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Project Choices program focuses on alcohol, sex and birth control for young women
The Project Choices program has been offered in Winnipeg, Manitoba since September 2010. Originally based on a program developed in the United States in the 1990s, it has continued to evolve to meet the needs of the community.
You can check out the recently launched website which includes FAQs and a great Links section. While the website is targeted at young women, it also includes information for service providers.
Project CHOICES is an FASD prevention program that works with girls/women of any age who are not currently pregnant, drink alcohol, and are sexually active. The goal of the program is to reduce the risk of an alcohol-exposed pregnancy through choosing healthy behaviours around alcohol and birth control use. Program partners include Klinic Community Health Centre, Norwest Co-op Community Health, and Healthy Child Manitoba.
Learn more about Project Choices in Canada and the research evidence to support the program in previous posts:
- College Binge Drinking and FASD Prevention (February 28, 2011)
- More on Project CHOICES (September 24, 2010)
- Project CHOICES Comes to Canada (September 14, 2010)
Asking “Do you drink alcohol?” is not enough
The American College for Obstetricians and Gynecologists is an organization of over 57,000 obstetricians and gynecologists. In 2011, the College did an extensive assessment of the needs of its membership to address at-risk drinking of all women, not only pregnant women. This new website contains tools that were collected and developed in response to this assessment.
The website is designed to support health care providers in screening and brief intervention and offers a cell phone app, downloadable patient information sheets, current news articles, and treatment referral information. Some examples of tools you can find include:
- iPhone app for identifying and intervening with women who drink at high-risk levels
- ACOG committee opinion: At risk drinking and alcohol dependence: Obstetric and gynecologic implications
- FAQs
The website feels a little cluttered (not all the resources are equally good) and not as dynamic and clean as I would like, but it’s great to see the interest in women and alcohol by the College and not just in relation to pregnancy.
Evaluating the role of mentoring programs in FASD prevention
FASD is an issue that spans across all populations. However, some women who use alcohol in high-risk ways during pregnancy have a history of complex background factors, including trauma, childhood abuse, mental illness, violence, and poverty. For this population, traditional strategies for addressing alcohol use are of limited effectiveness.
One approach to working with women struggling with high-risk substance use has been the development of intensive mentorship support services to women considered most at risk of having a child with FASD. (For examples of these mentoring programs, see earlier posts on Alberta’s First Steps Program and the Mentor Mother Home Visiting Program in South Africa and Saskatchewan’s KidsFirst Program).
Many of these programs are modelled on the Parent–Child Assistance Program (PCAP), which began in 1991 at the University of Washington. This program has been shown to be effective in preventing the births of children with FASD.
A group of researchers from Canada FASD Research Network (NAT 4) is focusing on the research and evaluation of Parent Child Assistance Programs (PCAP), or other mentoring support programs, that provide intensive mentorship support services to women considered most at risk to have a child with FASD. They are interested in better understanding the role these programs play in the prevention of FASD, how the programs are structured, what successes they achieve, what challenges they face, and what gaps exist.
At the moment, mentor-based intervention programs are unevenly distributed across the country. The provinces of Manitoba and Alberta have led the way in starting PCAPs and other kinds of mentoring programs, with British Columbia,
Saskatchewan, and First Nations communities throughout the north having created some programs that have close similarities to the original PCAP model.
- In Manitoba, the mentoring programs, called InSight, are funded by the provincial government. They began in 1998 with two sites in Winnipeg (the Nor’West Co-op Community Health Centre and the Aboriginal Health and Wellness Centre) and a rural site in the community of Norway House. By 2009, the program had six sites, 16 mentors and served up to 240 women. In 2010, there were seven sites, including one program that serves only Aboriginal women. Learn more about InSight here.
- In Alberta, urban PCAP programs were started in December 1999 in Edmonton and Lethbridge, followed soon after by a site in Calgary. There are now 21 PCAP or PCAP-like mentoring programs operating in Alberta under a variety of names such as First Steps, Step by Step, Open Arms, Parent-Child Advocate Program, Mothers to Be Mentorship Program, Coaching Families, and Youth with FASD Mentorship Program. Learn more about these programs here.
- On-reserve Aboriginal communities in Canada have developed numerous approaches to addressing FASD in their communities, many of which include a mentoring component. For example, in Saskatchewan, the Northern Inter-Tribal Health Authority began its “Strengthening the Circle” project in 2003 which now operates at four sites. In BC, the Inter-Tribal Health Authority runs the SOAR Mentoring Program. In Alberta, the Blood Tribe Department of Health offers the First Steps for Healthy Babies program.
Click here to learn more about the Network Action Team on the Evaluation of FASD Mentoring Programs, including links to their quarterly newsletter, a poster presentation from the 4th International Conference on FASD, and a report for 2010-2011 which summarizes their first year of work.
(In case you’re wondering about how many Network Action Teams (NAT) there are in the Canada FASD Research Network, the answer is 5. The NATs are:
NAT 1 – Research in Diagnostic Issues
NAT 2 – Intervention on FASD
NAT 3 – Evaluating FASD-Specific Public Health and Education Materials
NAT 4 – Evaluation of FASD Mentoring Programs
NAT 5 – Prevention from a Women’s Health Determinants Perspective
This blog is an initiative of NAT 5).
Image: SOAR mentoring program brochure, Intertribal Health
YouTube videos for physicians on screening for alcohol use in pregnancy
The Best Start Resource Centre has just uploaded many of their videos to You Tube, including its 2005 video Effective Practices in Screening for Alcohol Use in Pregnancy .
This video, designed as part of a training module, informs physicians about alcohol use and abuse in pregnancy and supports physicians in appropriate screening and assessment of their pregnant patients with tools and resources.
At less than 15 minutes (it’s split into two parts), it’s worth looking at – there’s some really great examples of what NOT to do and suggestions for ways of broaching and discussing alcohol with pregnant women. (You can also marvel at how training materials for 2005 already look dated to viewers in 2011…)
Check out other alcohol and pregnancy resources from Best Start here.
Kununurra : Lily Creek Lagoon by Peter Connolly
I first blogged about the Ord Valley Aboriginal Health Service FASD program back in January 2011 (see the post Getting Fathers Involved). Last week, an article called Ord Valley Aboriginal Health Service’s fetal alcohol spectrum disorders program: Big steps, solid outcome was published in the Australian Indigenous HealthBulletin. The author, Bridge, provides an overview of the program and reflects on successes and challenges as the first year draws to a close.
An FASD prevention program was initiated in August 2009 through the Ord Valley Aboriginal Health Service (OVAHS). OVAHS is a comprehensive primary health care (PHC) facility servicing Aboriginal people in the remote township of Kununurra and the surrounding communities. (Kununurra is situated in the far north east Kimberley region of Western Australia). The town has a population of approximately 7,500 people, and of those, approximately 50% are Aboriginal.
The program was developed to take a broad, holistic approach to working with women and their families. It also recognized the links between prenatal alcohol use, other drug taking behaviours and teenage sex/contraception issues. The program they developed targeted five groups:
- All Aboriginal women receiving prenatal care at OVAHS
- All Aboriginal women between the ages of 13 to 45
- OVAHS staff
- Local Aboriginal men
- Local, national and international interest groups and organisations.
The primary focus of the program is working with pregnant women. As part of their prenatal care, women receive FASD education, alcohol and other drug assessment and one-to-one counseling. Brief intervention, motivational interviewing and a three part antenatal assessment are key features of the program. When appropriate, these interventions are extended to include partners, families and the community as a whole. Information is also provided on contraception.
Contraception is viewed in the program as a cornerstone of FASD prevention. The author comments:
Dialogue with young women in the community revealed that their knowledge of puberty, menstruation, pregnancy and contraception varied, with a significant number reporting little knowledge of contraception in particular. Given the incidence of early alcohol use among young women (and its resultant impairment of judgement), and their attitudes and norms around consumption, the program has placed considerable emphasis on the promotion of alcohol awareness, contraception and safe sexual practices as part of all brief interventions.
One of the unique features of this program, I think, is the clear attempt to involve men in FASD prevention. Bridge says that men appear interested in FASD education for a variety of reasons. “The men also believe that Aboriginal culture, knowledge and stories rely heavily on oral tradition, and therefore memory, and that this is potentially lost if many of the next generation suffer neurological damage as a result of pre-natal alcohol exposure. Men within the local community are also aware that too many of their young men are leaving school early and with only basic education, and that rates of imprisonment are high among Aboriginal men. As such the local men have voiced concern that FASD could be a contributing factor, especially as Aboriginal people currently make up 21% of the total number of Australian prisoners, yet only comprise 2.5% of Australia’s population.”
Results from the program clearly demonstrate the role that men/fathers have in supporting women to make alcohol-free choices:
In some families, women report that men hold the power-base and as such strongly influence the choices made regarding alcohol use in their pregnancies. Through conversation with antenatal clients, a number of women identified pressure from their partners as being significant in determining drinking behaviours during pregnancy. The women reported they would like to stop drinking, but were often pressured to stay with their partners in the ‘drinking circle as a show of family loyalty and their commitment and faithfulness to the relationship. Some female clients also report that to remove themselves from this social circle and ‘sit’ with non-drinking family members or friends, or spend time doing activities such as fishing potentially results in relationship problems, arguments or even violence. The role men play in the decision making of some clients was not initially anticipated, but it was recognised early on that the success of the program lay in part in the inclusion and education of men.
You can read the full-text of the article here.
Read more on FASD prevention in Western Australia:
Bridge, P. (2011). Ord Valley Aboriginal Health Service’s fetal alcohol spectrum disorders program: Big steps, solid outcome. Australian Indigenous HealthBulletin 11 (4). Free full-text.
GG makes historic visit to Kimberley town (The West Australian, August 11, 2011)
Ch. 3: From community crisis to community control in the Fitzroy Valley. In The Aboriginal and Torres Strait Islander Social Justice Commissioner. (2011). Social Justice Report 2010. Australian Human Rights Commission.
CTIS applauds new efforts to prevent FASD in rural Australia (December 15, 2010)
Marulu: The Liliwan Project (The George Institute for Global Health)
Clinical resource for primary health care providers
The Centre for Addiction and Mental Health (CAMH) has an on-line toolkit for health care providers who work in a primary care setting and who have patients with substance use problems.
The have recently added two new sections on Alcohol problems in women and Alcohol use in pregnancy.
The Alcohol use in pregnancy section includes information and tools on the effects of alcohol use during pregnancy, screening for alcohol use during pregnancy, treatment and management of alcohol problems in pregnancy, breastfeeding and alcohol use, and postpartum relapse risk.
CAMH also invites health care providers to send in questions about any clinical issues related to addictions that come up in your practice.
FASD Learning Series from the Alberta government
The Alberta government is running another year of free lectures and educational opportunities on FASD. Click here to see the full list of lectures to be given by webcast.
The first webcast in the series is from an FASD prevention perspective. Cristine Urqhart, Co-Founder of Change Talk Associates, will be discussing “Talking with Women about Alcohol and Pregnancy.”
The session will address how we communicate with pregnant women and women in their childbearing years along the continuum of risk. “Combining substance-informed, trauma-informed, and motivational interviewing principles and approaches, strategies and skills will be shared that can be adapted to participants’ practice settings. Emphasis will be placed on opening the conversation and sharing information in a way that respects autonomy, is collaborative and avoids re-traumatization.”
The webcasts are free but you do need to register. Click here for a brief intro to motivational interviewing.
Free on-line tool from UK organization
Drinkaware, an industry-funded alcohol awareness charity in the United Kingdom, has developed a new resource that allows users to track their drinking patterns.
The tool can be used on-line or downloaded to any phone with a web browser. According to the press release, MyDrinkaware is intended:
to help consumers better understand the effects of drinking alcohol on their health and all-round wellbeing, Drinkaware has developed MyDrinkaware – an easy-to-use online unit calculator and drink diary.
The tool provides personalised feedback on risk levels based on consumers’ alcohol consumption and shows data in units, calories and spend. For instance, the tool equates alcohol intake into ‘burger’ equivalents – with a pint of 4% beer or two double gin and tonics comparable to around one burger.
MyDrinkaware also lets people set spending and lifestyle goals and gives tips on how to reach these.
The tool takes advantage of people’s greater awareness of nutrition, calories, and their bank accounts to encourage shifts in drinking practices.
Drinkaware aims to “promote responsible drinking and find innovative ways to challenge the national drinking culture to help reduce alcohol misuse and minimise alcohol-related harm.”
Cartoon from the HERD blog
Does vitamin C really prevent the common cold? Can antibiotics help in alleviating the symptoms of a sore throat? Does smoking affect schizophrenia? If you are looking for reliable evidence on questions like these, then you might be looking for a Cochrane review.
The Cochrane Collaboration is an international, non-profit, independent organisation that was established in 1993 to ensure that up-to-date, accurate information about the effects of healthcare interventions is readily available worldwide. There are more than 28,000 people working within The Cochrane Collaboration in over 100 countries to produce Cochrane Reviews – systematic assessments of evidence of the effects of healthcare interventions. There are over 4,500 Reviews so far.
A recent Cochrane Review examines the effectiveness of school-based universal programs for the prevention of alcohol misuse in young people. The reviewers looked at 53 well-designed experimental studies and found that certain generic psychosocial and developmental prevention programs can be effective in reducing alcohol misuse, especially drunkenness and binge drinking.
Readers of this blog might be interested in the reviews listed below. If not, there’s still several thousand other reviews you can browse in the Cochrane Library.
Brown HC, Smith HJ. Giving women their own case notes to carry during pregnancy. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD002856. DOI: 10.1002/14651858.CD002856.pub2
Doggett C, Burrett SL, Osborn DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004456. DOI: 10.1002/14651858.CD004456.pub2.
Foxcroft DR, Tsertsvadze A. Universal school-based prevention programs for alcohol misuse in young people. Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.: CD009113. DOI: 10.1002/14651858.CD009113
Hodnett ED, Fredericks S, Weston J. Support during pregnancy for women at increased risk of low birthweight babies. Cochrane Database of Systematic Reviews 2010, Issue 6. Art. No.: CD000198. DOI: 10.1002/14651858.CD000198.pub2.
Lui S, Terplan M, Smith EJ. Psychosocial interventions for women enrolled in alcohol treatment during pregnancy. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006753. DOI: 10.1002/14651858.CD006753.pub2.
Sibley LM, Sipe TA, Brown CM, Diallo MM, McNatt K, Habarta N. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005460. DOI: 10.1002/14651858.CD005460.pub2
Smith EJ, Lui S, Terplan M. Pharmacologic Interventions for Pregnant Women Enrolled in Alcohol Treatment. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007361. DOI: 10.1002/14651858.CD007361.pub2.
Stade BC, Bailey C, Dzendoletas D, Sgro M, Dowswell T, Bennett D. Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD004228. DOI: 10.1002/14651858.CD004228.pub2.
Terplan M, Lui S. Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006037. DOI: 10.1002/14651858.CD006037.pub2
Evaluation findings of program modeled on the Parent-Child Assistance Program (PCAP)
The Alberta First Steps program is modelled on the Parent–Child Assistance Program (PCAP), which began in 1991 at the University of Washington. It is an intensive three-year one-on-one mentoring program for women at high risk for giving birth to a baby exposed to prenatal alcohol. The primary aim of the program is to prevent future alcohol and drug exposed births among high-risk mothers who have already delivered at least one exposed child. The model has been evaluated and replicated across North America.
The First Steps program began in Edmonton, Alberta in the fall of 1999 with the hiring of three mentors and a program manager. Since that time, the program has grown to employ six mentors, one program supervisor, and a program manager. Mentors work with women and their families over a period of three years beginning during pregnancy or within six months after the birth of a child. Mentors are paraprofessionals and carry a maximum caseload of 15 families. They provide personalized and intensive support in a number of areas ranging from family planning and accessing substance use treatment to advocacy and case management to providing parenting support and developing support networks.
An evaluation study of First Steps between 1999 and 2007 found:
- The mean age of participants was 26 years
- Most had had an unplanned pregnancy (88%), and after the birth of their child had an average of 2.6 children; 63% had custody of at least one child.
- Nearly half of the clients enrolled were of Aboriginal ethnicity (49%)
- Over the course of the program, regular use of a family planning method increased from 36% to 56%
- Welfare use decreased from 92% to 72%
- After the birth of their child (either before or shortly after program began), 71% did not have a subsequent pregnancy.
- In terms of substance use, 44% were abstinent from drugs and 35% were abstinent from alcohol at program exit.
- During their enrollment in the program, 93% of clients had been clean and sober (with no relapses) for at least one month.
From a theoretical perspective, the program is based on relational theory (related to the concept of therapeutic alliance), stages-of-change theory (which utilizes motivational interviewing strategies), and harm reduction theory (which focuses on reducing risks associated with alcohol and drug use as well as other risk behaviors).
The Parent-Child Assistance Program is an example of an indicated prevention program which focuses on individuals at highest risk for delivering a child with FASD, i.e., women who misuse alcohol during pregnancy or who have already delivered a child with FASD and continue to use alcohol.
In terms of cost-effectiveness, Grant (2010) reports that PCAP costs approximately $15,000 USD per client for the three-year program, including intervention, administration and evaluation. The estimated average lifetime cost for an individual with FASD is at least $1.5 million. If PCAP were to prevent a single new case of FASD, the estimated lifetime cost savings would be equivalent to the cost of the PCAP intervention for 102 women.
References:
Grant, T. (2010). Preventing FASD: The Parent-Child Assistance Program (PCAP) Intervention with High Risk Mothers (pp. 193-206). In Riley, E.P., Clarren, S., Weinberg, J., and Jonsson, E. (editors), Fetal Alcohol Spectrum Disorder: Management and Policy Perspectives of FASD, Wiley-Blackwell.
Rasmussen, C., Kully-Martens, K., Denys, K., Badry, D., Henneveld, D., Wyper, K., Grant, T. (2010). The Effectiveness of a Community-Based Intervention Program for Women At-Risk for Giving Birth to a Child with Fetal Alcohol Spectrum Disorder (FASD). Community Mental Health Journal, DOI: 10.1007/s10597-010-9342-0.
