Preconception Evaluation Project
Preconception care integration within family planning
services:Exploring the client and provider experienceClaudine
Offer, MPHBarbara Kass, RNPCP, MSNMaryjane Puffer, BSN, MPAKathryn
Horsley, DrPH3rd National Summit on Preconception Health and Health
CareJune 13, 2011Explain: We trained providers to provide
preconception messages in FP visits and then collected information
on how clients and clinicians felt about the integration.1June 13,
20113rd National Summit on Preconception Health and Health
CareCalifornia Family Health Council, Inc.IntroductionCalifornia
Family Health CouncilDistributes federal Title X family planning
funds to 80 community agencies (347 clinic sites) throughout
California serving over 1.2 million clients annuallyPerforms
advanced research in reproductive health and contraceptionConducts
education, training, and community outreachImplements and monitors
effective community health programs
To beginId like to tell you a little bit about our organization.
The CaliforniaDefine Title X: federal funding for the national
family planning program, Title X of the Public Health Service
Act2June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council, Inc.Why preconception
care in family planning?Family planning clients:In reproductive
yearsSeeking health care services Title X clients:Low incomeHigh
rates of poor birth outcomes
Approximately 70% of the activities cited in the CDC MMWR on
preconception care are provided in family planning settingsFP
clients: Seeking health care services point of contact for
opportunistic intervention. Title X clients are family planning
clients with additional characteristics that make PCC intervention
ideal.Often this is the only opportunity for health care services
and pcc messages.CDC Morbidity and Mortality Weekly Report
3June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council, Inc.Preconception Care
and Intention for PregnancyIn the U.S. 49% of all pregnancies and
82% of teen pregnancies are unplanned (Finer & Henshaw, 2006)In
the U.S. 48% of unintended pregnancies occur among women who were
using a contraceptive method at the time they conceived (Finer
& Henshaw, 2006)Preconception care messages have potential
to:Improve womens health and birth outcomes regardless of intention
for pregnancyImprove womens health regardless of eventual
pregnancyId like to address the issue of intention for pregnancy
among family planning clients. Issue of client centered approach
and also will be a consideration as we explore the results of the
project. Title X services reach women who have both planned and
unplanned pregnancies
This also makes FP/TX setting ideal
6 Finer LB, Henshaw SK. Disparities in rates of unintended
pregnancy in the United States, 1994 and 2001. Perspectives on
Sexual & Reproductive Health 2006; 38(2):90-96.
California Family Health Council, Inc.June 13, 20113rd National
Summit on Preconception Health and Health Care4
Project DescriptionOrientation of clinic site staffReview of
health history form and client chartFour screening questions: Do
you want to get pregnant? If so, when? Are you sexually active (at
risk for pregnancy)? If so, are you trying to prevent pregnancy
(and how)? 5June 13, 20113rd National Summit on Preconception
Health and Health CareCalifornia Family Health Council,
Inc.Providers were asked to integrate core preconception messages
in family planning visits:
Folic acid intakeDiabetesObesitySubstance use
Project DescriptionDefine FP visits: birth control, annual,
breast exam, pap and pap f/up, pregnancy test, std/hiv testing and
resultsThese five issues prioritized as part of project and
evaluation. At least one issue addressedbased on review of health
history and chartIntervention was provided over six month period.
Varied by site.
6June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council, Inc.Preconception
Integration Clinic SitesClinic sites2 Los Angeles sites, 1 San
Francisco siteInterest in preconception integrationSufficient
family planning visits for recruitment7June 13, 20113rd National
Summit on Preconception Health and Health CareCalifornia Family
Health Council, Inc.Evaluation QuestionsClients attitudes about
receiving preconception care messages in family planning
visitsClients intentions for health behavior changes related to
core preconception messagesProviders experiences integrating
preconception care messages into family planning visitsWe wanted
information on these three areas. We saw promising responses to all
of these as you will see when we look at results.8June 13, 20113rd
National Summit on Preconception Health and Health CareCalifornia
Family Health Council, Inc.Data SourcesClient post-visit
surveyCompleted after family planning visitIntervention
logProviders recorded types of preconception messages, method of
intervention, and time spentPost project interview/surveyProviders
experience with process and continued integrationClient survey: one
site offered $5 gift cards as incentives9June 13, 20113rd National
Summit on Preconception Health and Health CareCalifornia Family
Health Council, Inc.Providers and ParticipantsProviders10
clinicians, 1 health educatorParticipantsFemaleFamily planning
visitAges 13 45n = 555
Explain health educator format for 1 clinic site. Limited info
on provider integration but adequate info from clients10June 13,
20113rd National Summit on Preconception Health and Health
CareCalifornia Family Health Council, Inc.Sample Population Survey
LanguageSurveys CompletedPercentEnglish33059%Spanish22541%n =
555Determined by which version of survey was completed.12June 13,
20113rd National Summit on Preconception Health and Health
CareCalifornia Family Health Council, Inc.RaceAgeMean Age = 27.2n =
552Representative of Title X agencies, 54% of respondents were
between 20-29
California Family Health Council, Inc.June 13, 20113rd National
Summit on Preconception Health and Health Care14Reason for Visitn =
549ResultsThese first two results summarize the intervention .The
following results will provide answers to our evaluation
questions.16June 13, 20113rd National Summit on Preconception
Health and Health CareCalifornia Family Health Council, Inc.Type of
Intervention ProvidedNote: Because providers could select multiple
response options, percentages add up to greater than 100%n =
555Provider response. Interv not mutually exclusive. Many women
received both verbal interventions as well as handouts.17June 13,
20113rd National Summit on Preconception Health and Health
CareCalifornia Family Health Council, Inc.Time Spent on
Preconception Care n = 543Data Source: Provider Intervention
LogProvider reported on intervention log. PCC interventions not
timed. Providers estimatedlimited accuracy.18June 13, 20113rd
National Summit on Preconception Health and Health CareCalifornia
Family Health Council, Inc.Intention for PregnancyIntend Future
PregnancyFrequencyPercentYes44082%No9217%Dont Know81%n = 540Some
clients may have opted out if no desire for pregnancy. Possibly not
representative of Title X clients.Greatest desire among age group
20-29. We did not gather information on # of previous pregnancies.
DK was not option on survey.19June 13, 20113rd National Summit on
Preconception Health and Health CareCalifornia Family Health
Council, Inc.Timeframe forIntended
PregnancyTimeframeFrequencyPercent< 1yr9422%2-4 yrs14633%> 5
yrs11426%DK8419%n = 43855% of women who desire a pregnancy would
like to be pregnant within 4 years
20June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council, Inc.Timeframe for
Pregnancy by RaceRace< 1 yr2-4yrs>
5yrsLatina31%40%29%Asian23%29%48%White7%41%52% p = .0023 n = 300 *
Cumulative21June 13, 20113rd National Summit on Preconception
Health and Health CareCalifornia Family Health Council, Inc.Client
Acceptance of Preconception Messages97% strongly agreed or agreed
that information about how women can prepare for healthy
pregnancies should be offered to women during their family planning
visits (n=527, mean 4.7)94% strongly agreed or agreed that they
were interested in the information they received during their visit
about how they can have a healthy pregnancy (n=486, mean 4.5)
Likert scale 1-5No desire for baby means: Acceptance 4.6,
Interest 4.3 (n=83, 67)An important finding that women are
receptive to PCC in the context of FP visits and reaffirms Title X
role in the provision of preconception care services and health
education.
22June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council, Inc.Intention to Make
Health Behavior Changes86% of respondents stated that they were
interested in making at least one change (n=524)70% of respondents
thought they would make changes within 3 months (n=503)PAUSE:
stress that here we begin to explore the answers to our evaluation
questions.These results are for all women responding regardless of
desire for pregnancy23June 13, 20113rd National Summit on
Preconception Health and Health CareCalifornia Family Health
Council, Inc.Change and Preconception IssuesPreconception Health
IssuePercent of Clients Desire Change*Folic acid61%Healthy
foods55%Exercise52%Weight42%Smoking8%Alcohol7%n = 451* Among those
intending at least one changeRegardless of desire for
pregnancy.24June 13, 20113rd National Summit on Preconception
Health and Health CareCalifornia Family Health Council, Inc.Change
and Preconception IssuesPreconception IssuePercent of Clients
Desire Change*n Weight72%n = 187Folic acid70%n = 349Smoking15%n =
167Alcohol14%n = 173Drugs10%n =72* Among those who recalled
specific intervention messageRegardless of desire for
pregnancy.Healthy Food 45%, Exercise 42%, n = 555 These two items
were not provided in Q5 pcc issues recalled. I can not include in
analysis of change desired among those who recalled message.
However, responses (desire for change) among all participants
(n=555) was high so we might conclude that desire for change would
have been even higher (as we saw with other results) if we could
have limited analysis to those who recalled/rec'd message.
California Family Health Council, Inc.June 13, 20113rd National
Summit on Preconception Health and Health Care25Desire for Changeby
Intent for Pregnancy Desire ChangeNoChangeIntend Pregnancy88%12%Do
Not Intend Pregnancy76%24%p < .0051n = 502Desire for change is
high among both groups. Perhaps women who dont desire pregnancy
recognize value of these general health issues.. Intention for a
pregnancy was not associated with the timeframe of making any
health changes
26June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council, Inc.Desire for Change
byTimeframe for PregnancyDesire changeDo Not Desire Change< 1
year99%1%2-4 years90%10%> 5 years82%18%p = .0004n= 346In a
previous slide we saw that 55% of those wanting a pregnancy desired
a pregnancy within 4 years. Timeframe associated with desire for
change. Highlight as important outcome for guiding intervention
development. Theory of health behavior change could be applied.
Among those who desire a pregnancygreater interest in making
changes associated with timeframe of pregnancy. Greater if
pregnancy desired sooner. On one hand this means interventions
could be focused on those who desire pregnancy within 1 yr, or 3
years. But, then unplanned pregnancies may not be prepared for.
Timeframe of pregnancy and timeframe of changesno association.
27June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council, Inc.Provider
ExperienceProvider themesSupportive of preconception
integrationPerception that clients welcome preconception
messagesConcern about additional burden of integrationIncreased
ease with preconception care implementation over timeIdentified
need for more appropriate materialsn = 8Post-project interview,
emergent themes summarized here. Materials: low-literacy, Spanish,
etc.Feedback on implementationthere were also comments about the
impact of evaluation. Log was too complex and time consuming,
clients not wanting to complete survey. Impact of preconception
intervention vs. the evaluation component. Not all providers were
able to attend.28June 13, 20113rd National Summit on Preconception
Health and Health CareCalifornia Family Health Council,
Inc.ConclusionsFamily planning clients were receptive to
preconception messagesFamily planning clients were interested in
making health behavior changes after hearing preconception
messagesInterest in making changes was associated with desire for
pregnancy and timeframe of desired pregnancyContinued 29June 13,
20113rd National Summit on Preconception Health and Health
CareCalifornia Family Health Council, Inc.Providers estimated that
identification and provision of most interventions took an
estimated 1-3 minutesProviders were supportive of preconception
integration but had concerns about time and burden
Conclusions California Family Health Council, Inc.June 13,
20113rd National Summit on Preconception Health and Health
Care30RecommendationsDevelop preconception interventions that
address intention and timeframe of pregnancyDevelop protocols and
guidelines for family planning providersProvide training for family
planning providers and clinic administratorsAdd screening questions
including intention for pregnancy and timeframe in health history
forms and EHR (Electronic Health Record) systemsConduct additional,
larger scale preconception intervention studies2nd point: client
fact sheets, health history formsthings that simplify intervention
delivery reduce burden on providers and make integration more
feasible for busy providers
31June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council,
Inc.AcknowledgementsTitle X Family Planning ClientsSan Francisco
Department of Public HealthMaxine Hall Health CenterLos Angeles
County Department of Health ServicesHarbor UCLA Womens Health Care
ClinicNortheast Valley Health CorporationSan Fernando Health
CenterMarch of Dimes
32June 13, 20113rd National Summit on Preconception Health and
Health CareCalifornia Family Health Council, Inc.Claudine Offer,
MPHProgram Evaluation ManagerCalifornia Family Health Council 2550
Ninth Street, Suite 110Berkeley, CA 94710phone: 510-486-0412 Ext.
2333email: [email protected]: www.cfhc.org
Please contact me if you have any questions about the
integration project or the evaluation.33June 13, 20113rd National
Summit on Preconception Health and Health CareCalifornia Family
Health Council, Inc.