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The Gabby Preconception Care System Healthy Start EPIC Center
March 31st, 2015
Megan Hempstead, MPH, Program Coordinator Clevanne Julce, BS, Study Coordinator Divya Mehta, BS, Research Assistant
Brian Jack, MD Karla Damus, PhD, MSPH, RN, FAAN
Department of Family Medicine BU School of Medicine/Boston Medical Center
Overview
• Preconception Care Basics • Gabby System Development • Gabby Research • How can you and Healthy Start
sites be involved?
Finland 2.3
Japan•••••••••••• 2.3 Portugal 2.5 Sweden 2.5
Czech Republic 2.7 Norway 2.8
Korea Spain
Denmark 3.4 Germany 3.4
Italy 3.4 Belgium 3.6 France 3.6
Israel 3.7 Greece ••••••••••••••••••••• 3.8 Ireland 3.8
Netherlands 3.8 Switzerland 3.8
Austria 3.9 Australia 4.1
United Kingdom 4.2 Poland
Hungary New Zealand
Slovakia United States
t--~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~--
0 1 2 3 4 5 6 Rate per 1 ,000 live births
6.1
7
NOTES: Canada's 2010 data were not available from the Organisation for Economic Co-operation and Development (OECD) at the time of manuscript preparation. The 2009 infant mortality rate for Canada was 4.9. If the 2010 data for Canada had been available, the U.S. ranking may have changed. Deaths at all gestational ages are ind uded, but countries may vary in completeness of reporting events at younger gestational ages. SOURCES: CDC/NCHS, linked birth/infant death data set (U.S. data); and OECD 2014 (all other data). Data are available from: http ://www.oecd.org .
Figure 1. Infant mortality rates: Selected Organisation for Economic Co-operation and Development countries, 2010
World Infant Mortality Rates
The Disparity
7
10.3
5.3 7
11.6
5.4
13.2
16.5
13.8
0
2
4
6
8
10
12
14
16
18
LBW1 PTB1 Infant Mortality2
White Hispanic African American
1. Martin JA, Hamilton BE, Osterman MJK, Curtin SC, and Mathews TJ. (2013). Births: Final data for 2012.National vital statistics reports: Volume 62, Number 9. Hyattsville, MD: National Center for Health Statistics
2. Kochanek KD, Xu J, Murphy SL, Miniño AM, & Kung HC. (2011). Deaths: Final Data for 2009. Washington, DC:Division of Vital Statistics.
Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.
Preconception Health (PCH) (including Interconception Health)
Preconception health and health care focuses on taking steps now to protect the health of a baby in the future. However, preconception health is important for all women and men, whether or not they plan to have a baby one day.
CDC. Preconception Health and Health Care. Retrieved March 27, 2014, from: http://www.cdc.gov/preconception/index.html
The Big Picture
Health promotion
Immunization
Infectious disease
Medical conditions
Psychiatric conditions
Parental exposure
Family and genetic history
Nutrition
Environmental exposure
Psychosocial risk
Medication
Reproductive history
Special populations
The Dilemma
The Need
There is a need for an efficient way to assess a woman’s preconception risks, in order to prioritize valuable appointment time with a provider, and to support the woman in taking action to minimize her risks.
Now Introducing: Gabby
Video: Gabby Explains PCC
Creating Gabby: Focus Group Feedback
• Clothing – “Layering” – Blue scrubs with institution’s
logo or lab coat – “Fitted” shirt that shows curves
• Accessories – Glasses – Badge or Stethoscope – Wedding ring, earrings,
necklace
• Hairstyle – “Honey” colored highlights or
dark brown hair – Short bob with “professional”
side bangs OR shoulder length wavy curls
• Layla
Top 10 Name Suggestions:• Gabrielle “Gabby” for short • Vanessa/Venessa • Angela • Maria • Jeanette • Annie • Lisa • Nicole • Natalie
“Someone I would
the street.” see walking down
La-La (MTV host) Rihanna (singer) Gabrielle Union (actress)
Step 1: PCC Risk Assessment
Step 2: Info About Identified Risks
V1 Results Risk Assessment: Risks by Domain
21%
17%
11%10%
7%
7%
7%
5%
4% 4%
4% 3% Nutrition Infectious Genetic Environmental Reproductive Immunization Health Conditions/ Meds Healthcare/ Programs Emotional Substance Men Relationships
V1 Results: Risk Status
Risks Discussed
11 (48%)
Risks Added to MHTDL
7.2 (65%) Status at 2 months
Resolved – 3.5 (54%)
Took Action – 2.2 (29%)
No action – 1.5 (17%)
Risks Identified (per person) 23 (100%)
V1 Results: Stage of Change
All Risks discussed with Gabby, n=67 Initial Stage # risks Pre-
contemplation Contemplation Preparation Action /
Maintenance
Pre-Contemplation 16 5 3 0 4
Contemplation 12 1 2 0 8
All Risks Discussed with Gabby and Added to MHTDL, n=43 Initial Stage # risks
(%) Pre-contemplation
Contemplation Preparation Action / Maintenance
Pre-contemplation 1 0 0 0 1
Contemplation 11 1 2 0 8
• Gabby best at moving those in “Contemplation” to “Action/Maintenance” • V2 programming to move from “Pre-contemplative” to “Contemplative”
Gabby Version 2: New Content
Longitudinal behavior change: • Motivational Interviewing to reach out to precontemplators • Shared decision making to assist with complicated decisions (i.e.
contraceptive choice) • Problem solving to provide solutions to common barriers • Goal setting to provide long-term motivation • Homework to keep users engaged outside of system • “Sequential Discrete” to walk users through processes step-by-step (i.e.
making and going to a healthcare appointment) • Tips, Direct observation, Social reinforcement, etc.
Supporting the user with information, tools, and encouragement throughout the behavior-change process
Gabby Version 2
1. Take Risk Assessment
2. Meet Gabby
4. Choose risk to learn about with Gabby
3. Review results (“My Survey
Results”)
5. Listen to first informational script(s) from Gabby .
6. Answer Stage of Change question for that risk and listen to stage-appropriate scripts
Precontemplation
Contemplation & Planning
Contemplation, Planning, Action,
Maintenance
Motivational Interviewing
- Problem Solving/Tips - Homework - Goal Setting - Educational Info (Nutrition, Activity, and Stress Management)
- Shared Decision Making (Family Planning) - Sequential Discrete (“Go to the Doctor” risks)
7a. Add to risk to MHTDL
7b. Don’t Add to MHTDL
8b. Choose new risk to discuss from “My Survey Results” OR “My Health To-Do List”
8a. Longitudinal behavior change scripts
Achieve Goal
Video: Gabby Can Share Her Experience
Gabby V2: RCT
Enrolled March – July 2013 • 100 participants (50 intervention, 50 controls) • 6-month intervention period • Recruited from: OMH Preconception Peer Educators (86);
Healthy Start, Jacksonville, FL (8); BMC Health Expo (4);word of mouth (2).
• Eligibility: Female, African American, 18-34, speak English,not currently pregnant
• All participants enrolled over the phone, answered baseline questionnaires, then were given a link to the online risk assessment. – Controls: received a letter in the mail with their results – Interventions: given a link to talk to Gabby about their results
• All participants contacted for outcome call at 6-months.
V2 Results: Demographics Variable Controls
(n=45) Interventions (n=46)
Age (Mean(SD)) 25.3 (3.6) 25.9 (3.4)
Hispanic, Latino, Yes 1 (2%) 3 (7%) Spanish origin? No 44 (98%) 43 (89%) (N(%))
Education (N(%)) At least some college 40 (89%) 42 (91%) Less than college 5 (11%) 4 (9%)
Household Income Less than $20,000 3 (7%) 3 (7%) $20,000-$50,000 7 (16%) 12 (26%) $50,000 or more 23 (51%) 14 (30%) Don’t Know/Refused/Missing 12 (27%) 17 (37%)
Currently a Yes 20 (44%) 19(41%) student (N(%)) No 25 (56%) 27 (59%)
REALM Score (Mean (SD)) 63.0 (5%) 61.3 (12%) >High School (N(%)) 5 (12%) 4 (9%) High School (N(%)) 38 (88%) 39 (91%)
How easy was it to talk to Gabby?
31%
7% 3%
6%
6%
Extremely Difficult Very Difficult Difficult Neutral Easy Very Easy Extremely Easy
78% thought that it was easy to talk to Gabby
28%
19%
V2 Results: Risks Identified (at Baseline, n=91)
27%
16%
10% 10%
6%
6%
6%
5%
4% 4%
4% 3% Nutrition Infectious Diseases Environmental Immunizations Relationships Genetic Reproductive Men Healthcare/ Programs Health Conditions/ Meds Substance Use Emotional Health
Tota
l Tim
e Ri
sk D
iscu
ssed
(min
) 500 450 400 350 300 250 200 150 100
50 0
Results: Risks Discussed, Time Risks
Nut
ritio
nFa
mily
Pla
nnin
gG
o to
Doc
tor
Iron
Stre
ssFo
lic A
cid
Calc
ium
Plas
tic B
ottle
sPh
ysic
al A
ctiv
ityEt
hnic
ity B
ased
Car
eAl
coho
lO
verw
eigh
t/O
bese
Heal
thy
Eatin
gLi
ster
iosis
Caffe
ine
No
Birt
h Co
ntro
lPr
escr
iptio
ns TBHe
p B-
No
Vacc
inat
eTo
bacc
o
Interventions (n=50) logged on 2.8 times on average (min 0, max 12)
Results: Risks Identified & Resolved
Randomization N Mean Identified
Mean Resolved
Std Dev
Control 43 24.2 5.5 4.4
Gabby 36 23.2 8.3 4.5
p < 0.01
Those who had access to Gabby resolved approximately 3 more risks than those who did not.
28% of risks were resolved in the Gabby group vs 20% in the Control group
V2 Results: Knowledge Scores, Nutrition
Controls Gabby p-value
Baseline Score (% correct)
6-month Score (% correct)
% Increase
Baseline Score (% correct)
6-month Score (% correct)
% Increase
Nutrition 78.2 80.2 1.2% 78.7 87.4 9.0% 0.06
Those who talked to Gabby increased their Nutrition knowledge score by an average of 9%, while Controls saw an increase of 1.16%.
How much do you trust Gabby?
12.5
28.3
59.4
0
10
20
30
40
50
60
70
Don't Trust Neutral Trust
Have you used info from Gabby to improve your health?
70 65.6
60
50
40
30 21.9
20 12.5
10
0 No Plan to Yes
70
Would you recommend Gabby to someone you know?
65.6
60
50
40
30 21.9
20
10
12.5
0 No Don't know Yes
You can help
us recruit!
What’s Happening Now? V3: RCT of 530 participants (NIMHD, R01MD006213)
• Enrollment began March 2014 • National sample, enrolled via phone • One-year intervention period
Kellogg Foundation Funding – 2 years of development: • Comprehensive content overview and update • Expand Family Planning Discussion • Make connections between risks to leverage past success
PCC for Men – Administrative Supplement from HRSA-BMCH • Created a Men’s Health Survey; focus groups (n=17); pilot testing
(n=29)
Gabby V3 National Study
Currently recruiting 530 women from across the country who are:
– Black or African American – Ages 18-34 – Not currently pregnant – have access to a computer with internet and a
telephone.
Gabby V3 Study: Steps for Participants
1. Enrollment: - Contact study team to set up enrollment call - Schedule enrollment phone call - Enrollment phone call takes ~ 30 minutes
- BMC staff explains the study, makes sure woman understands, then collects information like demographics and baseline questionnaires (e.g. self-efficacy, social support, discrimination)
- After the call, receive an email with username and password and link to the online health survey
Gabby V3 Study: Steps for Participants
2. Using the system - All participants take the online health survey,
which takes ~15-20 minutes - Gabby group: can click button to meet Gabby
and can log in to talk to Gabby any time for the next year
- Control group: receives letter via mail or email with their health survey results
Gabby V3 Study: Steps for Participants
3. Follow-up calls - BMC study staff contact all participants to set
up calls at 6 months and 12 months - Collect:
- Updates on their PCC risks - Feedback on Gabby (Gabby group only) - Re-do some of the questionnaires from the
enrollment phone call (e.g. General Self-Efficacy Scale)
Gabby V3 Study: Incentives
• All participants can earn $25 Target gift cards for completing each of the follow-up calls ($50 total if they complete both calls)
• Gabby group participants are entered in to a monthly raffle for a $100 Target gift card. They can earn one entry per week that they log in at least once (4 raffle entries maximum per month)
How you can help us recruit!
How you can help us recruit!
• Tell women about the study! • Give them flyers or “Gabby cards” with our
contact info – they reach out to us. • Provide basic info if they ask. It’s a one-year
study using a computer program to learn about health before pregnancy.
• Once they sign up, encourage them to take the online survey, log in, and do the follow-up calls
Email: [email protected] to ask us to email or mail you flyers and
Gabby cards
Our team will be happy to assist you!
Thank you!
We would like to thank our funders:
AHRQ: contract # W.F. Kellogg Foundation: HHSA290200600012I, TO #7 P3024018 HRSA B-MCH: R40 MC21510 Kirby Foundation NIMHD: R01 MD006213
And everyone who has contributed to developing and testing Gabby Brian Jack, MD (PI) Suzanne Mitchell, MD, MSc Fatima Adigun Natalie Rock Justin Alves, RN, BSN Huong Tran, MDTimothy Bickmore, PhD Jingjing RenKarla Damus, PhD, MSPH, RN Lazlo RingShayna Egan, MPH Ekaterina Sadikova, MPH Paula Gardiner, MD, MPH Meryl St. John, MAMegan Hempstead, MPH Daniel Schulman, PhD Kenn Harris Emily VishnjaCathryn Imperato, DNP Leanne Yinusa-Nyahkoon, ScDClevanne Julce …and more… Stephen Martin, MDDivya Mehta