Article Figures & Data
Figures
- Figure 1.
An image of “Gabby,” the preconception care conversational agent.
- Figure 2.
Diagram of a typical Gabby System interaction.
- Figure 3.
Diagram of subject participation in study phases.
Tables
- Table 1. Risks Identified at the Baseline Survey and Risks Reported to be Resolved or Improved at 6 months, by Content Area and Study Group
Risks* Gabby Group† Control Group‡ P Value Emotional and mental health Participants who triggered ≥1 risk (%) 21 (45.6) 19 (42.2) .74 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 12/18 (66.7) 4/16 (25.0) .02 Risks triggered that were resolved/total no. of risks triggered (%) 15/35 (43.0) 4/32 (13.0) .01 Environmental Participants who triggered ≥1 risk (%) 44 (95.6) 43 (95.6) 1.00 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 11 (32.4) 5 (12.8) .04 Risks triggered that were resolved/total no. of risks triggered (%) 13/119 (10.9) 6/102 (5.9) .18 Genetic health history Participants who triggered ≥1 risk (%) 46 (100.0) 45 (100.0) .32 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 14/36 (38.9) 12/41 (29.3) .37 Risks triggered that were resolved/total no. of risks triggered (%) 19/71 (26.8) 15/67 (22.4) .55 Health care Participants who triggered ≥1 risk (%) 16 (34.8) 31 (68.9) .01 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 5/12 (41.7) 5/27 (18.5) .13 Risks triggered that were resolved/total no. of risks triggered (%) 8/34 (23.5) 7/64 (10.9) .09 Health conditions and medicines Participants who triggered ≥1 risk (%) 28 (60.9) 28 (62.2) .89 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 12/22 (54.5) 5/25 (20.0) .01 Risks triggered that were resolved/total no. of risks triggered (%) 14/41 (34.1) 8/36 (22.2) .25 Immunizations and vaccines Participants who triggered ≥1 risk (%) 38 (82.6) 42 (93.3) .12 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 17/30 (56.7) 15/38 (39.5) .16 Risks triggered that were resolved/total no. of risks triggered (%) 25/80 (31.3) 21/111 (18.9) .05 Infectious diseases Participants who triggered ≥1 risk (%) 46 (100.0) 45 (100.0) NA Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 25/36 (69.4) 23/41 (56.1) .23 Risks triggered that were resolved/total no. of risks triggered (%) 52/172 (30.2) 44/182 (24.2) .20 Men and health care Participants who triggered ≥1 risk (%) 31 (67.4) 26 (57.8) .34 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 5/25 (20.0) 9/23 (39.1) .15 Risks triggered that were resolved/total no. of risks triggered 7/64 (10.9) 14/39 (35.9) .01 Nutrition and activity Participants who triggered ≥1 risk (%) 46 (100.0) 45 (100.0) NA Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 32/36 (88.9) 29/41 (70.7) .05 Risks triggered that were resolved/total no. of risks triggered (%) 101/292 (34) 67/302 (22.2) .01 Relationships Participants who triggered ≥1 risk (%) 21 (45.6) 30 (66.7) .04 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 5/16 (31.3) 6/27 (22.2) .51 Risks triggered that were resolved/total no. of risks triggered (%) 10/36 (27.8) 9/53 (17.0) .22 Reproductive health Participants who triggered ≥1 risk (%) 40 (87.0) 38 (84.4) .73 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 10/31 (32.3) 9/34 (26.5) .61 Risks triggered that were resolved/total no. of risks triggered (%) 16/87 (18.4) 12/62 (19.4) .88 Substance use Participants who triggered ≥1 risk (%) 27 (58.7) 25 (55.6) .76 Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 10/20 (50.0) 11/22 (50.0) 1.00 Risks triggered that were resolved/total no. of risks triggered (%) 17/36 (47.2) 17/41 (41.5) .61 Totals Participants with at least 1 risk resolved/no. of participants reached at follow-up who had triggered at least 1 risk (%) 36/36 (100.0) 37/41 (90.0) Risks triggered that were resolved/total no. of risks triggered (%) 297/1067 (27.8) 224/1091 (20.5) <.01 ↵* The various risks were categorized as follows:
Emotional and Mental Health: history of or diagnosis of or depression, anxiety, bipolar disorder, or schizophrenia; depression (2-item Patient Health Questionnaire score ≥325); stress (4-item Perceived Stress Scale score ≥826); family history of psychiatric conditions (depression, anxiety, schizophrenia, bipolar disorder).
Environmental Issues: exposure to lead; at risk for toxoplasmosis; living near toxic waste or a “superfund” site; untested well water in the home; frequently drinking from plastic water bottles; frequently eating food from cans with a white plastic lining; reported workplace exposure to chemicals or dangers; reported exposure to potentially toxic household chemicals.
Genetic Health History: ethnicity-based genetic health risk based on ancestry; family history of a genetic health condition; personal history of a genetic health condition; need to learn family health history.
Health Care and Programs: inadequate financial resources; does not have health insurance; has inadequate health insurance; does not have a primary care physician; not been to a dentist in over a year.
Health Conditions and Medicines: history of diagnosis of diabetes, prediabetes, gestational diabetes, hyper- or hypothyroidism, phenylketonuria, seizures, hypertension, rheumatoid arthritis, lupus, renal disease, cardiovascular disease, thrombophilia, asthma; history of or diagnosis of a disability; history of or diagnosis of cancer; currently taking any prescription medications; currently taking any over-the-counter medicines.
Immunizations and Vaccines: need human papillomavirus vaccine; need hepatitis B vaccine; need varicella vaccine; need measles, mumps, and rubella vaccine; need influenza vaccine; need tetanus vaccine; need tetanus-diphtheria-pertussis vaccine; unsure of immunization record.
Infectious Diseases: at risk for sexually transmitted infection; sexually active and has not been tested for sexually transmitted infections; history of or diagnosis of human immunodeficiency virus, gonorrhea/chlamydia/syphilis, herpes simplex virus; at risk for tuberculosis, malaria, cytomegalovirus hepatitis C; not born in the United States.
Men and Health Care: partner has not been to doctor in >1 year; partner does not have a primary care physician; partner has not been counseled on a reproductive life plan.
Nutrition and Activity: bad diet or food choices (<5 daily servings of fruits and vegetables and/or regular intake of junk food); possibly taking too much vitamin A; not using a multivitamin with folic acid or a folic acid supplement; use of herbal or weight-loss supplements; not taking supplements of vitamin D, calcium, iron; need more essential fatty acids in diet; at risk for toxic concentrations of mercury; at risk for listeriosis; underweight (body mass index <18.5 kg/m2); overweight (body mass index ≥30 kg/m2); self-reported potential eating disorder; use of caffeine; not enough exercise (<30 min/d, 5 d/wk).
Relationships: history of or current physical or sexual abuse; history of or current emotional or verbal abuse; does not feel safe.
Reproductive Health: does not use birth control; uses withdrawal method of birth control; uses other less effective birth control method (Plan B, rhythm/natural family planning method, or “other”); history of preterm birth; history of infant born with low or high birth weight; history of cesarean delivery; history includes 1 or 2 miscarriage(s); history includes ≥3 miscarriages; history includes ≥2 miscarriages in second trimester; history of abortion; history of stillbirth; history of uterine anomalies; history of infant or child death; <3 months between past pregnancies; history of vaginal bleeding late in pregnancy; history of infant in neonatal intensive care unit; history of infant with a birth defect; participant was born before term or with a low birth weight; participant's mother was born before term or with a low birth weight.
Substance Use: excessive alcohol (≥4 drinks in a day over the past year); any current tobacco use; any illicit substance use in the past year.
↵† At baseline, this group included 46 participants; n = 36 at 6 months.
↵‡ At baseline, this group included 45 participants; n = 41 at 6 months.
NA, not available.
- Table 2. Participant Demographics, Clinical Characteristics, and Computer Literacy and Availability* by Study Group (n = 99)
Gabby Group (n = 50) Control Group (n = 49) Demographics Age, mean years (SD) 25.9 (3.4) 25.1 (3.7) Hispanic, Latino, or Spanish origin No 47 (94.0) 47 (95.9) Yes 3 (6.0) 2 (4.1) Household income ($) <20,000 3 (6.0) 3 (6.1) 20,000–49,999 13 (26.0) 7 (14.3) ≥50,000 15 (30.0) 23 (46.9) Don't know/refused 19 (38.0) 16 (32.7) Education At least some college 36 (72.0) 30 (61.2) Less than college 14 (28.0) 19 (38.8) English as a primary language No 5 (10.0) 1 (2.0) Yes 45 (90.0) 48 (98.0) Currently a student No 30 (60.0) 28 (57.1) Yes 20 (40.0) 21 (42.9) Currently employed full time or part time No 16 (32.0) 12 (24.5) Yes 34 (68.0) 37 (75.5) Clinical characteristics REALM score, mean (SD)†‡ 61.5 (11.2) 63.0 (4.8) REALM-2 category§ High school 42 (91.3) 40 (88.9) Less than high school 4 (8.7) 5 (11.1) General Self-Efficacy Scale score, mean (SD)‖ 33.9 (4.7) 33.8 (3.8) Multidimensional Scale of Perceived Social Support score, mean (SD)¶ 71.0 (9.4) 70.1 (9.1) 10-Item Everyday Discrimination Scale score, mean (SD)** 12.4 (8.9) 12.7 (6.8) Information technology literacy and access Primary location of accessible computer Home 27 (55.1) 28 (57.1) Work 15 (30.6) 17 (34.7) Other 7 (14.3) 4 (8.2) Computer experience I'm an expert 23 (46.0) 28 (57.1) I use one regularly 27 (54.0) 21 (42.9) I've never used one 0 (0) 0 (0) I've tried one a few times 0 (0) 0 (0) Computer attitude I love playing with them 45 (90.0) 42 (85.7) They're okay 5 (10.0) 7 (14.3) I don't like them 0 (0) 0 (0) Do you ever read about health information online? No 3 (6.0) 3 (6.1) Yes 47 (94.0) 46 (93.9) Do you ever ask questions or share health information on social networking sites like Facebook, Twitter, or elsewhere? No 18 (36.0) 24 (49.0) Yes 32 (64.0) 25 (51.0) How frequently do you use the Internet for health information? Never 3 (6.0) 3 (6.1) Rarely 2 (4.0) 1 (2.0) Sometimes 18 (36.0) 17 (34.7) Frequently 9 (18.0) 16 (32.7) Very frequently 18 (36.0) 12 (24.5) Data are n (%) unless otherwise indicated.
↵* None of the data were statistically significant between the 2 groups at baseline.
↵† Columns do not always add up to number of participants because of missing data.
↵‡ The Rapid Estimate of Adult Literacy Levels in Medicine (REALM) is a screening tool designed to measure adults' ability to read common medical words or lay terms that correspond to anatomy or illnesses. It is a 66-item list, with possible scores ranging from 0 to 66.24
↵§ REALM scores are dichotomized by high school or more (score of 61 to 66) and less than high school (score ≤60).
↵‖ The General Self-Efficacy Scale is a 10-item psychometric scale designed to assess optimistic self-beliefs related to ability to cope with difficult demands in life. Response options are never (1), sometimes (2), usually (3), or almost always (4), with possible score ranging from 10 to 40.21
↵¶ The Multidimensional Scale of Perceived Social Support scale is a 12-item scale to measure perceived support from family, friends, and significant others. Response options ranged between strongly disagree (1), neutral (4), strongly agree (7) and were summed for a total score.22
↵** The Everyday Discrimination Scale is a 10-item scale to measure the perceived frequency of 10 specific discriminatory experiences. Response options include never (0), less than once a year (1), a few times a year (2), a few times a month (3), at least once a week (4), and almost every day (5), with a possible total score ranging from 0 to 50.23
SD, standard deviation.
- Appendix 1. Baseline Risks Identified, Criteria for Identification, Goal Behavior, and Definition of Risk Resolution, by Content Area
Risks By Preconception Care Content Area Criteria for Identification of Risk Goal Behavior and Definition of Risk Resolution A. Emotional and mental health 1. History of diagnosis of anxiety Selection of “anxiety” in response to, “Have you been diagnosed with any of the following conditions? Check all that apply.” Talking to a doctor about treatment for anxiety* 2. History of diagnosis of depression Selection of “depression” in response to, “Have you been diagnosed with any of the following conditions? Check all that apply.” Talking to a doctor about treatment for depression* 3. Potential depression PHQ-2 score ≥3 Talking with a doctor about depression* 4. History of diagnosis of bipolar disorder Selection of “bipolar disorder” in response to, “Have you been diagnosed with any of the following conditions? Check all that apply.” Talking to a doctor about treatment for bipolar disorder* 5. Family history psychiatric conditions (depression, anxiety, schizophrenia, bipolar disorder) Report of family member or partner's family member ever diagnosed with anxiety, bipolar, depression, or schizophrenia Talking to a doctor about the history of mental illness is your family* 6. Stress 4-Item Perceived Stress Scale score ≥8 Finding ways to manage your stress† B. Environmental issues 1. Living near toxic waste or a “superfund” site “Yes” in response to, “Do you live near a toxic waste site or “superfund site'?” Talking to a doctor about living near a toxic waste site* 2. Exposure to lead After indicating exposure to lead, either “no” in response to, “Have you been tested?”; or “I had too much lead in my blood” in response to, “What was the result?” and “no” in response to, “Have you been treated?” Talking to a doctor about getting your blood lead concentrations tested* 3. Reported exposure to potentially toxic household chemicals Selection of any chemical in response to, “In your home(s), have you or your partner been exposed to any of the following? Check all that apply: solvents (oil based paints), heavy metals (lead), paint-stripping chemicals (with methylene chloride), jewelry making or metal tempering, pesticides, herbicides, rodenticides, removal of old paint or wallpaper from walls containing lead-based paint, non-latex-based paints that are solvent based and contain metals for pigments and antifoulant agents.” Talking to a doctor about how to make your home safer* 4. Frequently eating food from cans with a white plastic lining “Yes” or “don't know” in response to, “Do you frequently eat foods that come from metal cans that have a white plastic lining, like canned soup or vegetables?” Talking to a doctor about avoiding cans with white plastic lining* 5. Frequently drinking from plastic water bottles “Yes” in response to, “Do you frequently drink water from plastic bottles?” Talking to a doctor about checking plastic water bottles to make sure they are safe* 6. At risk for toxoplasmosis “Yes” in response to, “Do you ever clean a cat's litter box?” or indicating intake of “raw or very undercooked meats or fish” Talking to a doctor about preventing toxoplasmosis* 7. Untested well water in the home “Yes” in response to, “Do you have well water in your home?,” then “no” or “don't know” in response to, “Has it been tested?” Talking to a doctor about getting your well water tested* 8. Reported workplace exposure to chemicals or dangers Selection of any job listed in response to, “Does your job or your partner's job fall into any of the following categories? Check all that apply: lab and clinical health care work, printing, dry-cleaning, jewelry making or metal tempering, jobs that use pesticides, herbicides, rodenticides, solvents (oil-based paints), heavy metals (lead), paint-stripping agents, lead-based paints or non-latex-based paints that are solvent based and contain metals for pigments” Talking to a doctor about how to be safer at work* C. Genetic health history 1. Ethnicity-based genetic health risk based on ancestry Selection of any ethnicity listed in response to, “What is your blood ancestors' ethnic/racial/geographic background? Please check all that apply: White, European, Ashkenazi Jewish, French Canadian, Cajun, African, Mediterranean, Asian” Talking with a doctor about health problems based on your ethnicity* 2. Family history of a genetic health condition Selection of any of the health conditions listed in response to, “Has anyone in your family or your partner's family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) any of the following?: Chromosomal disorders, deafness, facial clefts (cleft palate), sickle cell disease or trait, thalassemia, developmental delay/mental retardation, blood clots, cancer, neural tube defects (eg, spina bifida), heart disease, vision loss inherited from family member, sudden infant death syndrome, early infant death, muscular dystrophy, cystic fibrosis, family history of other congenital malformations or birth defects” Talking with a doctor about your family's health history* 3. Personal history of a genetic health condition Selection of any of the health conditions listed in response to, “Have you or your partner ever had any of the following conditions? Check all that apply: Chromosomal disorders, deafness, facial clefts (cleft palate), sickle cell disease or trait, thalassemia, developmental delay/mental retardation, blood clots, cancer, neural tube defects (eg, spina bifida), heart disease, vision loss, inherited from family member, family history of other congenital malformations or birth defects” Talking with a doctor about your health history or your partner's health history* 4. Need to learn family health history Selection of “don't know” in response to, “Has anyone in your family or your partner's family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) any of the following? (See list of conditions listed under “Family history of genetic health condition”) Talking with a doctor about your family's health history* D. Health care and programs 1. Does not have primary care physician “No” in response to, “Do you have a primary care provider? (PCP being a general doctor that you would see once a year for checkups and for illness); or selection of “emergency room” in response to, “When you do need medical care, do you usually go to your PCP or to the emergency room?” Choosing a PCP* 2. Inadequate health insurance “No” in response to, “Does your health insurance get you the health care you need?” Getting better health insurance* 3. Does not have health insurance No” in response to, “Do you have health insurance?” Getting health insurance* 4. Not been to dentist in over a year “No” in response to, “Have you been to the dentist in the past year?” Going to the dentist* 5. Inadequate financial resources “Yes” in response to, “Is it difficult to pay bills, like rent, water, heat, or electricity?” or selecting any of the following programs in response to, “Do you use any of these assistance programs?”: Medicaid (including Mass Health), health safety net or free care, Temporary assistance to needy families (welfare), food stamps, housing assistance, energy assistance, Women Infants and Children Applying for programs to help pay your bills* E. Health conditions and medicines 1. History of diagnosis of asthma Selection of “asthma” as a diagnosed health issue Talking to a doctor about your asthma* 2. History of diagnosis of disability ”Yes” in response to, “Do you have a disability?” (Disability specified as a physical or intellectual disability in which case extra care from a doctor is required.) Talking with a doctor about your disability* 3. History of diagnosis of hypertension (high blood pressure) Selection of “hypertension (high blood pressure)” as a diagnosed health issue Following your treatment plan for your blood pressure† 4. Currently taking any over-the-counter medicines “Yes” in response to, “Do you take any ‘over-the-counter’ medications?” Talking to a doctor about your “over-the-counter” medicines* 5. History of diagnosis of prediabetes Selection of “prediabetes” as a diagnosed health issue Following your treatment plan for pre diabetes† 6. Currently taking a prescription medication “Yes” in response to, “Do you take any medicines prescribed by a doctor?” Telling a doctor about your prescription medications* 7. History of diagnosis of rheumatoid arthritis Selection of “rheumatoid arthritis” as a diagnosed health issue Talking to a doctor about your RA* F. Immunizations and vaccines 1. Need hepatitis B vaccine Selection of “no” or “don't know” to, “Have you received a vaccination for hepatitis B?” Talking with a doctor about getting the hepatitis B vaccine* 2. Unsure of immunization record “No” in response to, “Do you know about any of the immunizations you have gotten in the past?” Talking with a doctor about getting the immunizations you need* 3. Need varicella vaccine Selection of “no” or “don't know” to, “Have you received a vaccination for varicella (2 doses) or ever had the chicken pox?” Talking with a doctor about getting the varicella, or chicken pox, vaccine* 4. Need influenza vaccine Selection of “no” or “don't know” to, “Have you received a vaccination for influenza (flu) this year for flu season (October through April)?” Talking with a doctor about getting the flu vaccine* 5. Need human papillomavirus vaccine Selection of “No” or “Don't Know” to, “Have you received a vaccination for HPV in 3 doses (ever)?” Talking with a doctor about getting the HPV vaccine ± 6. Need measles, mumps, and rubella vaccine Selection of “no” or “don't know” to, “Have you received a vaccination for measles, mumps and rubella (in childhood)?” Talking with a doctor about getting the MMR vaccine* 7. Need tetanus-diphtheria-pertussis vaccine Selection of “no” or “don't know” to, “Have you received a vaccination for tetanus, diphtheria, and pertussis once when you were 11 to 12 years old and/or another after you turned 18 years old?” Talking with a doctor about getting the Tdap vaccine* 8. Need tetanus vaccine Selection of “no” or “don't know” to, “Have you received a tetanus booster vaccination within the past 10 years?” Talking with a doctor about getting the tetanus vaccine* G. Infectious diseases 1. At risk for hepatitis C “Yes” in response to any of the following: “Have you received blood products or organs before 1992?”; “Are you a health care worker?”; “Do you work in a correctional institution, like a jail?”; “Have you ever stayed overnight in a jail?”; “Do you have a tattoo or body piercing that you got in your home or someone else's home?” “Yes” or “don't know” in response to, “Have any of your sexual partners had hepatitis C?” Talking with a doctor about getting tested for hepatitis C* 2. At risk for malaria “No” in response to, “If you traveled to Central America, South America, Africa, Asia, Eastern Europe, the South Pacific, or the Caribbean in the future, would you take antimalarial medicine?” Talking with a doctor about how to prevent malaria* 3. At risk for sexually transmitted infection “Yes” in response to any of the following: “Do you work in a correctional institution, like a jail?”; “Have you ever stayed overnight in a jail?”; “Has a doctor or nurse ever told you that you have gonorrhea?”; “Have you ever been paid for sex, or had sex for drugs?”; “Have you ever used illicit drugs (street drugs), including marijuana?” Talking with a doctor about getting tested for STIs and finding out how to prevent them* “Yes” or “don't know” in response to, “Have you ever had unprotected sex? (meaning vaginal intercourse without a condom, oral sex without a condom, or anal sex without a condom)”; “Have any of your sexual partners been diagnosed with an STI?”; “Have any of your sexual partners had syphilis or herpes?”; “Have any of your male sexual partners had sex with men?” 4. At risk for TB “Yes” in response to, “Are you a healthcare worker?”; “Do you work in a correctional institution, like a jail?”; “Have you ever stayed overnight in a jail?”; “Were you born in Latin America, Caribbean, Africa, Asia, Eastern Europe, or Russia?”; “Yes” or “don't know” in response to, “Have you been in contact with someone who has tuberculosis (TB)?” Talking with a doctor about getting tested for TB* 5. At risk for cytomegalovirus “Yes” in response to, “Do you work in a daycare, nursery school, or kindergarten?”; “Are you often in contact with children under 6 years old?” Talking to a doctor about how to prevent cytomegalovirus* 6. Sexually active and not been tested for sexually transmitted infections “No” (and still sexually active) in response to, “Have you ever been tested for an STI, including chlamydia, syphilis, HIV, and others?” Talking with a doctor about getting tested for STIs* 7. Not born in the United States “Yes” in response to, “Were you born in a country other than the United States?” Talking with a doctor about being born in another country* 8. History of diagnosis of gonorrhea, chlamydia, or syphilis “Yes” in response to, “Has a doctor or nurse ever told you that you have (any) STIs?” (selection of gonorrhea, chlamydia, or syphilis) Talking to a doctor about getting treated for chlamydia, syphilis, or gonorrhea* 9. History of diagnosis of HIV “Yes” in response to, “Has a doctor or nurse ever told you that you have HIV?” Talking to a doctor about getting treated for HIV* 10. History of diagnosis of herpes “Yes” in response to, “Has a doctor or nurse ever told you that you have genital herpes?” Talking to a doctor about getting treated for herpes* 11. Tuberculosis “Yes” in response to, “Has a doctor or nurse ever told you that you have tuberculosis (TB)?” Talking to a doctor about getting treated for TB* H. Men and health care 1. Partner does not have a primary care physician “No” or “don't know” to, “Does your partner have a primary care doctor (PCP), which is a doctor he would see for checkups or if he was sick?” Telling your partner that he should choose a PCP* 2. Partner has not been to a doctor in >1 year “No” or “don't know” to, “Has your partner been to the doctor in the past year?” Telling your partner that he should go to the doctor* 3. Partner not counseled on reproductive life plan “No” or “don't know” to, “Has your partner been counseled on his reproductive life plan (plan about birth control and when he wants to have children in the future)?” Telling your partner to talk to his doctor about his reproductive life plan (like birth control)* I. Nutrition and activity 1. Bad diet or food choices Response of <5 daily servings of fruits and vegetables; “yes” in response to, “Do you tend to snack on junk food (chips, soda, candy, desserts) most days?” Eating a healthier diet (≥5 servings of fruits and veggies each day and/or less junk food)† 2. Use of caffeine “Yes” to, “Do you drink caffeinated drinks like coffee, tea, soda, or energy drinks?” Cutting back to a safe amount of caffeine (<200 mg a day)† 3. Self-reported potential eating disorder “Yes” to, “Do you think you might have an eating disorder, like anorexia or bulimia?” Talking to a doctor about your eating disorder* 4. Not enough exercise (<30 min/d, 5 d/wk) “No” in response to, “Do you exercise or take part in regular activity, like walking or biking, 5 days a week for a minimum of 30 minutes?” Getting the recommended amount of exercise (30 minutes, 5 days a week)† 5. At risk for toxic concentrations of mercury “Yes” to, “Do you eat fish more than twice a week? (Certain types of fish may have high levels of mercury, which could cause health problems.)” Talking to a doctor about limiting the amount of fish you eat to the safe amount* 6. Use of herbal or weight-loss supplements “Have you ever taken herbs (like chamomile or ginseng), herbal teas, home remedies, or weight-loss products for your health?” Talking to a doctor about your herbal medicines* 7. At risk for listeriosis “Yes” to, “Do you eat unpasteurized dairy products or cheese; soft cheeses like feta, blue cheese, brie, goat cheese, or queso fresco?”; “Do you eat hot dogs or deli meat?” Talking to a doctor about preventing listeriosis* 8. Not using multivitamin with folic acid or folic acid supplement Selection of “none,” “don't know,” or “foods with folic acid” (without also selecting “folic acid pill” or “multivitamin with folic acid”) in response to, “What way(s) do you get folic acid?” Taking a multivitamin or folic acid pill daily† 9. Not taking calcium supplement Not selecting “calcium” in response to, “Do you take any of the following vitamins or minerals?” Getting more calcium† 10. Not taking iron supplement Not selecting “iron” in response to, “Do you take any of the following vitamins or minerals?” Getting more iron† 11. Need more omega-3 fatty acids in diet Indicating no intake of walnuts, olive oil, or fatty fish Eating more foods with omega-3 fatty acids† 12. Not taking supplement of vitamin D Not selecting “vitamin D” in response to, “Do you take any of the following vitamins or minerals?” Getting more vitamin D† 13. Overweight (BMI ≥ 30 kg/m2) BMI ≥30 kg/m2, based on self-reported height and weight Starting a healthy eating and exercise plan to manage your weight† 14. Possibly taking too much vitamin A Selection of vitamin A in response to, “Do you take any of the following vitamins or minerals?” Talking to a doctor about getting a safe amount of vitamin A* J. Relationships Interpartner violence (Any below) 1. Does not feel safe “Yes” in response to, “Are you afraid that someone you know may hurt you?”; “Are you ever afraid or nervous to go home?” Taking action to feel safer† 2. History or current emotional or verbal abuse “Yes” in response to, “Have you ever felt nervous or scared because of the things that someone said to you?”; “Has anyone ever told you that you are a bad person, that you are useless or that you are worth nothing?” Preparing to get out of an emotionally or verbally abusive relationship† 3. History or current physical or sexual abuse “Yes” in response to, “Have you ever been hit, slapped, kicked, or physically hurt in any way?”; “Has anyone ever made you do something sexual that you didn't want to do?” Preparing to get out of a physically or sexually abusive relationship† K. Reproductive health 1. History of abortion Selecting “≥1” in response to, “How many abortions (elective termination of pregnancy) have you had?” Talking with a doctor about your experience with abortion* 2. Prior cesarean deliveries Selecting “≥1” in response to, “How many cesarean sections (c-sections) have you had?” Talking with a doctor about your experience with cesarean delivery* 3. Less than 3 months between past pregnancies “Yes” to, “Have you ever gotten pregnant less than 3 months after the end of another pregnancy?” Talking with a doctor about the short time between your pregnancies* 4. Participant was born preterm or low birth weight “Yes” or “don't know” to, “Were you born very early or very small?” Telling a doctor that you were born with low birth weight or before term* 5. Participant's mother born before term or with a low birth weight “Yes” or “don't know” to, “When your mother was born, was she born very early or very small?” Telling a doctor that your mother was born with a low birth weight or before term* No/ineffective birth control 6. No birth control “No” in response to, “Do you use birth control on a regular basis?” Using birth control† 7. Withdrawal method Selection of “withdrawal” as birth control method used Using a more reliable type of birth control† 8. Other less effective birth control Selection of Plan B (morning after pill), rhythm/natural family planning, or “other” as birth control method used Using a more reliable type of birth control† Poor birth outcome (Any below) 9. History includes 1 or 2 miscarriage(s) Indicating 1 or 2 in response to, “How many miscarriages have you had?” Talking with a doctor about your experience with miscarriage* 10. History of infant born with a low birth weight “Yes” or “don't know” to, “Have you ever had a baby weighing 5.5 lb or less (or <2500 g) at birth?” Talking with a doctor about your baby born with a low birth weight* 11. History of preterm birth “Yes” or “don't know” to, “Have you ever had a premature or preterm baby (born at least 3 weeks early)?” Talking with a doctor about your preterm baby* 12. History of infant in NICU “Yes” to, “Have you ever had a baby that had to stay in an intensive care nursery (NICU)?” Talking with a doctor about your child who was in the NICU* 13. History of infant with a birth defect “Yes” or “don't know” to, “Have you ever had a baby with a birth defect?” Talking with a doctor about your child's birth defect* 14. History of infant or child death “Yes” to, “Have you ever had a child who died after he or she was born?” Talking with a doctor about your child's death* 15. History of stillbirth Selecting “≥1” in response to, “How many stillbirths have you had?” Talking with a doctor about your experience with stillbirth* 16. Prenatal appointments Not asked at time of baseline risk assessment; triggered during interactions with Gabby Starting prenatal care* 17. History of uterine anomalies “Yes” or “don't know” to, “Have you ever had a problem(s) with your uterus (womb)?” Talking with a doctor about the problems with your uterus* 18. History of vaginal bleeding late in pregnancy “Yes” to, “Have you ever had vaginal bleeding late in pregnancy?” Talking with a doctor about your history of vaginal bleeding during pregnancy* L. Substance Use 1. Any illicit substance use in the last year Selecting “≥1” in response to, “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” Talking to a doctor about quitting drugs† 2. Excessive alcohol (≥4 drinks in a day over the past year) Selecting “≥4” in response to, “During the past 12 months, what was the largest number of alcoholic drinks that you drank in a single day?” Cutting back to no more than 3 drinks at a time and cutting back to drinking no more than twice a week† 3. Any current tobacco use Selecting “I smoke, or use tobacco, regularly now”; “I smoke, or use tobacco, regularly now, but I've cut down”; or “I smoke, or use tobacco, every once in a while” in response to, “Which of the following best describes your tobacco use?” Quitting tobacco† ↵* Risk resolution was defined as the woman indicating that, “I've already talked to a doctor about it” (if risk was discussed with Gabby during the intervention) or “I have been working on this separately from Gabby” (if the risk was not discussed with Gabby during the intervention) when the risk-specific behavior was provided, after the following explanation: “Now we are going to go through the list of risks that were based on the health survey you took 6 months ago. I'll go through each item and please let me know if you: don't plan to talk to a doctor about it anytime soon, plan to talk to a doctor about it in the next 6 months, plan to talk to a doctor about it in the next month, have already talked to a doctor about it, or tell me if you don't think this risk should have been put on your list 6 months ago.”
↵† Risk resolution was defined as the woman indicating that, “I've done that at least once” or “I've been doing that for more than 6 months” (if risk was discussed with Gabby during the intervention) or “I have been working on this separately from Gabby” (if the risk was not discussed with Gabby during the intervention) when the risk-specific behavior was provided, after the following explanation: “Now we are going to go through the list of risks that were based on the health survey you took 6 months ago. I'll go through each item and please let me know if you don't plan to do it anytime soon, plan to do it in the next 6 months, plan to do it in the next month, have done it at least once, have been doing it for more than 6 months, or let me know if you don't think this risk should have been put on your list 6 months ago.”
BMI, body mass index; HIV, human immunodeficiency virus; MMR, measles, mumps, rubella; NICU, neonatal intensive care unit; PCP, primary care physician; PHQ-2, 2-item Patient Health Questionnaire; STI, sexually transmitted infection; TB, tuberculosis.
- Appendix 2. Risks Identified at Baseline and Resolved within 6 Months, By Study Group and Content Area
Preconception Care Risks Gabby Group Control Group P Value Baseline (n = 46) Resolved* (n = 36) Baseline (n = 45) Resolved* (n = 41) Emotional and mental health History of diagnosis of anxiety 4 (8.7) 0 (0.0) 3 (6.7) 0 (0.0) NA History of diagnosis of depression 5 (10.9) 2 (50.0) 2 (4.4) 0 (0.0) .47 Potential depression 6 (13.0) 2 (40.0) 5 (11.1) 0 (0.0) .44 History of diagnosis of bipolar disorder 1 (2.2) 0 (0.0) 2 (4.4) 0 (0.0) NA Family history psychiatric conditions (depression, anxiety, schizophrenia, bipolar disorder) 12 (26.1) 5 (55.6) 15 (33.3) 1 (7.7) .02 Stress 7 (15.2) 6 (100.0) 5 (11.1) 3 (60.0) .18 Total participants, Emotional and mental health 21 (45.6) 12 (66.7) 19 (42.2) 4 (25.0) .02 Total emotional and mental health risks (n) 35 15 32 4 Environmental issues Living near toxic waste or a “superfund” site 1 (2.2) 0 (0.0) 1 (2.2) 0 (0.0) NA Exposure to lead 24 (52.2) 3 (16.7) 21 (46.7) 3 (15.8) 1.00 Reported exposure to potentially toxic household chemicals 6 (13.0) 2 (40.0) 5 (11.1) 0 (0.0) .44 Frequently eating food from cans with a white plastic lining 14 (30.4) 0 (0.0) 13 (28.9) 1 (9.1) .44 Frequently drinking from plastic water bottles 36 (78.3) 5 (17.2) 38 (84.4) 2 (5.9) .23 At risk for toxoplasmosis 18 (39.1) 0 (0.0) 10 (22.2) 0 (0.0) NA Untested well water in the home 11 (23.9) 0 (0.0) 7 (15.6) 0 (0.0) NA Reported workplace exposure to chemicals or dangers 9 (19.6) 3 (50.0) 7 (15.6) 0 (0.0) .07 Total participants, environmental issues 44 (95.6) 11 (32.4) 43 (95.6) 5 (12.8) .05 Total environmental issues risks (n) 119 13 102 6 Genetic health history Ethnicity-based genetic health risk based on ancestry 44 (95.6) 10 (28.6) 44 (97.8) 9 (22.5) .55 Family history of a genetic health condition 18 (39.1) 6 (42.9) 15 (33.3) 4 (33.3) .70 Personal history of a genetic health condition 5 (10.9) 2 (66.7) 3 (6.7) 0 (0.0) .40 Need to learn family health history 4 (8.7) 1 (50.0) 5 (11.1) 2 (40.0) 1.00 Total participants, genetic health history 46 (100.0) 14 (38.9) 45 (100.0) 12 (29.3) .37 Total genetic health history risks (n) 71 19 67 15 Health care and programs Does not have a primary care physician 13 (28.3) 4 (44.4) 12 (26.7) 3 (33.3) 1.00 Inadequate health insurance 0 (0.0) 0 (0.0) 6 (13.3) 0 (0.0) NA Does not have health insurance 2 (4.4) 0 (0.0) 6 (13.3) 0 (0.0) NA Not been to dentist in over a year 15 (32.6) 4 (30.8) 16 (35.6) 4 (28.6) 1.00 Inadequate financial resources 4 (8.7) 0 (0.0) 24 (53.3) 0 (0.0) NA Total participants, health care and programs 16 (34.8) 5 (41.7) 31 (68.9) 5 (18.5) .23 Total health care and programs risks (n) 34 8 64 7 Health conditions and medicines History of diagnosis of asthma 7 (15.2) 2 (50.0) 9 (20.0) 3 (42.9) 1.00 History of diagnosis of disability 3 (6.5) 1 (33.3) 1 (2.2) 0 (0.0) 1.00 History of diagnosis of hypertension (high blood pressure) 2 (4.4) 1 (50.0) 1 (2.2) 0 (0.0) 1.00 Currently taking any over-the-counter medicines 13 (28.3) 1 (11.1) 10 (22.2) 2 (20.0) 1.00 History of diagnosis of prediabetes 2 (4.3) 2 (100.0) 1 (2.2) 0 (0.0) .33 Currently taking any prescription medications 14 (30.4) 7 (58.3) 13 (28.9) 3 (27.3) .21 History of diagnosis of rheumatoid arthritis 0 (0.0) 0 (0.0) 1 (2.2) 0 (0.0) NA Total participants, health condition and medicines 28 (60.9) 12 (54.5) 28 (62.2) 5 (20.0) .02 Total health condition and medicines risks (n) 41 14 36 8 Immunizations and vaccines Need hepatitis B vaccine 9 (19.6) 2 (28.6) 16 (35.6) 2 (14.3) .57 Unsure of immunization record 8 (17.4) 1 (14.3) 1 (2.2) 0 (0.0) 1.00 Need varicella vaccine 6 (13.0) 1 (20.0) 12 (26.7) 2 (20.0) 1.00 Need influenza vaccine 22 (47.8) 8 (47.1) 26 (57.8) 9 (40.9) .70 Need human papillomavirus vaccine 21 (45.6) 7 (41.2) 25 (55.6) 3 (13.0) .07 Need measles, mumps, and rubella vaccine 1 (2.2) 0 (0.0) 9 (20.0) 1 (12.5) NA Need tetanus-diphtheria-pertussis vaccine 2 (4.3) 1 (100.0) 11 (24.4) 2 (22.2) .30 Need tetanus vaccine 11 (23.9) 5 (71.4) 11 (24.4) 2 (22.2) .13 Total participants, immunizations and vaccines 38 (82.6) 17 (56.7) 42 (93.3) 15 (39.5) .22 Total immunizations and vaccines risks (n) 80 25 111 21 Infectious diseases At risk for hepatitis C 24 (52.2) 3 (16.7) 28 (62.2) 6 (24.0) .71 At risk for malaria 22 (47.8) 2 (11.1) 28 (62.2) 3 (11.1) 1.00 At risk for sexually transmitted infection 40 (87.0) 15 (48.4) 43 (95.56) 18 (46.2) .85 At risk for tuberculosis 23 (50.0) 12 (75.0) 23 (51.11) 6 (30.0) .02 At risk for cytomegalovirus 7 (15.2) 0 (0.0) 8 (17.78) 0 (0.0) NA Sexually active and not been tested for sexually transmitted infections 27 (58.7) 5 (22.7) 32 (71.11) 7 (23.3) .96 Not born in the United States 6 (13.0) 3 (60.0) 3 (6.67) 0 (0.0) .20* History of diagnosis of gonorrhea, chlamydia, or syphilis 16 (34.8) 9 (69.2) 13 (28.89) 3 (33.3) .19 History of diagnosis of human immunodeficiency virus 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) NA History of diagnosis of herpes 5 (10.9) 3 (75.0) 4 (8.89) 1 (25.0) .49 History of diagnosis of tuberculosis 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) NA Total participants, infectious diseases 46 (100.0) 25 (69.4) 45 (100.0) 23 (56.1) .25 Total infectious disease risks (n) 172 52 182 44 Men and health care Partner does not have primary care physician 21 (45.6) 2 (13.3) 9 (20.0) 4 (50.0) .13 Partner has not been to doctor in >1 year 13 (28.3) 1 (10.0) 8 (17.8) 3 (42.9) .25 Partner has not been counseled on reproductive life plan 30 (65.2) 4 (16.7) 22 (48.9) 7 (36.84) .17 Total participants, men and health care 31 (67.4) 5 (20.0) 26 (57.8) 9 (39.1) .21 Total men and health care risks (n) 64 7 39 14 Nutrition and activity Bad diet or food choices (<5 daily servings of fruits and vegetables and/or regular intake of junk food) 35 (76.1) 18 (64.3) 34 (75.6) 9 (30.0) <.01 Use of caffeine 41 (89.1) 12 (38.7) 32 (71.1) 10 (35.7) .81 Self-reported potential eating disorder 0 (0.0) 0 (0.0) 1 (2.2) 0 (0.0) NA Not enough exercise (< 30 min/d, 5 d/wk) 23 (50.0) 8 (50.0) 21 (46.7) 7 (26.8) .43 At risk for toxic concentrations of mercury 12 (26.1) 2 (20.0) 8 (17.8) 3 (50.0) .30 Use of herbal or weight-loss supplements 17 (37.0) 4 (30.8) 33 (73.3) 3 (9.7) .17 At risk for listeriosis 42 (91.3) 1 (3.1) 37 (82.2) 3 (9.1) .61 Not using a multivitamin with folic acid or a folic acid supplement 23 (50.0) 16 (80.0) 28 (62.2) 12 (50.0) .06 Not taking a calcium supplement 22 (47.8) 10 (50.0) 25 (55.6) 5 (23.8) .08 Not taking an iron supplement 29 (63.0) 13 (54.2) 37 (82.2) 6 (18.3) .004 Need more omega-3 fatty acids in diet 9 (19.6) 2 (28.6) 8 (17.8) 1 (16.7) 1.00 Not taking a vitamin D supplement 18 (39.1) 6 (37.5) 24 (53.3) 5 (25.0) .42 Overweight (BMI ≥30 kg/m2) 10 (21.7) 7 (100.0) 9 (20.0) 3 (42.9) .07 Possibly taking too much vitamin A 11 (23.9) 2 (33.3) 5 (11.1) 0 (0.0) .45 Total participants, nutrition and activity 46 (100.0) 32 (88.9) 45 (100.0) 29 (70.7) .09 Total nutrition and activity risks (n) 292 101 302 67 Relationships Interpartner violence (any below) 21 (23.3) 5 (31.3) 30 (66.7) 6 (22.2) .72 Does not feel safe 5 (5.6) 3 (60.0) 4 (8.9) 0 (0.0) .20 History or current emotional or verbal abuse 20 (22.2) 4 (26.7) 27 (60.0) 5 (20.8) .71 History or current physical or sexual abuse 11 (12.2) 3 (37.5) 22 (48.9) 4 (21.1) .63 Total participants, relationships 21 (45.6) 5 (31.3) 30 (66.7) 6 (22.2) .72 Total relationship risks (n) 36 10 53 9 Reproductive health History of abortion 9 (19.6) 3 (37.5) 6 (13.3) 3 (50.0) 1.00 Prior cesarean delivery 2 (4.3) 1 (100.0) 1 (2.2) 0 (0.0) 1.00 <3 Months between past pregnancies 0 (0.0) 0 (0.0) 2 (4.4) 0 (0.0) NA Participant was born before term or with low birth weight 14 (30.4) 2 (18.2) 7 (15.6) 1 (20.0) 1.00 Participant's mother was born before term or with low birth weight 18 (39.1) 1 (6.7) 20 (44.4) 1 (5.6) 1.00 No/ineffective birth control 24 (52.2) 4 (23.5) 19 (42.2) 6 (35.3) .71 No birth control 20 (43.5) 3 (18.7) 18 (40.0) 6 (37.5) .43 Withdrawal method 4 (8.7) 0 (0.0) 1 (2.2) 0 (0.0) NA Other less effective birth control 2 (4.3) 1 (5.9) 0 (0.0) 0 (0.0) 1.00 Poor birth outcome 7 (15.2) 1 (25.0) 4 (8.9) 0 (0.0) 1.00 History includes 1 or 2 miscarriage(s) 5 (10.9) 1 (50.0) 3 (6.7) 0 (0.0) 1.00 History of infant born with a low or high birth weight 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) NA History of preterm birth 2 (4.3) 0 (0.0) 0 (0.0) 0 (0.0) NA History of infant in the NICU 1 (2.2) 1 (100.0) 0 (0.0) 0 (0.0) NA History of infant with a birth defect 1 (2.2) 1 (100.0) 0 (0.0) 0 (0.0) NA History of infant or child death 2 (4.3) 0 (0.0) 0 (0.0) 0 (0.0) NA History of stillbirth 2 (4.3) 1 (50.0) 1 (2.2) 0 (0.0) 1.00 Prenatal appointments 2 (4.3) 0 (0.0) 0 (0.0) 0 (0.0) NA History of uterine anomalies 2 (4.3) 1 (100.0) 2 (4.4) 1 (50.0) 1.00 History of vaginal bleeding late in pregnancy 0 (0.0) 0 (0.0) 1 (2.2) 0 (0.0) NA Total participants, reproductive health 40 (87.0) 10 (32.3) 38 (84.4) 9 (26.5) .61 Total reproductive health risks (n) 87 16 62 12 Substance use Any illicit substance use in the last year 9 (19.6) 0 (0.0) 11 (24.4) 0 (0.0) NA Excessive alcohol (≥4 drinks in a day over the past year) 21 (45.6) 10 (62.5) 23 (51.1) 9 (42.9) .24 Cutting back to drinking alcohol on no more than 2 occasions per week Unknown 9 (56.3) Unknown 7 (33.3) .16 Eliminating binge-drinking (≥4 drinks in a day) Unknown 8 (50.0) Unknown 8 (38.1) .47 Any current tobacco use 6 (13.0) 0 (0.0) 7 (15.6) 2 (40.0) .44 Total participants, substance use 27 (58.7) 10 (50.0) 25 (55.6%) 11 (50.0%) 1.00 Total substance use risks (n) 36 17 41 17 Data are n (%) unless otherwise indicated.
↵* Percentage resolved calculated based on those participants who originally identified the risk and were reached at the 6-month follow-up.
NA, not available; NICU, neonatal intensive care unit.
