Improving Screening for Alcohol Use During Pregnancy: The Massachusetts ASAP Program

OBJECTIVE: To motivate prenatal care staff in public and private settings to universally screen for risk of alcohol and drug use and to conduct a brief intervention with follow-up referral when appropriate during a routine office visit. METHODS: The ASAP Project methods were engagement of site staff; staff training; self-administered questionnaires embedded with a relational and broad catch screening tool; a brief intervention protocol; unique clinical decision tree/protocols for each site; identification of treatment and referral resources; and ongoing technical assistance and consultation. Sites were located in four regions of the state and included four community health centers, a network of multi-specialty private practices and a teaching hospital. RESULTS: Across 16 sites, 118 prenatal staff were trained on use of the screening tool and 175 staff on the brief intervention. The ASAP Project resulted in 95% of pregnant women being screened for alcohol use and 77% of those screening positive for at least one risk factor receiving a brief intervention during a routine office visit. CONCLUSIONS: Screening and brief interventions for alcohol use can be delivered effectively within a routine prenatal care visit by prenatal staff by utilizing and building on existing office systems with practice staff, screening for any use not only at risk use, providing training with skills building sessions and information delivered by physicians, offering easy-to-access community treatment resources, and providing ongoing technical assistance.     

Outcomes of a brief alcohol abuse prevention program for Israeli high school students.

PURPOSE: To implement a brief intervention aimed at reducing abuse of alcohol among adolescents, and to assess its effectiveness. METHODS: One thousand 10th-grade students from seven high schools, chosen by random from the roster of all schools in southern Israel, were assigned to intervention and control groups. The intervention, which was based on Botvin's social skills theory, was conducted over 3 days and included dissemination of information, workshops, lectures by guest experts, and activity areas. It was administered by the staff of the high schools and the Psychological Counseling Service in Israel. A self-administered questionnaire was answered anonymously by students in the 10th grade (pretest) and again in the 11th and 12th grades (posttests). It included questions on sociodemographic data, alcohol-related habits, smoking habits, use of illicit drugs, knowledge, and attitudes. Data were collected between 1994 and 1997 with a 76% follow-up rate at 2 years. RESULTS: At baseline there was no statistical difference in alcohol consumption between the intervention and control groups. At 1- and 2-year follow-up the rates of alcohol consumption did not change in the intervention group (p > .05) but rose significantly in the control group (p < .001). In multiple regression analysis the variables male gender, positive attitudes, cigarette smoking, availability of illegal drugs, and intervention group were significant predictors of alcohol consumption. CONCLUSIONS: The results of this study show the effectiveness of this intervention program, based on reduced alcohol consumption in the intervention group at 1- and 2-year follow-up, compared with the control group. Compared with other programs, the present intervention is brief, intensive, and relatively easy to implement.     

Inconsistent Report of Pre-Pregnancy-Recognition Alcohol Use by Latinas

Objective This study compared pregnant Latinas’ report of alcohol use for the 3-month period before pregnancy recognition with two different methods of data collection, in an attempt to identify opportunities for improved screening. Methods Data were collected for 53 pregnant Latinas who have ever drunk alcohol and who were receiving services at Women, Infants, and Children (WIC) clinics in San Diego, California. This study compared alcohol use reported during in-depth research interviews conducted in homes, to responses to an alcohol screening question administered by WIC staff. Results Latinas were more likely to report alcohol use for the 3-month period before pregnancy recognition at the in-depth home interview than their reported date of last drink to the WIC clinic would indicate (70% vs. 15%, respectively). Of importance, 57% of home interview reports that were positive for pre-pregnancy-recognition alcohol use would not have been identified by their reported date of last drink to the WIC screening question. Younger age, higher income, and earlier recognition of pregnancy were associated with under-reporting of pre-pregnancy-recognition alcohol use. Conclusions Reporting of pre-pregnancy-recognition alcohol use may be influenced by the circumstances and scope of the screening questions employed, and varies by respondent’s characteristics. Asking about pre-pregnancy-recognition alcohol use, i.e., alcohol consumed before pregnancy is recognized, may improve identification of low-income pregnant Latinas who may benefit from targeted intervention services.     

Brief interventions for at-risk drinking: patient outcomes and cost-effectiveness in managed care organizations

AIMS: Evaluate effectiveness and costs of brief interventions for patients screening positive for at-risk drinking in managed health care organizations (MCOs). METHODS: A pre-post, quasi-experimental, multi-site evaluation conducted at 15 clinic sites within five MCO settings. At-risk drinkers (N = 1329) received either: (i) brief intervention delivered by licensed practitioners; or (ii) brief intervention delivered by mid-level professional specialists (nurses); or (iii) usual care (comparison condition). Clinics were randomly assigned to three study conditions. Data were collected on the cost of screening and brief intervention. Follow-up interviews were conducted at 3 and 12 months. RESULTS: Participants in all three study conditions were drinking significantly less at 3-month follow-up, but the decline was significantly greater in the two intervention groups than in the control group. There were no significant differences between the two intervention conditions. Of the patients in the intervention conditions 60% reduced their alcohol consumption by > or =1 drink per week, compared with 53% of those in the control condition. No differences were found on a measure of the quality of life. Differential reductions in weekly alcohol consumption between intervention and control groups were significant at 12-month follow-up. Average incremental costs of the interventions were 4.16 US dollar per patient using licensed practitioners and 2.82 US dollar using mid-level specialists. CONCLUSION: Alcohol screening and brief intervention when implemented in managed care organizations produces modest, statistically significant reductions in at-risk drinking. Interventions delivered to a common protocol by mid-level specialists are as effective as those delivered by licensed practitioners at about two-thirds the cost.     

Healthcare workers' attitudes to working during pandemic influenza: a qualitative study

Background

There have been many randomized controlled trials of screening and brief alcohol intervention in primary care. Most trials have reported positive effects of brief intervention, in terms of reduced alcohol consumption in excessive drinkers. Despite this considerable evidence-base, key questions remain unanswered including: the applicability of the evidence to routine practice; the most efficient strategy for screening patients; and the required intensity of brief intervention in primary care. This pragmatic factorial trial, with cluster randomization of practices, will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in primary care and different intensities of brief intervention to reduce excessive drinking in primary care patients.

Methods and design

GPs and nurses from 24 practices across the North East (n = 12), London and South East (n = 12) of England will be recruited. Practices will be randomly allocated to one of three intervention conditions: a leaflet-only control group (n = 8); brief structured advice (n = 8); and brief lifestyle counselling (n = 8). To test the relative effectiveness of different screening methods all practices will also be randomised to either a universal or targeted screening approach and to use either a modified single item (M-SASQ) or FAST screening tool. Screening randomisation will incorporate stratification by geographical area and intervention condition. During the intervention stage of the trial, practices in each of the three arms will recruit at least 31 hazardous or harmful drinkers who will receive a short baseline assessment followed by brief intervention. Thus there will be a minimum of 744 patients recruited into the trial.

Discussion

The trial will evaluate the impact of screening and brief alcohol intervention in routine practice; thus its findings will be highly relevant to clinicians working in primary care in the UK. There will be an intention to treat analysis of study outcomes at 6 and 12 months after intervention. Analyses will include patient measures (screening result, weekly alcohol consumption, alcohol-related problems, public service use and quality of life) and implementation measures from practice staff (the acceptability and feasibility of different models of brief intervention.) We will also examine organisational factors associated with successful implementation.

Trial registration

Current Controlled Trials ISRCTN06145674.     

Using Drink Size to Talk About Drinking During Pregnancy: A Randomized Clinical Trial of Early Start Plus

This clinical trial compared two brief alcohol use interventions in prenatal clinics: Early Start (ES), a substance-abuse screening and treatment program integrated with prenatal care focused on abstention (n?=?298), and Early Start Plus (ESP), adding a computerized drink-size assessment tool and intervention focused on drinking less (n?=?266). Controls were untreated alcohol users (n?=?344). Controls had higher adverse neonatal and maternal outcome rates. Findings favored ESP for preterm labor and ES for low birth weight. No differences between ES and ESP were statistically significant. ESP provides clinicians with an innovative assessment tool that creates open dialogue about drinking during pregnancy.     

Validation of a self-administered questionnaire to screen for prenatal alcohol use in Northern Plains Indian women

OBJECTIVE: This study among American Indian prenatal patients was conducted to validate a self-administered questionnaire (SAQ) designed to (1) identify women who had consumed alcohol during pregnancy, (2) identify women who may be at risk of drinking during pregnancy, and (3) determine the quantity and frequency of alcohol and other substance use just before and during pregnancy. METHODS: The validation involved three components: (1) review of the SAQ responses by a public health nurse; (2) structured patient interview with the research nurse; and (3) medical record abstraction postpartum. RESULTS: Compared to extensive interview and medical record data, the SAQ is sensitive (76.6%) and specific (92.8%) in detecting pregnant women who had consumed alcohol during pregnancy. CONCLUSION: The SAQ is a useful screening tool for alcohol use in this population.     

Low Prenatal Weight Gain Among Adult WIC Participants Delivering Term Singleton Infants: Variation by Maternal and Program Participation Characteristics

Objective: To determine the association of maternal and prenatal WIC program participation characteristics with low prenatal weight gain among adult women delivering liveborn, singleton infants at term. Methods: WIC program data for 19,017 Black and White Alabama women delivering in 1994 were linked with birth certificate files to examine the association of anthropometric, demographic, reproductive, hematologic, behavioral and program participation characteristics with low prenatal weight gain. Results: One third (31.0%) had low prenatal weight gain as defined by the Institute of Medicine. The incidence of low weight gain was increased among women who had < 12 years of education, were single, Black, anemic, had low or normal pre-pregnancy body mass index (BMI), increased parity, interpregnancy intervals 24 months, used tobacco or alcohol, or entered prenatal care or WIC programs after the first trimester. After adjusting for selected maternal characteristics, the adjusted odds ratios (AOR) for low weight gain were increased with short interpregnancy intervals (AOR 1.21 to 2.20); tobacco use (AOR 1.16 to 1.40), anemia (AOR 1.20 to 1.25), and second trimester entry into prenatal care (AOR 1.14 to 1.20); the size of the AORs and 95% confidence intervals varied by BMI and racial subgroup. Conclusions: The results of this study suggest that WIC interventions targeting low prenatal weight gain be focused on risk factors present not only during pregnancy, but during the pre- and interconceptional periods as well. Interventions should target low BMI, tobacco use, and anemia, and include attention to nutrition screening and risk reduction among women in postpartum and family planning clinic settings.     

A reduction in reported alcohol use in pregnancy in Australian Aboriginal communities: a prevention campaign showing promise

Objective : Aboriginal leaders in remote Western Australian communities with high rates of prenatal alcohol exposure invited researchers to evaluate the community‐led Marulu foetal alcohol spectrum disorder (FASD) Prevention Strategy initiated in 2010. Methods : The proportion of women reporting alcohol use during pregnancy to midwives was compared between 2008, 2010 and 2015. Initial midwife appointments were calculated by weeks of gestation. The proportions of women reporting alcohol use by age at birth were compared. Results : Alcohol use reduced significantly from 2010 (61.0%) to 2015 (31.9%) with first‐trimester use reducing significantly from 2008 (45.1%) to 2015 (21.6%). Across all years, 40.8% reported alcohol use during pregnancy and 14.8% reported use in both first and third trimesters. Most women attended the midwife in the first trimester. There was a significant relationship between increased maternal age and third‐trimester alcohol use. Conclusions : The reduction in reported prenatal alcohol exposure in an Aboriginal community setting during a period of prevention activities provides initial evidence for a community‐led strategy that might be applicable to similar communities. Implications for public health : The reductions in alcohol use reduce the risk of children being born with FASD in an area with high prevalence, with possible resultant reductions in associated health, economic and societal costs.     

Final results of the Maryland WIC 5-A-Day Promotion Program.

OBJECTIVES: This National Cancer Institute-funded study sought to increase fruit and vegetable consumption among women served by the WIC program in Maryland. METHODS: Over a 2-year period, a multifaceted intervention program using a randomized crossover design sought to increase fruit and vegetable consumption at 16 WIC program sites in Baltimore City and 6 Maryland counties. Participants were surveyed at baseline, 2 months postintervention, and 1 year later. RESULTS: Two months postintervention, mean daily consumption had increased by 0.56 +/- 0.11 servings in intervention participants and 0.13 +/- 0.07 servings in control participants (P = .002). Intervention participants also showed greater changes in stages of change, knowledge, attitudes, and self-efficacy. Changes in consumption were closely related to number of nutrition sessions attended, baseline stage of change, race, and education. One year later, mean consumption had increased by an additional 0.27 servings in both intervention and control participants. CONCLUSIONS: Dietary changes to prevent cancer can be achieved and sustained in this hard-to-reach, low-income population. However, many obstacles must be overcome to achieve such changes.     

The Maryland WIC 5 A Day Promotion Program Pilot Study: Rationale,Results, and Lessons Learned

Although the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves approximately 6.5 million participants nationwide, little research has been conducted to assess the effectiveness of health promotion programs aimed at the prevention of chronic diseases among its participants. Characteristics of the WIC program and the population it serves present numerous challenges to successfully implementing such initiatives. This National Cancer Institute-funded study seeks to increase fruit and vegetable consumption among women enrolled in WIC and women whose children are enrolled in WIC in Maryland. Key behavioral messages, motivators, and strategies tailored to the target population were identified first. The project team then developed a multifaceted intervention program. To assess its effectiveness and to learn about potential logistical problems prior to initiating a large-scale intervention program, we conducted a pilot study in two intervention sites and one control site. The pilot study demonstrated problems in client recruitment and participation. Both intervention sites showed small increases in fruit and vegetable consumption that were not statistically significant. Numerous lessons were learned, demonstrating the utility of conducting such a study prior to implementing a full-scale intervention.     

5 a day fruit and vegetable intervention improves consumption in a low income population

OBJECTIVE: This study evaluated the Michigan Farmers' Market Nutrition Program in one Michigan county to determine its effect on fruit and vegetable consumption behavior. SUBJECTS/SETTING: Subjects were selected from WIC and Community Action Agency populations: 564 low income women completed the pretest; 455 completed the posttest. Attrition rate was 19.3%. INTERVENTION: Subjects were assigned to one of 4 interventions: education about the use, storage and nutritional value of fruits and vegetables, distribution of farmers' market coupons, both education and coupons, or no intervention. DESIGN: Education-only and coupon and education groups were randomly assigned; clinic appointment timing determined assignment to no-intervention and coupon-only groups. MAIN OUTCOME MEASURES: A self-administered questionnaire before and after intervention measured attitudes about fruit and vegetable consumption and intake of fruits and vegetables. WIC records documented redemption of coupons. STATISTICAL ANALYSES: Data analysis included 2-way multivariate analysis of covariance, univariate analysis of covariance, logistic regression, and covariance structure modeling. RESULTS: Both the education interventions and the coupon interventions had positive effects. Coupons had a direct effect on increasing fruit and vegetable consumption behavior but no effect on attitudes. Education had a direct effect on attitudes and seemed to exert an effect on consumption behavior through attitudes. The maximum impact of the intervention was achieved through a combination of education and coupons. APPLICATIONS: This study demonstrated that a low-income population may be more likely to increase its fruit and vegetable consumption behavior when incentives such as coupons improve affordability.     

Factors associated with underimmunization at 3 months of age in four medically underserved areas

OBJECTIVE: Risk factors for underimmunization at 3 months of age are not well described. This study examines coverage rates and factors associated with under-immunization at 3 months of age in four medically underserved areas. METHODS: During 1997-1998, cross-sectional household surveys using a two-stage cluster sample design were conducted in four federally designated Health Professional Shortage Areas. Respondents were parents or caregivers of children ages 12-35 months: 847 from northern Manhattan, 843 from Detroit, 771 from San Diego, and 1,091 from rural Colorado. A child was considered up-to-date (UTD) with vaccinations at 3 months of age if documentation of receipt of diphtheria-tetanus-pertussis, polio, haemophilus influenzae type B, and hepatitis B vaccines was obtained from a provider or a hand-held vaccination card, or both. RESULTS: Household response rates ranged from 79% to 88% across sites. Vaccination coverage levels at 3 months of age varied across sites: 82.4% in northern Manhattan, 70.5% in Detroit, 82.3% in San Diego, and 75.8% in rural Colorado. Among children who were not UTD, the majority (65.7% to 71.5% per site) had missed vaccines due to missed opportunities. Factors associated with not being UTD varied by site and included having public or no insurance, >/=2 children living in the household, and the adult respondent being unmarried. At all sites, vaccination coverage among WIC enrollees was higher than coverage among children eligible for but not enrolled in WIC, but the association between UTD status and WIC enrollment was statistically significant for only one site and marginally significant for two other sites. CONCLUSIONS: Missed opportunities were a significant barrier to vaccinations, even at this early age. Practice-based strategies to reduce missed opportunities and prenatal WIC enrollment should be focused especially toward those at highest risk of underimmunization.     

Serum-gamma-glutamyltransferase in screening and continuous control of heavy drinking in middle-aged men

In an on-going population study in Malm?, serum-gamma-glutamyltransferase (GGT) is utilized both in biochemical screening of high alcohol consumption and as a tool in further investigation, treatment and control of middle-aged men with screening GGT in the top decile of the distribution. For this purpose, a special outpatient clinic has been instituted and is described in the present report. The composition of the intervention group and the feasibility of the program are reported for the first 6760 middle-aged male screening participants. A random one-half of the individuals with screening GGT in the top decile were allocated to the intervention group, which after primary dropouts and exclusion of concurrent diseases consisted of 252 individuals who have now been followed between three to six years. On the basis of structured interviews, hazardous levels of alcohol consumption were concluded to be present in 76% of the group. Although one-quarter of the group dropped out of the intervention program, the results indicate that it is feasible to institute an outpatient clinic for individuals with increased GGT levels found in a general health screening examination, to retain most individuals in this outpatient clinic and to consider alcohol habits and consumption levels in relation to the laboratory test value and general physical health status.     

Determinants of inadequate prenatal care utilization by African American women

A convenience sample of city-dwelling African American women (n=246) was interviewed during each woman's postpartum stay at one of five hospitals in Washington, D.C. to determine their perceptions of factors influencing their prenatal care utilization. The Kotelchuck Adequacy of Prenatal Care Utilization Index was used to classify prenatal care utilization as either adequate (Adequate Plus and Adequate groups combined) or inadequate (Intermediate and Inadequate groups combined). Of the 246 women studied, 40% (99) had adequate prenatal care utilization. Using Classification and Regression Trees analysis, the following risk groups for inadequate prenatal care utilization were identified: women who reported psychosocial problems as barriers and who were not participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) (percent adequate=8.8); women who reported psychosocial problems as barriers, were participants of the WIC program, and reported substance use (percent adequate=13.8); and women who reported psychosocial problems as barriers, were participants of the WIC program, denied substance use, and reported childcare problems as barriers (percent adequate=20.0).     

A Risk Assessment Screening Test for Very Low Birth Weight

Objectives: To develop a risk-assessment screening tool for very low birth weight (VLBW) and to compare our empirically derived tool to the nonempirically derived screening tool used by the State of Florida. Methods: Birth records from the State of Florida Vital Statistics between 04/01/92 and 12/07/94 were matched with State Healthy Start prenatal records, reported from 04/01/92 through 03/31/94. Known and additional potentially important risk factors were identified from both sources. Generalized Linear Modeling techniques were used to estimate associations between risk factors and VLBW. A risk assessment system was then developed using the estimated model. The resulting screening test was compared with the one used by the Florida State Department of Health in terms of sensitivity and specificity on an independent validation sample. Results: The proposed screening tool had comparable specificity to the Healthy Start screening tool but significantly better sensitivity. Both instruments are simple and easy to implement. Conclusions: Identification of women at high risk for VLBW would be improved using the model-based screening tool developed in this paper. Public health policy makers should use statistical methods in addition to expert opinion to improve existing risk assessment methods. The actual value of an improved screening instrument is dependent on the availability of effective intervention programs.     

Performance Measurement: A Proposal to Increase Use of SBIRT and Decrease Alcohol Consumption During Pregnancy

Alcohol consumption during pregnancy has negative implications for maternal and child health. Appropriate early universal Screening, Brief Intervention and Referral to Treatment (SBIRT) for pregnant women is necessary to identify women at risk and reduce the likelihood of continued drinking. Because SBIRT is not consistently used, the development and use of performance measures to assure implementation of SBIRT are key steps towards intervention and reduction of alcohol consumption during pregnancy. Practice guidelines provide ample support for specific instruments designed for SBIRT in prenatal care. An examination of existing performance measures related to alcohol consumption during pregnancy, however, reveals no comprehensive published performance measure designed to quantify the use of SBIRT for alcohol use in prenatal care. Process performance measures were developed that can determine the proportion of pregnant women who are screened during the course of prenatal care and the proportion of women requiring either brief intervention or referral to substance use disorder treatment who received those interventions. The measures require use of screening instruments validated for use with pregnant women. The two proposed measures would represent a significant step in efforts to assure appropriate intervention for women who drink during pregnancy, hold accountable providers who do not employ SBIRT, and provide a basis from which necessary systemic changes might occur. Pregnancy is a time when many women are motivated to stop drinking. That opportunity should be seized, with timely intervention offering assistance for pregnant women who have not stopped drinking of their own accord.