Preconception care and family planning: Exploring the potential for integration

1. Preconception care and family planning: Exploring the potential for integration Barbara Kass-Annese, RNPCP, MSN Claudine Offer, MPH Maryjane Puffer, BSN, MPA Kathryn Horsley, DrPH California Family Health Council, Inc. We trained providers to integrate preconception messages in FP visits and then collected information on what clients and clinicians thought about the integration.We trained providers to integrate preconception messages in FP visits and then collected information on what clients and clinicians thought about the integration.

2. Introduction California Family Health Council Distributes federal Title X family planning funds to 76 community agencies (321 clinic sites) throughout California serving over 1 million clients annually Performs advanced research in reproductive health and contraception Conducts education, training, and community outreach Implements and monitors effective community health programs To begin�I�d like to tell you a little bit about our organization. The California� Define Title X: federal funding for the national family planning program, Title X of the Public Health Service ActTo begin�I�d like to tell you a little bit about our organization. The California� Define Title X: federal funding for the national family planning program, Title X of the Public Health Service Act

3. Why preconception care in family planning? Family planning clients: In reproductive years Seeking health care services Title X clients: Low income High rates of poor birth outcomes Approximately 70% of the activities cited in the CDC MMWR on preconception care are provided in family planning settings FP 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 FP 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

4. Preconception Care and Intention for Pregnancy In U.S. 49% of all pregnancies and 82% of teen pregnancies are unplanned (Finer & Henshaw, 2006) Preconception care messages have potential to: Improve women�s health and birth outcomes regardless of intention for pregnancy Improve women�s health regardless of eventual pregnancy I�d 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. I�d 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.

5. Project Description Orientation of clinic site staff Review of health history form and client chart Four 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)?

6. Providers were asked to integrate core preconception messages in family planning visits: Folic acid intake Diabetes Obesity Substance use Rubella Define FP visits: birth control, annual, breast exam, pap and pap f/up, pregnancy test, std/hiv testing and results These five issues prioritized as part of project and evaluation. At least one issue addressed�based on review of health history and chart Intervention was provided over six month period. Varied by site. Define FP visits: birth control, annual, breast exam, pap and pap f/up, pregnancy test, std/hiv testing and results These five issues prioritized as part of project and evaluation. At least one issue addressed�based on review of health history and chart Intervention was provided over six month period. Varied by site.

7. Preconception Integration Pilot Clinic Sites Clinic sites 2 LA sites, 1 San Francisco site Interest in preconception integration Sufficient family planning visits

8. Evaluation Questions Clients� intentions for health behavior changes related to core preconception messages Clients� attitudes about receiving preconception care messages in family planning visits Providers� experiences integrating preconception care messages into family planning visits We wanted information on these three areas. We saw promising responses to all of these as you will see when we look at results.We wanted information on these three areas. We saw promising responses to all of these as you will see when we look at results.

9. Data Sources Client post-visit survey Completed after family planning visit Intervention log Providers recorded types of preconception messages, method of intervention, and time spent Post project interview/survey Providers experience with process and continued integration Client survey: one site offered $5 gift cards as incentivesClient survey: one site offered $5 gift cards as incentives

10. Providers and Participants Providers 10 clinicians, 1 health educator Participants Female Family planning visit Ages 13 � 45 n = 555 Explain health educator format for 1 clinic site. Limited info on provider integration but adequate info from clients Explain health educator format for 1 clinic site. Limited info on provider integration but adequate info from clients

11. Sample Population Here is what we learned about our sample�Here is what we learned about our sample�

12. Survey Language Determined by which version of survey was completed.Determined by which version of survey was completed.

13. Race Af Am slightly underrepresented. As we continue you will notice that the number recorded for �n� varies due to # of respondents answering the questions or the number of respondents included in various analysis. Af Am slightly underrepresented. As we continue you will notice that the number recorded for �n� varies due to # of respondents answering the questions or the number of respondents included in various analysis.

14. Age Representative of Title X agencies, 54% of respondents were between 20-29 Representative of Title X agencies, 54% of respondents were between 20-29

15. Reason for Visit Define General repro: menstrual issues, breast exam, pap/results, IUD removal, post-partum. Small #s of these responses. Define General repro: menstrual issues, breast exam, pap/results, IUD removal, post-partum. Small #s of these responses.

16. Results These first two results summarize the intervention .The following results will provide answers to our evaluation questions�.These first two results summarize the intervention .The following results will provide answers to our evaluation questions�.

17. Type of Intervention ProvidedProvider Record Provider response. Interv not mutually exclusive. Many women received both verbal interventions as well as handouts.Provider response. Interv not mutually exclusive. Many women received both verbal interventions as well as handouts.

18. Time Spent on Preconception Care Provider reported on intervention log. PCC interventions not timed. Providers estimated�limited accuracy.Provider reported on intervention log. PCC interventions not timed. Providers estimated�limited accuracy.

19. Desire for Pregnancy Some 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.Some 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.

20. Timeframe forDesired Pregnancy 55% of women who desire a pregnancy would like to be pregnant within 4 years 55% of women who desire a pregnancy would like to be pregnant within 4 years

21. Timeframe for Pregnancy by Race

22. Intention to Make Health Behavior Changes 86% 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 pregnancyPAUSE: stress that here we begin to explore the answers to our evaluation questions. These results are for all women responding regardless of desire for pregnancy

23. Barriers to Change 70% of respondents not planning to make changes identified at least one barrier to making changes (don�t need to, no time, previous failed attempt) n=43 We didn�t learn very much about barriers 19% of those who didn�t plan to make any changes said they didn�t need to n=43We didn�t learn very much about barriers 19% of those who didn�t plan to make any changes said they didn�t need to n=43

24. Change and Preconception Issues Regardless of desire for pregnancy.Regardless of desire for pregnancy.

25. Change and Preconception Issues Regardless 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. Regardless 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.

26. Desire for Changeby Intent for Pregnancy Desire for change is high among both groups. Perhaps women who don�t desire pregnancy recognize value of these general health issues�.. Intention for a pregnancy was not associated with the timeframe of making any health changes� Desire for change is high among both groups. Perhaps women who don�t desire pregnancy recognize value of these general health issues�.. Intention for a pregnancy was not associated with the timeframe of making any health changes�

27. Desire for Change by Timeframe for Pregnancy In 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 pregnancy�greater 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 changes�no association. In 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 pregnancy�greater 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 changes�no association.

28. Client Acceptance of Preconception Messages 97% �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) No 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. No 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.

29. Provider Experience Provider themes Supportive of preconception integration Perception that clients welcome preconception messages Concern about additional burden of integration Increased ease with preconception care implementation over time Identified need for more appropriate materials n = 8 Post-project interview, emergent themes summarized here. Materials: low-literacy, Spanish, etc. Feedback on implementation�there 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.Post-project interview, emergent themes summarized here. Materials: low-literacy, Spanish, etc. Feedback on implementation�there 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.

30. Continued Integration Preconception care activities continue in clinic Increase in preconception care activities and topics included in services Perception that fellow clinicians are �very interested� or �interested� in continuing preconception care n = 16 Brief survey regarding on-going integration, completed 6 months post intervention project, included admin and cliniciansBrief survey regarding on-going integration, completed 6 months post intervention project, included admin and clinicians

31. �It raised awareness among the clinicians, who are now more likely to discuss with patients their plan for pregnancy, now or for the future, and how to make sure the patient has optimal care before conceiving.�

32. Conclusions Family planning clients were receptive to preconception messages Family planning clients were interested in making health behavior changes after hearing preconception messages Interest in making changes is associated with desire for pregnancy and timeframe of desired pregnancy

33. Identifying and providing relevant intervention can be done in 1-3 minute discussions with clients Providers are supportive of preconception integration but have concerns about time and burden

34. Recommendations Develop preconception interventions that address intention and timeframe of pregnancy Develop protocols and guidelines for family planning providers Provide training for family planning providers and clinic administrators Add screening questions including intention for pregnancy and timeframe in health history forms and EHR (Electronic Health Record) systems 2nd point: client fact sheets, health history forms�things that simplify intervention delivery reduce burden on providers and make integration more feasible for busy providers 2nd point: client fact sheets, health history forms�things that simplify intervention delivery reduce burden on providers and make integration more feasible for busy providers

35. Acknowledgements Title X Family Planning Clients San Francisco Department of Public Health Maxine Hall Health Center Los Angeles County Department of Health Services Harbor � UCLA Women�s Health Care Clinic Northeast Valley Health Corporation San Fernando Health Center March of Dimes

36. Claudine Offer, MPHProgram Evaluation ManagerCalifornia Family Health Council 2550 Ninth Street, Suite 110Berkeley, CA 94710phone: 510-486-0412 Ext. 2333email: offerc@cfhc.orgwebsite: www.cfhc.org Please contact me if you have any questions about the integration project or the evaluation. Please contact me if you have any questions about the integration project or the evaluation.