Effective Strategies for Promoting Preconception Health—From Research to Practice

The development and publication of this supplement of the American Journal of Health Promotion have provided an opportunity to connect with new partners in the field of preconception health education, assess the current state of the science on this topic, and note gaps in research that we hope readers will consider filling. As guest editors, we appreciate our colleagues who submitted articles for consideration, the guest reviewers for their time and willingness to serve, and the journal staff for their flexibility and support throughout the process. This supplement serves as a platform to elevate contributions made in the context of preconception health promotion since 2006 as well as to issue a call to action to expand the work being done in this important arena.

Six years ago, in partnership with over 35 national organizations and hundreds of partners, a select panel of experts on preconception health issued a series of 4 goals, 10 recommendations, and over 40 action steps focused on improving the health and well-being of women and men of childbearing age.¹ The recommendations addressed a number of domains, including consumer education, clinical care, advocacy and policy, research, and public health and community interventions. A complete list of the recommendations and action steps is included in the online version of this article (http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5506a1.htm). Four national workgroups were created to move this agenda forward based on these different domains. To catalyze action in the context of consumer education and health promotion, the National Preconception Health Consumer Workgroup was formed. A main charge of the consumer workgroup continues to be to improve the knowledge, attitudes, and behaviors of men and women related to preconception health by using information that is relevant across various age groups, literacy levels, and cultural and ethnic groups.¹ This journal issue on preconception health focuses mainly on women's preconception health and is one example of the consumer workgroup's efforts.

In the context of women, preconception health refers to the health of a woman of childbearing age prior to or between pregnancies. The purpose of preconception care is to identify and modify biomedical, behavioral, and social risks to a woman's health¹ in order to maximize her health as well as that of any babies she may have in the future. Increasing awareness, knowledge, and engagement in preconception health practices among women and their partners are important objectives. Data suggest that pregnancy intentions can improve birth outcomes.² Given the high infant mortality rates in the United States, particularly as compared to 28 other countries with better birth outcomes, this work is essential.³ Preconception health is unique as it is comprised of numerous components, including lifestyle (i.e., healthy weight, physical activity, smoking, drinking, substance use), screenings and vaccination (i.e., sexually transmitted infections, human immunodeficiency virus, rubella), and chronic disease management (i.e., diabetes, hypertension), along with family planning and exposure to teratogens, to name a few. Mass communication and clinician intervention about preconception health are challenging because of the volume of health topics within this issue and in light of the fact that half of all pregnancies are unplanned.⁴ Ultimately, a key task of the preconception health movement is to change social norms about the importance of the health of women and men and the impact it can have on their future reproductive goals.

Formative research, education campaigns, and interventions on single health topics among women of childbearing age are well documented in the literature.^5–13 However, less is known about how to effectively bundle and deliver a preconception health “ package” to consumers in a way that resonates with them and motivates them to take action. One goal of this supplement is to inform this dialogue. In soliciting the content for this issue, we were particularly interested in preconception health audience research, advances in message development and dissemination strategies, and innovations in public and private partnerships, as well as insight into improving the preconception health of at-risk populations.

A critical step in the process of developing and disseminating health promotion messages is to conduct audience research. Squiers et al. describe the formative research undertaken to identify and understand women's perceptions of preconception health. Research by Lewis et al. describes couples' notions about preconception health. Results from these studies have informed the development of preconception health message and promotion strategies that will be applied to a national social marketing effort.

As described previously, there are many preconception components that need to be shared with consumers. To inform this discussion, the article by King et al. describes message bundling research to assess the number of preconception health messages women could recall at the same time. Message tailoring strategies are an important part of consumer materials development as well. Levis et al. summarize the results of a content analysis of preconception health education materials in order to provide guidance to practitioners about materials development. Gardiner et al. offer insight into the use of a computer-based preconception care system that provides women with tailored education though a virtual patient advocate named Gabby. The findings of these studies provide practitioners with insight into how to craft and disseminate audience-centered messages.

Another domain of interest for this supplement is innovative public-private partnerships reaching women of childbearing age. The commentary on the text4baby program offers an excellent example of a national effort to reach pregnant women and new mothers with health messages. Although this work has yet to expand to preconception health, the approach and partnership are innovative and model the potential that mobile technology can offer.

Understanding how to reach at-risk women of childbearing age with preconception care is very important. The first article by Dunlop et al. assesses the acceptability and impact of reproductive and preconception health risk assessment and counseling in Women, Infants, and Children locations. In a second article, Dunlop et al. report on the impact of targeted brief counseling on women's knowledge of preconception health risks in publicly funded primary care settings. Adams et al. describe the impact of public policy expansions through California's family planning waiver on the receipt of preventive and reproductive health services. Bombard et al. report on the 2009 Behavioral Risk Factor Surveillance System data that describe opportunities for health care providers influence on lifestyle changes for women who have hypertension.

Finally, this issue describes several promising practices that reach special populations in the context of their communities. These include the work of Dixon-Gray et al. and Torres et al., whose initiatives focus on providing culturally appropriate preconception health education and outreach to Latinas in Oregon and South Carolina. Handler et al. report on the lessons learned from an extensive longitudinal interconceptional care program in Chicago that integrated social services, family planning, and medical care to meet the unique needs of women in diverse health care settings. Hogan et al. discuss the findings from their ethnographic study of African-American women in Philadelphia in order to share insight into the social context, preconception health, illness, and well-being of study participants. The study by Hanson et al. describes an evaluation of an intervention to prevent alcohol-exposed pregnancies among American Indian women.

We hope this supplement on preconception health provides a catalyst for continued strategic thinking, research, and publication on this important topic. If we are to improve women's health and birth outcomes, we must consider health and social systems issues, environmental impacts, and the reality of life today for young women, men, and mothers. We can't disregard the gap that exists between knowing and doing, nor can we ignore the challenges that many consumers face in actualizing their health goals. Further, we must acknowledge the significant inequities in health status and birth outcomes among different racial and ethnic groups. Women's lives are busy, complex, and filled with multiple demands. Offering guidance and information about healthy living, preconception care, and behavior risk reduction will be more effective when delivered within a context that focuses on the whole woman and considers barriers she may have to taking action. With this as the canvas, health care providers, policy makers, educators, public health leaders, and community leaders need to develop systems and supports that provide women with resources and tools to improve their health and well-being.¹⁴ There are educators and programs around the country working on preconception health. We urge them to continue to evaluate their work and publish their findings so that lessons learned and promising practices can be documented and applied by others in the field. Additionally, we call upon the research community to continue to examine gaps in audience research, message development and dissemination, and best practice implementation of preconception health promotion to build the science required to move this work forward.

Looking to the future, the Preconception Health Consumer Workgroup, through its national, state, and local partners, remains committed to its call to action. In February 2013, the consumer workgroup will launch the “Show Your Love” campaign, which will target women of childbearing age 18–44. The campaign aims to increase awareness of preconception health in the context of a woman's pregnancy intentions as well as to underscore the importance of pregnancy planning should a woman wish to become pregnant. A suite of campaign tools and resources will be available for use by partners at www.cdc.gov/preconception. Clearly there is much work ahead if we are to collectively improve the health and wellness of our nation's mothers and babies. We hope the articles included in this issue, both in hard copy and online, are thought provoking and informative for your health promotion practices.