title: Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.
abstract: OBJECTIVE
  To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health.
  
  
  METHODS
  Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not.
  
  
  METHODS
  General practices in metropolitan and rural Victoria, Australia.
  
  
  METHODS
  General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients.
  
  
  METHODS
  This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening.
  
  
  METHODS
  Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data.
  
  
  RESULTS
  42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0.52, CI 0.28 to 0.96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0.66, CI 0.46 to 0.96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0.40, CI 0.20 to 0.80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool.
  
  
  CONCLUSIONS
  A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits.
  
  
  BACKGROUND
  ISRCTN.com ISRCTN16059206.
authors.affiliation: Department of General Practice, Melbourne Medical School, The University of Melbourne, 200 Berkeley St., Carlton, VIC, 3053, Australia.
authors.forename: Lena
authors.initials: L
authors.lastname: Sanci
authors.affiliation: Department of General Practice, Melbourne Medical School, The University of Melbourne, 200 Berkeley St., Carlton, VIC, 3053, Australia.
authors.forename: Patty
authors.initials: P
authors.lastname: Chondros
authors.affiliation: Centre for Adolescent Health, Royal Children's Hospital, 50 Flemington Rd., Parkville, VIC, 3052, Australia; Department of Paediatrics, The University of Melbourne, VIC, 3010, Australia; Murdoch Children's Research Institute, 50 Flemington Rd., Parkville, VIC, 3052, Australia.
authors.forename: Susan
authors.initials: S
authors.lastname: Sawyer
authors.affiliation: Melbourne School of Population and Global Health, Level 5, 207 Bouverie St., The University of Melbourne, VIC, 3010, Australia.
authors.forename: Jane
authors.initials: J
authors.lastname: Pirkis
authors.affiliation: Division of Adolescent & Young Adult Medicine, University of California San Francisco, San Francisco, 94118, United States of America; UCSF Office of Diversity and Outreach, University of California San Francisco, San Francisco, 94118, United States of America.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Ozer
authors.affiliation: Department of General Practice, Melbourne Medical School, The University of Melbourne, 200 Berkeley St., Carlton, VIC, 3053, Australia.
authors.forename: Kelsey
authors.initials: K
authors.lastname: Hegarty
authors.affiliation: Department of General Practice, Melbourne Medical School, The University of Melbourne, 200 Berkeley St., Carlton, VIC, 3053, Australia.
authors.forename: Fan
authors.initials: F
authors.lastname: Yang
authors.affiliation: Department of General Practice, Melbourne Medical School, The University of Melbourne, 200 Berkeley St., Carlton, VIC, 3053, Australia.
authors.forename: Brenda
authors.initials: B
authors.lastname: Grabsch
authors.affiliation: Centre of Excellence in Intervention and Prevention Science Limited, 15-31 Pelham St., P.O. Box 35, Carlton, VIC, 3053, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Shiell
authors.affiliation: Youth Research Centre, Melbourne Graduate School of Education, The University of Melbourne, 100 Leicester St., Carlton, VIC, 3053, Australia.
authors.forename: Helen
authors.initials: H
authors.lastname: Cahill
authors.affiliation: Division Interdisciplinaire de santé des adolescents, Centre Hospitalier Universitaire Vaudois Lausanne Switzerland, Av. De Beaumont 48, CH-101, Lausanne, Switzerland.
authors.forename: Anne-Emmanuelle
authors.initials: AE
authors.lastname: Ambresin
authors.affiliation: Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, 161 Barry St., Carlton, VIC, 3053, Australia.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Patterson
authors.affiliation: Centre for Adolescent Health, Royal Children's Hospital, 50 Flemington Rd., Parkville, VIC, 3052, Australia; Department of Paediatrics, The University of Melbourne, VIC, 3010, Australia; Murdoch Children's Research Institute, 50 Flemington Rd., Parkville, VIC, 3052, Australia.
authors.forename: George
authors.initials: G
authors.lastname: Patton
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003376:Counseling; D005260:Female; D058006:General Practice; D058005:General Practitioners; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D062405:Motivational Interviewing; D063868:Patient Outcome Assessment; D010820:Physicians; D011320:Primary Health Care; D012309:Risk-Taking; D014739:Victoria; D055815:Young Adult