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).

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 socio-economic 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).

Background

First Time Motherhood Initiative (FTMI)

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.

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.

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.

Data and SampleSocial Marketing CampaignNT1 = 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 presentationsN = 108 matched pre and posttestsPreconception Health Summit and Grand Round Presentations NPHS = 91 same-day pre and posttests; NPHS 30 day = 23; NGR = 120 matched pre and posttests

Analytic StrategyUnivariate, 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.

ResultsSocial Marketing CampaignLess 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.”

Community-based presentationsParticipants’ 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 PresentationsA 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.

Core Strategy Objectives Target population1. Social

Marketing Campaign

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.

African American women and men ages 18 – 30 years of age in Phoenix Metro Area

2. Community-based presentation and training for barbers and beauticians

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.

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.

3. Grand round presentations for health professionals and Physician education on preconception health

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.

Health care providers and professionals

Table 1. Key strategies of First-time Motherhood Initiative Grant in Arizona

Figure 1. Evaluation strategies of First Time Motherhood Initiative (FTMI)

MethodsThe 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.

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.

FTMI Core Strategies

Social Marketing Campaign

Pre-focus group baseline survey

Longitudinal focus groups (October 2009 N = 51; February 2010 N = 39;

and August 2010 N = 25)

Community-based Presentations

Same-day pretest and posttests

(N = 108)

Preconception Health Summit and Grand Round

Presentations

Same-day pretest and posttest

(N = 91; N = 120)

30- day follow-up posttest (N = 23)

• 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.

• 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)