The Gabby Preconception Care System Healthy Start EPIC Center

March 31st, 2015

Megan Hempstead, MPH, Program Coordinator Clevanne Julce, BS, Study Coordinator Divya Mehta, BS, Research Assistant

Brian Jack, MD Karla Damus, PhD, MSPH, RN, FAAN

Department of Family Medicine BU School of Medicine/Boston Medical Center

Overview

• Preconception Care Basics • Gabby System Development • Gabby Research • How can you and Healthy Start

sites be involved?

Finland 2.3

Japan•••••••••••• 2.3 Portugal 2.5 Sweden 2.5

Czech Republic 2.7 Norway 2.8

Korea Spain

Denmark 3.4 Germany 3.4

Italy 3.4 Belgium 3.6 France 3.6

Israel 3.7 Greece ••••••••••••••••••••• 3.8 Ireland 3.8

Netherlands 3.8 Switzerland 3.8

Austria 3.9 Australia 4.1

United Kingdom 4.2 Poland

Hungary New Zealand

Slovakia United States

t--~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~--

0 1 2 3 4 5 6 Rate per 1 ,000 live births

6.1

7

NOTES: Canada's 2010 data were not available from the Organisation for Economic Co-operation and Development (OECD) at the time of manuscript preparation. The 2009 infant mortality rate for Canada was 4.9. If the 2010 data for Canada had been available, the U.S. ranking may have changed. Deaths at all gestational ages are ind uded, but countries may vary in completeness of reporting events at younger gestational ages. SOURCES: CDC/NCHS, linked birth/infant death data set (U.S. data); and OECD 2014 (all other data). Data are available from: http ://www.oecd.org .

Figure 1. Infant mortality rates: Selected Organisation for Economic Co-operation and Development countries, 2010

World Infant Mortality Rates

The Disparity

7

10.3

5.3 7

11.6

5.4

13.2

16.5

13.8

0

2

4

6

8

10

12

14

16

18

LBW1 PTB1 Infant Mortality2

White Hispanic African American

1. Martin JA, Hamilton BE, Osterman MJK, Curtin SC, and Mathews TJ. (2013). Births: Final data for 2012.National vital statistics reports: Volume 62, Number 9. Hyattsville, MD: National Center for Health Statistics

2. Kochanek KD, Xu J, Murphy SL, Miniño AM, & Kung HC. (2011). Deaths: Final Data for 2009. Washington, DC:Division of Vital Statistics.

Life Course Perspective

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.

Preconception Health (PCH) (including Interconception Health)

Preconception health and health care focuses on taking steps now to protect the health of a baby in the future. However, preconception health is important for all women and men, whether or not they plan to have a baby one day.

CDC. Preconception Health and Health Care. Retrieved March 27, 2014, from: http://www.cdc.gov/preconception/index.html

The Big Picture

Health promotion

Immunization

Infectious disease

Medical conditions

Psychiatric conditions

Parental exposure

Family and genetic history

Nutrition

Environmental exposure

Psychosocial risk

Medication

Reproductive history

Special populations

The Dilemma

The Need

There is a need for an efficient way to assess a woman’s preconception risks, in order to prioritize valuable appointment time with a provider, and to support the woman in taking action to minimize her risks.

Now Introducing: Gabby

Video: Gabby Explains PCC

Creating Gabby: Focus Group Feedback

• Clothing – “Layering” – Blue scrubs with institution’s

logo or lab coat – “Fitted” shirt that shows curves

• Accessories – Glasses – Badge or Stethoscope – Wedding ring, earrings,

necklace

• Hairstyle – “Honey” colored highlights or

dark brown hair – Short bob with “professional”

side bangs OR shoulder length wavy curls

• Layla

Top 10 Name Suggestions:• Gabrielle “Gabby” for short • Vanessa/Venessa • Angela • Maria • Jeanette • Annie • Lisa • Nicole • Natalie

“Someone I would

the street.” see walking down

La-La (MTV host) Rihanna (singer) Gabrielle Union (actress)

Step 1: PCC Risk Assessment

Step 2: Info About Identified Risks

V1 Results Risk Assessment: Risks by Domain

21%

17%

11%10%

7%

7%

7%

5%

4% 4%

4% 3% Nutrition Infectious Genetic Environmental Reproductive Immunization Health Conditions/ Meds Healthcare/ Programs Emotional Substance Men Relationships

V1 Results: Risk Status

Risks Discussed

11 (48%)

Risks Added to MHTDL

7.2 (65%) Status at 2 months

Resolved – 3.5 (54%)

Took Action – 2.2 (29%)

No action – 1.5 (17%)

Risks Identified (per person) 23 (100%)

V1 Results: Stage of Change

All Risks discussed with Gabby, n=67 Initial Stage # risks Pre-

contemplation Contemplation Preparation Action /

Maintenance

Pre-Contemplation 16 5 3 0 4

Contemplation 12 1 2 0 8

All Risks Discussed with Gabby and Added to MHTDL, n=43 Initial Stage # risks

(%) Pre-contemplation

Contemplation Preparation Action / Maintenance

Pre-contemplation 1 0 0 0 1

Contemplation 11 1 2 0 8

• Gabby best at moving those in “Contemplation” to “Action/Maintenance” • V2 programming to move from “Pre-contemplative” to “Contemplative”

Gabby Version 2: New Content

Longitudinal behavior change: • Motivational Interviewing to reach out to precontemplators • Shared decision making to assist with complicated decisions (i.e.

contraceptive choice) • Problem solving to provide solutions to common barriers • Goal setting to provide long-term motivation • Homework to keep users engaged outside of system • “Sequential Discrete” to walk users through processes step-by-step (i.e.

making and going to a healthcare appointment) • Tips, Direct observation, Social reinforcement, etc.

Supporting the user with information, tools, and encouragement throughout the behavior-change process

Gabby Version 2

1. Take Risk Assessment

2. Meet Gabby

4. Choose risk to learn about with Gabby

3. Review results (“My Survey

Results”)

5. Listen to first informational script(s) from Gabby .

6. Answer Stage of Change question for that risk and listen to stage-appropriate scripts

Precontemplation

Contemplation & Planning

Contemplation, Planning, Action,

Maintenance

Motivational Interviewing

- Problem Solving/Tips - Homework - Goal Setting - Educational Info (Nutrition, Activity, and Stress Management)

- Shared Decision Making (Family Planning) - Sequential Discrete (“Go to the Doctor” risks)

7a. Add to risk to MHTDL

7b. Don’t Add to MHTDL

8b. Choose new risk to discuss from “My Survey Results” OR “My Health To-Do List”

8a. Longitudinal behavior change scripts

Achieve Goal

Video: Gabby Can Share Her Experience

Gabby V2: RCT

Enrolled March – July 2013 • 100 participants (50 intervention, 50 controls) • 6-month intervention period • Recruited from: OMH Preconception Peer Educators (86);

Healthy Start, Jacksonville, FL (8); BMC Health Expo (4);word of mouth (2).

• Eligibility: Female, African American, 18-34, speak English,not currently pregnant

• All participants enrolled over the phone, answered baseline questionnaires, then were given a link to the online risk assessment. – Controls: received a letter in the mail with their results – Interventions: given a link to talk to Gabby about their results

• All participants contacted for outcome call at 6-months.

V2 Results: Demographics Variable Controls

(n=45) Interventions (n=46)

Age (Mean(SD)) 25.3 (3.6) 25.9 (3.4)

Hispanic, Latino, Yes 1 (2%) 3 (7%) Spanish origin? No 44 (98%) 43 (89%) (N(%))

Education (N(%)) At least some college 40 (89%) 42 (91%) Less than college 5 (11%) 4 (9%)

Household Income Less than $20,000 3 (7%) 3 (7%) $20,000-$50,000 7 (16%) 12 (26%) $50,000 or more 23 (51%) 14 (30%) Don’t Know/Refused/Missing 12 (27%) 17 (37%)

Currently a Yes 20 (44%) 19(41%) student (N(%)) No 25 (56%) 27 (59%)

REALM Score (Mean (SD)) 63.0 (5%) 61.3 (12%) >High School (N(%)) 5 (12%) 4 (9%) High School (N(%)) 38 (88%) 39 (91%)

How easy was it to talk to Gabby?

31%

7% 3%

6%

6%

Extremely Difficult Very Difficult Difficult Neutral Easy Very Easy Extremely Easy

78% thought that it was easy to talk to Gabby

28%

19%

V2 Results: Risks Identified (at Baseline, n=91)

27%

16%

10% 10%

6%

6%

6%

5%

4% 4%

4% 3% Nutrition Infectious Diseases Environmental Immunizations Relationships Genetic Reproductive Men Healthcare/ Programs Health Conditions/ Meds Substance Use Emotional Health

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(min

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Results: Risks Discussed, Time Risks

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Interventions (n=50) logged on 2.8 times on average (min 0, max 12)

Results: Risks Identified & Resolved

Randomization N Mean Identified

Mean Resolved

Std Dev

Control 43 24.2 5.5 4.4

Gabby 36 23.2 8.3 4.5

p < 0.01

Those who had access to Gabby resolved approximately 3 more risks than those who did not.

28% of risks were resolved in the Gabby group vs 20% in the Control group

V2 Results: Knowledge Scores, Nutrition

Controls Gabby p-value

Baseline Score (% correct)

6-month Score (% correct)

% Increase

Baseline Score (% correct)

6-month Score (% correct)

% Increase

Nutrition 78.2 80.2 1.2% 78.7 87.4 9.0% 0.06

Those who talked to Gabby increased their Nutrition knowledge score by an average of 9%, while Controls saw an increase of 1.16%.

How much do you trust Gabby?

12.5

28.3

59.4

0

10

20

30

40

50

60

70

Don't Trust Neutral Trust

Have you used info from Gabby to improve your health?

70 65.6

60

50

40

30 21.9

20 12.5

10

0 No Plan to Yes

70

Would you recommend Gabby to someone you know?

65.6

60

50

40

30 21.9

20

10

12.5

0 No Don't know Yes

You can help

us recruit!

What’s Happening Now? V3: RCT of 530 participants (NIMHD, R01MD006213)

• Enrollment began March 2014 • National sample, enrolled via phone • One-year intervention period

Kellogg Foundation Funding – 2 years of development: • Comprehensive content overview and update • Expand Family Planning Discussion • Make connections between risks to leverage past success

PCC for Men – Administrative Supplement from HRSA-BMCH • Created a Men’s Health Survey; focus groups (n=17); pilot testing

(n=29)

Gabby V3 National Study

Currently recruiting 530 women from across the country who are:

– Black or African American – Ages 18-34 – Not currently pregnant – have access to a computer with internet and a

telephone.

Gabby V3 Study: Steps for Participants

1. Enrollment: - Contact study team to set up enrollment call - Schedule enrollment phone call - Enrollment phone call takes ~ 30 minutes

- BMC staff explains the study, makes sure woman understands, then collects information like demographics and baseline questionnaires (e.g. self-efficacy, social support, discrimination)

- After the call, receive an email with username and password and link to the online health survey

Gabby V3 Study: Steps for Participants

2. Using the system - All participants take the online health survey,

which takes ~15-20 minutes - Gabby group: can click button to meet Gabby

and can log in to talk to Gabby any time for the next year

- Control group: receives letter via mail or e­mail with their health survey results

Gabby V3 Study: Steps for Participants

3. Follow-up calls - BMC study staff contact all participants to set

up calls at 6 months and 12 months - Collect:

- Updates on their PCC risks - Feedback on Gabby (Gabby group only) - Re-do some of the questionnaires from the

enrollment phone call (e.g. General Self-Efficacy Scale)

Gabby V3 Study: Incentives

• All participants can earn $25 Target gift cards for completing each of the follow-up calls ($50 total if they complete both calls)

• Gabby group participants are entered in to a monthly raffle for a $100 Target gift card. They can earn one entry per week that they log in at least once (4 raffle entries maximum per month)

How you can help us recruit!

How you can help us recruit!

• Tell women about the study! • Give them flyers or “Gabby cards” with our

contact info – they reach out to us. • Provide basic info if they ask. It’s a one-year

study using a computer program to learn about health before pregnancy.

• Once they sign up, encourage them to take the online survey, log in, and do the follow-up calls

Email: pccstudy@bmc.org to ask us to email or mail you flyers and

Gabby cards

Our team will be happy to assist you!

Thank you!

We would like to thank our funders:

AHRQ: contract # W.F. Kellogg Foundation: HHSA290200600012I, TO #7 P3024018 HRSA B-MCH: R40 MC21510 Kirby Foundation NIMHD: R01 MD006213

And everyone who has contributed to developing and testing Gabby Brian Jack, MD (PI) Suzanne Mitchell, MD, MSc Fatima Adigun Natalie Rock Justin Alves, RN, BSN Huong Tran, MDTimothy Bickmore, PhD Jingjing RenKarla Damus, PhD, MSPH, RN Lazlo RingShayna Egan, MPH Ekaterina Sadikova, MPH Paula Gardiner, MD, MPH Meryl St. John, MAMegan Hempstead, MPH Daniel Schulman, PhD Kenn Harris Emily VishnjaCathryn Imperato, DNP Leanne Yinusa-Nyahkoon, ScDClevanne Julce …and more… Stephen Martin, MDDivya Mehta