Provider,Patient, and Family Perspectives of Adolescent Alcohol Use and Treatment in Rural Settings

Purpose: We examined rural primary care providers’ (PCPs) self‐reported practices of screening, brief interventions, and referral to treatment (SBIRT) on adolescent alcohol use and examined PCPs’, adolescents’, and parents’ attitudes regarding SBIRT on adolescent alcohol use in rural clinic settings. Methods: In 2007, we mailed surveys that inquired about alcohol‐related knowledge, attitudes, and treatment practices of adolescent alcohol use to all PCPs in 8 counties in rural Pennsylvania who may have treated adolescents. We then conducted 7 focus groups of PCPs and their staffs (n = 3), adolescents (n = 2), and parents (n = 2) and analyzed the narratives using structured grounded theory, evaluating for consistent or discordant themes. Results: Twenty‐seven PCPs from 7 counties returned the survey. While 92% of PCPs felt that routine screening for alcohol use should begin by age 14, 84% reportedly screened for alcohol use occasionally, and reportedly 32% screened all adolescent patients. The provider focus groups (n = 20 PCPs/staff) related that SBIRT for alcohol use for adolescents was not currently effective. Poor provider training, lack of alcohol screening tools, and lack of referral treatment options were identified barriers. Adolescents (n = 12) worried that physicians would not maintain confidentiality. Parents (n = 12) acknowledged a parental contribution to adolescent alcohol use. All groups indicated computer‐based methods to screen for alcohol use among adolescents may facilitate PCP engagement. Conclusions: Despite awareness that rural adolescent alcohol use is a significant problem, PCPs, adolescents, and parents recognize that SBIRT for adolescent alcohol use in rural PCP settings is ineffective, but it may improve with computer‐based screening and intervention techniques.     

Association between drug, alcohol and tobacco use in adolescents and socio-familiar factors

Substance abuse is the result of interaction between constitutional, environmental and socio-demographic factors. Several studies have been demonstrated that the adolescent substance abuse is a serious and growing problem. The aim of our study is to investigate the association between substance, alcohol and tobacco abuse and socio-familiar factors, to evaluate a substance abuse prevention program which decreases substance use in adolescents. A cross-sectional survey was developed and carried out by involving a group of adolescents, randomly selected from the secondary school of Teramo province. Data were collected by a self-administered questionnaire. The associations between substance use and the determinants taken into account was evaluated by the chi-square test of Fisher exact test or trend test when appropriated. Our data show that the alcohol abuse is more frequent in males (41.1%, p = 0.000), while the nicotine abuse is more frequent in females (46.1%, p = 0.005). However, our results show that the abuse of alcohol, nicotine, heroine, cocaine and ecstasy is associated to lack of stability in the family, respectively: 61.5% (p = 0.001); 61.5% (p = 0.022); 7.7% (p = 0.018); 7.7% (p = 0.010): 7.7% (p = 0.004). The nicotine abuse is higher in adolescents living with a smoker: 50.3% (p = 0.000). Finally, the substance abuse is higher in adolescents having friends that are drug-addicts, in particular: alcohol 49.6% (p = 0.000), nicotine 43.0% (p = 0.000), cannabis 27.9% (p = 0.000). This survey suggests that the knowledge of factors influencing the initiation, combination and cessation of the use of substance is crucial for the prevention of drug use among adolescents.     

Primary care physicians’ screening of adolescent patients: a survey of California physicians

Purpose: To determine how often primary care physicians screen adolescents for important risk factors and to determine how rates of screening vary by physicians' specialty and practice setting, patients' age, and type of risk factor.

Methods: A stratified random sample of 343 California physicians who are Board certified in pediatrics, family practice, or internal medicine, and physicians in these specialties who specialized in adolescent medicine were surveyed about their screening practices using a mailed questionnaire. Subjects were asked the percentage of routine comprehensive physical examination during which they personally queried or screened each age group of adolescents (11-14 years old and 15-18 years old) for each of the following risk factors: high blood pressure, alcohol use, cigarette use, sexual activity, and drug use.

Results: The frequency with which primary care physicians reported actually screening younger and older adolescents for the various risks were approximately: 93% and 96% for high blood pressure, 70% and 84% for alcohol use, 74% and 82% for drug use, 67% and 83% for sexual activity, and 76% and 86% for smoking, respectively. For all risk factors, providers screened older adolescents more frequently than younger adolescents (p < 0.01). Finally, screening rates varied by specialty (p < 0.01) but not by practice setting.

Conclusions: This study found that California physicians frequently screen adolescents for a variety of risk factors. However, the reported rates may not be consistent with published guidelines. Interventions may need to be developed which focus on improving primary care physicians' adolescent-specific screening practices.     

Provider self-efficacy and the screening of adolescents for risky health behaviors.

PURPOSE: To examine the extent to which providers' perceived self-efficacy to deliver adolescent preventive services relates to their screening practices. METHODS: Screening rates were determined by both provider self-reported screening practices and the independent report of the adolescent patient. First, 66 pediatric providers (pediatricians and nurse-practitioners), working in three pediatric clinics within a managed care organization, completed surveys assessing: (a) self-efficacy for screening adolescent patients in the areas of tobacco use, alcohol use, sexual behavior, seat belt use, and helmet use; and (b) self-reported screening of adolescents during well-visits over the past month. Second, a sample of patients, aged 14 years to 16 years, reported on whether their clinicians screened them for these behaviors during a well-visit. Adolescents completed reports (N = 323) immediately following the well visit. Data were analyzed using Pearson product-moment correlation coefficients. RESULTS: Provider self-efficacy to deliver preventive services was correlated with self-reported screening in each of the five content areas, ranging from r = .24 (p < .05) for seat belt use to r = .51 (p < .001) for helmet use. Provider self-efficacy was significantly related to adolescent reports of screening in three of the five content areas; r = .25 (p < .05) for sexual behavior and tobacco use; and r = .23 (p = .06) for alcohol use. CONCLUSIONS: Providers' self-efficacy to screen adolescents for risky behaviors was significantly related to both clinician self-report and independent adolescent reports of screening during well-visits. These findings point to the importance of enhancing clinicians' sense of competence to deliver adolescent preventive services.     

Do adults who believe in periodic health examinations receive more clinical preventive services?

BACKGROUND: Individuals who have periodic health examinations ("check-ups") with physicians even if they feel well have higher rates of screening and other preventive services than individuals who only see physicians when ill. This study assessed whether individuals' beliefs about the advisability of periodic health examinations contribute to the likelihood that they receive recommended clinical preventive services. METHODS: This study used data from a 2002-2003 telephone survey of adults in 150 rural counties in 8 states of the U.S. southeast. Weighted Chi-square and logistic regression analyses were used to assess associations between attitudes towards periodic health examinations and the receipt of preventative services. RESULTS: Of the 4879 respondents, 37% were African American, and 43% had annual household incomes of less than $25,000. A total of 8.5% (n=374) did not endorse periodic health examinations. Not endorsing periodic examinations was more common among subjects who were male, younger, white and had no health insurance. Compared to those who endorsed periodic examinations, persons who did not were less likely to have had a periodic examination (42% versus 80%, p<0.001) or mammogram (28% versus 60%, p<0.001) in the previous year, a Pap smear in past 3 years (74% versus 90%, p<0.001), a cholesterol check in the last 5 years (56% versus 81%, p<0.001) or to ever have had endoscopic screening (28% versus 48%, p<0.001). These rate differences remained after adjusting for sociodemographic characteristics. CONCLUSION: People's beliefs about the value of periodic health examinations are associated with the likelihood that they receive recommended preventative services. Understanding individuals' beliefs about health, disease prevention and the role of physicians in prevention could lead to improved targeted interventions aimed at increasing uptake of preventative services.     

Healthcare Providers' Beliefs and Attitudes About Electronic Cigarettes and Preventive Counseling for Adolescent Patients

PurposeElectronic cigarettes (e-cigarettes) are battery-powered nicotine delivery systems that may serve as a “gateway” to tobacco use by adolescents. Use of e-cigarettes by U.S. adolescents rose from 3% in 2011 to 7% in 2012. We sought to describe healthcare providers' awareness of e-cigarettes and to assess their comfort with and attitudes toward discussing e-cigarettes with adolescent patients and their parents.MethodsA statewide sample (n = 561) of Minnesota healthcare providers (46% family medicine physicians, 20% pediatricians, and 34% nurse practitioners) who treat adolescents completed an online survey in April 2013.ResultsNearly all providers (92%) were aware of e-cigarettes, and 11% reported having treated an adolescent patient who had used them. The most frequently cited sources of information about e-cigarettes were patients, news stories, and advertisements, rather than professional sources. Providers expressed considerable concern that e-cigarettes could be a gateway to tobacco use but had moderately low levels of knowledge about and comfort discussing e-cigarettes with adolescent patients and their parents. Compared with pediatricians and nurse practitioners, family medicine physicians reported knowing more about e-cigarettes and being more comfortable discussing them with patients (both p < .05). Nearly all respondents (92%) wanted to learn more about e-cigarettes.ConclusionsHealthcare providers who treat adolescents may need to incorporate screening and counseling about e-cigarettes into routine preventive services, particularly if the prevalence of use continues to increase in this population. Education about e-cigarettes could help providers deliver comprehensive preventive services to adolescents at risk of tobacco use.     

Domestic violence compared to other health risks: a survey of physicians' beliefs and behaviors

BACKGROUND: Physicians routinely confront patient risk behaviors once considered private, including tobacco use, alcohol abuse, and HIV/STD-risk behavior. We compared physicians' behaviors and beliefs on screening and intervention for domestic violence with each other risk. METHODS: Survey of nationwide, random sample of 610 primary care physicians from the American Medical Association Physician Masterfile. RESULTS: Fewer primary care physicians screened for domestic violence than for other risks (p <0.001); once domestic violence was identified, however, physicians intervened with equal or greater frequency than for other risks. Fewer believed that they knew how to screen or intervene for domestic violence compared with other risks, and significantly fewer believed that domestic violence interventions were successful compared with interventions for tobacco and HIV/STD risks (Bonferroni adjusted p<0.001). CONCLUSIONS: Lower domestic violence screening rates may reflect physicians' beliefs that they do not know how to screen or intervene, and that interventions are less successful for domestic violence than for other risks. We may improve screening rates by educating physicians that a simplified role, as for other risks, can be effective for domestic violence.     

Age, health beliefs, and attendance to a mammography screening program in the community of Valencia

BACKGROUND: Age has a significant bearing on health beliefs related to participating in breast cancer screening programs. This study is aimed at analyzing the breast cancer-related beliefs and attitudes influencing screening program participation among different age groups. METHODS: In a transversal study, a comparison is drawn between the health-related beliefs of a group of women participating in a screening program and a group of non-participating women, taking into account three age ranges (under age 50 (N = 279), 50-60 age range (N = 463), and over age 60 (N = 271). RESULTS: Some variables significantly differ between the participating and non-participating women solely in certain subgroups: perceived severity (50-60 age group: F = 5.14; p < 0.01); perceived benefits (under age 50: F = 8, 18; p < 0.01; over age 60: F = 4.54; p < .05); mammogram-related attitude (under age 50: F = 56.67; p? .001; over age 60: F = 18.42; p < 0.001); professional health checkups (under age 50: F = 11.30: p < 0.01) and luck or chance (under age 50: F = 3.78; p < 0.05; 50-60 age group: F = 4.29; p < 0.001). More specific beliefs, assessed by items from these scales, are also statistically significant (p < 0.05), although only for certain age groups. CONCLUSIONS: Women's breast cancer prevention program participation related beliefs and/or attitudes differ in terms of their age.     

Reactions to a concept for physician intervention in adolescent alcohol use.

PURPOSE: This study was designed to understand adolescent and parental perceptions, receptivity, and reactions to the concept of screening and brief intervention that primary care physicians can use to reduce alcohol consumption by their non-alcohol-dependent adolescent patients. METHODS: A total of six nation-wide computer-assisted telephone focus groups were conducted; three with low-to-moderate risk for alcohol problems adolescents aged 15-17 years and three with parents of such adolescents. RESULTS: Parents and adolescents held similar views on the prevalence and harms of adolescent alcohol consumption, but different levels of concern about them. After initial surprise and needed dispelling of misconceptions, all groups expressed interest, support, and suggestions for the concept of a physician-initiated, office-based intervention to address younger adolescent alcohol use. CONCLUSIONS: Because both adolescents and parents of adolescents expressed interest in this type of intervention, physicians should be aware of this receptivity and consider focus group findings in how to structure development of a potential counseling-based intervention. Prior education about the target and nature of the intervention is necessary, lest adolescents and parents assume--incorrectly--that it is about doctors preaching to high-risk adolescents to stop drinking.     

Childhood abuse and adolescent suicidality: a direct link and an indirect link through alcohol and substance misuse

Childhood abuse is responsible for a variety of outcomes that are characterized by maladjustment and maladaption. Two of the most significant results are suicide and alcohol and substance misuse. This paper explores the direct link between childhood abuse and adolescent suicide, the direct link between childhood abuse and adolescent alcohol and substance misuse, the indirect link between childhood abuse and adolescent suicide through alcohol and substance misuse, and finally implications of these links for practitioners working with adolescents who are experiencing or who have experienced childhood abuse. Both suicide and alcohol and substance misuse are prevalent in the adolescent population; however those adolescents who were victims of childhood abuse show an even greater prevalence of both suicidality and substance and alcohol misuse. Additionally adolescents who exhibit alcohol or substance misuse show greater rater of suicidality than those without alcohol and substance misuse. It appears that abuse is a risk factor for eventual suicidality. Practitioners working with children or adolescents who have experienced abuse need to work towards secondary prevention by identifying, predicting and treating those at risk for substance abuse and/or suicide; and those working with adolescents who are already abusing substances and/or are suicidal should work with the adolescent to identify and examine life events such as abuse that may have triggered the chain towards substance misuse and/or suicidal ideation.     

Physicians' attitudes toward preventive care services: a seven-year prospective cohort study.

We report results of a seven-year prospective cohort study of physicians' attitudes about and intentions to provide 27 preventive care services in their future practices. Respondents in the cohort were surveyed three times: first, during orientation to medical school; second, during their third year of medical school; and finally, following completion of their third-year of residency training. The majority of preventive care services were viewed as more important to clinical practice in primary care than in non-primary care specialties. Positive attitudes toward preventive care services generally persisted among both primary and non-primary care physicians. Respondents expressed only fair to medium levels of confidence in the ability of physicians in their specialty areas to provide any of the preventive services examined. Respondents reported low levels of confidence in the ability of primary care physicians to provide nutritional counseling, though they ranked it as important. Respondents were fairly or moderately confident in the ability of primary care physicians to provide counseling about smoking cessation, health, AIDS education, and substance abuse. Participants ranked smoking cessation counseling, health counseling, AIDS education, cancer detection education, and substance abuse counseling and education as very important. In general, physicians were less likely to plan on providing preventive services than they were to expect their residency programs to prepare most or all to provide the services. Findings document the need to prepare physicians better to provide preventive services.     

New York City Physicians’ Views of Providing Long-Acting Reversible Contraception to Adolescents

PURPOSE

Although the US adolescent pregnancy rate is high, use of the most effective reversible contraceptives—intrauterine devices (IUDs) and implantable contraception—is low. Increasing use of long-acting reversible contraception (LARC) could decrease adolescent pregnancy rates. We explored New York City primary care physicians’ experiences, attitudes, and beliefs about counseling and provision of LARC to adolescents.

METHODS

We conducted in-depth telephone interviews with 28 family physicians, pediatricians, and obstetrician-gynecologists using an interview guide based on an implementation science theoretical framework. After an iterative coding and analytic process, findings were interpreted using the capability (knowledge and skills), opportunity (environmental factors), and motivation (attitudes and beliefs) conceptual model of behavior change.

RESULTS

Enablers to IUD counseling and provision include knowledge that nulliparous adolescents are appropriate IUD candidates (capability) and opportunity factors, such as (1) a clinical environment supportive of adolescent contraception, (2) IUD availability in clinic, and (3) the ability to insert IUDs or easy access to an someone who can. Factors enabling motivation include belief in the overall positive consequences of IUD use; this is particularly influenced by a physicians’ perception of adolescents’ risk of pregnancy and sexually transmitted disease. Physicians rarely counsel about implantable contraception because of knowledge gaps (capability) and limited access to the device (opportunity).

CONCLUSION

Knowledge, skills, clinical environment, and physician attitudes, all influence the likelihood a physician will counsel or insert LARC for adolescents. Interventions to increase adolescents’ access to LARC in primary care must be tailored to individual clinical practice sites and practicing physicians, the methods must be made more affordable, and residency programs should offer up-to-date, evidence-based teaching.Key words: intrauterine devices, contraceptive IUD, qualitative research, contraceptive devices, contraception, physicians, primary care, adolescent, delivery of health care, health services accessibility     

The influence of alcohol outlet density and advertising on youth drinking in urban Tanzania

Despite the detrimental effects of alcohol on adolescent health, high rates of alcohol use are reported among Tanzanian youth. We conducted systematic community mapping and participatory group activities with 177 adolescents in Dar es Salaam to explore how alcohol outlet density and advertising may contribute to adolescent drinking in urban Tanzania. Findings revealed a high density of alcohol-selling outlets and outdoor advertisements. The abundance of alcohol-related cues, including their close proximity to places where youth congregate, may facilitate and increase adolescent alcohol use in Tanzania. Participants recommended several changes to the alcohol environment to reduce adolescent drinking. Structural interventions that reduce adolescents' access and exposure to alcohol are needed in Tanzania.     

Barriers to adolescent prenatal care.

It is estimated that over one-half of all adolescent mothers receive inadequate prenatal care. Our objectives were to explore the barriers to care as perceived by adolescents and to develop a model to identify adolescents at risk for inadequate care. Structured interviews were conducted with 101 adolescents less than 17 years of age who delivered infants at an urban university hospital between September 1988 and January 1989. All the interviews were conducted within 48 hr of delivery by a single investigator. The Maternal Health Services Index was used to divide subjects into those who received inadequate care (Group 1, n = 37) and those who received intermediate or adequate care (Group 2, n = 64). Both groups were predominantly black (99%), poor (mean Hollingshead score = 2), and unmarried (99%). Groups 1 and 2 differed (p less than 0.05) in 12 variables pertaining to beliefs about prenatal care and course during the pregnancy. Of the 12 variables, 7 comprised a stepwise logistic regression model designed to maximally differentiate Groups 1 and 2--negative attitudes towards physicians (20% vs 6%), perceived importance of first trimester care (78% vs 94%), confusion about available prenatal services (24% vs 5%), lack of health insurance (41% vs 16%), exposure to pregnant friends (76% vs 95%), mean gestational age at recognition of pregnancy (15 wks vs 11 wks), and desire for an adolescent-only prenatal clinic (78% vs 58%). The adjusted odds ratios of the variables ranged in declining order from 15.4 to 4.7. The attributable risks, or etiologic fractions, of the variables ranged in increasing order from 0.19 to 0.49. Receiver-operating characteristic curve analysis of the model demonstrated a curve area of 0.89 +/- 0.04, significantly better than chance. We conclude that the model clarifies the barriers to care and helps identify pregnant adolescents who are likely to receive inadequate prenatal care.     

The illness burden of alcohol-related disorders among VA patients: the veterans health study

Little is known about the illness burden associated with alcohol-related disorders (ie, problem drinking, alcohol abuse, and alcohol dependence) among patients in outpatient medical care. The objective of this study was to examine several aspects of illness burden-medical comorbidities, patterns of health services use, and functional status-among Veterans Health Administration (VA) ambulatory care patients with alcohol-related disorders. Male participants (N = 2425) were recruited at 1 of 4 Boston-area VA outpatient clinics. They completed self-report screening measures of current alcohol-related disorders (CAGE score > or =2 with past year alcohol consumption), health behaviors, medical comorbidities, and functional status (SF-36). A medical history interview, which assessed comorbid conditions and use of recent health services, was also administered. Screening criteria for current alcohol-related disorders were satisfied by 12%; however, only 40% of these reported ever receiving treatment specifically for alcohol-related disorders. Patients who screened positive for alcohol-related disorders reported significantly greater limitations in mental health function, longer hospitalizations for medical care in the prior year, and fewer outpatient medical visits in the previous 3 months. Findings suggest considerable illness burden associated with alcohol-related disorders among VA ambulatory care patients. Efforts to increase detection and treatment of alcohol-related disorders may lessen the illness burden and cost of alcohol-related disorders.     

Parent Involvement in Health Concerns for Youth: The Issue of Adolescent Immunization

ABSTRACT: Parents play a primary role in the health and health education of their children. In particular, parent involvement in planning and promoting adolescent immunization campaigns is critical to successful efforts. Parents serve as their children's primary educators on health issues, but where can they get accurate health information? To help guide local PTA units in their programmatic efforts, the National PTA maintains positions and policy statements on multiple health issues: alcohol and other drug abuse; emergency preparedness; environmental issues; family life education; firearm safety; HIV prevention; health screenings; immunization (measles, mumps, rubella, and hepatitis B); lead poisoning; nutrition; protective helmet use; sexual assault prevention; TB testing; tobacco use and access; violence prevention; and youth suicide prevention. Likewise, the school-home partnership is key to promoting the health of adolescents. Comprehensive school health programs and integrated services are necessary to support parent and community efforts to promote adolescent health issues, including immunization programs. Techniques for effective parent involvement, based on the National Standards for Family/Parent Involvement issued by the National PTA January 1997, are discussed.     

The delivery of preventive services for patient symptoms

BACKGROUND: Although data are available on rates of delivery of preventive services by primary care physicians, the proportion of services delivered because of related symptoms or signs, rather than for primary or secondary prevention of disease is not known. METHODS: Research nurses directly observed 4454 consecutive visits to 138 practicing family physicians. Direct observation was used to identify delivery of 36 different services recommended by the U.S. Preventive Services Task Force and to assess whether delivery of these services was associated with related signs or symptoms. RESULTS: One or more preventive services were delivered in 33% of visits, with rates ranging from 0.2% (HIV prevention) to 19.9% (tobacco counseling). In contrast to pure prevention, services were frequently performed for assessment or care of symptoms or signs, with the ratio ranging from 0% (eye examination; car seat, poison control, and HIV prevention counseling) to 66.7% (hearing test). Physicians varied considerably in the frequency at which their delivery of recommended preventive services was associated with patient symptoms, from 0% to 100% for screening services and from 0% to 100% for counseling services. CONCLUSIONS: Because of the illness focus of most primary care visits, preventive service delivery is often associated with related signs or symptoms. Care of illnesses appears to present an important impetus and perhaps teachable moments for providing preventive care. Clinician variability in preventive service delivery for patient symptoms shows an opportunity to improve the primary and secondary prevention focus of practice to meet public health prevention goals.     

Primary Care Physician Attitudes and Intentions Toward the Use of HIV Pre-exposure Prophylaxis in Adolescents in One Metropolitan Region

Purpose

Understanding the attitudes of physicians toward the use of pre-exposure prophylaxis (PrEP) for HIV prevention among youth is critical to improving access to PrEP. We examined PrEP-related attitudes among physicians who provide primary care to 13- to 21-year-old adolescents.

A state-based model of prevention: Indiana's example

Public health officials in the United States have battled alcohol, tobacco, and other drug (ATOD) use among adolescents for the past few decades, but only in 2002 did they begin to see a decline in rates of use. ATOD use and abuse are associated with numerous problems, including criminal behavior and increased adolescent morbidity and mortality rates. Researchers have sought to identify best-practice procedures for ATOD prevention; the state of Indiana has a strong ATOD prevention system in place that has the potential to serve as a model for other U.S. localities because of its best-practice approach to public health services. This article outlines the activities of the Indiana Prevention Resource Center to provide an example to strengthen public health professionals' ability to prevent ATOD use and abuse and to provide for a healthy adolescent population.     

Priorities among recommended clinical preventive services.

BACKGROUND: Many recommended clinical preventive services are delivered at low rates. Decision-makers who wish to improve delivery rates, but face competing demands for finite resources, need information on the relative value of these services. This article describes the results of a systematic assessment of the value of clinical preventive services recommended for average-risk patients by the U.S. Preventive Services Task Force. METHODS: The assessment of services' value for the U.S. population was based on two dimensions: burden of disease prevented by each service and cost effectiveness. Methods were developed for measuring these criteria consistently across different types of services. A companion article describes the methods in greater detail. Each service received 1 to 5 points on each of the two dimensions, for total scores ranging from 2 to 10. Priority opportunities for improving delivery rates were determined by comparing the ranking of services with what is known of current delivery rates nationally. RESULTS: The highest ranked services (scores of 7+) with the lowest delivery rates (< or =50% nationally) are providing tobacco cessation counseling to adults, screening older adults for undetected vision impairments, offering adolescents an anti-tobacco message or advice to quit, counseling adolescents on alcohol and drug abstinence, screening adults for colorectal cancer, screening young women for chlamydial infection, screening adults for problem drinking, and vaccinating older adults against pneumococcal disease. CONCLUSIONS: Decision-makers can use the results to set their own priorities for increasing delivery of clinical preventive services. The methods provide a basis for future priority-setting efforts.