Using film to adress reproductice health amoung central African immigrants/redugees resettled in Utah

This study investigated the knowledge and values surrounding reproductive and preconception health in a community of Central African refugees resettled in Utah and how the use of community representing film impacted their perspectives. We aimed to highlight main themes expressed by community members. Our team constructed a culturally appropriate film about a Central African refugee couple attending a PCC visit. A total of 22 male and female Central African refugees participated in this study. Demographic data were collected prior to the viewing using surveys and one-to one interviews with participants and interpreters. Qualitative data were collected in interpreter-led focus groups after the viewing. The focus group audio recorded transcripts were translated from Kirundi to English that included designation of the gender of the speaker. Inductive codes were created for novel insights shared by participants. After the review, the codes were then organized into categories and themes. Qualitative analysis of the participants' discussion produced three overarching themes: preparation, planning, and the role of the partner. Most of the preparation discussion explained the importance of planning for birth rather than pregnancy. Participants described how to be healthy during pregnancy with only few mentions of health preconception. Planning was discussed within the importance of pregnancy spacing. Participants stated that in general their community does not use pregnancy spacing methods and then later agreed to the importance of it. Lastly participants seemed to be impacted by the husband's accompaniment of the wife to a PCC visit. This initiated conversation about the role of a husband in the health of the pregnancy including reducing stress and working on the health of their parenting relationship. Overall, the film was well received, and many participants described it as "helpful" in their survey responses. The use of PCC is an essential step in addressing the birth outcomes and maternal health of American women. Refugees are an underserved population that benefits from consideration and inclusion in education about PCC. Healthcare providers and educators can be more effective by considering the cultural beliefs and knowledge of African refugees when discussing PCC and must also include strategies to overcome language and communication barriers.

ABSTRACT This study investigated the knowledge and values surrounding reproductive and preconception health in a community of Central African refugees resettled in Utah and how the use of community representing film impacted their perspectives. We aimed to highlight main themes expressed by community members. Our team constructed a culturally appropriate film about a Central African refugee couple attending a PCC visit. A total of 22 male and female Central African refugees participated in this study. Demographic data were collected prior to the viewing using surveys and one-to one interviews with participants and interpreters. Qualitative data were collected in interpreter-led focus groups after the viewing. The focus group audio recorded transcripts were translated from Kirundi to English that included designation of the gender of the speaker. Inductive codes were created for novel insights shared by participants. After the review, the codes were then organized into categories and themes. Qualitative analysis of the participants’ discussion produced three overarching themes: preparation, planning, and the role of the partner. Most of the preparation discussion explained the importance of planning for birth rather than pregnancy. Participants described how to be healthy during pregnancy with only few mentions of health preconception. Planning was discussed within the importance of pregnancy spacing. Participants stated that in general their community does not use pregnancy spacing methods and then later agreed to the importance of it. Lastly participants seemed to be impacted by the husband’s accompaniment of the wife to a PCC visit. This initiated conversation about the role of a husband in the health of the pregnancy including ii reducing stress and working on the health of their parenting relationship. Overall, the film was well received, and many participants described it as “helpful” in their survey responses. The use of PCC is an essential step in addressing the birth outcomes and maternal health of American women. Refugees are an underserved population that benefits from consideration and inclusion in education about PCC. Healthcare providers and educators can be more effective by considering the cultural beliefs and knowledge of African refugees when discussing PCC and must also include strategies to overcome language and communication barriers. iii TABLE OF CONTENTS ABSTRACT ii INTRODUCTION 1 METHODS 7 RESULTS 10 DISCUSSION 18 CONCLUSION 21 REFERENCES 22 iv INTRODUCTION Preconception care (PCC) is a form of medical intervention focusing on the health of an individual with the objective of helping to increase the health of their future child and the mother during pregnancy and beyond (Preconception Health and Health Care Is Important For All, 2022). According to both the Centers for Disease Control and Infection (CDC) and the American College of Obstetricians and Gynecologists (ACOG) women of reproductive age should receive PCC, even if not actively planning for pregnancy (Preconception Health and Health Care Is Important For All, 2022),("Prepregnancy Counseling," 2019). While we realize that not all people who can become pregnant identify as women, in this thesis, the terms woman/women/maternal will be used to refer to people with the potential to become pregnant, regardless of their gender, in alignment with terminology used in the literature. The purpose of PCC is to reduce the risk of adverse health effects for the patient carrying a pregnancy, their fetus, and neonate by working with the patient to “address modifiable risk factors” and educate the patient on pregnancy before they become pregnant ("Prepregnancy Counseling," 2019). PCC is strongly recommended by the CDC and ACOG because of its multimodal approach and its integral role in improving healthy pregnancies. PCC visits promote healthy and successful pregnancies by monitoring and treating chronic illness, reconsidering any existing health conditions (including medication), assessing the mother’s dietary and exercise habits, and performing screenings for sexually transmitted infection and intimate partner violence. A more holistic understanding of a patient's history and lifestyle can result in an appropriate plan of care and an opportunity for patient education regarding optimizing health prior to pregnancy. The World Health Organization asserts that PCC decreases “maternal and neonatal mortality and morbidity”, and results in, “fewer stillbirths, fewer preterm births, fewer low-birth-weight babies and more healthy babies”("Meeting to Develop a Global Consensus on Preconception Care to Reduce Maternal and Childhood Mortality and Morbidity," 2013). Furthermore, PCC visits result in the administration of folic acid supplements which reduce fetal neural tube defects (NTDs) by 93% (Lumley et al., 2001). To see the ACOG’s recommendations for PCC interventions and counseling, reference Table 1. Table 1. ("Prepregnancy Counseling," 2019) Preconception Care Visit Outline Timing of pre-pregnancy counseling “Would you like to become pregnant in the next year?” Health status and risk factors change over time so pre-pregnancy counseling should occur multiple times during reproductive age. Family planning and pre-pregnancy spacing Advise women to avoid any interpregnancy interval less than 6 months. Counsel about the risks of any repeat pregnancies within 18 months. Contraceptive counseling. A review of medical, surgical, and psychiatric history Screen patients for risk factors. A review of current medications Adjust medication use as appropriate. A review of family medical and genetic history Screen for genetic disorders. Assess and counsel regarding risk. Immunizations Review immunization history/ administer any recommended vaccines. Counsel regarding the risks associated with not receiving vaccines prior to pregnancy. Infectious disease screenings Sexually transmitted infection screening. Consider potential exposure to diseases. Substance use assessment Counsel regarding risk of drug use during pregnancy. Advise to avoid drug use. Exposure to violence, intimate person violence, and reproductive coercion Use self-administered questionaries and physician interviews. Assess nutritional status 2 Recommend use of folic acid and prenatal supplements. Counsel on dietary habits. Achieving and maintaining body weight Counsel regarding healthy weight before and during pregnancy. Assess exercise and physical activity Counsel on healthy amount of exercise and its benefits. Assess teratogens and environmental/occupational exposures Assess exposure to risk causing factors. Unfortunately, the United States’ infant mortality rate is considerably higher than most other high-income countries (MacDorman et al., 2014; Mathews & MacDorman, 2007). The U.S. also has high maternal mortality rates in comparison to countries such as Austria and Poland (Tikkanen et al., 2020). These rates are particularly concerning for U.S. women of color. More than half of the pregnancies in America are unplanned, and people of color disproportionately represent this statistic (Grady et al., 2015). In 2020, the maternal mortality rate for Non-Hispanic Black women in the U.S. was 55.3 deaths per every 100,000 live births. This represents a maternal mortality rate 2.9 times the rate of Non-Hispanic White women. There was a significant increase in the mortality rate for Non-Hispanic Black women between the years of 2019 and 2020 while there was no significant increase in the mortality rate of Non-Hispanic White women (Hoyert, 2020). Not only were maternal mortality rates among Blacks almost 3 times that of Whites in 2020 in the U.S., but their maternal mortality rate recently increased. The morality rate for infants who are Non-Hispanic Black Americans per every 1,000 live births is significantly higher than that of any other race. In 2019 the Non-Hispanic Black infant mortality rate was 10.6 which was more than double that of the 4.5 rate of Non-Hispanic White infant mortality (Infant Mortality, 2022). Preconception care addresses these issues 3 by providing education, contraception methods for recommended pregnancy spacing, and promotion of healthy pregnancies and births. A particularly high-risk group is people who identify as not only Non-Hispanic Black, but who arrived in the United States from Africa as refugees/immigrants seeking asylum here in Utah. In this study, we are working with Central African refugees/immigrants, many of whom came here to escape violence and political unrest. Paradoxically, immigrant women typically have better birth outcomes than U.S.-born women. African-born women have lower rates of preterm births and small for gestational age babies when compared to U.S.-born women (Agbemenu et al., 2019; Elo et al., 2014). These statistics, however, neglect to consider the reality of African immigrant/refugee women experiencing high levels of stress and any other risk factors they may have experienced in the violent political unrest in their birth countries. As the result of any potential adversity experienced in their home countries or during the immigration process, refugee women from areas of high stress may have worse birth outcomes when compared to women born in the U.S. It is possible that refugees/immigrants are lacking information regarding standard and recommended health intervention here in the U.S. Refugee and immigrant status alone is considered a barrier to healthcare related to health literacy, cost, cultural beliefs, and lack of social support. Although there is not an abundance of research on the rates in which resettled African refugees seek and receive PCC; it’s known that African refugee and immigrant women postpone the initiation of prenatal care when compared to both white and black women born in the U.S. (Ray et al., 2004; Agbemenu et al., 2019). This is likely correlated with a lack of PCC utilization. Postponing prenatal care and, furthermore, 4 preconception care neglects mothers/potential mothers the opportunities to best prepare for and manage their pregnancies and thus pregnancy outcomes. A systematic review found that African women with knowledge of PCC are nearly two times more likely to initiate care before conception (Tekalagn et al., 2021). We can address the discrepancy in PCC for immigrant/refugee women by increasing their knowledge about PCC. One way to address lack of knowledge about PCC is through community-engaged film. Community-engaged films are planned, coordinated, and produced with the help of the community members who make up the audience. Community engaged film has been used to increase awareness or knowledge, to promote discussion, and to change attitude and behaviors relative to the topic (Gurman et al., 2014). A scoping review showed that community engaged film improved mental health literacy and can be helpful in reducing mental health stigma and increase the rate at which community members seek mental health care (Ito-Jaeger et al., 2022). We applied these same methods to improve PCC health literacy, use of PCC, and further understand the community perspectives on preconception health among the Central African immigrant/refugee community in Utah. About 60,000 refugees live in Utah. Almost 40% of refugees in Utah are from African nations experiencing violent political unrest (Christensen, 2021). Best of Africa (BOA) is a community organization founded by Central African Refugees to help improve the healthcare disadvantages of Central African Refugees here in Utah. BOA has noted reproductive health concerns in the community of Central African Refugees here in Utah. With the close help and guidance of BOA leaders, this project evaluated the use of community-engaged film to present PCC information to a group of African refugees who may be unfamiliar with the kind of care they can receive here in the U.S. We believe 5 increasing knowledge about PCC will help inform this community of their options and potentially increase their PCC use. This study provides information about whether community engaged film is helpful to inform underserved communities about PCC to increase PCC utilization. The study had the following research questions: 1. What were the common themes of the preconception health film perceived by the audience and how do they compare to the research team's objectives? 2. As a result of the film, what actions do community members intend to make related to preconception care/reproductive health? 3. How does the audience feel about the film, and do they consider this type of film with community actors to be a helpful tool to their community? If so, how? 6 METHODS Film Production Our team constructed our film script working with leaders of BOA and several community members to create a culturally appropriate script about a Central African refugee couple attending a PCC visit. Our script includes reference to the use of a community health worker, the importance of annual healthcare check-ups, and standard PCC practices such as discussion of the patient's medical history, medication use, drug use/recommendations, exercise and diet habits/recommendations, pregnancy planning, and the administration of folic acid. BOA recommended that we not emphasize contraception use or pregnancy planning in the script. As a result, the couple in the script were informed about pregnancy spacing recommendations and encouraged to discuss these topics at home for their comfort. An important theme in our script is the patient’s right to make her own medical decisions and take time to discuss what is best for her and her family. With the approval of BOA and community members, our script was filmed in a clinical environment with members of the community as the actors. One man and one woman from the community were paid to act as a husband and wife using the script we co-created. BOA suggested we use a White actor as the medical provider to align with the real demographics of practicing providers in Utah ("Diversity in Medicine: Facts and Figures 2019," 2019). The use of community members as actors was important to the project so our viewers could feel accurately represented. During the filming process, a leader in BOA (VM) oversaw the process and provided relevant input. 7 Recruitment Study participants were recruited by BOA leaders through email, telephone, and social media. Inclusion criteria included men and women 18 years or older from the African refugee/immigrant community. The date of the film viewing event was scheduled at the convenience of participants. Pre-viewing To show the film we invited study participants to a viewing event at the Utah Refugee Center where we brought food traditional to Central Africa. Both the event's setting and the food provided were important to creating a comfortable atmosphere for participants. The audience members were all guided in an informed consent process with a cover-letter using community member interpreters to translate from English to Kirundi. Prior to viewing the films, we handed out a survey to collect preliminary demographic data and data on participants’ knowledge and views around PCC. Because pregnancy spacing is an important part of PCC, some of the questions asked about family planning/contraception. The participants completed the survey with the help of interpreters. Viewing During the film's showing, interpreters translated the script to Kirundi as the audience watched. Post-Viewing After the viewing, participants completed a post viewing survey with the help and translation of interpreters. The questions in the post viewing survey collected data on the participants' knowledge of PCC information after the film and were developed in 8 collaboration with BOA community leaders. We also collected data on the participants' overall opinion of the film. Then the participants were split into groups for focus group discussions. We consciously separated married partners so they could feel as comfortable as possible to discuss their views without any outside pressure that may come from an intimate relationship. Our groups consisted of both men and women in attempts to better represent community views. Each group went into a separate room for the post-viewing focus group discussion. Each focus group was facilitated by a bilingual community leader/interpreter who used a facilitator guide and a research team member who audiorecorded the discussion. The focus groups were conducted in Kirundi and the facilitator guides were developed in collaboration with BOA community leaders. During the focus group discussions, qualitative data were collected to answer the questions of this project and obtain feedback from participants about the film and the event. At the event's end, the audience members and interpreters were given a $20 gift card to thank them for their participation. The focus group recordings were transcribed and then translated from Kirundi to English with gender designation. The transcriptionist designated the gender of each speaker based on voice and context. Excel software was used to conduct qualitative content analysis. Inductive codes were created for novel insights shared by participants. To eliminate bias the initial codes were established by two independent team members. Two independent coders coded the transcripts. The entire research team reviewed the codes and addressed any discrepancies using consensus. The codes were then organized into categories and themes. 9 RESULTS Demographics The study included 22 participants who were split into 3 focus groups (spouses separated) (Table 2). The participants were 19 documented refugees, 2 family-sponsored immigrants and 1 green card program member. The participants ranged from 18 to 70 years old. The median age was 47.5 years old. Our participants were 72.7% female (16) and 27.3% male (6). The Central African participants had varying countries of origin including 63.6% from Congo, 22.7% from Rwanda, and 4.5% from Burundi, Zambia, and Tanzania. At the time of the study, participants had lived in the U.S. for varying lengths of time ranging between less than a year to twenty years (less than 1 year (9.1%), 1-5 years (36.4%), 6-10 years (31.8%), 11-15 years (18.2%) and 16-20 years (4.5%)). None of the participants had engaged in a similar event/study. The highest level of education earned by the participants varied including: no formal education (22.7%), elementary school (13.6%), middle school/ junior high (4.5%), high school (40.9%), or associates, bachelor’s, or master's degrees (18.2%). Most participants were married (61.9%). The remainder were either widowed (4.8%), divorced (4.8%), or not in a relationship (28.6%). Table 2. Demographics of Study Participants Age (years) Number of Participants n=22 6 4 1 6 5 18-29 30-39 40-49 50-59 60+ 10 Percentage of Participants 27.3 18.2 4.5 27.3 22.7 Gender Country of Origin Time Living in the U.S. (years) Highest Level of Education Current Marital or Relationship Status Female Male Other 16 6 0 72.7 27.3 0 Congo Rwanda Burundi Zambia Tanzania 14 5 1 1 1 68.2 22.7 4.5 4.5 4.5 <1 1-5 6-10 11-15 16-20 2 8 7 4 1 9.1 36.4 31.8 18.2 4.5 No School Elementary School Middle School/ Junior High High School Associate degree Bachelor’s Degree > Bachelor's Degree 5 3 1 22.7 13.6 4.5 9 3 0 1 40.9 13.6 0 4.5 Married Widowed Living with partner in a married-like relationship In a relationship, but not living together Separated Divorced Single (not in a relationship) 13 1 0 61.9 4.8 0 0 0 0 1 6 0 4.8 28.6 11 Pre-Viewing Survey Our pre-viewing survey asked questions to understand the participants' views and familiarity with reproductive health care before the video showed. All participants completed the pre-viewing survey. Responses are summarized in Table 3. Before the video, when asked if they felt people in their community plan for pregnancy, 40.0% of the participants answered yes, 35.0% answered no, and 25.0% said they were unsure/ did not know. A total of 76.2% of our participants had previously heard of contraception/family planning, leaving 23.8% who had not. When asked about their views on people in their community using contraception for pregnancy spacing or family planning, 76.2% of the participants felt it is acceptable, 4.8% felt it is unacceptable, and 19% felt they were unsure/did not know. The participants were asked what things women in their community do before pregnancy to help promote a healthy pregnancy. Most participants thought that pregnant women in their community eat healthy food (81.0%), avoid smoking (80.0%), avoid alcohol use (76.2%), exercise (76.2%), avoid drug use (71.4%), visit a doctor/healthcare provider (76.2%), improve general health (61.9%), avoid/ reduce stress (66.7%) and get advice from friends and family (57.1%). Fewer participants believed that women in their community take folic acid during pregnancy (42.9%). 12 Table 3. Participant Views on the Behavior of Pregnant Women in Their Community Take folic acid 43% Get Advice from Friends and Family 57% Improve General Health 62% Avoid/Reduce Stress 67% Avoid Drug Use 71% Visit a Doctor/Healthcare Provider 76% Exercise 76% Avoid Alcohol Use 76% Avoid Smoking 80% Healthy Food 81% Shown above is the percentage of participants that believe members of their community do (X) to improve the health of their pregnancy. Participants were asked if they knew how to prevent pregnancy. No participants strongly disagreed. One participant (4.8%) disagreed and one participant (4.8%) neither agreed nor disagreed. Most participants either agreed (42.9%) or strongly agreed (47.6%) that they know how to prevent pregnancy. The last question of the pre-viewing survey asked if the participants knew what healthy behaviors are important to ensure that a future pregnancy is healthy. Most participants responded confidently; none strongly disagreed, one participant (4.8%) disagreed, one participant (4.8%) neither agreed nor disagreed, 42.9% agreed, and 47.6% strongly agreed that they know what behaviors are important for supporting a healthy pregnancy. Post-Viewing Survey Our post-viewing survey repeated some questions from the pre-viewing survey to understand how their answers may have changed as the result of the film. When asked after the viewing, the participants all either agreed (63.6%) or strongly agreed (36.5%) 13 that they know how to prevent pregnancy, even though details about family planning/contraception were not discussed during the film. After viewing the film all our participants also either agreed (61.9%) or strongly agreed (38.1%) that they know what healthy behaviors are important to ensure that a future pregnancy is healthy. Viewing Assessment The viewing assessment collected data to understand how the participants felt in response to the film. We asked if the participants enjoyed the program. Most of the participants either agreed (45.5%) or strongly agreed (50.0%) and one participant (4.8%) neither agreed nor disagreed. All participants either agreed (54.5%) or strongly agreed (45.5%) that they felt more confident about pregnancy planning after the program. Most participants either agreed (59.1%) or strongly agreed (36.4%) that they would like to learn more about how to get healthy before a pregnancy however one participant (4.5%) neither agreed nor disagreed. When asked if they would like to learn more about preventing pregnancy, one participant (4.5%) disagreed, 59.1% agreed, and 36.4% strongly agreed. Focus Groups Three themes were identified by our team: preparation for pregnancy, pregnancy planning, and the partner's role during pregnancy. I also discuss feedback from the participants to understand the success/opinions of our film. Preparation. In our focus groups, discussions predominantly revolved around preparation for labor and parenthood during pregnancy, with less emphasis on preparing for pregnancy itself. This highlights a difference in our objectives and the community's perceptions (reference research question 1). While the overarching theme of preparation 14 was consistent, some participants highlighted variations in understanding the film's content. One participant emphasized the film's focus on (Male:)"preparing to get pregnant," outlining aspects such as medications, a healthy diet, and exercise. Others perceived the film as a guide to avoiding unprepared pregnancies, emphasizing the importance of understanding what actions to take for personal well-being and the health of future offspring. (Male:) “So it's about not getting pregnant without being prepared...the purpose of showing it to us is to teach us to understand whenever you want to get pregnant, what you have to avoid and what you have to do for your good health and for your future baby." Many comments touched on prenatal care, (Female:) “When you get pregnant you should take care of yourself, eat fruits, and have peace at home.” Our theme of preparation also concerns this community’s lacking use of preconception care. A participant stated, (Female:) “In Africa people don't see the doctor as often as they are supposed to, they do not get the medications they are supposed to be getting.” In discussion of PCC one participant stated, (Female:) “We do not practice it.” Planning. Family planning and contraception emerged prominently in our focus group conversations, despite our efforts to minimize content about these topics in the script. This highlights a difference in the audience's perception of the film and our objective (reference research question 1). Some participants even attributed the film's intention to educating them on (Female:) "spacing pregnancies." Many understood the importance of pregnancy spacing and described their intention of spacing pregnancies after the film. (Female:) “It has taught me to use family planning.” (Female:)"After giving birth, to avoid having closely spaced pregnancies, you may go to the hospital and get some pills or injection for birth control.” It was said that (Female:) “Some people in 15 the African community have children like every year.” The use of contraception was regarded as uncommon, (Female:) “many people in our community do not use family planning.”, but it was also encouraged by the community members (Male) “I would advise him to use family planning.” The discrepancy between the film's content and the extensive discussions on contraception by the community members was a notable observation. Partner. Discussions also centered on the role of partners before and during pregnancy. One participant described the video as being about, (Female:) “husband and wife going to the hospital together.” Participants appreciated the portrayal of a husband accompanying his wife to a PCC visit in the film, highlighting that such involvement is not commonly discussed in their community. (Female:) “The thing I liked is the way she went to the hospital together with her husband. I usually see or hear that men feel ashamed to talk about topics related to pregnancy and contraception. So, it is good to show them that it is okay to go with your wife as you won’t do anything other than listening and show her support throughout the pregnancy.” Male participants expressed the importance of not “stressing” their wife to support their pregnancies and conception. This idea was paired with discussion of the partner's role during pregnancy by providing healthy foods and encouraging “peace in the home.” Feedback. We used feedback from the audience to evaluate the participants attitudes towards the film (reference research question 3). The film had a widespread positive reception and was consistently described as “helpful” by nearly all participants. The overall feedback indicated a favorable perception of the film as a valuable resource within the community (see Table 4), with expressions of appreciation such as, (Male:) 16 "we like them because we know that their content can help us.” Participants suggested the film be shared to further help others. (Female:) “People should share that movie with others, so that everyone watches it, learn from it themselves.” The participants encouraged us to make the film more accessible. (Female:) “That movie or similar teachings should be available and reach to people where they live; I think that there should be similar programs in our local communities.” Accessibility, in this context, also involves ensuring the film's content is easily comprehensible. A participant highlighted the potential for some viewers to face challenges in understanding the film independently: (Female:) “The movie we watched, there are people who may not understand it, it would be better if they watch it together with an experienced person to explain to them, there are many things that have not been said in words.” Table 4. Additional Relevant Quotes Theme Preparation Quote Female: “it is a good lesson because you have to ask your family doctor like ‘as I am planning on getting pregnant, would vitamins help me?’” Preparation Female: “What we like is that she seek medical advice about how she should behave.” Planning Male: the movies are good, first of all, we saw that people should give birth to children they are able to take care of, to make a family planning, to take care of their health and their baby’s, to go together with their husband because he is the father, so that they can decide to have another child when the last is grown up, to avoid closely spaced pregnancies. That’s my opinion.” Female: “I learned something from it because even though I knew about it, sometimes I look at what others are doing and because I was not encouraged, I find myself not doing the right thing, but now i am encouraged, I have to change.” Male: “What I should do is to find good for her good food, to try give a wellbeing to the baby in the womb.” Planning Partner 17 DISCUSSION In summary, this study sheds light on the fact that many immigrants and refugees from Central Africa perceive a lack of utilization of Preconception Care (PCC) within their communities. However, the implementation of a community-engaged film proved to be an effective method for educating this community about the advantages of PCC. The community displayed receptivity towards the use of prenatal vitamins and interestingly pregnancy planning, despite the research team's avoidance of encouraging the use of contraception. BOA advised against advocating contraception for pregnancy planning within the context of the community's views on contraception. Studies reveal diverse perspectives on contraception within African immigrant/refugee communities. For instance, one study highlighted varying opinions based on country of origin, with some participants embracing contraception while others regarding it as unnatural (Chalmiers et al., 2022). Additionally, research indicates that resettled African immigrants may possess limited knowledge about modern contraception methods(Weber et al., 2016). There is little evidence comparing American and African immigrant attitudes towards contraception. Factors influencing contraception use in this population encompass cultural beliefs, educational levels, and accessibility. Beyond general attitudes toward contraception, racial disparities affect healthcare accessibility in the United States. Black American women exhibit higher birth rates compared to white American women, possibly linked to their greater reliance on less effective contraception methods (Dehlendorf et al., 2014). We need more research to better understand the use of and views on contraception in this 18 community but ultimately took the advice of our BOA collaborators. Despite acknowledging the sensitivity and accessibility challenges surrounding family planning, our audience notably engaged in discussions regarding family planning and contraception use, despite our decision not to address these topics in the film. This indicates that perhaps further conversations about family planning with this community would be valued. The themes highlighted by our participants may reflect their cultural values, particularly their openness to the idea of partners preparing for pregnancy and labor together. During our event two films were shown. The focus groups were held directly after a viewing of an interpersonal violence film. This additional variable may have contributed to the audience’s receptivity to a strong paternal relationship. The discussion often revolved around preparing for pregnancy rather than PCC. This could indicate a potential gap in understanding PCC or may be attributed to translation errors during the research process. There is little research that describes the general English speaker’s ability to distinguish the difference between prenatal and preconception care. However, we know that only 12% of Americans have what is considered a proficient health literacy (Health Literacy Reports And Publications, 2019). Our sample group likely experienced some misunderstanding of the definition of preconception care. In this paragraph we will summarize the actions that participants intend to do because of the films (refence research question 2). Participants left the study with a heightened motivation to seek out medical resources for pregnancy preparation. Moreover, they expressed increased confidence in their ability to either prevent 19 pregnancies or space them. This positive outcome underscores the potential impact of community engagement and highlights areas where further research and outreach efforts can be directed to enhance reproductive health awareness within this population. This study contributes a better understanding of the general notions/opinions of PPC and effectively motivated people to seek PPC. The results are strengthened by qualitative analysis. Themes were created to elucidate prevalent responses, providing a platform for the participant community to express their perspectives. The use of BOA was vital to creating a culturally appropriate study. The guidance of this organization and actors from the community enriched the intention of the film. Among these strengths there were limitations. The primary challenge was the language barrier, as live translators were employed, preventing a precise understanding of the verbal script received by the audience. Additionally, potential errors in the translation of our transcripts may have contributed to less accurate interpretations and thus impacted the results. Another noteworthy limitation stems from the sequence in which the preconception health film discussion was following a similar film on interpersonal violence. This might have influenced the participants' emotions and responses to the PPC film. We must also consider that our participants' willingness to discuss our topics may suggest that their opinions do not represent their community as a whole. It is essential to recognize that our sample was drawn from the Salt Lake Valley, potentially limiting the generalizability of our findings to Central African refugees and immigrants residing in more rural areas who may experience less exposure to American culture and ideals. 20 CONCLUSION The utilization of community-engaged film as an educational tool to foster discussions on preconception health care among Central African refugees and immigrants resettled in Utah proved successful. Through our study, we identified viewers' attitudes toward both preconception care and our film, revealing a willingness among participants to modify their behavior concerning the pursuit of preconception care and overall health before and during pregnancy. This underscores the importance of health organizations and clinicians employing community-engaged film and discussion methods when serving immigrant and refugee populations to better comprehend and address their unique needs. However, there remains a need for further research on the experiences of African refugees and immigrants regarding preconception, rather than prenatal, healthcare, including an exploration of their understanding of the distinction between the two. Additionally, the utilization of contraception and related beliefs within this community remains inadequately understood and warrants further investigation. Further research is needed to find the most proficient method for encouraging preconception healthcare to Central African refugee/immigrants in a culturally appropriate way. 21 REFERENCES Agbemenu, K., Auerbach, S., Murshid, N. S., Shelton, J., & Amutah-Onukagha, N. (2019). Reproductive Health Outcomes in African Refugee Women: A Comparative Study. J Womens Health (Larchmt), 28(6), 785-793. https://doi.org/10.1089/jwh.2018.7314 Chalmiers, M., Karaki, F., Muriki, M., Mody, S., & Chen, A. (2022). 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Weber, L., Jenkins, A., Sanders, J., Gawron, L., & Turok, D. (2016). Family planning knowledge and contraceptive use among resettled African refugee women. Elsevier Contraception, 94(4), 423-424. https://doi.org/https://doi.org/10.1016/j.contraception.2016.07.149 23 Emma Norris: Honors Student Date of Submission: 24