Abstract:
Few interventions address adolescent relationship abuse (ARA) in clinical settings. This cluster randomized controlled trial tested the effectiveness of a brief relationship abuse education and counseling intervention in school health centers (SHCs). The School Health Center Healthy Adolescent Relationship Program (SHARP) is a SHC provider-delivered multi-level intervention to reduce ARA among adolescents ages 14-19 seeking care in SHCs. Intervention SHCs also involved student outreach teams who conducted school-wide ARA educational events and encouraged students to seek care at the SHC to learn more about how to respond to ARA. SHCs offer the opportunity to reach adolescents experiencing ARA (targeted intervention), identify adolescents at risk for ARA (early intervention), and provide universal education about ARA and healthy relationships (primary prevention). Methods: During academic year 2012-2013, 11 SHCs (10 clusters) were randomized to intervention (SHC providers received training to implement SHARP) or standard-of-care control condition. Among 1062 eligible students ages 14 to19 years at 8 SHCs who continued participation after randomization, 1011 completed computer-assisted surveys before a clinic visit; 939 completed surveys 3 months later (93% retention). Surveys with providers in the intervention SHCs (n=38) were conducted prior to their training and six months after the training (74% retention). Focus groups with the student outreach teams (n=22 of 29 outreach team members) were conducted at school in a confidential space, to seek their feedback on the SHARP intervention in the SHC, the range of activities they included to raise awareness about ARA and the SHC as a resource. Results: Intervention versus control adjusted mean differences (95% confidence interval) on changes in primary outcomes were not statistically significant: recognition of abuse = 0.10 [-0.02 to 0.22]; intentions to intervene = 0.03 [-0.09 to 0.15]; and knowledge of resources = 0.18 [-0.06 to 0.42]. Intervention participants had improved recognition of sexual coercion compared with controls (adjusted mean difference = 0.10 [0.01 to 0.18]). In exploratory analyses adjusting for intensity of intervention uptake, intervention effects were significant for increased knowledge of relationship abuse resources and self-efficacy to use harm reduction behaviors. Among participants reporting relationship abuse at baseline, intervention participants were less likely to report such abuse at follow-up (mean risk difference = -0.17 [-0.21 to -0.12]) Adolescents in intervention clinics who reported ever being in an unhealthy relationship were more likely to report disclosing this during the SHC visit (adjusted odds ratio = 2.77 [1.29 to 5.95]). At the six month post-training time point, 33% of providers reported increased counseling about harm reduction strategies with their clients and 65% reported more comfort working with a client to identify a safe adult with whom they can share sexual and violence-related concerns. Focus groups with the student outreach teams identified key strategies for increasing ARA awareness such as information placed in bathrooms, using lunch time to provide ARA and SHC information to peers, and use of interactive theater to engage more youth. Conclusions: This is the first evidence of the potential benefit of a SHC intervention to address abusive relationships among adolescents. (Author Abstract)