An Interactive On-line Preconception
Counseling Program for Teens with
Diabetes: READY-Girls
Denise Charron-Prochownik, PhD, CPNP, FAAN
School of Nursing
University of Pittsburgh
Funded by ADA Clinical Research Awards
National Institute of Health-NICHD
Background
• Diabetes can cause reproductive complications
• Up to 9% of diabetic women with unplanned pregnancies
have complications (e.g., infants with congenital
abnormalities).
• Up to 2/3 of diabetic women have unplanned pregnancies.
• Reproductive complications can be reduced from 9% to 2%
through Preconception Counseling (PC)
• ADA recommends PC for all women of child-bearing
potential to prevent unplanned pregnancies
Background
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.
AWARENESS
PRECONCEPTION COUNSELING
Survey of 16 - 21 yr old females w/ T1D:
What do you know about preconception
counseling (PC)?
 Nothing
75%
 Misconceptions
3%
AWARENESS
PRECONCEPTION COUNSELING
Survey of 13 - 21 yr old females w/ T2D:
What do you know about preconception
counseling (PC)?

Nothing
100%
Purpose
The purpose of this presentation is to describe
the development, promotion and evaluation
of an interactive PC educational program
(book and CD-ROM) for girls with diabetes,
called
Reproductive-health Education and
Awareness of Diabetes in Youth for Girls
(READY-Girls).
“READY-Girls” is
Reproductive-health Education and Awareness of
Diabetes in Youth for Girls
READY-Girls is
a theory- and evidence-based Preconception
Counseling program developed as a DVD and book
that targets teens with diabetes
Expanded Health Belief Model
(STRECHER & ROSENSTOCK, 1997)
STAR decision model
(MEICHENBAUM, 1983)
Theoretical/ Decision-making
Models for READY-Girls
EXPANDED HEALTH BELIEF MODEL
(STRECHER & ROSENSTOCK, 1997)
STAR model
S = Stop
T = Think about your choices
A = Act on your decision
R = Reflect on results of your choice
(MEICHENBAUM, 1983)
APPLICATION OF THE EXPANDED HEALTH BELIEF
MODEL (STRECHER & ROSENSTOCK, 1997)
Individual Perceptions
Mediating/Modifying Factors
Likelihood of Action
Reproductive
Health
Behaviors
Knowledge
Psychosocial Variables
Intervention
Perceived
susceptibility/severity
of reproductive
problems
(e.g. Unplanned
pregnancy,
complications
Demographic Variables
Adherence
Perceived threat of
reproductive problems
Motivational Cues
Ability to make decisions
Sexually Active
Awareness of PC
Risk Profile/Personal Health
*Variables not amendable to change from intervention.
Attitudes/Beliefs are italicized.
Perceived benefits minus
perceived barriers to
behavior change for
promoting
reproductive health
Self-Efficacy to
perform reproductive
health behaviors
Intention (likelihood) to
change behavior
for promoting
reproductive health
Figure 1

Preventing an
unplanned
pregnancy

Seeking
preconception
counseling

Ability to
initiate
discussion
Metabolic
Control
Significant Association of
PC Awareness with Seeking PC
Survey 16-21 yr. old:
Motivational Cue:
Initial awareness of PC
r = .27 (p < .05)
(Charron-Prochownik, 01)
Survey pregnant women with diabetes:
Motivational Cue:
HCP encouraged PC
OR = 3.13 (p = .02)
(Janz, 95)
3 Phases of Preconception Care (PC)
• Phase 1: “Awareness Counseling” (anyone, anytime
“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
What Is Given In
“Awareness Counseling”
• Information about:
– Diabetes and pregnancy / risk of complications
– Importance of tight control before conception
– Importance of planning a pregnancy with PC
– How to prevent an unplanned pregnancy
– Family planning advice
The READY-Girls Message:
Impact of a Newly Developed CDROM Reproductive Health Education
Program on Teen Women with DM:
3-month Follow-up
Denise Charron-Prochownik, PhD, RN, CPNP
Dorothy Becker, Susan Sereika,
Meg Ferons, and Jamie Reddinger
University of Pittsburgh
Funded by an American Diabetes Association
Clinical Research Award
Sample
• 53 adolescent women with T1D,
1 session and 3 groups: CD, BK, SC
• Ages 16 to <20 years
• No other chronic illness or mental retardation
• Not pregnant
• Have had type 1 diabetes for at least one year
• Recruited from one large Diabetes Center:
Children’s Hospital of Pittsburgh
Comparison of Intervention vs Control
Outcomes
Diff (Post - Pre)
2
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
Results
• Compared to CG, IG had significantly
increased in knowledge, perceived
attitudes and social support
• Knowledge, benefits, & barriers were
sustained over the 3-month period, but
other variables were not
Reproductive Health Education for
Adolescent Girls with Diabetes
(READY-Girls): Sustaining Long-range
(9 month) Outcomes
Denise Charron-Prochownik, Susan M. Sereika, Margaret
Ferons Hannan, Andrea Rodgers-Fischl, Dorothy Becker,
Joan Mansfield, Peter Draus, William Herman,
Linda Freytag, Kerry Milaszewski,
University of Pittsburgh, Pittsburgh, PA
Funded by American Diabetes Association
Methods
• Two-group (IG vs standard care control CG), randomized,
controlled, repeated measures design
• Intervention: Two CD-ROM sessions and one book session
of the education program before 3 consecutive routine
Diabetes Clinic visits; randomized to web-based message
board (for teens and RN); and an RN counseling session
• Self-Administered questionnaires
(4 Time Points: base, immediate-post CD #1 and CD #2, 9-mo f/u )
• Subjects received $80 for participation
Measures / Analyses
• Outcome measurements:
knowledge, attitudes (EHBM), decision-making and
behavior regarding DM and pregnancy, sexuality, birth
control (BC), and PC; A1C blood test; and use of the website message board
• To compare between and within group differences,
2 time points were selected:
baseline and 9-mo follow-up
• Descriptive
• Mixed Model Repeated Measures Analysis
Sample
• 88 adolescent women with T1D
– Intervention group (n=43)
– Standard care control group (n=45)
• Ages 13 to <20 years
• No other chronic illness or mental retardation
• Not pregnant
• Have had type 1 diabetes for at least one year
• Recruited from 2 large Diabetes Center: Children’s
Hospital of Pittsburgh and Joslin Clinic Boston
BASELINE DEMOGRAPHICS*
•
•
•
•
•
•
•
•
•
•
Mean Age (yrs.)
16.7
Mean Duration of Illness (yrs.)
7.2
African American
5
Living with Parents
85
Mothers completing College
42
Teens currently in High School
54
Current Boyfriend (all single)
34
Ever Sexually Active
24
Age first sexual intercourse (yrs.) 15.6
Had an episode unprotected sex 12/24
*No statistically significant differences between treatment groups.
(13.2-19.7)
(1-17)
(6 %)
(96%)
(49%)
(64%)
(38%)
(21%)
(13-19)
(50%)
RESULTS
Results
KNOWLEDGE
• - IG teens increased post-CD (p<.001) in
knowledge of PC.
- IG teens sustained knowledge over 9months (p<.001).
BEHAVIOR
• IG teens consistently used highly effective
birth control methods over time compared to
CG teens (98.2% vs 95.6% BC effectiveness)
Conclusion
Teens with T1D are becoming sexually active at an early
age; with a high risk for an unplanned pregnancy.
Following the CD-ROM IG teens were more likely to:

Be more knowledgeable about DM and pregnancy,
sexuality and PC

Be more consistent in their use of effective birth control

Be more likely to seek additional PC information
Innovative Measure of
Knowledge Associated with
Attitudes regarding Reproductive
Health in Teens with Diabetes
Denise Charron-Prochownik, PhD, CPNP, FAAN
Sereika, S. , White, N. , Becker, D. , Powell, A. B. , Schmitt, P.
, Kennard, K. , Diaz, A. , Jones, J. , Downs, J.
University of Pittsburgh
Washington University, Carnegie Mellon University
Funded by the National Institute of Health-NICHD
Sample
• 97 adolescent females with T1D and T2D
• Ages 13 to <20 years
• No other chronic illness or mental retardation
• Not pregnant
• Had diabetes for at least one year
• Recruited from 2 large university
Children Hospitals’ Diabetes Clinics
Measures
Outcome measurements:
• Knowledge, beliefs (EHBM),
decision-making regarding DM and
pregnancy, sexuality and PC;
• Intention to & actual initiating
PC discussion with Health Care Professional
(HCP)
Measures
Knowledge - 82 multiple choice
2 split-halves : A = pretest B = posttest
contextualized within mini-scenarios,
with option “I really don’t know”.
Other variables - Likert-type scales using the
validated RHATD questionnaire.
Comprehensive Diabetes Specific RH
Knowledge Measure
7 subscales confirmed by factor analysis:
preconception counseling (14 items);
pregnancy (14 items); contraception (2 items);
sexuality (4 items); puberty (2 items);
general family planning (4 items);
general diabetes (4 items).
Questions were multiple choice problem-solving
vignettes developed by a mental model technique
of topics identified by groups of expert health
professionals and teens with T1D and T2D.
Scores are summed and based on 100% correctness.
Comparison of Reproductive Health
Knowledge Change Scores Within and Between
Treatment Groups
Knowledge
Mean (SD)
IG
Pre
CG
p
Post
Pre
p
Post
Between
Groups p
Preconception
Counseling
67.9
(10.6)
77.4
(11.8)
<.01
67.0
(14.4)
65.0
(15.4)
.44
<.01
Pregnancy
63.4
(11.5)
76.8
(13.2)
<.01
65.5
(15.1)
63.3
(15.0)
.33
<.01
Contraception
82.9
(26.6)
85.0
(21.6)
.70
76.7
(29.6)
72.4
(28.7)
.36
.38
Sexuality
68.3
(29.4)
90.6
(21.0)
<.01
73.9
(26.2)
73.0
(30.9)
.86
<.01
Puberty
67.5
(43.2)
82.5
(29.0)
.05
58.6
(43.1)
65.5
(42.1)
.37
.47
General Family
Planning
83.1
(16.4)
91.3
(16.6)
.01
81.5
(21.2)
82.8
(20.0)
.68
.14
General Diabetes
50.0
(15.7)
57.5
(17.1)
.02
45.5
(18.7)
46.6
(19.2)
.67
.10
Correlations between Changes in Scores
(Post-Pre) in Total Knowledge
with Beliefs
Change scores for total knowledge were
significantly associated with
• perceived risk of complications (r=-.49; p<.001)
• severity (r=.40; p=.005)
• benefit (r=.32; p=.025)
Conclusion
• The proposed knowledge measure is more
comprehensive; demonstrated content and
construct validity; and subscales should be used in
analyses.
• Teens with diabetes lack knowledge regarding
diabetes especially with reproductive health.
• Findings appear to indicate early beneficial effects
of the READY-Girls program on knowledge which
was associated with some positive changes in
beliefs (risk & benefit)
Discussion
This suggests that READY-Girls intervention with boosters
stimulates interest and discussion; can sustain long-range
effects. This early self-instructional program could
potentially empower these young women to make wellinformed reproductive health choices for themselves and
their future children.
 Starting at puberty, Health Care Professionals should introduce all diabetic
women to the Preliminary Components of PC:

The effects of diabetes on pregnancy.

The risks of complications.

The benefits of preplanning a pregnancy with PC.

Discuss prevention of an unplanned pregnancy.
What age do we target?
Young adolescents, starting at puberty
(~13 yrs. old), need developmentally
appropriate information with a
sensitive/proactive/preventative
approach before becoming sexually
active to empower them to make
informed choices regarding
reproductive health.
Prior to sexual activity,
during routine clinic visits,
health care professionals
should introduce all
women with diabetes to the
“Awareness” Phase of
Preconception Counseling
It was developed in partnership with
the ADA and promoted to
healthcare providers and consumers
with diabetes. The resource
utilization cost of the program is
$18, a minimal expense considering
the potential economic and human
costs of an unplanned high-risk
pregnancy.
Programs like:
“READY-Girls” an effective,
inexpensive, DVD educational, selfadministered Preconception Counseling
program for teens with diabetes can be
placed online for greater dissemination.
These programs could decrease health
costs in the future.
Social Marketing
Raising awareness of PC during early adolescence
through a social marketing tool could have far
reaching social and public health implications.
Starting PC during early adolescence can empower
these young women to become educated
consumers of health care and alter their
reproductive-health behavior to improve their
future chances of having healthy pregnancies and
healthy babies.
Acknowledgements
•
Carnegie Mellon University
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•
Wayne State University
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•
Julie Downs
Baruch Fischhoff
Mandy Holbrook
Mark Huneke
Kerry Reynolds
Wandi Bruine de Bruin
Rebecca Hunnicutt
Margaret M. Maly
Kathleen Moltz
Angela Purleski
University of Pittsburgh
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Patricia Schmitt
Susan Sereika
Margaret Hannan
Andrea Rodgers Fischl
Dorothy Becker
Sarah Ecklund
Shiaw-Ling Wang
Jessica Devido
Monica DiNardo
CIDDE
Other collaborators
-
Neil White
Joan Mansfield
Bill Herman
Nancy Janz
Nicole Johnson
dbaza, inc. Production Co.
- All the Research Nurses
- All the teens who participated
Acknowledgements
Other team members:
- Beth Cohen
- Peter Draus
- Linda Freytag
- Danielle Lockhart
- Cindy McQuaide
- Brenda Michel
- Kerry Milaszewski
- Jamie Reddinger
Funded by American Diabetes Association
and National Institute of Health - NICHD