Formative Research with Consumers about Preconception Health and Care

1. Formative Research with Consumers about Preconception Health and Care Linda Squiers, PhD,1 Elizabeth W.  Mitchell, PhD2 Denise M. Levis, PhD,2 Molly Lynch, MPH,1 Karen Isenberg, MPH1 Megan A. Lewis, PhD,1 Marjorie Margolis, BS,1 Julia Kish-Doto, PhD1 Monica Scales, PhD,1 Patricia Green, PhD2 • 1 RTI International • 2 CDC Division of Birth Defects and Developmental Disabilities

2. 2 • Social Marketing Phases • Goal: To develop an actionable multi-organizational social marketing plan • 2 Market Research research to inform Social marketing strategy

3. What are the challenges in marketing preconception health and health care? The target population is large 50% of women 18-44 years old have not heard of preconception health (Mitchell et al., 2009) PCH terminology is not lay-friendly Having a healthy baby is a great motivator, however 65% of pregnancies are unplanned (Chandra et al. 2005) Messages that focus on having a baby may not work for women who are not planning to become pregnant

4. Study Aims • Conduct formative research with consumers to learn more about their knowledge, attitudes, and beliefs about preconception health behaviors and health care services • Use findings to inform the development of a social marketing plan: • a brand • advertising concepts • messages

5. Methods

6. Theoretical Framework: Social Marketing

7. Research Questions Product • How do consumers refer to/think about the terms preconception health and preconception care? What other terms could be used to describe PCH or PCC? • Should this be referred to as a set of behaviors, a set of services, or both? Are there terms or words that make more sense to them, or that they use to describe this type of care or set of behaviors? • Do consumers understand the behaviors that fall under the PCC/PCH umbrella?

8. Research Questions Price • What motivates consumers to engage in PCH behaviors? • What are the barriers/challenges to engaging in these behaviors? Promotion • What types of messages would be most effective (e.g., reduced rates of birth defects vs. healthy bodies vs. healthy babies)? Place • What are consumers’ preferred channels for receiving information about PCC? • What venues would be most effective to promote these messages?

9. Segmenting the Target Audience • Target audience for PCH is women 18-44 years of age • Need to identify smaller segments to effectively target messages • Literature review suggested that these factors would affect receptivity to the message: • future pregnancy plans • whether woman already has a child • Used 2007 HealthStyles (n=639) data to examine demographic questions and attitudes to determine if segmentation approach was viable

10. Audience Segmentation Analysis Results

11. Age Distribution across Audience Segments

12. Descriptive Statistics for Active Pregnancy Planning Scale

13. Mean Active Pregnancy Planning Scale Scores by Audience Segments

14. Segmentation Strategy: Consumers

15. Methods • Held 10 Focus Groups with consumers in Atlanta • Professional recruitment firm used screener to recruit group members • 90 minute discussion groups • Exit survey on demographics • Provided $75 incentive • Analyzed data using QSR NVivo 8.0

16. Participant Eligibility Criteria • Woman between the ages 18-44 years • Not currently pregnant • Do not have condition that would make them unable to get pregnant • Total annual household income no more than $75,000

17. Participant Characteristics • N=65 participants • 21% had given birth in the last 12 months • Age: • 20% aged 18-24 • 35% aged 25-34 • 45% aged 35-44 • Race/ethnicity: • 51% White, 42% Black, 1% Latino, 1% American Indian

18. Participant Characteristics • Insurance status • 78% had private or employer-based • 10% had Medicaid or Tricare • 12% were uninsured • 76% of those who had children had notseen a provider before becoming pregnant. • 63% of those who plan to become pregnant plan to see a provider before becoming pregnant.

19. Findings

20. Product – Consumer Understanding • Participants had a general understanding of PCH behaviors and their importance • Limiting alcohol, quitting smoking, and taking prenatal vitamins were most salient, especially for planners • Non-planners questioned the need to do these behaviors when not preparing for a pregnancy • Recommendation for vaccinations (Rubella and Influenza) were confusing to some • Overall, PCH perceived as a lifestyle (i.e. being healthy) rather than a set of services

21. Product –Terminology

22. Product – What is Preconception Health? • “Making sure you’re healthy enough and you have all the, I guess, essential vitamins and make sure your blood pressure and everything, that you’re healthy enough to carry a child.” • “Preparing your body for a pregnancy.” • “I’m just looking at it going, if I was to say that to one of my friends, they would just look at me and go ‘Huh?” Because, I mean, it, it’s just not something that I would use in my everyday vocabulary.” • “People might be like, ‘Oh, that’s not me’. Because really I’ll probably read it and be like, ‘I don’t fall in that group. I’m not looking to get conceived, or pregnant.’”

23. Price - Motivators • Age and maturity • Social support: partner, family, friends • Access to a doctor: ability to discuss with a doctor • Health insurance • Planning: the desire to be pregnant was the strongest motivator across groups • Motivators for Planners: • Health of the baby and mother • Contribution to fertility • Being in the pregnancy mindset • Motivators for Non-planners: • Not much motivation overall besides living a generally health lifestyle

24. Motivators - Examples of what Participants Said • “My boyfriend…was all like, ‘Did you take your, your vitamins?’ I’m like, “Yeah.” He was like on me.” • “If they’re planning then they’re like 100% [motivated].” “But even if you are planning on trying to get pregnant and you’re young, I don’t think you think about this stuff because you’re not mature…and you’re just like ‘My baby’s going to be fine, I don’t need to do nothing…’ You’re older, then you’re going to think more about the stuff and go through the steps to do it…”

25. Price - Barriers • Addiction (e.g., cigarettes, alcohol, drugs) • Lack of social support: unsupportive partner or family “My family wasn’t really a great support system…so you, you have to get your information from somewhere else.” • Perceived lack of control over outcomes: • Cause of premature births or birth defects not always clear • Healthy women have premature babies, smokers and drug addicts can have a healthy babies • Finances: living a healthy lifestyle is expensive

26. Price – Barriers by Planning Status PLANNERS • Low income (being healthy is expensive) • Lower education level (not having awareness/knowledge) • Lack of support systems • Lack of access to healthcare NON-PLANNERS • Lack of trigger event such as pregnancy or planning for pregnancy • Even if practicing healthy behaviors, not likely to do pregnancy-specific behaviors (e.g., folic acid, Rubella vaccine) • Enjoyment of non-pregnancy behaviors, e.g., smoking, street drugs, and drinking too much alcohol

27. Promotion – Types of Messages • Messages for planners • PCH contributes to a healthy baby • Negative behaviors can lead to serious consequences • Baby with birth defects (fear appeals) • PCH contributes to a healthy mother • Different messages needed for non-planners • Overall health, healthy lifestyle • OOPS! campaign: “Oops. Did you know that 50% of women get pregnant later in life when they say that they’re done having children?”

28. Promotion – Types of Messages • Emphasis on consequences of negative behaviors • “…hit on where it hurts almost to stop them in their tracks” • “…enough to shock you, but not enough to traumatize you” • “…people are so much more motivated by the consequences of their actions”

29. Place – Channels and Venues • Discussion with provider (e.g., routine check-ups) • Sexual education curriculum • Points of temptation • At lunch hour when choosing between a salad and a hamburger: “And you’re bombarded with bad stuff everywhere so you should be bombarded with this stuff everywhere.” • Product placement for non-planners • Pharmacy – birth control pills • Tampax boxes • Yogurt tabs • Backs of beer bottles, fliers at bars, • Women’s apparel stores (e.g. Victoria’s Secret)

30. Women’s healthcare providers/resource centers Women’s health clinics Planned Parenthood Childbirth classes WIC Women’s consumer brands Tampax, Playtex, Yoplait Web-based Partners WebMD Facebook Results – Potential Partners

31. Next Steps • Use findings to inform: • A Social Marketing Plan for a Preconception Health Campaign • The development of a brand and ads for PCH • Plan is being developed with the Preconception Health & Health Care Consumer Workgroup • CDC staff from the National Center for Birth Defects and Developmental Disabilities

32. Partners • March of Dimes • State and local health departments • National Healthy Mothers Healthy Babies Coalition • Office of Minority Health Resource Center • National Healthy Start Association • CityMatCH • Every Woman Southeast • UNC Center for Maternal and Infant Health

33. Questions?

34. Contact Linda Squiers, Ph.D. Senior Research Scientist RTI International 919-597-5128 lsquiers@rti.org

35. References Mitchell, E. W., Lewis, M. A., Bann, C., Squiers, L. B., McKnight, M., Isenberg, K. L., Levis, D., Mersereau, P., & Taylor, M. (2009, August). Formative research on preconception health for consumers. Poster presented at annual meeting of the National Center for Health Marketing, Centers for Disease Control and Prevention, Atlanta, GA. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. National Center for Health Statistics. Vital Health Stat 23(25). 2005.