Implementation and Dissemination of 'Gabby,' a Health Information Technology System for Young Women, Into Community-Based Clinical Sites

Women’s health prior to pregnancy is of critical importance, as healthy women are more likely to have healthy babies. Many women enter pregnancy at risk for poor outcomes because of preexisting medical conditions, exposures to teratogenic factors, or not following preventive actions, such as taking folic acid. In efforts to improve maternal and child health, there has been a focus on preconception care, or engaging young women before they become pregnant. Despite over 30 years of research on maternal and child health outcomes, Black and African American women are still twice as likely as White women to deliver a low-birthweight baby, a racial disparity that calls for specific intervention. Additionally, despite the broad interest in preconception care in recent years, there has been little progress in implementing these strategies into clinical practice.

To address this, the Gabby Preconception Care System (‘Gabby’) was created as a tool to support preconception care screening and education for Black and African American women. Using Embodied Conversational Agent technology, Gabby mimics face-to-face interactions through nonverbal gestures and evidenced-based communication practices. During development, qualitative feedback from Black and African American women of reproductive age was collected at each iteration to inform system changes, character design, voice, personality, and content development to ensure that the system would be engaging and relatable for the patient population this innovation was intended for.

The specific aims of the research were as follows:

• Recruit six Healthy Start sites and six Community Health Centers with Federally Qualified Health Center designation as implementation sites.
• Conduct site-level needs and resource assessments to guide implementation efforts.
• Perform training at each site around implementation of the Gabby system into the clinical workflow of the 12 sites.
• Assemble a preliminary, revised, and final Gabby Implementation toolkit.
• Analyze each step of the implementation process, and broadly disseminate the results of this work to the information technology, clinical, and health services research communities.

Using a Hybrid Type II implementation-effectiveness design, researchers evaluated the appropriateness, acceptability, feasibility, and effectiveness of the Gabby System among Black and African American Women receiving care at 10 community-based clinical sites. Seven sites carried out a 3- to 6-month Gabby rollout (‘implementers’). Among implementers, five sites successfully enrolled individuals to use the Gabby system. Pre-implementation interview and survey data highlighted contradictory findings, with interviews indicating more positive sentiments towards the Gabby implementation and overall site readiness. However, barriers, including technological access, the length of the preliminary health assessment, and changes to operational workflow due to the COVID-19 pandemic, limited implementation appropriateness, acceptability, and feasibility. Post-implementation feedback indicates the need for ongoing support and adaptation to implementation efforts to address challenges and improve implementation feasibility. An eight-module Gabby implementation toolkit, informed by a modified Delphi panel was developed during the study.