Preconception health interventions delivered in public health and community settings: A systematic review.

Brown, Hilary K. ; Mueller, Melissa ; Edwards, Sarah 等

Despite advances in medicine and universal access to prenatal care, poor perinatal outcomes persist in Canada. Many individuals are not in good health at conception, (1) and ever-growing research suggests that preconception health affects reproductive, maternal, and neonatal health outcomes. (1,2) Preconception health describes the health of all individuals during their reproductive years with a particular focus on reducing risk factors, promoting healthy lifestyle behaviours, and increasing readiness for pregnancy, regardless of sex, sexual orientation, or whether or not individuals plan to have children. (3) There is mounting consensus that interventions before conception are necessary to improve perinatal outcomes. (4) Many risk factors for poor birth outcomes, such as lifestyle behaviours, are modifiable in the preconception period with appropriate individual intervention and public policy initiatives. (5-7) Improved preconception health promotes fertility, prevents congenital anomalies, decreases the rate of preterm birth, improves birth weight, and reduces infant and maternal mortality. (1,8-12) However, approximately 50% of pregnancies are unplanned. (13) Every contact between individuals of reproductive age and health care providers in clinical, public health, and community settings is an opportunity to discuss preconception health issues such as chronic medical conditions, mental health, sexual health, environmental exposures, nutrition, immunization, physical activity, lifestyle behaviours, and reproductive life planning. (14-16) The first prenatal appointment, when many of these topics are often addressed, is too late. (17)

A recent position paper by the Ontario Public Health Association identified barriers to optimal preconception health in Canada. (18) Although Canada has achieved some progress in this field in recent years, a comprehensive, standardized approach to preconception health promotion and care with specific guidelines is absent both provincially and federally. (18) In Ontario, for example, where preconception health promotion is mandated under the Ontario Public Health Standards, (19) public health units have no uniform program to follow and are left to prioritize resources and develop and implement programming according to local need. (18) One of the major barriers to preconception health in Canada is the lack of data on interventions and their effectiveness. There is growing evidence to suggest that interventions promoting preconception health delivered in primary care settings may improve knowledge, self-efficacy, and health locus of control, and reduce poor lifestyle behaviours. (20) These interventions tend to address risk factors in high-risk populations (e.g., women with chronic medical conditions). (18) However, given the wide scope of preconception health and the high rate of unplanned pregnancies, it is important that preconception health promotion and care also be delivered to individuals in public health and community settings, in addition to primary care, to maximize population impact. There is a need to identify and assess preconception health interventions that adopt a broader health promotion and prevention approach and that are suitable for delivery in public health and community settings (e.g., education programs, public awareness campaigns, peer support, interactive electronic risk assessments, healthy public policy, and supportive environments).

The objective of this systematic review was to assess the effects of preconception health interventions, delivered to individuals of reproductive age in public health and community settings, on reproductive, maternal, and child health outcomes.

METHODS

Search strategy

We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. (21) An expert librarian searched seven databases in July 2016. These databases were Ovid MEDLINE, CINAHL, EMBASE, PsychINFO, Scopus, Gender Studies Database, and SocINDEX. Searches were conducted of article titles, abstracts, and keywords or descriptors employing combinations of the following search terms: "preconception care" or "preconception assessment" or "preconception health" or "prepregnancy care" or "pre-pregnancy assessment" or "periconception care" or "periconception assessment" or "periconception health" AND "public health" or "health promotion" or "health prevention" or "preventative health" or "community health service" or "community health care" or "community clinic" or "family planning service" or "ambulatory care" or "urgent care clinic" or "primary health care" or "family doctor" or "family practice" or "general practice." Where possible, all terms were included as full text, truncation being used to capture variation in terminology. The database search was limited to the period July 1999 to July 2016; the start date was selected following the end of a search of an earlier review by Korenbrot et al. (22) Hand searches of the reference lists of included articles were also performed.

Selection criteria

For inclusion in the review, studies were required to fulfill the following criteria: a) reported original data on the effectiveness of preconception health interventions aimed at improving reproductive, maternal, or child health outcomes; b) used an interventional study design (e.g., randomized controlled trial, quasi-experimental, pre-post, or interrupted time series design); c) included women or men of reproductive age (15-45 years); d) were written in English; and e) were published in a peerreviewed journal. We included both primary interventions (e.g., advice on environmental exposures, mental health, sexual health, nutrition, immunization, physical activity, lifestyle behaviours, or reproductive planning) and secondary prevention interventions (e.g., screening for genetic disorders or chronic medical conditions such as diabetes).

Studies were excluded if the article a) did not report original data (e.g., meta-analyses, review papers, commentaries); b) used a purely observational study design (e.g., cohort studies, case-control studies) or did not have a comparison group; or c) included women or men with specific medical needs (e.g., diabetes, human immunodeficiency virus) or women who were already pregnant. All titles and abstracts were reviewed independently by three reviewers (HKB, MM, and SAE) for relevance.

Data extraction and management

All selected abstracts were compared across the three reviewers (HKB, MM, and SAE) and, upon agreement, the full articles were retrieved. From the included studies, information on the date of publication, study design, location, setting of the study, study population, participation rate, duration of participation, type of intervention(s), type of outcome(s), analysis approach, and findings with their statistical significance were extracted using a standardized extraction form.

Quality assessment

Each study was critically appraised by two assessors (from among HKB, MM, and SAE); a third assessor was used to adjudicate disagreements (n = 1). We employed the Effective Public Health Practice Project Quality Assessment (EPHPP) tool. (23) Developed by Canadian public health professionals, the EPHPP has been validated and is widely used in public health research. (23) The tool rates articles as strong, moderate, or weak on the basis of the following domains: a) selection bias, b) study design, c) confounding, d) blinding, e) data collection methods, and f) withdrawals and dropouts.

Analysis approach

We planned to perform a quantitative synthesis of the data using either fixed effects meta-analysis (in the absence of heterogeneity) or random effects meta-analysis (in the presence of heterogeneity). However, given the substantial diversity of the study populations, interventions, and outcomes among the retrieved articles, it was not possible to complete a meta-analysis. Instead, we performed a narrative synthesis.

RESULTS

Characteristics of included studies

The literature search yielded 3045 records (Figure 1). Following removal of duplicates, 2100 records were retained. We excluded 2066 articles on the basis of title and abstract review. Through the search, a recent systematic review of preconception health interventions in primary care settings was identified. (20) As such, these studies of primary care interventions (n = 8) were excluded from the current review. Additionally, we excluded articles that had no intervention (i.e., purely observational or descriptive designs), included only pregnant women, described only the process or program with no outcome measurement, or were incomplete (e.g., abstracts only, pilot studies). In total, 12 studies met the inclusion criteria for our search. (24-35) (See the Supplementary file, in the ARTICLE TOOLS section on the journal site.) No additional studies were identified through hand searches of these studies.

The 12 studies identified represent study periods spanning 1994 through 2013 in three countries (Table 1). A majority of studies (n = 8, 67%) were conducted in the United States, (25,27-33) three in Australia, (26,34,35) and one in Italy. (24) Study designs included randomized controlled trials (n = 5, 42%), (25,28,31,32,34) quasiexperimental studies (n = 1, 8%),30 pre-post studies (n = 5, 42%), (24,26,27,29,33) and interrupted time series (n = 1, 8%). (35) In total, four studies (33%) had sample sizes greater than 500 subjects. (28,30,34,35) Only four studies (33%) provided participation rates, which ranged from 32% to 77%. (24,25,27,32) Four studies (33%) recruited specific groups of individuals, including female college students (27,32,33) and African American women. (29) Only one study (8%) included men. (29) Participants were recruited using a variety of strategies: online, (24) E-mail, (32) and telephone invitations (26,35) and in-person approaches in a number of settings, such as colleges (33) and shopping malls. (30)

The interventions identified focused on a range of risk factors related to adverse perinatal outcomes, including chronic and genetic diseases, (24,33) stress, (28) sexually transmitted diseases, (24,27,28,33) nutrition and folic acid supplementation, (24-27,28,31-35) vaccinations, (24,33) physical activity, (24,27) tobacco exposure, (24,28,33) and alcohol use. (24,28,33) Delivery of information was varied and included tailored documents based on individual risk information, (24) simple print materials such as posters and brochures, (26,30,34) and web-based platforms such as Twitter (31) and E-mail. (32) In addition, two studies examined media campaigns delivered by radio and billboards. (29,35) Four studies (33%) used education sessions ranging from a single 15-minute computerized intervention (25) to instructor-led group sessions of 90-120 minutes. (27,28,33) Four studies (33%) had intensive interventions involving multiple contacts. (27,28,31,32) However, a majority (n = 8, 67%) had only a single contact. Half of the studies (n = 6) had no follow-up period (i.e., outcomes were assessed immediately after the intervention). (26,29,30,33-35) Among those with a follow-up period, two had a duration of less than 2 weeks, (28,31) two had a duration of between 4 and 6 weeks, (27,32) and two had a duration of 6 months. (24,25)

Study outcomes were grouped into three broad categories: knowledge increase, behaviour change, and health outcomes (Table 2). Most of the studies (n = 9, 75%) examined individuals' knowledge of preconception health. (24-27,29,30,33-35) These studies varied in the type of intervention as well as the topics selected to assess knowledge increase. Examples of knowledge tested include general preconception health, folic acid intake and its effects, types of foods enriched with folate, and risks of smoking and alcohol exposures. All studies measuring knowledge increase reported statistically significant increases in knowledge. Four studies examined self-reported change related to a specific health behaviour, such as using folic acid supplements, (24,25,28,32) updating vaccinations, (24) increasing physical activity, (28) and reducing smoking and alcohol consumption. (24) All of these studies reported statistically significant positive changes in behaviour. Another study reported on behavioural intentions and did not have any statistically significant results. Finally, one study examined an actual health outcome. This study found a statistically significant decrease in the prevalence of neural tube defects following a folic acid health promotion intervention aimed at both health professionals and the general public, which used posters and pamphlets in public spaces such as community health centres, childcare centres, and schools. (26)

Quality assessment

Using the EPHPP quality assessment tool, the global rating for 11 of the studies was weak (Table 3). One study was rated as moderate; (32) this study was a randomized controlled trial of a folic acid awareness intervention. The most common limitations of the studies were related to selection bias, blinding, data collection methods, and withdrawals and dropouts. The selection bias component of the EPHHP had the highest number of weak ratings (n = 8, 67%) (24,25,27,29-33) due to low (32%-77%) or unreported participation rates, as well as study participants' poor representativeness of the broader target population because of self-referral into the study. A majority of studies also received a weak rating on blinding (n = 7, 58%); (24,27-29,33-35) this was mostly due to study design (e.g., pre-post) and the nature of the interventions, resulting in awareness among both assessors and participants of intervention status. A similar number of studies received a weak rating on data collection methods (n = 7, 58%) (24-26, 28-30, 34-35) because most authors did not use validated tools or did not report their psychometric properties. Finally, five (42%) of the studies received a weak rating for withdrawals and dropouts because of high attrition (52%-77%) or unreported follow-up rates. (24,25,27,28,31) Only one study that included a follow-up rate reported that over 80% of individuals who started the study completed it. (32)

DISCUSSION

Summary of findings

Our systematic review consisted of 12 studies that examined the effectiveness of preconception health interventions, delivered to individuals of reproductive age in public health and community settings, on reproductive, maternal, and child health outcomes. There was substantial heterogeneity among the included studies in terms of study design, study population, type of intervention, and type of outcome. Only five studies used a randomized controlled trial design, the gold standard for measuring intervention effectiveness. The majority instead adopted quasi-experimental, pre-post, or interrupted time series designs. Most studies examined educational interventions with a single point of contact with participants and no follow-up. Overall, the diverse interventions appeared to have a positive effect on preconception health knowledge, behaviour change, and the specific health outcomes that were targeted. However, the quality of the included studies was weak, and notable gaps in the focus of the studies included a lack of information on the effectiveness of preconception health interventions delivered to men and to LGBTQ (lesbian, gay, bisexual, transgender and queer) populations as well as on interventions targeting broader preconception health determinants, such as mental health and environmental exposures.

Comparison with previous research

Our study contributes to the literature by systematically evaluating the effectiveness of preconception health interventions delivered outside of clinical settings (i.e., in public health and community settings). Such an evaluation is critical, given the wide scope of preconception health, the high rate of unplanned pregnancies, (13) and the barriers experienced by some population groups (e.g., recent immigrants and those of low socio-economic status) in accessing clinical care. (36,37) To our knowledge, three previous systematic reviews have evaluated the effectiveness of preconception health interventions on reproductive, maternal, and child health outcomes. (20,22,38) Unlike our review, they included studies that were conducted mainly among women in clinical settings such as primary care, obstetrics or midwifery, and urgent care.

The earliest of these reviews was conducted by Korenbrot et al. (22) The authors identified 19 randomized controlled trials, quasiexperimental studies, and pre-post studies published between January 1990 and July 1999. Interventions, conducted mainly in hospital settings, were education sessions, diet supplementation, and nutritional counselling. The authors found some evidence of improved uptake of screening for risk conditions, folate supplement use among sexually active women, and nutrition quality among women with specific metabolic conditions (e.g., diabetes, phenylalanemia). However, the quality of included studies was not systematically evaluated. A Cochrane systematic review and meta-analysis was conducted by Witworth and Dowswell. (38) After excluding studies with a high risk of bias, the authors identified only four randomized controlled trials and quasi-experimental studies of preconception health interventions published before February 2009. Interventions were education sessions delivered across one or multiple time points in clinical settings. In the meta-analysis, the authors found no effect of these interventions on preterm birth, weight for gestational age, or congenital anomalies. Most recently, a systematic review by Hussein et al. (20) evaluated eight randomized controlled trials published between July 1999 and July 2015. Interventions, mainly education sessions, counselling, and health risk assessments, were delivered in general clinical practices, gynecology outpatient clinics, or women and infant clinics, or during home visits by midwives. Generally, the authors found a positive effect of the interventions on knowledge increase and behaviour change as well as self-efficacy and health locus of control. The quality of included studies was rated as weak or moderate. As shown by the variable findings and quality of the existing literature, there is a need for rigorous research in this area across diverse health care settings.

Limitations

Our ability to provide practice recommendations about the effectiveness of preconception health interventions delivered to all individuals in public health and community settings is limited by the quality of the studies included in the review. Given the small number of studies on the topic, we included both randomized controlled trials and other, weaker, interventional study designs, including quasi-experimental, pre-post, and interrupted time series designs. These latter designs are more vulnerable to confounding than randomized controlled trials, either because of differences between intervention and control groups (e.g., for quasi-experimental designs) or because of changes in health behaviours or population characteristics across time (e.g., for pre-post or time series designs). (39) Therefore, it is more difficult to attribute changes in knowledge, behaviour, or health outcomes to the intervention itself as opposed to these underlying differences.

Although implementation of randomized controlled trials in public health and community settings can be difficult, high-quality research is needed so that the effectiveness of interventions can be evaluated. Upon assessment, all included studies except one were given a "weak" quality rating. A common limitation of the studies was selection bias. Of the studies that provided information on participation rates, between 32% and 77% of individuals approached agreed to participate. Similarly, many studies with follow-up periods reported high rates of withdrawal from studies, with follow-up rates of only 52% to 77%. Collectively, low participation rates and high attrition make it possible that included participants were not representative of the broader population. Moreover, half of the included studies had no follow-up beyond the immediate study period, leaving it unclear whether interventions had a lasting, meaningful impact. Finally, few studies used validated outcome assessments, and only a handful of studies reported piloting their questionnaire before study implementation. The one moderate-quality study was a randomized controlled trial of a folic acid intervention. (32) While promotion of folic acid supplementation certainly warrants attention, there is a need for evaluation of interventions that address other risk factors and take a much broader approach to preconception health.

While the literature surveyed in our review does not necessarily represent all interventions being practised, formal evaluation of interventions is critical; as stated in the Select Panel on Preconception Care of the US Centers for Disease Control and Prevention, there is clearly a need to "increase the evidence-base for preconception health and promote use of evidence in delivering preconception health". (40)

Implications

Our review highlights several areas that warrant further research. As demonstrated by our findings, most of the interventions to date have been targeted at women. Ontario data from the Best Start Resource Centre survey of reproductive-aged women and men showed gaps in understanding of the man's contribution to the health of a pregnancy and baby. (41) The World Health Organization recommends that men should be active partners in preconception health promotion and care. (3) Yet, few preconception health risk assessments, screening programs, or education initiatives include or target men. There is also a paucity of research including LGBTQ populations. (18) There is a need to design inclusive preconception health interventions that are accessible for all individuals of reproductive age, regardless of their gender identity, gender expression, or sexual orientation, including those planning and not planning a pregnancy.

Most interventions focused on medical and lifestyle determinants of preconception health (e.g., nutrition, immunization, physical activity, and lifestyle behaviours) aimed at the individual, and there was a particular emphasis on folic acid interventions. While such interventions are important, there was a lack of information on interventions targeting mental health and environmental exposures. Mental illness is the most common cause of disability in women and men, (42) and there is evidence that maternal and paternal mental illness affects infant outcomes. (43) Environmental hazards, such as living near industrial or landfill sites or exposure to plastics (e.g., phthalates), are increasingly being recognized as risk factors for poor perinatal outcomes. (44) There is a clear need for high-quality research evaluating the effectiveness of preconception health interventions that address the broad determinants of preconception health; many of these determinants (e.g., environmental exposures) may require community- and population-level action.

To move beyond this narrow focus, preconception health promotion and care within a public health context should adopt a health equity lens. This perspective is based on a broad socioenvironmental approach that shifts the responsibility for preconception health from the individual level alone to the community and system levels as well. (18) Such an approach highlights the roles of the social determinants of health, including income, employment, and social connectedness, which are known to have an impact on birth outcomes (e.g., pre-term birth) (45) and also recognizes that many upstream social determinants of health are complex and involve factors outside of an individual's control (e.g., affordable housing). (46) A health equity approach to preconception health promotion and care is consistent with the Ontario Public Health Standards (19) and requires greater political awareness and support for preconception health. In Ontario, reproductive health is a recognized component of the mandates of the Ministry of Health and Long-Term Care and the Ministry of Children and Youth Services; however, a focus on preconception health is lacking. (18) Political momentum is needed to develop a comprehensive, standardized approach to preconception health promotion and care in Canada.

It is notable that all included studies were conducted outside of Canada (i.e., the US, Australia and Italy). It is likely that the social and health context of these studies affected their results. It is unclear to what extent results may be generalizable to the Canadian context. There is a real need for assessment of preconception health promotion and care interventions delivered and evaluated in Canada.

CONCLUSION

There is growing evidence that preconception health interventions, delivered to women and men in public health and community settings, improves health knowledge, behaviour change, and health outcomes. However, the methodological quality of existing research is poor, and there is a lack of information on interventions appropriate for men and LGBTQ populations. Further, no studies have targeted the broader determinants of preconception health, including mental health and environmental exposures. Future research should consider adopting a health equity lens that considers the broader socioenvironmental determinants of preconception health and includes all individuals.

doi: 10.17269/CJPH.108.6029

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(45.) Blumenshine P, Egerter S, Barclay CJ, Cubbin C, Braveman PA. Socioeconomic disparities in adverse birth outcomes: A systematic review. Am J Prev Med 2010; 39(3):263-72. PMID: 20709259. doi: 10.1016/j.amepre.2010.05.012.

(46.) Mill C, Enders J, Montanaro C, Moore KM. Delayed parenthood on the rise: A call for upstream preconception health promotion in Canada. Can J Public Health 2016; 107(3):e333-35. PMID: 27763852. doi: 10.17269/cjph.107.5497.

Received: December 8, 2016

Accepted: April 21, 2017

Hilary K. Brown, PhD, [1-3] Melissa Mueller, BA, [4,5] Sarah Edwards, PhD, [2,4] Catriona Mill, RN, MHSc, CCHN(c), [5,6] Joanne Enders, BScN, RN, [6,7] Lisa Graves, MD, [8] Deanna Telner, MD, MEd, CCFP, FCFP, [9] Cindy-Lee Dennis, PhD [3,10-12]

Author Affiliations

[1.] Interdisciplinary Centre for Health & Society, University of Toronto Scarborough, Toronto, ON

[2.] Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[3.] Women's College Research Institute, Women's College Hospital, Toronto, ON

[4.] Alberta Health Services, Edmonton, AB

[5.] Toronto Public Health, Toronto, ON

[6.] Ontario Public Health Association, Toronto, ON

[7.] Region of Waterloo Public Health and Emergency Services, Waterloo, ON

[8.] Department of Family and Community Medicine, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, MI

[9.] Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON

[10.] Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON

[11.] Department of Psychiatry, Faculty of Medicine, Toronto, ON

[12.] Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON

Correspondence: Hilary K. Brown, PhD, Interdisciplinary Centre for Health & Society, University of Toronto Scarborough, 1265 Military Trail, Scarborough, ON M1C 1A5, Tel: 416-208-2239, E-mail: hk.brown@utoronto.ca

Acknowledgements: The authors thank Jorden Smith-Habib for performing the database searches and Natalie Bourdages, Shelley Charbonneau, Josee Dion-St. Pierre and Kimberley Marshall for reviewing previous versions of the manuscript.

Conflicts of Interest: None to declare.

Caption: Figure 1. Summary of studies selected for inclusion. Table 1. Description of included studies (n = 12) Study, Design Study Location year period Agricola Pre-post September Italy 2014 (24) 2011-May 2013 Bimla RCT March US Schwarz 2005-2006 2008 (25) Chan 2001 Pre-post October Australia (26) 1994-August 1995 DeJoy Pre-post N/A US 2014 (27) Hillemeier RCT N/A US 2008 (28) Hussaini Pre-post October US 2013 (29) 2009-August 2010 King 2013 Quasi- N/A US (30) experimental Mackert RCT N/A US 2012 (31) Milan 2010 RCT N/A US (32) Wade 2012 Pre-post N/A US (33) Watson RCT November Australia 2001 (34) 1996-April 2000 Williams Interrupted July Australia 2001 (35) time series 1998-May 1999 Study, Population/no. Intervention(s) year participants Agricola Criteria: Italian- Approach: Tailored, 2014 (24) speaking women aged individual education 18-45 years with plan of document getting pregnant in following year Content: Based on self- reported risk factors; Recruitment: Self- recommendations based on referred online ACOG guidelines; provided details on exposure, Sample size: 282 associated adverse events and strategies to change Participation rate: 56.7% behaviours Delivery: Online; encouraged to take document to physician Bimla Criteria: English- Approach: One 15-minute Schwarz speaking women aged 18-45 counselling session; 2008 (25) years women also received 200 folate tablets at the end Recruitment: Urgent care of the counselling centre waiting rooms session Sample size: 446 Content: Periconceptional folate supplementation Participation rate: 42% (what it is, why it should be used, how often it should be used, where supplements can be purchased) Delivery: Computerized questions and videos, in a semi-private space Chan 2001 Criteria: Southern Approach: Posters and (26) Australian women aged pamphlets 15-44 years Content: Information on Recruitment: Random digit folate in prevention of dialing from Electronic neural tube defects White Pages Delivery: Posted in Sample size: 408 before, community health centres, 401 after health food stores, shopping centres, Participation rate: N/A libraries, child care centres, schools, pharmacies, doctors' waiting rooms, and hospitals (aimed at public and health professionals) DeJoy Criteria: College-aged Approach: Four 90-minute 2014 women education sessions (27) Recruitment: Flyers and Content: Reproductive TV advertisements on life planning, HIV and campus STIs, healthy lifestyle choices, maternity care Sample size: 20 Delivery: Women's circle Participation rate: 77% at a small public liberal arts college Hillemeier Criteria: Non-pregnant Approach: Six biweekly 2008 (28) women aged 18-35 years two-hour small group sessions over 12 weeks Recruitment: Triangular community-based approach Content: Motivation for in 15 low-income rural behavioural changes communities related to managing stress, nutrition, Sample size: 692 gynecologic infection, tobacco and alcohol use Participation rate: N/A Delivery: Group sessions led by trained facilitators Hussaini Criteria: Approach: 1) media 2013 (29) African-American men and campaign, 2) community- women aged 18-30 years based presentations, 3) grand rounds for health professionals Recruitment: In the Content: Awareness about community using flyers life course perspective Sample size: 24 men, 27 and general preconception women and interconception health, with an emphasis on improving birth Participation rate: N/A Delivery: 1) radio, billboards, flyers, 2) barber and beautician shops frequented by African-American community members, 3) clinical settings (for health professionals) King 2013 Criteria: Women aged 18- Approach: Professionally (30) 36 years with plan of developed brochures with getting pregnant in next preconception health 5 years (excluded messages individuals working in health field, Content: Different participating in other combinations of messages research studies) on screening for disease, healthy lifestyles, Recruitment: Shopping managing and monitoring malls health Sample size: 698 Delivery: Shopping mall Participation rate: N/A Mackert Criteria: Women aged Approach: Health 2012 (31) 18-24 years promotion messages, time frame N/A Recruitment: Content: Multivitamin Undergraduate campuses information related to (method N/A) beautify, internal health, general health, Sample size: 295 disease prevention, nutrition, delivered in Participation rate: N/A randomized order Delivery: Twitter Milan 2010 Criteria: Women aged 18- Approach: Four education (32) 29 years (excluded women messages, stage- who were pregnant, tailored, one per week following diet that for four weeks; education restricted vitamins, modules minerals, or supplements) Content: Folic acid Recruitment: University supplementation knowledge E-mail system and behaviours Sample size: 468 Delivery: Messages delivered by e-mail; Participation rate: 32% website for education modules Wade 2012 Criteria: College Approach: Education (33) students program, including DVD, brochure, risk assessment tool, discussion Recruitment: Sophomore Content: Chronic and health promotion nursing STIs, folic acid, course obesity, vaccinations, smoking and alcohol use, Sample size: 53 genetic conditions, medications, social Participation rate: N/A determinants of health (e.g., domestic violence) Delivery: By peers in classroom setting Watson Criteria: Women aged Approach: Printed 2001 (34) 15-44 years material including posters, leaflets, and Recruitment: Surveyed as information kits, for part of population- four months representative surveys Content: Folic acid Sample size: 1196 before, supplementation 1204 (1997) and 1127 recommendations (2000) after Delivery: Distributed Participation rate: N/A broadly throughout the community (e.g., supermarkets, pharmacies, health centres) Williams Criteria: Women aged Approach: Education 2001 (35) 18-44 years campaign using general messages in magazine and Recruitment: Selected to TV advertisements, for be surveyed as part of a six months; education stratified random campaign using specific telephone-based sampling health claim in magazine process and TV advertisements and on cereal packages, for Sample size: 1742 six months Participation rate: N/A Content: Folic acid supplementation recommendations Delivery: Distributed broadly throughout the community Study, Follow-up year Agricola Duration: 6 months 2014 (24) Follow-up rate: 56% Bimla Duration: 6 months Schwarz Follow-up rate: 59% 2008 (25) Chan 2001 Duration: Assessment (26) immediately post-intervention Follow-up rate: Not applicable DeJoy Duration: 1 month 2014 (27) Follow-up rate: 77% Hillemeier Duration: 2 weeks 2008 (28) Follow-up rate: 52% Hussaini Duration: Assessment 2013 (29) immediately post-intervention Follow-up rate: Not applicable King 2013 Duration: Assessment (30) immediately post-intervention Follow-up rate: Not applicable Mackert Duration: 1 week 2012 (31) Follow-up rate: N/A Milan 2010 Duration: 6 weeks (32) Follow-up rate: 87% Wade 2012 Duration: Assessment (33) immediately post-intervention Follow-up rate: Not applicable Watson Duration: Assessment 2001 (34) immediately post-intervention Follow-up rate: Not applicable Williams Duration: Assessment 2001 (35) immediately post-intervention Follow-up rate: Not applicable Note: ACOC = American College of Obstetricians and Gynecologists; DVD = digital video disc; N/A = not available; RCT = randomized controlled trial; STIs = sexually transmitted infections. Table 2. Outcomes and results of included studies (n = 12) Study, Outcome(s) Analysis year Agricola Prevalence of risk Descriptive differences in 2014 (24) factors: proportions (post-test vs. pre-test) No folic acid supplementation BMI < 18.5 BMI [greater than or equal to] 25 Need rubella vaccination Need varicella vaccination Need hepatitis B vaccination Smoking Drinking Knowledge of risk factors: General preconception behaviours Folic acid supplementation Timing of preconception counselling Inheritability of malformations and genetic diseases Age at risk for Down syndrome Maintaining a normal weight Overweight and obesity Underlying maternal diseases Smoking Medications Drinking alcohol Need of testing for susceptibility to infectious diseases Immunization before pregnancy Bimla Knowledge that: Relative risk from Schwarz propensity score- 2008 (25) Folate prevents birth weighted models, defects intervention vs. control Folate is important in early pregnancy Prevalence of risk factors: Recent use of folate supplementation Chan Knowledge of: Mantel-Haenszel tests for 2001 (26) differences in proportions Sufficient folate in comparing pre- and diet prevents spina post-test; Poisson bifida regression for incidence of neural tube defects Food groups with the most folate Increase folate before and in first three months of pregnancy DeJoy Health outcome: 2014 (27) Incidence of neural tube Mean score for each defects, decline per composite measure year between pre- and post-test compared using Knowledge of: paired t test Preconception health Midwifery care Risks associated with: Childbirth interventions Hillemeier Self-efficacy: GLM or logistic 2008 (28) regression model, For eating healthy food comparing intervention vs. control Preconceptional control Behavioural intent: To eat healthier foods To be more physically active Behaviour change: Reads food labels for nutritional values Uses daily multivitamin with folic acid Meets recommended physical activity Hussaini Opinions after community Mean scores, post- vs. 2013 (29) presentations (males and pre-test compared using females): paired t test Community perception of problem severity Preconception health Self-perception of positive health behaviours Self-perception of negative health behaviours Knowledge of health disparities Health self-efficacy Agreement with health statements (females only): Using birth control is an important aspect of health A father's health decisions will affect the future health of his child A mother's health decisions will affect the future health of her child A strong community support network is important for health and well-being Sexual health is an important aspect of health Stress is an important factor during pregnancy affecting a baby's future health Agreement with health statements (males only): Using birth control is an important aspect of health A father's health decisions will affect the future health of his child A mother's health decisions will affect the future health of her child A strong community support network is important for health and well-being Sexual health is an important aspect of health Stress is an important factor during pregnancy affecting a baby's future health King 2013 Unaided correct recall Mean proportion, (30) of health behaviours: intervention vs. control For all 15 messages in 3 group compared using categories and labelled For all 15 messages not in categories For 1 category, 4 ANOVA messages labelled For 4 messages, each from different categories For 1 category, 3 messages (labelled) For 1 message Aided correct recall of health behaviours: For all 15 messages in 3 categories and labelled For all 15 messages not in categories For 1 category, 4 messages labelled For 4 messages, each from different categories For 1 category, 3 messages (labelled) For 1 message Mackert Beliefs: Mean scores, intervention 2012 (31) vs. control group Positive beliefs about compared using t test multivitamins Attitudes, norms, behavioural control, intentions: Positive attitudes about multivitamin intake Subjective norm in support of taking multivitamins Perceived control over multivitamin intake Intentions to take multivitamins Milan 2010 Health behaviours: Proportions, intervention (32) vs. control group Take multivitamin compared using Chi square tests; mean scores, intervention vs. Began in pre-action, control group compared moved to using t tests action/maintenance Began in pre-action, no movement Began in contemplation, no movement Began in pre-action, moved to action Self-efficacy: Self-efficacy Pros of multivitamin use Cons of multivitamin use Wade 2012 Preconception health Mean scores pre- vs. (33) knowledge (measured with post-test an 18 item pre/post test) Watson Role of folate on Adjusted odds ratios, 2001 reduction of risk of comparing intervention (34) neural tube defects with control group Correct food sources for folate Correct timing of taking folate Both correct food source and timing Know of foods with added folate Correct for added folate, of those who know Nominate ready-to-eat breakfast cereals with added folate, of those who know Use correct foods with added folate, of those who know Do not know what folate is important for Know folate is important: To prevent birth defect To help in pregnancy As a vitamin or nutrient To do with iron/blood/ anemia To do with healthy bones Williams Aware of folate Proportions at baseline vs. after intervention 1 vs. after intervention 2 2001 (35) Aware of recommendation to increase folate before pregnancy Nominating foods as sources of folate, unprompted: Leafy green vegetables Breakfast cereals Fruit Bread Meat Fish Cheese Believe folate reduces disease risk: Heart disease Cancer Spina bifida Birth defects Study, Outcome(s) Findings p value year Agricola Prevalence of risk 2014 (24) factors: No folic acid -23.4% <0.001 supplementation BMI < 18.5 -2.5% 0.25 BMI [greater than or 3.2% 0.34 equal to] 25 Need rubella vaccination -13.8% <0.001 Need varicella -7.4% 0.002 vaccination Need hepatitis B -22.3% <0.001 vaccination Smoking -7.4% 0.002 Drinking -46.4% <0.001 Knowledge of risk factors: General preconception 20.9% <0.001 behaviours Folic acid 1.7% 0.24 supplementation Timing of preconception -7.4% 0.04 counselling Inheritability of -37.2% <0.001 malformations and genetic diseases Age at risk for Down 1.4% 0.48 syndrome Maintaining a normal -0.3% 0.78 weight Overweight and obesity -1.4% 0.61 Underlying maternal -4.6% 0.15 diseases Smoking -0.7% 0.59 Medications 0.0% 1.00 Drinking alcohol 3.2% 0.44 Need of testing for 3.2% 0.25 susceptibility to infectious diseases Immunization before -6.7% 0.11 pregnancy Bimla Knowledge that: Schwarz 2008 (25) Folate prevents birth 1.72 <0.001 defects (1.32-2.23) Folate is important in 2.11 <0.001 early pregnancy (1.50-2.97) Prevalence of risk factors: Recent use of folate 1.54 0.01 supplementation (1.12-2.13) Chan Knowledge of: 2001 (26) Sufficient folate in 25.5% vs. <0.0001 diet prevents spina 41.9% bifida Food groups with the 19.4% vs. <0.0001 most folate 35.5% Increase folate before 11.5% vs. <0.0001 and in first three 28.4% months of pregnancy DeJoy Health outcome: 2014 (27) Incidence of neural tube 1% decline 0.03 defects, decline per per year year Knowledge of: Preconception health +1.1 of <0.001 6 points Midwifery care +0.7 of 0.008 3 points Risks associated with: Childbirth interventions +1.0 of N/A 3 points Hillemeier Self-efficacy: 2008 (28) For eating healthy food 1.109 0.018 Preconceptional control 1.192 0.031 Behavioural intent: To eat healthier foods 1.757 0.008 To be more physically 2.185 0.000 active Behaviour change: Reads food labels for 2.264 0.001 nutritional values Uses daily multivitamin 6.595 0.000 with folic acid Meets recommended 1.867 0.019 physical activity Hussaini Opinions after community 2013 (29) presentations (males and females): Community perception of 3.65 vs. <0.01 problem severity 3.14 Preconception health 3.67 vs. <0.01 3.48 Self-perception of 3.33 vs. <0.01 positive health 3.16 behaviours Self-perception of 3.17 vs. <0.01 negative health 2.89 behaviours Knowledge of health 1.30 vs. <0.01 disparities 0.55 Health self-efficacy 3.79 vs. <0.01 3.68 Agreement with health statements (females only): Using birth control is 95.96% vs. N/A an important aspect of 92.69% health A father's health 94.41% vs. N/A decisions will affect 93.04% the future health of his child A mother's health 98.72% vs. N/A decisions will affect 96.55% the future health of her child A strong community 96.89% vs. N/A support network is 93.90% important for health and well-being Sexual health is an 96.48% vs. N/A important aspect of 94.04% health Stress is an important 94.32% vs. N/A factor during pregnancy 91.42% affecting a baby's future health Agreement with health statements (males only): Using birth control is 94.59% vs. N/A an important aspect of 93.24% health A father's health 94.94% vs. N/A decisions will affect 86.25% the future health of his child A mother's health 97.47% vs. N/A decisions will affect 90.12% the future health of her child A strong community 89.33% vs. N/A support network is 89.74% important for health and well-being Sexual health is an 93.42% vs. N/A important aspect of 93.51% health Stress is an important 90.91% vs. N/A factor during pregnancy 85.71% affecting a baby's future health King 2013 Unaided correct recall (30) of health behaviours: For all 15 messages in 3 27.0% vs. <0.05 categories and labelled 10.7% For all 15 messages not 29.1% vs. <0.05 in categories 10.7% For 1 category, 4 58.7% vs. <0.05 messages labelled 10.7% For 4 messages, each 50.5% vs. <0.05 from different 10.7% categories For 1 category, 3 57.8% vs. <0.05 messages (labelled) 10.7% For 1 message 58.2% vs. <0.05 10.7% Aided correct recall of health behaviours: For all 15 messages in 3 49.8% vs. <0.05 categories and labelled 16.4% For all 15 messages not 54.0% vs. <0.05 in categories 16.4% For 1 category, 4 72.0% vs. <0.05 messages labelled 16.4% For 4 messages, each 64.4% vs. <0.05 from different 16.4% categories For 1 category, 3 71.5% vs. <0.05 messages (labelled) 16.4% For 1 message 76.5% vs. <0.05 16.4% Mackert Beliefs: 2012 (31) Positive beliefs about 5.21 vs. 0.68 multivitamins 5.27 Attitudes, norms, behavioural control, intentions: Positive attitudes about 5.68 vs. 0.06 multivitamin intake 5.49 Subjective norm in 5.43 vs. 0.09 support of taking 5.49 multivitamins Perceived control over 5.19 vs. 0.29 multivitamin intake 5.07 Intentions to take 4.56 vs. 0.09 multivitamins 4.24 Milan 2010 Health behaviours: (32) Take multivitamin 32.6% vs. 0.02 19.9% Began in pre-action, 22% vs. N/A moved to 10% action/maintenance Began in pre-action, no 33% vs. <0.001 movement 55% Began in contemplation, 36% vs. 0.005 no movement 58% Began in pre-action, 32% vs. 0.004 moved to action 17% Self-efficacy: Self-efficacy 6.02 vs. <0.001 1.64 Pros of multivitamin use 1.15 vs. 0.038 -0.10 Cons of multivitamin use -0.63 vs. >0.05 -0.59 Wade 2012 Preconception health 72.4 vs. 0.01 (33) knowledge (measured with 89.3 an 18 item pre/post test) Watson Role of folate on 2001 reduction of risk of (34) neural tube defects Correct food sources for 1.24 0.007 folate Correct timing of taking 1.90 0.06 folate Both correct food source 1.67 0.07 and timing Know of foods with added 1.73 0.16 folate Correct for added 3.75 0.002 folate, of those who know Nominate ready-to-eat 2.70 0.03 breakfast cereals with 1.55 0.2 added folate, of those who know Use correct foods with 1.50 0.003 added folate, of those who know Do not know what folate 0.33 <0.001 is important for Know folate is important: To prevent birth defect 2.21 <0.001 To help in pregnancy 2.80 0.005 As a vitamin or nutrient 2.27 0.002 To do with iron/blood/ 0.98 0.5 anemia To do with healthy bones 1.18 0.4 Williams Aware of folate 63% vs. <0.05 72% vs. 84% 2001 (35) Aware of recommendation 37% vs. <0.05 to increase folate 45% vs. 67% before pregnancy Nominating foods as sources of folate, unprompted: Leafy green vegetables 29% vs. <0.05 33% vs. 41% Breakfast cereals 17% vs. <0.05 26% vs. 37% Fruit 7% vs. <0.05 12% vs. 11% Bread 5% vs. <0.05 6% vs. 10% Meat 9% vs. [greater 8% vs. 9% than or equal to]0.05 Fish 1% vs. [greater 3% vs. 2% than or equal to]0.05 Cheese 5% vs. [greater 4% vs. 6% than or equal to]0.05 Believe folate reduces disease risk: Heart disease 6% vs. [greater 3% vs. 3% than or equal to]0.05 Cancer 5% vs. [greater 3% vs. 4% than or equal to]0.05 Spina bifida 13% vs. <0.05 15% vs. 20% Birth defects 21% vs. <0.05 29% vs. 44% Table 3. Quality appraisal of included studies (n = 12) Study, year Selection Study Confounders bias design Agricola 2014 (24) Weak Moderate Strong Bimla Schwarz 2008 (25) Weak Strong Weak Chan 2001 (26) Moderate Moderate Weak DeJoy 2014 (27) Weak Moderate Strong Hillemeier 2008 (28) Moderate Strong Strong Hussaini 2013 (29) Weak Moderate Strong King 2013 (30) Weak Strong Weak Mackert 2012 (31) Weak Strong Weak Milan 2010 (32) Weak Strong Strong Wade 2012 (33) Weak Moderate Strong Watson 2001 (34) Moderate Strong Strong Williams 2001 (35) Moderate Moderate Weak Study, year Blinding Data Withdrawals/ collection dropouts method Agricola 2014 (24) Weak Weak Weak Bimla Schwarz 2008 (25) Moderate Moderate Weak Chan 2001 (26) Moderate Weak Strong DeJoy 2014 (27) Weak Moderate Weak Hillemeier 2008 (28) Weak Weak Weak Hussaini 2013 (29) Weak Weak Weak King 2013 (30) Moderate Weak Moderate Mackert 2012 (31) Strong Moderate Weak Milan 2010 (32) Strong Strong Strong Wade 2012 (33) Weak Moderate Moderate Watson 2001 (34) Weak Weak Moderate Williams 2001 (35) Weak Weak Moderate Study, year Global rating Agricola 2014 (24) Weak Bimla Schwarz 2008 (25) Weak Chan 2001 (26) Weak DeJoy 2014 (27) Weak Hillemeier 2008 (28) Weak Hussaini 2013 (29) Weak King 2013 (30) Weak Mackert 2012 (31) Weak Milan 2010 (32) Moderate Wade 2012 (33) Weak Watson 2001 (34) Weak Williams 2001 (35) Weak