1. 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

2. 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:10.1177/1059840511426577http://jsn.sagepub.com/ 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.

3. 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

4. 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

5. 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

6. YEAR2010 (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 __________________________________________________ 1. Partner 2. When 3. Type 4. Contraception Have you had any of these behaviors? Smoking, Alcohol, Drugs, Cutting, Eating Problems, Other? (ex., x- ---Drink Alcohol--- , x---Smoke Weed----  )

8. 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.”

9. 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.

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Adolescent Demographics NRace White Black Females19 (63%)13 6 Males11 (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%)

19. Comparison of Sexual Risk Behavior – Study Sample and Detroit YRBSS

20. 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

21. 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%)

22. Comparison of Sexual Risk Behavior 1 & 3 Month Post-Intervention

23. 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

24. 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.”

25. 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.

26. 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.”

27. Year 2013 (next year) What is your Age? 17 What is your Grade in School (grade, repeated grades, school changes, & if dropped out)? 12 th 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 soccer Start 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 initials 2.when (use x----x) 3.type (oral,/vaginal/anal) contraception including how often used ------------------------------ X Want 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

28. 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

29. 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