Brandi CookeStudent Intern

3rd National Summit on Preconception Health and Health Care

June 12-14, 2011

Factors Affecting the Willingness of Counselors to Integrate Preconception Care into Sexually Transmitted Disease

Clinics

National Center on Birth Defects and Developmental Disabilities

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Preconception Care

Best time to identify and address risk factor for reproductive health is before not after conception Not universally available Advancing as standard of care

• “Recommendations to Improve Preconception Health Care -- United States” (Johnson et al., 2006)

• “Policy and Financing Issues for Preconception and Interconception Health “ (Markus, 2008)

• “Preconception Health and Health Care: The Clinical Content of Preconception Care” (Jack & Atrash, 2008)

Preconception Care Challenges Major Challenges

Insufficient reimbursement for risk assessment and health promotion activities

Lack of clinical training programs emphasizing PCC risk assessment

Lack of data on effectiveness

Ongoing Challenge Rate of unintended pregnancies

“Despite these national recommendations and the plethora of newly published content there are many challenges to ensuring that all women of childbearing age in the United States receive preconception care services that will enable them to enter pregnancy in optimal health “

Preconception Care Solutions

Integrating PCC into other public health programs accessed by women at risk for unintended pregnancy STD clinics in unique position to offer PCC information

• Women at high risk for contracting STD also at high risk for unintended pregnancy

• More likely to have modifiable medical and behavioral risks• STD clinics have skilled counselors• Service admirable to expansion of preconception

counselingo Similar content- risk assessment, education, client-

centered intervention

Previous Studies vs Present Study

Previous Studies- Ignore counselors focus on doctors and nurses

Present Study- Assess counselor perception of PCC importance Identify factors that affect willingness of counselors to

integrate PCC into STD clinics

Initial Questionnaire Development

Initial Draft- self-administered, structured, closed- end questionnaire utilizing questions modified from:

• March of Dimes, Folic Acid and the Prevention of Birth defects, and ACOG surveys

Pretested by 10 former STD counselors currently working as project managers at CDC

6 questions assessed:• Completion time• Level of complexity• Readability• InterestInitial- - self-administered, structured, closed-end

questionnaire

Final Questionnaire

Final Draft solely professional attributes no demographics Questionnaire emailed to current and former STD

counselors in urban ,suburban, and rural areas of US• Counselors found through CDC listing• All counselors had at least 2 years experience providing HIV

pretest/posttest counseling and syphilis interviewing

201 counselors emailed, 140 (71.4%) counselors participated and signed IRB consent form

Final- - self-administered, structured, closed-end questionnaire

Counselor Classifications

Level of responsibility

Lower level- counselors and first line supervisors Higher level- managers and administration

Level of Syphilis Morbidity High morbidity- primary and secondary case rate

>2.0/100,000 population Moderate morbidity- primary and secondary case rate

1.0-2.0/100,000 population Low morbidity- primary and secondary case rate

<1.0/100,000 population

Counselor Classifications

Knowledge of PCC counseling Years of experience providing STD

counseling Are patients asked about PCC issues? (i.e.,

obesity, drug use, smoking, diabetes, physical activity, asthma, cardiovascular disease)

Does clinic provide referrals for high risk issues?

How prepared are you to provide PCC counseling?

Major Characteristics of Study Participants and Clinics

Low

er

Hig

her

Exce

llent

Good

Poor

2 -

- 5

6--

10

> 1

0

Yes

No

Yes

No

Very

pre

pare

d

Som

ew

hat

pre

pare

d

Not

pre

pare

d

Hig

h

Modera

te

Low

Level of re-sponsibility

Knowledge of PCC Years of Experience Clinic refer-rals for PCC

Do you ask about PCC

How prepared are you to deliver PCC

Level of Syphillis morbidity

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

81%

97%100%

91%

69%63%

91%88%86%

83%85%81%81%

93%

72%

92%86%

45%

PCC is Important ?

Low

er

Hig

her

Exce

llent

Good

Poor

2 -

- 5

6--

10

> 1

0

Yes

No

Yes

No

Very

pre

pare

d

Som

ew

hat

pre

pare

d

Not

pre

pare

d

Hig

h

Modera

te

Low

Level of re-sponsibility

Knowledge of PCC Years of Experience Clinic refer-rals for PCC

Do you ask about PCC

How prepared are you to deliver PCC

Level of Syphillis morbidity

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

51%

78%75%

81%

14%

23%

57%

81%

63%

51%

59%

48%

81%

72%

24%

75%

31%

15%

Preconception Care Should be Delivered?

Low

er

Hig

her

Exce

llent

Good

Poor

2 -

- 5

6--

10

> 1

0

Yes

No

Yes

No

Very

pre

pare

d

Som

ew

hat

pre

pare

d

Not

pre

pare

d

Hig

h

Modera

te

Low

Level of re-sponsibility

Knowledge of PCC Years of Experience Clinic refer-rals for PCC

Do you ask about PCC

How prepared are you to deliver PCC

Level of Syphillis morbidity

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

58%

78%75%

80%

33%

47%

60%

84%

64%61%63%62%

69%74%

41%

75%

52%

25%

Interconception Care Should be Delivered?

Univariate Results: Most likely to report PCC as important and believe in

PCC and ICC delivery

High level of responsibility Good or excellent knowledge of PCC >5 years of experience Moderate or high level of syphilis morbidity

Series10

10

20

30

40

50

60

70

80

PCC Findings

Findings Reveal Mostly all STD counselors report PCC was important but

counselors vary on whether PCC should be delivered Cannot make conclusion about some factors

Reason for varied findings Counselors recognize interrelationship between PCC and

STD Counselors predisposed to HIV and hepatitis B

integration attempts Counselors already asking patients about high-risk

behaviors

PCC Study Limitations

Focus on integration of PCC into STD clinics No account for variability among clinics and counselors Difficult to evaluate effect of counseling session Findings not generalizable to other professionals ( i.e.,

nurses and social workers) Self reported error assessing level of knowledge and

attributes

What’s Next?

STD clinics may be plausible alternative for targeting females who might not otherwise receive PCC benefits CDC guidelines for STD clinic sessions tailored to provide

PCC counseling Additional PCC training for STD counselors

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Failure to provide adequate medical consultation and care before

conception for both planned and unplanned pregnancies will

continually result in long term consequences for parents and

children

National Center on Birth Defects and Developmental Disabilities

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