“How do we get to them?” Insights on Preconception and Interconception Health for Women in Rural Northwest Ohio

Background: Rural women in the United States are at increased risk for poor preconception and interconception health. In a previous study, women living in Hardin County, a Primary Care Health Professional Shortage Area and maternity care desert in rural northwest Ohio expressed their concerns and their need for more resources to improve their health. As a follow-up study, key informants of Hardin County were interviewed to provide further insight on current resources for preconception and women’s health available to community members, barriers and challenges community members face, and interventions could be implemented in the county to improve health and pregnancy outcomes. Methods: A purposive sample of 14 key informants from community assets in Hardin County were recruited and individually interviewed with semistructured questions from 2 domains: perceived needs and barriers to care. Interview recordings were transcribed, precoded, and thematically analyzed. Participants received a $20 gift card as a token of appreciation. Results: Three themes were characterized from the data: current resources available, community observations, and suggested intervention strategies. Key informants identified the federally-qualified health center and YMCA, among others, as potentially underutilized resources for reproductive-age women. The small-town culture was described as both an advantage and disadvantage when trying to raise awareness about preconception/interconception health. Interventions built on partnerships and utilizing various outlets were suggested. Childcare, intergenerational knowledge transfer, and trust were issues crossing multiple themes. Conclusion: Key informants gave direction on available resources for reproductive-age women and potential approaches to provide education and outreach regarding preconception/interconception health and care.


INTRODUCTION
Preconception and interconception health are wide-ranging concepts that encompass overall health for nonpregnant girls and women of reproductive age. The term "preconception" is applied to nulliparous women while "interconception" is used for multiparous women. Preconception and interconception health encompass biomedical, behavioral, and social issues that may harm a Rural women in the US are at even greater risk for poor preconception and interconception health due to the social determinants they often face. These may include lower socioeconomic status, geographic isolation, and limited access to health care providers, healthy food options, and transportation. Each of these contributes to health disparities. [8][9][10][11][12][13] Furthermore, studies have found that women living in largely rural areas in the US had concerning preconception health risk behaviors, such as high rates of smoking, overweight/obesity, and physical inactivity. [14][15][16] Governmental agencies, including the US Department of Health and Human Services and Centers for Medicare and Medicaid Services, have raised awareness for the need to improve rural maternal health. 17, 18 Rural experts rank maternal and infant health as a top concern, with calls to better study rural women's health. 10,19 However, to date, literature detailing preconception and interconception health and care for reproductive-age women specifically in the rural Midwestern US has been scant. Therefore, a series of studies has been conducted to better understand preconception and interconception health and care among women in rural northwest Ohio. [20][21][22] During interviews with reproductive-age women in Hardin County, Ohio, as part of a qualitative study to better understand their most pressing health needs, it became apparent that most were not aware of community assets they could utilize to improve or maintain their health. 23 Consequently, it was decided to conduct a second qualitative study with key informants in the county knowledgeable about such resources. The primary objective of this study was to gather information regarding resources available in the county for reproductive-age women. Secondary objectives were to characterize the challenges they observe reproductive-age women facing and intervention strategies they believe would be beneficial for reproductive-age women in Hardin County to improve preconception and interconception health.

Setting
Hardin County, Ohio, has a population of approximately 31 000. The county is considered to be a non-core county, the most rural classification, with no cities, towns, or urban clusters of 10 000 residents or more. 23 The county is additionally labeled as a Primary Care Health Professional Shortage Area (HPSA) and a maternity care desert, without proper resources and facilities for preconception and women's health care. 24,25 While there are a few primary health care facilities in Hardin County, some have restricted hours or are not open each day of the week. A free mobile health clinic has started in the county, providing limited secondary preventive care services, such as diabetes and hypertension screening, as well as disease state management to patients on certain days of the month; uptake among reproductive-age women has been minimal to date. 26 Some sources of care, such as the family planning clinic at the local health department, have recently closed.

Design
Prior to designing the study, a literature review was performed to identify gaps and determine potential design models for structuring interview questions. The study was designed to be phenomenological after bracketing that it was expected to identify resources and barriers. 27 The semistructured interview (Appendix) consisted of 9 questions from 2 domains: perceived needs and barriers to care. Interview questions included probes and followup questions for gathering additional information when needed, and all questions were open-ended. Interviews were thematically analyzed to identify reoccurring patterns in the data and characterize key informants' beliefs. 28

Participants and Procedures
Key informants representing community assets and stakeholders in the county were purposively recruited to participate in individual interviews to identify what resources are available in the county for reproductive-age women, what challenges they observe reproductive-age women facing, and what intervention strategies they believe would be beneficial for reproductive-age women in Hardin County. First, an email describing this study was sent to members of the Healthy Lifestyles Coalition of Hardin County, a group representing organizations involved in prevention initiatives to improve the health of Hardin County residents. 29 Members interested in participating in the study were asked to contact the investigators to arrange the interview. After seeing which organizations were represented by those volunteers, the investigators used personalized email messages or phone calls to individuals at agencies that they were aware of in the county that engage with reproductive-age women but had not been reached through the Healthy Lifestyles Coalition listserve. Despite multiple contact attempts, certain key informants the investigators had hoped to interview were not able to be reached.
Interviews were conducted individually using audio phone calls and video calls in June 2021. Prior to the interview questions, basic information regarding how long they have worked at their current organization and how long they have worked or lived in Hardin County were collected. The duration of the interviews was 15 to 60 minutes per participant, and each received a $20 Dollar General gift card as a token of appreciation following the interview. Upon informed consent, interviews were recorded with a Sony-PX Series digital voice recorder and manually transcribed verbatim. Transcripts were labeled sequentially so as to not explicitly identify each key informant. Interviews were conducted until saturation was reached.
The Ohio Northern University Institutional Review Board exempted the study.

Analysis
Before analysis, the transcripts were reviewed to gain familiarity with the data. The interview transcripts were precoded based on primary expectations and ideas to identify and highlight the key ojph.org Ohio Public Health Association 87 data wanted from the question script for the initial analysis. A concept map of the initial parent codes was made in order to see where there were differences and similarities in the data, leading to the identification of the emerged child codes. No analysis software was used and the coding process was done manually. For consistency, one researcher conducted the theoretical thematic analysis and interpretation of the interview data, while the other researcher ensured validity of the data codes by reviewing the analysis findings. Before the code tree was finalized, codes were redefined, modified, and discussed until discrepancies were resolved. The parent and child codes identified the reoccurring patterns in the data and became the 3 overarching themes and 8 subthemes due to the overlaps in the smaller data set (Table 1).

RESULTS
Fourteen key informants were interviewed, representing a variety of organizations and stakeholders in Hardin County. Participants had worked at their current organization in Hardin County for 1 to 35 years (mean = 8.7 years, standard deviation = 8.3 years). Twelve were residents of the county (4 to 50 years, mean = 27 years, standard deviation = 14.7 years). All but 1 of the participants were female, which gave a unique perspective as not only a key informant but also, in many cases, as a resident of the county themselves.

Organizations Represented by Key Informants (n=14)
Chamber of commerce Three main themes were characterized from information the key informants shared during the interviews. Table 1 displays the 3 overarching themes, subthemes of each main theme, and exemplar quotes.

Theme 1: Current Resources Available
Hardin County is known to be a maternity care desert and HPSA; however, there are some valuable resources in the county. Participants discussed the resources the county has readily available and sometimes not routinely tapped into, such as the federallyqualified health center, mobile health clinic, YMCA, and OSU Extension. Figure 1 shows the resources in Hardin County that the participants specifically named as potentially helpful for repro-ductive-age women and designates the location of Kenton and Ada, the 2 communities with the largest population in the county.
While mentioning the current assets in the county, key informants also recognized there are many resources missing from both inside and outside the health care system in Hardin County that are necessary for all members of the community. For instance, one participant said: We have no pediatricians in the county-so it's not only the health of women but it's the health of girls as well. (KI-14) She went even further to expand on how the lack of resources can hinder the community and said: …access is a problem, education is a problem. Unless we change generationally, it will continue as a cycle, then the children pick up the cycle and we are back to where we are before….  Several participants indicated that many women had to go outside of the county to access health care services or did not get needed care due to cost or transportation issues.

Theme 2: Community Observations
Many participants mentioned their observations of needs in the community or the hardships in Hardin County resulted from being a rural community and small-town culture. Some of the barriers or challenges mentioned were social determinants of health including poverty and low educational attainment, as well as geographic issues from lack of access or transportation. As a participant explained: Our number one disparity is poverty in the county-but the health care system in the county is not going to overcome poverty itself. There are so many different players to improve the poverty within the county…. (KI-14) Compounding these challenges is a lack of childcare options. Several participants mentioned this as a barrier preventing women from obtaining services or participating in events to improve their health. A participant shared:  Clinical "I think women are much more comfortable with some of the women's health services when they see women health care providers or they know it's dedicated to women." (KI-14)

Theme 3: Suggested Intervention Strategies
Some key informants from Hardin County have attempted interventions to improve health and mentioned their success and failures to suggest what interventions may be best for Hardin County in the future. Suggested intervention strategies included partnerships between organizations, improving education and awareness outreach, and increasing access to clinical facilities and services. Table 2 organizes the recommendations based on the socioecological model. 30 Participants went on to provide additional perspectives regarding their proposed intervention strategies. One participant suggested using the small-town culture of the community as a foundation of intervention strategies and said: Several participants mentioned that incorporating entertainment would be helpful to capture and maintain residents' attention.
Others reiterated the importance of childcare to enable women to utilize services, or that organizations should provide on-site activities for children. As one participant stated: Finally, many participants indicated that in their experience, providing education and outreach at an event already attended by women, such as fairs or high school football games, increased participation as compared to stand-alone events where it was hard to attract attendance.

DISCUSSION
To our knowledge, this is the first qualitative study to interview representatives of community assets to better understand the landscape regarding health among rural, reproductive-aged women in the US. The results of this study provide important insights from key informants to improve or maintain health for reproductive-age women in rural northwest Ohio. Three themes were characterized from the data: current resources available, community observations, and suggested intervention strategies.
Key informants identified resources both inside and outside of the health care system currently available in the county. This is significant as many residents who live in rural areas have low health literacy 10 ; further compounding this challenge is that many do not know the resources available to them. 22 Raising awareness about such resources is paramount to increasing their utilization and impact. However, when examining Figure 1 it becomes apparent that many of the resources cited by the key informants are concentrated in the county seat of Kenton which may limit their accessibility to women living in the outlying areas. This demonstrates a continued need to establish more assets across the county. In ad- dition, all but 3 of the resources named by the key informants had direct links to provision of or access to clinical health services.
Although key informants often mentioned issues related to social determinants of health during their interviews, they did not tend to list resources addressing such challenges (such as food banks or other charitable organizations) when asked about available resources for reproductive-age women. Key informants also mentioned important deficits in the county. For example, the lack of pediatricians may mean that girls are not receiving the clinical care they need and may be entering their reproductive-years in suboptimal health. The life course perspective must be taken into account, realizing that the foundation for good preconception health begins far earlier than the onset of puberty and involves resources both inside and outside of the health care system. 31 Key informants also shared their observations about Hardin County. Consistent with previously-published literature, [8][9][10][11][12][13] key informants indicated poverty as well as limited access to health care resources, transportation, and healthy foods as potential barriers to optimal health for reproductive-age women. Furthermore, many stated the difficulty in making residents aware of the resources available to them, because they may not perceive the need to avail themselves of the resources and there is not one medium readily available to communicate about the resources to all members of the community. However, there was a sense that there were strengths that the community derived from its small-town culture that could be better utilized to improve or maintain women's health.
Additionally, key informants made recommendations to improve preconception and interconception health at the individual, community, and policy levels. This is valuable as it can be used to inform the development of needed interventions. Many spoke of the need for a multipronged approach built on partnerships and utilizing both traditional and social media outlets as well as established venues that women already attend. When developing these interventions, planners should take care to ensure they are comprehensive and address both upstream (social and policy issues) as well as downstream (biomedical and lifestyle issues) factors that impact health. [31][32][33] Finally, 3 issues emerged that crossed multiple themes, indicating these may be priority areas to address. One of these was lack of childcare readily available in the county that serves as a barrier for women to receive services or attend programming. Another regarded the intergenerational cycle where women use older generations in the family as knowledge sources. This was indicated to be, at times, both a barrier (eg, when women have the perception that they do not need any education about a particular topic) and a benefit (eg, recognizing that information is likely to be shared among family members) when trying to raise awareness about preconception/interconception health. The third was trust, with a recognition that improving women's health in the county will like-ly not be successful if it is not a grassroots effort or if residents don't see their peers represented.
There are 2 major limitations to this study. The key informants consulted were extensive, but not exhaustive. For example, there was not an opportunity to speak with a physician or with staff from certain nonprofit organizations, such as food banks, who may have been able to provide further insights. In addition, the population of Hardin County is not racially or ethnically diverse 34 ; therefore, while these findings and recommendations may be helpful to counties with similar demographic profiles, they may not be applicable in rural communities with more diversity.
Future studies could utilize the methodology described here to ascertain barriers and recommendations for preconception and interconception health in other type of communities, such as urban areas, or other rural areas such as rural Appalachia, which has distinct cultural differences when compared to northwest Ohio. This information could then be used to guide potential interventions to improve preconception/interconception health at the individual, community, and policy level. Once the interventions are implemented, repeating interviews with key informants may yield insights into their effectiveness, needed changes, and new gaps to be addressed.

PUBLIC HEALTH IMPLICATIONS
Good preconception/interconception health is important for all reproductive-age women, regardless of their intent to conceive, as it reflects their personal health. [1][2][3][4] In addition, given that fact that nearly half of pregnancies in the US are unintended, 35 ensuring good preconception/interconception health can help to mitigate risks that could adversely affect a pregnancy. [1][2][3][4] However, women may not know of or utilize local resources that can improve or maintain their health. 22 Key informants can be consulted in order to collate information regarding community assets. Furthermore, they can provide perspectives regarding new strategies or services. The findings from this study will be helpful not only to Hardin County but also for similar rural communities. Communities that are different than Hardin County can utilize the methodology shared here to do their own studies to gain insights relevant for them.