Preconception Care Program Essay Example

Compliance, Consistency and Continuity. Importantly, the resources are designed to work in conjunction with information provided by the model Community Health Center physicians and not as a replacement for physician-based healthcare recommendations within the organization. CASE STUDY 1: Problem-Based Community Health Center Background

A Community Health Center (CHC) is defined by the National Association of Community Health Centers (NACHC) (2010) as “A Federally Qualified Health Center (FQHC) that provides comprehensive primary and preventive health care as well as dental, mental health and pharmacy services. ” The FQHCs are deemed to be a cost effective method of providing increased access to care. FQHCs provide educational tools, support and information that are vital to the health status of underserved communities. In an effort to increase access to care, transportation services and language translations are also provided to registered patients as needed.

FQHCs are patient centered and as reported by the Community Health Care Association of New York State (CHCANYS) (2009) “at least 51% of the board members of a federally qualified community health center must be consumers of the health services, ensuring patient and community involvement in service delivery. ” The target Community Health Centers of Westchester consist of three FQHC designated facilities located in three distinct, underserved communities in Westchester County, New York. CHCs are a vital resource for provision of health care in the populations that they serve.

The CHC population consists predominantly of minorities, uninsured, underinsured, undocumented, low-to-no-income and Medicaid recipients. For the purposes of confidentiality in the report, the interventions will focus on the model CHC, one of the three FQHCs in Westchester County, New York. The CHC provides comprehensive primary and preventive health care services

including: obstetrics/gynecology, pediatrics, internal medicine, family medicine, dental, ophthalmology, mental health and podiatry. The model CHC, located in the mid-northern section of Westchester County in New York was established in 1972.

When the model CHC merged with the primary location, it became the second satellite location in 2005. A third CHC site is located in the southwest section of the county. The primary CHC is the largest facility with the broadest range of services, while the model CHC and the third site focus on primary care. The CHC’s mission incorporates strategies to provide culturally sensitive, high quality, health care in a comprehensive manner to medically underserved residents of the community and to actively engage the community to address health issues.

The model CHC serves over 19,000 registered patients and averages more than 90,000 annual patient visits. This CHC provides healthcare services six days per week with extended hours on two days to accommodate the high patient volume. The model CHC is currently working on enhancing their information technology department to introduce electronic medical records within the next few months. The Hispanic community served by the model CHC is predominantly from Central America.

Therefore, the main population target for treatments and any educational interventions at the CHC consists of a Central American Hispanic population. In 2009, a pilot study assessed women’s knowledge of the risk factors affecting pregnancy outcomes (Carter and Rahman, 2009). The 2009 Capstone Team (Carter and Rahman, 2009) recommended a variety of interventions including: wellness care and health promotion; involvement of women and family members; screening of immunization status; and nutrition education, use of folic acid, improved dental care, provider review of lifestyle and environmental risk

exposures.

The PCH Pilot Study recommended these components as central to the success of preconception healthcare initiatives (Carter and Rahman, 2009). The 2009 pilot study group called for a paradigm shift from prenatal care to preconception care because more and more researchers as well as key health organizations (i. e. , Centers for Disease Control and Prevention and the March of Dimes) are realizing that the benefits of prenatal care are not optimally utilized by women who do not seek medical care until after the seventh week of gestation.

Maternal health during the first seven weeks of gestation is essential as this most sensitive time of embryo/fetal development and is usually before prenatal care is normally initiated (CDC, 2006). Prenatal care provided after this point is past the critical embryo development stage (Carter and Rahman, 2009; Quinn et al, 2005; Korenbrot et al, 2002). This point demonstrates the need that exists in getting these women to seek care before this crucial gestational period is over. Prenatal Healthcare The provision of good health care to women during their reproductive years is vital.

Prenatal care pertains to the reproductive care a woman receives upon the discovery of pregnancy. At this point, she should receive the education, management and support needed in order to ensure a healthy birth outcome. Medline Plus (2009) describes the prenatal care process to be “more than just health care while you are pregnant”. The health care provider may discuss many issues, such as nutrition and physical activity, what to expect during the birth process and basic skills for caring for the newborn.

The doctor or midwife then explains to the expectant parents the importance of keeping scheduled

prenatal visits and breaks down the frequency of visits by trimester. The expectation is for the patient to see their health care provider more often as the due date gets closer. A typical schedule includes visiting the doctor or midwife about once each month during the first six months of pregnancy, every two weeks during the seventh and eighth months of pregnancy, and weekly during the ninth month of pregnancy.

Since reproductive care is provided to a woman upon discovery of pregnancy, the delivery of maximally effective prenatal care is inhibited. A large percentage of women are usually unaware that they are pregnant until a few weeks after conception, which causes many women to miss the opportunity for care during the fetus’ most critical developmental stage, the embryonic stage, weeks 1-8 (University of Maryland, 2009).

Thus, a strong possibility exists that a woman may still be engaging in habits damaging to the development of the fetus may still be occurring before she realizes she is pregnant. Moos (2004) addressed the reasons for changes in the approach to reproductive health: The movement, which came to be known as preconception health promotion, was motivated by the realization that the incidences of the two leading causes of infant mortality and morbidity in the United States, congenital anomalies and low birth weight, had remained remarkably constant for nearly 80 years.

Proponents for rethinking traditional prevention strategies argued that prenatal care starts too late for primary prevention to exercise much influence on outcomes and that the window of opportunity needed to be widened to include purposefully the pre-pregnancy period as the starting point for impacting on reproductive outcomes. The sixteenth objective of Healthy

People 2010 / 2020, addresses maternal, infant and child health including reduction in low birth weight babies, preterm births, congenital anomalies (i. e. , neural tube defects), mortality of mother, baby or infants.

The program also advocates for an increase in early and adequate prenatal care. Despite efforts to promote prenatal care, the rates of preterm births and low birth weight babies in the United States, New York State and Westchester County have stagnated in the past 5 years. To reach the Healthy People 2010 / 2020 goal of no more than 5% of live births being low birth weight babies and no more than 7. 6% preterm live births a new approach for maternal care is required. The new approach should also address the Millennium Development Goals four and five of reducing childhood mortality and improving maternal health (UNDP, 2006).

Preconception Care “Preconception care is comprised of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management, emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact”(CDC, 2009). Preconception care is an effective form of preventive medicine for maternal and child health. Increasing universal availability of preconception services should be a national priority (WHO, 2008).

Preconception health serves as an important contributor to preventive health care, especially in women and infants. Preconception health care offers an important opportunity for physicians involved in women's health, such as internists and obstetricians/gynecologists to expand toward a primary care and primary prevention focus (Bower, Cefalo, & Moos, 2006). Internists and obstetricians/gynecologists are not only involved in acute diagnosis and treatment

plans but also in disease prevention, risk and behavior modification, and counseling, which are integral parts of primary prevention and coordinated women's health care (Bower et al, 2006). Preconception health promotion guidance can provide prospective parents with an opportunity to prevent the preventable and to know they did all they desired to encourage a healthy pregnancy and infant” (Moos, 2003). According to the American Congress of Obstetricians and Gynecologists, preconception care “should address the optimal number, timing, and spacing of children; determine the steps needed to prevent or plan for and optimize a pregnancy; and evaluate current health status and other issues relevant to the health of pregnancy” (ACOG, 2006).

Current Pregnancy Outcomes According to Kent (2006), “nationwide statistics show that an estimated 30% of U. S. women have complications during pregnancy. 12% of babies are born prematurely, 8% are born with low birth weight, and 3% have major birth defects”. The latest estimates from the US Census (2010) show that the national population is 15. 4% Hispanic and 12. 8% African American (U. S Census, 2010). In comparison, New York State’s population is 16. 7% Hispanic and 17. 3% African American (U. S. Census, 2010) and Westchester County is 19. 5% Hispanic and 14. % African American (U. S. Census, 2010). The county and state demographics of Hispanic and African American populations are nationally representative. Hispanics and African Americans suffer more adverse birth outcomes in comparison to Asian and Caucasian ethnic groups in most categories. According to the New York State Department of Health (2007), the acquisition of prenatal care differs among racial/ethnic groups. The New York State Department of Health states that for 252,662

live births, 60,326 were Hispanic and 52,450 were African American.

Among both Hispanics and African-Americans, contributors to adverse birth outcomes consist of education level, socio-economic status, maternal health behavior, age and acquisition of prenatal care (Gilbert et al, 2004). Statistics from the Westchester County Department of Health (2009) illustrate that 62. 3% of Central American women sought care in the first trimester, 32. 2% sought care in the second trimester and 4. 1% sought care in the third trimester. The delay in acquisition of prenatal care leaves room for much improvement in preventing adverse birth outcomes.

There is a plateau in the percentage of women who chose to seek early prenatal care within a space of about ten years, as illustrated in Figure 1. It is important to find ways in which reproductive care can be given to everyone at the most critical point in the reproductive process, as a means of reaching the Healthy People 2010 / 2020 goal on prenatal care and birth outcomes. While the Healthy People 2010 / 2020 goal was set at 90%, New York State had an average of about 75%, while New York City and Westchester County reported 73% and 76%, respectively.

In addition, there is an urgent need for a new strategic approach that would contribute to actualizing the Millennium Development Goal (MDG) 2015 target of reducing the maternal mortality ratio by 75% (UNDP, 2010). Figure 1: Percentage of Women Who Acquired Early Prenatal Care Over Time 1995-2004 [pic] Source: New York State Department of Health, Vital Statistics Program Definition The current NYSDOH data indicate that the maximum benefit of prenatal care may have been achieved as the rates of

preterm births and low birth weight babies has reached a plateau over the last 5 years.

A new approach is needed in order to reach the Healthy People 2010 / 2020 goal of no more than 5% of live births low birth weight and no more than 7. 6% of live births preterm (March of Dimes, 2009). As a way of reaching the Healthy People 2010 / 2020 prenatal care and birth outcomes goal, the central purpose of Healthy Families for a Healthy Future (PCH-HF2) is to find ways in which reproductive care is given to everyone at the most effective point in the reproductive process.

If preconception healthcare education is introduced in a clinical care setting such as that provided by the model CHC and is implemented in such a way that patients can adhere to most of the recommendations and information given, then there is an increased chance of an improvement in birth outcomes in the targeted communities (D’Angelo et al, 2004; Boggess and Edelstein, 2006). The aim of this project is to provide the target CHCs with recommendations and a strategic implementation plan for a comprehensive year-long, preconception health education program.

As the model CHC already provides prenatal care to patients, a need exists to proactively expand reproductive healthcare to the preconception level. The recommendations provided for the model CHC must also be adaptable for the patients at the other CHC sites. Key Issues A follow up program must be implemented to accommodate the paradigm shift from prenatal care to preconception care. The proposed plan must follow up from where the Carter and Rahman (2009) Pilot Study left off. An improvement in maternal and paternal

health prior to conception will improve pregnancy outcomes and decrease identifiable risks (i. . , lack of folate, diabetes, immunization status, obesity, alcohol consumption and smoking) that can result in adverse birth outcomes (i. e. , premature births, low birth weight, and other birth defects) (D’Angelo et al, 2004). The program approach must help to achieve the Healthy People 2010 / 2020 objective that early and adequate prenatal care should be received by 90% of the women by 2010 / 2020. The goals should be for all women before and between pregnancies to: • Attain a healthy weight • Take folate • Stop smoking/drug or alcohol use

After careful investigation of the model CHC, there are several barriers that have been taken into consideration in the development of program recommendations. First, the literacy level of the patients served by the model CHC is at the second-to-sixth grade level. Second, language is a major barrier for the model CHC community. Since the CHC community is predominantly Hispanic many of the patients’ first language are Spanish. At present, the materials being distributed at the center are 1) educationally too advanced for the population and 2) mostly available in English.

A third barrier that must be acknowledged is the wait time at the facility. Currently the patient wait time to see a physician can be anywhere from fifteen minutes up to two hours. There are several contributing factors to the variation and overall length of the patient wait time. First is the patient-to-provider room ratio. Presently, the model CHC has outgrown its available space. As a result, the providers can only run one examination room at a time because there

are no additional rooms available.

This drastically increases the wait time because if a provider is scheduled to see four patients per hour, then he should be able to see thirty-two patients in an eight-hour day. Assuming the physician/provider spends more than the prearranged time of fifteen minutes with three patients, then the provider will be backlogged for the remaining day’s patients and that does not include any walk-in patient(s). Also the complexity of treating patients with several co-morbid conditions for example those with diabetes and hypertension is affecting the wait times. The providers may take up to an hour to treat one medically complex patient.

Consequently, a patient visit is not always fifteen minutes in duration. Another factor affecting patient wait time is language. Although the model CHC has a large number of bilingual staff, not all of the healthcare providers speak Spanish, which creates a challenge. This CHC has an interpreter, but the interpreter cannot reach every patient in need expeditiously. For example, a patient may have seen the provider and completed the visit, but he or she has to wait in the examination room for the interpreter or the nurse that speaks Spanish in order to confirm that he or she understood the provider’s instructions and plan of care.

The process of sending a patient back to the waiting room is inefficient and is in addition to an already long wait time to see a provider. The staff turnover rate is also affecting the patients’ wait time. This poses several issues for the PCH-HF2 program in terms of continuity of the education of the patients. If there are fewer staff members then everyone has to

take on additional duties in order to close the gap of required daily services so there will not be a break in patient care. These key issues must be taken into consideration during the development of the program that will continue the efforts of the pilot study.

The implementation should include materials, innovations and strategies by which to most successfully aid the model CHC in making the shift from prenatal to preconception care. References American Congress of Obstetricians and Gynecologists [ACOG], 2006). ACOG Releases Revised Recommendations for Women's Health Screenings and Care. Retrieved April 8, 2010. Atrash, H. , Jack, B. W. , Johnson, K. (2008) Preconception care: a 2008 update. Curr Opin Obstet Gynecol. 2008 (6): 581-589. Bower, J. A. , Cefalo, R. C. , & Moos, M. -K. (2006). Preconception care: a means of prevention . Bailliere's Clinical Obstetrics and Gynaecology , 403-416.

Boggess, K. A. , Edelstein, B. L. (2006) Oral health in women during preconception and pregnancy: implications for birth outcomes and infant oral health. Matern Child Health J. (5 Suppl): S169-74. Carter C, Rahman N. (2009). Preconception health (pch) pilot study. Proceedings of the Capstone presentation (pp. 1-96). Valhalla: NY Centers for Disease Control and Prevention. National Center for Health Statistics. (2009). VitalStats. Retrieved March 22, 2010, from http://www. cdc. gov/nchs/vitalstats. htm Community Health Care Association of New York State. (2010). Defining New Directions. Retrieved March 15, 2010. http://www. hcanys. org/index. php? submenu=About_Us&src=gendocs&link=aboutus_whatischcanys&category=Main D'Angelo, D. , Williams, L. , Morrow, B. , Cox, S. , Harris, N. , Harrison, . L, Posner, S. F. , Hood, J. R. , Zapata, L. , (2004). Centers for Disease Control and Prevention (CDC). Preconception and

interconception health status of women who recently gave birth to a live-born infant--Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. MMWR Surveill Summ. 56 (10):1-35. Gilbert, W. , Jandial, D. , Field, N. , Bigelow, P. , Danielsen, B. (2004). Birth outcomes in teenage pregnancies.

J Matern Fetal Neonatal Med. 16(5):265-270. Healthy People 2010. (2010). Maternal health. Retrieved March 22, 2010 from http://www. healthypeople. gov/hpscripts/KeywordResult. asp? n350=350=Submit Hood, J. R. , Parker, C. , Atrash, H. K. (2007). Recommendations to improve preconception health and health care: strategies for implementation. J Womens Health (Larchmt). 16 (4): 454-457. Kent, Helene. (2006) Proceedings of the Preconception Health and Health Care, Centers for Disease Control and Prevention. National Center on Birth Defects and Developmental Disabilities. 3-30. Korenbrot, C. C. Steinberg, A. , Bender, C. , Newberry, S. (2002). Preconception care: a systematic review. Matern Child Health J. 6 (2):75-88. March of Dimes. (2009). Welcome to Peristats. Retrieved April 8, 2010, from March of Dimes: http://www. marchofdimes. com/peristats/ Medline Plus (2009). Prenatal Care. Retrieved March 8, 2010 from http://www. nlm. nih. gov/medlineplus/prenatalcare. html Moos, MK. Preconception Health Promotion: A Focus for Women's Wellness. 2nd ed. White Plains, NY: March of Dimes; 2003. Moos, Merry-K MPH, RN, FNP, FAAN. Preconceptional Health Promotion: Progress in Changing a Prevention Paradigm.

The Journal of Perinatal & Neonatal Nursing: January/February/March 2004 - Volume 18 - Issue 1 - p 2-13. Retrieved March 15, 2010, from http://journals. lww. com/jpnnjournal/Fulltext/2004/01000/Preconceptional_Health_Promotion__Progress_in. 2. aspx National Association of Community Health Centers (NACHC). 2010. Meeting America’s Most Pressing Needs. Retrieved March 15, 2010. http://nachc. com/client/documents/9117-NACHC-web%20(2)1. pdf New York State Title V Application FFY 2007, p. 51. Quinn, L. A.

, Thompson, S. J. , Ott, M. K. (2005). Application of the social ecological model in folic acid public health initiatives.

J Obstet Gynecol Neonatal Nurs. 34(6): 672-681. Spano, Andrew (n. d) Community Health Assessment 2010-2013. Retrieved March 15, 2010, from http://www. westchestergov. com/health/CommunityHealthAssessment/WC_CHA_2010_2013_. pdf United Nations Development Program. (2006) About the Millennium Development Goals. Accessed and retrieved on April 7th 2010 from http://www. undp. org/mdg/basics. shtml U. S. Census Bureau. (2009). Preconception Health Care. Washington, DC Accessed March 15, 2010 from http://quickfacts. census. gov/qfd/states/36000. html University of Maryland. (2009) Fetal development: overview.

Accessed March 3, 2010 from http://www. umm. edu/ency/article/002398. htm Westchester County Department of Health. (2009). Annual Databook 2009. New Rochelle: Department of Health. World Health Organization (WHO). SE, E. , JE, A. , & al. , C. -d. -A. R. (2008, November 21). Overcoming Social and Health Inequalities among U. S. women of Reproductive Age. Retrieved April 1, 2010, from WHO: The Partnership for Maternal, Newborn, and Child Health from http://www. who. int/pmnch/topics/maternal/20081121_healthpolicy/en/ CASE STUDY 2: Reference Case Community Health Center Background

A Community Health Center (CHC) is defined by the National Association of Community Health Centers (NACHC) (2010) as “A Federally Qualified Health Center (FQHC) that provides comprehensive primary and preventive health care as well as dental, mental health and pharmacy services. ” The FQHCs are deemed to be a cost effective method of providing increased access to care. FQHCs provide educational tools, support and information that are vital to the health status of underserved communities. In an effort to increase access to care, transportation services and language translations are also provided to registered patients as needed.

FQHCs are patient centered and as reported by

the Community Health Care Association of New York State (CHCANYS) (2009) “at least 51% of the board members of a federally qualified community health center must be consumers of the health services, ensuring patient and community involvement in service delivery. ” The target Community Health Centers of Westchester consist of three FQHC designated facilities located in three distinct, underserved communities in Westchester County, New York. CHCs are a vital resource for provision of health care in the populations that they serve.

The CHC population consists predominantly of minorities, uninsured, underinsured, undocumented, low-to-no-income and Medicaid recipients. For the purposes of confidentiality in the report, the interventions will focus on the model CHC, one of the three FQHCs in Westchester County, New York. The CHC provides comprehensive primary and preventive health care services including: obstetrics/gynecology, pediatrics, internal medicine, family medicine, dental, ophthalmology, mental health and podiatry. The model CHC, located in the mid-northern section of Westchester County in New York was established in 1972.

When the model CHC merged with the primary location, it became the second satellite location in 2005. A third CHC site is located in the southwest section of the county. The primary CHC is the largest facility with the broadest range of services, while the model CHC and the third site focus on primary care. The CHC’s mission incorporates strategies to provide culturally sensitive, high quality, health care in a comprehensive manner to medically underserved residents of the community and to actively engage the community to address health issues.

The model CHC serves over 19,000 registered patients and averages more than 90,000 annual patient visits. This CHC provides healthcare services six days per week with extended

hours on two days to accommodate the high patient volume. The model CHC is currently working on enhancing their information technology department to introduce electronic medical records within the next few months. The Hispanic community served by the model CHC is predominantly from Central America.

Therefore, the main population target for treatments and any educational interventions at the CHC consists of a Central American Hispanic population. In 2009, a pilot study assessed women’s knowledge of the risk factors affecting pregnancy outcomes (Carter and Rahman, 2009). The 2009 Capstone Team (Carter and Rahman, 2009) recommended a variety of interventions including: wellness care and health promotion; involvement of women and family members; screening of immunization status; and nutrition education, use of folic acid, improved dental care, provider review of lifestyle and environmental risk exposures.

The PCH Pilot Study recommended these components as central to the success of preconception healthcare initiatives (Carter and Rahman, 2009). The 2009 pilot study group called for a paradigm shift from prenatal care to preconception care because more and more researchers as well as key health organizations (i. e. , Centers for Disease Control and Prevention and the March of Dimes) are realizing that the benefits of prenatal care are not optimally utilized by women who do not seek medical care until after the seventh week of gestation.

Maternal health during the first seven weeks of gestation is essential as this most sensitive time of embryo/fetal development and is usually before prenatal care is normally initiated (CDC, 2006). Prenatal care provided after this point is past the critical embryo development stage (Carter and Rahman, 2009; Quinn et al, 2005; Korenbrot et al, 2002). This point demonstrates

the need that exists in getting these women to seek care before this crucial gestational period is over. Prenatal Healthcare The provision of good health care to women during their reproductive years is vital.

Prenatal care pertains to the reproductive care a woman receives upon the discovery of pregnancy. At this point, she should receive the education, management and support needed in order to ensure a healthy birth outcome. Medline Plus (2009) describes the prenatal care process to be “more than just health care while you are pregnant”. The health care provider may discuss many issues, such as nutrition and physical activity, what to expect during the birth process and basic skills for caring for the newborn.

The doctor or midwife then explains to the expectant parents the importance of keeping scheduled prenatal visits and breaks down the frequency of visits by trimester. The expectation is for the patient to see their health care provider more often as the due date gets closer. A typical schedule includes visiting the doctor or midwife about once each month during the first six months of pregnancy, every two weeks during the seventh and eighth months of pregnancy, and weekly during the ninth month of pregnancy.

Since reproductive care is provided to a woman upon discovery of pregnancy, the delivery of maximally effective prenatal care is inhibited. A large percentage of women are usually unaware that they are pregnant until a few weeks after conception, which causes many women to miss the opportunity for care during the fetus’ most critical developmental stage, the embryonic stage, weeks 1-8 (University of Maryland, 2009). Thus, a strong possibility exists that a woman may still be

engaging in habits amaging to the development of the fetus may still be occurring before she realizes she is pregnant. Moos (2004) addressed the reasons for changes in the approach to reproductive health: The movement, which came to be known as preconception health promotion, was motivated by the realization that the incidences of the two leading causes of infant mortality and morbidity in the United States, congenital anomalies and low birth weight, had remained remarkably constant for nearly 80 years.

Proponents for rethinking traditional prevention strategies argued that prenatal care starts too late for primary prevention to exercise much influence on outcomes and that the window of opportunity needed to be widened to include purposefully the pre-pregnancy period as the starting point for impacting on reproductive outcomes. The sixteenth objective of Healthy People 2010 / 2020, addresses maternal, infant and child health including reduction in low birth weight babies, preterm births, congenital anomalies (i. e. , neural tube defects), mortality of mother, baby or infants.

The program also advocates for an increase in early and adequate prenatal care. Despite efforts to promote prenatal care, the rates of preterm births and low birth weight babies in the United States, New York State and Westchester County have stagnated in the past 5 years. To reach the Healthy People 2010 / 2020 goal of no more than 5% of live births being low birth weight babies and no more than 7. 6% preterm live births a new approach for maternal care is required. The new approach should also address the Millennium Development Goals four and five of reducing childhood mortality and improving maternal health (UNDP, 2006).

Preconception Care “Preconception care is

comprised of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management, emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact”(CDC, 2009). Preconception care is an effective form of preventive medicine for maternal and child health. Increasing universal availability of preconception services should be a national priority (WHO, 2008).

Preconception health serves as an important contributor to preventive health care, especially in women and infants. Preconception health care offers an important opportunity for physicians involved in women's health, such as internists and obstetricians/gynecologists to expand toward a primary care and primary prevention focus (Bower, Cefalo, & Moos, 2006). Internists and obstetricians/gynecologists are not only involved in acute diagnosis and treatment plans but also in disease prevention, risk and behavior modification, and counseling, which are integral parts of primary prevention and coordinated women's health care (Bower et al, 2006). Preconception health promotion guidance can provide prospective parents with an opportunity to prevent the preventable and to know they did all they desired to encourage a healthy pregnancy and infant” (Moos, 2003). According to the American Congress of Obstetricians and Gynecologists, preconception care “should address the optimal number, timing, and spacing of children; determine the steps needed to prevent or plan for and optimize a pregnancy; and evaluate current health status and other issues relevant to the health of pregnancy” (ACOG, 2006).

Current Pregnancy Outcomes According to Kent (2006), “nationwide statistics show that an estimated 30% of U. S. women have complications during pregnancy. 12% of babies are born prematurely, 8% are born with low birth weight,

and 3% have major birth defects”. The latest estimates from the US Census (2010) show that the national population is 15. 4% Hispanic and 12. 8% African American (U. S Census, 2010). In comparison, New York State’s population is 16. 7% Hispanic and 17. 3% African American (U. S. Census, 2010) and Westchester County is 19. 5% Hispanic and 14. % African American (U. S. Census, 2010). The county and state demographics of Hispanic and African American populations are nationally representative. Hispanics and African Americans suffer more adverse birth outcomes in comparison to Asian and Caucasian ethnic groups in most categories. According to the New York State Department of Health (2007), the acquisition of prenatal care differs among racial/ethnic groups. The New York State Department of Health states that for 252,662 live births, 60,326 were Hispanic and 52,450 were African American.

Among both Hispanics and African-Americans, contributors to adverse birth outcomes consist of education level, socio-economic status, maternal health behavior, age and acquisition of prenatal care (Gilbert et al, 2004). Statistics from the Westchester County Department of Health (2009) illustrate that 62. 3% of Central American women sought care in the first trimester, 32. 2% sought care in the second trimester and 4. 1% sought care in the third trimester. The delay in acquisition of prenatal care leaves room for much improvement in preventing adverse birth outcomes.

There is a plateau in the percentage of women who chose to seek early prenatal care within a space of about ten years, as illustrated in Figure 1. It is important to find ways in which reproductive care can be given to everyone at the most critical point in the

reproductive process, as a means of reaching the Healthy People 2010 / 2020 goal on prenatal care and birth outcomes. While the Healthy People 2010 / 2020 goal was set at 90%, New York State had an average of about 75%, while New York City and Westchester County reported 73% and 76%, respectively.

In addition, there is an urgent need for a new strategic approach that would contribute to actualizing the Millennium Development Goal (MDG) 2015 target of reducing the maternal mortality ratio by 75% (UNDP, 2010). Figure 1: Percentage of Women Who Acquired Early Prenatal Care Over Time 1995-2004 [pic] Source: New York State Department of Health, Vital Statistics Program Definition The current NYSDOH data indicate that the maximum benefit of prenatal care may have been achieved as the rates of preterm births and low birth weight babies has reached a plateau over the last 5 years.

A new approach is needed in order to reach the Healthy People 2010 / 2020 goal of no more than 5% of live births low birth weight and no more than 7. 6% of live births preterm (March of Dimes, 2009).. As a way of reaching the Healthy People 2010 / 2020 prenatal care and birth outcomes goal, the central purpose of Healthy Families for a Healthy Future (PCH-HF2) is to find ways in which reproductive care is given to everyone at the most effective point in the reproductive process.

If preconception healthcare education is introduced in a clinical care setting such as that provided by the model CHC and is implemented in such a way that patients can adhere to most of the recommendations and information given, then there

is an increased chance of an improvement in birth outcomes in the targeted communities(Boggess and Edelstein 2006). The aim of this project is to provide the target CHCs with recommendations and a strategic implementation plan for a comprehensive year-long, preconception health education program.

As the model CHC already provides prenatal care to patients, a need exists to proactively expand reproductive healthcare to the preconception level. The recommendations provided for the model CHC must also be adaptable for the patients at the other CHC sites. Recommendations Preconception Healthcare: “Healthy Families for a Healthy Future” (PCH-HF2) is a follow-up program to the 2009 Preconception Health (PCH) Pilot Study produced by the New York Medical College Capstone team (Carter and Rahman, 2009).

The pilot study assessed women’s knowledge of the risk factors affecting pregnancy outcomes (Carter and Rahman, 2009). Carter and Rahman (2009) recommended interventions including: wellness care and health promotion; involvement of women and all family members; screening of immunization status; nutrition, use of folic acid, improved dental care, provider review of lifestyle and environmental risk exposures. The PCH Pilot Study recommended these components as central to the success of preconception healthcare initiatives (Carter and Rahman, 2009).

The 2009 Capstone group called for a paradigm shift from prenatal care to preconception care because more and more researchers are realizing that the effects of prenatal care are not as beneficial for women who realize that they are pregnant after the seventh week of gestation, which is past the critical embryo development stage (i. e. , 2-8 weeks) (Carter and Rahman, 2009; Quinn et al, 2005; Korenbrot et al, 2002). The challenge that exists is getting these women to seek care before

this crucial gestational period is over.

In order for all women to enter into pregnancy in optimal health, interventions must encourage the family to adopt healthy behaviors and to seek the age appropriate preconception care from medical providers (Hood et al, 2007). PCH-HF2 interventions encourage the adoption of a healthy lifestyle through multiple practitioners such as internists and pediatricians and involve the whole family. A familial approach compounded with the expertise of practitioners encourages sustainable, healthful behavior change (trash et al, 2008).

Literature shows patients prefer personal contact and patients choose intervention approaches that facilitate interaction with a counselor or coach rather than those that are self-guided (Cohen et al, 2005). Therefore, practitioners can provide their expertise and the families can support healthful behavior changes at home. If this approach is taken, the entire family can buy-in to the prescribed healthy lifestyle and be empowered to maintain that healthy lifestyle. The PCH-HF2 strategy includes all the providers in the model CHC because it is important to achieve a standard of care for all of the centers’ patients.

After careful investigation of the model CHC, there are several barriers that have been taken into consideration in the development of the PCH-HF2 recommendations. First, the literacy level of the patients served by the model CHC is at the second-to-sixth grade level. The first intervention of PCH-HF2 is to provide educational materials that will try to address this issue by offering pamphlets that incorporate greater visual content than technical text and/or medical jargon. Second, language is a major barrier for the model CHC community.

Since the model CHC community is predominantly Hispanic, many of the patients’ first language is Spanish. To manage

this challenge the PCH-HF2 recommends the educational materials be available in Spanish and English. The plan is to leverage the existing materials at the model CHC and modify them. At present, the materials being distributed at the center are 1) educationally too advanced for the population and 2) mostly available in English. New pamphlets will be created from the existing ones, the reading level will be lowered, and the pamphlets will be translated into Spanish.

The pamphlets will focus on important preconception care issues to promote healthier patients before conception. The educational materials will define for example the specific intervention the importance of this intervention, its benefits, how much of this intervention is recommended daily and alternative ways of incorporating the said intervention into everyday life. The text in these pamphlets would be written at a second grade reading level so as to guarantee that the messages can be clearly understood.

In addition, pictures will be added to further supplement the text and provide examples of the topic discussed in the pamphlet. A lower literacy level for the pamphlets is critical because this is a way to ensure healthful behavioral change information is communicated and understood. If the materials are easy to read and understand then the patients will be more receptive to the recommendations and more likely to engage with their providers. Table 2 below provides a brief description of each pamphlet. Table 2: PCH-HF2 Proposed Educational Pamphlets by Topic Appendix Location |Topic |Key Message |Source | |1 |Folate supplementation |Folate is a vitamin your body needs every day|CDC | | | |to be healthy | | |2 |Dental care |Taking care of your teeth and

gums is |New York State Department of | | | |important for all women, men and children |Health, bureau of Dental Health | |3 |Immunizations |Vaccines can prevent some infections and help|http://pregnancyshotsca. org | | | |you to stay healthy |http://www. cdc. gov/vaccines | |4 |Nutrition |Your health is affected by what you eat. A |http://www. MyPyramid. ov | | | |healthy diet helps you reach a healthy weight| | | | |and helps you get all the nutrients your body| | | | |needs | | |5 |Environmental Risk exposures |There are many chemicals used in homes and |March of Dimes | | | |business every day which can affect your | | | | |health and your baby’s health – learn more | | | | |about to keep yourself and baby healthy | | |6 |Physical Activity |Daily exercise helps keep your heart and body|CDC and | | | |strong |http://www. health. gov/paguidelines| |7 |Smoking Cessation |Smoking can damage your body and the health |The American Cancer Society | | | |of your children... on’t start smoking, and |The American Lung Association | | | |if you need help quitting please talk to your| | | | |doctor | | |8 |Sexually Transmitted Diseases |It’s important to practice safe sex, even if |http://www. cdc. gov/std | | | |you’re in a committed relationship | | |9 |Drug Abuse |Taking drugs without your doctor’s |http://www. adp. ca. gov | | | |recommendation/ prescription can damage your | | | | |body and the health of your children... on’t | | | | |start, and if you need help quitting please | | |

| |talk to your doctor | | |10 |Alcohol Abuse |Alcohol can be harmful to your health. If |http://www. aa. org | | | |you are pregnant, alcohol can also cause | | | | |birth defects.

Any alcohol use can affect | | | | |the neurological development of the | | | | |developing baby. | | A third barrier that has been acknowledged is the wait time at the facility. Currently the patient wait time to see a physician can be anywhere from fifteen minutes up to two hours. There are several contributing factors to the variation and overall length of the patient wait time (i. e. , provider-room ratio, volume of medically complex patients seeking care, overwhelming demand for interpreter/translation services, staff turnover rate).

Although PCH-HF2 cannot directly change the wait times at the facility, the new and updated educational materials recommended for the center can help occupy the patients while they wait. In addition, a component of the educational program is to update the videos in the waiting areas. An alternative method of information delivery is to add educational messages about preconception care to “on hold” messages to the existing telephone system at the center by recording a series of scripts. In addition to the telephone waiting line messages, free give-a-ways have been identified containing important concepts of wellness care and health promotion (table 3).

Table 3: Free Recommended Educational Resources |Resource |Population |Language |Source | |Eat Smart New York |Family & Youth |English/ Spanish |Cornell University | | | | |http://counties. cce. cornell. edu/wyoming/nu| | | | |trition/esny/Flyer_Eat%20Smart%20NY. pdf | |Text4Baby |Expectant Parents |English/ Spanish |http://www. text4baby. rg/ | |Growing Up Healthy

Hotline |Expectant Parents, Parents |English/ Spanish |NYSDOH | | | | |1-800-522-5006 | |Su Famila (National Hispanic Family|Family |English/ Spanish |1-866-783-2645 | |Health Help Hotline) | | | | |Folic Acid/Multivitamin |Expectant Parents, Teenagers|English/ Spanish |Folic Acid Council | | | | |http://www. getfolic. com/order/index. htm | |Vegetable Guide |Family |English (photos) |http://www. marketfresh. com. u/images/downl| | | | |oads/VegetableGuide. pdf | |Choose Smart, Choose Healthy |Family |English |CDC | |(Nutrition) | | |http://www. fruitsandveggiesmorematters. org| | | | |/wp-content/uploads/UserFiles/File/pdf/res| | | | |ources/cdc/ChooseSmart_Womens_Brochure(1). | | | |pdf | |Healthy Mothers, Healthy Babies |Expectant Parents |English/ Spanish |CDC | | | | |http://www2. cdc. gov/ncbddd/faorder/orderfo| | | | |rm. htm#CDC-099-5142 | |Various Health Issues |Expectant Parents |English/ Spanish |FDOH | | | | |http://www. doh. state. l. us/environment/new| | | | |sroom/brochures/index. html | |Sesame Workshop (Healthy Habits for|Children |English/ Spanish |http://www. sesameworkshop. org/initiatives/| |Life) | | |health/healthyhabits | |Printable Coloring Pages |Children |English |http://www. wohfkidsconnect. com/kids/activi| | | | |ties/color1. tml | |Growing Together Coloring Pages |Children |English |http://www. dltk-kids. com/nutrition/colorin| | | | |g. html | |Coloring Pages & Matching Games |Children |English/ Spanish |http://www. eatsmart. org/article. asp? id=378| | | | |2 | The second intervention of PCH-HF2 will also incorporate free local educational initiatives.

Examples include the free group nutritional classes of Eat Smart New York provided by the Cornell University Cooperative Extension of Westchester County and text4baby, a free mobile telephone information service for pregnant women and new moms from pregnancy through a baby’s first year. The third intervention is to promote wellness visits across providers within the CHCs: pediatrics, internal medicine, family medicine, etc. PCH-HF2 wants to encourage the provision

and access to comprehensive care meaning an expansion of the existing prenatal care protocols to other areas within the center(s). In order to achieve program goals the PCH-HF2 recommendations are grounded on the need to educate the community and encourage healthy lifestyles from childhood so that later on in adulthood these habits have already been established and therefore will lead to better birth outcomes (Atrash 2008) . Deliverables

PCH-HF2 suggests that the model CHC include the following materials during the implementation of the proposed preconception care plan. All recommended materials aim to support the 5-Cs model: Comprehension, Confidence, Compliance, Consistency and Continuity. The materials will help to educate the model CHC patients. These resources are designed to work in conjunction with information provided by the model CHC physicians and not as a replacement for physician-based healthcare recommendations. These supplemental materials will help patients to better understand the rationale behind what their health care providers are recommending during appointments. There are several items that PCH-HF2 recommends in order to achieve the 5-Cs.

Some of these items include: more comprehendible brochures and materials; additional video content for the waiting room television, telephone waiting line messages playing important health related messages while patients are on hold, educational materials at the elementary level for children, and take-a-ways to distribute to patients to remind them to be conscious of health issues. The majority of the recommended resources will be made available in English and Spanish. Comprehension The take home materials given to patients are comprehensive for the patients at the model CHC. As mentioned above in the recommendations section, the CHC patient population consists of primarily a Spanish-speaking population. The education level

for the majority of the patients ranges from the second to sixth grade equivalent and consists of mostly foreign education.

These factors are important to consider in planning for the success of PCH-HF2 interventions for this particular population: • Materials must be available in Spanish in addition to English • Materials must also be clear and concise Providing appropriate educational materials for the patients of the model CHC will equip them with the preconception comprehension needed to lead to better maternal and infant outcomes (D’Angelo et al, 2004; Hood et al, 2008). Educational materials should also have a heavy emphasis on pictures and photographs rather than text. In support of the family centered approach of the proposed program, materials for healthy living will focus on the entire family.

Although women of childbearing age are the main focus, the PCH-HF2 program recognizes the importance of including the entire family in adoption of healthy habits. If the entire family buys into a healthier lifestyle, it will help to reduce co-morbidities associated with adverse birth outcomes (D’Angelo et al, 2004; Boggess and Edelstein, 2006). Family planning materials will also be directed at the male partners and healthy living materials will be supplied at the elementary level for children. Additional items are recommended to increase the comprehension of important health concepts related to preconception healthcare. The first is the recommendation to enhance the waiting room videos.

During the first site visit to the model CHC, the PCH-HF2 team observed that the educational video content in English that was playing in the waiting room was widely disregarded due in part to the patients’ lack of comprehension. It is recommended that the video(s) be

available in both English and Spanish. In addition to language barrier, another reason that the videos do not elicit much attention is that the same video is played over and over again in a continuous loop. Since the waiting room queue time can reach up to two hours, patients might hear the same message played several times. The solution to this problem is that the model CHC has additional content that can be added into the video rotation. As patients are sitting in the waiting area for at least fifteen minutes and up to two hours, the model CHC ust take advantage of this time by providing valuable health education. Another opportunity to make the most of the time that patients spend waiting is through the use of educational telephone messages on the waiting line. This audience is especially captive, which provides a unique opportunity to inform, educate and motivate patients. At the same time, keeping patients busy during their wait time creates a more positive customer-service experience. The plan is to use telephone recorded messages that are interesting, informative and educate patients. The messages should provide information that pertains to preconception care and healthy family behaviors.

The messages should also follow up with the information that is provided by quizzing patients on what they just heard. Messages would be recorded in English and Spanish. The information reel should be relatively brief so that patients can hear a complete segment in the time that they are on hold. There would be four different topics covered and the messages can be rotated and updated periodically. Confidence Provision of comprehensive educational materials will not only act to inform,

but can also instill confidence in women of childbearing age, their partners, and their families. Knowledge is powerful. Simple recommendations given by health care providers regarding changes for healthier living are not always sufficient for healthy life changes.

Being told to change certain habits is never as strong as discovering the need of change for oneself (Gruber, 1991). Thus, providing materials to not only inform but to convince patients that making healthy decisions will result in healthier living and healthier families. In accordance with the likelihood of adopting healthy lifestyles, information must not only be convincing, but it must be feasible. If a patient does not believe that they have the power or the means to achieve the changes that are needed for a healthier life, they are not going to put in the effort. Programs mentioned in PCH-HF2 recommendations including Eat Smart New York courses, POWR against Tobacco and text4baby can aid in establishing and strengthening patient confidence.

Some other recommended services to introduce to patients in order to encourage self-confidence and empower the pregnant women/new mothers include the use of text services and telephone hotlines, such as the text4baby system mentioned in the recommendations above. This service provides helpful information pertaining to the stage of development that the fetus or infant is in. The service also sends reminders to the parents of important check up milestones for their baby via cellular phone text messages. As this service is provided in both English and Spanish it is an ideal freely available service to incorporate in the PCH-HF2 program. Services like these not only instill confidence in patients, but also help to ensure compliance, consistency and continuity

of healthy habits. Compliance

After a patient has the comprehension to make changes and the confidence to do so, provisions must be implemented in order to enable them to stick to the healthy lifestyle change and promote compliance. Making lifestyle changes is a difficult feat. In order to continue making healthy choices a part of daily life, a patient must be reminded as to what the healthy changes are and why they are important. Compliance is more likely to continue when the entire family is involved, which again ties into the family-centered approach to healthy lifestyle changes. If, for example, the family as a unit is focused on eating more nutritious foods or adopting healthy dental practices, they are far less likely to stray off course.

Involvement of the entire family in healthy lifestyles makes it much more likely that the healthy habits will become part of their lifestyle. This is why materials related to family planning and family health should be directed not only at women, but at their partners and their entire family as well (Atrash et al 2008). By providing educational materials on health topics to children, the model CHC can equip these children with healthy habits early on in life. The idea is not solely to have children adopt these lifestyles, but twofold. Children who are aware of bad habits are likely to call attention to a parent when they are not engaging in healthy behaviors, thus keeping the parent on track.

Consistency Consistency is important to making a healthy change part of everyday life. Doing something on a constant until it is seamlessly incorporated into daily life is the key to adopting successful

positive habits. PCH-HF2 proposes that the model CHC should implement the dissemination of certain materials that will act to remind patients to always practice the recommended interventions. Distribution of items such as calendars, key chains, pens, water bottles, magnets, hand sanitizer, etc. will help to establish continuity of healthy practices. These items and others used on a daily basis will serve as reminders of the recommended daily practices.

For example, utilizing a water bottle with a reminder to take a daily vitamin will increase the likelihood that one would remember to take a daily vitamin. Continuity Continuity will be achieved through follow-up visits with each patient’s primary care physician at the model CHC (Atrash et al, 2008). Each physician should follow the check-list in order to assure that they have addressed all key areas of health concern with each patient during each visit. Each patient should also receive a checklist with the items that they discussed with their physician. This checklist will serve as a reminder to the patient of what was discussed during the wellness visit. Please refer to Appendices 1 and 2 for the physician and patient checklists, respectively. Funding Sources

There are sources of funding that could help the model CHC offset the costs of deliverable expenses including printing costs and the price of promotional items. Three potential sources of funding include: Consumer Value Store (CVS), Walgreens and Wal-Mart. The CVS Caremark Charitable Trust issues grants up to $5,000/yr for five years ($25,000). The model CHC is eligible for this grant under the group of health care organizations that are “dedicated to improving the quality of health and well-being of uninsured seniors, adults, youth

and children that address: pre-natal care, screening and preventative programs, better health outcomes and general health programs. ” (cvscaremark. com, 2010).

Walgreens also provides funding for nonprofit organizations that seek funds that focus specifically on improving: access to health and wellness in their communities or perform community outreach. Wal-Mart also issues grants on a state-by-state basis to nonprofit organizations with programs that align with their