Preconception Health Care by Mmuo Et Al.

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Preconception Healthcare: Healthy Families for a Healthy Future

Lara Angelo, Heather Archer-Dyer, Jessica Colon, Simone Edwards, Emeka Anthony Mmuo, Karyn Monahan, Oby Nwankwo

New York Medical College School of Health Sciences and Practice Capstone, Spring 2010

CONTENTS – April 13, 2010 Moodle Submission

Executive Summary Case Study 1 (Problem-Based) Case Study 2 (Reference Case) Project Report

page 3 pages 4 – 17 pages 18 – 45 pages 46 - 147

Executive Summary According to the World Health Organization, preconception healthcare is most effectively channeled through the individual and should incorporate healthy lifestyle messages beginning in childhood. If preconception healthcare education is introduced in a community clinical care setting there is an increased chance of an improvement in birth outcomes. The aim of this project, Preconception Health Care: Healthy Families for a Healthy Future (PCH-HF2), is to provide a comprehensive year long program for three Community Health Centers in Westchester County, New York. PCH-HF2 will focus primarily on the mid-size CHC as the model. The recommended interventions will target women and their families prior to conception (preconception), early in pregnancy (prenatal) and in-between pregnancies (interconception). PCH-HF2 program recommendations focus on three key interventions: (1) improvement of the educational materials distributed at the center; (2) incorporation of free local initiatives; and (3) increased wellness education during visits across the center’s providers. The PCH-HF2 strategic approach is to proactively expand reproductive healthcare within the Community Health Centers beyond prenatal care by leveraging the current strengths and existing resources. This program has the potential to be successful in contributing positively to the goals set by Healthy People 2010 / 2020. This program can also be tailored for the patients in the other Community Health Center locations. All recommended materials will support the 5-Cs model: Comprehension, Confidence, 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 14.6% 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

W e s tc h e s te r E a r ly P r e n a ta l C a r e o v e r T im e 1995 - 2004
1 0 0 .0 % 8 0 .0 % 6 0 .0 % 4 0 .0 % 2 0 .0 % 0 .0 %
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04
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

To ta l W e s tc he s te r To ta l N YC To ta l N YS

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.e., 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 . Baillière'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.chcanys.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=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): 672681. Spano, Andrew (n.d) Community Health Assessment 2010-2013. Retrieved March 15, 2010, from http://www.westchestergov.com/health/CommunityHealthAssessment/WC_CHA_2010_20 13_.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:

Healthy Families for a Healthy Future 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

2

Healthy Families for a Healthy Future 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

3

Healthy Families for a Healthy Future 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

4

Healthy Families for a Healthy Future 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).

5

Healthy Families for a Healthy Future “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 14.6% 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

6

Healthy Families for a Healthy Future 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).

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Healthy Families for a Healthy Future Figure 1: Percentage of Women Who Acquired Early Prenatal Care Over Time 1995-2004

W e s tc h e s te r E a r ly P r e n a ta l C a r e o v e r T im e 1995 - 2004
1 0 0 .0 % 8 0 .0 % 6 0 .0 % 4 0 .0 % 2 0 .0 % 0 .0 %
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04
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 8

To ta l W e s tc he s te r To ta l N YC To ta l N YS

Healthy Families for a Healthy Future 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

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Healthy Families for a Healthy Future 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

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Healthy Families for a Healthy Future 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

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Healthy Families for a Healthy Future Appendix Location 1 2 Topic Folate supplementation Dental care Key Message Folate is a vitamin your body needs every day to be healthy Taking care of your teeth and gums is important for all women, men and children Vaccines can prevent some infections and help you to stay healthy Your health is affected by what you eat. A healthy diet helps you reach a healthy weight and helps you get all the nutrients your body needs There are many chemicals used in homes and business every day which can affect your health and your baby’s health – learn more about to keep yourself and baby healthy Daily exercise helps keep your heart and body strong CDC New York State Department of Health, bureau of Dental Health http://pregnancyshotsc a.org http://www.cdc.gov/v accines http://www.MyPyrami d.gov Source

3

Immunizations

4

Nutrition

5

Environmental Risk exposures

March of Dimes

6 7

Physical Activity Smoking Cessation

8 9

Sexually Transmitted Diseases Drug Abuse

10

Alcohol Abuse

CDC and http://www.health.gov /paguidelines Smoking can damage your The American Cancer body and the health of your Society children...don’t start smoking, The American Lung and if you need help quitting Association please talk to your doctor It’s important to practice safe http://www.cdc.gov/st sex, even if you’re in a d committed relationship Taking drugs without your http://www.adp.ca.go doctor’s recommendation/ v prescription can damage your body and the health of your children...don’t start, and if you need help quitting please talk to your doctor Alcohol can be harmful to http://www.aa.org your health. If you are pregnant, alcohol can also

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Healthy Families for a Healthy Future Appendix Location Topic Key Message 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-aways have been identified containing important concepts of wellness care and health promotion (table 3). Source

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Healthy Families for a Healthy Future Table 3: Free Recommended Educational Resources Resource Eat Smart New York Population Family & Youth Language English/ Spanish Source Cornell University
http://counties.cce.cornell.edu /wyoming/nutrition/esny/Flye r_Eat%20Smart%20NY.pdf http://www.text4baby.org/

Text4Baby Growing Up Healthy Hotline Su Famila (National Hispanic Family Health Help Hotline) Folic Acid/Multivitamin Vegetable Guide

Expectant Parents English/ Spanish Expectant English/ Parents, Parents Spanish Family English/ Spanish Expectant Parents, Teenagers Family English/ Spanish English (photos) English

NYSDOH 1-800-522-5006 1-866-783-2645 Folic Acid Council
http://www.getfolic.com/orde r/index.htm http://www.marketfresh.com. au/images/downloads/Vegeta bleGuide.pdf

Choose Smart, Choose Family Healthy (Nutrition)

CDC
http://www.fruitsandveggies morematters.org/wpcontent/uploads/UserFiles/Fil e/pdf/resources/cdc/ChooseS mart_Womens_Brochure(1).p df

Healthy Mothers, Healthy Babies Various Health Issues

Expectant Parents English/ Spanish Expectant Parents English/ Spanish Children Children Children Children English/ Spanish English English English/ Spanish

CDC
http://www2.cdc.gov/ncbddd/ faorder/orderform.htm#CDC099-5142

FDOH
http://www.doh.state.fl.us/env ironment/newsroom/brochure s/index.html http://www.sesameworkshop. org/initiatives/health/healthyh abits http://www.wohfkidsconnect. com/kids/activities/color1.ht ml http://www.dltkkids.com/nutrition/coloring.ht ml http://www.eatsmart.org/articl e.asp?id=3782

Sesame Workshop (Healthy Habits for Life) Printable Coloring Pages Growing Together Coloring Pages Coloring Pages & Matching Games

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Healthy Families for a Healthy Future 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.

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Healthy Families for a Healthy Future 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 PCHHF2 program recognizes the importance of including the entire family in adoption of

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Healthy Families for a Healthy Future healthy habits. If the entire family buys into a healthier lifestyle, it will help to reduce comorbidities 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 PCHHF2 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 must 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

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Healthy Families for a Healthy Future 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

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Healthy Families for a Healthy Future 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,

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Healthy Families for a Healthy Future 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

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Healthy Families for a Healthy Future 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 WalMart. 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 mission “to create opportunities so that people can live better.” (walmartstores.com, 2010). These three companies can also be a resource for the model CHC because of their distribution of multivitamin products. PCH-HF2 recommends that the model CHC expand the distribution of multivitamins from only women of childbearing age to include the entire family. Multivitamins with folate help to enhance nutrition, which might be lacking in the existing diet, therefore patients of all ages would benefit from taking a multivitamin (Quinn et al, 2005). Partnering with one or all of these pharmacies could enable the model CHC to expand vitamin dispensing to their patients at little to no cost.

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Healthy Families for a Healthy Future Ultimately the PCH-HF2 program will strive to expand upon the 2009 PCH Pilot Study, which can lead to better pregnancy outcomes. In addition, an intended goal of the program is to achieve maternal and child health goals set by CDC’s Healthy People 2010 / 2020. The program also strives to improve knowledge and behavior during periods of preconception as well as inter-conception. The high costs associated with adverse birth outcomes such as preterm and low birth weight babies in the United States, New York State, and Westchester county justifies the need to support cost-effective and cost-efficient preconception health interventions at the model CHC. The goal of the recommended interventions will be to target women and their families prior to conception, early in pregnancy and in-between pregnancies.

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Healthy Families for a Healthy Future 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. 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. Bower, J. A., Cefalo, R. C., & Moos, M.-K. (2006). Preconception care: a means of prevention . Baillière's Clinical Obstetrics and Gynaecology , 403-416. 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.chcanys.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. Gruber, T. (1991). Learning why by being told what: Interactive acquisitions of justifications. IEE Expert: Intelligence Systems and Their Applications 6(4). Retrieved on April 1, 2010, from: http://portal.acm.org/citation.cfm?id=629781 Healthy People 2010. (2010). Maternal health. Retrieved March 22, 2010 from http://www.healthypeople.gov/hpscripts/KeywordResult.asp? n350=350&Submit=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.

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Healthy Families for a Healthy Future 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. 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): 672681. 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. (2010). 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.

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Healthy Families for a Healthy Future 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/

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Healthy Families for a Healthy Future Appendix 1: Physician Preconception Checklist

A Physician’s Preconception Checklist for Family Planning:
Important topics for a physician to discuss with male and female patients of childbearing age (ages 14-44):
o Patient’s medical history o Patient’s sexual health history o Abstinence and alternative contraceptive methods o Benefits of continued daily use of a multivitamin with folate for the entire family o Importance of a nutritious well-balanced diet for the entire family o Importance of a healthy lifestyle including exercise o Significance of healthy dental hygiene and semiannual dental visits o Importance of vaccinations for all family members o Importance of proper hand sanitation o Benefits of quitting smoking o Benefits of avoiding drugs and alcohol

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Healthy Families for a Healthy Future Appendix 2A: Patient Preconception Checklist (English)

Planning on Starting or Expanding your Family?
Preconception Checklist for Men & Women: o Step 1: Schedule a complete physical
o Discuss all prescription medications you are taking with your physician o Discuss your medical history and immunization status with your physician o Get an HIV test

o Step 2: Take charge of your weight
o Get your weight under control with caloric goals & exercise

o Step 3: Stop Smoking
o At least 3 months prior to conception o Programs are available for help quitting. Please speak with your physician

o Step 4: Stop using drugs and alcohol o Step 5: Take a multivitamin with folate

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Healthy Families for a Healthy Future Appendix 2B: Patient Preconception Checklist (Spanish)

¿Planificación en comenzar o la extensión de su familia?
Lista de comprobación de la preconcepción para el & de los hombres y mujeres: o Paso 1: Programe una comprobación complete
o Discuta todas las medicaciones de la prescripción que usted está tomando con su medico o Discuta su estado del historial médico y de la inmunización con su medico o Consiga una prueba del VIH

o Paso 2: Carga de la toma de su peso
o Consiga su peso bajo control con el & calórico de las metas; ejercicio

o Paso 3: Pare el fumar
o Por lo menos 3 meses antes del concepto o Los programas están disponibles para el abandono de la ayuda. Hable por favor con su medico

o Paso 4: Pare el usar de las drogas y del alcohol o Paso 5: Tome un multivitamin con el float

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PROJECT REPORT

Running Head: Healthy Families for a Healthy Future

Preconception Health care: Healthy Families for a Healthy Future

Lara Angelo, Heather Archer-Dyer, Jessica Colon, Simone Edwards, Emeka Anthony Mmuo, Karyn Monahan, Oby Nwankwo

New York Medical College School of Health Sciences and Practice Capstone, Spring 2010

Executive Summary According to the World Health Organization, preconception healthcare is most effectively channeled through the individual and should incorporate healthy lifestyle messages beginning in childhood. If preconception healthcare education is introduced in a community clinical care setting there is an increased chance of an improvement in birth outcomes. The aim of this project, Preconception Health Care: Healthy Families for a Healthy Future (PCH-HF2), is to provide a comprehensive year long program for three Community Health Centers in Westchester County, New York. PCH-HF2 will focus primarily on the mid-size CHC as the model. The recommended interventions will target women and their families prior to conception (preconception), early in pregnancy (prenatal) and in-between pregnancies (interconception). PCH-HF2 program recommendations focus on three key interventions: (1) improvement of the educational materials distributed at the center; (2) incorporation of free local initiatives; and (3) increased wellness education during visits across the center’s providers. The PCH-HF2 strategic approach is to proactively expand reproductive healthcare within the Community Health Centers beyond prenatal care by leveraging the current strengths and existing resources. This program has the potential to be successful in contributing positively to the goals set by Healthy People 2010 / 2020. This program can also be tailored for the patients in the other Community Health Center locations. All recommended materials will support the 5-Cs model: Comprehension, Confidence, 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.

Healthy Families for a Healthy Future Table of Contents

Background & Introduction

1

Recommendations

15

Deliverables

29

Anticipated Results

36

Financial Analyses

41

Timeline

49

References

52

Appendices

58

Healthy Families for a Healthy Future Background and Introduction “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). The integration of preconception health education into a woman’s reproductive care plan can play a critical role in the improvement of America’s birth outcomes (Boggess and Edelstein, 2006). Preconception care is most effectively channeled through the individual and should incorporate healthy lifestyle messages beginning in childhood (WHO, 2008). In addition, healthy lifestyle messages may be more meaningful when presented with intergenerational benefits and in a supportive social environment (WHO, 2008). Other components of preconception care include incorporating the involvement of the spouse and other members of the family into the educational process. The intent is to involve the family and caregivers to support the interconception period for existing mothers (Atrash, Jack and Johnson , 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

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Healthy Families for a Healthy Future 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 (ACOG)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). Since preconception health promotes the health status of a woman before she conceives a child, there is an increased chance of preventing multiple fetal developmental defects and thus improving birth outcomes through contact with primary care providers (Lu, 2007). In most cases, fetal developmental defects result from the exposure to various risk factors such as infections and toxins during the period of organogenesis. Organogenesis is the formation of and differentiation of organs and organ systems during embryonic development (Mosby’s Medical Dictionary, 2009). The period of organogenesis extends approximately from the end of the second week throughout the eighth week of gestation (Mosby’s Medical Dictionary, 2009). During this time the embryo undergoes rapid growth and differentiation and is extremely vulnerable to environmental hazards and toxic substances (Mosby’s Medical Dictionary, 2009; D’Angelo et al, 2004). According to Moos (2004), “exposures to the embryo that could impact on organogenesis include maternal nutritional status (for instance, maternal folate levels),

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Healthy Families for a Healthy Future environmental exposures, maternal habits (such as alcohol use), underlying maternal diseases known to impact on embryogenesis (such as diabetes and phenylketonuria), and prescription and nonprescription drug exposures (such as isotretinoin, antieleptics, and megadoses of Vitamin A)”. Moos (2004) further stresses the point that “this critical window of prevention opportunity is initiated three days after the first missed menstrual period, making it virtually impossible to begin prenatal care in a timely enough fashion to avoid preventable anomalies”. Prenatal Care The provision of good health care to women during their reproductive years is vital. Women must receive not only receive good prenatal care, but also good preconception care prior to organogenesis. Thus, once pregnancy begins a healthy baby is more likely to result. Earlier provision of care, such as preconception care, will decrease the incidence of congenital anomalies (ACOG, 2006; Quinn et al 2005). If a woman and her family are educated and empowered to engage in effective family planning, enter the pregnancy in good health, and have a clear understanding of reproductive care then there is an increased chance of significantly reducing adverse birth outcomes. The engagement of the family and partner prior to pregnancy is a more proactive approach than the commonly used prenatal care approach (Sanders, 2009). 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

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Healthy Families for a Healthy Future 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 month 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 woman may still be engaging in habits damaging to the development of the fetus may still be occurring before the she realizes she is pregnant. For example, if a woman drinks alcohol while she is pregnant, the child may develop a Fetal Alcohol Spectrum Disorder (FASD). FASDs include negative adverse birth such as abnormal facial features, small head size, shorter-than-average height, low body weight, hyperactive behavior, poor memory, and learning disabilities (Streissguth et al, 2004). Adverse birth outcomes such as those caused by FASDs due to the delay in women receiving care support the need for a different approach to address the process in which a woman receives reproductive care (Korenbrot et al, 2002). Moos (2004) pointed out the reason for the change in approach to reproductive health:

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Healthy Families for a Healthy Future “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 prepregnancy period as the starting point for impacting on reproductive outcomes.” Pregnancy Outcomes & Rates 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 prenatal health care approach is thought to be a contributing factor for the lack of recent improvements in the birth outcomes in the US. An important fact to consider is the scope of all the available reproductive care and demographic statistics on a national, state, county and local/municipal level to fully understand birth outcomes in the United States. 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 14.6% 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

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Healthy Families for a Healthy Future categories. According to the U.S Census Bureau in 2000, the Hispanic population in Westchester County ranges from12.8% to 25.9% and 12.6% to 61.6% African American depending on the neighborhood. Some consistencies in the contribution to health disparities, including adverse birth outcomes, among both groups include education level, socioeconomic status, mother’s health risk behaviors and age. 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). Among White women, 73% acquired prenatal care during the first trimester, 17% in the second trimester, and 3% in the third trimester while among African Americans, 61% acquired prenatal care during the first trimester, 24% in the second trimester, and 7% in the third trimester. Hispanic women were also more likely to delay or not seek prenatal care compared to White women. Among Hispanic women 63% acquire prenatal care in the first trimester, 25% in the second trimester, and 6% in the third trimester, Jent, 2006). In Westchester County specifically, 31.8% of Hispanic women sought care in the second trimester, 5.2% sought care in the third trimester, and 0.7% sought no care (Westchester County Department of Health, 2007). In addition, infants born to women from Central America are more likely to have mothers who delayed prenatal care compared to those from other regions (Westchester County Department of Health, 2007). Statistics from the Westchester County Department of Health (2009) illustrate that 62.3% of Central

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Healthy Families for a Healthy Future 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 (D’Angelo et al, 2004). 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 goal on prenatal care and birth outcomes. While the Healthy People 2010 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

W e s tc h e s te r E a r ly P r e n a ta l C a r e o v e r T im e 1995 - 2004
1 0 0 .0 % 8 0 .0 % 6 0 .0 % 4 0 .0 % 2 0 .0 % 0 .0 %
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04
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To ta l W e s tc he s te r To ta l N YC To ta l N YS

Healthy Families for a Healthy Future

Source: New York State Department of Health, Vital Statistics Maternal age and the delay of prenatal care indicate that preconception health interventions are needed. In many cases, the younger the age of the mother, the more likely she is to delay prenatal care (Spano, 2010). The average maternal age among African-American mothers was younger than that of White mothers, 28.5 vs. 32.1 years (Spano, 2010). Among children born to African-American women in 2007, 20.9% were born to women aged 20-24; 25.8% were born to women aged 25-29; 23.6% were born to women aged 30-34; and 15.5% were born to children aged 35-39. Just under 5% percent were born to mothers aged 40 and over, and 9.3% were born to mothers younger than 20. Spano (2010) reports: “Young women were more likely to delay or not seek prenatal care. For example, among the infants born to mothers aged 10-17 years of age, 64.7% were born to mothers who did not have or delayed prenatal care. Among those born to mothers 18-19 years of age, 50.8% of mothers did not have or delayed prenatal care. In comparison, those born to mothers aged forty and over, 21.1% did not seek or delayed prenatal care.” Young maternal age not only delays a woman’s ability to seek prenatal care, but also increases the chances of a woman bearing a low birth weight baby. In a study by Gilbert et al (2004) a higher rate of adverse pregnancy and birth outcomes including major neonatal morbidities (delivery <37 weeks of gestation and birth weight <2500 grams) among the teenage pregnancies when compared to older women regardless of ethnic/racial

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Healthy Families for a Healthy Future background. In Westchester County there are more than 1,400 babies born prematurely each year of which Non-Hispanic Whites and Hispanics each represent 10.8% of these premature births. For African-Americans the rate of premature births increases to 18.2% (Lower Hudson Valley Perinatal Network, 2007). Among infants born in Westchester during 2007, 7.1% were born with a birth weight between 1,500 to 2,499 grams, and 1.3% of newborns were born with a birth weight below 1,500 grams. The proportion of infants born with low birth weight (<2,500 grams) varied by race and ethnicity. African-Americans had the highest proportion of low birth weight and very low birth weight babies,13.9% (Westchester County DOH, 2007). 6.5% of Hispanic babies born in 2007 were low birth weight or very low birth weight, the lowest percentage in comparison to those individuals of Caucasian or Black race/ethnicity, 7.9% and 13.9% respectively. The percentage of low birth weight Hispanic infants indicates a high compliance rate with prenatal care because infant birth weight is associated with maternal behavior during pregnancy (Westchester County Department of Health, 2007). These data suggest that once a Hispanic woman seeks prenatal care, she is more likely to comply with the provider’s instructions. Thus, if health education-based preconception interventions reach more Hispanic families during the first trimester, the interventions will help prevent more adverse birth outcomes such as low-birth weight babies because Hispanic women are extremely compliant with care, emphasizing the importance of at education. Educational level is also an indicator for timeliness of prenatal care being sought. As the level of the mother’s education increases, the percentage of mothers who delayed or did not seek prenatal care decreases (Westchester County Department of Health, 2007).

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Healthy Families for a Healthy Future 45.6% percent of infants born to mothers with less than a high school degree did not seek or delayed prenatal care until the second or third trimester (Westchester County DOH, 2007). In comparison, only 11.8% of infants born to women with an advanced degree beyond college did not seek or delayed prenatal care until the second or third trimester” (Spano, 2010). These statistics confirm the need for the components of the preconception health care interventions to be education-based (Westchester County Department of Health, 2007). Access & Services of Community Health Centers In order to maximize success of the preconception approach, an appropriate and effective site in which to incorporate a program is important. A Community Health Center located in Westchester County is an ideal setting because it is accessible to most of the individuals in the community, focuses on primary care and promotes buy-in among the members of the target population. Thus, the population identifies with the way in which services are offered. 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”. FQHCs may also provide specialty services such as ophthalmology, dermatology, and podiatry. Many FQHCs provide additional services such as immigration physicals, laboratory tests, pediatrics, immunizations, nutritional consultations, community outreach, and specialty referrals. FQHCs are not-for-profit organizations that are usually located in underserved areas. These organizations provide much needed health care to individuals who experience health disparities at alarming rates.

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Healthy Families for a Healthy Future The centers focus primarily on preventive medicine address the ways in which health disparities can be reduced within the community and ultimately throughout the nation. FQHCs predominantly serve minorities, who are usually covered by Medicaid, uninsured or underinsured. Many are undocumented and have low to no income. FQHCs have several programs in place that help to reduce health disparities amongst different racial/ethnic populations. Some of these programs include Family Planning, Community Health Workers (CHW), Prenatal Care Assistance Program (PCAP), Women’s Health and Pediatric Care. The Community Health Worker Program (CHW) provides support for women in the community with a focus on removing barriers to care such as language, health insurance, and access to various specialty physicians as needed. In addition, the Women, Infant, Children (WIC) Program provides food and nutritional information to women and their families. The CHW and WIC programs exemplify the broad reach of the FQHCs to improve the health status of the population served. The FQHCs are deemed to be a cost effective way of providing increased access to care. Additionally, the centers provide transportation and language translations as needed for patients, along with the tools, support and information that are vital to the health status of the community. FQHCs are patient centered. 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.” This approach guarantees that at least one of the main stakeholders within the system has a say in how the services are provided within the community.

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Healthy Families for a Healthy Future 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. 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 preventative health care services including: obstetrics/gynecology, pediatrics, internal medicine, family medicine, dental, ophthalmology, mental health and podiatry. Model Community Health Center’s Background The model Community Health Center (CHC), located in the mid-northern section of Westchester County in New York, GHC was established in 1972. When the model CHC merged with the primary location, it became the second satellite location 2005. There is a third CHC location 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. All three locations combined, provide comprehensive health care for the individuals in each community. For example, patients at the model CHC needing specialty treatment have free access and transportation to specialty treatment at the primary CHC. 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 health care services six days per week with extended hours on two days to accommodate the high patient volume. The model

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Healthy Families for a Healthy Future CHC provides the best possible care with limited economic resources. The center relies on community partnerships, employee commitment, and smart investment. The model CHC has established a partnership with the local neighborhood pharmacy, which provides pharmaceutical supplies for the health center. 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 model CHC consists of a Central American Hispanic population. The model CHC’s health care providers work long hours, but are very committed to their patients. The employees’ commitment to their patients, the central location of the center, and the one-stop delivery system of comprehensive care provide ample reasons to develop targeted preconception interventions at the model CHC. Another factor for targeting the model CHC as a venue for preconception health is the co-location of all these services being given to a targeted community under one roof. Program Definition The current NYSDOH data indicate that the maximum benefit from prenatal care may have been achieved as the rates of preterm births and low birth weight babies has reached a plateau over the last five 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 (Healthy People; March of Dimes, 2009). As a way of reaching the Healthy People 2010 prenatal care and birth outcomes goal, the central purpose of Healthy Families for a Healthy Future (PCH-HF2) is to find ways in which

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Healthy Families for a Healthy Future reproductive care is given to everyone at the most effective point in the reproductive process. If preconception health care 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. 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 health care to the preconception level. Leveraging the strengths and existing resources, this program has the potential to be successful in contributing positively to the goals set by Healthy People 2010. The recommendations provided for the model CHC can also be incorporated and tailored for the patients at the remaining CHC sites.

Recommendations Preconception Health Care: “Healthy Families for a Healthy Future” (PCH-HF2) is a follow-up program to the 2009 Preconception Health (PCH) Pilot Study developed 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 multiple 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

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Healthy Families for a Healthy Future recommended these components as central to the success of preconception health care 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 (Carter and Rahman, 2009; Quinn et al, 2005; Korenbrot et al, 2002). Maternal health early during gestation is crucial, and weeks four through ten are the most important in fetal development (CDC, 2006). 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 (Sanders, 2009; 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 (Atrash 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. PCH-HF2 seeks to expand the current prenatal and family care programs at the Westchester CHCs in order to achieve optimal health for all the participants. “Optimizing a

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Healthy Families for a Healthy Future woman’s health before and between pregnancies is an ongoing process that requires access to the full participation of all segments of the health care system” (ACOG, 2006). Prenatal care consists of a series of check-ups by a provider during pregnancy. These check-ups are coupled with information about healthy behaviors for the pregnant woman, including: not smoking, not drinking alcohol, making positive changes in her diet, taking prescribed dietary supplements and exercising. This approach can also help to achieve the Healthy People 2010 / 2020 objective that early and adequate prenatal care should be received by 90% of the women by the year 2010 / 2020. The goals should be for all women before and between pregnancies to: • • • • • Attain a healthy weight Maintain a healthy diet Take a multivitamin with folate Managed medical conditions (i.e., diabetes, oral health, obesity) Stop smoking/drug or alcohol use

The purpose of PCH-HF2 is to educate families in the areas of preconception care, interconception care, overall wellness and health promotion. PCH-HF2 aims to educate and empower women and their families about specific risk factors for improved pregnancy outcomes. An improvement in maternal and paternal health prior to conception will improve pregnancy outcomes and decrease identifiable risks (i.e., 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, brain and spine development). The PCH-HF2 will take a comprehensive approach to preconception care as suggested by the American Academy of Pediatrics and the American College of Obstetricians and

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Healthy Families for a Healthy Future Gynecologists, which includes physical assessment, risk screenings, vaccinations and counseling (AAP, 2002). This approach can improve the health of women of childbearing age in order to minimize risk factors that might affect future pregnancies. The most effective way to accomplish this goal is to incorporate the entire family in the process. If the men and women visiting CHC are modifying their behaviors and adopting healthier lifestyles, these changes will ultimately lead to more positive birth outcomes in the future. By engaging the entire family and not only women of childbearing age, the following project goals can be achieved: 1. Decrease the number of unplanned pregnancies 2. Promotion of birth spacing 3. Decrease negative pregnancy outcomes among the center’s female patients The PCH-HF2 will focus on three interventions: 1. Improvement of the educational materials distributed at the center 2. Incorporation of free local initiatives, such as nutritional classes and text4baby 3. Increase wellness visits across the center’s providers: pediatrics, internal medicine, family medicine, etc. The first intervention, the improvement of educational materials, is best achieved through leveraging the existing educational materials at the CHC, modifying the materials, and making use of patient wait time. However, several barriers have been taken into consideration in the development of educational materials for the CHC. First, the literacy level of the patients served by the CHC is at the second-to-sixth grade level (Watson, 2010). The best solution is to offer pamphlets that incorporate greater visual content than

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Healthy Families for a Healthy Future technical text and/or medical jargon. Second, language is a major barrier for the CHC community. Since the CHC community is predominantly Hispanic, many of the patients’ primary language is Spanish. To manage this challenge PCH-HF2 recommends the educational materials be available in Spanish and English. Presently, the materials being distributed at the center are 1) educationally too advanced for the population and 2) only 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. More specifically, the educational materials will define what the intervention is, the benefits of the intervention, how much of this intervention is recommended daily and alternative ways of incorporating the intervention into everyday life. For example, a pamphlet on folate will define folate, its importance, how much to take daily, and how patients can incorporate folate into their diets. The text in these pamphlets will be written at a second grade reading level so 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. The lower literacy level of the pamphlets is critical to ensure that healthful behavioral change information is communicated and understood. In addition, if the materials are easy to read and understood, than the patients will be more receptive to the recommendations and more likely to engage with their providers. Table 1 below provides a brief description of each pamphlet, and appendices 1 – 10 provide samples of each. Table 1: PCH-HF2 Proposed Educational Pamphlets by Topic

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Healthy Families for a Healthy Future Appendix Location 1 2 Topic Folate supplementation Dental care Key Message Folate is a vitamin your body needs every day to be healthy Taking care of your teeth and gums is important for all women, men and children Vaccines can prevent some infections and help you to stay healthy Your health is affected by what you eat. A healthy diet helps you reach a healthy weight and helps you get all the nutrients your body needs There are many chemicals used in homes and business every day which can affect your health and your baby’s health – learn more about to keep yourself and baby healthy Daily exercise helps keep your heart and body strong CDC New York State Department of Health, bureau of Dental Health http://pregnancyshotsc a.org http://www.cdc.gov/v accines http://www.MyPyrami d.gov Source

3

Immunizations

4

Nutrition

5

Environmental Risk exposures

March of Dimes

6 7

Physical Activity Smoking Cessation

8 9

Sexually Transmitted Diseases Drug Abuse

10

Alcohol Abuse

CDC and http://www.health.gov /paguidelines Smoking can damage your The American Cancer body and the health of your Society children...don’t start smoking, The American Lung and if you need help quitting Association please talk to your doctor It’s important to practice safe http://www.cdc.gov/st sex, even if you’re in a d committed relationship Taking drugs without your http://www.adp.ca.go doctor’s recommendation/ v prescription can damage your body and the health of your children...don’t start, and if you need help quitting please talk to your doctor Alcohol can be harmful to http://www.aa.org your health. If you are pregnant, alcohol can also

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Healthy Families for a Healthy Future Appendix Location Topic Key Message cause birth defects. Any alcohol use can affect the neurological development of the developing baby. Another major barrier that exists within the CHC that challenge the delivery of optimal care is patient wait time. Currently, a patient waits anywhere from fifteen minutes 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 facility and used up all available space. As a result, the providers can only run one examination room at a time. 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 thirtytwo 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. Consequently, a patient visit is not always fifteen minutes in duration. The providers may take up to an hour to treat one medically complex patient. Again, this creates a severe backlog for the providers. Another factor affecting patient wait time is language. Although the model CHC has a large number of bilingual staff, yet not all of the health care providers speak Spanish, which creates a challenge. This CHC has an interpreter, but the interpreter cannot reach Source

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Healthy Families for a Healthy Future 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. Although the extended wait times are cumbersome for the patients, the available time provides a unique opportunity to educate patients while they wait for their health care provider. The new and updated educational materials recommended for the center can help occupy the patients while they wait. An additional component of the educational program is to update the videos in the waiting areas. The videos, developed by Accent Health, are health promotion videos. Currently, the educational videos available at the model CHC are in English. Given the majority of the population using the centers’ services are Central Americans who speak little or no English, the plan is to provide a series of videos in Spanish. The videos will address the same topics as the pamphlets in order to make sure that consistent messages are delivered. 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. In order to prevent further burden on the model CHC’s staff, freely available alternatives have been identified to help reinforce preconception health education and messages. Eat Smart New York and text4baby are federally funded programs that will convey the necessary

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Healthy Families for a Healthy Future components of nutrition and pragmatic tips to support healthy eating recommendations. These programs will be discussed in detail in the second intervention. An alternative method of delivery is to add educational messages about preconception care to waiting line messages on the existing telephone system at the center by recording a series of scripts. The PCH-HF2 team has developed several phone scripts that will give information on aspects of healthy living followed by short fun quizzes or health trivia. These messages will provide information on important topics of preconception health care, such as folate and then ask a question such as “What is folate?” Next, the answers will be announced and the person on hold will have the option to answer. Answer: a) a vitamin, b) candy, c) a book. Correct answer: a) a vitamin. These announcements are intended to be fun and interactive to allow the patients/callers to be entertained while learning important information related to wellness care and health promotion while they wait for their provider, scheduling, and/or test results. PCH-HF2 may not be able to reduce the wait time but this approach can certainly make it more tolerable for the patients. In addition to the telephone hold messages, free give-a-ways have been identified containing important concepts of wellness care and health promotion: • Nutritional calendars from Health First Health Plans. The calendars have a different healthy and delicious recipe every month. They provide overall nutritional information that will help our patients strive to live better lives. • POW’R against Tobacco, a community partnership coalition provides promotional items such as pens, chapstick, notepads, mints and letter moisteners and provider cards with scripts that help patients to quit

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Healthy Families for a Healthy Future smoking. These materials will be a constant reminder that a smoke free environment is the best way to live. • Coloring pages, cross word puzzles, word search, and other pages for the children in Spanish and English from MYPyramid.gov and the National Dairy Council. Since the PCH-HF2 encompasses a familial approach to preconception care, children must be included. The information in these give-ways is child-friendly and caters exclusively to children’s education. In addition, the child friendly materials include sample menus for seven days, including breakfast, lunch and dinner, as well as tips for families in Spanish. Samples have been included in Appendices 11 – 20. The second intervention of PCH-HF2 incorporates free local educational initiatives, such as the free group nutritional classes provided by the Cornell University Cooperative Extension of Westchester County. Eat Smart New York is a free healthy cooking and nutritional workshops program provided by Cornell University, which can be made available to CHCs patients. This is a federally funded program that is available to agencies working with families and individuals receiving food stamps or who are participating in other governmental assistance programs in New York or individuals and families with limited or no income. Eat Smart New York offers a series of interactive classes for adults that include: • • • • Making healthy food choices Menu planning Saving money at the supermarket Understanding food labels

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Healthy Families for a Healthy Future • • • • Food safety How to be physically active Healthy recipe/food preparation Sampling recipes

The program emphasis is on fruits, vegetables, whole grains and low fat protein sources, using the MyPyramid and the 2005 Dietary Guidelines for Americans as their guide. Eat Smart New York’s standard program is a series of eight to ten interactive workshops each for a duration of one to two hours, depending on the needs of the group. The workshops can be provided during the day or evening, whenever it is more convenient for the community at large. The topics and recipes of the classes are individualized to the participant’s wants and needs. For example, classes may cover prenatal health, postpartum health and activities, managing diabetes and obesity. As the community at the model CHC is predominantly Hispanic, the Eat Smart New York team can provide a bilingual educator in an effort to offer a culturally sensitive approach for this population. A sample of the Eat Smart New York promotional material is provided in Appendix 21. Another available free program to take advantage of and use within the PCH-HF2 construct is text4baby. Text4baby is a new free mobile telephone information service providing health information to pregnant women and new moms from pregnancy through a baby’s first year. This is an educational program offered by the National Healthy Mothers, Healthy Babies Coalition. Women can sign up for this service by texting BABY to 511411 (or BEBE for Spanish) in order to receive three free SMS text messages each week timed to their due date or the baby’s first birthday. These messages focus on a variety of topics critical to maternal and child health, including:

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Healthy Families for a Healthy Future • • • • • • • Preventing birth defects Immunization Nutrition Seasonal flu Mental health Oral health Safe sleep for babies

Text4baby is made possible through a broad, public-private partnership that includes government, corporations, academic institutions, professional associations, tribal agencies and non-profit organizations. Founding partners include HMHB, Voxiva, CTIA – The Wireless Foundation and WPP. Johnson & Johnson is the founding sponsor and there are a host of other premier sponsors. CHC can either choose to become an outreach partner or just simply promote this free service in its facilities by downloading free artwork from http://text4baby.ning.com/ and displaying it throughout the center. Samples of the promotional posters for text4baby that could be used for PCH-HF2 are display in Appendices 22 and 23. This free program is just another way to reach and engage patients to promote healthy behaviors. This service is just an alternative method of educating pregnant and new mothers in order to decrease negative pregnancy outcomes such as premature births. If free text messaging can help to get the important message to the model CHC’s population then it is worth a try. If this program can encourage expectant and new moms to modify some of their unhealthy behaviors, then in the long run it will help to decrease negative birth outcomes.

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Healthy Families for a Healthy Future The third intervention is to promote wellness visits across providers within the model CHC including pediatrics, internal medicine, family medicine, etc. The PCH-HF2 strategy includes all the providers in the model CHC not just obstetrics/gynecology and family planning because it is important to achieve a standard of care for all of the centers’ patients. Patients must receive the same health care information from all providers and be routed through the same process. For example, if providers refer patients for mandatory dental, nutritional and mental health visits all patients will receive an increased standard of preventive care. The establishment of mandatory referrals will not only increase preventive care visits, but communicate a consistent message of healthful behavior change and encourage patient buy-in. Furthermore, PCH-HF2 wants to encourage the expansion of the existing prenatal care protocols to other areas within the center(s). Presently when a patient is identified as a new prenatal patient, she is automatically referred to the dentist, nutritionist, social worker and all the other required services such as PCAP at the initial visit. Expansion of this care protocol/policy to all providers and patients in CHC is important in order for preconception health care to be incorporated into everyday activities. For example, repetitive messages of visiting the dentist, healthy eating, and adequate physical activity will affect a child’s development and emphasize the importance of maintaining a healthy lifestyle and reinforce healthy habits for the future. Another example, as part of primary care visits, all women and men should receive risk assessments and health promotion counseling in order to reduce reproductive risks and improve pregnancy outcomes. PCH-HF2 aims for men and women of reproductive age to have a high reproductive awareness, meaning to understand the risks and protective factors related to childbearing.

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Healthy Families for a Healthy Future In order for this to happen, all providers must be on board and actively involved. The model CHC’s health care providers will have to make sure that immunizations are up to date; encourage healthy behaviors, and discourage destructive ones. For example, if a pediatric patient is being examined, the pediatrician should provide sex education and refer to family planning, if needed. A second example, if bad nutritional habits are identified then the provider should encourage physical activity and refer the patient to the nutritionist. 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 are already established and therefore will lead to better birth outcomes. PCH-HF2 has identified the support approach as the most effective method of preconception care management. Research shows the support approach is the best approach in changing negative behaviors. Examples include Alcoholics Anonymous, Diabetes support group, and other rehabilitative groups. The model CHC provides a good environment to implement a support approach because the population is extremely familyoriented. The second objective of the PCH-HF2 is to encourage birth spacing with appropriate inter-conception care. Appropriate birth spacing is mentally healthy for women. First-time pregnancies or multiple pregnancies can be mentally taxing for a woman and the providers at the model CHC must be aware of the patients’ mental state. For example, if a patient within the CHC has been identified as having had a previous pregnancy and/or adverse pregnancy outcome, the PCH-HF2 recommendations are to have the primary care, pediatric care and/or OB-GYN provider refer the patient for mental health counseling and services within the center. The purpose is to ensure the patient is mentally

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Healthy Families for a Healthy Future competent before beginning another pregnancy. Recent studies have shown that up to 20% of women suffer from mood or anxiety disorders during the gestation and postpartum periods (Stanford School of Medicine, 2010). Whether the symptoms develop at the onset of pregnancy or are a continuation of a previous history, women face difficult decisions about how to manage their illnesses during pregnancy (Stanford School of Medicine, 2010). It is common for women to discontinue or avoid pharmacologic treatment in order to decrease the risks of prenatal exposure to medications (Stanford School of Medicine, 2010). This is not always the safest option, however, as psychiatric illness in the mother can in some cases cause significant morbidity for the mother and child (Stanford School of Medicine, 2010). The risks reinforce the importance for the patient to be well informed about the danger involved on both sides and to take into account her specific diagnosis and the recommendations of her health care provider (Stanford School of Medicine, 2010). The emphasis on mental health is part of a broader concept to encourage overall health and wellness, not just physical health. As a means of evaluating the preconception knowledge of the patient, PCH-HF2 has identified a preconception health quiz from the women’s health.gov. and is included in Appendix 24. PCH-HF2 believes in the 5 Cs approach: Comprehension, Confidence, Compliance, Consistency and Continuity in order to provide the best care for the patients. The program will provide families with extensive education regarding health and wellness promotion that their comprehension level will far surpass their current levels (Sanders, 2009). This education will give them the confidence they need to make great decisions regarding the care of their families as well as themselves. All that is required from these patients is their

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Healthy Families for a Healthy Future compliance and consistency. This will give them the continuity of great health for the rest of their lives.

Deliverables PCH-HF2 suggests that the 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 CHC patients. These resources are designed to work in conjunction with information provided by CHC physicians and not as a replacement for physician-based health care 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 takeaways 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 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

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Healthy Families for a Healthy Future 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 concise and to the point, including resources with heavy emphasis on pictures and photographs rather than text will be a better asset for this population. Providing appropriate educational materials for the patients of 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, 2006). 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. Please refer to Appendix 25 for a listing of the free recommended educational resources. Additional items are recommended to increase the comprehension of important health concepts related to preconception care. The first is the recommendation to enhance the waiting room videos. During the first CHC site visit, 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 a video plays the video in both English and Spanish. In addition to language barrier, another

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Healthy Families for a Healthy Future reason that the videos do not elicit much attention is that the same video is played over and over again on repeat. 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 CHC have 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, CHC must 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. Please refer to Appendix 26 for scripts of the proposed telephone message recordings. 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

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Healthy Families for a Healthy Future 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 that 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 life change

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Healthy Families for a Healthy Future 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 they 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 (Sanders, 2009; Atrash et al, 2008). 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 (Boggess and Edelstein, 2006). 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. By providing educational materials on health topics to children, 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 to attention when a parent is not doing the right thing, 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 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

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Healthy Families for a Healthy Future 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. Please see Appendix 27 for recommended promotional takeaways and the costs associated with purchasing these items in bulk. Continuity Continuity will be achieved through follow-up visits with each patient’s primary care physician at the CHC. 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 check list with the items that they discussed with their physician. This check list will serve as a reminder to the patient of what was discussed during the wellness visit. Please refer to Appendices 28 and 29 for the physician and patient checklists, respectively. Funding Sources There are sources of funding that could help 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). 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). Additional information and an online grant application may be found at: http://info.cvscaremark.com/community/our-impact/charitable-trust/how-apply

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Healthy Families for a Healthy Future 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. Application information can be found at: http://www.walgreens.com/marketing/about/community/guidelines.jsp Another potential source of funding is Wal-Mart. Wal-Mart issues grants on a state-by-state basis to nonprofit organizations with programs that align with their mission “to create opportunities so that people can live better.” (walmartstores.com, 2010). Grants for accepted programs begin at $25,000. Please refer to the following site for additional information and to apply for the State Giving Program: http://walmartstores.com/CommunityGiving/8168.aspx These three companies can also be a resource for CHC because of their distribution of multivitamin products. PCH-HF2 recommends that the CHC expand the distribution of multivitamins from only women of childbearing age to include the entire family. Multivitamins help to enhance nutrition, which might be lacking in the existing diet, therefore patients of all ages would benefit from taking a multivitamin with folate (Quinn et al, 2005). Both CVS and Walgreens manufacture their own multivitamin. Wal-Mart distributes the major brand-name multivitamin products. Partnering with one or all of these pharmacies could enable the CHC to expand vitamin dispensing to their patients at little to no cost.

Anticipated Results & Comparative Data Ultimately the PCH-HF2 program will strive to expand upon the 2009 PCH Pilot Study, which can lead to better pregnancy outcomes. In addition, an intended goal of the

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Healthy Families for a Healthy Future program is to achieve maternal and child health goals set by CDC’s Healthy People 2020 (HP2010) and the Millennium Development Goals (MDGs). The program also strives to improve knowledge and behavior during periods of preconception as well as interconception. Prior to assessing the goals set forth by Healthy People 2020, one must evaluate those set and met (or not met) by Healthy People 2010. Over the last few decades, trends have shown disparities in preconception care among different ethnic groups on a national level, state-wide (New York State) level and local (Westchester) level. Despite programs put in place to address health disparities, little has changed. Early Prenatal Care Healthy People 2010 (HP2010) set a national goal of 90% for early prenatal care. The aim was to increase the amount of women who began prenatal care in their first trimester (i.e., conception or week one (1) rather than later in the pregnancy). The Centers for Disease Control and Prevention (2009) reports that the average percent of mothers in the United States who began prenatal care during the first trimester was 83.2 %, in comparison with 76.1% in New York State. According to the New York State Department of Health, in Westchester County the rate of mothers seeking prenatal care was 74.3%. This trend remained the same from 2004-2009. This shows that United States, New York State and Westchester all fall below the Healthy People 2010 target. There is clearly a need for the PCH-HF2 program. Furthermore, the data demonstrates that as of 2006, in the United States, 88.1% of Non-Hispanic White mothers began prenatal care during the first trimester of their pregnancies. Additionally in 2006, 76.1% of Non-Hispanic Black mothers and 77.3% of Hispanic mothers began prenatal care during their first trimester (CDC,

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Healthy Families for a Healthy Future 2009). On a state level (New York State), 81.6% of non-Hispanic white mothers began prenatal care during their first trimester, whereas only 60.3% of Non-Hispanic Black mothers and 61.0% of Hispanic mothers began prenatal care in their first trimester (CDC, 2009). In Westchester County, African Americans and Hispanics fall below their NonHispanic White counterparts at 63%, 61% and 79%, respectively (New York State Department of Health, 2009). Appendices 30 and 31 provide visual summaries of these data. In order to obtain a better picture of the situation at hand, it is important to consider the statistics on women who begin prenatal care in the late stages of their pregnancies and women who receive no prenatal care at all throughout their pregnancies. ‘Late stages’ is defined as beginning prenatal care in their third trimester. The New York State Department of Health (2009) reports approximately 4.9% of women began prenatal care in the late stages of their pregnancies or received no prenatal care at all. In Westchester County, this statistic was 4.5% (New York State Department of Health, 2009). Looking at the data by ethnicity, approximately 2.5% of non-Hispanic White women began prenatal care in the late stages of their pregnancies or received no prenatal care at all. In contrast, 7.8% of nonHispanic Black women and about 6.4% of Hispanic women began prenatal care in the third trimester of their pregnancy or received no prenatal care at all. Appendix 32 provides a detailed graphical data representation on late prenatal care among the three key ethnic groups in New York state and Westchester county. The lack of prenatal care or the late start of prenatal care among non-Hispanic Black women and Hispanic women in Westchester County is a troubling trend that CHCs must address. This data highlights the disparities in prenatal care based on ethnicity and

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Healthy Families for a Healthy Future clearly illustrate the need for preconception care. Encouraging preconception care can aid in reducing disparities in prenatal care and lead to better outcomes. Low Birth Weight The HP2010 goal for low birth weight is 5% (Healthy People, 2010). In the United States as of 2006, 8.3% of all births result in low birth weights. This percentage is the same in New York State (New York State Department of Health, 2009) while in Westchester County, the low birth weight percentage is at 8.2%. As the data show room for improvement as the HP2010 goal of 5% is not being met at all three levels - - nationally, statewide for New York or at the county level in Westchester. Nationally the rate of lowbirth weight births for Hispanics is at 7.0% and 14.0% for non-Hispanic Blacks (New York State Department of Health, 2009). It is important to note that in Westchester County the 2006 rate of low birth weight births among African Americans and Hispanics was well above the HP2010 goal, estimated at 14.6% and 6.1%, respectively (New York State Department of Health, 2009). This data, also illustrated in Appendix 32, undeniably outlines the need for more interventions and education to help reduce these disparities in care and health outcomes. Premature Birth The premature birth goal set by HP2010 is 7.6% (Healthy People, 2010). The Center for Disease Control (2009) reports that 12.8% of births in the United States are premature and approximately 12.4% of babies born in New York State are premature. Furthermore, in the United States, 12.2% of Hispanic births are premature and 18.5% of babies born non-Hispanic blacks are premature. In New York State, 16.6% of babies born to non-Hispanic blacks are born premature and 13.0% of babies born to Hispanics are born

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Healthy Families for a Healthy Future premature (CDC, 2009). As of 2006, data by the New York State Department of Health shows that Non-Hispanic Whites and Hispanics each have a 10.8% premature birth rate while African American rates are 18.2%, in Westchester County (New York State Department of Health, 2009). See Appendix 33 for additional data on the incidence of premature births over time in New York state and Westchester County. Infant Mortality Rates Infant Mortality Rates are another cause for concern. PCH-HF2 strives to meet MDG4a, which is to reduce by two-thirds the mortality rate among children under five (Millennium Development Goals, 2006). The Healthy People 2010 goal for U.S. infant mortality rates was 4.5 infant deaths per 1,000 live births (Healthy People, 2010). Nationally, the rate is at 6.8 infant deaths per 1,000 live births. On the state level in New York there are 6.0 infant deaths per 1,000 live births and in Westchester County, there are 4.5 infant deaths per 1,000 births. In comparison, Westchester meets that goal. When broken down by ethnicity, African-Americans fall below Hispanics and Caucasians in the United States. African-American infant mortality rates were 13.6 and Hispanics and NonHispanic Whites were at 5.6 and 5.7 respectively. The same applies on a state and county level. In New York State, the African American infant mortality rate was at 11.8 and that of Non-Hispanic Whites and Hispanics fall at 4.6 and 5.50 for correspondingly (CDC, 2009). In Westchester County, African-American infant mortality rates were 12.1 per 1000 births and both Hispanics and Non-Hispanic Whites tied were 3.1 per 1000 births in 2006 (New York State Department of Health, 2009). Appendix 34 provides a summary of the available state and county level data for infant mortality in New York and Westchester. Teen Births

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Healthy Families for a Healthy Future The HP2010 goal for teen births (Ages 13-19) was 4.6% (Healthy People, 2010). The CDC ranks teens, those aged fifteen to nineteen years. In the United States, 41.9 of every 1,000 babies were born to teens and in New York State, 25.7 of every 1,000 babies were born to teens (CDC, 2009; Gilbert et al, 2004). According to the New York State Department of Health (2009), Westchester County teen births, as of 2007, were at 4.1%. Further, the data available by ethnicity in Westchester County indicate African-American teen births were at 4.6% and Hispanics were at 8.7%, while the rate among Non-Hispanic Whites was 2.6%. Appendix 35 illustrates the trends in teen births for both New York state and Westchester county.

Financial Analysis-Cost of Low Birth/Pre Term Infants in U.S. and Westchester County Preterm and low birth weight infants are important health indicators of adverse birth outcomes. In the United States, according to 2001 hospital discharge data, about 384,200, infants were diagnosed as a preterm birth or with low birth weight, which represents about 8.4% of infants born (American Academy of Pediatrics, 2007). In 2006, 12.4% of infants, 30,946 babies, were born preterm in New York and 8.3% of infants, 20,790 babies, were born low birth weight (March of Dimes, 2009). 2007 data on preterm and low birth weight babies in Westchester County is strikingly similar (Westchester County Department of Health, 2007). In Westchester County, according to the 2007 data, 996 infants were born with a low birth weight or very low birth weight, representing 8.4% of all infants born (Westchester County Department of Health, 2007). The similarity of data at all three levels, national, state and county, illustrates a plateau effect on the

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Healthy Families for a Healthy Future incidence of low birth weight and preterm infants. Importantly, the Westchester County data is similar to the nationwide data six years earlier and does not include preterm infants, which may indicate an even higher rate of preterm and low birth weight babies born. In 2001 costs for preterm and low birth weight hospital admissions totaled $5.8 billion, representing 47% of all infant hospitalization costs and 27% of all pediatric stay costs (American Academy of Pediatrics, 2007). 66% percent of all preterm and low birth weight infant hospitalizations were low birth weight and 17% were very low birth weight (American Academy of Pediatrics, 2007). Low birth weight hospital discharges in 2001 accounted for 90% of the total costs associated with low birth weight and preterm hospital admissions for an estimated $5.2 billion (American Academy of Pediatrics, 2007). The health care system is spending a significant amount of money on treatment for low birth weight and preterm infants. A higher rate of preterm and low birth weight babies drives up the cost of medical care for the infants because medical costs for a premature baby are much greater than they are for a healthy newborn (March of Dimes, 2009). Over 85% of the medical costs are delivered in early infancy (March of Dimes, 2009). In 2005, preterm births cost the United States at least $26.2 billion, or $51,600 per infant born (March of Dimes, 2009). This annual cost estimate accounts for direct and indirect costs. Figures 2 through 5 provide a summary of the scope of the financial impact on the health care system. More specifically the $26.2 billion dollars was spent on (March of Dimes, 2009): • • • Medical care = $16.9 billion representing 65 % of total annual expenditures Maternal delivery = $1.9 billion, 7 % of total annual expenditures Early intervention services = $611 million, 2% of total annual expenditures

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Healthy Families for a Healthy Future • • Special education services = $1.1.billion, 4% of total annual expenditures Lost household and labor market productivity = $5.7 billion, 22 % of total annual expenditures Figure 2: Distribution of Costs

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Healthy Families for a Healthy Future Figure 3: New York State Received Grade “D” with a Preterm Birth Rate of 12.3% (March of Dimes, 2010)

Figure 4: Frequency of Low Weight Births by State (National Conference of State Legislatures, 2010)

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Healthy Families for a Healthy Future

Figure 5: Economic Burden >$26B for Pre-term Births in 2005 (National Conference of State Legislatures, 2010)

As the data above indicates, over 70% of the money went towards hospital services, medical care, maternal delivery, and intervention services. The cost of low birth weight and preterm infants to U.S. hospitals is extremely high because of the intensive services used and the length of stay. Since preterm and low birth weight infants have a longer length of stay in hospital than other infants, the associated average length of stay cost is also higher. Preterm and low birth weight infants had an average cost of $51,600 per infant born with an average 44

Healthy Families for a Healthy Future length of stay of 12.9 days (American Academy of Pediatrics, 2007). In addition, hospitalization costs for extremely preterm babies born at less than 28 weeks, and very low birth weight infants in the United States represented 8% of preterm and low birth weight infants and had an average cost of $65,600 and an average length of stay of 42.2 days in 2001 (American Academy of Pediatrics, 2007). In comparison, in 2001 healthy infant stays averaged $600 with an average length of stay of 1.9 days and other infants averaged $2300 with an average length of stay of 3 days (American Academy of Pediatrics, 2007). Financial Analysis-Cost of Implementing a Preconception Health Program in the Model CHC The high costs associated with adverse birth outcomes such as preterm and low birth weight babies in the United States, New York state, and Westchester County justify the need to support cost-effective and cost-efficient preconception health interventions at the model CHC. The goal of the recommended interventions will be to target women and their families prior to conception, early in pregnancy and in-between pregnancies. The three key components of the interventions will focus on improving nutrition education, health education materials, and provider visits and referrals. The first component emphasizes a healthy lifestyle through nutrition awareness and education. The recommendation is to include the Cornell Cooperative Extension Westchester County’s Eat Smart New York program (Cornell Cooperative Extension, 2010) into the model CHC services. The Eat Smart New York curriculum can be offered at no cost to the model CHC as this program is federally funded and the CHC has a conference room available (Cornell Cooperative Extension, 2010). However, minor costs will be incurred for providing fresh fruit and water during each class/workshop session.

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Healthy Families for a Healthy Future For example, providing 30 adults each with one apple and one bottle of water is estimated $25.90 per class/workshop, the program would include at least eight but up to ten classes/workshops for a total cost ranging from $207.20 to $259.00 (A&P, 2010). In addition, the adults will bring children, who will need a babysitter. A babysitter is necessary because the Eat Smart New York Program will get a higher attendance if adults can bring their children. A volunteer, from CHC staff or New York Medical College’s (NYMC) DrPH, Practicum, Capstone student, could “in-kind” time to watch the children for the one to two hours of each class/workshop. The second component focuses on health education aspects of preconception care. As mentioned above, the health education component will incorporate free pamphlets, brochures, and coloring books and worksheets on the importance of maintaining a healthy lifestyle, nutrition, and contraception as well as a looped video in the waiting room. In addition, a telephone message in English and Spanish will be recorded for the person(s) waiting on hold. The telephone message will incur minor labor cost due to the need for employees to record the messages, but will not incur supply costs because the messages will be provided for the center. The brochures and pamphlets will be provided at minimal cost; the only costs incurred are for the manual labor, printing and production for the worksheets and pencil costs for the waiting rooms. Wood pencils cost $15.44 for a set of 96 (Costco, 2010). In addition, the children’s coloring books described above in recommendations can be obtained for a minimal cost, of $0.36 cents per book (Healthy Promotions Now, 2010). The third component encourages more provider visits via referrals. The Healthy Families New York (HFNY) program has a location in Westchester and could be a good

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Healthy Families for a Healthy Future partner for the model CHC. Internists, pediatricians, and ob/gyns can refer patients to the Healthy Families New York program at no cost to the model CHC. Since the CHC only has one Community Health Worker, the HFNY program is a good alternative for providers to make referrals in case the CHW is overburdened. HFNY has shown that home visits help decrease low birth weight and preterm babies and costs (Healthy Families New York, 2009). For example, HFNY, based on the Healthy Families America home visiting model, offers home based services to at-risk expectant and new parents in order to improve birth outcomes, promote the child’s healthy development, reduce child abuse and neglect, enhance positive parent-child interaction, and increase self-sufficiency (Healthy Families New York, 2009). A randomized controlled trial of HFNY in three sites showed that mothers who were offered the program before their 31st week of pregnancy were about half as likely to deliver a low birth weight baby as mothers not in the HFNY (Healthy Families New York, 2009). According to the available data, in 2007 Medicaid covered the delivery of 107,418 babies in New York State, including 9800 low birth weight deliveries for a total cost of $241,429,3722 (Healthy Families New York, 2009). If these pregnant women had initiated services with HFNY prior to the 31st week of pregnancy, the program would have had the opportunity to avert an additional 4,300 low birth weight deliveries and save Medicaid $96.8 million (Healthy Families New York, 2009). A no-cost referral partnership with HFNY provides the opportunity to save the model CHC on-site provider, administration, and hospital-affiliated costs in the future.

PCH-HF2 Timeline

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Healthy Families for a Healthy Future The involvement of faculty and students from NYMC is critical to the successful implementation of the interventions discussed throughout this report. A significant commitment on behalf of the NYMC community can help ensure the implementation, sustainability, and measurement of interventions at the model CHC. Capstone, practicum, and/or Doctor of Public Health (DPH) students from the School of Health Sciences and Practice will need to provide “in-kind” their time and carry out the preconception health interventions at the CHCs during alternating school semesters through the years of 2010 and 2011. The implementation of interventions would take place over one year, beginning June 1, 2010 and ending on June 1, 2011. The 2010 Capstone group would complete the needs assessment and framework for the preconception health interventions. Thus, the foundation will be laid for future students to implement the interventions. Figures 6 and 7 provide a summary of the timeline as well as roles and responsibilities associated with implementing PCH-HF2. To successfully implement the PCH-HF2 program a central point of contact is going to be required. Therefore the recommendation is to recruit a series of un-paid interns from the area colleges and graduate schools who will be able to manage the daily activities for the program while not adding to the financial burden/cost of the program to the model CHC. The intern program coordinators would be assigned for a minimum of three months and a maximum of nine months. The interns should be able to support the program activities including grant writing to access the funding sources mentioned above; scheduling and coordination of NYMC’s graduate students to support the implementation by semester, and oversee/manage the production and distribution of educational materials recommended by the PCH-HF2.

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Healthy Families for a Healthy Future The capstone, practicum, and/or DrPH students, depending on the semester, will implement the interventions. First, during summer 2010, practicum students will administer a pre-test survey, created by the 2009 Capstone group, to assess patient and provider awareness about preconception health before the interventions are implemented. The pre-test will establish a baseline of comparison for a future post-test administration. The students can analyze the pre-test data utilizing the statistical package, STATA, available on NYMC’s campus. The students will write a report and present findings to the faculty of NYMC as well as the administrators of the model CHC. In addition, the practicum students should make sure all aspects of the recommended interventions are in place to ensure that the process will be smooth when the fall DrPH students implement the interventions. More specifically, the summer practicum students should further establish relationships with partners through email and site visits and retrieve any educational materials necessary to implement the interventions. In addition, practicum students should complete outside research and provide additional educational materials emphasizing healthful behavior change, decreasing barriers, and increasing access to early preconception care. The materials should be fully prepared to hand over to fall 2010 DrPH students. During fall 2010, DrPH students will implement the interventions suggested by the spring 2010 capstone students and any additional materials added by the summer 2010 practicum students. Thus, the DrPH student will implement the family nutrition and literacy classes, distribute educational materials to the populations served by the CHC. In addition, DrPH students could provide in-kind support by volunteering to babysit during

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Healthy Families for a Healthy Future the nutrition classes, complete additional research and add beneficial changes to the interventions if necessary once implementation takes place. Once interventions are implemented, unintended programmatic issues may arise. If so, the students need to troubleshoot issues in a timely manner. The early implementation of interventions allows adequate time for the interventions to be put in place and for trouble shooting. In addition, the early implementation of interventions allows them to be in place for at least six months before a post-test is administered to assess the effect of the interventions on behaviors and attitudes of the patients and staff. During spring 2011, capstone students can administer a post-test survey. The students would then analyze the post-test data utilizing the statistical package, STATA, available at NYMC. Upon analysis of the post-test data, the students should be able to determine the effectiveness of the PCH-HF2 interventions and provide suggestions for improvement and/or expansion. The spring 2011 students would be expected to compile the data and results into a single report and present the findings to NYMC faculty and CHCs administrators. Although the spring 2011 capstone group will conclude the one year timeline for implementing interventions to decrease adverse birth outcomes at the CHCs, the group will lay a basic foundation for another project, such as health literacy, that can be implemented the following year to further aid the communities served by the CHCs. In addition, creating the framework for another project, such as health literacy, will strengthen the relationship between NYMC and the CHCs. A strong relationship will ensure the sustainability of the interventions and improve the health of the populations served. Figure 6

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Healthy Families for a Healthy Future

Figure 7

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Healthy Families for a Healthy Future References Agency for Toxic Substances and Disease Registry. Lead: CAS #7439-92-1, September 2005. American Academy of Pediatrics Committee on Environmental Health. Pesticides. In: Etzel, R.A., ed., Pediatric Environmental Health, 2nd edition. Elk Grove Village, IL, American Academy of Pediatrics, 2003, pages 323-359. 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. 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. Bower, J. A., Cefalo, R. C., & Moos, M.-K. (2006). Preconception care: a means of prevention . Baillière's Clinical Obstetrics and Gynaecology , 403-416. Brawarsky et. al. “Pre-pregnancy and pregnancy related factors and the risk of excessive or inadequate gestational weight gain.” International Journal of Gynecology and Obstetrics (2005) Vol. 91, p. 126. 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 (CDC). Natural Disasters and Special Populations: Effects on Pregnant Women�Environmental Exposures. July 5, 2007. Center for Disease Control. (n.d). Recommendations for to Improve Preconception Health and Health Care. Retrieved March 10, 2010 from http://stlouis.missouri.org/citygov/health/pdf/website-CDC-preconception%20care %20recommendation%20summary.pdf 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 Choi, H., et al. International Studies of Prenatal Exposure to Polycyclic Aromatic Hydrocarbons and Fetal Growth. Environmental Health Perspectives, volume 114, number 11, November 2006, pages 1744-1750. Cohen, D., Crabtree, B., Tallia, A., & Young, D. (2005). Implementing Health Behavior Change in Primary Care: Lessons From Prescription for Health. Annals of Family Medicine , s12–s19.

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Healthy Families for a Healthy Future Correa, Adolfo, et al. Ethylene Glycol Ethers and Risks of Spontaneous Abortion and Subfertility. American Journal of Epidemiology, volume 143, number 7, 1996, pages 707-717. 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. Greenburgh Health Center Website (2010). Retrieved on March 15, 2010, from http://greenburghhealthcenter.com Gruber, T. (1991). Learning why by being told what: Interactive acquisitions of justifications. IEE Expert: Intelligence Systems and Their Applications 6(4). Retrieved on April 1, 2010, from: http://portal.acm.org/citation.cfm?id=629781 Healthy People 2010. (2010). Maternal health. Retrieved March 22, 2010 from http://www.healthypeople.gov/hpscripts/KeywordResult.asp? n350=350&Submit=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. Khattak, S., et al. Pregnancy Outcome Following Gestational Exposure to Organic Solvents: A Prospective Controlled Study. Journal of the American Medical Association, volume 281, number 12, March 24/31, 1999, pages 1106-1109. Korenbrot, C.C., Steinberg, A., Bender, C., Newberry, S. (2002). Preconception care: a systematic review. Matern Child Health J. 6 (2):75-88. Lawson, C.C., et al. Workgroup Report: Implementing a National Occupational Reproductive Agenda: Decade One and Beyond. Environmental Health Perspectives, volume 114, number 3, March 2006, pages 435-441. Lindhohm, M.L., et al. Occupational Exposure in Dentistry and Miscarriage. Occupational and Environmental Medicine, volume 64, number 2, February 2007.

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Healthy Families for a Healthy Future Lu Michael. (2007) Recommendations for Preconception Care. American Family Physician. 1 aug: 76(3): 397-400. Accessed 5 March 2010 from http://www.aafp.org/afp/2007/0801/p397.html March of Dimes. (2010). 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

Morgan, M.A., Hawks, D., Zinberg, S., Schulkin, J. (2006). What obstetriciangynecologists think of preconception care? Matern Child Health J. 10 (5 Suppl):S59-65. 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. National Conference of State Legislatures. (2008, February). The Cost of Low Birthweight Babies. Retrieved April 7, 2010, from National Conference of State Legislatures: http://www.ncsl.org/IssuesResearch/Health/LowBirthweightBabies/tabid/14387/De fault.aspx New York State Department of Health, Bureau of Dental Health, “The Impact of Oral Disease in NewYork State,” 2006. New York State Department of Health, Vital Statistics. (2009). New York State Community Health Data Set. Retrieved March 22, 2010, from http://www.health.state.ny.us/statistics/chac/chds.htm New York State Title V Application FFY 2007, p. 51.

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Healthy Families for a Healthy Future Parker, J.D., et al. Air Pollution and Birth Weight Among Term Infants in California. Pediatrics, volume 115, number 1, January 2005, pages 121-128. http://www.babyzone.com/pregnancyis-it-safe/article/illegal-recreations-drugs. Retrieved March 15, 2010 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): 672681. Sanders, L.B. (2009). Reproductive life plans: initiating the dialogue with women.MCN Am J Matern Child Nurs. 34(6):342-7; 348-349. Savitz, D.A., et al. Drinking Water Disinfection By-Products and Pregnancy Outcome. AWWA Research Foundation/Environmental Protection Agency Report, 2005. Spano, Andrew (n.d) Community Health Assessment 2010-2013. Retrieved March 15, 2010, from http://www.westchestergov.com/health/CommunityHealthAssessment/WC_CHA_2 010_2013_.pdf Stanford School of Medicine. (2010). Pregnancy and Mental Health. Retrieved April 4, 2010, from Stanford School of Medicine: Center for Neuroscience in Women's Health. Accessed from http://womensneuroscience.stanford.edu/wellness_clinic/Pregnancy.html Streissguth, A.P., Bookstein, F.L., Barr, H.M., Sampson, P.D., O’Malley, K., & Young, J.K. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Developmental and Behavioral Pediatrics, 5(4), 228-238. 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. University of Maryland. (2009) Fetal development: overview. Accessed March 3, 2010 from http://www.umm.edu/ency/article/002398.htm U.S. Census Bureau. (2009). Preconception Health Care. Washington, DC. Accessed March 15, 2010 from http://quickfacts.census.gov/qfd/states/36000.html U.S. Department of Health and Human Services and U.S. Environmental Protection Agency. What You Need to Know About Mercury in Fish and Shellfish. March 2004. U.S. Environmental Protection Agency. Lead in Paint, Dust, and Soil. February 20, 2007. Waller, K., et al. Trihalomethanes in Drinking Water and Spontaneous Abortion. Epidemiology 1998, volume 9, pages 134-140.

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Healthy Families for a Healthy Future Watson, J. (2010, March 18). The Greenburgh Health Center. (L. Angelo, Interviewer) 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/ http://counties.cce.cornell.edu/westchester/cce-west-esny.htm http://shop.mywebgrocer.com/shop.aspx?&sid=37553174&sid_guid=3aed2d48-af3c-4cd5bb74-92fd68ab2e19&strid=36333823&catL0=570&catL1=-1&catL2=-1&catL3=1&HasProducts=0&ns=1 http://www.healthpromotionsnow.com/products/A_Trip_to_the_Doctors_Office_Coloring_ and_Activity_Book_66786.aspx?GUID=1121343b-e96f-498b-99e0-c761d3ced1b8 http://pediatrics.aappublications.org/cgi/reprint/120/1/e1 http://www.ocfs.state.ny.us/main/reports/HFNY%20Program%20Cost%20Synopsis %2012-14-09%20.pdf http://www.marchofdimes.com/peristats/pdflib/999/pds_36_3.pdf http://www.marchofdimes.com/index_about_10734.asp

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Healthy Families for a Healthy Future Appendix 1 The Folate Supplementation Pamphlet: Folate is a vitamin your body needs every day to be healthy. It can reduce your risk of some diseases. You need folate for the growth and repair of every cell in your body. If you get pregnant, it can help to prevent birth defects of the brain and the spine in the baby. But it will only help if you start to take it months before you get pregnant. The Centers for Disease Control and Prevention (CDC) reports that women who take the recommended daily dose of folic acid (400 micrograms) starting at least one month before they conceive and during the first trimester of pregnancy reduce their baby's risk of brain and spine defects by 50% to 70% (a lot). Folate is not only good for women, but for men and children as well. Children who do not get enough folate can develop anemia (low red blood cell counts), diarrhea, weight loss, weakness, irritability, may not grow properly and have a slower than normal growth rate. Please encourage your children to eat foods rich with folate such as green leafy vegetables, fruits, peanuts, sunflower seeds, eggs and dried beans. If they do not like these foods try to get breakfast cereals that have folate in them such as Cheerios, Rice Krispies, Honey Nut Cheerios, Total, Wheaties, etc. The recommended daily dose is different for every age group, so try to give your child a multivitamin with folate in it so they will have what they need. Remember: Folate is good for you now, and it can help prevent birth defects if you get pregnant later.

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Healthy Families for a Healthy Future Appendix 2 The Dental Care Pamphlet: Taking care of your teeth and gums is important for all women, men and children. Problems with your teeth and gums can affect the health of your entire body. Even though it is often separated from general health overall health of the body), important links between oral (teeth and gums) health and general health have been discovered recently. For example, periodontal (gum) disease has been linked (connected) with an increased risk of heart disease. If you get pregnant, these problems can affect the health of your baby. Gum disease has also been linked with the increased likelihood of premature delivery and low birth-weight in infants. Given the relationship between oral health and perinatal health, care seeking among pregnant women is essential. According to New York State Department of Health, Bureau of Dental Health, gum disease has been associated with diabetics’ difficulty controlling blood sugar. In order to keep your mouth healthy, men, women and children should visit a dentist or a dental clinic at least once a year; brush your teeth at least two times a day, especially before going to bed; floss your teeth everyday; and do not smoke or use tobacco products.

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Healthy Families for a Healthy Future Appendix 3 The Immunizations (Vaccines) Pamphlet: Vaccines are shots that can prevent some infections. They can help you to stay healthy. Getting all your shots is also important in case you get pregnant. If you get pregnant, infections can be dangerous for you and the baby. They can cause birth defects or illnesses in the baby. Some vaccines need to be given before you get pregnant. Ask your doctor about getting shots to prevent these diseases now, so you are prepared in case you get pregnant. • Measles, mumps and rubella (MMR) • Tetanus, diphtheria and whooping cough (Tdap) • Chickenpox • Hepatitis B • Flu (influenza) Also talk to your doctor about the Human papillomavirus (HPV) and polio vaccines. For more information about vaccines, go to http://pregnancyshotsca.org or http://www.cdc.gov/vaccines

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Healthy Families for a Healthy Future Appendix 4 The Nutrition Pamphlet: Your health is affected by what you eat. A healthy diet helps you reach a healthy weight and helps you get all the nutrients your body needs. A healthy diet is very important in case you want to get pregnant in the future. It will help you to have a healthier pregnancy and better birth outcomes. In order to start eating better try doing some of these suggestions listed below: • Eat different kinds of vegetables. Fill your half of your plate with different vegetables. • Eat a lot of fruits. Choose whole, canned or frozen fruits instead fruit juices. • Choose calcium-rich foods. Low-fat or fat-free milk, low-fat yogurt and/or low-fat cheese. • Eat whole grains. Choose whole-grain cereals, breads, crackers, rice, or pasta. Make sure that grains such as wheat, rice, oats, or corn are listed as “whole” at the beginning of the ingredients. • Choose lean protein. Choose lean meats and poultry. Also eat more fish (without mercury), beans, peas, nuts, and seeds. • Limit fats. Read the Nutrition Facts labels on foods. Choose foods with less than 30 percent of the calories from fat. Limit sweet rolls, cookies, cakes and pies. • Limit sugars. Drink plenty of water instead of sweetened drinks. Fruit drinks and regular soft drinks are high in sugar and can leave you with a sugar crash. • Limit fast food. If you do have fast foods sometimes, choose foods that are grilled instead of fried. Have a salad, soup or fruit instead of fries. Order small entrée portions. For example, instead of a large sub, try a small sub with a side salad or fruit. According to the Institute of Medicine, “inadequate weight gain is associated with pre-term birth and low birth weight, while excessive weight gain is associated with large infants, cesarean delivery and maternal weight retention after delivery.” (Brawarsky et al, 2005) “The study found that women with high pre-pregnancy body mass index (BMI) were most likely to experience excessive weight gain, and women with low BMI were more likely to experience inadequate weight gain.”( Brawarsky et al, 2005) This is why it is very important that we focus on changing bad nutritional habits. Learn more at http://mypyramid.gov.

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Healthy Families for a Healthy Future Appendix 5 The Environmental Risk Exposure Pamphlet: There are more than 84,000 chemicals used in homes and businesses in this country, with little information on the effects of most of them during pregnancy (Lawson, et al, 2006). However, a small number of chemicals are known to be harmful to an unborn baby. Most of these are found in the workplace, but certain environmental pollutants found in air and water, as well as chemicals used at home, also may pose a risk during pregnancy. A pregnant woman can inhale these chemicals, ingest them in food or drink, or, in some cases, absorb them through the skin. For most hazardous substances, a pregnant woman would have to be exposed to a large amount for a long time in order for them to harm her baby. What are the risks of lead exposure during pregnancy? Lead poses health risks for everyone, but young children and unborn babies are at greatest risk. Exposure to high levels of lead during pregnancy contributes to miscarriage, preterm delivery, low birth weight and developmental delays in the infant (Agency for Toxic Substances and Disease Registry). Lead is harmful even after birth. Children exposed to high levels of lead may develop behavioral and learning problems, slowed growth and hearing loss (U.S. Environmental Protection Agency). A pregnant woman also can be exposed to significant amounts of lead in her drinking water if her home has lead pipes, lead solder on copper pipes, or brass faucets, contact the local health department or water supplier to find out how to get pipes tested for lead. The EPA recommends running water for 15 to 30 seconds before using it for drinking or cooking to help reduce lead levels (U.S. Environmental Protection Agency). Water from the cold water pipe, which contains less lead than hot water, should be used for cooking and drinking during pregnancy, and for preparing baby formula. Other possible sources of lead in the home include: • • • • • • • Lead crystal glassware and some ceramic dishes. Pregnant women and children should avoid frequent use of these items. Commercial ceramics are generally safer than those made by craftspeople. Some arts and crafts materials (for example, oil paints, ceramic glazes, stained glass materials). A woman should use lead-free alternatives (such as acrylic or watercolor paints) during pregnancy and breastfeeding. Certain folk remedies for upset stomach, including those containing greta and azarcon. Vinyl mini-blinds imported from other countries. Lead solder in cans of food imported from other countries. Old painted toys. Cosmetics containing surma or kohl.

Does mercury exposure pose a risk in pregnancy? Mercury is a metal that is present in the environment. Elemental (pure) mercury and 61

Healthy Families for a Healthy Future methylmercury are two forms of mercury that may pose risks in pregnancy. Elemental mercury is used in thermometers, dental fillings and some batteries. One recent study found a slightly increased risk of miscarriage in women working with amalgam in dental offices (Lindhohm et al, 2007). Amalgam is a silver-colored material used to fill cavities in teeth, containing elemental mercury, silver and other metals. Trace amounts of mercury are present in many types of fish, but mercury is most concentrated in large fish that eat other fish. For this reason, the U.S. Food and Drug Administration (FDA) and the EPA advise pregnant women to avoid eating swordfish, shark, king mackerel, tilefish and to limit consumption of albacore (white) tuna to 6 ounces or less a week (EPA, 2004). These fish may contain enough mercury to harm an unborn baby's developing nervous system, sometimes leading to learning disabilities. What other metals pose a risk in pregnancy? Arsenic is another metal suspected of posing pregnancy risks. Although arsenic is a well-known poison, the small amounts normally found in the environment are unlikely to harm a fetus. However, certain women may be exposed to higher levels of arsenic that may pose an increased risk of pregnancy complications, including miscarriage and birth defects. Can pesticides harm an unborn baby? Some studies suggest that high levels of exposure to pesticides may contribute to miscarriage, preterm delivery and birth defects (AAP, 2003). Therefore, pregnant women should avoid pesticides whenever possible. Pregnant women may be concerned about the safety of insect repellants during pregnancy. The insect repellant DEET (diethyltoluamide) is among the most effective at keeping insects, such as mosquitoes and ticks, from biting. Preventing insect bites is important during pregnancy because mosquito- and tick-borne infections, such as West Nile virus and Lyme disease, may be harmful in pregnancy. Because the safety of DEET during pregnancy has not been fully assessed, a pregnant woman should apply insect repellents with DEET mainly to her clothing and only in small amounts to exposed skin, when necessary (CDC, 2007). She can minimize her need for DEET by staying indoors during dawn and dusk, when mosquitoes are most likely to bite, and by wearing long pants and long sleeves. What are organic solvents? Solvents are chemicals that dissolve other substances. Organic solvents include alcohols, degreasers, paint thinners and varnish removers. Lacquers, silk-screening inks and paints also contain these chemicals. A 1999 Canadian study found that women who were exposed to solvents on the job during their first trimester of pregnancy were 13 times more likely than unexposed women to have a baby with a major birth defect, like spina bifida (open spine), clubfoot, heart defects and deafness (Khattak et al, 1999). Other studies have found that women workers in semiconductor plants exposed to high levels of solvents called glycol ethers were almost 3 times more likely to miscarry than unexposed women (Correa et al, 1996). Glycol ethers also are used in jobs that involve photography, dyes and silk-screen

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Healthy Families for a Healthy Future printing. Pregnant women, who work with solvents, including women who do arts and crafts at home, should minimize their exposure by making sure their workplace is well ventilated and by wearing appropriate protective clothing, including gloves and a face mask. They should never eat or drink in their work area. Is drinking chlorinated tap water safe during pregnancy? In recent years, media reports have raised concerns about possible pregnancy risks from by-products of chlorinated drinking water. When chlorine combines with other materials in water, it forms chemical by-products, including trihalomethanes (THMs). The level of THMs and other chlorification by-products in water supplies varies. A 1998 California study suggested that women who consumed more than five glasses a day of cold tap water containing high levels of trihalomethanes had an increased risk of miscarriage (Waller et al, 1998). However, a more recent North Carolina study found little or no increased risk from these chemicals (Savitz et al, 2005). Scientists continue to study the safety of these chemicals during pregnancy. Until we know more, pregnant women who are concerned about chlorination byproducts may choose to drink bottled water. Can air pollution harm the fetus? Most women who live in areas with higher-than-average levels of air pollution have healthy babies. However, studies from the United States and other countries suggest that babies of pregnant women exposed to high levels of certain air pollutants (such as polycyclic aromatic hydrocarbons and small particle pollution, both of which result from vehicle exhaust and industrial sources) may be slightly more likely than babies of pregnant women living in less polluted areas to be small for their gestational age (Parker et al, 2005 and Choi et al, 2006). Some pregnant women, including those living in large cities, are still exposed to unhealthful levels of pollution. Individuals can help limit their exposure to pollution by limiting outdoor activities, especially exercise, on days when air quality is expected to be poor. Do household cleaning products pose a risk in pregnancy? Although some household cleansers contain solvents, there are many safe alternatives. Pregnant women should read labels carefully and avoid products (such as some oven cleaners) with labels stating that they are toxic. Products that contain ammonia or chlorine are unlikely to harm an unborn baby, although their odors may trigger nausea in a pregnant woman. A pregnant woman who is worried about household cleansers or bothered by their odors can substitute safe, natural products. For example, baking soda can be used as a powdered cleanser to scrub greasy areas, pots and pans, sinks, tubs and ovens. A solution of vinegar and water can effectively clean many surfaces, such as countertops. For more information on environmental exposures and pregnancy visit http://www.marchofdimes.com/professionals/14332_9146.asp Appendix 6 The Physical Activity Pamphlet:

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Healthy Families for a Healthy Future Daily exercise helps keep your heart strong and helps you feel your best. Daily exercise also helps you reach a healthy weight. Also, if you get pregnant, staying active now can help you have a healthy pregnancy in the future. Adults need at least 30 minutes of aerobic activity every day. Aerobic activity gets you breathing harder and your heart beating faster. You should be able to talk, but not sing the words to your favorite song. 30 minutes every day may sound like a lot of time. But, you do not have to do it all at once. Just be active for at least 10 minutes at a time. You can go for a 10-minute brisk walk 3 times a day. Or, you can go for a 30-minute brisk walk once a day. Some examples include walking fast or jogging, playing tennis, riding a bike, pushing a lawn mower and doing water aerobics. Adults also need strength activities on 2 or more days a week. Strength activities work all the muscle groups of your body. This means your legs, hips, back, chest, stomach, shoulders and arms. Some examples are pushups, sit ups or leg lifts; using resistance bands; yoga, heavy gardening, lifting weights: you can use cans of food as weights too. For more information and helpful videos about physical activity, go to http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html

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Healthy Families for a Healthy Future Appendix 7 The Smoking Pamphlet: Smoking can cause many serious health problems in women. Some examples of these are heart disease, lung cancer and stroke. For women who could get pregnant, it is even more important to know about the dangers of smoking. According to the New York State Title V Application FFY 2007, “Smoking during pregnancy can cause still birth (baby will be born dead), low birth weight (small baby), Sudden Infant Death Syndrome (SIDS) (the baby will die shortly after birth) and other serious complications.” No amount of smoking is safe during pregnancy. Each puff of smoke has many harmful chemicals. If you are pregnant, the baby gets these chemicals too. Smoking can hurt the baby before you know you are pregnant. If you want to get pregnant, smoking may make it harder. You will improve your health if you quit smoking. Quitting is not easy. Most people try several times before they can quit. Talk to your doctor about making a plan to stop smoking. You can also call The American Cancer Society (800) 227-2345 (Spanish Service Available) or The American lung Association, (800) 586-4872 (Spanish Service Available).

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Healthy Families for a Healthy Future Appendix 8 The Sexually Transmitted Diseases Pamphlet: Sexually transmitted diseases, or STDs, are infections you can get by having sex with someone who is infected. STDs are very common. Usually you cannot tell if your partner is infected. STDs can cause serious health problems. Some can cause cancer or death. If you get pregnant, STDs can cause birth defects or illnesses in the baby. Some STDs can leave you unable to have children. They also increase your risk of tubal pregnancy. Types of STDs: • HIV/AIDS – HIV is the virus that causes AIDS. HIV can be deadly for women and for their babies if they get pregnant. You can get HIV if you have sex with an infected person. You can also get HIV if you or your partner shares needles with other people who have HIV. HIV is a lifelong infection, but early treatment can help you stay well. Treatment may also prevent HIV from being passed to baby if you get pregnant. All women should talk with their doctor being tested for HIV. • Chlamydia and Gonorrhea – these can cause serious infections. They can also cause damage that leaves you unable to have children. • Genital Herpes – can cause painful sores. You can get it from someone even when they do not have sores. If you get pregnant, genital herpes can lead to fatal infections in the baby. • Syphilis – is a serious infection. It can cause damage to the brain, heart and bones. It can also cause death. If you get pregnant, syphilis can cause severe problems and death in the baby. • Human papillomavirus – (HPV) can cause genital warts. It can also cause several types of cancer, such as cervical cancer. There is a vaccine you can get to prevent HPV. It is also important to get regular pap tests. • Hepatitis B – Hepatitis B virus (HBV) can cause liver disease and liver cancer. If you get pregnant, it can cause severe liver problems and even death in the baby. There is a vaccine you can get to prevent HBV. You can prevent STDs by not having sex. You can also have sex with only one person who has been tested and does not have an STD. Your risk of getting some STDs goes down if you use latex condoms correctly. Your risk of getting an STD goes up if you have more than one sexual partner and unprotected sex. To prevent STDs, use a condom every time you have sex and get tested for STDs. For more information about STDs in general and about specific STDs, go to http://www.cdc.gov/std/. You can also call 1 (800) 367-2437 or 1 (888) 225-2437 (TDD)

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Healthy Families for a Healthy Future Appendix 9 The Drug Pamphlet: Taking any type of drug can be harmful to your health. Drugs can cause damage to your organs and lead to serious infections. Drugs can also decrease your ability to make good decisions. This can put your life in danger. Examples of dangerous drugs include marijuana, cocaine, crack, heroin, and amphetamines. For women who could get pregnant, it is even more important to know about the dangers of using drugs. All illegal drugs are dangerous to pregnant women. If you get pregnant, marijuana may slow the growth of the baby. Also, if you’re trying to get pregnant, marijuana may make it harder. If a pregnant woman takes amphetamines (speed, crack, meth and ecstacy) it causes the heart rate to increase to dangerously high levels and can cause the baby to get less oxygen leading to the birth of a small baby, or cause the baby to be born too soon and other serious birth defects. Amphetamines and cocaine increase the chances of going into labor too soon, miscarriage (losing the baby), or placental abruption (Placental abruption is a condition where the placenta, which provides oxygen rich blood and nutrients to the baby while in the mother’s womb, separates too early from the wall of the uterus. Placental abruption can cause the baby not to get oxygen and can lead to brain damage, mental retardation and possible seizure disorders.) These babies are sometimes born addicted and suffer from withdrawal symptoms. Heroin use during pregnancy is a risk to the baby because heroin use is associated with poor nutrition, and if injected, HIV/AIDS. If the mother continues to use drugs during pregnancy the baby will be born addicted; if she stops using, the baby will also experience withdrawal and the associated risks. (Baby Zone, 2010) Prescription medications can also be dangerous. Legal drugs or over the counter medicines such as Aspirin, Tylenol, Ibuprofen, should not be used without consulting with your doctor. To find drug treatment facilities near you, go to: http://www.adp.ca.gov or you can call (800) 662-4357.

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Healthy Families for a Healthy Future Appendix 10 The Alcohol Pamphlet: Alcohol can be harmful to your health. It can damage your liver and other organs. It affects your ability to make good decisions. If you plan on getting pregnant or are pregnant, alcohol can also cause birth defects. Any alcohol use can affect the neurological development of the developing baby. Alcohol use during pregnancy can cause mental retardation in the baby. These effects happen very early in pregnancy, before you may know that you are pregnant. Excess alcohol use during pregnancy can result in babies being born with fetal alcohol syndrome. Remember: there is no safe amount of alcohol during pregnancy. If you need help to stop drinking or smoking, talk to your doctor or other health care worker. For information about support groups for alcohol abuse, go to http://ww.aa.org/ or http://www.adp.ca.gov/. To learn more about how alcohol can affect pregnancy, go to http://www.cdc.gov/ncbddd/fas/.

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Healthy Families for a Healthy Future Appendix 11

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Healthy Families for a Healthy Future Appendix 12

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Healthy Families for a Healthy Future Appendix 17

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Healthy Families for a Healthy Future Appendix 18

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Healthy Families for a Healthy Future Appendix 19

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Healthy Families for a Healthy Future Appendix 20

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Healthy Families for a Healthy Future Appendix 21

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Healthy Families for a Healthy Future Appendix 22

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Healthy Families for a Healthy Future Appendix 23

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Healthy Families for a Healthy Future Appendix 24: Preconception Health Quiz Please circle the correct answers 1) Preconception health only matters if you have health problems. True or False 2) A reproductive life plan is an agreement a woman makes with her doctor. True or False 3) Unplanned pregnancies are at greater risk of both preterm birth and lowbirth-weight babies. True or False 4) Only pregnant women need to take folic acid. True or False
5) About 1 in 8 babies is born too early.

True or false 6) Men don't need to worry about preconception health. True or False
7) Women should make an appointment with their doctors to discuss their

preconception health at least 1 month before becoming pregnant. True or False 8) It’s okay to drink alcohol when you’re trying to become pregnant. True or False 9) Men can improve their own reproductive health by limiting alcohol use and quitting smoking and/or illegal drug use. True or False 10) Knowing about health problems that run in your or your partner’s family can help your doctor figure out any genetic risk factors that could affect the health of any children you might have. True or False

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Healthy Families for a Healthy Future Appendix 25: Free Recommended Educational Resources Resource Eat Smart New York Population Family & Youth Language(s) English/Spanish Source Cornell University http://counties.cce.cornell.e du/wyoming/nutrition/esny/ Flyer_Eat%20Smart %20NY.pdf http://www.text4baby.org/ NYSDOH 1-800-522-5006 1-866-783-2645 Folic Acid Council http://www.getfolic.com/or der/index.htm http://www.marketfresh.co m.au/images/downloads/Ve getableGuide.pdf CDC http://www.fruitsandveggie smorematters.org/wpcontent/uploads/UserFiles/F ile/pdf/resources/cdc/Choos eSmart_Womens_Brochure (1).pdf CDC http://www2.cdc.gov/ncbdd d/faorder/orderform.htm#C DC-099-5142 FDOH http://www.doh.state.fl.us/e nvironment/newsroom/broc hures/index.html http://www.sesameworksho p.org/initiatives/health/healt hyhabits http://www.wohfkidsconnec t.com/kids/activities/color1. html http://www.dltkkids.com/nutrition/coloring. html http://www.eatsmart.org/art icle.asp?id=3782

Text4Baby Growing Up Healthy Hotline Su Famila (National Hispanic Family Health Help Hotline) Folic Acid/Multivitamin Vegetable Guide Choose Smart, Choose Healthy (Nutrition)

Expectant Parents Expectant Parents, Parents Family Expectant Parents, Teenagers Family Family

English/Spanish English/Spanish English/Spanish English/Spanish English (photos) English

Healthy Mothers, Healthy Babies Various Health Issues

Expectant Parents

English/Spanish

Expectant Parents

English/Spanish/ Creole English/Spanish English English English/Spanish

Sesame Workshop (Healthy Habits for Life) Printable Coloring Pages Growing Together Coloring Pages Coloring Pages & Matching Games

Children Children Children Children

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Healthy Families for a Healthy Future Appendix 26: Scripts for Telephone Message Recordings 1 Thank you for calling CHC. All circuits are currently busy. While you wait for the next available representative, please take the time to listen to the following important information regarding your health. Did you know that visiting the dentist twice a year is not only important for your mouth, but also for your overall health? Plaque is caused by a layer of bacteria on your teeth. The bacteria release acids that damage tooth enamel and lead to tooth decay if the plaque is not removed. As plaque hardens on your teeth, tarter is formed. On your gum line, tarter can cause gum disease and other problems in your mouth. Once tarter is formed, it cannot be brushed away. This is why it is so important to visit your dentist twice a year and to brush your teeth at least twice a day and to floss daily. Build up of plaque is also associated with increased risk of major health issues like stroke and heart attack. Other health care issues associated with poor dental hygiene include: respiratory infections, problems with bone strength, heart disease, diabetes, and pregnancy problems. Poor oral health can be a contributing factor of underweight and premature babies. Keeping your mouth healthy during pregnancy is a critical component to having a healthy baby. Now that you have learned some important facts about dental health, please take the time to test your knowledge by answering the following questions. True or false-brushing your teeth and flossing daily is enough to keep tarter away. (Pause for 10 seconds). If you answered true, you are correct! Tarter cannot be removed by flossing and brushing alone. You must visit your dentist for a cleaning every six months in order to remove tarter and prevent gum disease and other problems in your mouth. Which of the following health concerns can result from poor dental health? A) Diabetes B) Pregnancy Problems C) Gum Disease D) All of these issues (Pause for 10 seconds). If you chose all of these issues, you are correct! Poor dental health contributes to a variety of poor health outcomes including osteoporosis, diabetes, pregnancy problems and gum disease. Now that you are aware how important dental health is, please remember to make your semi-annual appointment with your CHC dentist today. Thank you for continuing to hold. Your call is very important to us. As you wait for your CHC representative to take your call, please direct your attention to the following important announcements regarding your health. Are you up to date with your shots? Is every member of your family up to date? Keeping current on vaccinations is important to individuals of all ages. Disease prevention is important in keeping healthy. Disease prevention is better than disease treatment. Diseases that are vaccine-preventable have a costly impact. Some resulting in doctor’s visits, hospitalizations and even premature death. Today we have vaccinations to thank for the control of many infectious diseases that were once common in the United States. Diseases that you should be vaccinated for include: polio, measles, mumps, tetanus and chicken pox. These disease can make you very sick but they are preventable with vaccinations. Protect yourself and your family by asking your physician if all your family members are up to date with their vaccinations. If you are planning on starting or expanding your family, it is especially important to be sure that you are current with all necessary vaccinations. If you are planning on becoming pregnant and have not been immunized, you could be putting the health of your baby at risk. Please take the time to answer a couple of questions about what you just learned about vaccinations. True or falsevaccinations are only important for expectant mothers, fathers who are not immunized cannot cause harm to a child. (Pause for 10 seconds). If you answered false, you are correct.

2

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Healthy Families for a Healthy Future The immunization status of both parents is important in decreasing the possibility of spreading an illness to your child. True or false-there is no need to get yourself and your children immunized, because if others are immunized, there is no chance of contracting the preventable illnesses. (Pause for 10 seconds). If you answered false, you are correct. Being vaccinated is the only way to prevent getting these illnesses. Vaccinations are available at the CHC. Please speak to your CHC primary care physician about immunizations today. Thank you for your patience. A CHC representative will be right with you. As you wait, please listen to the important messages that follow regarding your health. Are you currently at a healthy weight? The instances of overweight and obese Americans are at an all time high and are increasing. Fortunately, by making healthy choices, you can help to maintain a healthy weight. A lifestyle complete with nutritious foods and exercise can help to keep you at a healthy weight and decrease your chances of developing chronic illnesses that are on the rise in the United States. The leading causes of death in the United States today include heart disease, diabetes and stroke. Many of these deaths are preventable with healthy diet and exercise habits. Adopting healthy eating habits and exercise can be fun for the whole family. Children who develop healthy eating and activities early on are less likely to become overweight in the future. Take a walk outside together before or after dinner. Keeping active is important in maintaining healthy weights and decreasing your chances of developing heart disease and diabetes. Take the time to answer a couple of questions about what you just learned about maintaining healthy weight. Being overweight can lead to which of the following diseases? A) Gum Disease B) AIDS C) Diabetes D) HIV. If you answered C) Diabetes, you are correct. Diabetes, heart disease and stroke are among the leading causes of death in individuals who are overweight and obese. Please speak with your CHC physician for free materials on how to keep yourself and your family eating right and keeping active. Thank you for holding. The next CHC representative will be able to take your call momentarily. While you wait, please listen to the following important message regarding your health. Did you know that smoking is the single leading cause of all preventable illness? A pack-a-day smoker pours 1 cup of tar into their lungs each year. Poisons are present in cigarette tar and smoke that can cause diseases including certain types of cancer. Common diseases associated with smoking include: throat cancers, mouth cancers, bladder cancer, lung cancer, chronic bronchitis, emphysema and heart disease. Each cigarette that you smoke takes away approximately 5-8 minutes of your life. Unfortunately, even if you don’t smoke, your health can be affected by breathing in the smoke of others. Secondhand smoke can be just as deadly as direct smoking. Children who have parents who smoke have an increased risk of ear infections, asthma, bronchitis and tonsillitis. Smoking cigarettes during pregnancy can lead to adverse birth defects. Please answer the following questions regarding the effects of smoking. True or false-parents who smoke are increasing the risk of certain medical issues. (Pause for 10 seconds). If you answered true, you are correct. Children who are exposed to smoke throughout development are up to four times more likely to have asthma than children who are not exposed. True or false-diseases associated with smoking are not preventable. (Pause for 10 seconds). If you answered false, you are correct. Diseases caused by smoking are preventable. Not smoking or quitting smoking will decrease your risk for developing these diseases. It is recommended that a couple planning on starting a family should stop smoking at least three months prior to conception. There are programs and materials available to aid in quitting smoking. Please speak with your CHC physician

3

4

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Healthy Families for a Healthy Future for assistance in quitting smoking.

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Healthy Families for a Healthy Future Appendix 27: Recommended Promotional Takeaways Item Calendar Quantity 100 250 500 1,000 2,500 300 1,500 3,000 6,000 9,000 15,000 300 500 1,000 2,500 10,000 250 500 1,000 2,500 500 1,000 2,500 5,000 500 1,000 2,500 5,000 500 1,000 2,500 5,000 Price Each (+Setup Fee) $5.10 $3.90 $3.30 $2.25 $1.80 $0.38 $0.36 $0.34 $0.32 $0.30 $0.27 $0.36 $0.34 $0.30 $0.28 $0.24 $1.38(+$45) $1.38(+$45) $1.38(+$45) $1.38(+$45) $0.85(+40) $0.75(+40) $0.66(+40) $0.59(+40) $0.48 $0.32 $0.30 $0.28 $1.35 $1.25 $1.15 $1.05 Total Cost $510 $975 $1,650 $2,250 $4,500 $114 $540 $1,020 $1,920 $2,700 $4,050 $107 $170 $300 $700 $2,400 $390 $735 $1,425 $3,495 $465 $790 $1,690 $2,990 $240 $320 $750 $1,400 $675 $1,250 $2,875 $5,250 Source http://www.logocalendarsusa.c om/budgetcustom.html

Keychain

http://www.branders.com/prod uct/promotional_items_Keytag _Circle? prdid=40701&folder_id=3207 19 http://www.discountmugs.com /nc/promotionalpens/925/company-pens.htm http://soldbyangels.com/keyrin gs/metal-pen-withcarabiner.htm http://www.mapleleafpromotio ns.com/SportsBottle.html http://www.inkhead.com/viewproduct.html? pid=7011&reftypeid=11&utm _source=Google%20Product %20Search&utm_medium=org anic http://www.mapleleafpromotio ns.com/Hand-Sanitizers.html

Pen

Keychain/pen

Water Bottle

Magnet

Hand Sanitizer

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Healthy Families for a Healthy Future Appendix 28: Physician Preconception Checklist

A Physician’s Preconception Checklist for Family Planning:

Important topics for a physician to discuss with male and female patients of childbearing age (ages 14-44):
o Patient’s medical history o Patient’s sexual health history o Abstinence and alternative contraceptive methods o Benefits of continued daily use of a multivitamin with folate for the entire family o Importance of a nutritious well-balanced diet for the entire family o Importance of a healthy lifestyle including exercise o Significance of healthy dental hygiene and semiannual dental visits o Importance of vaccinations for all family members o Importance of proper hand sanitation o Benefits of quitting smoking o Benefits of avoiding drugs and alcohol
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Healthy Families for a Healthy Future Appendix 29A: Patient Preconception Checklist (English)

Planning on Starting or Expanding your Family?
Preconception Checklist for Men & Women: o Step 1: Schedule a complete physical
o Discuss all prescription medications you are taking with your physician o Discuss your medical history and immunization status with your physician o Get an HIV test

o Step 2: Take charge of your weight
o Get your weight under control with caloric goals & exercise

o Step 3: Stop Smoking
o At least 3 months prior to conception
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o Programs are available for help quitting. Please speak with your physician

o Step 4: Stop using drugs and alcohol o Step 5: Take a multivitamin with folate

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Healthy Families for a Healthy Future Appendix 29B: Patient Preconception Checklist (Spanish)

¿Planificación en comenzar o la extensión de su familia?
Lista de comprobación de la preconcepción para el & de los hombres y mujeres: o Paso 1: Programe una comprobación complete
o Discuta todas las medicaciones de la prescripción que usted está tomando con su medico o Discuta su estado del historial médico y de la inmunización con su medico o Consiga una prueba del VIH

o Paso 2: Carga de la toma de su peso
o Consiga su peso bajo control con el & calórico de las metas; ejercicio

o Paso 3: Pare el fumar
o Por lo menos 3 meses antes del concepto o Los programas están disponibles para el abandono de la ayuda. Hable por favor con su medico

o Paso 4: Pare el usar de las drogas y del alcohol
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o Paso 5: Tome un multivitamin con el floato

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Westchester Early Prenatal Care over Time 1995 - 2004
100.0% 80.0% 60.0% 40.0%

People 2010 goal Appendix 30: New York State and Westchester County data beginning prenatal care 20.0% = 90% 0.0%
Total NYC Total NYS
95 96 97 98 99 00 01 02 03 19 19 19 19 19 20 20 20 20 20 04

Healthy Total Westchester

•Healthy Families for a Healthy Future

in the first trimester of their pregnancies

Westchester Early Prenatal Care by Race/Ethnicity Over Time 1995 - 2004
100.0% 80.0% 60.0% 40.0% 20.0% 0.0%
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04
Source: NYS Department of Health, Vital Statistics

White Black Hispanic

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Healthy Families for a Healthy Future Appendix 31: New York State and Westchester County data on mothers beginning prenatal care in the late (third trimester) stages of their pregnancies or who begin no prenatal care at all
Westchester Late/No PNC Over Tim e 1995 - 2004
14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Total Westchester Total NYC Total NYS

Westchester Late/No PNC By Race/Ethnicity Over Time 1995 - 2004
16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% Source: NYS Department of Health, Vital Statistics 0.0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 White Black Hispanic

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Healthy Families for a Healthy Future Appendix 32: New York State and Westchester County data on Low Birth Weight births
Westchester Low Birth Weight Over Time 1995 - 2004
10.0% 8.0% 6.0% 4.0% 2.0% 0.0%
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04

Total Westchester Total NYC Total NYS

•Healthy People 2010 goal = 5%

Westchester Low Birth Weight by Race/Ethnicity Over Time 1995 - 2004
16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0%
Source: NYS Department of Health, Vital Statistics

White Black Hispanic

0.0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

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Healthy Families for a Healthy Future Appendix 33: New York State and Westchester County data on premature birth
Westchester Prematurity Over T ime 1995 - 2004
14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0%
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04

Total Wes tches ter Total NYC Total NYS

•Healthy People 2010 goal = 7.6%

Westchester Prematurity by Race/Ethnicity Over Time 1995 - 2004
20.0% 15.0% 10.0% 5.0% 0.0%
Source: NYS Department of Health, Vital Statistics

W hite Black Hispanic

19951996 19971998199920002001 200220032004

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Healthy Families for a Healthy Future Appendix 34: New York State and Westchester County data on Infant Mortality Rates
In fa n t M o rtality R a tes - L H V P N R e g io n 2 0 04
30.0 25.0 20.0 W h ite 15.0 10.0 5.0 0.0 D utc hes s P u tnam R oc k land W es tc hes ter NYC NYS B lac k H is panic

Rate per 1,000 live births

•Healthy People 2010 goal = 4.5/1,000
Source: NYS Department of Health, Vital Statistics

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Healthy Families for a Healthy Future Appendix 35: New York State and Westchester County data on Teen Births
Westchester % Teen Births Over Time 1995 - 2004
12.0% 10.0% 8.0% Total Westchester 6.0% 4.0% 2.0% 0.0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Total NYC Total NYS

Westchester % Teen Births by Race/Ethnicity Over Time 1995 - 2004
14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0%
Source: NYS Department of Health, Vital Statistics

White Black Hispanic

0.0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

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Healthy Families for a Healthy Future Appendix 36: Percentage of Mothers Beginning Prenatal Care in the First Trimester,2006
United States Non-Hispanic White Non-Hispanic Black Hispanic

Percent 88.1% 76.1% 77.3%
1 1 1

0.0% - 100.0%

New York

Percent 81.6% 60.3% 61.0%

0.0% - 100.0%

Non-Hispanic White Non-Hispanic Black Hispanic

2 2 2

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. http://www.cdc.gov/nchs/vitalstats.htm. Accessed 1/7/2009.

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