Internet–Based Preconception Care: The
Perspective of Young,
African American Females
Leanne Yinusa-Nyahkoon, ScD
Megan Cuoco, MPH, CHES
Lazlo Ring
Timothy Bickmore, PhD
Michael Paasche-Orlow, MD, MA, MPH
Karla Damus, PhD, MSPH, MN
Brian Jack, MD
Department of Family Medicine
Boston University, Boston University Medical Center
Boston, MA
The Disparity
• In 2008, African American women were almost twice as likely
to deliver a low birth weight baby (< 2,500 grams) than white
or Hispanic women1
16
14
12
10
8
6
4
2
0
13.7
White
7.2
7
Hispanic
African
American
% of Low Birth Weight Births by
Mother's Race
The Disparity
• In 2008, African American women were almost three times as
likely to deliver a very low birth weight baby (< 1,500 grams)
than white or Hispanic women1
3.5
3
2.5
2
1.5
1
0.5
0
3
White
1.2
1.2
Hispanic
African
American
% of Very Low Birth Weight Births by
Mother's Race
The Disparity
• In 2005, the infant mortality rate for African
American women was more than double that of
white women (13.6 and 5.8 per 1,000 live births
respectively)2
Health Education May Minimize the Disparity
• Barriers to health education within the African American community
– Healthcare accessibility3
– Clinician time restraints4,5
– Perceived racism6,7
– Patient-provider communication8,9
American Medical Association Statistics10
60
White
54.5
50
Black
40
Hispanic
30
Asian
23.4
American Native/Alaska
Native
Other
20
12.2
10
3.5
4.9
1.3
0
% of US Physicians by Race/Ethnicity - 2008
Unknown
IOM Recommendation
• Culturally tailored health education can minimize common
barriers that contribute to health disparities within the African
American community3
– Internet-based health education
Who is Our Target Population?
• Mean age of African American mothers at the
time of their first child’s birth1…
22.8 years old
Internet-Based Health Education11
• 90% participants ages 15-24 report > 1 on-line
experience
• 75% of these “on-line” participants search the
internet for health information
– Specific diseases (e.g. cancer, diabetes)
– Sexual health
– Weight loss/gain
Internet-Based Health Education11
“On-line” participants used health information to:
1. Start a health related conversation with a lay person
or health care professional
2. Take action or change health behavior
Internet Use Among African Americans
• African Americans report less internet access than whites12
• In a sample of low income, urban African American adults
between the ages of 18 and 25, the majority whom were
female13…
– 45% owned a home computer
– 32% had home internet access
– 49% used the internet at least once to find health information
Using Innovative Technology to Improve the
Health of Young, African American Women
•
Agency for Healthcare Research and Quality [AHRQ]
•
Aim of the study
–
•
Develop and evaluate an internet based virtual patient advocate [VPA]
system to deliver a preconception care behavior change intervention for
young African American women (ages 15-21)
Qualitative phase
–
What components do African American women perceive are needed to
make a preconception care education website culturally acceptable?
Focus Group Eligibility
• Inclusion criteria:
– Female
– Self-identify as African American
– 15-21 years old
– Speak English
• Exclusion criteria:
– Currently pregnant
Focus Group Recruitment
• Craigslist
• College employment centers
• Community center
• Community newspaper
• Stores, restaurants, and other venues
• Focus group participants
Focus Group Participants
• 31 African American females ages 15-21
– Mean age = 19.3
• 84% enrolled in a college/university
• 87% have an assigned primary care physician
• 71% use internet > 5 times per day
• 84% access internet via home computer/laptop
• 61% access internet via cell phone
Participant Demographics (N=31)
Age
15-17 years old
18-21 years old
3 (10%)
28 (90%)
Education level
< High school diploma
2 year college/university student or graduate
4 year college/university student or graduate
5 (16%)
6 (19%)
20 (65%)
Internet Use
1-2 times per day
3-4 times per day
> 5 times per day
6 (19%)
3 (10%)
22 (71%)
Device(s) Used to Access the Internet
Home computer/laptop
Cell phone
School computer/laptop
Work computer/laptop
Friend or family member’s computer/laptop
26 (84%)
19 (61%)
10 (32%)
7 (23%)
7 (23%)
Primary Care Physician
Pediatrician
Family Medicine
OB/GYN
Family Medicine and OB/GYN
Unsure of physician’s specialty area
Do not have a primary care physician
9 (29%)
8 (26%)
2 (6%)
7 (23%)
1 (3%)
4 (13%)
Focus Groups
• Occurred at an inner-city academic medical center serving
predominantly racially and ethnically diverse patients and low
income families
• 7 focus groups and 1 follow-up focus group
• Between 2 and 8 females participated in each focus group
• Participants were given $30 at the end of each focus group
Focus Group Agenda
• Reviewed existing preconception care websites
–
–
–
–
http://mariatalks.com/
http://sexreally.com/
http://goaskalice.com/
http://www.plannedparenthood.org/info-for-teens/index.asp
• Viewed images of existing and potential website characters
• Edited educational scripts about 12 domains of preconception
care14 (health promotion, psychiatric disease, psychosocial risks, immunizations, infectious diseases, chronic medical
conditions, family and genetic history, reproductive history, parental exposures, nutrition, environmental exposures, medications)
• Discussed social networking features
• Provided feedback about specific components of our internet
based intervention
Data Analysis
• Focus group interviews were audio recorded and transcribed
verbatim
• Transcripts were reviewed to ensure transcription accuracy
and to alter names and identifying information in order to
honor participant confidentiality
• Data analysis began after the first focus group allowing new
points of inquiry to be discussed during subsequent focus
groups
Data Analysis
• Two research team members independently coded each transcript
• Coding discrepancies were reconciled using supporting evidence
from transcripts
• Content codes from the topics discussed during focus groups were
defined in a coding dictionary
– 74 codes
• Related codes were organized into categories and themes
summarizing focus group findings
• NVIVO used to manage codes and transcript data
Findings
• Visual Layout
• Characters
• Educational Information
• Social Networking Features
Visual Layout
• Less is more
• Quick and easy
• Bold colors
– Purple
– Orange
– Blue
• Feminine images and designs
– Flowers
– Swirls
•
•
•
•
Professional affiliation
Different fonts in different colors
Minimize words
Different options to access information
– Animated videos
– “Ask the doctor”
– Recorded vignettes
http://mariatalks.com/
http://sexreally.com/
http://www.plannedparenthood.org/info-for-teens/index.asp
Participant Quotes
“The colors. It like grabs out at you. It looks organized. They don’t have too, too
much information right there. Like I feel like-- I don’t know which website it was
but it was just like stuff on this column, stuff on this column and stuff in the middle
It was just like too much like of, like too much going on. And then Planned
Parenthood is a well known place. So you know that the information will be good
and useful. “
“There’s a lot of words than pictures. It seems like it’s school-related and not
health related because there is nothing but the words. I don’t like it.
“It’s like very neat and organized and you know where to start. It’s like just enough
information on one page, and then you can just go to the next and click on
whatever. “
Characters
• Animated vs. human characters
• Different characters can provide different
information
“I would stay with a minority
–
–
–
–
–
Friend or peer
Mentor (camp counselor)
Older family member
Nurse
No celebrities
• Race
type of person if they’re going to
be teaching a minority group.
Like, any type of minority. I
would say anything but white.
Because I don't know, I think it
just reaches us better if it’s
someone that's just different.
Like someone that's not like
typical; typical like blonde haired,
blue eyes wouldn’t be so good to
be preaching
to us about things.”
http://mariatalks.com/
http://www.plannedparenthood.org/info-for-teens/index.asp
“It looks like Michelle
Obama. We don’t want
Michelle Obama.
Not if we're going to
relate to her for this.
Not for these purposes.”
Characters
• Gender
• Name
–
–
–
–
–
–
–
–
–
–
–
Gabrielle
Layla
Vanessa/Venessa
Angela
Maria
Jeanette
Annie
Lisa
Nicole
Natalie
Keisha
• Avoid names ending with “sha” or “qua”
“Someone I would see walking down the street”
“Layering”
• Clothing
– White lab coat
– Blue scrubs with institution’s logo
embroidered on them
– “Fitted” button-up shirt
– Shirts that show breast definition and
waist curvature
• “Shading” Animated Characters
– Different colors for skin, lips, and hair
– Light lipstick color (e.g. soft pink),
natural lip color, or shiny lip gloss
– Eyebrows should be arched, long, and
thick
– Eyeliner or eye shadow to make the
eyes “pop”
• Accessories
– Glasses
– Badge (include name, profession, and
institution)
– Stethoscope
– Wedding ring
– Earrings
•
•
•
•
•
Studs (pearl studs not recommended)
Small or medium hoop earrings
Dangle earrings
Diamond tear drop necklace
Charm necklace/Chain with pendant
“Someone I would see walking down the street”
“Layering”
• Hairstyle
– Shoulder length, layered hair
styled in loose, wavy curls (see
pictures of Gabrielle Union)
Gabrielle Union (movie actress)
– “Honey” colored highlights (see
pictures of La-La)
– Pony tail (see pictures of La-La)
La-La (MTV host)
– Short bob with “professional”
side bangs (see pictures of Rihanna)
– Dark brown hair color (see pictures of
Gabrielle Union, La-La, and Rihanna)
Rihanna (singer)
Educational Information
• Stories
–
–
–
–
–
Written in first person
Display author’s name, age, gender, and city/state of residence
Display picture
Avoid slang and negative language
Include a lot of contextual details to help the reader understand
the storyline
– Realistic vs. fairytale endings
– Basic information and celebrity comparisons indicate a young
target audience
• Factual data and statistics
– Provide pros and cons
Social Networking Features
• Reasons to visit and return to the website
– New information or features posted daily or weekly
– Monthly or bi-monthly drawings for popular items
(e.g. iPad)
– Receive money, gift cards, or “electronic bucks” after
several logins
– Opportunities to receive free health related products
or promotions
• Facebook
http://goaskalice.com/
Implications
• Findings indicate that a culturally tailored preconception care
website is perceived to be an acceptable educational tool by
young, African American women
• Findings may improve the usability and effectiveness of
existing and future internet based health education programs
targeting young, African American women
Limitations
• Educated sample
• Few participants ages 15-17
• All participants had daily access to and familiarity
using the internet
• Most participants had an assigned primary care
physician
References
1.
National Center for Health Statistics. (2010). Births: Final data for 2008, 59(1).
2.
Mathews, T.J. & MacDorman, M.F. (2008). Infant mortality statistics from the 2005 period linked birth/infant death
data set. National Vital Statistics Reports, 57(2), 1-32.
3.
Institute of Medicine [IOM]. (2003). Unequal treatment: Confronting racial and ethnic disparities in healthcare.
Washington, DC: The National Academies Press.
4.
Mechanic, D., McAlpine, D.D., & Rosenthal, M. (2001). Are patients office visits with physicians getting shorter? New
England Journal of Medicine, 344, (3), 198-204.
5.
Oliver, M.N., Goodwin, M.A., Gotler, R.S., Gregory, P.M., & Stange, K.C. (2001). Time use in clinical encounters: Are
African-American patients treated differently? Journal of the National Medical Association, 93, 380-385.
6.
Geronimus, A.T. (2001). Understanding and eliminating racial inequalities in women’s health in the United States:
The role of the weathering conceptual framework. Journal of American Medical Women’s Association, 56(4), 133-136,
149-150.
7.
Collins, J.W., David, R.J., Handler, A., Wall., S., & Andes, S. (2004). Very low birthweight in African American infants:
The role of maternal exposure to interpersonal racial discrimination. American Journal of Public Health, 94(12), 21322138.
References
8. Roter, D.L., Stewart, M., Putnam, S.M., Lipkin, M., Stiles, W., & Inui, T.S. (1997). Communication patterns of primary
care physicians. JAMA: The Journal of the American Medical Association, 277(4), 350-356.
9. Johnson, R.L., Roter, D., Powe, N.R., & Cooper, L.A. (2004). Patient race/ethnicity and quality of patient-physician
communication during medical visits. American Journal of Public Health, 94, 2084-2090.
10. Smart, D.R. (2010). Physician characteristics and distribution in the US, 2010 edition. United States: American Medical
Association.
11. Rideout, V. (2001). Generation Rx.com: How young people use the internet for health information. Menlo Park, Ca:
Kaiser Family Foundation.
12. Dickerson, S., Reinhart, A.M., Feeley, T.H., Bidani, R., Rich, E., Garg, V.K., & Hershey, C.O. (2004). Patient internet use for
health information at three urban primary care clinics. Journal of the American Medical Association, 11(6), 499-504.
13. Kind, T., Huang, Z.J., Farr, D., & Pomerantz, K.L. (2005). Internet and computer access and use for health information in
an underserved community. Ambulatory Pediatrics, 5, 117-121.
14. Atrash, H., Jack, B.W., & Johnson, K. (2008). Preconception care: A 2008 update. Current Opinion in Obstetrics and
Gynecology, 20(6), 581-589.