The intervention content of Strong Healthy Women was developed by a multidisciplinary team of co-investigators led by the first two authors. The content was assessed by members of the CePAWHS Executive Committee and modifications were made as needed. A set of behavioral objectives guide each of the content areas and these are discussed below. The end result was content addressing the following topics: pregnancy and conception, stress, physical activity, nutrition, infection, sources of smoke in the home, and substance use/abuse (i.e., tobacco and alcohol use).
The specific content and style of presentation to address each topic was developed with general communication guidelines in mind. For instance, we considered the issue of a persuasion dilemma
]. In view of the reality that the ultimate goal in the intervention is to improve preconceptional health to ultimately enhance pregnancy outcomes, communication may arouse anxieties or fears; and/or distort or manipulate information to achieve these aims. It is assumed that each one has the right to make decisions for herself on any matter affecting her so far as it does not harm others (i.e., the principle of autonomy). This principle suggests interventions should avoid “scaring” people into action. That is, we did not distort or manipulate the information through strategies such as selective information dissemination. We were also careful to avoid a coercion dilemma
. That is, we did not employ approaches within the intervention that coerced women into making changes (e.g., need to quit smoking or leave the intervention); rather, the intervention content was informative and provided helpful suggestions for making behavior changes regardless of women's choices to engage in unhealthy behaviors. We were careful to consider these communication issues in the development of the intervention content and delivery.
We organized the intervention content across the six sessions based on two major considerations. First, improving health-related behaviors in some areas is difficult as such behaviors (e.g., stress management, diet, and physical activity) are entrenched in longtime habits, preferences, and lifestyles. For such topics, we attempted to facilitate incremental change in attitudes and behaviors across several sessions [38
]. Content in later sessions reinforced the earlier material, allowed for participants to discuss problems and receive supportive feedback. For other topics, health-related behavior is not as pervasive but rather enacted in a more limited sphere. For these areas (i.e., preconceptional healthcare), we addressed topics in only one or two sessions. Second, evidence from the Phase I population survey indicated that some risk factors (e.g., stress, physical inactivity, and poor nutrition) are more prevalent than other risk factors (e.g., alcohol, infection) in our target population. Thus, we dedicated more time for these higher prevalence risk factors across sessions.
In Session 1, we introduced each of the seven content areas and discussed their association with elevated disease risk including cardiovascular disease, stroke, diabetes, cholesterol, hypertension, and immune disorders. Session 2 is comprised of information on pregnancy/conception, stress, physical activity, nutrition, and smoking, with time set aside for guided physical activity and relaxation sessions. The third and fourth sessions are focused on pregnancy/conception, stress, physical activity, and nutrition with time set aside for physical activity (e.g., guided aerobics, walking) and healthy eating demonstrations (e.g., reading food labels, grocery shopping trip). Session 5 is focused mainly on overcoming barriers to stress, physical inactivity, and poor eating habits. Session 6 was primarily dedicated to physical activity. The rationale for the order and sequence of the content is based on: (1) basic flow of content from other model interventions (e.g., DPP [29
] and WISEWOMAN [30
]); (2) pairing content based on topic area (e.g., having information about an exercise buddy paired with information about social support for overcoming barriers to stress within the same session); and (3) the goal of keeping the sessions interesting and engaging for the participants (e.g., a nearly 2-h session of just education is not as appealing as a 2-h session filled with interactive talk, physical activity, healthy eating demonstrations, etc). The seven content areas are presented below.
Content Area #1: Pregnancy and Conception
The three behavior change objectives of the pregnancy and conception content are: (1) taking a daily multivitamin with folic acid (0.4 mg); (2) planning the timing of the next pregnancy by (a) selecting an optimal spacing between pregnancies, (b) considering lifecourse development (e.g. education, employment, relationship quality and status), and (c) developing and utilizing planning, preparation, and organizational skills; and (3) accessing preconception care and addressing individual risk factors for poor pregnancy outcomes. The content thus includes: the benefits of good preconceptional health and folic acid for infant health and reduction of neural tube defects, identification of modifiable risk factors for adverse pregnancy outcomes and the importance of optimizing general maternal health. Regarding pregnancy planning, the intervention content focuses on the effects of increasing age on conception and pregnancy, the benefits of optimal pregnancy spacing, the potential consequences of an unplanned pregnancy, life-course factors related to pregnancy timing (e.g., health status, financial circumstances, career/school goals, etc.), and available family planning methods (e.g., contraception, natural family planning, abstinence, etc.). In addition, the content focuses on the essentials of genetic screening and vaccinations (e.g., hep-B, rubella, varicella) to identify individuals risks for adverse pregnancy outcomes. With each issue, emphasis on the actions that women might take to enhance their control over their health and possible future pregnancy outcomes is addressed.
Content Area #2: Stress
The three behavior change goals of the stress content are: (1) decreased overall physical and psychological stress, (2) increased problem solving and coping skills, and (3) increased amount of sleep. The content includes information about stress and the role that unhealthy behaviors play in increasing daily stress; identifying personal sources of stress; physiological stress responses; the connection between stress, emotions, and psychological health; strategies for coping with stress and ways to solve problems; and the benefits of and strategies for promoting increased relaxation and sleep in daily life. Again, the aim is to include strategies that any woman might adopt to enhance her motivation, self-efficacy, and well-being while reducing and coping with daily stressors.
Content Area #3: Physical Activity
The three behavior change objectives of the physical activity content are: (1) meet physical activity guidelines during the intervention and follow-up (i.e., at least 30 min of moderate to strenuous physical activity on most, if not all, days of the week; ACSM [27
]), (2) achieve personal exercise goals, and (3) improve psychosocial determinants (i.e., exercise beliefs and attitudes, social support, and self-efficacy) and barriers of physical activity participation. The content includes the benefits of regular exercise behavior and the importance of meeting the current exercise guidelines; basic principles of goal setting, exercise training, and general adaptations to walking and jogging; importance of social support for exercise and sources of support for exercise in one's personal environment; and helpful tips for overcoming exercise barriers and staying motivated for life-long exercise behavior. Women are encouraged to engage in regular exercise behavior (i.e., meet the guidelines for exercise behavior) in their own environment. Support for these recommendations included: (1) women are given a pedometer and tracking log to self-monitor their daily activity steps, (2) each woman uses an individual goal-setting and tracking sheet and the intervention leaders provide tailored feedback on strategies to increase daily physical activity (e.g., park farther away from the store, use the steps instead of the elevator, etc.); and (3) women are encouraged to find an exercise buddy at home (e.g., family member, friend, etc.) to exercise with on days that the intervention does not meet. The objective is to expose women to guided physical activity and increase women's physical activity motivation and self-efficacy to engage in more free-living physical activity that is done in their own environment (e.g., home, work, and leisure).
Content Area #4: Nutrition
The two behavior change goals of the nutrition content are: (1) increasing healthy food choices, and (2) increasing consumer food knowledge. The content includes discussion of personal barriers (e.g., no time to make a healthy meal); factors that promote healthy eating (e.g., self-recognition of success in packing a healthy lunch versus going out to a fast food restaurant); tips on storing fruits and vegetables to maximize freshness; understanding food labels and ingredients lists, sources of calcium, iron, folate, and protein in foods; and recognition of appropriate portion sizes for common foods. The integrative nature of lesson content is well illustrated in this lesson. An emphasis on folic acid is linked to efforts to understand and comprehend the sources of food folate. Efforts to integrate the program into women's lives is emphasized via links to the likelihood that women would dine at fast food restaurants, do the grocery shopping, and prepare foods in the home.
Content Area #5: Infection
The two behavioral objectives of the infection content are: (1) decreasing behaviors that increase vaginal infections (e.g., inappropriate antibiotics, douching), and (2) seeking medical attention when necessary. The content includes description of common causes of vaginal infections; the importance of healthy bacteria in the vagina for preventing bacterial vaginosis, which is related to preterm labor; activities that reduce “good” bacteria in the vagina (e.g., douching, multiple sexual partners, etc.); and seeking medical attention when a woman is experiencing symptoms of vaginal infection. The behavioral objectives of the infection content thus emphasize improving health for both the woman and a future pregnancy as is also the case in other areas of the intervention (e.g., optimizing management of chronic medial conditions).
Content Area #6: Sources of Smoke in the Home
The two behavioral goals of the smoking content are: (1) examining the home for sources of smoke, and (2) removing sources of smoke from the home. Because the personal habit of smoking is one that is hard to change, the planned intervention sought to introduce novel content associated with the benefit of others in addition to the individual woman. As a result, we connect to information about a growing incidence of asthma and sources of environmental smoke. In view of the geographical location of the intervention, many homes are heated with sources that may introduce smoke into the home. The content thus includes understanding the relation of indoor air quality and smoke-free homes to good preconceptional and prenatal health and identifying factors that facilitate (e.g., supports) and inhibit (e.g., barriers) change to the home environment.
Content Area #7: Substance Use
The two behavioral objectives of the substance use content are: (1) decreasing alcohol and tobacco use, and (2) increasing positive beliefs and attitudes toward healthy alternatives. The content includes health risks of alcohol and tobacco use for both women and their families; the impact of alcohol and tobacco use on preconceptional and prenatal health; barriers and supports for reducing/stopping alcohol and tobacco use; recommendations for alcohol and tobacco use in pregnancy; reasons for alcohol and tobacco use or nonuse; and healthy alternative options to integrate into daily living.