Characteristics and Factors Associated with the Risk of a Nicotine ...

Matern Child Health J (2012) 16:1224–1231 DOI 10.1007/s10995-011-0848-z

Characteristics and Factors Associated with the Risk of a Nicotine Exposed Pregnancy: Expanding the CHOICES Preconception Counseling Model to Tobacco Danielle E. Parrish • Kirk von Sternberg • Mary M. Velasquez • Jerry Cochran • McClain Sampson • Patricia Dolan Mullen

Published online: 7 July 2011 Ó Springer Science+Business Media, LLC 2011

Abstract The preconception counseling model tested in the CDC funded Project CHOICES efficacy trial to reduce the risk of an alcohol-exposed pregnancy (AEP) could be extended to smokers to prevent a nicotine-exposed pregnancy (NEP), when pharmacotherapy can be provided safely and disclosure of these risk behaviors is more likely. The CHOICES model, which incorporates motivational interviewing, encourages reduction of AEP risk by decreasing risky drinking or using effective contraception; in the efficacy trial, most women chose both options. We conducted a secondary analysis of the CHOICES epidemiologic survey data (N = 2,672) (Project CHOICES Research Group in Am J Prev Med 23(3), 166–173, 2002) to identify the prevalence of risk of NEP and the factors associated with this risk using logistic regression modeling procedures. Conducted in six settings with women at risk for AEP, the percentage of AEP was 12.5% (333/2,672) among

women of childbearing age (18–44). A total of 464 of the 2,672 (17.4%) were at risk for NEP. Among women at-risk of an unplanned pregnancy (n = 1,532), the co-occurrence of AEP and NEP risk was more prevalent (16.3%) than AEP risk alone (5.5%) or NEP risk alone (14.0%). In the multivariable model, statistically significant correlates for NEP risk included lifetime drug use, prior alcohol/drug treatment, drug use in the last 6 months, being married or living with a partner, having multiple sexual partners in the last 6 months, physical abuse in the last year, and lower levels of education. These findings suggest that preconception counseling for NEP could be combined with a program targeting AEP. Keywords Nicotine Pregnancy Alcohol Preconception Prevention

Introduction Danielle E. Parrish: Work completed as a post-doctoral research fellow at the University of Texas at Austin, School of Social Work, Health Behavior Research and Training Institute. D. E. Parrish (&) K. von Sternberg M. M. Velasquez J. Cochran M. Sampson Health Behavior Research and Training Institute, University of Texas at Austin, School of Social Work, Austin, TX, USA e-mail: [email protected] P. D. Mullen Center for Health Promotion and Prevention Research, University of Texas School of Public Health (Houston), Houston, TX, USA Present Address: D. E. Parrish Graduate College of Social Work, University of Houston, Houston, TX, USA

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Women of childbearing age constitute the largest proportion (21.9%) of female smokers, with as many as 22% of women smoking during pregnancy and 14% throughout the entire pregnancy [1–4]. Smoking during pregnancy is the leading preventable cause of low birth weight, chiefly growth restriction, and is widely recognized as having deleterious effects during and after pregnancy [3]. Of the 60% of pregnant women who continue to smoke past their first antenatal visit, non-pharmacological smoking interventions rarely result in a prenatal quit rate greater than 20% and they make almost no impact on heavier smokers who are disproportionately poor, undereducated, and whose social networks are saturated with smokers [5, 6] and whose pregnancies are most likely to have poor outcomes. One of the most powerful interventions available in the general population, pharmacologic aids [7, 8], have been

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difficult to test in pregnant women [9–11]. Consequently, evidence for the safety and efficacy of such aids for cessation is unclear, and medication is not recommended as the first line of treatment for pregnant smokers. It appears, therefore, more promising to focus on the preconception period to prevent smoking during pregnancy, especially with women who are more strongly addicted to nicotine or are less likely to present early in pregnancy for prenatal care. Preconception counseling, an idea first introduced in 1987 [12], has been tested across a broad range of risks (low rubella titers) and pregnancy/fetal health promoting behaviors (folic acid supplementation) and more recently, control of diabetes and hypertension [13, 14]. Since just under half of pregnancies are unintended [15, 16], and many women do not realize they are pregnant until several months after conception, a preconceptional approach to prevention may help to reduce or eliminate health risk behaviors or conditions that may lead to a problematic pregnancy before or in the early stages of pregnancy [13]. Project CHOICES was developed through a program of research that first identified high-risk populations [1], then tested the feasibility and impact of the intervention [17], and, finally, tested the impact of the intervention in a randomized controlled trial [18]. The CHOICES preconception counseling model, which incorporates motivational interviewing, was efficacious in reducing the risk of alcohol-exposed pregnancy (AEP) among women of childbearing age by helping them reduce risky drinking, improve use of effective contraception, or both; most women chose both [18]. The current paper is based on a secondary data analysis from the CHOICES epidemiologic survey in which high-risk populations were identified. Recent epidemiologic studies have found that consumption of both alcohol and nicotine result in a multiplicative increase in negative health outcomes for mothers and infants, such as cancer and cardiovascular disease for the mother and more deleterious prenatal and neurocognitive outcomes for the child [19, 20]. Moreover, a recent review of the literature has concluded that smoking cessation is unlikely to deter abstinence from alcohol or other drugs, and may even result in greater abstinence [21]. Although we know that individual risk behaviors can be effectively targeted and changed (e.g., tobacco use, risky drinking), there remains a need to develop and test interventions that target multiple risk behaviors which frequently present together in real practice settings [21, 22]. Integrated screening and treatment models have promise for improving both the efficiency and effectiveness with which such services are provided [22]. Given the common co-occurrence of smoking and drinking among high-risk women during both the preconceptional and prenatal periods [23, 24], and the paucity of literature that has proposed or tested bundled, multi-risk prevention models

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for this population, there exists a need to adapt, develop and test such models. The Project CHOICES model has promise for future adaptation to prevent nicotine-exposed pregnancy (NEP), or perhaps to address both risk factors (AEP and NEP) simultaneously. However, research is needed to determine the characteristics and risk factors associated with the risk of NEP among women in the preconception period to inform future targeted prevention efforts [25], and to identify the prevalence of women at risk for both NEP and AEP. The current study relies on the original CHOICES cross-sectional survey data (N = 2,672) to: (1) identify the prevalence of the risk of NEP, (2) examine the overlap between the risk of AEP and NEP, (3) identify bivariate correlates of NEP risk, and (4) use multivariable analysis to identify the most parsimonious set of predictors of NEP risk. The Project CHOICES epidemiologic dataset is appropriate to address these aims as it provides a large sample of women already identified as high-risk on numerous health behaviors, including use of illicit drugs, risky alcohol consumption, and unsafe sexual behaviors, such as trading sex for drugs or money [1]. In addition, the sample has been identified as having a large proportion of women who reported smoking (50%), with as many as 44% of fertile, sexually active women who were not currently pregnant or trying to get pregnant reporting ineffective contraception [1]. Additionally, drinking and smoking are frequently comorbid [26]. In this study, of those at risk for AEP, 70 percent were also smokers [1].

Methods Design and Sample The existing data (n = 2,672) were collected as a crosssectional epidemiologic survey (November 1998 to February 2000) of women of childbearing age (18–44 years) to assess the prevalence of AEP risk [1]. Women were recruited from six settings that were suspected to contain a large proportion of women at risk of an alcohol-exposed pregnancy (AEP), with the primary aim of identifying the prevalence of AEP risk and characteristics associated with this risk. These settings included a large urban county jail and two publiclyfunded drug and alcohol treatment facilities in Texas; an OB/ GYN clinic in Virginia; a media-recruited sample in Florida; and two primary care clinics, one in Virginia and one in Florida. Given the diversity of settings, several different recruitment methods were used. A probability sample was obtained for the jail subsample; women from the Texas residential treatment facilities were recruited from admissions lists during regular visits by the assessor. In the Virginia clinics, flyers were posted and distributed to recruit

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women. In the Florida primary care clinics, potential participants were identified by reviewing the appointment list for scheduled and ‘‘walk-in’’ appointments. Finally, the media sample was recruited from Broward County, Florida (e.g., newspaper, cable television, and flyers). Study data were collected in person by trained interviewers. Interviewers received 2 days of local training, using standard procedures and training manuals, and were monitored regularly. Participants received compensation for lost time ($10 cash or deposits in jail commissary accounts [Texas], $35 vouchers for establishments such as fast food restaurants [Virginia]), and $25 cash [Florida]). Across sites, 3,219 women were given information about the survey and asked to participate and 2,673 agreed to participate, yielding an overall consent rate of 83%. The consent rate by site includes: 94% in the jail and 100% in the treatment centers; 67 and 76% in the Virginia gynecology and primary care clinics, respectively; and 85% in both of the Florida settings. Measures Independent Measures The survey included closed-ended questions and took about 20 min to complete [1]. Data were collected on socio demographic characteristics, current and past alcohol use, relationship status, abuse history, current and past smoking, obstetric history, current sexual behavior, current and past contraceptive use, alcohol and drug use during a previous pregnancy, mental health treatment, and homelessness (Table 2). All questions that asked participants to recall a specific time (e.g., ‘‘in the past 6 months’’) were modified for respondents in jail and treatment settings to say ‘‘in the 6 months before coming here’’ [1]. Most measures were from nationally accepted and validated instruments such as the Alcohol Use Disorders Identification Test (AUDIT), the Mental Health Index (MHI-5), the Addiction Severity Index (ASI), and the National Health Interview Survey (NHIS). Definition of NEP Risk A variable for NEP risk was created based on the AEP risk variable from the original CHOICES epidemiological study where at-risk participants were presumed fertile (no reported hysterectomy, oophorectomy, or menopause), sexually active (vaginal intercourse with at least one male partner in the past 6 months and not using effective contraception), and also drinking at risky levels (current drinking of more than seven drinks per week or consuming five or more drinks in a single day more than once in the past 6 months) [1]. A dichotomous NEP risk variable was

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computed for the present study using the entire study sample that completed the survey (N = 2,672), where women were presumed fertile and at risk for pregnancy and smoking cigarettes in the last 30 days (1 = at risk for NEP, 0 = not at risk for NEP). Figure 1 presents a flow diagram that demonstrates how the NEP risk variable was formulated. Our reasons for defining the NEP risk variable using any smoking in the past 30 days is threefold: (1) social desirability associated with non-smoking status often leads individuals to underreport the prevalence of smoking [27], (2) the Surgeon General has concluded, ‘‘There is no safe level of exposure to tobacco smoke’’ and there is not extant literature that indicates a safe level of smoking during pregnancy [27], and (3) fewer cigarettes consumed does not always result in less nicotine consumption or health risk [28]. Data Analysis Descriptive statistics were utilized to describe the sample and prevalence of NEP risk using SPSS 17.0. Correlates of risk for a NEP were based on comparing women at risk of NEP with sexually active respondents presumed to be fertile who were not at risk. A model building procedure recommended by Hosmer and Lemeshow was used to identify correlates of NEP risk using Stata 10.0 [29]. First, the linearity of the logit for the one continuous predictor variable (years of education) assumption was assessed and was not found to be problematic. Next, univariable logistic regression analyses were conducted to identify correlates of risk for the baseline multivariable model. Variables measuring current smoking and contraceptive behaviors were not selected as predictor variables, as they were used to define the at-risk sample. Variables found to be correlated with NEP risk using a value of P \ .25 were entered as the first set of predictor variables into a baseline multivariable model with NEP risk as the criterion variable. In an effort to identify the most parsimonious model, predictor variables that were not correlated with NEP risk, using a value of P \ .10, in the multivariable model were excluded from the subsequent model. To verify the importance of remaining predictor variables and to help determine that important variables were not eliminated within this model, each variable was examined to ensure that estimated coefficients did not change markedly in magnitude from the baseline model to the preliminary main effects model. Practically relevant interaction terms, based on the extant literature, were also explored. Since the interaction terms were not statistically significant or meaningful, the likelihood ratio test was then used to compare the baseline multivariable model with the new, more parsimonious model. Because there was no significant decrement in fit (LRT X2 = 6.16, df = 9,


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Fig. 1 Flow diagram of women at risk for alcohol or nicotine exposed pregnancy, or both

P = .72), the more parsimonious main effects model was retained.

Results Sample Study participants had a mean age of 32 and were primarily Black, non-Hispanic and between the ages of 25–44 years; most respondents were single (70%), living below the poverty level (55%), and employed (51%). Nearly onethird reported being physically abused in the past year. With regard to illicit drug use, 75 percent reported lifetime use, while 48 percent reported using illicit drugs in the last 6 months. Over one-third (35%) of participants were identified as drinking at risky levels. As shown in Fig. 1, nearly a third (n = 864) of the sample were infertile, largely due to tubal ligation (n = 740). Of those who were sexually active and fertile (n = 1,559), 44% (n = 686) were using effective contraception.

Prevalence of Risk for a Nicotine-Exposed Pregnancy Women at-risk of NEP (n = 464, 17.4%), as previously defined, were fertile, sexually active, reported ineffective contraception, and smoked at least one cigarette in the last 30 days (Fig. 1). The co-occurrence of risk for NEP and AEP among women in the sample (N = 2,672) was 9.3% (n = 249). When considering only those women at risk of NEP and/or AEP (n = 548), 45% were at risk for both (n = 249). Table 1 displays a cross-tabulation of AEP and NEP risk for women who were sexually active and fertile (n = 1,532). Over 16% of these women were at risk for both AEP and NEP, compared to 5.5% at risk of AEP alone and 14.0% at risk of NEP alone. Three-fourths of women at risk of AEP were also at risk of NEP (249/333), while more than half of women at risk of NEP were also at risk of AEP (249/464). Over 30% of sexually active, fertile women were at risk of NEP, while 22% were at risk of AEP. Settings differed with regard to NEP risk (X2 = 183.73, df = 5, P \ .001; Table 2). The risk of NEP, like the risk of AEP, was highest for women in substance abuse

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treatment (32%) and jail settings (29.5%) and lowest in the primary care clinics, gynecology clinic and media sample. When looking only at the latter non-residential settings combined, the prevalence of NEP risk was 10.4% (178 of 1,713). The NEP risk subsample was primarily Black, nonHispanic (52%), followed by White, non-Hispanic (28%) women. Nearly 47% of women at-risk of NEP experienced physical violence in the last year, while the majority reported prior illicit drug use (97%), illicit drug use in the last 6 months (80%), drinking at risky levels (54%), and were at-risk of AEP (53%).

Multivariable Model In the final multivariable model (v2 = 485.48, df = 7, P \ .001), prior use of illicit drugs (OR = 5.0; 95% confidence interval [CI] = 2.7–9.0), use of illicit drugs in the last 6 months (OR = 2.2; 95% confidence interval [CI] = 1.6–3.0), and prior alcohol and drug treatment (OR = 2.6; 95% confidence interval [CI] = 2.0–3.5) were the strongest predictors of risk for a NEP (Table 4). Other predictors of risk included (in the following order of importance): being married or living with a partner, having multiple partners in the last 6 months, physical abuse in the last year, and lower levels of education.

Correlates of NEP Risk Women at-risk of NEP were more likely to be older, White, less educated, unemployed, uninsured and married or living with a partner when compared to other women who were presumed to be fertile and not at-risk (Table 3). Women at-risk were also more likely to begin smoking after the age of 16 years. Similarly, they were more likely to engage in several substance abuse behaviors such as drinking at risky levels, using drugs in the last 6 months, and smoking and drinking during their most recent pregnancy. Also more common among women at-risk of NEP were prior mental health and alcohol/drug abuse treatment, and other risk behaviors such as multiple partners and trading sex for gain. Finally, at-risk women were also more likely to have experienced sexual and physical abuse in the past year and to have been homeless for over 48 h. These results are aggregated for all six settings as further meaningful analysis by site was precluded by the relatively low number of women at-risk in any one setting. Table 1 Frequency of sexually active, fertile women of childbearing age at-risk for alcohol- or nicotine exposed pregnancy, or both

At-risk for nicotine exposed pregnancy

Yes Total

Setting

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At-risk for alcohol exposed pregnancy

Total

No

n

Yes %

n

%

%

984

64.2

84

5.5

1,068

69.7

215 1,199

14.0 78.2

249 333

16.3 21.8

464 1,532

30.3 100.0

Total surveyed

Number at risk

Percent at risk

Treatment center, TX

453

149

32.1

Jail, TX

506

137

29.5

Gynecology clinic, VA

425

63

13.6

Media sample, FL

452

35

7.5

Primary care #1, VA

421

53

11.4

Primary care #2, FL *One case with missing responses excluded

This study analyzed secondary data from the CHOICES epidemiologic survey to assess the risk prevalence of nicotine-exposed pregnancy (NEP) among women of childbearing age (18–44), the factors associated with this risk, and the proportion of women with overlapping risk of NEP and alcohol-exposed pregnancy (AEP). Seventeen percent of the women in the study were at risk of NEP (nearly 26% of women presumed to be fertile), suggesting the importance of targeting women in the preconception period, when they can safely use pharmacotherapy and the disclosure of such risk is more likely. The findings from this study have several important implications for the future development and planning of preconception interventions in real settings. Among women at-risk of an unplanned pregnancy (n = 1,532), the co-occurrence of AEP and NEP risk was more prevalent (16.3%) than AEP risk alone (5.5%) or NEP

n No

Table 2 Number and proportion of women at-risk of NEP by setting

Discussion

All settings

415

27

5.8

2,672*

464

17.4


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Table 3 Univariable correlates of NEP risk Variable

At-risk

Not at-risk n

OR

95% CI

At risk women more likely to

n

%

%

229

48.8

914

41.5

1.3

1.1–1.6

Be older

129

27.5

426

19.4

1.6

1.3–2.0

Be white, non-Hispanic

201

42.9

664

30.2

1.7

1.4–2.1

Be less educated

145

30.9

492

22.4

1.6

1.2–1.9

Be unemployed

284

60.7

1,202

54.7

1.3

1.0–1.6

Be uninsured

132

28.1

448

20.4

1.5

1.2–1.9

Begin smoking [age 16

307

75.8

584

31.6

6.8

5.3–8.7

Smoke—most recent pregnancy

Age [30 Race/ethnicity White, non-Hispanic Education \High school Employment Unemployed Insured (health) Uninsured Age first smoked [16 Smoked during last pregnancy Drank during last pregnancy

66

16.4

145

7.8

2.3

1.7–3.1

Drink—most recent pregnancy

Drink at risk levels

252

53.7

684

31.1

2.6

2.1–3.1

Drink at risky levels

Ever use illicit drugs

453

97.0

1,544

70.0

12.0

7.2–19.9

Have used illicit drugs—lifetime

Drug use in last 6 months

375

80.1

917

41.8

5.6

4.4–7.1

Have used drugs in last 6 months

Any alcohol/drug treatment

298

63.5

684

31.1

3.9

3.1–4.8

Have ever had alcohol/drug treatment

Any mental health treatment

163

34.8

604

27.5

1.4

1.1–1.7

Have ever had mental health treatment

Sexual abuse

94

20.0

217

10.0

2.3

1.8–3.0

Have been sexually abused in past year

Multiple partners

244

52.6

297

22.6

3.8

3.0–4.7

Have had more than one partner in last 6 months

Traded sex for gain

143

30.8

97

8.9

4.6

3.4–6.1

Have traded sex for money or drugs or other gain—in last 6 months

Homeless [48 h

173

36.9

401

18.2

2.6

2.1–3.3

Have been homeless in last year

Physical abuse

219

46.8

565

25.7

2.5

2.1–3.1

Have been physically abused in last year

Married or living together

157

33.5

642

29.2

1.2

risk alone (14.0%). Among women at risk for either alcohol or nicotine exposure during pregnancy, close to half (45.4%) were at risk for both. This overlap of risk suggests the potential utility of a bundled approach to prevention in the preconception period, whereby screening and intervention would simultaneously target smoking, risky alcohol use, and effective contraception. The CHOICES preconception model, which was efficacious in reducing the risk of alcoholexposed pregnancy by using motivational interviewing to assist women in reducing alcohol consumption below risk levels and/or using effective contraception, may have promise in expanding to also target a reduction in the risk of NEP [18]. A bundled approach that targets multiple risk behaviors can be personalized for each woman’s specific risk profile and unique preferences and values (e.g., while contraception may not be acceptable for some women given their religious or cultural beliefs, they can successfully reduce their risk by choosing to reduce risky drinking and smoking). It may also result in a more efficient service

.987–1.5

Be married or live with a partner

delivery model, as the same practitioner can be trained to apply motivational interviewing to target one or more risk behaviors, as opposed to more traditional uni-risk prevention models. An expanded CHOICES preconception model is currently being tested in the CHOICES Plus efficacy trial (PI: Mary Velasquez, Ph.D; funded by the Centers for Disease Control and Prevention), where women are screened for the risk of alcohol-exposed pregnancy and current smoking, and offered a referral to an evidence-based smoking cessation program that provides access to smoking cessation pharmacotherapy (in addition to other behavioral treatments). The risk of NEP was substantially higher in jail (29%) and treatment centers (32%), despite very similar rates of tubal ligations, hysterectomies, oophorectomies, or menopause across all settings (59–68%, with a median of 65%). Similarly, the risk of AEP was also considerably higher in these subgroups (21% in the jail; and 24% in the substance abuse treatment centers compared to less than 10% in other settings, [18]), suggesting that the use of preconception interventions

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Table 4 Multivariable analysis results: variables predicting NEP risk Predictors

OR

95% CI

Women at-risk for NEP were more likely to

2.7–9.0

Ever use drugs

2.0–3.5

Ever have had alcohol/drug treatment

Any prior use of drugs Yes/no

5.0

Prior alcohol/drug treatment Yes/no

2.6

Recent drug use (last 6 months) Yes/no

2.2

1.6–3.0

Use drugs recently

1.5–2.7

Be married or live with a partner

Married or living together Yes/no

2.0

Multiple partners last 6 months Yes/no

1.8

1.3–2.3

Have had multiple partners— in last 6 months

1.1–2.0

Have been physically abused—in past year

Physical abuse last year Yes/no Years of education (continuous)

1.5

.86 .81–.91

Be less educated

that target multiple risk factors, if effective, may be particularly important for these higher risk populations. Within the multivariable model, recent or lifetime illicit drug use and prior alcohol drug and alcohol treatment were most strongly associated with NEP risk. This strong association, and the finding that recent illicit drug use and prior alcohol and drug treatment were also two of the top three predictors for AEP risk [18], suggests potential utility in expanding the CHOICES model to target illicit drug use. The risk of NEP was also associated with various life stressors, such as physical abuse. This is consistent with other findings, which have reported a high prevalence of smoking and unwanted pregnancy among women experiencing partner abuse [29, 30]. The variation between the two primary clinics from disparate geographic regions within this study may suggest the importance of assessing the unique risk profile of each distinct target population, as well as the possible advantage of developing interventions that can be adapted to target multiple risk factors based on a given risk profile. In doing this, preconception counseling could extend beyond substance use and abuse in the preconception period to encompass other chronic health and preconceptional issues, such as elevated blood pressure or the consumption of folic acid supplements. Preconceptional interventions that rely on motivational interviewing, such as the CHOICES intervention, could then be personalized for each woman’s unique health issues and habits, providing her the choice to reduce her risk by changing specific health behaviors and/or using effective contraception to prevent an unplanned pregnancy. The targeting of multiple risks and the flexibility in

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personalizing each intervention using motivational interviewing, which has been found to help individuals change a variety health issues, may lead to a more transferable and cost-effective intervention in real settings when compared to single risk interventions. Like the aforementioned CHOICES Plus project, future research should test the efficacy of preconception interventions that target various combinations of health related risk factors. While this study had several strengths, there are also limitations. The sampling methods varied by site, affecting the representativeness of some of the samples, and the selected settings are not representative of all settings of their type. Also, although this study relied solely on self-report measures, this concern is somewhat offset by the fact that 50% of the entire sample reported smoking and 75% reported prior illicit drug use. These findings should also be interpreted in light of when this data was collected (1998–2000), as more recent questions for self-disclosure of tobacco use have improved and trends in smoking have generally decreased in the US population [32]. However, smoking rates have remained eminent among high risk populations, such as those reported in this study. Finally, although the quantity of smoking was not factored into the definition of NEP risk, there is no well-defined cutoff point at which smoking becomes detrimental during pregnancy, and there is considerable variation regarding how much nicotine enters the body based on the brand of cigarette and how it is smoked.

Conclusions Seventeen percent of women were at risk of NEP, with the largest proportion of women at risk in the jails and substance abuse centers. There was also a substantial overlap between the risk of alcohol-exposed pregnancy (AEP) and nicotineexposed pregnancy (NEP), suggesting the potential utility and promise of the expansion of the CHOICES preconception model to target both risks in an efficient manner in real settings. Preconception counseling is important to prevent NEP, as it offers an opportunity to initiate smoking cessation prior to pregnancy, when it is safer to use pharmacotherapy and women may be more likely to disclose risky health behaviors. Future research should examine the utility, efficacy and effectiveness of the CHOICES model to target multiple health behaviors and assist women in planning for pregnancy during preconception period.

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