Transcript Slide 1

Using community-based participatory mixed methods research to understand
Preconception Health in African American communities of Arizona
Khaleel S. Hussaini1 Ph.D. Eric Hamm MPH2 Antoinette Means1 MBA
1Bureau of Women & Children’s Health 150 N 18th Ave Ste. # 320 Phoenix, AZ 85007
2University of Arizona Mel and Enid Zuckerman College of Public Health
Literature review
Preconception health care is defined as health care that optimizes the health of the mother prior to
conception; and several professional, public, and private organizations have championed the use of
preconception care in helping reduce poor birth outcomes (Freda, Moos, & Curtis, 2006).
Table 1. Key strategies of First-time Motherhood Initiative Grant in Arizona
Core Strategy
1. Social
Marketing
Campaign
While there is obvious momentum toward the rise and integration of preconception care into
standard health care services for women of child bearing age, it is less obvious whether or not health
care providers are providing , and women themselves, are accessing these services.
There is varying evidence regarding the amount of knowledge, health practitioners and women have
regarding the benefits of preconception care. It has been reported that internal medicine residents do
not have adequate training on preconception care upon the completion of their training (Spencer &
Kern, 2008). Studies have found that primary care practitioners are more likely to view preconception
care services as elective care, and feel that other commitments make the delivery of care difficult
(Heyes, Long, & Mathers, 2004).
Studies have reported that women prefer to receive information and care from their primary care
physicians (Frey & Files, 2006); underserved populations, such as minority and women with low socioeconomic status, are less likely to have access to primary care services, putting them at greater risk for
poor birth outcomes (Badura, Johnson, Hench, & Reyes, 2008).
African American women are among the underserved; and recent evidence suggests that chronic
exposure to stress associated with racism as well as living in poverty erode their physical as well as
psychological health, predisposing them to poor birth outcomes (Sheeder, Lezotte, & Stevens-Simon,
2006; Geronimus, 1996; Rauh, Andrews, & Garfinkel, 2001; Rowley, 1998).
2. Communitybased
presentation
and training
for barbers
and
beauticians
3. Grand round
presentations
for health
professionals
and Physician
education on
preconception
health
Background
The objective is to increase awareness, at
the community level in a culturally
appropriate manner, among African
American men and women ages 18-30
about the life course perspective and the
importance of preconception care in
improving birth outcomes.
Increase awareness about the life course
perspective and the importance of
preconception care in improving birth
outcomes among physicians, health care
providers makers, as well as health care
policy makers. This increase in knowledge is
intended to result in the integration of
preconception care into clinical practice and
program policies.
Geared towards African
American women and men
of all ages in Maricopa
county, Tucson, Sierra Vista
and Yuma, but primarily
geared towards 18-30 year
olds.
Health care providers and
professionals
Social Marketing
Campaign
Pre-focus group
baseline survey
Community-based
Presentations
Preconception Health Summit
and Grand Round
Presentations
Same-day pretest
and posttests
Same-day pretest
and posttest
(N = 108)
(N = 91; N = 120)
Longitudinal focus groups (October
2009 N = 51; February 2010 N = 39;
and August 2010 N = 25)
30- day follow-up
posttest (N = 23)
Methods
FTMI utilized a multi prong approach consisting of a social media campaign, community-based
presentations that included training of barber and beauticians, and a series of Grand Round
Presentations following a Preconception Health Summit as a means for increasing awareness about
the importance of preconception health in Arizona.
The social marketing campaign was assessed for efficacy using longitudinal focus groups based
on Ethnographically Informed Cultural (EIC) evaluation, which contextualizes the attitudes and
behavior in social, physical, and the environment of the participants. It specifically assessed
whether African American men and women in the targeted areas recalled and comprehend
the message of preconception and to understand the participants’ perception on health and
well-being. Seven core domains were assessed: (i) personal habits and related risks; (ii)
healthy living and pregnancy; (iii) personal health priorities; (iv) access to healthcare
resources, (v) the role of healthcare providers in health care; (vi) support networks, and (vii)
neighborhood safety.
Table 1 outlines the core strategies and specific objectives along with target population for Arizona’s
FTMI grant. Figure 1 outlines the evaluation strategies for each of the core strategies. Participatory
approach was the core philosophy for the entire FTMI grant process in Arizona, which included
planning, implementing, and evaluation.
Matched pre and posttests were utilized to assess whether community presentations
impacted community members’ knowledge of preconception. Similarly, matched pre and
posttests were utilized to assess if health providers’ (including physicians) perceptions on
preconception improved over time and if they intended to change their practice.
Because these disparities have persisted over time Bureau of Women and Children’s Health (BWCH),
initiated the First-Time Motherhood Initiative (FTMI). The two-year FTMI Grant was awarded to
BWCH, to increase awareness about preconception health among health care providers as well as
African American men and women in the state of Arizona.
Analytic Strategy
Univariate, and bivariate statistics were conducted using SAS v9.2 (2008). Chi-square statistics,
one-way ANOVA, paired sample t-tests independent sample t-tests, one-sample z-test; Cohen’s
Kappa assessing inter-rater reliability for qualitative data coding was calculated.
Results
Social Marketing Campaign
Less than one-third of the participants were able to recall the campaign. Of those who were
able to recall the campaign and its message, three-fourths of the respondents used assisted
recall (i.e. with facilitator aid). Many participants stated that they receive a lot of their health
information from TV, particularly from a show titled “Dr. Oz.” Participants felt that this show
was accessible and provided them with genuine health information that they did not receive
from other sources “Dr. Oz, yeah he’s pretty accessible on Channel 3”. Male and female
participants in particular indicated that advertising for healthy food is scarce, female
participants indicated the ads need to make healthy foods look good, and contain ‘subliminal
messages.’
Participants felt the need to research their health conditions themselves before seeking care,
and many also stated that they research their diagnosis and treatments online after seeing
seeking care as well.
While respondents understood the importance of healthy living and preconception health, they
could not distinguish between health and well-being especially with regards to their personal
health habits and behaviors. They recognized that personal and immediate social network (i.e.
family and friends) significantly influenced their health and well-being. Healthy food was
equated to “nasty tasting and expensive…. soda is cheaper than water.”
FTMI Core Strategies
• AA IMR was 17.7 (per 1000 live
births) and there were 316 excess
infant deaths during this period.
They have significantly greater rate
of death from prematurity, and low
birth weight (3.5 per 100 vs. 0.6)
First Time Motherhood Initiative (FTMI)
Target population
African American women
and men ages 18 – 30 years
of age in Phoenix Metro
Area
Figure 1. Evaluation strategies of First Time Motherhood Initiative (FTMI)
• As per 2008 count there were
approximately 221,258 African
Americans (AA) in Arizona
comprising of approximately 4% of
the total population (N = ~6.5
million);
• Both preterm and low birth weight
has averaged around 12 percent for
AA during 1998-2008 compared to
10 and 7 percent among non-AA.
Objectives
Develop a social marketing campaign
designed to increase awareness about the
life course perspective and the importance
of preconception care in improving birth
outcomes among African American women
and men ages 18 – 30 years of age.
Data and Sample
Social Marketing Campaign
NT1 = 51 (27 Males + 24 Females); NT2 = 39 (20 Males + 19 Females ); NT3 = 25 (11 Males + 14
Females) = Attrition rate from T1 to T2 was 25% and from T2 to T3 was 35%.
Community-based presentations
N = 108 matched pre and posttests
Preconception Health Summit and Grand Round Presentations
NPHS = 91 same-day pre and posttests; NPHS 30 day = 23; NGR = 120 matched pre and posttests
Community-based presentations
Participants’ views on the severity of problems in their community (e.g. heart disease, diabetes,
oral health, stroke, teen pregnancy, infant mortality, etc.) increased from pretest to posttest;
their perceptions about the importance of life-course and preconception health increased (i.e.
father’s health, mother’s health, community support, stress, sexual health, birth control); and
their knowledge of health disparities also increased from pretest to posttest. Increase in
posttest scores was not related to age and/or gender of the participant.
However, in the case of positive health behaviors (e.g. eating healthy, physical activity, seeing
doctor and dentists regularly etc.) and negative health behaviors (e.g. smoking tobacco, use of
alcohol and drugs, and consuming diet with high fat, sugar, and sodium) there were no
significant changes from pretest to posttest. There were no significant changes in self-efficacy
health statements. In particular, participants’ perceptions on testing for STI, smoking marijuana
and tobacco, importance of woman’s health prior to pregnancy, and father’s health did not
significantly change from pretest to posttest. Age and gender of the participant was not
associated with self-efficacy, positive and negative health behaviors.
Preconception Health Summit and Grand Round Presentations
A significant finding from the summit as well as the Grand Rounds was changes in perceptions
of doctors and nurses on the importance of maternal stress during pregnancy. Another
significant finding was participants perceived that general practice was the most ‘ideal’ setting
for preconception care and health care providers (including doctors and nurses) intentions to
change clinical practice increased from pretest to posttest.
Overall there was a significant increase in clinical knowledge of preconception health care from
pretest to posttest and this effect remained consistent after 30-day follow-up. Differences in
test scores for the health summit varied by attendance requirements indicating that mandatory
attendance impacted participation as well as learning objectives.