My Health ESnapshot: A Preconception Health Research Study

Report to: Board of Health

Meeting Date: May 4, 2016

Report Number: BOH Report – BH.01.MAY0416.R08

Prepared by: Liz Robson, Manager Reproductive Health; Lyn Lacey, Public Health Nurse; and Cynthia Montanaro, Public Health Nurse

Approved by: Andrea Roberts, Director, Family Health and Health Analytics 

Submitted by: Dr. Nicola Mercer, Medical Officer of Health & CEO

Recommendation(s)

(a) That the Board of Health receive this report for information.

EXECUTIVE  SUMMARY

The Preconception Health (PCH) Evidence Informed Path at WDGPH

  1. Literature Review
  2. Public Health Survey
  3. Community Survey
  4. PCH Research Study

Key Research Findings:

Start a PCH conversation with a Doctor or Healthcare Provider (HCP) Vs. Follow Advice From a Doctor or HCP:

  • 82% likely follow advice by HCP
  • 40% likely start conversation with HCP

Preferred Health Information Sources:

  • 83% Doctor/HCP
  • 61% Internet
  • 49% Public Health
  • 42% Family/Friend
  • 36% Printed Material

The Preconception Health Research Study “My Health eSnapshot”

  1. Risk Assessment
  2. PCP Discussion
  3. Patient Handout      

BACKGROUND

What is preconception health?

Preconception Health (PCH) refers to the health of all individuals during their reproductive years. It focuses on all individuals, regardless of gender identity and sexual orientation, taking steps now to promote healthy lifestyles and reduce risks in order to increase one’s chance of having a healthy baby in the future1. All individuals can benefit from PCH, whether or not they plan to have a baby one day.

Why is preconception health important?

Approximately 50% of pregnancies are unplanned1. Therefore, increasing our attention to PCH will help reduce the prevalence of poor maternal and childbirth outcomes such as preterm birth, low/high birth weights, congenital anomalies, infant mortality and maternal mortality.

Why involve primary care settings?

In 2013 and 2014, Wellington-Dufferin-Guelph Public Health (WDGPH) conducted a literature review2, a Public Health Unit environmental scan3 and a WDG community survey4 on PCH. These steps led to key findings that were foundational to the development of the My Health eSnapshot: A Preconception Health Research Study, “The Study”. In the literature review, public awareness and primary care provider outreach emerged as two promising strategies for PCH2. The literature also highlighted the importance of exploring innovative ways to deliver PCH messages, as well as the need for more research. The Public Health Unit environmental scan revealed that limited PCH health strategies existed targeting primary care providers and that there was limited evaluation of PCH initiatives led by public health across the province3. From the WDG community survey, the majority of respondents expressed an interest in PCH. In addition, the majority of respondents reported their doctor or healthcare provider as their preferred source of health information (83%) and were more likely to follow PCH advice if prompted by their doctor or healthcare provider (82%) 4. As well, in Canada, 83% of women ages 18-64 years reported consultation with their physician annually; this sets physicians in a promising position for PCH service delivery1.  

What is the research question?

Can a patient-driven electronic PCH risk assessment tool, for use in a primary care setting, increase PCH knowledge and behaviour change among women of reproductive age (15-49 years)?

This study has received ethics approval from WDGPH’s internal ethics committee.

Terminology Used in this Report

The term “primary care provider” is used throughout this report to refer to individuals involved in The Study in participating primary care settings. The specific primary care providers involved in The Study include: Physicians, Nurse Practitioners, Nurses and a Physician’s Assistant. The terminology “doctor of healthcare provider” is used in this report only in reference to the WDG PCH community survey to align with the question wording that was used in that survey tool. 

ANALYSIS/RATIONALE

The Study being led by WDGPH has led to both provincial and international interest as it is attempting to explore and evaluate innovative ways to improve PCH. If proven to be effective, findings from The Study will have the potential to influence how PCH care is delivered across Ontario and beyond. While PCH is specifically mentioned in the Ontario Public Health Standards, public health across the province has traditionally focused its reproductive health efforts on prenatal and postpartum services such as prenatal classes and the Healthy Babies Healthy Children (HBHC) program. This study is the first of its kind in Ontario and it has the potential to influence how PCH can be addressed using innovation, technology and partnerships between public health and primary care to promote optimal maternal and infant health outcomes. 

Based on key findings from the literature review, environmental scan and community survey, WDGPH has developed a patient driven preconception health risk assessment tool and patient handout called “My Health eSnapshot”. A patient-driven risk assessment tool and patient handout does not currently exist in Ontario and has been modelled after a tool developed by Boston Medical Centre in the United States. WDGPH has entered into a research agreement with Boston Medical Centre for the purpose of The Study. My Health eSnapshot is also intended to be complementary to a Preconception Health Care Tool developed for primary care providers by the Centre for Effective Practice in collaboration with the Ontario College for Family Physicians5. The risk assessment tool and patient handout developed by WDGPH were reviewed by 13 PCH experts in Ontario and the United States.

To develop My Health eSnapshot, WDGPH has also partnered with Cognisant MD, a Toronto-based software company that has developed a user-friendly tablet technology called Ocean. Ocean is a cloud based platform that allows patients to securely share encrypted health information for clinical use and research6. The use of Ocean has provided WDGPH with an innovative way for patients to complete the PCH risk assessment tool on a tablet prior to their primary care provider appointment. Ocean automatically integrates results into patients’ electronic medical records (EMR’s), has the capacity to generate a patient handout and allows public health to access non-identifying information collected from the PCH risk assessment tool. This approach aligns with a key PCH recommendation from the Ontario Public Health Association (OPHA) which is to invest in e-strategies to support the seamless integration of PCH into the delivery of care which in turn support data gathering and reserach1. 

Appendix “A” outlines the four steps involved in the preconception health intervention component of The Study. Phase I of The Study will be taking place at seven primary care sites in Wellington County and the City of Guelph from February 2016 until June 2016.  WDGPH has entered into a research agreement with each of the primary care sites participating in The Study. Participation was also extended to sites in Dufferin County but involvement in The Study was declined at the time of site recruitment. WDGPH will be recruiting a sample of 720 individuals to participate in The Study. For Phase II, WDGPH is planning to partner with the University of Guelph Health Services and is currently in the process of obtaining University of Guelph ethics approval.

Appendix “B” outlines the four steps involved in the evaluation phase of the PCH intervention. For Phase I of The Study, the evaluation phase began in February 2016 and will continue until August 2016. To begin the evaluation, WDGPH will access the de-identified data from the completed risk assessment tools via Ocean Studies to monitor PCH risk factors in the community. In addition, WDGPH will be following up with participants using an email survey one week and two months after the intervention. The purpose of the follow-up surveys will be to assess the effectiveness of the intervention including its impact on knowledge gain and behaviour change pertaining to the identified PCH risk factors. WDGPH will be able to link the risk assessment tool with the one-week and two-month evaluation surveys using a unique identifier created by each participant. The third phase of the evaluation will involve key informant interviews with all participating sites to assess the benefits, challenges and long-term sustainability of the PCH intervention. 

The data analysis and synthesis component of The Study began in February 2016 and will continue until November 2016. Study findings will be summarized in an overall report anticipated to be available at the end of 2016.

This study is rooted in evidence as a promising practice to improve the maternal and childbirth outcomes in our community. Based on the evaluation findings from the study, WDGPH may need to engage in additional pilot testing and/or explore opportunities to implement this strategy on a larger scale throughout WDG and Ontario.

This study has also been the successful recipient of a $15,000 grant from Women’s College Hospital. Funding from the grant will be primarily used to support knowledge translation activities at the conclusion of the study. 

Ontario Public Health Standards

Reproductive Health Standard

Goal

To enable individuals and families to achieve optimal preconception health, experience a healthy pregnancy, have the healthiest newborn(s) possible, and be prepared for parenthood.

Assessment and Surveillance Requirement

The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends overtime, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current) in the area of – preconception health.

Health Promotion and Policy Development Requirements

The board of health shall work with community partners, using a comprehensive health promotion approach, to influence the development and implementation of healthy policies and the creation or enhancement of supportive environments to address – preconception health.

The board of health shall increase public awareness of preconception health by adapting and/or supplementing national and provincial health communications; and/or developing and implementing regional/local communications strategies.

The board of health shall provide advice and information to link people to community programs and services on – preconception health.

WDGPH Strategic Commitment

Strategic Directions
DIRECTION APPLIES? (YES/NO)
Health Equity: Our programs and services use health equity principles to reduce or eliminate health differences in our communities.  YES
Organizational Capacity: We will improve our capacity to effectively deliver public health programs and services.  NO
Service Centred Approach: We are committed to providing excellent service to anyone interacting with Public Health. NO
Building Healthy Communities: We will work with communities to support the health and well-being of everyone. YES

Health Equity

Providing PCH care to Ontarians is not routine 1, 7. Clinical care standards supporting PCH care are fragmented1 and it is often up to individual patients to initiate a PCH conversation with their primary care provider in order to proactively seek out preconception advice and information. This study will allow the opportunity for women of reproductive age at participating primary care sites to have a PCH conversation with their primary care provider that likely would not have happened without the presence of this study.

This research study would disproportionally affect individuals in WDG that are attached to a primary care provider. Given that 98% of residents in the Waterloo Wellington LHIN8 and 95% of residents in the Central West LHIN9 have a primary care provider, very few individuals would fall through the cracks with an intervention that is based in the primary care setting. In addition, 83% of women ages 18-64 years in Canada reported consultation with their physician annually; this sets physicians in a promising position for PCH service delivery1. 

Study eligibility criteria would prevent some individuals from participating in this study as it is a requirement that individuals be able to read and write in English, have a valid email address and be comfortable using a tablet. If this study were to continue beyond the pilot testing phase, measures would be put in place to mitigate these restrictions including making the tool available in multiple languages and having a paper option available for those who are not comfortable using technology. 

Appendices

Appendix “A”:  My Health eSnapshot Intervention

Appendix “B”:  My Health eSnapshot Evaluation

References

1 Ontario Public Health Association. (2014). Shift- Enhancing the health of Ontarians: A call to action for preconception health promotion and care. Toronto, ON.

2 Wellington-Dufferin-Guelph Public Health (2013). Preconception Health Project 2013: Synthesis of Findings. Guelph, Ontario.

3 Wellington-Dufferin-Guelph Public Health (2014). Preconception Health: What’s Happening in Public Health? Guelph, Ontario.

4 Wellington-Dufferin-Guelph Public Health (2014). Insight into Preconception Health: Community Survey Findings 2014. Guelph, Ontario.

5 Preconception Health Care Tool [Internet]. 2015. Centre for Effective Practice. [Cited 2016 April 11]. Available from http://effectivepractice.org/resources/preconception-health-care-tool/

6 Ocean [Internet]. 2016. Cognisant MD. [Cited 2016 April 11]. Available from http://www.cognisantmd.com/

7 No Time to Wait: The Healthy Kids Strategy [Internet]. 2013. Healthy Kids Panel. [Cited 2016 April 11]. Available from http://www.health.gov.on.ca/en/common/ministry/publications/reports/healthy_kids/healthy_kids.pdf

8 Waterloo Wellington LHIN Community Report 2014-2015 [Internet]. 2015. Waterloo Wellington LHIN [Cited 2016 April 11]. Available from file:///C:/Users/lizr/Downloads/RPT_20150702_communityreport_Final_web2.pdf

9 Central West LHIN Annual Report 2014-2015 [Internet]. 2015. Central West LHIN [Cited 2016 April 11] Available from file:///C:/Users/lizr/Downloads/2014-2015%20AR_Eng.pdf

APPENDIX “A”: My Health eSnapshot Intervention

STEP 1: Patient completes the risk assessment tool on a tablet prior to appointment in the waiting room or exam room.

STEP 2: Information from the completed tool transfers to the patient’s electronic medical record (EMR).

STEP 3: Primary care provider has a discussion with the patient based on identified risks or areas of concern flagged from the completion of the risk assessment tool in the EMR.

STEP 4:Patient receives a customized handout based on responses to the risk assessment tool to take home. The patient handout includes sections: “What is going well?”, “What to think about?”, “Why does it matter now?” and “Why does it matter for pregnancy?”

APPENDIX “B”:  My Health eSnapshot Evaluation

STEP 1: WDGPH to access the de-identified data from the completion of the risk assessment tool via Ocean Studies to monitor preconception health risk factors in the community.

STEP 2: Participants complete the I-week follow up survey to evaluate the risk assessment tool, the patient handout and patient experience discussing PCH with their primary care provider.

STEP 3: Participants complete the two-month follow up survey to evaluate knowledge gain and behaviour change for identified PCH risk factors.

STEP 4: WDGPH to link participant responses from the risk assessment tool, the one-week follow up survey and the two-month follow up survey using the patient generated unique identifier.

STEP 5: Key informant interview with all participating sites to assess the benefits, challenges and long-term ustainability of the preconception health intervention.