Lesson 4: ETHR Development

So now I am really excited to share a little bit more about engaging together for Healthy Relationships or ETHR, how we developed this program, and a little bit about, the first round of pilot testing that we did. So I wanna start with the patient story. So it's actually a patient story that inspired this, intervention in this program.

So I had a patient, she was 15 and she disclosed that she was in an unhealthy relationship. And she, was interested in resources and also wanted to know how she could talk to her, mom about this relationship and get support from her mom. And so I was able to talk with her mom and her mom, was

very interested in hearing about resources and how she could support her daughter, and also was really interested in helping her younger child. And was noting that, you know, how should I talk about dating with my younger child, before they start dating. And so. She also said, you know, I think it would be great if the clinic had more resources around this topic and if there were more resources for me as a parent in how to support my child who's experience unhealthy relationship and talk about healthy relationships as well.

And so that story really inspired a lot of this work. And I'm excited to kind of show how we developed ETHR and a little bit about some of the initial testing. So, how was ETHR developed? So this has been a long process and really caregivers, adolescents and clinicians have been deeply involved in the entire process to develop ETHR.

So we started with qualitative interviews with adolescents, caregivers, and clinicians, and we asked them a little bit about what their experience was like receiving, healthy and unhealthy relationship education and resources at the pediatrician's office, and their recommendations for how to develop an optimal program for the pediatrician's office focused on healthy relationships.

Dating violence prevention. And so these are a couple of examples from some of our interviews. So one parent said it would be helpful if providers have resources because there's so many resources that I don't even know where to begin to look. And a clinician said it would be nice to have something to also involve the parents because doctors can't screen all the time.

The parents are right there watching for unhealthy things that might be going on. Everybody said that they really would appreciate this type of intervention and that they hadn't actually seen a a dating violence prevention program

specifically tailored for primary care and one that includes parents and caregivers.

And then we, after the qualitative interviews, we did a series of collaborative sessions with caregivers and adolescents, and then individual feedback sessions with, with a healthcare provider, sorry to co-create the design of the intervention as well as all of the materials, the content.

And really this adolescent quote kind of sums it up very well, which is how can we compact it small enough, but meaningful enough that doctors are able to give all the information they need and have a good enough impact that it means something to patients. And I think that was the thing that we were really focusing on throughout the development is how do we.

Provide content and support and resources that is feasible within a busy clinical visit that naturally fits in to the clinical workflow of a well-child visit and which actually provides meaningful resources for families. And so that was what we worked on through the series of collaborative sessions.

So I really wanna just highlight how much caregivers, adolescents, and clinicians were involved in the process. And I think that's what makes this program really unique is that it wasn't just me creating it or a small team, but it was really multiple people over multiple years creating this program.

So who did we develop ETHR for? So it's for middle school age adolescents ages 12 to 16. It's for their caregivers and by caregiver. That could mean a parent, but it could also mean a grandparent, an older sibling. But it's really a caregiver who's a trusted adult and

for primary care pediatric clinicians. And I wanna just pause here that there is, and I'll go through all of this material subsequent videos, but there is material for the clinician. There's material for the clinic, there's material for the caregivers, for the adolescents, and for the dyad.

So it's a multi-level intervention, which I think is one thing I'm really excited about. And why did we focus on middle school? So 12 to 16 is sort of early, you know, early middle school to early to mid high school. So we know that first romantic relationships typically begin in middle adolescents around 12 to 14 years of age.

Like I said earlier, dating can look like lots of different things. It may not be a they may not use the word relationship, but sort of talking to, folks

with a romantic interest that often happens in middle adolescence. And since the focus is on education and prevention, we really wanna talk about.

Dating, before young people, ideally before young people start dating, or as they're starting to develop interest in dating, and then we can keep checking in as they're getting older and starting to date. The other thing I will say is that, studies have shown that caregivers report the most challenges around monitoring and communication, in the middle adolescents kind of middle school time period.

So we thought that was another reason that this would be a good time to focus on this age group. And so now I wanna share a little bit about, how we tested ETHR, and what some of the results look like. I will say the next video really focuses on. What the actual intervention is.

But I do wanna share a little bit about the testing because it was exciting to be able to test it out. The, intervention that we tested out, was a smaller version of what you're gonna see in the next video. It included. Training for the clinicians, some guides for the clinicians and some resource guides.

And as you'll see subsequently, the next round that you'll be using in your clinical setting has a lot more components to it. But the way that we did this is we had four clinicians at two different clinics. So two at each clinic and, at one clinic, one clinician at each clinic was randomized to be the intervention clinician and the other, the control clinician.

And then we enrolled 34 dyads. Where the adolescent was a patient of the intervention clinician, and 16 dyads the adolescent was the patient of the control clinician. And the dyads received baseline surveys. The intervention dyads received ETHR during their well-child visit.

And then, the dyads received post-visit surveys as well as follow-up surveys and completed an interview. So that was how the trial went. And I wanna share just briefly the results. So we had four clinicians. We had, 50 dyads, and a variety in terms of gender, although we did not enroll any gender diverse young people.

So that is something that we really wanna focus on for the future. And a variety in terms of age, in terms of 11 to 15. So for this trial, we did enroll some 11 year olds. But for subsequent programming, we'll focus on 12 to 16, as we found that 11 year olds, we're not resonating with this program as much as 12 to 15 year olds.

And in general we found high acceptability. So adolescents score the intervention positively and caregivers, score the intervention extremely positively. We found that intervention groups had significantly more conversations and interactions regarding healthy relationships.

So compared with the control group intervention, adolescents and parents reported more conversations around dating violence at follow-up surveys. For young people who had started dating the intervention adolescents were more likely to say that they had told their parent about their dating partner compared to the controller adolescents at the follow-up surveys compared to the baseline surveys.

Additionally we found that, in the doctor's office, families in the intervention dyad were much more likely to have had conversations around healthy relationships and to have received resources. In general, all participants supported the intervention, the clinicians, the caregivers, and the adolescents.

They really enjoyed information on the types of abuse, particularly the red and green flags. They enjoyed, the resources and really appreciated the resource connection. Participants did share a lot of feedback about ways to make the intervention more engaging, particularly that they wanted more content after the visit.

To continue the caregivers and adolescents engaging around these topics. So that was what we've done so far. And then the [00:09:00] next video, I'm gonna share a little bit about what ETHR looks like, now and, the current version, version 2.0, and what you will be, implementing in your clinical setting.