RAAPS) risk screening tool was developed to identify the risk behaviors contributing most to adolescent morbidity, mortality, and social problems and to provide a more streamlined assessment to help providers address key adolescent risk behaviors in a time-efficient and user-friendly format.
      The Rapid Assessment for Adolescent Preventive Services (RAAPS) risk screening tool was developed to identify the risk behaviors contributing most to adolescent morbidity, mortality, and social problems and to provide a more streamlined assessment to help providers address key adolescent risk behaviors in a time-efficient and user-friendly format. The development and clinical use of the RAAPS was described in an earlier publication (
      • Yi C.H.
      • Martyn K.
      • Salerno J.
      • Darling-Fisher C.S.
      Development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS) questionnaire in school based health centers.
      ). Research conducted in several school-based clinic programs demonstrated that providers using the RAAPS were able to detect the major risk behaviors associated with poor outcomes in adolescents, discuss and document these risk behaviors in a single clinic visit, and refer adolescents for further management when appropriate.
      Strengths of the RAAPS include its concise format, ease of use, assessment of major risks in a short time, and establishment of rapport with adolescents (
      • Yi C.H.
      • Martyn K.
      • Salerno J.
      • Darling-Fisher C.S.
      Development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS) questionnaire in school based health centers.
      ). The RAAPS is a 21-item questionnaire that can be completed by adolescents in an average of 5 to 7 minutes. Paper and computerized online versions of the RAAPS screening tool are available for use (a detailed description of the tool and ways to access it can be found at www.raaps.org). Further research has demonstrated the reliability and validity of the RAAPS as a tool for identifying the adolescent risk behaviors contributing most to adolescent morbidity, mortality, and social problems (
      • Salerno J.
      • Marshall V.
      • Picken E.
      Rapid assessment for adolescent preventive services: Validity and reliability of the RAAPS adolescent risk screening tool.
      ).
      • Salerno J.
      • Marshall V.
      • Picken E.
      Rapid assessment for adolescent preventive services: Validity and reliability of the RAAPS adolescent risk screening tool.
      used psychometric methods to establish face-, content-, and criterion-related validity and inter-rater and equivalence reliability of the paper-based RAAPS. Face validity was established by focus group consensus. Adolescent expert content validity index scores ranged from 0.825 to 1.0, with inter-rater content agreement ranging from 0.9 to 1.0. Criterion-related validity and equivalence between the RAAPS and GAPS paired questions was demonstrated by Cohen’s kappa scores ranging from 0.44 to 0.99, with percent agreement ranging from 0.71 to 0.99. Fisher’s exact test showed that all p values were >.05, indicating no statistically significant differences in responses to the GAPS- and RAAPS-paired questions (
      • Salerno J.
      • Marshall V.
      • Picken E.
      Rapid assessment for adolescent preventive services: Validity and reliability of the RAAPS adolescent risk screening tool.
      ).
      The purpose of this study was to evaluate the clinical use of the RAAPS screening tool by surveying health care providers from a wide variety of clinical settings and geographic locations who had requested the tool via the RAAPS Web site: www.raaps.org. Specifically, providers were surveyed on their current use of the RAAPS in their practice; their perceptions of its influence on their practice; their assessment of the RAAPS’ performance in terms of its ease of use and efficiency; its ability to identify adolescent high-risk behaviors; and its impact on providers’ communication with adolescents around their risk behaviors.

      Methods

      A mixed methods descriptive study was conducted using an online survey to assess providers’ use of the RAAPS and their perspectives on its implementation and effect on adolescent-provider communication. The survey included quantitative multiple choice and Likert-scaled items with qualitative open-ended items to supplement quantitative data analysis.

      Procedure

      An online survey was used to obtain providers’ perspectives about the clinical use of the RAAPS tool. Institutional Review Board approval of the study was obtained through the University of Michigan. An e-mail message describing the study with a Web-based address link to an online Qualtrics survey was sent to all providers who had downloaded the paper version or were currently using the Web-based version of the RAAPS between 2006 and 2010. All respondents provided demographic information about themselves and their practice. The first survey question asked about current use of the RAAPS. Those responding “No” were asked to state their reasons for not using the tool and ended the survey. Individuals who answered “Yes” completed a 16-item survey consisting of multiple choice and open-ended questions and eight Likert-scaled statements rating the RAAPS.
      The provider survey was evaluated for content validity by members of the research team who had experience developing scales for prior funded research on adolescent risk screening, quality of adolescent care, and patient-provider communication. The survey’s open-ended questions asked providers to describe their method of assessing adolescent risk behaviors prior to using the RAAPS, their current assessment of the RAAPS’ influence on their practice with adolescents, the strengths of the RAAPS, limitations to the RAAPS, any proposed changes, and whether they would recommend the RAAPS survey to other health providers, along with why or why not.
      Providers were also asked to respond to eight statements reflecting their experiences with the RAAPS in terms of its impact on communication with adolescents and its performance in their practice using a 5-point Likert scale with responses ranging from strongly agree to strongly disagree (see Table 1). The statements were selected by the research team based on review of and experience with existing tools used in research to assess quality of care, patient-provider communication, and implementing new approaches in clinical practice with adolescents (
      • Woods E.R.
      • Klein J.D.
      • Wingood G.M.
      • Rose E.S.
      • Wypij D.
      Development of a new Adolescent Patient-Provider Interaction Scale (APPIS) for youth at risk for STDs/HIV.
      ;
      • Martyn K.K.
      • Darling-Fisher C.
      • Pardee M.
      • Ronis D.L.
      • Felicetti I.L.
      • Saftner M.A.
      Improving sexual risk communication with adolescents using event history calendars.
      ). Statements were then slightly modified to be more specific to the experience with the RAAPS. Once responses were obtained, each statement was examined by the team for the distribution of responses, its correlation with other items, and its conceptual meaning. The statements that were highly correlated with one another (p < .001) and that shared conceptual similarities were combined to form composite index scores assessing Performance (three items) and Communication (four items). An overall assessment of experience with the RAAPS or Overall Experience score, composed of responses to all eight statements, was also calculated. Internal consistency for each of the scales and the Overall Experience score was determined using Cronbach’s coefficient alpha with a cutoff of 0.7 as an indicator of acceptability (
      • Nunnally J.C.
      Psychometric theory.
      ). Cronbach’s alpha determines the internal consistency or intercorrelation of items in a survey instrument to gauge its reliability. Cronbach’s standardized alphas for the three scales ranged from 0.81 to 0.91 and are shown in Table 1.
      Table 1Scales assessing providers’ experiences with the Rapid Assessment for Adolescent Preventive Services on performance, communication, and overall rating (n = 98)
      ScaleStatementMSDRangeα
      Performance (3 items)RAAPS helped me to document patient encounters related to their risk behaviors.

      RAAPS is easy to use.

      RAAPS helped me identify risk behaviors in adolescents.
      10.491.773-120.81
      Communication (4 items)RAAPS was used to direct risk behavior discussions with my adolescent patients.

      RAAPS helped me to develop rapport with my adolescent patients.

      RAAPS helped to improve communication with my adolescent patients.

      RAAPS gave adolescents an opening for discussion of their behaviors and experiences.
      13.322.474-160.86
      Overall experience (8 items)RAAPS helped me identify risk behaviors in adolescents.

      RAAPS was used to direct risk behavior discussions with my adolescent patients.

      RAAPS helped me develop rapport with my adolescent patients.

      RAAPS helped to improve communication with my adolescent patients.

      RAAPS helped me to document patient encounters related to their risk behaviors.

      RAAPS helped adolescents understand their own risk behaviors and potential outcomes.

      RAAPS gave adolescents an opening for discussion of their behaviors and experiences.

      RAAPS is easy to use.
      26.844.4910-320.91
      RAAPS, Rapid Assessment for Adolescent Preventive Services.
      Statement responses were scored on a 5-point Likert scale ranging from strongly disagree to strongly agree (scale 0-4).

      Data Analysis

      SAS 9.2 (SAS Institute Inc., Cary, NC) was used to carry out statistical tests. Missing values were excluded from statistical tests. Descriptive statistics were obtained for the sample and the responses on each of the survey items. Two-sample t-tests assumed equality of variances unless otherwise specified. Chi-square and McNemar tests were used to test associations between variables. The Fisher exact test was used when the expected cell count was less than five. Qualitative analyses were performed by the fourth author (an experienced qualitative researcher) using the constant comparative method to identify common themes related to use of the RAAPS from the perspectives of the providers (
      • Glaser B.G.
      Basics of grounded theory analysis.
      ). The final determination of themes was guided by the following research question: “How does the RAAPS influence adolescent risk assessment and adolescent-provider communication from providers’ perspectives?” The research team confirmed that the themes were relevant and reflected the perceptions of the providers. The common themes were used to enhance interpretation of the quantitative results.

      Results

      Descriptive Analyses

      Sample characteristics

      The provider survey was distributed to 567 providers, of whom 201 responded, for a response rate of 35%. Responses came from providers from 26 U.S. states and three foreign countries (Canada, Korea, and Ireland).

      Use of the RAAPS

      More than half of the respondents (n = 111; 55%) reported they were using the RAAPS in their clinical practices. Respondents who were not using the RAAPS (n = 90; 45%) had a variety of reasons for not using it. Most reasons were related to constraints of their health system or practice site; other reasons were satisfaction with their current method of assessment (e.g., GAPS, HEADSS assessment questions [Home, Education/employment, Activities, Drugs, Sexuality, and Suicide/depression], or their perceived skill at interviewing) and that they were interested in the RAAPS for academic or research purposes rather than clinical use.

      Description of risk assessment practices

      Of the persons who responded to this question (n = 107), the majority (n = 92, 86%) were already assessing adolescent risk behaviors before using the RAAPS. Of the respondents who provided more detailed information (n = 85), most were using the GAPS (n = 45, 53%); some were doing an informal assessment as part of their history (n = 18, 21%); the remainder used a variety of methods, including self-made forms; the HEADSS during the history; or Bright Futures Guidelines.

      Characteristics of RAAPS users compared with nonusers

      Table 2 presents demographic characteristics of the RAAPS users and nonusers, as well as the statistically significant differences between these groups, using chi-square analyses. The majority of providers who used the RAAPS survey were female (n = 153, 96.5%), worked as health care providers (n = 161, 75.3%), and practiced in school-based health centers (n = 152, 75.9%) located in the Midwest (n = 151, 67.1%), in which the majority of the patient population (greater than 50%) were adolescents (n = 154, 69.4%). About 45% of RAAPS users (n = 145) were older than 50 years. Approximately half of the providers who were using the RAAPS had been in practice for less than 5 years (n = 157, 51.8%) and predominantly worked with adolescents between the ages of 13 and 15 years (n = 154, 55.3%). Almost half of these providers were practicing in an urban setting (n = 154, 45.9%). The largest racial/ethnic group represented (n = 201) was White (59.5%), followed by African American (9.9%). Seventy-five percent of the RAAPS users were health care providers, the majority of whom were nurse practitioners (RAAPS users, n = 57, 67%; RAAPS nonusers, n = 50, 66%), but the health care provider category also included physicians (RAAPS users, n = 4, 4.7%; RAAPS nonusers, n = 5, 6.6%) and physician assistants (RAAPS users, n = 3, 3.5%; nonusers, n = 0).
      Table 2Demographic comparisons between Rapid Assessment for Adolescent Preventive Services users and nonusers
      Current userYes (%)No (%)χ2p
      Provider type (n = 161)12.7652, df = 2< .00
       Health care provider64 (75.3)55 (72.4)
       Mental health provider13 (15.3)2 (2.6)
       Other8 (9.4)19 (25.0)
      Practice setting (n = 152)12.7652, df = 1< .00
       Outpatient health clinic20 (24.1)36 (52.2)
       School-based health clinic63 (75.9)33 (47.8)
      % Adolescent patients (n = 154)7.3780, df = 1.01
       ≤ 50%26 (30.6)36 (52.2)
       > 50%59 (69.4)33 (47.8)
      Years in practice (n = 157)6.2597, df = 1.01
       ≤ 5 years44 (51.8)23 (31.9)
       > 5 years41 (48.2)49 (68.1)
      U.S. Practice region (n = 151)29.68, df = 3< .00
       Northeastern United States13 (15.3)15 (22.7)
       Southern United States11 (12.9)22 (33.3)
       Midwestern United States57 (67.1)16 (24.2)
       Western United States4 (4.7)13 (19.7)
      Race (n = 201)1.2865, df = 2.53
       Black/African American11 (9.9)5 (5.6)
       White/Caucasian66 (59.5)56 (62.2)
       Other34 (30.6)29 (32.2)
      Provider age in years (n = 145)4.00, df = 2.14
       20–39 years21 (25.6)8 (12.7)
       40–49 years24 (29.3)19 (30.2)
       50+ years37 (45.1)36 (57.1)
      df, degrees of freedom.
      Statistically significant differences between characteristics of RAAPS users and nonusers using chi-square analyses are displayed in Table 2. Statistically significant differences were noted between RAAPS users and nonusers with respect to provider types, practice setting, percent of adolescent patients, years in practice, and practice region. No statistically significant demographic differences were found between RAAPS users and nonusers with respect to race, age, gender (Fisher exact test, n = 153, p = .47) or practice profile (urban, suburban, or rural, Fisher exact test, n = 154, p = .95).

      Time spent counseling

      Of the 85 providers who provided information about counseling using the RAAPS, more than half of providers (n = 45, 53%) spent less than 10 minutes counseling adolescents on their identified risk behaviors. The majority of those (n = 37, 43%) spent 6 to 10 minutes counseling. When compared, providers who spent 11 minutes or more counseling were more likely to be mental health providers. The longer counseling visits occurred in practices where more than 50% of the population were adolescents (n = 85, χ2 = 3.99, df = 1, p < .05) and in school-based clinics (n = 83, χ2 = 3.99, df = 1, p < .02).

      RAAPS influence on practice

      When asked about their use of the RAAPS, 98 providers responded. Of these, 85% (n = 83) believed that the RAAPS had influenced their practice and 74 provided examples of its benefits (refer to qualitative results). Of those who believed it had not influenced practice (n = 15), 12 provided comments. Most noted that they were already addressing risks in their current practice, and thus it did not change their prior practice.

      Recommendation to other providers

      When asked if they would recommend the RAAPS to other providers, 86 responded, and 98% (n = 84) stated they would recommend the RAAPS. The two most common reasons cited for their recommendation were for screening (n = 76, 92%) and identification of risk behaviors (n = 75, 90%). Improved communication (n = 52, 63%) and improved documentation (n = 46, 55%) and increased patient understanding of their risk behaviors (n = 48, 58%) were also cited by respondents as reasons to recommend the RAAPS.

      Assessment of RAAPS: Performance, communication, and overall experience rating scales

      Results of analyses of the composite scales evaluating the influence of the RAAPS in terms of its Performance (ability to identify risks, ease of use, and facilitation of documentation) and effect on Communication with adolescents, as well as the Overall Experience using the RAAPS, showed positive ratings in all areas. The average scores for Performance, Communication, and the Overall Experience were relatively high for each scale and are presented in Table 3. However, participants who indicated that the RAAPS had influenced their practice had statistically significant higher average ratings on all three scales than did those who indicated their practice was not influenced by use of this tool (p < .001; see Table 3).
      Table 3Comparison of performance, communication, and overall experience scores between providers who reported that Rapid Assessment for Adolescent Preventive Services did and did not have an influence on practice
      ScaleInfluence on practice

      Yes (n = 83)
      Influence on practice

      No (n = 15)
      t-test
      MeanSDMeanSD
      Performance10.841.428.532.263.82
      p < .001, df = 16.
      Communication13.851.9310.332.134.33
      p < .001, df = 16.
      Overall experience27.823.5721.473.894.42
      p < .001, df = 16.
      p < .001, df = 16.

      Assessment of RAAPS: Survey item analysis

      To better understand the ways in which the RAAPS influenced individual practice, the responses on each of the eight statements about their experience with the RAAPS were further examined for the participants who believed that the RAAPS had influenced their practice. Each question was coded dichotomously with strongly agree/agree in one category and neutral/disagree/strongly disagree in another category. The McNemar’s chi-square test was then used to test for an association between favorable perceptions (strongly agree/agree responses) and responding that the RAAPS had influenced practice (yes/no). Statistically significant differences were found for those who believed the RAAPS had influenced practice compared with those who did not on four questions: RAAPS helped me identify risk behaviors (McNemar χ2 = 13, df = 1, p = .0003); RAAPS was used to direct risk behavior discussions with patients (McNemar χ2 = 12, df = 1, p = .0005); RAAPS gave adolescents an opening for discussion of their behaviors and experiences (McNemar χ2 = 6.23, df = 1, p = .01); and RAAPS is easy to use (McNemar χ2 = 3.77, df = 1, p = .05).

      Qualitative Results

      Providers’ general perceptions of the RAAPS

      Providers’ qualitative comments indicated that the RAAPS was viewed overall as an effective adolescent assessment and communication tool. One provider summed up the benefits of the RAAPS by saying that the RAAPS is: “Quick, efficient . . . helps get to the heart of the matter in a way that is engaging to adolescents, using a vehicle with which they are comfortable (computer) . . . and I believe that this piece alone helps them share in ways that they might not otherwise.”

      Identification of risk

      Providers pointed out the ease of using the RAAPS to identify risk behaviors with comments such as, “It has helped to identify students at risk and helped me keep these issues upfront,” and “Improved identification of risk factors leading to face to face interview/assessment,” and “Patient acknowledges his/her own concerns; self-disclosure without pressure.” In addition, providers indicated “(RAAPS) makes it easier for me to come right out and ask the questions that I am thinking . . . for the students to answer honestly too,” “I used to dread coming up with a way to discuss risk behaviors. The RAAPS gives me a way to not only bring it up, but identify risky behaviors that warrant intervention,” and “Has given important info that would otherwise go undetected.”
      The RAAPS was also consistently noted as being easy to use, concise, and comprehensive. Providers described the RAAPS as, “Easy for the children to read and understand; Easy to quickly see red flags for discussion; Easy to understand questions; comprehensive yet brief, straightforward, non-judgmental.” They also said it was:“. . . easy for me to evaluate” and “I like the fact that you can visually scan the columns and all risk factors are in a line for easy viewing” and “Documenting intervention on the form makes follow-up easy.” In addition, many liked the Web-based version of the RAAPS, saying that since the RAAPS is: “on the computer (not face to face answering questions), maybe they [teens] feel more comfortable being honest.”

      Facilitation of risk discussions

      Providers believed that the RAAPS facilitated risk discussions with adolescents in numerous ways. They noted that the “(RAAPS) acts as a launching tool for discussion and intervention regarding risk behaviors,” “It has given me a starting point with students that I am unfamiliar with,” and “gives this provider justification to address, educate, and refer adolescents.” Many providers shared that the RAAPS “opens door for discussion,” “presents opportunities for teens to ask questions,” and “provides a consistent ‘opening’ to address risky behaviors, ask about possible issues and generally address intimate issues.” In addition, sensitive topics are easier to discuss as evidenced by comments such as, “It assists in developing a relationship and trust with my patients,” “It puts sensitive topics right out on the table for discussion and helps clients feel comfortable discussing topics that impact greatly on their overall health,” “It makes discussing sensitive subjects less embarrassing for students and staff,” and “The student completes the survey, so the topics are on their minds…helps students have a voice for topics they may be shy of discussing.” Lastly, comments such as the RAAPS “provides more information to help guide intervention and increases opportunities to provide health guidance and education” show the impact the RAAPS can have on improving patient outcomes related to their risk behaviors.

      Efficiency and consistency in assessment

      Strengths of the RAAPS were identified by many providers as “Quick; concise; efficient; fast; easy to interpret,” “The RAAPS definitely speeds the process and is a very efficient tool,” and “It’s quick for adolescents to fill out in the office” and “Format is quick and easy to look over.” Providers believed that by using the RAAPS, “More frequent screenings are possible,” and “(RAAPS) opens the door to risk discussions without having to ask each question verbally.” Many providers also shared the feeling that the RAAPS “Saves time…more time-efficient for my practice and yet effective.” In addition, RAAPS helps to reduce disparities in risk assessment provided to different adolescent populations. When using the RAAPS: “All adolescents are screened in the same manner by all …providers here,” and “Because it’s a standard form that every student gets… it helps with asking difficult questions without making kids feel weird about it,” and “Allows for more thorough risk assessment on EVERY adolescent.”

      Areas for improvement

      Some providers listed limitations or areas to change in the RAAPS, including: it was not as comprehensive as other assessment tools; not having time to complete and to address risk behaviors identified; and concerns that adolescents would not answer honestly. For example, some providers noted that they did not use the RAAPS because they used other assessment forms, such as the GAPS form. One provider stated: “We are using the GAPS form . . . a more in depth form and really creates an atmosphere for adolescents to expand on their answers and opens up the lines of communication for a more detailed educational response.” However, others found the RAAPS to be a more efficient tool than the GAPS and said: the “. . . GAPS puts teens off and starts the visit off on negative note as many were not happy about filling out such a long form.”
      It was also noted by providers that some history information was not included on the RAAPS, such as more details on risk behaviors, general health, mental health, resiliency, body size, and treatment for sexually transmitted infection. Health care providers expressed concerns about needing to clarify sensitive issues, and one said: “Many students check that they are abused because they were in a fight at school. I have to spend a lot of time trying to determine if they are abused or not.” Another provider questioned applicability for certain populations when they said, “Some questions are not applicable for inner-city impoverished kids or kids 18 years and over, like helmet use. Also, in our clinic, diet concerns just are not a priority when STIs, pregnancy, and drug use are so prominent.” Issues were also raised about using the RAAPS with younger age groups and those with limited literacy. Several respondents wished for tools specific to younger age groups: “Would like an elementary age risk assessment please” and “Younger kids have different risks—more safety and less sexual.” Constructive suggestions were also made with regard to format, such as adding more room for recording, changing of wording for certain questions, and additional risk questions to add.

      Overall perception of the RAAPS

      At the end of the survey, providers were asked, “Is there anything else you would like to tell us about the RAAPS?” Providers were very positive, with many expressing “Thanks” for the development of the survey. One comment summarized some of the issues raised concerning implementation and the need for such a tool.I am a fan of the RAAPS survey. I wish it was more accepted here in (my state) as a screening tool. I think that more research needs to be conducted with regard to identification of risks and the promotion of positive health behaviors. I think that we also need to screen our patient’s strengths to help them understand the positive behaviors and resources that they employ.

      Discussion

      The majority of the RAAPS users from a wide range of practice sites were very positive in their assessment of the RAAPS as an efficient and easy-to-use tool both to identify high-risk behaviors of their adolescent patients and to facilitate discussion and communication with adolescents around these issues.
      The results of this study provide strong support for use of the RAAPS in clinical practice settings. The majority of the RAAPS users from a wide range of practice sites were very positive in their assessment of the RAAPS as an efficient and easy-to-use tool both to identify high-risk behaviors of their adolescent patients and to facilitate discussion and communication with adolescents around these issues. A large proportion of the providers (85%) believed that the RAAPS had positively influenced their practice with adolescent patients. The significant factors identified as affecting their practice were: identification of risk behaviors; ability to direct risk behavior discussions; giving the adolescents an opening for discussion of their behaviors and experiences; and ease of use.
      Implications for practice are significant in terms of working with individual adolescent patients to develop a better understanding of potential group education interventions in the practice setting and providing quality care to adolescent patient populations. The availability of a tool with demonstrated reliability and validity that is well accepted in the clinical practice setting promotes standardization of care so providers can efficiently and systematically assess all their adolescent patients for potential risk behaviors.
      Providers repeatedly stated that the RAAPS helped them initiate communication and identify risky behaviors that might otherwise go undetected. For instance, the RAAPS assisted providers in discussing sensitive topics with their adolescent patients and provided opportunities for teens to ask questions. Providing confidential preventive services through risk assessment and counseling has an additional benefit of establishing trust between the adolescent and the provider. This mutual alliance with the teens and their providers allows for disclosure of information about teen risk behaviors and provides an opportunity to seek advice. Research has shown that for sensitive topics such as sex, contraception, and sexually transmitted infections, adolescents consider their health care providers the most reliable sources of information, thus enhancing the effectiveness of preventive services (
      • Duncan P.M.
      • Garcia A.C.
      • Frankowski B.L.
      • Carey P.A.
      • Kallock E.A.
      • Dixon R.D.
      • Shaw J.S.
      Inspiring healthy adolescent choices: A rationale for and guide to strength promotion in primary care.
      ;
      • Elster A.B.
      Comparison of recommendations for adolescent clinical preventive services developed by national organizations.
      ;
      • Elster A.B.
      • Levenberg P.
      Integrating comprehensive adolescent preventive services into routine medicine care: Rationale and approaches.
      ). For many adolescents, a health care provider is the primary adult they can confide in about health concerns and health risk behaviors (
      • Levenberg P.B.
      GAPS: An opportunity for nurse practitioners to promote the health of adolescents through clinical preventive services.
      ;
      • Schaeuble K.
      • Haglund K.
      • Vukovich M.
      Adolescents’ preferences for primary care provider interactions.
      ). Identifying and discussing risk behaviors can be a comfort to adolescents who may have no other source of information or support (
      • Bartlett R.
      • Holditch-Davis D.
      • Belyea M.
      Problem behaviors in adolescents.
      ). Furthermore, when providers are able to identify and discuss risk behaviors during health care visits, teens learn that their behaviors are legitimate health care concerns and their health care providers are open to talking with them about these topics (
      • Harrison P.A.
      • Beebe T.J.
      • Park E.
      • Rancone J.
      The adolescent health review: Test of a computerized screening tool in school-based clinics.
      ).
      Using a tool like the RAAPS could also prevent the bias that has been identified in the literature both in terms of assumptions made by providers about who should be screened for risk and with respect to practice variations based on gender or provider experience. This systematic approach to assessment also facilitates implementation of the current national screening recommendations in a brief and time-efficient format. Thus the use of the RAAPS can help enhance the quality of care in clinical practice.
      Further research is needed to understand ways the RAAPS can be used to identify and then intervene with at risk youth. Providers commented that the RAAPS provides an excellent way to identify risk behaviors and open the discussion, but the actual intervention/risk reduction counseling is dependent on the provider’s skill. Approaches such as Motivational Interviewing have been shown to be effective in work with adolescents (
      • Bernstein E.
      • Edwards E.
      • Dorfman D.
      • Heeren T.
      • Bliss C.
      • Bernstein J.
      Screening and brief intervention to reduce marijuana use among youth and young adults in pediatric emergency department.
      ;
      • Black M.M.
      • Hager E.R.
      • Le K.
      • Anliker J.
      • Arteaga S.S.
      • DiClemente C.
      • Wang Y.
      • et al.
      Challenge! Health promotion/obesity prevention mentorship model among urban, black adolescents.
      ;
      • D’Amico E.
      • Miles J.N.V.
      • Stern S.A.
      • Meredith L.S.
      Brief motivational interviewing for teens at risk of substance use consequences: A randomized pilot study in a primary care clinic.
      ;
      • Kiene S.M.
      • Barta W.D.
      A brief individualized computer-delivered sexual risk reduction intervention increases HIV/AIDS preventive behavior.
      ;
      • McCambridge J.
      • Strang J.
      The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: Results from a multi-site cluster randomized trial.
      ;
      • Monti P.M.
      • Barnett N.P.
      • Colby S.M.
      • Gwaltney C.J.
      • Spirito A.
      • Rohsenow D.J.
      • Woolard R.
      Motivational interviewing versus feedback only in emergency care for young adult problem drinking.
      ;
      • VanVoorhees B.W.
      • Fogel J.
      • Reinecke M.A.
      • Gladstone T.
      • Stuart S.
      • Gollan J.
      • Bell C.
      • et al.
      Randomized clinical trial of an internet-based depression prevention program for adolescents (PROJECT CATCH-IT) in primary care: 12 week outcomes.
      ). Event History Calendars are another effective approach to more fully involve high-risk adolescents in the discussion of their sexual risk behaviors and to help them focus on their goals (
      • Martyn K.K.
      • Reifsnider E.
      • Murray A.
      Improving adolescent sexual risk assessment with event history calendars: A feasibility study.
      ;
      • Martyn K.K.
      • Darling-Fisher C.
      • Pardee M.
      • Ronis D.L.
      • Felicetti I.L.
      • Saftner M.A.
      Improving sexual risk communication with adolescents using event history calendars.
      ;
      • Martyn K.K.
      • Saftner M.A.
      • Darling-Fisher C.
      • Schell M.
      Sexual risk assessment using event history calendars with male and female adolescents.
      ). Research that uses the RAAPS to identify youth at risk combined with “adolescent friendly” intervention strategies to promote behavior change is needed to determine ways in which providers can best affect these risk behaviors.
      Although the RAAPS is an excellent tool to identify the major risk behaviors in adolescents, it is not a comprehensive assessment tool. As several providers commented, a number of areas are not included in the RAAPS, such as school performance and general health. The RAAPS does not take the place of a full history; however, it does allow all adolescents and their providers (regardless of their comfort with this population) to identify risk behaviors in an easy and efficient fashion. Although this study provided input from a wide range of providers across the United States, it was limited in that a majority of the providers were nurse practitioners who currently worked with adolescent patients in school-based settings in the Midwest. Additional research with physicians and physician assistants and other providers in outpatient or community clinics in other areas of the United States may be warranted. However, the positive response from a significant number of experienced adolescent providers provides strong support for broader implementation of the RAAPS in adolescent health care. In this era of managed care, health assessment and preventive services are increasingly needed to improve adolescent health and reduce costs (
      • Harrison P.A.
      • Beebe T.J.
      • Park E.
      • Rancone J.
      The adolescent health review: Test of a computerized screening tool in school-based clinics.
      ;
      • Institute of Medicine & National Research Council
      The science of adolescent risk-taking workshop report.
      ). Health care providers need to consider the interrelatedness of health risk behaviors among their adolescent patients with various behavioral risks (

      Fox, H. B., McManus, M. A., & Arnold, K. N. (2010). Significant multiple risk behaviors among U.S. high school students (Fact Sheet No. 8). Retrieved from http://www.thenationalalliance.org.

      ). Use of the RAAPS as a standard component of adolescent health care practice can help achieve these goals.
      This study has shown that the RAAPS risk screening tool was able to identify and facilitate risk behavior discussions between health care providers and adolescents in a time-efficient manner. Use of the RAAPS could lead to more effective adolescent preventive services by providing a tool to systematically assess and identify those adolescents in need of specific services. This may reduce the documented disparities that occur in identification of risk. This may also allow health care providers to tailor the education provided to adolescent patients with the ultimate goal of decreasing their morbidity and mortality and improving their overall health.

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      Biography

      Cynthia S. Darling-Fisher, Clinical Assistant Professor, Health Promotion and Risk Reduction Programs at the University of Michigan, School of Nursing, North Ingalls, Ann Arbor, MI.
      Jennifer Salerno, Director, Regional Alliance for Healthy Schools (RAHS), University of Michigan Health System, and Clinical Adjunct Faculty, University of Michigan School of Nursing, North Ingalls, Ann Arbor, MI.
      Chin Hwa Y. Dahlem, Clinical Assistant Professor, Health Promotion and Risk Reduction Programs at the University of Michigan, School of Nursing, North Ingalls, Ann Arbor, MI.
      Kristy K. Martyn, Associate Professor and Chair, Health Promotion and Risk Reduction Programs at the University of Michigan, School of Nursing, North Ingalls, Ann Arbor, MI.