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Open Access Research article

The design, implementation and acceptability of an integrated intervention to address multiple behavioral and psychosocial risk factors among pregnant African American women

Kathy S Katz1*, Susan M Blake2, Renee A Milligan1, Phyllis W Sharps3, Davene B White4, Margaret F Rodan1, Maryann Rossi5 and Kennan B Murray6

Author Affiliations

1 Department of Pediatrics, Georgetown University Medical Center, 2201 Wisconsin Ave NW, Suite 220, Washington DC 20007, USA

2 School of Public Health and Health Services, George Washington University, 2175 K St. NW, Suite 700, Washington, DC 20037, USA

3 Johns Hopkins University School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205, USA

4 Department of Pediatrics, Howard University Hospital, 2041 Georgia Ave NW, Washington DC 20060, USA

5 Office for the Protection of Human Subjects, Children's Hospital National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, USA

6 Research Triangle Institute-International, 6110 Executive Blvd, Rockville MD 20850, USA

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BMC Pregnancy and Childbirth 2008, 8:22  doi:10.1186/1471-2393-8-22

Published: 25 June 2008



African American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format.


Six academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported.


Forty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended ≥ 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed.


While implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.