Assessing Health Literacy and Preconception Healthcare (PCH) Risk amongst Black/African-American Women via web-based Conversational Agent Technology
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1 7 th Annual Health Literacy Research Conference (HARC) November 2-3, 2015, Bethesda, MD Assessing Health Literacy and Preconception Healthcare (PCH) Risk amongst Black/African-American Women via web-based Conversational Agent Technology Brian Penti MD Academic Research Fellow, Department of Family Medicine Data & Support from the Gabby Preconception Care System team
2 Topics to be discussed Background information on: Health Disparities in Birth Outcomes Preconception Care The Gabby Preconception Care System Results Future directions
3 HEALTH LITERACY is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Women with poor health literacy are more likely to: Have an unplanned pregnancy Less likely to take folic acid prior to becoming pregnant Less to have discussed pregnancy with their physician prior to becoming pregnant
4 Infant Mortality Rates, by race and ethnicity, United States, 2005 and 2013 Source: National Vital Statistics Reports Aug 6, 2015
5 Preconception care is: a set 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 CDC, Johnson K, Posner SF, Biermann J, Cordero JF, et al. (2006) CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep 55: 23 50% of all pregnancies are unplanned, hence important to address preconception healthcare (PCH) risk factors in healthy young women before they become pregnant, such as: Folic Acid supplementation Vaccinations Intimate Partner Violence (IPV) Smoking Obesity Opioid use and/or abuse
6 Preconception Health & Health Care Although most women understand optimizing health before pregnancy is important & most physicians think preconception care is important, few obstetricians/gynecologist or family physicians provide comprehensive PCH care to their patients Hence we need to create tools to assist busy clinicians in providing this care
7 Using Health IT to improve Preconception Health: Gabby is a Conversational Agent, which is a computerized, animated character designed to integrate best practices from providerpatient communication theory Gabby may be ideal for delivering PCH because: can reach large number of patients Alleviate clinician time restraints Can control costs High patient acceptability: Culturally appropriate Provide understandable info for those with low Health literacy Gabby
8 The Gabby Preconception Care System..
9 Development of the Gabby Preconception Care System Version 1 (V1) (2012) 24 black/african American (AA) women enrolled, used Gabby system for 2 months (HRSA) Version 2 (V2) (2013-4)- 100 AA women enrolled and completed RCT to assess the effectiveness of the Gabby system to reduce PCH risk during 6 month period, completed 2014, published in JABFM July (HRSA) Version 3 (V3) (2015 to present) AA women currently being recruited for RCT of 1 year duration (NIMHD) Version 4 (V4)- refinement, update of Gabby System (Kellogg Foundation)
10 Gabby Version 2 and 3 (V2 and V3) 1. Meet Gabby Achieve Goal 8a. Longitudinal behavior change scripts 7a. Add to risk to MHTDL 2. Take Risk Assessment (RA) 8b. Choose new risk to discuss from My Survey Results OR My Health To-Do List 7b. Don t Add to MHTDL 3. Review results ( My Survey Results ) Precontemplation Motivational Interviewing 4. Answer Stage of Change question for each triggered risk Contemplation & Planning - Shared Decision Making (Family Planning) - Sequential Discrete ( Go to the Doctor risks) 5. Choose risk to learn about with Gabby 6. Listen to first stage-appropriate script(s) from Gabby Contemplation, Planning, Action, Maintenance - Problem Solving/Tips - Homework - Goal Setting - Educational Info (Nutrition, Activity, and Stress Management)
11 Research hypothesis Black/AfAm women with low health literacy will have increased PCH risks. Use of Gabby system did not vary with level of health literacy. Gabby system PCH risk mitigation was not associated with health literacy.
12 Gabby Version 2 (V2) Methods: 6 month RCT with 100 nongravid primarily collegeattending AA women between years of age, screened for PCH risks. Results: Mean # of PCH risks: 23.7 At 6 months, the Gabby group had greater reduction in number of PHC risks compared to controls (8.3 vs 5.5 risks, P<0.5) Women averaged 2.9 logins and 63.7 minutes of interaction time with Gabby 78% reported it was easy to talk to Gabby 64% reported they had used information from Gabby to improve their health
13 Rapid Estimate of Adult Literacy in Medicine (REALM) REALM Score REALM equivalent Education Level Health Literacy 0-18 <3 rd grade Low th -6 th grade th -8 th grade Marginal >9 th grade Adequate
14 PCH Risks and REALM Category (Gabby Baseline Data, V2 & V3 to 9/2015): REALM Category of Equivalent Educational Grade (n) PCH Risks mean (sd) ANOVA p=0.09 <3 rd Grade (1) 24 (6.5) 4-6 th Grade (4) 31.3 (3.2) 7-8 th Grade (12) 27.3 (1.9) >9 th Grade (156) 24.4 (0.5)
15 REALM Score & Self-Reported Education Level (Gabby Baseline Data, V2 & V3 to 9/2015): Self-reported Education level (n) Mean REALM score mean (sd) Have not graduated High School (7) 59.8 (2.3) Graduated High School (16) 50.0 (1.5) At least 1 year of College (172) 63.6 (0.46) ANOVA p <0.001
16 PCH Risks & Self-Reported Educational Level (Gabby Baseline Data, V2 & V3 to 9/2015): Self-Reported Education level (n) PCH Risks mean (sd) Have not graduated High School (8) (2.3) Graduated High School (10) 27.4 (2.1) At least 1 year of College (161) 24.2 (0.5) ANOVA p <0.015
17 Adverse Health Conditions and Health Literacy Gabby V2 Baseline Assessment Lower Health Literacy more likely to be associated with: Poor Birth Outcomes (p<0.05) Preterm Baby (p<0.001) Smoking (p<0.001) No health insurance (p<0.01) High blood pressure (p<0.05) Missing Immunizations (p<0.001) Disability (p<0.001) Higher Health Literacy is positively associated with: Better Social Supports (per Multidimensional Scale of Social Support, p=0.08) Better self-efficacy (per General Self-Efficacy Scale, p<0.05)
18 Gabby V2 Use & REALM Scores 6 month follow-up, Gabby V2 Number of times Gabby System Accessed (n) ANOVA p=0.56, n=35 REALM Score mean (sd) None (4) 56.5 (6.4) Once (7) 65.1 (4.8) Two to Three times (7) 58 (4.8) Four to Five times (10) 64.3 (4.1) More than Five Times (7) 56.6 (4.9)
19 Number of PCH Risks Resolved and REALM Score 6 month follow-up, Gabby V2 PCH Risks Resolved (n) REALM Score mean (sd) 0-4 (10) 65.1 (1.7) 5-8 (12) 53.6 (20.3) 9-20 (12) 64.0 (1.3) ANOVA, p=0.06
20 Computer Use Location and Health Literacy Gabby V2 & V3 Where Women Access Internet (n) REALM Score mean (sd) At friends (2) 59 (4.6) Home (107) 62.5 (0.6) Library (7) 47.1 (2.4) Other (10) 59.9 (2.0) Work (68) 63.9 (0.8) ANOVA P<0.001
21 Limitations REALM Score REALM correlates with three standardized reading tests (PIAT-R, WRAT-R, SORT-R), but does not assess for comprehension of printed health materials, numeracy, and information seeking/navigation.. (Dumenci L et al, 2013) Does not consider cultural variation in pronunciation Sample primarily college educated women Gabby only assessable via computers, not mobile phones Longer follow-up and larger sample needed to assess impact on reproductive outcomes.
22 In Summary Lower Health Literacy associated with more PCH Risks Women with lower Health Literacy attained similar benefits from the Gabby Preconception Care System as women with higher health literacy Women with lower health literacy may have issues related to accessing computers/tablets to utilize the Gabby System
23 Thank you Brian Jack MD Timothy Bickmore PhD Karla Damus PhD MSPH RN The Entire Gabby Preconception Care System Team Leanne Yinusa-Nyahkoon ScD Suzanne Mitchell MD Paula Gardiner MD MPH Fatima Adigun Clevanne Julce Michael Paasche-Orlow MD Funders: HRSA National Institute of Minority Health and Health Disparities The Kellogg Foundation
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