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d

Promoting Wellness—What Works in Managed Care (aka Prevention)

B1041. R. Thomas, J. Cahill, and L. Santilli (1997) Using an interactive computer game to increase skill and self-efficacy regarding safer sex negotiation: Field test results. HEALTH EDUCATION & BEHAVIOR 24(1):71-86.

• Summary: Although youth in their 20s have the highest incidence of preventable sexually-transmitted conditions, including unwanted pregnancy, the behaviors that place them at risk often begin during adolescence. An interactive "Life Challenge" game teaches and reinforces abstinence and condom negotiation skills among youth at highest risk for these conditions. Field tests in Job Corps sites, community-based organizations and addiction clinics found that even "tough" youth took the negotiation tasks seriously and achieved statistically relevant gains in knowledge and self-efficacy after playing the game on a CD-ROM at a kiosk for 40-to-50 minutes. Feedback indicated that the youth particularly valued hearing their own voices and words incorporated into the game. This issue of HEALTH EDUCATION & BEHAVIOR describes additional efforts to use computer-based preventive health tools among adolescents at risk for sexually-transmitted conditions, including one using a videodisk and a British entry based on 3.5" diskettes. Unlike "Life Challenge," the focus of most games appears to be on teaching dire consequences rather than practicing negotiation skills; detailed outcomes were not available but the UK authors admitted that one-third of the youth found at least parts of the game to be "patronizing."

Comment: "Life Challenge," developed by the New York State health department, is potentially a useful, inexpensive addition to health fairs and in-clinic health education because it provides personalized education on sexual issues without requiring an hour of staff time with each client.

B1042. WHO Brief Intervention Study Group (1996) A cross- national trial of brief interventions with heavy drinkers. AMERICAN JOURNAL OF PUBLIC HEALTH 86(7):948-955.

• Summary: Describes a randomized clinical trial in eight countries comparing effects on the behavior of heavy drinkers of "simple advice" and brief counseling sessions. Screenings indicated a population who (a) averaged high levels of daily alcohol consumption or (b) were frequently intoxicated and at risk for arrest, accidents, or work-related problems. Patients were excluded for (a) current pregnancy, history of serious mental illness or alcohol dependence, or other reason to completely avoid alcohol, (b) age <18 or >70 years, and (c) social/residential instability (e.g., shelter residents, homeless, etc.). All participants received an illustrated booklet describing the choices of total abstinence and a low-risk drinking goal. Five-minute "advice" and 15-minute "brief counseling" strategies were chosen as the upper and lower range of efforts that can be expected from primary care personnel in a health screening. At some sites , patients receiving "brief counseling" returned for 5-to-15 minute follow-up visits at 30, 90, and 180 days after the intervention. Nine months after initial intervention, 28% of men with average daily consumption greater than 40 g of ethanol drank within "moderate" limits. Controls with no intervention continued to drink at "risky" levels. Results were consistent across all cultures, ranging from Mexico and Kenya to Russia and the US. The two intervention strategies achieved similar results; a larger number of female clients exposed to brief counseling chose abstinence, but there were too few women in either category to make a statistically relevant assessment.

Comment: This clinical trial proves that advice and intervention in a clinical setting do not have to be complicated or time-consuming to produce clinically-relevant changes in drinking behavior. Given that most adults with alcohol-related problems are NOT alcohol- dependent, the fact that five minutes of advice and a pamphlet transformed nearly a third of heavy drinkers into consumers of moderate and light amounts of alcohol promises significant cost savings for health care providers.

B1043. K. Resnicow, R. Vaughan, R. Futterman, R.E. Weston, J. Royc, C. Parms, M.D. Hearn, M. Smith, H.P. Freeman, and M.A. Orlandi. (1997) A self-help smoking cessation program for inner-city African Americans: Results from the Harlem Health Connection Project. HEALTH EDUCATION & BEHAVIOR 24(2):201-217.

• Summary: Report on a culture-specific smoking cessation program for African-Americans using a video and printed guide provided during a home visit and a telephone booster call. The health education materials used Prochaska's "readiness to change" concepts. Participants were recruited in churches, primary care settings, and housing projects. After six months, self-report indicated that the intervention participants overall did not evidence statistically higher rates of smoking cessation than a comparison group that received no intervention. However, among participants recruited in health care settings, 18% of the participants who received a booster call reported quitting after six months compared to 11% who received health education materials but no call and 9% of the comparison group. About one-fourth of the participants, including most with the lowest incomes, could not be reached by telephone for the booster call.

Comment: While a readiness-to-change self-help program with a booster call doubled the self-reported quit rate among African- Americans smokers, we don't know if targeting health education specifically to African-Americans was important. The one-fourth of the participants who face the greatest health risks from tobacco use often missed that critical booster call. Managed care organizations using wellness programs based on telephone contacts should remember that a significant percentage of the Medicaid population may not be reachable via a telephone! Also, plan on modest expectations: even among those receiving the full intervention, 4 out of 5 participants continued to smoke after six months.

B1044. D. Mechanic (1998) Topics for our times: Managed care and public health opportunities. AMERICAN JOURNAL OF PUBLIC HEALTH 88(6):874-875 (June).

• Summary: Think piece briefly outlines "the economic value of public health activities within the medical marketplace" and suggests taxing health insurance premiums to ensure equitable distribution of the burden and rewards of public health among managed care entities. The author points out that "such direct taxation faces strong resistance," but the alternative according to the author, is that "as managed care is extended to cover more individuals with chronic diseases and disabilities, and as public sector services are privatized...costs may be shifted to families, human service organizations, and other public programs."

Comment: Succinctly makes the case for ensuring that managed care supports prevention, but doesn't discuss the potential downside of keeping control of preventive care in the hands of the public sector rather than transferring more responsibility to the private sector.

B1045. C.K. Ewart, D.R. Young, and J.M. Hagberg (1998) Effects of school-based aerobic exercise on blood pressure in adolescent girls at risk for hypertension. AMERICAN JOURNAL OF PUBLIC HEALTH 88(6):949-955 (June).

• Summary: 44 9th grade girls (70% African-American) in the top third of normal distribution for systolic or diastolic blood pressure received 18 weekly 50-minute aerobic exercise classes while 44 controls with similar blood pressure values took normal physical education classes. Mean systolic blood pressure for the aerobics group dropped from 120.0 to 114 during the classes; mean pressure for the physical education group dropped from 120.0 to 116.2. Aerobics class participants averaged a one-minute increase in step-test exercise duration, a measure of aerobic fitness, while the control group indicated a possible slight average decline in exercise duration during the same period. No significant differences between the two groups were found for diastolic blood pressure, pulse rate, or body mass.

Comment: Answers two questions about aerobics class as wellness: who MCOs should send to a class (answer: young enrollees with higher-than-average systolic blood pressure), and how much of the intervention is needed (answer: weekly 50-minute sessions). Given findings on exercise and mental health status, it may be interesting to add a depression screening to the before/after findings of future studies.

B1046. K.C. Davis, M.E. Cogswell, S.Lee, R. Rothenberg, and J.P. Koplan (1998) Lipid screening in a managed care population. PUBLIC HEALTH REPORTS 113(4):346-350.

• Summary. A retrospective medical record review of patients aged 40 to 64 years with five or more years enrollment at three Prudential HealthCare HMO/POS sites (2 group model and 1 IPA) found that blood cholesterol levels were recorded for 84 percent of the patients and 67 percent recorded high density lipoprotein (HDL) levels. This is significantly higher than the Year 2000 target objective. Most importantly, records for 56 percent of the patients with elevated cholesterol documented clinician counseling on physical activity and 83 percent documented clinician counseling on diet. In discussion, however, the authors caution that 20 percent of the enrollee medical records selected randomly for inclusion in the analyses could not be located during the study period.

Comment: Although this is not specifically behavioral health promotion, the article documents that both staff model and IPA model HMOs regularly document clinician counseling on lifestyle changes in enrollee medical records, and that screening rates and lifestyle counseling rates for at least some conditions are high in at least one for- profit MCO. The study also shows that MCOs are less-than-perfect data sources for retrospective studies.

B1047. K.S. Courneya, P.A. Estabrooks, and C.R. Nigg (1997) A simple reinforcement strategy for increasing attendance at a fitness facility. HEALTH EDUCATION & BEHAVIOR 24(6):708-715.

• Summary: Most people who sign up for membership in a health club don't use the facility enough to obtain the various preventive health benefits; roughly half of all adults who begin a structured exercise program will drop out within 6 months. A clinical trial with random assignment determined that an offer of a one-month free membership for completing 12 or more work-outs in one month improves activity levels among fitness club members. The number of club members exercising 12 or more times per month increased 300% among those receiving the offer, while control and placebo groups exhibited no statistically significant change.

Comment: Discounted fitness club membership and exercise classes for enrollees are popular health promotion benefits for MCOs. In addition to the physical health benefits, regular exercise reduces stress levels and symptoms of chronic depression and anger management disorder, and may reduce craving for alcohol, tobacco, and drugs. For these benefits to occur, enrollees actually have to follow the regimen. This study documents that participation rates improve from positive reinforcement...and the authors suggest that t-shirts, food items, and additional discounts may be used for this purpose.

B1048. S.B. Fawcett, R.K. Lewis, A Paine-Andrews, V.T. Francisco, K.P. Richter, E.L. Williams, and B. Copple. (1997) Evaluating community coalitions for prevention of substance abuse: The case of Project Freedom. HEALTH EDUCATION & BEHAVIOR 24(6):812-829.

• Summary: This is a four-year, multilevel evaluation of the impact of the community coalition organized to reduce substance abuse in the Wichita area, one of the top-rated coalitions in the US. Community activity (mostly in form of regulatory changes) increased in years 2 and 3; no comparable increases were observed after the original executive director and community mobilization staff left and were replaced. Analyses found modest reductions in alcohol abuse, measured by the proxy of single-nighttime vehicle crashes in years two and three, and in regular teenage alcohol use. Marginal reductions in local marijuana and cocaine use may be attributed to the coalition. The authors conclude that "at least under some conditions, community coalitions can have an impact on community-level indicators of substance abuse."

Comment: After awarding at least $1 billion in grants for community substance abuse coalitions, Federal and State governments now are encouraging MCO support and involvement. Despite authors' conclusions, the very modest results of this model coalition and the fact that reduced substance abuse was associated with regulatory and enforcement changes rather than educational efforts casts doubt on whether coalitions represent a cost-effective investment of MCO prevention resources.

B1049. R.A. Bell and R. Alcalay (1997) . The impact of the Wellness Guide/Guia on hispanic women's well-being-related knowledge, efficacy beliefs, and behaviors: The mediating role of acculturation. HEALTH EDUCATION & BEHAVIOR 24(3):708-715. 

• Summary: The California Department of Mental Health distributed 100,000 copies of an 80-page self-care manual in 1993 to women attending health clinics under WIC. This Wellness Guide/Guia del Bienestar has two versions: one for women who were relatively comfortable in the dominant English-language culture and one for less acculturated women, defined by the use of Spanish in the home. The Guia is not a Spanish translation of The Wellness Guide: it uses different concepts, examples, and recommendations allegedly attuned to the Hispanic cultures of California. Baseline measures found that less acculturated women were less able to cope with health and life crises, in terms of knowledge of appropriate responses, ability to seek help, and a sense of helplessness. Two years after distribution of the manual, recipients indicated statistically significant gains in most of these measures, compared to controls without the manual. About 20% of both groups reported behavior changes due to the Guide. Users of the Guia del Bienestar reported lower scores for helplessness; respondents with a preference for English evidenced no change on this measure.

Comment: Some preventionists disparage the value of distributing Wellness Guides to MCO enrollees, but this large-scale multiyear study documents benefits from this type of intervention that are relevant to behavioral health. In particular, the less acculturated women who were less familiar with mainstream healthcare systems improved their ability to seek help effectively and to take control of their situation.

B1050. D. Neumark-Sztainer, M. Story, L.B. Dixon, and D.M. Murray (1998) Adolescents engaging in unhealthy weight control behaviors: Are they at risk for other health-compromising behaviors? AMERICAN JOURNAL OF PUBLIC HEALTH 88(6):952-955 (June).

• Summary: The answer to the question posed in the title, based on the national 1993 Youth Risk Behavior Survey, is "yes." Authors report particularly strong associations between extreme weight control measures (diet pills and self-induced vomiting) and suicide attempts, suicide ideation (girls only), tobacco use, alcohol use (among White and African-American youth only) and unprotected sexual activity (among all girls and among higher SES boys).

Comment: Adolescent weight control measures, including requests to MCOs to prescribe diet pills, might be helpful to flag potential early stage mental health/substance use cases...before they require hospitalization or other extensive care.