As part of this initiative, they have also been offering a series of webinars (open to all, not just those who attended the training) to continue the learning in an on-line setting.
The slides and the presentation recordings from the first two webinars have now been posted on the BCCEWH website here.
The first webinar discussed working with women who may themselves have FASD and the second webinar introduced a series of new resources on women and alcohol and provide examples on how to incorporate these resources into your work with women.
Manual for Counselors in Native American Communities
Motivational Interviewing was developed by William R. Miller, PhD and Stephen Rollnick, PhD. It is a client-centred counselling approach that seeks to enhance an individual’s capacity to change.
It was originally developed as an approach for addressing problem drinking, but has been shown to effective in addressing change in a range of substance use and health-related areas. Motivational interviewing is often a key approach in many FASD prevention interventions.
FASD prevention can be approached from many levels. For example, Poole (2008) discusses four levels of FASD prevention:
Level 1 – Broad awareness building, health promotion efforts, and public policy Level 2 – Brief Counselling with Girls and Women of Childbearing Age Level 3 – Specialized Prenatal Support Level 4 – Postpartum Support
Level 2 focuses on ensuring girls and women of childbearing years have the opportunity for safe discussion about reproductive health, contraception, pregnancy, alcohol use, and related issues, with their support networks and healthcare providers.
Overall, research evidence supports screening and brief interventions for alcohol misuse as efficacious and cost-effective in a variety of settings. While there are many variations in “brief intervention” approaches, most are grounded in social-cognitive theory and commonly incorporate elements of motivational interviewing. Brief interventions often provide feedback on alcohol use (e.g., is it considered “risky”?), information on the effects and possible consequences of alcohol use, and discussion of possible strategies to moderate or reduce alcohol use.
A recent systematic review by Gebara et al (2013) specifically examines brief interventions to reduce at-risk drinking in women, including studies related to alcohol use during pregnancy. They found that many types of brief interventions could be effective for women, e.g., face-to-face or by computer or telephone, and resulted in changes in both in the number of days of consumption and in the number of doses, or both.
The latest toolkit is on “The Essentials of … Women and Problematic Substance Use” which is a four page overview of the unique aspects of women and substance use and implications for allied professionals. The toolkit was written by Colleen Ann Dell from the University of Saskatchewan. (You can also check out a previous post on work she has done related to Aboriginal women and healing from illicit substance use here).
Other resources that might be of interest include:
Nancy Poole and Lorraine Greaves have a short commentary in the March/April issue of the Canadian Journal of Public Health on the Healthy Choices in Pregnancy Program developed in British Columbia as part of the ActNow Initiative that led up to the Olympics in 2010. The article is an interesting case study on building support for FASD prevention work at the level of government and looking at system-level strategies for increasing awareness of FASD.
In 2003, the Canadian province of British Columbia won the bid to host the 2010 Winter Olympic and Paralympic Games. The government of the day saw this achievement as a window of opportunity to establish a health promotion legacy.
In 2005, the BC government launched ActNowBC, a intersectoral initiative that integrated activities across government with civil society initiatives to achieve five health promotion targets by 2010. Among its several components and streams, ActNow had a focus on the reduction of alcohol (and tobacco) use during pregnancy called Healthy Choices in Pregnancy (HCIP).
The Healthy Choices in Pregnancy initiative took a unique approach to addressing alcohol use during pregnancy by focusing on helping healthcare and social service practitioners to change the ways in which they engage with women. Rather than focusing on the development and dissemination of information about the risks of alcohol use in pregnancy targeted at women directly, the program aimed its resources at providers.
This approach was intended to relieve the burden of change from individuals and allowed women—who are often highly stigmatized for drinking and smoking when pregnant—to experience health care and social service systems as welcoming and helpful.
Collaboration across a range of groups, professions and services was encouraged. Researchers, health system planners, service providers, policy-makers, and women themselves worked collaboratively on the initiative. In shifting from individual to systemic change, the program created a shift in attitude and focus from blaming individual women for drinking during pregnancy, to creating systemic change and action based on effective and supportive approaches to reducing alcohol use during pregnancy.
Poole, N. and Greaves, L. (2013). Alcohol Use During Pregnancy in Canada: How Policy Moments Can Create Opportunities for Promoting Women’s Health. Canadian Journal of Public Health, 104(2): e170-e172.
“The Handbook for Aboriginal Alcohol and Drug Work is a practical tool written for Aboriginal drug and alcohol workers, mental health workers and others working in this field. It offers a detailed look at alcohol and drug work from clinical, through to prevention, early intervention and harm reduction. This handbook is also likely to help people working to improve policy and those advocating for change.
The idea for it came from workers all over Australia. They told us that they needed an easy to use handbook that can help them respond to the range of alcohol and drug issues they face every day. They also told us that such a book needs to take into account the complex challenges facing workers when helping clients, their families and, sometimes, whole communities.”
This plain language, evidence-based guide was created in partnership between the University of Sydney and Aboriginal and non-Aboriginal agencies and health professionals. Four of the six editors are Aboriginal.
It covers alcohol and drug use as well as a whole range of other issues, including child protection notifications, legal issues, working with clients without housing, mental health and polydrug use, and community-wide approaches.
Chapter 2 focuses on alcohol and Chapter 16 focuses on Special situations, settings, and groups, including pregnancy, breastfeeding and early childhood. It discusses the use of brief intervention and counselling approaches in the context of alcohol and pregnancy. It also has sections covering Neonatal Abstinence Syndrome, Alcohol use in pregnancy and Foetal Alcohol Spectrum Disorders.
The handbook was first distributed to alcohol and drug professionals from around Australia at the National Indigenous Drug and Alcohol Conference in Western Australia in June 2012.
The project started in 2010 with a grant from the Foundation for Alcohol Research and Education (FARE) and continued with the support of the NSW Ministry of Health.
The online resource, available in both English and French, uses a three-step alcohol screening, brief intervention, and referral process. The resource section includes information on seven sub-populations, including women, alcohol and pregnancy, and alcohol and breastfeeding.
Research evidence supports screening and brief interventions for alcohol misuse as efficacious and cost-effective in a variety of settings.
There’s been a fair amount of discussion recently about the over-representation of individuals with FASD in the criminal justice system. So, I was interested to see a research study on alcohol and pregnancy among women serving community sentences, i.e., women on probation and parole.
According to the US Bureau of Justice Statistics, more than 1.1 million women were under community supervision in 2008. The study found that, on average for the time period, 4.7% of women under community supervision were pregnant (as compared to 1.9% in the general population). This means that women under community supervision have a pregnancy rate approximately two times as high as the general population. It also means that approximately 53,000 women on probation or parole were pregnant in 2008.
The study does a great job at showing patterns of alcohol use before and after pregnancy and linking these patterns to mental health and physical health problems, other substance use including smoking, poverty, ethnic background, and age.
In general, pregnant women under community supervision are at a much higher risk of using or misusing alcohol during their pregnancy than women in the general population.
The author describes potential opportunities within the criminal justice system to better support women. Overall, I found this task in which “probation and parole overseer must be transformed from bureaucratic agents of control and surveillance into active screeners for medical needs and providers of healthcare services” (p. 507) to be rather ambitious – clearly beyond the scope of the paper.
But I did find the author’s comment on relational care and motivational interviewing interesting, especially as it supports the evidence-base in other areas:
“Probation and parole officers trained in motivational interviewing and positive conduct reinforcement have proved to be more effective….The working relationship between officers and supervised pregnant women is important in creating an environment where offenders feel they can trust the officer and are motivated to comply with the conditions of release.” (p. 507)
Sung, H.-E. (2012). Pregnancy and drinking among women offenders under community supervision in the United States: 2002-2008. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 89(3): 500-509. doi:10.1007/s11524-011-9658-2
Between 1996 and 2004, alcohol consumption in Sweden increased by 30% from approximately 8 to 10.4 litres per person and year. This was attributed partly to Sweden’s entry into the European Union (EU) in 1995 which led to a weakening of some areas of alcohol policy such as limits on private imports of alcohol and high alcohol taxes.
Sweden continues to have a national retailing monopoly called Systembolaget. The minimum purchase age at Systembolaget is 20 years, but people can drink at age 18 in restaurants and bars.
In 2009, overall rates had declined to about 9.5 litres per person and year. In general, Swedish men drink roughly twice as much as women in the same age category. Survey data suggests that approximately 6% of pregnant women in Sweden drink at least once during their pregnancy.
Brief Interventions in Prenatal Care
In Sweden, all pregnant women receive free prenatal care by midwives. Usually, women will have 8-10 visits with their midwife over the course of their pregnancy.
In the early 2000s, standard prenatal care in Sweden involved a meeting between a midwife and her patient during week 10–12 of the pregnancy. This visit included a question about a woman’s current frequency of drinking which was recorded in her file. Women were advised to abstain from drinking during pregnancy, if at all possible.
Shifting Policy Directions
Because of the difficulties of implementing policies based on controlling the price and availability of alcohol (which have been shown to be extremely effective) following EU entry, the Swedish government decided to shift their policy efforts.
The Risk Drinking Project was a national government initiative carried out from 2004 to 2010. The focus of the project was to encourage healthcare professionals to raise the issue of alcohol with their patients to support reducing risky drinking.
The project focused on all areas of healthcare including routine primary, child, maternity and occupational health care. It emphasized the use of motivational interviewing and promoting health professionals’ behavior change. “The Risk Drinking Project’s objective is for questions about drinking habits to have a natural place in everyday healthcare.” (Swedish National Institute of Public Health, 2010, p. 8)
Midwives and the Risk Drinking Project
Different approaches to brief interventions by healthcare professionals were adopted depending on the setting. Midwives in maternity health care adopted the use of the AUDIT screening form. However, this was more as a pedagogic tool and basis for discussion.
Rather than asking about a pregnant woman’s drinking during pregnancy, the project introduced a modified routine whereby a woman fills out the AUDIT questionnaire concerning her alcohol use in the year preceding her pregnancy. (This has been shown in research to be an important predictor for drinking during pregnancy). The AUDIT results then provided the basis for a discussion between the midwife and her patient.
Midwives reportedly supported this shift in practice. Using the AUDIT in this way was seen as a way of avoiding direct questions about self-reported alcohol use during pregnancy and allowed for a gentle entry way into the subject.
Changes in Prenatal Care
The two graphs below show changes in practice between 2006 and 2009.
The proportion of midwives who considered themselves to have very good or good knowledge in identifying patients with risky alcohol consumption increased from 72 to 92 per cent between 2006 and 2009.
The proportion of midwives who used forms to assess hazardous alcohol consumption increased dramatically between 2006 and 2009. In all regions except three, a minimum of 90 per cent of the midwives used forms in 2009.
A Good Start
In 2009, the Swedish National Institute of Public Health developed an 8-page pamphlet on alcohol and pregnancy for use in prenatal care called “A Good Start.” The pamphlet has an abstinence message: “It is best to abstain from alcohol completely whilst you are pregnant or planning to become pregnant.”
It covers fetal development, discusses situations in which women might be expected to drink alcohol, mentions partner drinking and support, provides reasons for refusing offers of alcohol, and includes a recipe for a mocktail.
For more on FASD prevention in Europe, check out earlier posts:
Nilsen P, Skagerstro¨m, J, Rahmqvist M, Hultgren E, Blomberg M. (2012). Alcohol prevention in Swedish antenatal care: effectiveness and perceptions of the Risk Drinking project counseling model. Acta Obstetricia Gynecologica Scandinavica, 91. DOI: 10.1111/j.1600-0412.2012.01402.x.
Nilsen, P., Wahlin, S., and Heather, N. (2011). Implementing Brief Interventions in Health Care: Lessons Learned from the Swedish Risk Drinking Project. International Journal of Environmental Research and Public Health, 3609-3627. Download free full-text from here.
Swedish National Institute of Public Health. (2010). Alcohol issues in daily healthcare. The Risk Drinking Project – background, strategy and results. Download from here.
Swedish National Institute of Public Health. (2009). A Good Start pamphlet. Available to download in Swedish, English and other languages from here.