EVENT HISTORY CALENDARS: AN INNOVATION IN ADOLESCENT

RISK BEHAVIOR ASSESSMENT AND COMMUNICATION

Kristy K. Martyn, PhD, RN, CPNP-PCCynthia Darling-Fisher, PhD, RN, FNP-BCMichelle Pardee, DNP, RN, FNP-BCDavid Ronis, PhDIrene Felicetti, MSMelissa 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)

Communication Process

• Affective Support

• Health Information

• Decisional Control

Patient-Provider Communication

Individual Characteristics

Health Outcomes

Sexual Risk Behaviors and

Intentions

Cognitive Appraisal• Risk Perception• Attitudes

Background Variables• Race/Ethnicity, SES, Education, Gender• Social Factors• Previous Risk Behaviors

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)

2011(last year)

2012(this year)

2013(next year)

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__________________________________________________

5. Partner6. When7. Type8. Contraception

Have you had any of these behaviors? Smoking, Alcohol, Drugs, Cutting, Eating Problems, Other? (ex., x----Drink Alcohol---, x---Smoke Weed----)

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 post-intervention 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 post-intervention interview

• The nurse practitioners completed post-

intervention surveys and a post-study interview

• Adolescent received $25 gift cards after each session

EHC Intervention

Adolescent self-administers the EHC using open-ended 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-by-side and together view and discuss the adolescent’s integrated sexual risk history, facilitating cognitive appraisal, affective support, decisional control

• Meaningful (i.e., tailored) adolescent-provider 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 DemographicsN 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

0%

20%

40%

60%

80%

100%

120%

Sexual Activity

Condom Use

Study Sample

Detroit YRBS

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 Behavior1 & 3 Month Post-Intervention

0%10%20%30%40%50%60%70%80%90%

100%

Sexual Activity

Condom Use

1-month

3-month

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 2013 (next year)

What is your Age? 17

What is your Grade in School (grade, repeated grades, school changes, & if dropped out)?

12th

What are your Activities

(Jobs/Sports/Clubs/Church/etc.)?

Use x---x to show when involved, for ex., x------youth group -----x

Hope to play soccerStart looking for colleges

Where do you Stay and who do you stay with? For example, x----live w/Mom, Dad, Sister---→

Mom, Stepdad

Who are your Family and Friends? Other important people? (Circle who helps you)

What Positive Events have you had or What are your Goals?

Get good grades again so that I can get into college

What Negative Events or Losses have you had (Divorce, Accidents, Deaths, Violence experiences, Emotional problems, Others)?

Want to stay out of trouble and avoid bad things!

What is your Sexual Activity?1. partner (use initials2. when (use x----x)3. type (oral,/vaginal/anal)

contraception including how often used

------------------------------ XWant to stay with L.Z.

Have you had any of these behaviors? Smoking, Alcohol, Drugs, Cutting, Eating Problems, Others)? For ex., x--Drink Alcohol/Smoke Weed→

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-PCCynthia Darling-Fisher, PhD, RN, FNP-BCMichelle Pardee, DNP, RN, FNP-BCDavid Ronis, PhDIrene Felicetti, MSMelissa Saftner, PhD, RN, CNM