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School-based Health Centers, Computer-delivered Health Care, and the Value of the Warm Handoff: Optimizing Behavioral Interventions for At-risk Adolescents

      See Related Article on p.577
      The changing landscape of health care and the rapidly shifting circumstances during the COVID-19 pandemic have challenged the delivery of health services. In striving for access and autonomy for adolescents and young adults, providers have used some unique and promising means to deliver health care. In the past decade, there has been increased application of computer-facilitated or social media–assisted health care [
      • Williams J.
      The Evidence-based Synthesis Program (ESP) Center Durham Veterans Affairs Healthcare System Durham, N. C
      Computerized cognitive behavioraltherapy for adults with depressive or anxiety disorders.
      ]. Computerized care delivery may reduce logistical barriers, privacy concerns, cost, and time burdens to providers and patients. There is an increasing body of evidence regarding the effectiveness of computer-based interventions for substance use disorders and mixed data for mood disorders that shows computer-based interventions generally prevailed over control groups that received no interventions; however, the data for other health conditions and settings are still emerging [
      • Harris S.K.
      • Sherritt L.
      • Grubb L.
      • et al.
      Practical tools to support adolescent substance abuse prevention in primary care: A multi-site randomized controlled trial of computer-facilitated screening and provider brief advice in the medical office.
      ,
      • Gibson E.B.
      • Knight J.R.
      • Levinson J.A.
      • et al.
      Pediatric primary care provider perspectives on a computer-facilitated screening and brief intervention system for adolescent substance use.
      ]. Before we embrace widespread computer utilization in health care, we need data regarding its effectiveness and appropriateness in different settings with different populations.
      Recently, with swings in political temperaments and rapid changes during the pandemic, there have been exciting developments as providers quickly pivot to provide high-quality care or continue research with minimal disruption. Barney et al. switched quickly from in-person recruitment to an internet platform to engage participants for a pregnancy prevention program and experienced higher recruitment in a shorter time with a more diverse population and geographic catchment with significant cost savings [
      • Barney A.
      • Rodriguez F.
      • Schwarz E.B.
      • et al.
      Adapting to changes in teen pregnancy prevention research: Social media as an expedited recruitment strategy.
      ]. Another recent study showed that recruitment of adolescents and young adults for a behavioral sexually transmitted infection (STI) intervention trial using social media is feasible, has lower direct costs, and results in similar outcomes compared with clinic-based recruitment [
      • Woods C.
      • Yusuf H.
      • Matson P.
      • et al.
      Social media versus traditional clinic-based recruitment for a dyadic sexually transmitted infection prevention trial: Results from the sexperience study.
      ].
      In this issue, Anjalee Sharma et al. add interesting information by comparing the effectiveness of offering STI testing at school-based health centers (SBHCs) via two formats: computer-delivered behavioral intervention (CBI) and nurse practitioner–delivered behavioral intervention (NBI) [
      • Sharma A.
      • Mitchell S.G.
      • Nordeck C.D.
      • et al.
      Sexually transmitted infection (STI) testing after brief intervention for risk behaviors in school-based health centers (SBHCs).
      ]. The authors analyzed the receipt of STI testing across several variables including SBHC site, gender, relationship status, and other risk factors (unprotected intercourse, use of impairing substance before intercourse). Sharma et al. culled these data from a larger study of at-risk youth with risky alcohol or cannabis use who received CBI or NBI. Overall, the authors found that CBI is overall cost-effective, but resulted in less STI testing among participants than the NBI groups (adjusted odds ratio of 2.51) [
      • Gryczynski J.
      • Mitchell S.G.
      • Schwartz R.P.
      • et al.
      Computer- vs. nurse practitioner-delivered brief intervention for adolescent marijuana, alcohol, and sex risk behaviors in school-based health centers.
      ]. Although CBI recommended and offered STI testing, participants still had to initiate such testing. In working with nurse practitioners (NPs), students may have benefited from developing rapport and being able to ask questions and engage with NPs in making care choices. Most participants also opted for STI testing through the SBHCs, indicating that there may be unmet needs in the community, and the significant difference in testing rates among CBI and NBI groups shows that youth may still need to work with trusted providers to achieve their health goals.
      Overall, this study shows the value of SBHCs in providing vital interventions and services to high-risk student populations and the significance of having a therapeutic alliance with human providers to mitigate risk behaviors through longer-term engagement and health education. As we continue to struggle with primary care access, especially during the pandemic, we may consider novel approaches such as using computer platforms for history taking and health screenings and engage NPs and other advanced practice providers to deliver care and interventions [
      • Santa Maria D.
      • Guilamo-Ramos V.
      • Jemmott L.S.
      • et al.
      Nurses on the front lines: Improving adolescent sexual and reproductive health across health care settings.
      ]. This study adds to the variety of settings and circumstances to trial computer-based health care delivery, which can be effective and practical in adolescent health care and shows the enduring significance of human interactions.

      References

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        • The Evidence-based Synthesis Program (ESP) Center Durham Veterans Affairs Healthcare System Durham, N. C
        Computerized cognitive behavioraltherapy for adults with depressive or anxiety disorders.
        Department of Veterans Affairs, 2013
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        • Sherritt L.
        • Grubb L.
        • et al.
        Practical tools to support adolescent substance abuse prevention in primary care: A multi-site randomized controlled trial of computer-facilitated screening and provider brief advice in the medical office.
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        Adapting to changes in teen pregnancy prevention research: Social media as an expedited recruitment strategy.
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        • Woods C.
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        Social media versus traditional clinic-based recruitment for a dyadic sexually transmitted infection prevention trial: Results from the sexperience study.
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