Intervention to Address Behavioral, Psychosocial Risk Factors in Pregnancy
Background: African American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format.
Methods: Six academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported.
Results: Forty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended ≥ 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed.
Conclusion: While implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.
While infant mortality rates in the US have shown a decrease of nearly 23% in the past decade, significant disparities continue to exist for some racial-ethnic groups, particularly for African-Americans. In Washington DC, with a predominately African American population, the overall infant mortality rate fell from 18.6/1000 live births in 1992 to 11.6/1000 in the year 2003. However, African American infant death rates in DC continued to be nearly three times that of white DC infants and two and a half times that of the US as a whole.. The NIH-DC Initiative to Reduce Infant Mortality in Minority Populations, a congressionally mandated community-based research program, was created to address the high rate of infant mortality and morbidity in Washington, DC. The study described in this manuscript, DC-HOPE, was initiated in 2000.
The NIH-DC Initiative. The NIH-DC Initiative in Washington, DC, is a collaboration among four academic research institutions (Children's National Medical Center, Georgetown University, George Washington University, Howard University), a data coordinating center (RTI International) and the National Institutes of Health (National Institute of Child Health and Human Development, National Center on Minority Health and Health Disparities). Phase II (1997-2003) of the DC Initiative focused on a multiple risk factor intervention trial, Healthy Outcomes of Pregnancy Education (DC-HOPE), to reduce behavioral and psychosocial risks for adverse infant health outcomes among pregnant minority women in Washington DC. This randomized intervention trial targeted four risk factors with demonstrated associations with preterm delivery, low birth weight, and infant mortality: maternal cigarette smoking, environmental tobacco smoke exposure (ETSE), depression, and intimate partner violence (IPV). Additionally, an educational component addressing reproductive behavioral health risks such as unintended pregnancy and sexually transmitted infections (STIs) was included with any one of these four risks.
Although multiple risk factors are associated with increased morbidity and mortality for many health outcomes, most health promotion interventions tend to apply single rather than multiple risk behavior approaches. Multiple risk behavior interventions in communities, primary care and school settings, have primarily focused on the prevention of cardiovascular and cancer disease risks. Such interventions may result in a complexity of design that can make it difficult to achieve full integration. While interventions that focus on multiple factors contributing to health outcomes may be more effective, they can also increase participant burden by emphasizing change in several behaviors at once. Although interventions to prevent poor pregnancy outcomes may have significant population benefits, few multiple risk factor interventions have been designed or tested for efficacy in prenatal care settings.
Evidence points to the importance of addressing interactions between lifestyle behaviors, the social environment, and health outcomes. Conclusions drawn from reviews of primary care interventions highlight the following: 1) behavioral counseling interventions are underutilized in healthcare settings, 2) behavioral counseling interventions in primary care settings may help people change when risk behaviors are linked, 3) intervention strategies should focus on ways to facilitate adoption of implementation practices into routine health care, and 4) addressing multiple risk factors simultaneously versus sequentially may be more effective.
The purpose of this paper is to describe the conceptual design, implementation characteristics, and acceptability of a multiple risk factor intervention. This paper provides a full report of the feasibility of implementing psychosocial and behavioral interventions in prenatal care settings, to address single or multiple risks presented by inner city African American women, which place them at risk for poor pregnancy outcomes. For health professionals considering offering psychosocial and behavioral interventions in primary health care settings, a summary of challenges faced in the DC-HOPE study is also provided. In order to give proper attention to these issues, the effects of the intervention on pregnancy outcome and risk reduction will be described in separate papers.
Background: African American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format.
Methods: Six academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported.
Results: Forty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended ≥ 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed.
Conclusion: While implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.
While infant mortality rates in the US have shown a decrease of nearly 23% in the past decade, significant disparities continue to exist for some racial-ethnic groups, particularly for African-Americans. In Washington DC, with a predominately African American population, the overall infant mortality rate fell from 18.6/1000 live births in 1992 to 11.6/1000 in the year 2003. However, African American infant death rates in DC continued to be nearly three times that of white DC infants and two and a half times that of the US as a whole.. The NIH-DC Initiative to Reduce Infant Mortality in Minority Populations, a congressionally mandated community-based research program, was created to address the high rate of infant mortality and morbidity in Washington, DC. The study described in this manuscript, DC-HOPE, was initiated in 2000.
The NIH-DC Initiative. The NIH-DC Initiative in Washington, DC, is a collaboration among four academic research institutions (Children's National Medical Center, Georgetown University, George Washington University, Howard University), a data coordinating center (RTI International) and the National Institutes of Health (National Institute of Child Health and Human Development, National Center on Minority Health and Health Disparities). Phase II (1997-2003) of the DC Initiative focused on a multiple risk factor intervention trial, Healthy Outcomes of Pregnancy Education (DC-HOPE), to reduce behavioral and psychosocial risks for adverse infant health outcomes among pregnant minority women in Washington DC. This randomized intervention trial targeted four risk factors with demonstrated associations with preterm delivery, low birth weight, and infant mortality: maternal cigarette smoking, environmental tobacco smoke exposure (ETSE), depression, and intimate partner violence (IPV). Additionally, an educational component addressing reproductive behavioral health risks such as unintended pregnancy and sexually transmitted infections (STIs) was included with any one of these four risks.
Although multiple risk factors are associated with increased morbidity and mortality for many health outcomes, most health promotion interventions tend to apply single rather than multiple risk behavior approaches. Multiple risk behavior interventions in communities, primary care and school settings, have primarily focused on the prevention of cardiovascular and cancer disease risks. Such interventions may result in a complexity of design that can make it difficult to achieve full integration. While interventions that focus on multiple factors contributing to health outcomes may be more effective, they can also increase participant burden by emphasizing change in several behaviors at once. Although interventions to prevent poor pregnancy outcomes may have significant population benefits, few multiple risk factor interventions have been designed or tested for efficacy in prenatal care settings.
Evidence points to the importance of addressing interactions between lifestyle behaviors, the social environment, and health outcomes. Conclusions drawn from reviews of primary care interventions highlight the following: 1) behavioral counseling interventions are underutilized in healthcare settings, 2) behavioral counseling interventions in primary care settings may help people change when risk behaviors are linked, 3) intervention strategies should focus on ways to facilitate adoption of implementation practices into routine health care, and 4) addressing multiple risk factors simultaneously versus sequentially may be more effective.
The purpose of this paper is to describe the conceptual design, implementation characteristics, and acceptability of a multiple risk factor intervention. This paper provides a full report of the feasibility of implementing psychosocial and behavioral interventions in prenatal care settings, to address single or multiple risks presented by inner city African American women, which place them at risk for poor pregnancy outcomes. For health professionals considering offering psychosocial and behavioral interventions in primary health care settings, a summary of challenges faced in the DC-HOPE study is also provided. In order to give proper attention to these issues, the effects of the intervention on pregnancy outcome and risk reduction will be described in separate papers.
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