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How to discuss alcohol use with women of childbearing age is a topic in women’s health that is getting more attention and focus. Within FASD prevention circles, we have understood that women and their partners may not know about the risks of alcohol consumption during pregnancy or may drink before they realize they are pregnant.  Thus, they benefit from discussion of what they know, what the evidence says and options for action.

Screening, Brief Intervention, and Referral (SBIR) has long been known as an approach to guide clinicians when assessing risky alcohol use. But is the SBIR model the best approach to discussing alcohol with women of childbearing age and their partners? What are the approaches currently used across Canada? How should we discuss alcohol with women and who should do it? What works best according to the evidence?

The Centre of Excellence for Women’s Health (CEWH), the Canadian Centre on Substance Use and Addiction (CCSA), and the University of British Columbia Midwifery Program have teamed up to answer these questions. The Dialogue to Action on Discussing Alcohol with Women project has three high-level objectives: to identify current approaches; to summarize and share the available evidence; and, to promote best practices.

Nancy Poole of CEWH and Audrey McFarlane of CanFASD and Lakeland Centre for FASD at the Dialogue to Action regional meeting in Edmonton.

In order to meet their first objective, project researchers are currently conducting 12 regional meetings across Canada with physicians, midwives, nurses, and service providers in, sexual health clinics, violence against women services, alcohol and drug services, and Indigenous health services.

They are learning what is already being done and sharing what is known about promising practices and existing resources that can guide discussions and referrals. Participants are suggesting resources and tools – such as webinars, guidelines, policies and programs – that will be helpful in conducting meaningful discussions and support in their communities with women who use legal substances – or soon to be legal, like cannabis.

One early emerging idea arising from this project is that “screening” may be currently placed in the wrong location in the mnemonic list of SBIR.  Starting with brief information sharing and support (the relationship first), followed by screening/referral can be more engaging, trauma-informed, collaborative and person-centred. The rearranged approach prioritizes eliciting and appreciating individual needs and perspectives.

So the list might become BISR or even BISBIRT – repeating the conversation about substance use and ideas for action after screening as well as before it.

Participants from a regional meeting in Winnipeg, MB, discuss approaches to discussing alcohol with women that are working in their communities.

This project is one of several projects addressing FASD in Canada being funded by the Public Health Agency of Canada. You can learn more about all the projects here: https://www.canada.ca/en/public-health/news/2017/05/fetal_alcohol_spectrumdisorderincanadanewprojectfunding1.html

Read more:

Conversations on alcohol: Women, their partners, and professionals – April 23, 2017

Preconception Interventions: Trending or Mainstream? – July 21, 2016

Alcohol and FASD: It’s not just about women  – June 6, 2017

 

 

3rd in Series: First-ever FASD Prevention Plenary at the 7th International Conference on FASD: PART 2

“International Research on Discussing Alcohol with Women and Their Partners, and Empowering Professionals to Have These Conversations”: Tatiana Balachova, PhD, Associate Professor, University of Oklahoma Health Sciences Center & Prevent FAS Research Group; Jocelynn Cook, Chief Scientific Officer for The Society of Obstetricians and Gynaecologists; Lisa Schölin, Consultant at WHO Regional Office for Europe – Alcohol, Illicit Drugs and Prison Health; Leana Oliver, CEO of FARR; Cheryl Tan, Health Scientist CDC

Research shows that building awareness and offering brief interventions can help women reduce alcohol-exposed pregnancies. For a variety of reasons, not all providers feel comfortable or confident in giving information or asking about alcohol use, and they may not be sure it makes a difference in preventing alcohol-exposed pregnancies. Consequently, researchers from around the world presented their findings at the 7th International FASD Conference Prevention Plenary. They discussed whether or not brief interventions work, and if they do, then which strategies work best.

Russian study picRussia – Positive Messaging Improves Knowledge and Action

Tatiana Balachova, PhD, and her research group conducted a 3-part study to develop, implement, and test a prevention program in Russia. They found that women in Russia most trusted their OB/GYN physicians, so they developed FASD educational materials and trained physicians to deliver prevention information in two face-to-face structured interventions. FASD brochures using positive messages and images improved women’s knowledge of FASD and reduced risk for alcohol-exposed pregnancies. As well, they found that women who received the intervention reduced their frequency of alcohol use – most quitting – during in pregnancy.

JOGC picCanada – Care/Service Provider Education is key

Jocelynn Cook, Chief Scientific Officer for The Society of Obstetricians and Gynaecologists of Canada (SOGC) detailed the Vision 2020 strategies: advocacy, quality of care, education, and growing stronger. These strategies underpin their goals for care providers to focus on preconception as well as pregnancy, and deliver consistent messaging. In line with these goals. Alcohol Use and Pregnancy Consensus Clinical Guidelines that were first published by the SOGC in August 2010 were updated in 2016. The guidelines highlight the value of brief interventions and will be supported in the coming year with online education and training that recognizes “red flags” and provide best practices for supporting women’s health and engagement in discussions on potentially stigmatizing topics such as alcohol use.

who-coverWorld Health Organization – Prevalence Rates Inform Strategy

Lisa Schӧlin, consultant with the World Health Organization’s European office, described the data from Europe on alcohol consumption and drinking during pregnancy. The most recent prevalence data shows that Europe has the highest consumption rate of alcohol per capita of anywhere else in the world. As well, at 25.2%, it has the highest rate of alcohol consumption during pregnancy and the highest rate of FAS (37.4 per 10,000). These data were published in a review of the evidence and case studies illustrating good practices and areas of European action called “Prevention of harm caused by alcohol exposure in pregnancy” – you can view or download here.

FARR picSouth Africa – Short Messages Can Build Awareness

Leana Oliver, CEO of Foundation for Alcohol Related Research (FARR), explained how FARR builds upon existing health services by providing prenatal support, pregnancy planning and teaching of coping strategies to women through their programmes. Their “Do you have 3 Minutes?” campaign has been successful in building awareness within communities and in supporting prevention programmes (learn more here). As well, the FARR Training Academy offers accredited trainings and continued professional development on FASD to professionals, providers and educators. Research projects and FARR publications detail what has been learned such as the benefits of motivational interviewing and the need for preconception care and planning.

CDC picU.S. – Promoting Universal Screening and Brief Intervention

Cheryl Tan, Health Scientist, Centers for Disease Control and Prevention reviewed FASD activities currently underway. Surveillance of alcohol consumption by women of reproductive age is ongoing alongside efforts by the CDC to promote universal screening and brief interventions (aSBI) of adults 18+ years. She noted the wide discrepancy between how often providers say they conduct SBI (85%) and how often patients say they receive it (25%). As well, as a partner of the Collaborative of Alcohol-free Pregnancy, the CDC is helping to change healthcare practice through high-impact projects: 1) implement interprofessional model for prevention of AEP; 2) provide evidence for aSBI to insurers in the US; and, 3) reduce stigma associated with drinking during pregnancy.

For more these topics see earlier posts:

First-ever FASD Prevention Plenary at the 7th International Conference on FASD, March 22, 2017
WHO Europe: Prevention of harm caused by alcohol exposure in pregnancy, December 22, 2016
“Supporting pregnant women who use alcohol or other drugs: A guide for primary health care professionals”, May 15, 2016
How do partners affect women’s alcohol use during pregnancy?, August 11, 2014
Empowering Conversations to Prevent Alcohol Exposed Pregnancies: Extended Learning Webinars, May 8, 2014
The Prevention Conversation Project – Free Webcast on January 21, 2015 (Alberta FASD Learning Series), December 15, 2014
Alcohol and Pregnancy campaign from Norway, December 12, 2011
FASD Prevention in Russia, February 15, 2012

thunder-bay-report-coverAs part of the work of the Family Health Program, the Thunder Bay District Health Unit has published results from a research project on best practices to preventing alcohol-exposed pregnancy. Alongside reviewing literature, they looked at practices both in their health unit and among local community programs and services, and at provincial public health standards.

Seven over-arching themes were identified for a multi-pronged approach to preventing FASD:

1.  Population Health Surveillance
2. Public Awareness
3. Public Programs
4. Education for Health Care and Social Service Providers
5. Screening and Intervention by Health Care and Social Services Providers
6. Partnerships
7. Policy/Government Directives (1)

The report targets gaps to be addressed within each of these themes. As an example, within “Public Programs” there is a call to expand or develop programming that is culturally based and that includes women’s partners, and within “Education” to replace generalized training and education with approaches that target specific provider needs.

The authors caution readers not to “dilute the alcohol and pregnancy focus” when incorporating recommendations into existing service structures, and stress that additional research and evidence of programming, policy, and partnerships is needed.

Download the full report here to read more about their research methods, findings and recommendations, and to explore linkages with the Ontario Public Health Standards for reproductive health.


REFERENCES
  1. Thunder Bay District Health Unit, Family Health Program. (2016). Effective interventions and strategies to prevent alcohol-exposed pregnancies. Thunder Bay, ON.

NDARC Guide

This new resource from the National Drug & Alcohol Research Centre, University of New South Wales, Australia, is designed for all primary health care professions who see women in a broad range of health care service settings during the course of their practice.

The best practices guide builds on the evidence for providing coordinated, supportive and comprehensive care to pregnant women who use substances by providing a model for reducing the harm from alcohol and substance for women and their babies. See page 12 of this guide for a clearly charted overview of how physicians and other health care practitioners can support withdrawal, do psycho-social and nutritional interventions, and address barriers to care for pregnant women.

The model acknowledges the interconnections that impact a woman’s use of substances during pregnancy – including domestic violence, mental health, smoking, and stigma – and provides a guide for identifying risk and next steps for further assessment, support and/or treatment. See page 9 for a view of how identification differs for women who are pregnant, planning a pregnancy, or not planning a pregnancy.

It also moves beyond normal referral and coordination practices by using a holistic assessment process and designating a case coordinator or clinical lead to ensure “assertive follow-up.” Assertive follow-up consists of: making sure women are supported during pregnancy and birth; keeping mothers and their babies in the hospital so that post-birth assessments for mother and child can be done and plans for support and services are in place; providing breastfeeding, safe sleeping, parenting skills and contraception support; as well as, interfacing with partners, family members, and community agencies in support of the woman and her child.  See page 16 for more discussion on assertive follow-up and pages 19-20 for “Addressing barriers to care”.

Although the extensive resources that are included in this guide are geared for practitioners in Australia, many of them provide topic-specific information that practitioners everywhere may find helpful. See pages 24-27 for website links.

For more on screening in primary care settings, see previous posts:

For more on FASD prevention in Australia, see previous posts:

 

 

 

 

 

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

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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.

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telegraph screen shot

Recent research from the UK is sparking discussion about whether routinely testing pregnant women for alcohol use would be helpful.

While the researchers are insisting that binge drinking is ‘prevalent and socially pervasive’ and stronger measures are required, others argue that biological testing is a form of policing women and one that is counteractive in long-run

Sally Peck in her article in The Telegraph says:

“But here’s why we shouldn’t test pregnant women on their alcohol consumption: policing rather than supporting pregnant women fails to prepare them for motherhood.

Instead of imposing prison-style booze tests, let’s talk more about how to help women and men navigate the early years of parenthood, and how to get help when they need it. And let’s make sure that the help we promise – or say that they should have – is actually available to them.”

Research has shown that testing women for alcohol and drug use during pregnancy fails to support women and their babies in the long-run. Women with substance misuse concerns are less likely to seek help from health care providers and avoid prenatal care. And while women in all socio-economic brackets use substances, certain groups of women are unfairly targeted and subject to more invasion of their privacy and are likely to experience adverse outcomes from testing (e.g., child protection reports, custody hearings). As well, routine testing raises ethical issues around consent (e.g., what happens if a mother says she doesn’t want to be tested? Should a health care provider do the test anyway?), women’s autonomy and self-determination, and patient-doctor confidentiality.

Read early posts on the politics and ethics of testing pregnant women for alcohol use:

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Overall, alcohol and tobacco are the most commonly used drugs during pregnancy in Canada. They are also the two drugs that can be the most harmful to a fetus during pregnancy and in the long-term for babies that are exposed.

New research, using data from the Canadian Community Health Survey (2003-2012), takes a closer look at this relationship. Internationally, research has shown that women who smoke are also more likely to drink and vice versa. (One study by Cannon et al showed that 74% of mothers who had a child with FASD also smoked during their pregnancy).

The researchers looked at a national sample of 22,962 women who had given birth in the previous five years. They found that the overall prevalence of smoking during pregnancy in this group of women was 14.3% (of the women who smoked, 52.5% smoked daily and 47.5% smoked occasionally). The prevalence was the lowest in British Columbia at 9.0% and the highest in the territories (Yukon, Northwest Territories, and Nunavut combined) at 39.9%.

They found that:

  • Women who smoked during pregnancy were more likely to be younger, single, white/non-immigrants, and have a lower income.
  • Women who smoked during pregnancy were more likely to drink while pregnant. Women who were daily or occasional smokers during pregnancy were 2.54 and 2.71, respectively, times more likely to have consumed alcohol during pregnancy as compared to non-smokers.
  • Women who had a lifetime history of smoking, but who did not smoke during pregnancy, were also more likely to have consumed alcohol during pregnancy.
  • Binge drinking was the only factor that had a relationship to whether women used alcohol, smoked or used both during pregnancy.

These findings suggest the importance of public health interventions that address alcohol use and smoking together both before and during pregnancy.

References

Bailey, B.A., McCook, JG., Hodge, A. and McGrady, L. (2012). Infant birth outcomes among substance using women: why quitting smoking during pregnancy is just as important as quitting harder drugs. Matern Child Health J, 16:414–422.

Cannon, M.J., Dominique, Y., O’Leary, L.A., Sniezek, J.E., & Floyd, R.L. (2012). Characteristics and behaviors of mothers who have a child with fetal alcohol syndrome. Neurotoxicology and Teratology, 34: 90–95.

Janisse, J.J., Bailey, B.A., Ager, J., and Sokol, R.J. (2014). Alcohol, Tobacco, Cocaine, and Marijuana Use: Relative Contributions to Preterm Delivery and Fetal Growth Restriction. Substance Abuse, 35(1): 60-67, DOI: 10.1080/08897077.2013.804483

Lange, S., Probst, C., Quere, M., Rehm, J., Popova, S. (2015). Alcohol use, smoking and their co-occurrence during pregnancy among Canadian women, 2003 to 2011/12. Addictive Behaviors, 50: 102–109.

projectchoices_infographic_en

Project CHOICES is a program in Winnipeg, Manitoba, that works with girls and 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.

This infographic summarizes changes for participants three months after completing the program.

Project CHOICES is based on motivational interviewing which is a counseling approach that is respectful, non-judgmental and client-centred. Motivational interviewing allows health care providers and clients to explore possible areas of change, discuss strategies that make sense for the client and their life circumstances, and provides encouragement and support.

The program considers three different routes to reducing the risk of an alcohol-exposed pregnancy: (1) reducing alcohol use (2) using effective contraception (3) reducing alcohol use and using effective contraception.

Learn more about the evaluation from Healthy Child Manitoba. Check out the program website to learn more about the program, how to make a referral, and for resources on alcohol, pregnancy and birth control.

word on the street

plan

Elizabeth Elliott recently wrote a short article describing current FASD prevention efforts in Australia for the journal Public Health Research and Practice (available here).

Increasing awareness and understanding of FASD has resulted in a number of positive developments at a national level, including a federal parliamentary inquiry into FASD (2011), the development of an Australian Government action plan to prevent FASD (2013) and the announcement of government funding to progress the plan and appoint a National FASD Technical Network (June 2014).

Some of the earliest FASD prevention activities in Australia were led by indigenous communities. In 2007, a group of Aboriginal women from Fitzroy Crossing in remote northern Western Australia led a campaign to place a ban on the sale of full strength alcohol in their community.

This led to the Lililwan Project, the first ever prevalence study of FASD in Australia and a partnership between Nindilingarri Cultural Health Services, Marninwarntikura Woman’s Resource Centre, the George Institute for Global Health and the Discipline of Paediatrics and Child Health at The University of Sydney Medical School.

This ‘research in action’ project included diagnosis and development of individualised management plans to address the health issues of each child. Earlier this year, the researchers reported that one in eight (or 120 per 1000) children born in 2002 or 2003 in the Fitzroy Valley have FAS.

In 2009, the National Health and Medical Research Council revised the guidelines regarding alcohol use in pregnancy to state “For women who are pregnant or planning a pregnancy, not drinking is the safest option.”

HealthPro_Page_1

In 2014, the Women Want to Know project was launched. Developed by the Foundation for Alcohol Research and Education (FARE) in collaboration with leading health professional bodies across Australia and with support from the Australian Government Department of Health, the project encourages health professionals to routinely discuss alcohol and pregnancy with women in keeping with the revised guidelines.

FARE also launched the Pregnant Pause campaign in 2013 to encourage ‘dads-to-be’ and all Australians to support someone they care about through their pregnancy by taking a break from alcohol.

November 2013 also marked the first Australasian Fetal Alcohol Spectrum Disorders Conference  held in Brisbane.

Organizations such as the National Organisation for FASD Australia have taken a leadership role in education and advocacy related to FASD, including advocating for pregnancy warning labels on alcohol.

resizedimage300138-pregnancy-logo

Drinkwise, an alcohol industry-funded organization, has voluntarily developed ‘consumer information messages’ such as ‘It is safest not to drink while pregnant’ and ‘Kids and Alcohol Don’t Mix.’ However, an audit found that 26% of products carried a DrinkWise alcohol pregnancy warning label. (Visit Drink Tank for a discussion of alcohol industry led product labeling in Australia).

For more on FASD prevention in Australia, see earlier posts:

Overview: Four Levels of FASD Prevention

Information Sheet: What Men Can Do To Prevent FASD

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