LiveitChangeit

1. LiveitChangeit.com First Time Motherhood/New Parents Initiative Arizona Department of Health Services Toni Means June 13, 2011

2. LiveitChangeit.com Goal of social marketing campaign • Increase awareness about preconception health and the life course perspective among African American men and women ages 18-30 years of age. Target Communities • Maricopa County • Tucson • Yuma • Sierra Vista

3. LiveitChangeit.com Planning activities • Contract with social marketing company – RIESTER • Conducted secondary research • Interviewed seven stakeholders • Conducted 12 dyad and triad interviews

4. LiveitChangeit.com Planning Activities, cont. • Contract with Tanner Community Development Corporation and Black Nurses Association of Greater Phoenix • Worked in conjunction with RIESTER to recruit participants for the interviews • Provided input on the development of the PowerPoint for the community presentations

5. LiveitChangeit.com Campaign Launch • November 28, 2009 • Premier of movie Precious • Partnered with a local radio station DJ • Exhibit

6. LiveitChangeit.com Components of the Social Marketing Campaign • LiveitChangeit.com website • Radio Spots • Billboards • Print Ads/Editorial Board • Brochures • Promotional materials • Community education PowerPoint/videos

7. LiveitChangeit.com Partners • Tanner Community Development Corporation(TCDC) • Greater Phoenix Black Nurses Association (BNA) • Informant Newspaper • ASU Graduate Chapter of the Pan-Hellenic Council

10. LiveitChangeit.com Community Presentation Introduction Slide • Black Nurses Association of Greater Phoenix • Why are we here? • LiveItChangeIt • Campaign Overview • What’s going on in our community • How can we influence positive change • Impacting the future

11. LiveitChangeit.com Community Education Presentations • TCDC outreached to African American churches and other agencies that serve the target population • BNA conducted the presentations and administered pre and post tests • BNA educated Barbers/Beauticians

12. LiveitChangeit.com Challenges/Barriers • Procurement delays • Reaching target population in churches – conflicting priorities • Staffing • Limited life of campaign

13. LiveitChangeit.com Challenges/Barriers, cont. • Building relationships with churches in rural communities • Pre and post test • Summer

14. Using community-based participatory mixed methods research to understand Preconception Health in African American communities of Arizona Khaleel S. Hussaini1 Ph.D. Eric Hamm2MPH Antoinette Means1 MBA 1Bureau of Women and Children’s Health, Arizona Department of Health Services 2University of Arizona Mel and Enid Zuckerman College of Public Health

15. 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. • Varying evidence on the amount of knowledge health practitioners and women have regarding benefits of preconception care and it is reported that residents do not have ‘adequate’ training on preconception care (Spencer & Kern, 2008).

16. Arizona’s African American Women & Children • 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.

17. First-Time Motherhood Initiative (FTMI) • Bureau of Women’s and Children’s Health (BWCH) initiated FTMI in Arizona to reduce these disparities. • FTMI utilized a multi prong approach as a means for increasing awareness about the importance of preconception health in Arizona, 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. • Participatory approach was the core philosophy for the entire FTMI grant process in Arizona, which included planning, implementing, and evaluation.

18. Evaluation strategies for FTMI FTMI Core Strategies Community-based Presentations Preconception Health Summit (PR) and Grand Round Presentations (GR) Social Marketing Campaign Pre-focus group baseline surveys Same-day pretest and posttest (NPHS = 91; NGR = 120) Same-day pretest and posttests (N = 108) Longitudinal focus-groups (October, 2009 N = 51; February, 2010 N = 39; and August 2010 N = 25) 30-day follow-up posttest for random group of PHS participants (N = 23)

19. Methods • Social Marketing Campaign • The 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 (Aronson, et al . 2006). • Assessed whether African American men and women in the targeted areas recalled and comprehend the message of preconception and also assessed their perceptions of 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. • Preconception Health Summit and • Grand Round Presentations • Expert reviews of questionnaire based on presentation material was conducted. • A total of 33 questions were developed to assess the knowledge and perceptions of attendees. 26 questions specifically related to presentations and the remaining 7 questions related to attendees’ opinions on preconception health and preconception health care related issues. • Same-day pretest and posttests with 30-day follow-up posttest with a random sample. • Community-based presentations • Matched pre and posttests were utilized to assess whether community presentations impacted community members’ knowledge of preconception. • Demographic questions and 33 likert-type questions and open-ended questions was developed by the partners with BWCH.

20. Analytic Strategy • Univariate, and bivariate statistics were conducted using SAS v9.2 (2008). Chi-square statistics, one-way ANOVA, paired sample t-tests, and independent sample t-tests, one-sample z-test; • Factor analyses and reliability statistics were conducted wherever feasible. • Independent coders (one graduate student and one epidemiologist) coded the transcribed focus-groups into seven domains. • Content analyses was performed and inter-coder reliability (i.e. inter-rater agreement) for qualitative data using Cohen’s Kappa was estimated (0.75 or greater was used as a threshold).

21. Design • Single-group pre-posttest design against the traditional non-equivalent group design. In design notation the study can be represented as: O X O • It is well-known that single-group pre-post tests are subject to internal validity threats and therefore limits the study’s scope. • The use of a single-group pre-posttest design was developed based on discussions with community partners who implemented the presentations with other community members and prior research that indicated poor response rates for conducting surveys in these communities. • Expert reviews for developing questions for Preconception Health Summit and Grand Rounds.

22. Results: Social Marketing Campaign • Less than one-third of the participants were able to recall the campaign. Of those who were able to recall the campaign and its message, 75% of the respondents used assisted recall (i.e. with facilitator aid) and the remaining 25% learned about the campaign through community-based presentations. • 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.’ • Internet was a major source of information and participants used this to research their health conditions prior to seeking treatment and after diagnosis.

23. Results: Social Marketing Campaign • Participants recognized that personal and immediate social network (i.e. family and friends) significantly influenced their health and well-being and vice-versa. My family my grandma my sisters because I’ll go over there and eat if I don’t want to cook so I’ll go over there and eat their food so health wise I think it’s the people your around the most because your gonna pick up their habit and they gonna pick up yours and what is….exercising and food ….. don’t eat It’s the kids they are the biggest influence for me because I love kids so much and the things that I see like you know what’s happening with kids and stuff makes me wanna do better and you know go to school and try to see what I can do to help them in the future so I think kids are a big influence for me – Female Participant I’d say family like my daughter living long enough to see her graduate and stuff like that…initiative to keep in shape and stuff…seen people die of smoking, lung cancer and all that all that from being unhealthy so don’t wanna be like that….And if you care about yourself you wanna live and be healthy you know and do stuff you don’t wanna be all fat can’t do nuttin ..Like my dad, my pop pop definitely, my mom like my girlfriend cuz I don’t really want her to be workin an so that’s like motivation cuz she workin and stuff like that – Male Participant • Healthy food was equated to “nasty tasting and expensive…. soda is cheaper than water.”

24. Results:Community-based presentations • Participants’ 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; • 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); • Knowledge of health disparities also increased from pretest to posttest. • No significant increases in 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) and self-efficacy health statements (e.g. 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. • Increase in posttest scores was not related to age and/or gender of the participant.

25. Results:Preconception Health Summit & Grand Rounds • A 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. • 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. • Grand Round Presentations seem to be an effective tool to target direct health care providers.

26. Conclusion • Mixed-methods that include qualitative data such as focus-groups and data from surveys (such as pretest and posttest) is suitable when there is a hard to reach population. • Involving different stakeholders community as well as subject-matter experts in conceptualization of planning, implementing, and evaluating can enhance triangulation of data as well as increase the validity of findings and community ‘buy in.’ • In general, multiple strategies enabled Arizona to bring ‘greater visibility’ to the issue of preconception health and life-course among community members and health care providers, which has now culminated into a Preconception Health Task Force. • While there are promising results they are severely limited by study design (single-group validity threats and issues relating regression to mean).