Transcript EVENT HISTORY CALENDARS

EVENT HISTORY CALENDARS: AN
INNOVATION IN ADOLESCENT RISK
BEHAVIOR ASSESSMENT AND
COMMUNICATION
Kristy K. Martyn, PhD, RN, CPNP-PC
Cynthia Darling-Fisher, PhD, RN, FNP-BC
Michelle Pardee, DNP, RN, FNP-BC
David Ronis, PhD
Irene Felicetti, MS
Melissa Saftner, PhD, RN, CNM
Related Publication & Research Support
• Martyn, K.K., Darling-Fisher, C., Pardee, M., Ronis, D.L.,
Felicetti, I.L., & Saftner, M.A. (2011). Improving sexual risk
communication with adolescents using event history calendars.
Journal of School Nursing. Access: http://jsn.sagepub.com/.
doi:10.1177/1059840511426577
• We gratefully acknowledge the following grant support by the
National Institutes of Health and National Institute of Nursing
Research, The Michigan Center for Health Intervention, P30
NR009000.
Theoretical & Evidence Frame
• Autobiographical memory (past experiences
cues to remembering) (Belli, 1998; Conway,
1996)
• Quantitative research (Freedman et al., 1988;
Furstenburg et al., 1987; Yoshihama, 2000;
Youngblut et al., 1999; 2001)
• Clinical assessment (Caspi et al., 1996)
• Qualitative research (Martyn et al., 2001;
2002; 2003; 2006; 2009; 2011; 2012)
• Interaction Model of Client Health Behavior
Interaction Model of Client Health Behavior:
Adolescent Sexual Risk Behavior (Cox, 1982; 2003)
Individual
Characteristics
Background
Variables
• Race/Ethnicity, SES,
Education, Gender
• Social Factors
• Previous Risk Behaviors
Patient-Provider
Communication
Communication
Process
• Affective Support
• Health Information
• Decisional Control
Cognitive
Appraisal
• Risk Perception
• Attitudes
Health Outcomes
Sexual Risk
Behaviors and
Intentions
Event History Calendars
“My whole life on paper”
• Time and context-linked health history graph
• Open-ended questions about events,
behaviors, relationships and related goals
• Shows interrelationships, patterns, triggers
• Facilitates patient-provider awareness and
communication
• Actively engages patients in co-constructing
health
YEAR
2010
(2 years ago)
What is your Age?
What is your Grade in School (grade, repeated grades,
school changes, and if dropped out)?
What are your Activities (Jobs/Sports/Clubs/Church/etc.)?
Use x------ to show when involved, ex., x---youth group--
Where do you Stay and who do you stay with? For
example, x----live with Mom, Sister------
Who are your Family and Friends? Other important
people? (Circle who helps you)
What Positive Events have you had?
What are your Goals?
What Negative Events or Losses have you had (Divorce,
Accidents, Deaths, Violence, Emotional Problems, Others)?
What is your Sexual Activity?
1.
Partner (use initials)
2.
When (use x----x)
3.
Type (oral/vaginal/anal)
4.
Contraception including how often used
__________________________________________________
1.
2.
3.
4.
Partner
When
Type
Contraception
Have you had any of these behaviors? Smoking,
Alcohol, Drugs, Cutting, Eating Problems, Other? (ex., x---Drink Alcohol---, x---Smoke Weed----)
2011
(last year)
2012
(this year)
2013
(next year)
Adolescents on Why a Clinical EHC
• “[The calendar] would be good to have
and fill out, I think. Like if you're at a
doctor, I'm sure your doctor would need to
know something about you. And half of
this is definitely not on my record. My
whole life on paper.”
Specific Aims
• Specific Aim 1: To examine the effects
of the EHC intervention on adolescent
risk perception, communication with
provider, and intentions to abstain
from intercourse and avoid
unprotected intercourse postintervention and at 1- and 3-months.
Specific Aims
• Specific Aim 2: To explore whether
the EHC intervention is viewed by
adolescents and providers as easy to
use and helpful for reporting and
discussing sexual histories.
Methods
• Mixed method exploratory study
• Pilot intervention study
• Thirty 15-19 year old females and
males
• Two nurse practitioners
• School-linked Health Center in SE
Michigan
Methods
• Adolescents self-administered the Event History
Calendar (EHC), discussed their EHC with a
nurse practitioner during a clinic visit, completed
pre, post, 1 and 3-month surveys, a postintervention interview
• The nurse practitioners completed postintervention surveys and a post-study interview
• Adolescent received $25 gift cards after each
session
EHC Intervention
Adolescent self-administers the EHC using openended questions on context and risk behaviors,
autobiographical memory cues, and retrieval cycles
 Encourages reflection (i.e., cognitive appraisal)
on their time-linked integrated sexual risk history
graph
 Prepares the adolescent to discuss his or her
actual and potential risk behavior history with the
provider
EHC Intervention – Pre-Visit
• Prior to the visit with the adolescent,
the provider reviews the adolescent’s
EHC in context of a timeline that
shows interaction of risk behaviors
and life events
• Provider identifies potential risks and
strengths in context
EHC Intervention Visit
• Provider and adolescent sit side-byside and together view and discuss
the adolescent’s integrated sexual
risk history, facilitating cognitive
appraisal, affective support,
decisional control
• Meaningful (i.e., tailored) adolescentprovider communication
Adolescent Surveys
• Clinic Visit:
– Adolescent Pre-EHC Survey: Demographics,
Risk Behavior, Attitudes, Intentions, Risk
Perception, and Adolescent-Provider Communication
– Adolescent Post-EHC Visit Survey: Repeated above
measures
• One- and Three-Month Sessions:
– Adolescent Outcomes Surveys: Risk Behavior, Attitudes,
Intentions, and Risk Perception
• Alphas = .61-.99 & Positive feedback
Provider Data
• Clinic Visit:
– Provider Post-Training Survey: Demographics,
Provider-Adolescent Communication (Usual)
– Provider Post-Visit Survey: Provider-Adolescent
Communication (This Visit); Perceptions of Clinical
Use of EHC
• End of Study:
– Provider Post-Study Survey
– Interview
• Chart Audit
Adolescent Demographics
N
Race
White
Black
Females
19 (63%)
13
6
Males
11 (37%)
6
5
• Participants
School-linked Health Center patients
• Mean age: 17.3 years; Age Range: 15-19 years
• Study Retention over 3 months (95.5%)
Comparison of Sexual Risk Behavior
– Study Sample and Detroit YRBSS
120%
100%
80%
60%
Study Sample
Detroit YRBS
40%
20%
0%
Sexual
Activity
Condom Use
Survey Results
Adolescent-Provider Communication
(Pre- & Post-Visit)
• Greater Satisfaction with Communication (p=.004)
• Greater Satisfaction with Interpersonal Style (p=.001)
• Greater Involvement in Decision-Making (p=.001)
• Greater Amount of Communication (p<.001) about
– Sexual Activity
– Risk Behaviors
– Risk Patterns Over Time
– Linkages Between Risk Behaviors
Survey Results
Risk Behavior (Pre-, Post-Visit, 1 & 3 months)
• Decreased sexual intercourse at one month
(p=.031)
• Sex in last 30 days (97%, 100%, 79%, 88%)
• Condom use last sex (57%, 54%, 48%, 59%)
Comparison of Sexual Risk Behavior
1 & 3 Month Post-Intervention
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1-month
3-month
Sexual
Activity
Condom Use
Adolescents’ Perception of the EHC
and Provider Communication
• “It’s not like I had to bring it up”
– Getting communication started
• “Seeing it for my own eyes”
– Increasing awareness of risks
• “Just getting it all out there”
– Encouraging discussion about sexual risks
• “Made me express myself more”
– Enhanced communication with provider
Providers’ Perception of the EHC and
Adolescent Communication
• “[The EHC] was very easy to show [the adolescent]
visually what their behavior was.”
• “I think we got a richer amount of information and
were able to . . . intervene on a different level.”
• “I think they enjoyed filling it out . . . allowed them to
look at their behavior in a way that they haven’t in
the past.”
Conclusions
• The Event History Calendar (EHC) can
easily be integrated with tools and
practices in health care settings to actively
engage patients in risk assessment and
communication with providers.
Eliciting Patient-Desired Outcomes
• “My future goals”
• “I liked the calendar . . . I haven’t really
sat down and rethought back in my
past. But it really made me sit down
and think about who was I with,
what was I doing, and what are my
goals.”
Year
What is your Age?
What is your Grade in School (grade,
repeated grades, school changes, & if
dropped out)?
What are your Activities
(Jobs/Sports/Clubs/Church/etc.)?
Use x---x to show when involved, for ex.,
x------youth group -----x
Where do you Stay and who do you stay
with? For example, x----live w/Mom,
Dad, Sister---→
Who are your Family and Friends?
Other important people? (Circle who
helps you)
What Positive Events have you had or
What are your Goals?
What Negative Events or Losses have
you had (Divorce, Accidents, Deaths,
Violence experiences, Emotional
problems, Others)?
What is your Sexual Activity?
1.
partner (use initials
2.
when (use x----x)
3. type (oral,/vaginal/anal)
contraception including how often
used
Have you had any of these
behaviors? Smoking, Alcohol,
Drugs, Cutting, Eating
Problems, Others)? For ex.,
x--Drink Alcohol/Smoke
Weed→
2013 (next year)
17
12th
Hope to play soccer
Start looking for colleges
Mom, Stepdad
Get good grades again so that I can get into
college
Want to stay out of trouble and avoid bad
things!
------------------------------ X
Want to stay with L.Z.
Going to stay away from weed and
alcohol
Conclusions
• EHC methods enhance person-centered
health care and research by eliciting and
including patient-desired outcomes
– in health research
– in health care decision-making
– with patients of variety of ages, cultures,
health needs
EVENT HISTORY CALENDARS: AN
INNOVATION IN ADOLESCENT RISK
BEHAVIOR ASSESSMENT AND
COMMUNICATION
Kristy K. Martyn, PhD, RN, CPNP-PC
Cynthia Darling-Fisher, PhD, RN, FNP-BC
Michelle Pardee, DNP, RN, FNP-BC
David Ronis, PhD
Irene Felicetti, MS
Melissa Saftner, PhD, RN, CNM