Improving adolescent sexual risk assessment with event history calendars: a feasibility study

Facilitators, Barriers, and Opportunities to Implementing Sexual History Screening and Human Immunodeficiency Virus Pre-Exposure Prophylaxis at a Federally Qualified Health Center

Sexual history screening (SHS) is recommended to determine risk for acquisition of human immunodeficiency virus (HIV) and eligibility for pre-exposure prophylaxis (PrEP). SHS and PrEP are underutilized, sequential screening, and prevention practices. This study aimed to understand factors impacting the implementation of SHS and PrEP at a multi-site federally qualified health center (FQHC) in Connecticut. Guided by the Consolidated Framework for Implementation Research, semistructured interviews were conducted on Zoom with primary care providers (PCPs), medical assistants, clinical leadership, and PrEP navigators. Convenience and purposive sampling took place via email until thematic saturation was achieved. Thematic analysis was conducted. Twenty-two participants were interviewed for this study. PCPs lacked knowledge and reported limited or no use of SHS to determine patients' level of HIV risk, which may explain why most PCPs relied on patients to request PrEP. While PCPs perceived organizational support to prescribe PrEP, clinical staff were unaware of structural resources. Lastly, participants described a vertical trajectory of influence from external sources (policies and insurance) to time allocated to appointments that limits their ability to implement SHS and PrEP, further complicated by the electronic health record and disparities in structural resources across clinical sites. This study provides foundational evidence for future research on implementation strategies to improve HIV prevention through universal, comprehensive SHS to identify patients for PrEP. Overcoming barriers to SHS and PrEP, particularly in clinical settings such as FQHCs that care for vulnerable populations, may improve identification, prevention, and treatment of HIV and aid in ending the HIV epidemic.

Ask me, listen to me, treat me well and I shall tell: a qualitative study of Swedish youths' experiences of systematic assessment of sexual health and risk-taking (SEXIT)

Sexual ill health among young people, in terms of sexually transmitted infections (STIs), unintended pregnancy, transactional sex and sexual violence, is a global public health concern. To that end, the SEXual health Identification Tool (SEXIT) was developed. The purpose of this study was to explore the visitors' experiences of a youth clinic visit when SEXIT was used. A purposively selected sample of 20 participants (16-24 years of age) was recruited from three Swedish youth clinics using SEXIT. Participants were interviewed individually in March and April 2016, and data were analysed using inductive qualitative content analysis. The analysis resulted in four main categories describing the participants' experiences of using SEXIT: "Issues of concern" includes descriptions of the items in SEXIT as important; "Enabling disclosure" describes how SEXIT serves as an invitation to talk and facilitates disclosure of negative experiences; "Road to change" captures experiences of the conversation with the healthcare professional; and "Managing power imbalance" describes experiences regarding the response and attitudes of the healthcare professional as well as the participants' fears of being judged. The categories are connected by the overarching theme "Ask me, listen to me, treat me well and I shall tell". This study contributes knowledge on young people's experiences of a tool-supported dialogue on sexual health and risk-taking initiated by the healthcare professional. Structured questions in a written format, as a basis for dialogue, are appreciated and experienced as a functioning way of addressing sexual ill health and risk-taking at Swedish youth clinics.

Nurse to adolescent health communication process: approach to Event History Calendar

OBJECTIVES

comprehend the Event History Calendar components that are relevant for the nurse to adolescent communicative process, in the context of Primary Health Care.

METHODS

reflective study, based on the Event History Calendar approach, in the relational, communicative, and educational dimensions.

RESULTS

best practices for adolescent health promotion are vital and constitute a challenge to nurses. The Event History Calendar is a potential tool for research and care practices to comprehend the needs of adolescents, with reminder of key personal events, culturally and socially specific. The comprehension of retrospective data referring to activities, behaviors, experiences and transitions of life, in certain periods of time, enables dialogue and new understandings about the history of adolescents.

FINAL CONSIDERATIONS

the Event History Calendar provides nursing professionals with an expansion of their practice in educational, relational, and communicative dimensions, as well as to instruct care planning and management.

What consultation resources are available to support delivery of integrated sexual and reproductive health services? A scoping review

BACKGROUND

Contraceptive and sexual healthcare is increasingly delivered in an integrated setting in the UK and worldwide, requiring staff to be competent in differing styles of delivery, and to have a wide knowledge base.

OBJECTIVES

We did a scoping review of the literature for evidence of the resources that exist for healthcare professionals to guide or structure the process of conducting an integrated sexual and reproductive health (SRH) consultation.

ELIGIBILITY CRITERIA

Articles were included in the review if (1) their primary focus was a consultation resource related to one or more aspects of an SRH consultation and (2) they provided details of the resource and/or its application including evaluation of use.

SOURCES OF EVIDENCE

Peer-reviewed articles published in English, published non-peer-reviewed guides, and web-based guidelines addressing the conduct of a contraception or sexual health consultation were included. Date range: 1998-December 2018. Searches were carried out in the databases AMED (Ovid), ASSIA (ProQuest), CINAHL Complete (EBSCO), Cochrane Library (Wiley), HMIC (NHS Evidence), Medline (EBSCO), PsycINFO (Proquest) and Scopus (Elsevier) on 10 February 2017, and incremental searching performed until December 2018.

RESULTS

A total of 12 peer-reviewed journal articles, two web-published guidelines from the Faculty of Sexual & Reproductive Healthcare and three published, non-peer-reviewed resources were included.

CONCLUSION

Many resources exist to guide either the contraceptive or sexual health consultations, but there is a lack of a comprehensive consultation resource to guide the conduct of an integrated consultation.

Adaptation of the event history calendar for Ugandan adolescents

Adolescent and emerging adult risk behavior is a concern globally. Discussing health promotive and risk behaviors with adolescents and young adults can be challenging regardless of the country of data collection and dominant culture. In the United States, event history calendars have been used in both research and clinical settings to identify healthy and risky behaviors among adolescents and emerging adults, and contextual factors that may influence their behavior. After an unsuccessful attempt to employ a particular event history calendar on family life, negative and positive events, sexual behavior and substance use in data collection in rural fishing villages in Western Uganda, the current study aimed to modify the United States validated event history calendar for use with adolescents in Uganda, as a first step to cultural adaptation. Focus groups with 24 college students provided information about ways to modify the event history calendar for Ugandan youth. This paper discusses the modifications of the event history calendar for Ugandan young people.

The Effect of a Youth-Centered Sexual Risk Event History Calendar (SREHC) Assessment on Sexual Risk Attitudes, Intentions, and Behavior

INTRODUCTION

The purpose of this study was to examine the effect of a youth-centered assessment, the Sexual Risk Event History Calendar (SREHC), compared with the Guidelines for Adolescent Preventive Services (GAPS) assessment, on sexual risk attitudes, intentions, and behaviors.

METHODS

The Interaction Model of Client Health Behavior guided this participatory research-based randomized control trial. Youth participants recruited from university and community clinics in the Midwestern United States were randomized to a health care provider visit using either the SREHC or GAPS and completed surveys at baseline, postintervention, and 3, 6, and 12 months.

RESULTS

Participants included 181 youth (15-25 years old) and nine providers. Findings showed that youth in the SREHC group reported stronger intentions to use condoms compared with those in the GAPS group. Age and race were also significant predictors of sexual experience.

DISCUSSION

This study highlights the importance of using a youth-centered, systematic approach in the assessment of sexual risk behaviors.

Patient-Centered Participatory Research in Three Health Clinics: Benefits, Challenges, and Lessons Learned

Research informed by individuals' lived experiences is a critical component of participatory research and nursing interventions for health promotion. Yet, few examples of participatory research in primary care settings with adolescents and young adults exist, especially with respect to their sexual health and health-risk behaviors. Therefore, we implemented a validated patient-centered clinical assessment tool to improve the quality of communication between youth patients and providers, sexual risk assessment, and youths' health-risk perception to promote sexual health and reduce health-risk behaviors among adolescents and young adults in three community health clinic settings, consistent with national recommendations as best practices in adolescent health care. We describe guiding principles, benefits, challenges, and lessons learned from our experience. Improving clinical translation of participatory research requires consideration of the needs and desires of key stakeholders (e.g., providers, patients, and researchers) while retaining flexibility to successfully navigate imperfect, real-world conditions.

Urban American Indian Adolescent Girls: Framing Sexual Risk Behavior

PURPOSE

The purpose of this study was to explore factors that influence urban adolescent American Indian (AI) girls' sexual risk behavior.

DESIGN

A qualitative study was conducted with grounded theory methodology to reveal factors and processes that influence sexual risk behavior.

METHOD

Talking circles, individual interviews, and event history calendars were used with 20 urban AI 15- to 19-year-old girls to explore influences on sexual risk behavior.

RESULTS

The generated theory-framing sexual risk behavior-describes social and structural factors and processes that influenced the girls' sexual risk behavior. The theory extends Bronfenbrenner's ecological model by identifying microsystem, mesosystem, and macrosystem influences on sexual risk behavior.

DISCUSSION

Urban AI girls reported similar social and structural influences on sexual risk behavior as urban adolescents from other racial and ethnic groups. However, differences were noted in the family structure, cultural heritage, and unique history of AIs.

IMPLICATIONS

This theory can be used in culturally responsive practice with urban AI girls.

The Rapid Assessment for Adolescent Preventive Services (RAAPS): providers' assessment of its usefulness in their clinical practice settings

INTRODUCTION

The purpose of this study was to evaluate health providers' use of the Rapid Assessment for Adolescent Preventive Services (RAAPS) screening tool to identify adolescent high-risk behaviors, its ease of use and efficiency, and its impact on provider/patient discussions of sensitive risk behaviors.

METHOD

This mixed methods descriptive study used an online survey to assess providers' use of the RAAPS and their perspectives on its implementation and effect on adolescent-provider communication. The survey was completed by providers from a variety of settings across the United States (N = 201).

RESULTS

Quantitative and qualitative analyses indicated that the RAAPS facilitated identification of risk behaviors and risk discussions and provided efficient and consistent assessments; 86% of providers believed that the RAAPS positively influenced their practice.

DISCUSSION

Adoption of the RAAPS in practice settings could lead to more effective adolescent preventive services by giving providers a tool to systematically assess and identify adolescents at risk. Implementation of RAAPS offers health providers an efficient, consistent, and "adolescent friendly" way to identify risky behaviors and open the discussion needed to tailor interventions to meet their needs.

Using mixed-method assessment to advance adolescent HIV prevention

This two-phase, community-based pilot study examined the impact of an innovative calendar-based assessment on HIV risk perception and risk reduction planning with racially diverse youth aged 14 to 21 at a public health clinic. Participants (N = 232) completed a Sexual Health History Calendar (SHHC) assessing behaviors over the previous 12 months, risk self-appraisals, and future behavioral intentions. Youths' narratives included negative self-appraisals (36%), named a risk-related critical incident (13%) or regret (9%), or expressed increased risk awareness (9%) and need for behavior change (18%). A minority were positive (28%) or reflected improvement (7%). All Phase 2 participants (n = 122) identified at least one specific risky behavior they intended to change. These data and the SHHC's visual cues facilitated risk-reduction intervention tailored to the unique circumstances in which each youth's risk taking occurred. For nurses and other providers in clinical settings, the SHHC can offer a critical link between assessment and intervention.

Patient-centered communication and health assessment with youth

BACKGROUND

Patient-centered communication is fundamental to individualizing healthcare, but there has been limited evaluation of provider communication with youth.

OBJECTIVES

The aim was to compare communication outcomes after use of an event history calendar (EHC) and Guidelines for Adolescent Preventive Services (GAPS) to structure interactions during a clinic visit. Patient and provider descriptions of EHC and GAPS communication experiences were also obtained.

METHODS

This is a secondary analysis of data obtained during a randomized controlled trial. A sequential explanatory mixed-methods approach was used. A split-plot design with one between factor (EHC, GAPS) and one within factor (pretest, posttest) was used for the quantitative portion. Qualitative data were collected from open-ended questions, audiotaped visits, and exit interviews. Providers (n = 9) at three clinics were assigned at random and trained to implement either the EHC or GAPS protocol. Male and female youth (n = 186) were randomly assigned to the EHC or GAPS intervention. Before their clinic visit, youth completed assessments of past communication experiences with healthcare providers (pretest); communication during the current visit was assessed immediately after the visit (posttest).

RESULTS

Communication outcomes from pretest to posttest improved for youth in both the EHC and GAPS groups. Post hoc subgroup analysis suggested that men and Arab Americans derived more benefit from the EHC intervention in some aspects of communication. Qualitatively, the EHC group identified improved outcomes in validating patient perspective, being viewed in context, reaching a shared understanding of needs and preferences, and being helped to share power in the healthcare interaction.

DISCUSSION

EHC and GAPS provided effective frameworks for structuring communication during a clinic visit. Compared with GAPS, the integrated time-linked assessment captured by the EHC enhanced patient-centered communication in select groups.

Sexual risk assessment using event history calendars with male and female adolescents

INTRODUCTION

The purpose of this study was to explore male and female adolescents' perceptions of and differences in Event History Calendar (EHC) sexual risk assessment in a clinical setting.

METHOD

This study is a secondary analysis exploring male and female qualitative data from a mixed methods study of adolescent and provider communication. Participants included 30 sexually active 15- to 19-year-old male (n = 11) and female (n = 19) patients at a school-linked clinic. The adolescents completed a pre-clinic visit EHC and then discussed it with a nurse practitioner during their visit. The adolescents shared their perceptions of the EHCs in a post-clinic visit interview.

RESULTS

Constant comparative analyses revealed gender differences in: (a) adolescents' perceptions of how EHCs helped report, reflect on, and discuss sexual risk histories; (b) how adolescents self-administered EHCs; and (c) the histories they reported.

DISCUSSION

The EHC was well received by both male and female adolescents, resulting in a more complete sexual risk history disclosure. Self-administration of the EHC is recommended for all adolescents, but further sexual risk assessment by nurse practitioners who use EHCs is needed.

Exploring eating and activity behaviors with parent-child dyads using event history calendars

Despite advances in science, the prevalence of childhood obesity persists and outcomes remain inconsistent. An event history calendar (EHC) is a tool to facilitate understanding of family life dynamics influencing eating and activity choices. This tool uses reflection to assess temporally linked behavior in the context of life events so that choices related to eating and activity are more explicit. Fourteen parent-child (6-14 years) dyads completed an EHC and interview 2 months following a healthy eating/activity intervention. Phenomenological analysis revealed themes including "awareness" of activity/eating behaviors, "healthy lessons," "family time," and "barriers" to change. The EHC facilitated participant communication and understanding by making connections between behaviors, habits, and events in family context, so that eating and activity behaviors could be realistically reviewed. This tool has potential to guide development of individualized interventions through barrier identification and goal establishment in research and clinical settings to help counteract childhood obesity over time.

Comparison of adolescents' reports of sexual behavior on a survey and sexual health history calendar

Assessing sexual risk is critical for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention with adolescents. This article compares sexual risk reports from two self-administered instruments, a standard survey and a sexual health history calendar (SHHC), among racially diverse youth (n = 232) ages 14 to 21 seeking services at a public health clinic. Agreement between methods was assessed using Lin's concordance correlation coefficients (CCC) and Bland-Altman plots. Lin's CCC showed poor to moderate agreement between instruments on reports of sexual partners in the past 3 (0.47), 6 (0.55), and 12 (0.49) months. While individual sexual partner questions were refused a total of 179 times on the survey, youth reported having sexual partners during the same time period on the SHHC in most (77.1%) of these instances. Poor agreement was also found for condom use frequency (CCC = 0.17), with youth's frequency of condom use on the SHHC differing from that reported on the survey for more than half (55.6%) of the months they were sexually active. While lack of objective sexual behavior measures limits conclusions about the accuracy of reports, the ways in which youth's responses varied across instruments may offer insight into the complexity of adolescent sexual risk taking as well as have important implications for development of HIV/STI preventive interventions.

Prenatal psychosocial risk assessment using event history calendars with Black women

OBJECTIVE

To explore the clinical acceptability and perceptions of use of a prenatal event history calendar (EHC) for prenatal psychosocial risk assessment in Black pregnant women.

DESIGN

A qualitative descriptive study focused on interviews and prenatal EHCs completed by Black pregnant women.

SETTING

Inner city hospital prenatal care clinic in Southeastern Michigan.

PARTICIPANTS

Thirty 18-35 year old pregnant Black women receiving prenatal care at the participating clinic.

METHODS

Women completed the prenatal EHCs and their perceptions of its use were obtained through face to face interviews. The constant comparative method of analysis (Glaser, 1978, 1992) revealed themes from participants' descriptions about use of a prenatal EHC for prenatal psychosocial risk assessment.

RESULTS

Three main themes emerged describing how the prenatal EHC enhanced communication. The prenatal EHC provided "an opening" for disclosure, "an understanding with you," and a way for providers to "know you, your life, and future plans." The participants' completed prenatal EHCs included information regarding their pre-pregnancies, trimester histories, and future plans. These completed prenatal EHCs showed patterns of change in life events and behaviors that included worries, stressors, and risk behaviors. The participants perceived the prenatal EHC as an easy to use tool that should be used to improve communication with health care providers.

CONCLUSIONS

The prenatal EHC allows the patient and provider to "start on the same page" and provides an additional avenue for discussion of sensitive psychosocial issues with Black pregnant women. As a clinical tool, the prenatal EHC facilitated patient-provider communication for pregnant women often marked by health disparities. The prenatal EHC is a clinically acceptable tool to assess for psychosocial risk factors of Black women in a prenatal clinical setting.

Assessing Developmental Trajectories of Sexual Minority Youth: Discrepant Findings from a Life History Calendar and a Self-Administered Survey

Research suggests that the timing and sequence of sexual identity development milestones impacts myriad health and mental health outcomes for sexual minority youth. Because these milestone events are typically assessed retrospectively, traditional data collection approaches are limited by recall bias and lack of precision in the recording of milestone events, which may conceal the distinctions between events and distort the recording of youths' developmental trajectories. The purpose of this exploratory study was to compare responses to questions about psychosexual milestones elicited by a Life History Calendar and a self-administered survey. Results indicated discrepancies in the reported occurrence and timing of milestone events between the survey and Life History Calendar. Differences in the timing of specific milestone events ranged from two months to 15 years. Implications of these discordant findings for sexual minority youth are discussed.

Improving sexual risk communication with adolescents using event history calendars

This study was conducted to explore the effects of an event history calendar (EHC) approach on adolescent sexual risk communication and sexual activity. Adolescent school-linked health clinic patients (n = 30) who reported sexual activity self-administered the EHC that was used by nurse practitioners (NPs; n = 2) during a clinic visit. Immediately pre- and post-visit, and at 1 and 3 months, adolescents reported sexual risk behaviors and perceptions about EHC communication on questionnaires and by interview. NPs reported their perceptions of EHCs by questionnaire after the visit and poststudy interview. The EHC approach facilitated communication and adolescent awareness of their risk behaviors. Scores increased on Amount of Communication, t(29) = 8.174, p < .001; Satisfaction with Communication, t(29) = 3.112, p = .004; Client Involvement in Decision Making, t(29) = 3.901, p = .001, and Client Satisfaction with Interpersonal Style, t(29) = 3.763, p = .001. Adolescents reported decreased sexual intercourse at 1 month, p = .031. School nurses could use the EHC approach to facilitate adolescent communication and tailoring of interventions.

Sexually active adolescent women: assessing family and peer relationships using event history calendars

The purpose of this qualitative study is to explore family and peer relationships (including support and influence on risk behavior) among sexually active European American and African American adolescent girls in the context of risk behaviors documented on retrospective event history calendars (EHCs) and in interviews. The EHCs were completed by the adolescents prior to a clinic visit with a nurse practitioner at a school-based clinic in Southeast Michigan, and interviews were conducted after the visit. Constant comparative analysis of EHCs and interview data of 19 sexually active 15 to 19-year-old girls revealed that those with positive familial and peer support were less likely to report risk behaviors compared to those with poor family and peer relationships. School nurses and other providers working with adolescents to prevent risk behaviors could utilize the EHC to determine risks and develop education plans and interventions to reduce risk behaviors.

Early pregnancy in adolescents: diagnosis, assessment, options counseling, and referral

Health care providers are faced with many challenges when working with adolescents. Vague symptoms, unreliable menstrual history, and adolescent reluctance to disclose sexual activity present challenges to early diagnosis. When pregnancy is suspected, clinicians need skills for accurate diagnosis, conducting comprehensive assessments, and providing options counseling. Complexities of providing confidential care while balancing the needs of the adolescent and family may deter some clinicians. A clinical case scenario illustrates important elements of care. Through sharing lessons learned from 10 years of working in a Pregnancy Follow-up Clinic, the authors hope to empower other clinicians as they care for adolescents during this critical time.

Development of prenatal event history calendar for Black women

OBJECTIVES

To identify psychosocial factors that Black women think should be addressed in prenatal care assessment and develop a Prenatal Event History Calendar to assess these factors.

DESIGN

A qualitative descriptive study.

SETTING

Two inner city hospital prenatal care clinics in Southeastern Michigan.

PARTICIPANTS

Twenty-two Black women who had attended at least 2 prenatal care visits.

METHOD

Three focus groups were conducted using a semistructured interview guide.

MAIN OUTCOME MEASURE

Using the constant comparative method of analysis (Glaser, 1978, 1992) themes were identified that were relevant to Black women during prenatal care visits.

RESULTS

The women in this study wanted to talk with their providers about psychosocial factors and not just the physical aspects of pregnancy. To "go off the pregnancy" represents pregnant women's desire to discuss psychosocial factors that were important to them during prenatal care. Five themes emerged from the data and were used to develop categories for the Prenatal Event History Calendar: relationships, stress, routines, health history perceptions, and beliefs.

CONCLUSION

One vital component of prenatal care assessment is assessing for psychosocial risk factors. Prenatal Event History Calendar was specifically developed to provide a comprehensive and contextually linked psychosocial risk assessment for use with pregnant Black women.