How interagency and cross-sectoral partnerships are contributing to prevention of FASD

Over the past three years, the Co-Creating Evidence study (CCE) has been exploring best practices in the delivery of community-based wraparound programs that support pregnant and parenting women with substance use concerns in Canada. The CCE team recently published an article about how the partnerships fostered and maintained by community-based wraparound programs make a difference in their work and are in fact a best practice.

The CCE project team interviewed 60 partners and 108 staff of the eight programs involved in the CCE study. The interviews focused on the nature and benefits of interagency and cross-sectoral partnerships. The study found that these programs most commonly formed partnerships with child welfare and health services such as primary care, public health, mental health services and maternal addictions programmes, yet they also partnered to some degree with housing, income assistance, Indigenous cultural programming, infant development and legal services.

Key benefits of partnerships identified were:

  • improved access by clients to health and social care that addresses social determinants of health. This access includes expanded programming in the program sites, increased understanding of partners’ services, and greater ease of referral to other supports and programs as needed by clients.
  • increased knowledge on the part of both the interagency partners and the wraparound service providers about the experiences that women face, such as the significance of poverty and trauma to women’s substance use. In turn this positively promotes non-judgemental and trauma-informed approaches with pregnant women and new mothers, as well as provision of more multifaceted and paced supports to address their needs.
  • improved child welfare outcomes. The program level relationships with child welfare workers, and in some cases integration of a social worker onsite, results in increased planning for positive mother-child outcomes during the pregnancy, improved mother-child connections after birth and reduced likelihood of the infant being removed from the woman’s care at birth.
  • strengthened cultural safety within the programming and (re)connection to culture by women. Partnerships with Indigenous organizations enhances learning by program providers about how to work in a culturally safe way and increased opportunities for referral to Indigenous programming for those women interested in connecting to their culture as a part of their wellness/recovery.

“The programmes participating in the Co-Creating Evidence study were both creative and flexible when developing partnerships, seeking opportunities in areas in which they did not have the resources or expertise, as well as with services with whom they had a common cause, for example mutual clients, a shared desire to ‘wrap support’ around women to meet their evolving needs and aligned approaches (harm reduction, trauma informed practice).”

Hubberstey, C., Rutman, D., Van Bibber, M., & Poole, N. (2021). Wraparound programmes for pregnant and parenting women with substance use concerns in Canada: Partnerships are essential Health and Social Care in the Community  https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13664

The partnerships continue to evolve through dialogue, collaboration and communication. What the study has identified is how, through these partnerships, wraparound program providers are contributing to the reduction of fragmentation between the health, child welfare and addictions fields – and in turn to important benefits for clients in terms of access to care and enduring connections with their children. In the work on prevention of FASD, it has repeatedly been emphasized how important the role of “Level 3 and 4” programming is, particularly in how such programs attend to the range of determinants of women’s health and alcohol use. Clearly it is in part through partnership work that FASD prevention is achieved.

Where there’s a will, there’s a way. US system-level action to institute Plans of Safe Care

Members of the Prevention Network Action Team recently attended a webinar sponsored by the Children and Family Futures Program (CCFutures) in the US. During the webinar, a CFFutures representative shared how Plans of Safe Care (POSCs) were being developed to support women who are using substances during pregnancy and promote mother/child togetherness at the time of delivery.

These POSCs are being instigated by court teams, who convene multi-agency collaborations that include child welfare, substance use treatment and OAT providers, medical/health care providers and children’s services, including home visitation and peer recovery supports.  The peer supports play a key role in engaging families in voluntary services prenatally or prior to child welfare involvement, helping them navigate social services systems, as well as assisting with creating and monitoring the POSC, and providing important insights into barriers experienced by the families.

This POSC approach has the benefits of forging strong and deliberate partnerships across providers and is positively informing child welfare responses to women and infants where there has been prenatal substance exposure. This work to provide organized, trauma-informed and effective care prenatally is preventing removal of children at birth and family separation overall. At the court level, it is integrating a prevention mindset by asking what it would take to maintain the child in the home and ensure that reasonable and active efforts are made to support the woman’s and family’s health. At the community level, it involves the funding of community coordinators to oversee collaboration and implementation, as well as community education and training. It means that there is coordination from pre-to postnatal care, and that continuity of services is provided. And it is reducing NICU stays and the need for pharmacological interventions.

This is an excellent example of system level change to prevent FASD, as opposed to individualizing and medicalizing the response. The leaders cite similar barriers to what has been identified in many locations and in research about system-level barriers including limited staff and system capacity, concerns about confidentiality, stigma, as well as lack of knowledge about POSCs and their benefits – yet they are addressing these.  One of the sites was quoted to say that most of the efforts did not require funding, with the implication that the accomplishments can be sustained in the local systems of care.  Instead of requiring significant additional funding for the POSC work they “required commitment and investment by all involved parties to systems change and improved practices – collaboratively and individually – as providers and entities working with the target population.”

The description of this fine work has echoes in the conversations we at the Prevention Network Action Team have had over the years, and when developing the Mothering and Opioids: Addressing Stigma-Acting Collaboratively resource (see the policy values diagram from that resource below).  Many of us have, and continue to, advocate for and deliver components of this coordinated system level response. The webinar covered the solid evaluation evidence for this type of response in detail, but the big story is that system level can be done that effectively and safely supports women, children and families.  Where there’s a will, there’s a way.

Source: Page 42, Mothering and Opioids Toolkit

“Learning to Understand”

When we first formed the Prevention Network Action Team over a decade ago, we insisted on calling it the Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective.  We did not want FASD prevention to have a sole focus on stopping or reducing alcohol use but instead to have a wider focus on the need for changing systemic as well as personal and interpersonal influences on women’s alcohol use.  One such systemic influence is women’s experience of trauma and violence.

Understanding the impact of trauma and violence on women and gender diverse people’s lives has never been more important as we in Canada read and absorb the findings of Reclaiming Power and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls in Canada. We are called upon to understand and act against systemic processes such as racism, sexism and misogyny, and structural oppression related to ongoing and widespread violence against women, social and economic marginalization of Indigenous women, and the multigenerational effects of horrific colonial and patriarchal practices.

The MMIWG report sets out seven principles for change that inform the 231 Calls for Justice needing action across federal, provincial, territorial and Indigenous governments, industries, institutions, health care, child welfare, correctional services, and policing.  Some of these principles we have often discussed and promoted in our work on FASD prevention. They include:

  1. A focus on substantive equality and human and Indigenous rights
  2. A decolonizing approach
  3. The inclusion of families and survivors
  4. Self-determined and Indigenous-led solutions and services
  5. Recognition of distinctions (i.e., the diversity of Indigenous peoples)
  6. Cultural safety
  7. A trauma-informed approach

In addition to the Calls for Justice, several action plans have been created in order to enact change. The Native Women’s Association of Canada has committed to taking leadership and action to end the violence and genocide, and to the full implementation of an Action Plan they have developed for: ending the violence including all forms of race-and gender-based violence, and upholding dignity and justice for Indigenous women, girls and gender-diverse people in Canada. There are many opportunities within their Action Plan where we who are working on FASD prevention can work together on key actions they have identified.  Here are three examples:

  • Continue ongoing health, policy, research, training and programs to support Indigenous-led health initiatives (page 22)
  • Create and implement awareness building campaigns that will educate the public about MMIWG and the issues and roots of violence (page 38)
  • Monitor media stories and track inaccurate portrayal of Indigenous women (page 41), so that portrayals that perpetuate negative stereotypes of Indigenous women are challenged/stopped and the “curious silence” (page 388 of the MMIWG report) of the media in covering the lives of Indigenous women is addressed.

National and regional Inuit organizations have also developed an action plan. The National Inuit Action Plan was developed by a 10-member Working Group, co-chaired by Inuit Tapiriit Kanatami (ITK) and Pauktuutit Inuit Women of Canada. The National Inuit Action Plan also identifies a wide range of areas where concrete, timely and measurable positive changes need to be made for Inuit women, girls and 2SLGBTQQIA+ people to achieve substantive equality. The image from page 6 of that report illustrates the breadth of the work that needs to be done, how we in FASD prevention can align our actions.

Harriet Visitor, an Indigenous educator and niece of Chanie Wendak, used the expression “learning to understand” on the radio this past week. She describes this as different than simply learning, it involves unlearning, not turning a blind eye, and acting. In the case of missing and murdered Indigenous women and girls, it involves supporting decolonization and revitalization of Indigenous culture and doing everything in our power to ensure the future is one where Indigenous women can thrive as leaders, teachers and healers, and be acknowledged and honoured for their expertise, agency and wisdom.

Resources:

The Remarkable Findings of the Co-Creating Evidence Evaluation Study

Preventing Fetal Alcohol Spectrum Disorder (FASD) requires a range of efforts from general awareness to targeted prevention and treatment services. In the Canadian Four-Part FASD Prevention Model, Level 3 and 4 programs provide low barrier holistic services for pregnant or parenting women who face substance use and a range of other health and social burdens and challenges.

Over a four-year period, the Co-Creating Evidence (CCE) evaluation study has involved eight different community-based Level 3 & 4 programs that support women through the provision of holistic, wraparound services, and in doing so, see FASD prevention as part of their mandate. These programs are guided by theoretical approaches such as being trauma-informed, relationship-based, women-centred, culturally grounded and harm reducing. The evaluation team has been led by the Nota Bene Consulting Group and has involved researchers from the Centre of Excellence for Women’s Health and representatives of the eight programs. 

This CCE evaluative study (2017-2020) has had three main research questions:

  1. What are the common elements of the diverse Level 3 programs across Canada?
  2. What program components are helpful from women’s perspectives?
  3. What are best measures to evidence outcomes and what outcomes are being achieved?

The answers to these questions are now available via:

In all these documents, service providers, researchers, policy makers and women with lived/living experience will see promising approaches and outcomes that these programs provide and the women who access these programs are realizing, together with their community partners. This study makes a significant contribution to our understanding of this level of FASD prevention. It hopefully will be an inspiration to all those committed to this important work. 

Funding for this project has been received from the Public Health Agency of Canada, Fetal Alcohol Spectrum Disorder (FASD) National Strategic Project Fund. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.

Addressing the priorities of the pNAT in 2020

As we continue to connect our work in Canada on FASD prevention, via the Prevention Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective (pNAT), new priorities for action emerge.  These are five priorities that this virtual community identified for the coming year.

  1. Cross-sector collaboration

Collaboration across fields provides an important opportunity to support mothers, children, and women who may be at risk of using substances during pregnancy. Resources, such as Mothering and Opioids: Addressing Stigma – Acting Collaboratively, highlight opportunities for collaboration across fields to foster advocacy, streamline service delivery and referrals, and offer systems navigation.

  1. Indigenous approaches to FASD prevention

There are an increasing number of wholistic FASD prevention and wellness programs that are incorporating culture and language, traditional knowledge, and land-based programming, while responding to the needs of families and communities. Programs such as Circle of Life in Terrace, Xyólhmettsel Syémyem (Family Empowerment Team) in Chilliwack and others highlighted in the recent booklet, Revitalizing Culture and Healing: Indigenous Approaches to FASD Prevention, bring attention to the importance of community-led, community-driven FASD prevention and wellness programs.

  1. Trauma-informed practice

Trauma-informed practice and policy development are essential components in responding to each level of the four-part prevention model. Trauma-informed services recognize the interconnections of trauma, mental health, and substance use and the role that substance use may have in coping with past or current violence or trauma. When discussing alcohol and other substance use, trauma-informed approaches will promote building relationships, building upon individuals’ strengths, and offering choice and collaboration in service provision.

  1. Stigma reduction

There has been an increasing focus on reducing stigma that mothers and women who use substances during pregnancy experience. By reducing stigma, pregnant women and mothers will be able to better access necessary supports and servicces that support stigma reduction. The recent issue paper from the Canada FASD Research Network on mothers’ experience of stigma through a multi-level model offers recommendations and recommended resources for service providers, health systems planners, and policymakers.

  1. Keeping families together

More attention is being brought to service delivery models that have the goal of keeping families together. These programs, which range from co-located multi-service programming to mentor and peer support models increase women’s access to prenatal care, health care, social support, advocacy, and childcare. PNAT members from programs such as the Parent-Child Assistance Program, Sheway in Vancouver, HerWayHome in Victoria, H.E.R. Pregnancy Program in Edmonton, Manito Ikwe Kagiikwe (the Mothering Project) in Winnipeg, and Mothercraft (Breaking the Cycle) in Toronto are helping us understand how this goal can be achieved in community contexts.

Considerations for Supporting Healthy Families and Healthy Beginnings

Revitalizing Culture and Healing: Indigenous Approaches to FASD Prevention is a new resource developed by program providers and experts in Indigenous women’s health and researchers from the Centre of Excellence for Women’s Health, in partnership  with the First Nations Health Authority in BC. The resource includes a beautiful and FASD preventionthoughtful introduction by Marilyn Van Bibber and highlights seven community led and culture driven programs. Each program successfully integrates culture, language, and healing into their program in order to improve the health and wellness of women, children, their families, and their communities. Marilyn is well known for her development of the first resource on Indigenous approaches to FASD prevention in Canada, entitled It Takes a Community published in 1996.

The programs highlighted in this resource use the traditional holistic view of health and wellness that encourages balance between mental, physical, emotional, and spiritual health. They incorporate culture and language, coordinate basic needs, and address women, their families, and their communities’ unique and complex needs by promoting healing through language, ceremony, traditional knowledge, land-based programming, involvement of Elders, and more.

The driving principles that contribute to the success of these programs is that they are community led, culture driven, strengths-based, and provide wraparound support that address broad social and structural factors that impact individuals’ and their families’ lives across the lifespan.

Program planners and service providers can learn from the lessons shared from these programs and integrate the following 4 considerations that support healthy beginnings:

  1. Use Non-Stigmatizing Language

Service providers and healthcare professionals should use strengths based language that promotes wellbeing, creates safe spaces for women and girls to discuss their substance use, and helps women and girls build confidence and ask for support. Providers should shift towards using person-first language in their practices, where clients are identified as a person rather than by their health condition or behaviours. Some examples my include shifting from language “addicts” to “women who use alcohol” and from “she admitted to drinking alcohol during pregnancy” to “she reported drinking during pregnancy.”

For more information on the strengths-based language, the Canadian Centre on Substance Use and Addiction and Canada FASD Research Network have released language guides to support the use of non-stigmatizing language when discussing substance use and FASD.

  1. Identify Existing Community Strengths and Programming

Meeting with existing services to see how they are, or could be, a part of wellness and FASD prevention initiatives is an important strategy in identifying community strengths and linkages that can better support healthy beginnings and healthy families. Identifying these strengths and linkages can better support current or existing program planners in developing a realistic goal for program delivery in your community.

  1. Connecting with those who have Walked the Path Before Us

The programs featured in this booklet enact approaches that have been successful at implementing community led, and culture based approaches to improving the health of women, their families, and their communities. The lessons and approaches in these programs demonstrate what decolonized approaches to FASD prevention can look like.

  1. Identifying Potential Funding Partners

Building relationships with potential funders is an important step towards developing or supporting community-based prevention programs. The breadth of these programs – in addressing a multitude of needs – demonstrate the varied funding that can support families. Given how the programs enact evidence informed and wise practices, it is important that stable and long term support is provided to ensure the programs’ ongoing responsivity and development.

For more information on the seven highlighted programs, four critical considerations, and to review the eight reflection questions on how to support healthy beginnings in your community, see the booklet, Revitalizing Culture and Healing: Indigenous Approaches to FASD Prevention.

Emerging Approaches to FASD Prevention

One year ago, the Centre of Excellence for Women’s Health released Doorways to Conversation: Brief Intervention on Substance Use with Girls and Women. Since then, there has been a growing interest in expanding work on brief interventions and FASD prevention, to be inclusive of multiple substances and multiple health issues for women, their families and communities.

Here are four innovative ways that brief discussion about alcohol and other substance use is being expanded:

In Sexual Health

Sexual health clinicians are well positioned to deliver brief substance use interventions due to their open, non-judgmental and harm reduction-oriented model of practice. Sexual health providers are able to discuss substance use together with contraceptive use and/or sexually transmitted and blood borne infections [1, 2]. Conversations about substances, sex, and safety can support a woman’s decisions and confidence for change towards improving health in whatever area fits for her.

Linking Discussion of Multiple Substances

Cannabis legalization provides a ‘window of opportunity’ to engage in discussions about alcohol, tobacco, and cannabis use in pregnancy. Discussing what we know and don’t know about cannabis use in pregnancy can now be linked to open conversations about alcohol and other substance use in pregnancy.

Understanding the Link to Adverse Childhood Experiences (ACEs)

Research on ACEs shows how a history of childhood stressors, including physical, sexual, and emotional abuse, may influence alcohol use among adults including pregnant women [3]. Adopting a trauma-informed approach in conversations about alcohol use in pregnancy supports women who experienced childhood adversity with safety, choices, collaboration, self compassion and skills for change.

Advancing Indigenous Wellness Approaches

Holistic, relational, community-based, and culture-led FASD prevention initiatives are key to wellness for pregnant women in Indigenous communities [4]. These interventions address the broad social and structural determinants of health that are associated with substance use and respond to the Truth and Reconciliation Commission Call to Action #33.

References

  1. Lane, J., et al., Nurse-provided screening and brief intervention for risky alcohol consumption by sexual health clinic patients. Sexually Transmitted Infections, 2008. 84(7): p. 524-527.
  2. Crawford, M.J., et al., The clinical effectiveness and cost-effectiveness of brief intervention for excessive alcohol consumption among people attending sexual health clinics: a randomised controlled trial (SHEAR). Health Technology Assessment, 2014. 18(8): p. 1-48.
  3. Frankenberger, D.J., K. Clements-Nolle, and W. Yang, The Association between Adverse Childhood Experiences and Alcohol Use during Pregnancy in a Representative Sample of Adult Women. Women’s Health Issues, 2015. 25(6): p. 688 – 695.
  4. Wolfson, L., et al., Collaborative Action on Fetal Alcohol Spectrum Disorder Prevention: Principles for Enacting the Truth and Reconciliation Commission Call to Action #33. International Journal Of Environmental Research And Public Health, 2019. 16(9).

The work of the Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective (CanFASD Research Network)

 

FASD Conference 2
Marsha Wilson, Nancy Poole and Dorothy Badry at the 7th National Biennial Conference on Adolescents and Adults with Fetal Alcohol Spectrum Disorder (FASD). Session E3: Developments in Prevention of FASD – The Work of the Can FASD Prevention Network Action Team

At the 7th National Biennial Conference on Adolescents and Adults with FASD in Vancouver on April 9, 2016, Nancy Poole and Dorothy Badry described the work of CanFASD’s Prevention Network Action Team (pNAT).  They provided examples of the pNAT’s work on:

  1. Network building – Sharing expertise and skills through a network of researchers, policy analysts, clinicians, community-based service providers and advocates dedicated to FASD prevention
  2. Research – Building multidisciplinary research teams, developing research proposals, and conducting research
  3. Collaborative knowledge exchange – Developing and implementing strategies for moving “research into action” such as through workshops, curricula development for health and social service professionals, and policy analysis
  4. Influencing policy and service provision  Guiding service and policy improvements with governments and communities

Given the conference focus on adolescents and adults with FASD, the 2011 research led by pNAT member Deborah Rutman on prevention with girls and women with FASD and substance use problems was highlighted.   Treatment and support with girls and women who live with FASD is one of the least researched areas of FASD prevention.

A list of FASD prevention resource materials developed by pNAT members was provided. Reports and infographics that summarize research, and thereby support research-to-practice and -policy are included below.

LINKS

7th National Biennial Conference on Adolescents and Adults with FASD

Research on prevention with girls and women with FASD

CanFASD  – description of the pNAT

FASD Prevention Resources Spring 2016

FASD Resources

Webinar: “Caregiving, FASD, and Alcohol: Caring about FASD Prevention” – September 9, 2015

screenshot2

The Canadian Association of Pediatric Health Centres is hosting a free webinar on International FASD Day, September 9th, 2015.

Award-winning journalist and author, Ann Dowsett Johnston will discuss dismantling stigma and how to address an alcogenic culture that blames and shames the FASD community.

Dr. Dorothy Badry and Dr. Deb Goodman will discuss a practical set of tools and resources that will be useful to healthcare practitioners and caregivers. The Caregiver Curriculum on FASD and the website www.fasdchildwelfare.ca were developed in response to an identified need for training on FASD that was accessible and available to caregivers supporting individuals with this lifelong disability on a day to day basis.

The webinar will be held on September 9th from 11:00am-12:30pm EST. Click here for more information and to register.

Learning about FASD Training Package for Post-Secondary Instructors

screenshot

Developed by the Saskatchewan Prevention Institute, the FASD Training Package for Post-Secondary Instructors is a resource  for post-secondary instructors and professors.

The focus of the resource is on understanding and preventing FASD. It can be used to provide information and education about Fetal Alcohol Spectrum Disorder (FASD) to students enrolled in professional programs leading to a career working with women of child bearing age.

Examples of programs include that this resource might be helpful for include: health care, education, justice, addictions, psychology, social work, and other community services’ programs (e.g., Early Childhood Education, Disability Support Worker, and Correctional Studies.)

The teaching package contains 11 modules with references. These modules provide evidence-based information on topics such as “What is FASD”, “Alcohol, Women, and Pregnancy”, “Prevention of FASD”, and “Primary and Secondary Disabilities”.

A downloadable PowerPoint with teaching notes is ready for use in class. Both the PowerPoint and written modules contain case studies, activities, and discussion questions that may be used with any group.

Download the package from the Saskatchewan Prevention Institute’s website.

toc