An Interactive On-line An Interactive On-line Preconception Counseling Preconception Counseling

Program for Teens with Program for Teens with Diabetes: READY-GirlsDiabetes: READY-Girls

Denise Charron-Prochownik, PhD, Denise Charron-Prochownik, PhD, CPNP, FAANCPNP, FAAN

School of NursingSchool of NursingUniversity of PittsburghUniversity of Pittsburgh

Funded by ADA Clinical Research AwardsFunded by ADA Clinical Research Awards National Institute of Health-NICHDNational Institute of Health-NICHD

Background Background • Diabetes can cause reproductive complicationsDiabetes can cause reproductive complications

• Up to 9%Up to 9% of diabetic women with unplanned of diabetic women with unplanned pregnancies have complications (e.g., infants with pregnancies have complications (e.g., infants with congenital abnormalities).congenital abnormalities).

• Up to 2/3Up to 2/3 of diabetic women have unplanned of diabetic women have unplanned pregnancies.pregnancies.

• Reproductive complications can be reduced from Reproductive complications can be reduced from 9% 9% to 2%to 2% through through Preconception Counseling Preconception Counseling (PC)(PC)

• ADA recommends ADA recommends PCPC for all women of child-bearing for all women of child-bearing potential to prevent unplanned pregnanciespotential to prevent unplanned pregnancies

BackgroundBackground

Adolescent girls are unaware of PC and reproductive complications, early and some unsafe practices, and are at high risk for an unplanned pregnancy.

• 39% of teenage girls with diabetes had an episode of unprotected sex.

• Teens average age of sexual debut was 15.6 years.

AWARENESSAWARENESS

PRECONCEPTION COUNSELINGPRECONCEPTION COUNSELING

Survey of 16 - 21 yr old females w/ Survey of 16 - 21 yr old females w/ T1D:T1D:

What do you know about What do you know about preconception counseling preconception counseling (PC)?(PC)?

NothingNothing 75%75% MisconceptionsMisconceptions 3% 3%

AWARENESSAWARENESS

PRECONCEPTION COUNSELINGPRECONCEPTION COUNSELING

Survey of 13 - 21 yr old females w/ Survey of 13 - 21 yr old females w/ T2D:T2D:

What do you know about What do you know about preconception counseling preconception counseling (PC)?(PC)?

NothingNothing 100%100%

PurposePurpose

The purpose of this presentation is The purpose of this presentation is to describe the development, to describe the development, promotion and evaluation of an promotion and evaluation of an interactive PC educational interactive PC educational program (book and CD-ROM) for program (book and CD-ROM) for girls with diabetes, called girls with diabetes, called

RReproductive-health eproductive-health EEducation ducation and and AAwareness of wareness of DDiabetes in iabetes in YYouth for outh for GirlsGirls ( (READY-Girls)READY-Girls)..

““READY-Girls”READY-Girls” is is

RReproductive-health eproductive-health EEducation and ducation and AAwareness of wareness of DDiabetes in iabetes in YYouth for outh for GirlsGirls

READY-GirlsREADY-Girls isis a theory- and evidence-based a theory- and evidence-based

Preconception Counseling program Preconception Counseling program developed as a DVD and book that developed as a DVD and book that targets teens with diabetestargets teens with diabetes

Expanded Health Belief Model Expanded Health Belief Model (STRECHER & ROSENSTOCK, 1997)(STRECHER & ROSENSTOCK, 1997)

STAR decision modelSTAR decision model(MEICHENBAUM, 1983)(MEICHENBAUM, 1983)

Theoretical/ Decision-Theoretical/ Decision-making Models for READY-making Models for READY-

GirlsGirlsEXPANDED HEALTH BELIEF EXPANDED HEALTH BELIEF

MODELMODEL (STRECHER & ROSENSTOCK, 1997)(STRECHER & ROSENSTOCK, 1997)

STAR modelSTAR modelS = StopS = StopT = Think about your choicesT = Think about your choicesA = Act on your decisionA = Act on your decisionR = Reflect on results of your R = Reflect on results of your

choicechoice(MEICHENBAUM, 1983)(MEICHENBAUM, 1983)

Reproductive Health

Behaviors

Preventing an unplanned pregnancy

Seeking preconception counseling

Ability to initiate discussion

Metabolic Control

Individual Perceptions Likelihood of ActionMediating/Modifying Factors

Perceivedsusceptibility/severity

of reproductive problems

(e.g. Unplanned pregnancy,

complications

Knowledge

Psychosocial Variables

Demographic Variables

Adherence

Perceived threat ofreproductive problems

Motivational CuesAbility to make decisions

Sexually ActiveAwareness of PC

Risk Profile/Personal Health

Self-Efficacy toperform reproductive

health behaviors

Intention (likelihood) tochange behavior

for promotingreproductive health

Perceived benefits minusperceived barriers tobehavior change for

promoting reproductive healthIntervention

APPLICATION OF THE EXPANDED HEALTH BELIEF MODEL (STRECHER & ROSENSTOCK, 1997)

*Variables not amendable to change from intervention.Attitudes/Beliefs are italicized.

Figure 1

Survey 16-21 yr. oldSurvey 16-21 yr. old::Motivational Cue: Motivational Cue:

Initial awareness of PCInitial awareness of PC r = .27 ( r = .27 (p < .05)p < .05)

(Charron-Prochownik, 01)(Charron-Prochownik, 01)

Survey pregnant women with Survey pregnant women with diabetes:diabetes:

Motivational Cue:Motivational Cue:

HCP encouraged PC OR = 3.13 HCP encouraged PC OR = 3.13 (p = .02)(p = .02) (Janz, 95)(Janz, 95)

Significant Association of Significant Association of PC Awareness with Seeking PC PC Awareness with Seeking PC

3 Phases of Preconception 3 Phases of Preconception Care (PC)Care (PC)

• Phase 1: “Awareness Counseling” Phase 1: “Awareness Counseling” (anyone, anytime (anyone, anytime “not ready”)“not ready”)

• Phase 2: “Overview” PC (> 6 months “getting ready”)

• Phase 3: “In-Depth” PC (< 6 months “being ready”)

(Jones, 1995)

* READY-Girls is Phase 1* READY-Girls is Phase 1

What Is Given In What Is Given In “Awareness Counseling”“Awareness Counseling”

• Information about:Information about:– Diabetes and pregnancy / risk of Diabetes and pregnancy / risk of

complicationscomplications– Importance of tight control before Importance of tight control before

conceptionconception– Importance of planning a pregnancy Importance of planning a pregnancy

with PCwith PC– How to prevent an unplanned pregnancyHow to prevent an unplanned pregnancy– Family planning adviceFamily planning advice

The The READY-GirlsREADY-Girls Message:Message:

Impact of a Newly Developed Impact of a Newly Developed CD-ROM Reproductive Health CD-ROM Reproductive Health Education Program on Teen Education Program on Teen

Women with DM:Women with DM: 3-month Follow-up3-month Follow-up

Denise Charron-Prochownik, PhD, RN, Denise Charron-Prochownik, PhD, RN, CPNPCPNP

Dorothy Becker, Susan Sereika,Dorothy Becker, Susan Sereika,

Meg Ferons, and Jamie ReddingerMeg Ferons, and Jamie Reddinger

University of PittsburghUniversity of PittsburghFunded by an American Diabetes Association Funded by an American Diabetes Association

Clinical Research AwardClinical Research Award

SampleSample

• 5353 adolescent women with adolescent women with T1D, T1D, 1 session and 3 groups: CD, BK, SC 1 session and 3 groups: CD, BK, SC

• Ages Ages 16 to <20 years16 to <20 years

• No other chronic illness or mental No other chronic illness or mental retardationretardation

• Not pregnantNot pregnant

• Have had type 1 diabetes for at least one Have had type 1 diabetes for at least one yearyear

• Recruited from Recruited from oneone large Diabetes Center: large Diabetes Center: Children’s Hospital of PittsburghChildren’s Hospital of Pittsburgh

Comparison of Comparison of IIntervention vs ntervention vs CControlontrol

Outcomes Diff (Post - Pre) Outcomes Diff (Post - Pre)

22

Normative Beliefs I > C .114

Intention I > C .062

Severity I > C .136

Benefits I > C .095

Social Support I > C .197

D&P Knowledge I > C .291

D&C Knowledge I > C .068

Overall Knowledge I > C .254

2 near .0588, .2000, denote medium and large effects in behavioral sciences

ResultsResults

• Compared to CG, IG had Compared to CG, IG had significantly increased in significantly increased in knowledge, perceived attitudes knowledge, perceived attitudes and social supportand social support

• Knowledge, benefits, & barriers Knowledge, benefits, & barriers were sustained over the 3-month were sustained over the 3-month period, but other variables were period, but other variables were notnot

Reproductive Health Education for Reproductive Health Education for Adolescent Girls with Diabetes Adolescent Girls with Diabetes (READY-Girls): (READY-Girls): SustainingSustaining Long-Long-

range range (9 month) Outcomes(9 month) Outcomes

Denise Charron-Prochownik, Susan M. Denise Charron-Prochownik, Susan M. Sereika, Margaret Ferons Hannan, Andrea Sereika, Margaret Ferons Hannan, Andrea

Rodgers-Fischl, Dorothy Becker, Joan Rodgers-Fischl, Dorothy Becker, Joan Mansfield, Peter Draus, William Herman, Mansfield, Peter Draus, William Herman,

Linda Freytag, Kerry Milaszewski, Linda Freytag, Kerry Milaszewski,

University of Pittsburgh, Pittsburgh, PAUniversity of Pittsburgh, Pittsburgh, PA

Funded by American Diabetes AssociationFunded by American Diabetes Association

MethodsMethods• Two-group (IG vs standard care control CG),Two-group (IG vs standard care control CG),

randomized, controlled, repeated measures randomized, controlled, repeated measures designdesign

• Intervention: Two CD-ROM sessions and one Intervention: Two CD-ROM sessions and one book sessionbook session of the education program before of the education program before 3 3 consecutive routine Diabetes Clinic visits; consecutive routine Diabetes Clinic visits; randomized to web-based message board (for randomized to web-based message board (for teens and RN); and an RN counseling sessionteens and RN); and an RN counseling session

• Self-Administered questionnaires Self-Administered questionnaires (4 Time Points: base, immediate-post CD #1 and CD #2, 9-mo (4 Time Points: base, immediate-post CD #1 and CD #2, 9-mo f/u )f/u )

• Subjects received $80 for participationSubjects received $80 for participation

Measures / AnalysesMeasures / Analyses• Outcome measurements: Outcome measurements:

knowledge, attitudes (EHBM), decision-knowledge, attitudes (EHBM), decision-making and behaviormaking and behavior regarding DM and regarding DM and pregnancy, sexuality, birth control (BC), and pregnancy, sexuality, birth control (BC), and PC; PC; A1C A1C blood test; and use of the web-site blood test; and use of the web-site message boardmessage board

• To compare between and within group To compare between and within group differences,differences, 2 time points were selected:2 time points were selected: baseline and baseline and 9-mo follow-up9-mo follow-up

• Descriptive Descriptive • Mixed Model Repeated Measures AnalysisMixed Model Repeated Measures Analysis

SampleSample

• 8888 adolescent women with adolescent women with T1DT1D– Intervention group (n=43)Intervention group (n=43)– Standard care control group (n=45)Standard care control group (n=45)

• Ages Ages 13 to <2013 to <20 years years

• No other chronic illness or mental No other chronic illness or mental retardationretardation

• Not pregnantNot pregnant

• Have had type 1 diabetes for at least one yearHave had type 1 diabetes for at least one year

• Recruited from Recruited from 22 large Diabetes Center: large Diabetes Center: Children’s Hospital of Pittsburgh and Joslin Children’s Hospital of Pittsburgh and Joslin Clinic BostonClinic Boston

BASELINE DEMOGRAPHICS*BASELINE DEMOGRAPHICS*• Mean Age (yrs.) 16.7 (13.2-Mean Age (yrs.) 16.7 (13.2-

19.7)19.7)• Mean Duration of Illness (yrs.) 7.2 (1-17)Mean Duration of Illness (yrs.) 7.2 (1-17)• African American 5 (6 %)African American 5 (6 %)• Living with Parents 85 (96%)Living with Parents 85 (96%)• Mothers completing College 42 Mothers completing College 42 (49%) (49%)• Teens currently in High School 54 (64%)Teens currently in High School 54 (64%)• Current Boyfriend (all single) 34 (38%) Current Boyfriend (all single) 34 (38%) • Ever Sexually Active 24 Ever Sexually Active 24 (21%) (21%)• Age first sexual intercourse (yrs.) Age first sexual intercourse (yrs.) 15.6 (13-19)15.6 (13-19)• Had an episode unprotected sex 12/24 Had an episode unprotected sex 12/24 (50%)(50%)

*No statistically significant differences between treatment groups.

RESULTSRESULTS

ResultsResultsKNOWLEDGE KNOWLEDGE • - IG teens increased post-CD - IG teens increased post-CD

(p<.001) in knowledge of PC. (p<.001) in knowledge of PC. - IG teens sustained knowledge - IG teens sustained knowledge over 9-months (p<.001). over 9-months (p<.001).

BEHAVIORBEHAVIOR• IG teens consistently used highly IG teens consistently used highly

effective birth control methods effective birth control methods over time compared to CG teens over time compared to CG teens (98.2% vs 95.6% BC effectiveness)(98.2% vs 95.6% BC effectiveness)

ConclusionConclusion

TeensTeens with T1D are becoming with T1D are becoming sexually activesexually active at an at an early early age; with a age; with a high riskhigh risk for an for an unplanned unplanned pregnancypregnancy..

Following the CD-ROMFollowing the CD-ROM IG teens were more likely IG teens were more likely to: to:

Be Be more knowledgeablemore knowledgeable about DM and about DM and pregnancy, sexuality and PCpregnancy, sexuality and PC

Be more consistent in their use of effective birth Be more consistent in their use of effective birth controlcontrol

Be more likely to seek additional PC informationBe more likely to seek additional PC information

Innovative Measure of Innovative Measure of Knowledge Associated Knowledge Associated

with Attitudes regarding with Attitudes regarding Reproductive Health in Reproductive Health in

Teens with DiabetesTeens with DiabetesDenise Charron-Prochownik, PhD, CPNP, Denise Charron-Prochownik, PhD, CPNP,

FAANFAANSereika, S. , White, N. , Becker, D. , Powell, A. Sereika, S. , White, N. , Becker, D. , Powell, A. B. , Schmitt, P. , Kennard, K. , Diaz, A. , Jones, B. , Schmitt, P. , Kennard, K. , Diaz, A. , Jones,

J. , Downs, J.J. , Downs, J.University of PittsburghUniversity of Pittsburgh

Washington University, Carnegie Mellon Washington University, Carnegie Mellon University University

Funded by the National Institute of Health-Funded by the National Institute of Health-NICHDNICHD

SampleSample

• 97 adolescent females with T1D and T2D97 adolescent females with T1D and T2D

• Ages Ages 13 to <2013 to <20 years years

• No other chronic illness or mental No other chronic illness or mental retardationretardation

• Not pregnantNot pregnant

• Had diabetes for at least one yearHad diabetes for at least one year

• Recruited from Recruited from 2 large2 large university university

Children Hospitals’ Diabetes ClinicsChildren Hospitals’ Diabetes Clinics

MeasuresMeasuresOutcome measurements: Outcome measurements:

• Knowledge, beliefs (EHBM), Knowledge, beliefs (EHBM),

decision-making regarding DM decision-making regarding DM and pregnancy, sexuality and PC;and pregnancy, sexuality and PC;

• Intention to & actual initiating Intention to & actual initiating

PC discussion with Health Care PC discussion with Health Care Professional (HCP)Professional (HCP)

MeasuresMeasures

KnowledgeKnowledge - 82 multiple choice - 82 multiple choice 2 split-halves : A = pretest B = 2 split-halves : A = pretest B =

posttestposttestcontextualized within mini-scenarios, contextualized within mini-scenarios, with option “I really don’t know”. with option “I really don’t know”.

Other variablesOther variables - Likert-type scales - Likert-type scales using the validated RHATD using the validated RHATD questionnairequestionnaire. .

Comprehensive Diabetes Comprehensive Diabetes Specific RH Knowledge Specific RH Knowledge

MeasureMeasure77 subscales confirmed by factor analysissubscales confirmed by factor analysis: :

preconception counseling (14 items); preconception counseling (14 items); pregnancy (14 items); contraception (2 pregnancy (14 items); contraception (2 items); items); sexuality (4 items); puberty (2 items); sexuality (4 items); puberty (2 items); general family planning (4 items); general family planning (4 items); general diabetes (4 items). general diabetes (4 items).

Questions were multiple choice problem-Questions were multiple choice problem-solving vignettessolving vignettes developed by a mental developed by a mental model technique of topics identified by model technique of topics identified by groups of expert health professionals and groups of expert health professionals and teens with T1D and T2D. teens with T1D and T2D.

Scores are summed and based on 100% Scores are summed and based on 100% correctness. correctness.

Comparison of Reproductive Health

Knowledge Change Scores Within and Between Treatment Groups

PreconceptioPreconception Counselingn Counseling

67.967.9

(10.6)(10.6)77.477.4

(11.8)(11.8)

<.0<.011

67.067.0

(14.4)(14.4)65.065.0

(15.4)(15.4)

.44.44 <.01<.01

PregnancyPregnancy 63.463.4

(11.5)(11.5)76.876.8

(13.2)(13.2)

<.0<.011

65.565.5

(15.1)(15.1)63.363.3

(15.0)(15.0)

.33.33 <.01<.01

ContraceptioContraceptionn

82.982.9

(26.6)(26.6)85.085.0

(21.6)(21.6)

.70.70 76.776.7

(29.6)(29.6)72.472.4

(28.7)(28.7)

.36.36 .38.38

SexualitySexuality 68.368.3

(29.4)(29.4)90.690.6

(21.0)(21.0)

<.0<.011

73.973.9

(26.2)(26.2)73.073.0

(30.9)(30.9)

.86.86 <.01<.01

PubertyPuberty 67.567.5

(43.2)(43.2)82.582.5

(29.0)(29.0)

..0505 58.658.6

(43.1)(43.1)65.565.5

(42.1)(42.1)

.37.37 .47.47

General General Family Family PlanningPlanning

83.183.1

(16.4)(16.4)91.391.3

(16.6)(16.6)

.01.01 81.581.5

(21.2)(21.2)82.882.8

(20.0)(20.0)

.68.68 .14.14

General General DiabetesDiabetes

50.050.0

(15.7)(15.7)57.557.5

(17.1)(17.1)

.02.02 45.545.5

(18.7)(18.7)46.646.6

(19.2)(19.2)

.67.67 .10.10

KnowledgeMean (SD)

IG

Pre Post pCG

Pre Post pBetween Groups p

Correlations between Changes Correlations between Changes in Scores (Post-Pre) in Total in Scores (Post-Pre) in Total

Knowledge Knowledge with Beliefs with Beliefs

Change scores for total knowledge Change scores for total knowledge were significantly associated with were significantly associated with

• perceived risk of complications perceived risk of complications (r=-.49; p<.001)(r=-.49; p<.001)

• severity (r=.40; p=.005)severity (r=.40; p=.005)• benefit (r=.32; p=.025)benefit (r=.32; p=.025)

ConclusionConclusion• The proposed knowledge measure is The proposed knowledge measure is

more comprehensive; demonstrated more comprehensive; demonstrated content and construct validity; and content and construct validity; and subscales should be used in analyses.subscales should be used in analyses.

• Teens with diabetes lack knowledge Teens with diabetes lack knowledge regarding diabetes especially with regarding diabetes especially with reproductive health. reproductive health.

• Findings appear to indicate early Findings appear to indicate early beneficial effects of the READY-Girls beneficial effects of the READY-Girls program on knowledge which was program on knowledge which was associated with some positive changes in associated with some positive changes in beliefs (risk & benefit) beliefs (risk & benefit)

DiscussionDiscussion This suggests that READY-Girls intervention This suggests that READY-Girls intervention

with boosters stimulates interest and with boosters stimulates interest and discussion; can sustain long-range effects. This discussion; can sustain long-range effects. This early self-instructional program could early self-instructional program could potentially empower these young women to potentially empower these young women to make well-informed reproductive health choices make well-informed reproductive health choices for themselves and their future children.for themselves and their future children.

Starting at puberty, Health Care Professionals should Starting at puberty, Health Care Professionals should introduce all diabetic women to the Preliminary Components introduce all diabetic women to the Preliminary Components of PC:of PC:

The effects of diabetes on pregnancy.The effects of diabetes on pregnancy.

The risks of complications.The risks of complications.

The benefits of preplanning a pregnancy with PC.The benefits of preplanning a pregnancy with PC.

Discuss prevention of an unplanned pregnancy.Discuss prevention of an unplanned pregnancy.

What age do we target?What age do we target?

Young adolescents, starting at Young adolescents, starting at puberty puberty (~13 yrs. old), need (~13 yrs. old), need developmentally appropriate developmentally appropriate information with a information with a sensitive/proactive/preventativsensitive/proactive/preventative approach before becoming e approach before becoming sexually active to empower sexually active to empower them to make informed choices them to make informed choices regarding reproductive health.regarding reproductive health.

Prior to sexual activity, Prior to sexual activity, during routine clinic visits,during routine clinic visits,health care professionalshealth care professionals

should introduce all should introduce all women with diabetes to thewomen with diabetes to the

““AwarenessAwareness” Phase of ” Phase of Preconception CounselingPreconception Counseling

It was developed in partnership with It was developed in partnership with the ADA and promoted to the ADA and promoted to

healthcare providers and consumers healthcare providers and consumers with diabetes. The resource with diabetes. The resource

utilization cost of the program is utilization cost of the program is $18,$18, a minimal expense considering a minimal expense considering the potential economic and human the potential economic and human

costs of an unplanned high-risk costs of an unplanned high-risk pregnancy.pregnancy.

Programs like:Programs like:

“READY-Girls”“READY-Girls” an effective, an effective, inexpensive, DVD educational, inexpensive, DVD educational, self-administered self-administered Preconception Counseling Preconception Counseling program for teens with program for teens with diabetes can be placed diabetes can be placed onlineonline for greater for greater disseminationdissemination. .

These programs could These programs could decrease health costsdecrease health costs in the in the future.future.

Social MarketingSocial Marketing

Raising awareness of PC during early Raising awareness of PC during early adolescence through a social marketing adolescence through a social marketing tool could have far reaching social and tool could have far reaching social and public health implications. public health implications.

Starting PC during early adolescence Starting PC during early adolescence can empower these young women to can empower these young women to become educated consumers of health become educated consumers of health care and alter their reproductive-health care and alter their reproductive-health behavior to improve their future behavior to improve their future chances of having healthy pregnancies chances of having healthy pregnancies and healthy babies. and healthy babies.

AcknowledgementsAcknowledgements• Carnegie Mellon UniversityCarnegie Mellon University Other collaboratorsOther collaborators

– Julie DownsJulie Downs - Neil White- Neil White– Baruch FischhoffBaruch Fischhoff - Joan Mansfield- Joan Mansfield– Mandy HolbrookMandy Holbrook - Bill Herman- Bill Herman– Mark HunekeMark Huneke - Nancy Janz - Nancy Janz – Kerry ReynoldsKerry Reynolds - Nicole Johnson- Nicole Johnson– Wandi Bruine de BruinWandi Bruine de Bruin - dbaza, inc. Production Co.- dbaza, inc. Production Co.

• Wayne State UniversityWayne State University - All the Research - All the Research NursesNurses– Rebecca HunnicuttRebecca Hunnicutt - All the teens who - All the teens who

participatedparticipated– Margaret M. MalyMargaret M. Maly– Kathleen MoltzKathleen Moltz– Angela PurleskiAngela Purleski

• University of PittsburghUniversity of Pittsburgh– Patricia SchmittPatricia Schmitt– Susan SereikaSusan Sereika– Margaret HannanMargaret Hannan– Andrea Rodgers FischlAndrea Rodgers Fischl– Dorothy BeckerDorothy Becker– Sarah EcklundSarah Ecklund– Shiaw-Ling WangShiaw-Ling Wang– Jessica DevidoJessica Devido– Monica DiNardoMonica DiNardo– CIDDECIDDE

AcknowledgementsAcknowledgements

Other team membersOther team members::

- Beth Cohen- Beth Cohen- Peter Draus- Peter Draus- Linda Freytag- Linda Freytag- Danielle Lockhart- Danielle Lockhart- Cindy McQuaide- Cindy McQuaide- Brenda Michel- Brenda Michel- Kerry Milaszewski- Kerry Milaszewski- Jamie Reddinger - Jamie Reddinger

Funded by American Diabetes AssociationFunded by American Diabetes Association and National Institute of Health - NICHDand National Institute of Health - NICHD