Arden Handler, DrPH, Kristin Rankin, PhD, Nadine Peacock, PhD, Stephanie Townsell, Andrea McGlynn, L.Michele Issel
This study focused on barri rier ers s to effective implementation of an Interco erconceptional nceptional Care e Pr Program gram (ICCP) P) implemented ented as part of the He Healthy thy Bi Births hs for He Healthy hy Communi uniti ties es in Chicago ago and a consideration of lessons learned with respect to overcoming these barriers
Interconceptional Care Program (ICCP) provided in 2 communities on Chicago’s West Side by two different health providers (Agenc gencies es A and B) B) Evaluation carried out by researchers at the University of Illinois School of Public Health Longitudinal, multi-method approach ◦ Focu cus s on success cess in achie ievi ving g ICCP CP program rogram objectives as well as on women’s experiences in the ICCP CP ◦ No comparison group
Beginning in Dec. 2006, African- American women with ad adve vers rse e pre regnancy gnancy outcom comes es (PTB, LBW, fetal loss) were invited to participate in ICCP by program staff at the two agencies Evaluation based on data collected between Dec. 2006 and June 2010
Servi rvices ces delivered: vered: from database base designed for use by ICCP case-managers to document all services delivered to participants (n= 220) He Health th Status, us, Goals, s, KAP: P: Pa Participant cipant questionnaire estionnaire completed face to face or via telephone (n=99; average week pp at time of the interview was 20 weeks) ◦ Questions based on established surveys (e.g., PRAMS, BRFSS) Key Inform rman ant t Interviews rviews (n = 4) with ICCP staff at each site
Focused on whether program objectives were met and whether ICCP participants were able to establish self-management and reproductive goals as well as on their utilization of medical care, family planning, and the other social and health services provided For both services database and interview information, simple frequencies were produced: ch chi-squa square e an and t-tests ests wer ere e used ed to co compare are ach chiev evement ement of object ctives ives and partici cipants pants at Agency cy A v versus us Agency cy B Key Inform ormant nt intervi rview ews: key themes developed to highlight/extend/support quantitative findings
ICCP focused on the integration of soc ocial ial servic vices, es, fa family ily planning, nning, and nd medical cal care while fostering women’s empowerment ◦ ultimate aim: reducing future adverse pregnancy outcomes
Figure 1: Healthy Births for Healthy Communities Interconceptional Care Program (ICCP) Program Guidelines PROGRAM MONTH SERVICE Where 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Case Finding C, Ho X Assessment C or H X X History & Physical Complete C X Reassessment C or H X Enrollment- HBHC ID in system C or H X Medical care home continuity – min. C X X X X X as needed → → → → → → Specialty visits for chronic conditions C → → → → → Enrollment in medical insurance plan C X as needed Patient /Care Team face-to-face mtg. C or H X X X X X X X X X X X X X X X X X X Care team case conf. w/ provider C X X X X X X X X X X X X X X X X X X Care team + provider conf. w/ patient C X X X Self mgmnt goals set & reassessed C or H X X X X X X X X X X X X X X X X X X Reproductive education delivered C or H X X Reproductive goals set C or H X X Repro. goals reviewed, as approp. C or H X X X X X X X X X X X X X X X X X X Smoking cessation education C or H X X X Smoking cessation service as needed C or H X → → → → Substance abuse education C or H X X X and as needed → → → → Substance abuse service C or H X and as needed Substance abuse referral C as needed Depression screening completed C X X X X X → → → → Depression service as needed C X as needed Domestic violence screening C or H X X X Domestic violence counseling C as needed Friends & Family Network C or H A minimum of 3 sessions in first year Oral health service C as needed WIC enrollment C X
ICCP participants were predominantly young, poor, and had low educational attainment Very few were in the program for the program target of 18 months (avg. length, 11.7 mos.) Most received the core intervention: a care team in inclu ludi ding ng a ca case-ma manag nager er and medica ical l provid ider er Most interventions were delivered at women’s homes
Finding ding: Even though participating women had experienced an adverse pregnancy outcome, a majo jor focus s on medical al needs ds did not emerge because of women’s pressing social al and ec economic mic nee eeds ds Lesson: sson: In future interconceptional care projects, women’s need to cope with crises in daily y livi ving g and SE SES S rel elated ed issues ues may take precedence over a series of planned interventions aimed at improving their health status
Finding: ding: Despite a high prevalence of a variety of acute and chronic health problems, the wo women consider dered ed themsel selve ves s healthy thy Les esson: son: If preventive medical care is to be the anchor of interconception care, interconception care programs will need to focus on educating women about the importance rtance of seekin king g health th care eve ven if they y perceiv eive e themselves selves to be healthy thy
Finding ding: Despite participation in an interconceptional care program, many wo women repo ported rted use of less effecti tive ve birth th control l me metho hods ds and had notions ns of ef effec ective veness ness at va varian ance e wi with clinical knowl wledg edge Lesson: sson: Po Postpartum partum contracep racepti tive ve use is a proce cess ss: it is necessary to me meet et wo wome men wh wher ere e they y are at and provide support to enable women to swi witch to more effective ive methods ods as thei eir contracepti aceptive ve nee eeds ds change nge
Finding: ding: Although the ICCP program had objectives related to ongoing contact between the women and the case- management staff and a minimum um of 3 me medical cal vi visits during the first program year, it was difficult to reach these targets Lesson: sson: It is important to recognize that low- income women with adverse pregnancy outcomes often have complicated lives and as such, staff must remain n extremely mely flexibl ble e in ma maintaining taining the e clien ent-st staff aff connecti ection on
Findi ding: ng: The interaction of the case-management system with the medical system was not easily achieved; it was particula ularl rly y challenging ging to engage medical providers rs in preventi ntive ve care during ng the interconc oncept eption ion period; ; many medical providers are used to meeting acute care needs or providing an annual checkup when women are not pregnant Lesson: n: Educati tion on of me f medical providers rs in future interconceptional care programs will be essential; clear guidelines will be needed
Lu et al. recommended that interconception care include a multitude of interventions within the domains of cli linic ical al car are, , psy sycho hosocial social car are, , an and heal alth th pro romotio motion ◦ Healthy women should receive three ee vi visi sits ts withi hin n the first rst six months ths, with additional visits for women with chronic conditions or prior preterm birth
Despite reporting multiple health conditions, women did not see medical care as a priority Likewise, even though the ICCP staff were prepared to deliver a multitude of interventions based on women’s “health” needs, the delivery of these interventions was often replaced by efforts to meet women’s socioeconomic needs Finally, many medical providers did not understand their role with respect to the delivery of interconception care
These results suggest that: ◦ Organizations designing interconceptional care programs should conduct needs s assessments ssments to more effectively target the women to be served ◦ Educati cation on of both h wome men n and me medical ical provi viders ders about the importance of medical care during the interconception period is essential ◦ Inter ercon concepti ception n care e and d the AC ACA A associ ciated ated preven eventiv tive healt lth h vi visi sit t for women will not gain traction unless women are aware of its value and relevance to their lives
No comparison group limited our ability to compare ICCP participants to similar nonparticipants Interview information was based on self-report and there was no access to medical records Interview data were not longitudinal; they were only used to provide information about women’s experiences in the year after the adverse pregnancy outcome rather than to evaluate the effect of the intervention Given data limitations, in effect, the majority of lessons learned were based on the smaller group of women for whom we had both interview and services data
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