Internet–Based Preconception Care: The Perspective of Young, African American Females

1. Internet–Based Preconception Care: The Perspective of Young, African American Females Leanne Yinusa-Nyahkoon, ScD Megan Cuoco, MPH, CHES Lazlo Ring Timothy Bickmore, PhD Michael Paasche-Orlow, MD, MA, MPH Karla Damus, PhD, MSPH, MN Brian Jack, MD Department of Family Medicine Boston University, Boston University Medical Center Boston, MA

2. The Disparity • In 2008, African American women were almost twice as likely to deliver a low birth weight baby (< 2,500 grams) than white or Hispanic women1

3. The Disparity • In 2008, African American women were almost three times as likely to deliver a very low birth weight baby (< 1,500 grams) than white or Hispanic women1

4. The Disparity • In 2005, the infant mortality rate for African American women was more than double that of white women (13.6 and 5.8 per 1,000 live births respectively)2

5. Health Education May Minimize the Disparity • Barriers to health education within the African American community • Healthcare accessibility3 • Clinician time restraints4,5 • Perceived racism6,7 • Patient-provider communication8,9

6. American Medical Association Statistics10

7. IOM Recommendation • Culturally tailored health education can minimize common barriers that contribute to health disparities within the African American community3 • Internet-based health education

8. Who is Our Target Population? • Mean age of African American mothers at the time of their first child’s birth1… 22.8 years old

9. Internet-Based Health Education11 • 90% participants ages 15-24 report > 1 on-line experience • 75% of these “on-line” participants search the internet for health information • Specific diseases (e.g. cancer, diabetes) • Sexual health • Weight loss/gain

10. Internet-Based Health Education11 “On-line” participants used health information to: • Start a health related conversation with a lay person or health care professional • Take action or change health behavior

11. Internet Use Among African Americans • African Americans report less internet access than whites12 • In a sample of low income, urban African American adults between the ages of 18 and 25, the majority whom were female13… • 45% owned a home computer • 32% had home internet access • 49% used the internet at least once to find health information

12. Using Innovative Technology to Improve the Health of Young, African American Women • Agency for Healthcare Research and Quality [AHRQ] • Aim of the study • Develop and evaluate an internet based virtual patient advocate [VPA] system to deliver a preconception care behavior change intervention for young African American women (ages 15-21) • Qualitative phase • What components do African American women perceive are needed to make a preconception care education website culturally acceptable?

13. Focus Group Eligibility • Inclusion criteria: • Female • Self-identify as African American • 15-21 years old • Speak English • Exclusion criteria: • Currently pregnant

14. Focus Group Recruitment • Craigslist • College employment centers • Community center • Community newspaper • Stores, restaurants, and other venues • Focus group participants

15. Focus Group Participants • 31 African American females ages 15-21 • Mean age = 19.3 • 84% enrolled in a college/university • 87% have an assigned primary care physician • 71% use internet > 5 times per day • 84% access internet via home computer/laptop • 61% access internet via cell phone

16. Participant Demographics (N=31)

17. Focus Groups • Occurred at an inner-city academic medical center serving predominantly racially and ethnically diverse patients and low income families • 7 focus groups and 1 follow-up focus group • Between 2 and 8 females participated in each focus group • Participants were given $30 at the end of each focus group

18. Focus Group Agenda • Reviewed existing preconception care websites • http://mariatalks.com/ • http://sexreally.com/ • http://goaskalice.com/ • http://www.plannedparenthood.org/info-for-teens/index.asp • Viewed images of existing and potential website characters • Edited educational scripts about 12 domains of preconception care14(health promotion, psychiatric disease, psychosocial risks, immunizations, infectious diseases, chronic medical conditions, family and genetic history, reproductive history, parental exposures, nutrition, environmental exposures, medications) • Discussed social networking features • Provided feedback about specific components of our internet based intervention

19. Data Analysis • Focus group interviews were audio recorded and transcribed verbatim • Transcripts were reviewed to ensure transcription accuracy and to alter names and identifying information in order to honor participant confidentiality • Data analysis began after the first focus group allowing new points of inquiry to be discussed during subsequent focus groups

20. Data Analysis • Two research team members independently coded each transcript • Coding discrepancies were reconciled using supporting evidence from transcripts • Content codes from the topics discussed during focus groups were defined in a coding dictionary • 74 codes • Related codes were organized into categories and themes summarizing focus group findings • NVIVO used to manage codes and transcript data

21. Findings • Visual Layout • Characters • Educational Information • Social Networking Features

22. Visual Layout • Less is more • Quick and easy • Bold colors • Purple • Orange • Blue • Feminine images and designs • Flowers • Swirls • Professional affiliation • Different fonts in different colors • Minimize words • Different options to access information • Animated videos • “Ask the doctor” • Recorded vignettes

23. http://mariatalks.com/

24. http://sexreally.com/

25. http://www.plannedparenthood.org/info-for-teens/index.asp

26. Participant Quotes “The colors. It like grabs out at you. It looks organized. They don’t have too, too much information right there. Like I feel like-- I don’t know which website it was but it was just like stuff on this column, stuff on this column and stuff in the middle It was just like too much like of, like too much going on. And then Planned Parenthood is a well known place. So you know that the information will be good and useful. “ “There’s a lot of words than pictures. It seems like it’s school-related and not health related because there is nothing but the words. I don’t like it. “It’s like very neat and organized and you know where to start. It’s like just enough information on one page, and then you can just go to the next and click on whatever. “

27. Characters • Animated vs. human characters • Different characters can provide different information • Friend or peer • Mentor (camp counselor) • Older family member • Nurse • No celebrities • Race “I would stay with a minority type of person if they’re going to be teaching a minority group. Like, any type of minority. I would say anything but white. Because I don't know, I think it just reaches us better if it’s someone that's just different. Like someone that's not like typical; typical like blonde haired, blue eyes wouldn’t be so good to be preaching to us about things.” “It looks like Michelle Obama. We don’t want Michelle Obama.Not if we're going to relate to her for this. Not for these purposes.” • http://www.plannedparenthood.org/info-for-teens/index.asp http://mariatalks.com/

28. Characters • Gender • Name • Gabrielle • Layla • Vanessa/Venessa • Angela • Maria • Jeanette • Annie • Lisa • Nicole • Natalie • Keisha • Avoid names ending with “sha” or “qua”

29. “Someone I would see walking down the street”“Layering” • Clothing • White lab coat • Blue scrubs with institution’s logo embroidered on them • “Fitted” button-up shirt • Shirts that show breast definition and waist curvature • “Shading” Animated Characters • Different colors for skin, lips, and hair • Light lipstick color (e.g. soft pink), natural lip color, orshiny lip gloss • Eyebrows should be arched, long, and thick • Eyeliner or eye shadow to make the eyes “pop” • Accessories • Glasses • Badge (include name, profession, and institution) • Stethoscope • Wedding ring • Earrings • Studs (pearl studs not recommended) • Small or medium hoop earrings • Dangle earrings • Diamond tear drop necklace • Charm necklace/Chain with pendant

30. “Someone I would see walking down the street”“Layering” • Hairstyle • Shoulder length, layered hair styled in loose, wavy curls (see pictures of Gabrielle Union) • “Honey” colored highlights (see pictures of La-La) • Pony tail (see pictures of La-La) • Short bob with “professional” side bangs (see pictures of Rihanna) • Dark brown hair color (see pictures of Gabrielle Union, La-La, and Rihanna) Gabrielle Union (movie actress) La-La (MTV host) Rihanna (singer)

31. Educational Information • Stories • Written in first person • Display author’s name, age, gender, and city/state of residence • Display picture • Avoid slang and negative language • Include a lot of contextual details to help the reader understand the storyline • Realistic vs. fairytale endings • Basic information and celebrity comparisons indicate a young target audience • Factual data and statistics • Provide pros and cons

34. Social Networking Features • Reasons to visit and return to the website • New information or features posted daily or weekly • Monthly or bi-monthly drawings for popular items (e.g. iPad) • Receive money, gift cards, or “electronic bucks” after several logins • Opportunities to receive free health related products or promotions • Facebook

35. http://goaskalice.com/

36. Implications • Findings indicate that a culturally tailored preconception care website is perceived to be an acceptable educational tool by young, African American women • Findings may improve the usability and effectiveness of existing and future internet based health education programs targeting young, African American women

37. Limitations • Educated sample • Few participants ages 15-17 • All participants had daily access to and familiarity using the internet • Most participants had an assigned primary care physician

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