Brief FASD prevention intervention: physicians’ skills demonstrated in a clinical trial in Russia

The study was conducted at public women’s clinics in two locations in Russia represented by the major urban population of St. Petersburg (SPB) and more rural population of the Nizhny Novgorod Region (NNR). A total of ten clinics, five at each location (SPB and NNR), were assigned to the intervention. The clinics varied from a small rural clinic with one OB/GYN in the NNR to a large urban clinic with over 20 OB/GYNs in SPB. Commitments from the SPB and NNR Health Administrations were received to ensure cooperation from the participating clinic directors. Organizational support was obtained from the clinic directors to participate in the study and to allow participating physicians at intervention clinics to incorporate the study intervention into routine clinic visits with the study participants. Participating physicians met the following criteria: 1) certified in obstetrics and gynecology, 2) employed at least 50% time at a clinic assigned to the intervention, 3) agreed to serve in the study, 4) participated in the intervention training, and 5) demonstrated skills in completing the intervention protocol. A total of 26 OB/GYN physicians were trained in the protocol. Two did not commit to participate in the study, and one did not meet the post-training skills criteria and was removed. A total of 23 OB/GYN physicians (8 in NNR and 15 in SPB) participated in the study as interventionists. The physicians were female with a mean age of 38 years and average of 13 years in practice. Physicians were reimbursed approximately $20 per intervention.

Patient participants were recruited for the study as consecutively enrolled non-pregnant women who were at risk for AEP between July, 2009-July, 2011. Patient inclusion criteria were: a) childbearing age women (ages 18–44 years); b) fertile; c) not currently pregnant (by self-report or a test result); d) engaging in AEP risk behaviors, i.e., specifically reporting having unprotected intercourse at least once in the last six months and drinking eight or more drinks per week on average or four or more drinks on one occasion within the past three months; e) living in the area served by one of the study clinics; f) available for follow-up for 12 months; and g) providing voluntary informed consent. A plan was made to over-recruit women with higher alcohol consumption to have at least 20% of the sample score 8 or higher on the Alcohol Use Disorders Identification Test (AUDIT) [40]. A review of women’s AUDIT scores conducted after enrolling 80% of the targeted sample at each study location indicated a significant number of study participants with high AUDIT scores at the majority of clinics (N=8). At the remaining two clinics, AUDIT was administered upon screening to recruit few heavier drinkers. A total of 374 women were recruited at the 10 intervention clinics in SPB (n=197) and the NNR (n=177); 29% of the study participants scored 8 or higher on AUDIT. Participants received a gift at completion of the baseline assessment and the first intervention session (an equivalent of $25).

The intervention was adapted from two evidence-based FASD prevention interventions, Healthy Moms [30] and Project CHOICES [41]. Results from our previous studies in Russia guided selection and adaptation of this intervention protocol. The high prevalence of AEP risk among non-pregnant women in Russia who combine at-risk drinking with a possibility of becoming pregnant [19] dictated a need in intervention that would target women prior to pregnancy, e.g., non-pregnant women of childbearing age, and addressing both behaviors that place women at AEP risk, e.g. at-risk drinking and inconsistent family planning/contraception. Women from our prior studies indicated that advice by OB/GYN physicians or nurses would be the most trusted source of information about health behaviors and alcohol consumption during pregnancy [42]. There is a well-established Russian OB/GYN health care system with services such as prenatal care and family planning/contraception services provided at district women’s clinics free of charge. Based on our prior surveys of physicians and interviews with Russian experts, it was decided that the intervention protocol should be brief, incorporated in a routine clinic visit, and should require one to two sessions maximum as it is unlikely that some non-pregnant women would return for more than one follow-up visit. This is the first intervention protocol for AEP prevention in Russia and the first protocol for a dual-focused AEP prevention intervention designed to be deliverable by OB/GYN physicians during routine women’s clinic visits.

First, we reviewed BI guidelines to make certain that the major components of effective interventions (e.g., advice, feedback, goal setting, additional contacts for further assistance, and support [24, 43]) were included in the intervention protocol. Second, we reviewed FASD prevention studies and extracted elements from two evidence-based FASD prevention interventions with sound evidence for reducing AEP risk in non-pregnant women: Healthy Moms [30] and Project CHOICES [41]. Project CHOICES is a dual-focused intervention drawn from the Motivational Interviewing (MI) [44] framework and designed to decrease the AEP risk in non-pregnant childbearing age women by either reducing drinking or improving contraception or both. However, CHOICES itself could not be directly used within our intended parameters because it requires four 45 to 60 min counseling sessions with a mental health professional/counselor and one contraception session with a family planning clinician. A key reason for selecting CHOICES as one source for adaption to the Russian context was its flexibility in targeting both prevalent among Russian women problematic behaviors (risky drinking and lack of contraception) in one intervention. Also, OB/GYN physicians assess and assist women in contraception use and are in a unique position to deliver this facet of the CHOICES approach. This is the first feasibility study testing delivery a dual-focused AEP prevention intervention by OB/GYN physicians.

We adapted the structural elements from the Healthy Moms [30] protocol to make our intervention deliverable during routine clinic visits. The Healthy Moms protocol was designed for women in the postpartum period to be deliverable in two 15-min clinic visits followed by two phone calls by OB/GYNs, outpatient nurses, or research staff. Similarly to CHOICES, Healthy Moms utilizes MI and includes a patient workbook that contains results of screening and personalized feedback about AEP risk, worksheets on drinking (and contraception in CHOICES), and drinking diary cards.

The adapted protocol, which was termed the Dual-Focused Brief Physician Intervention protocol (DFBPI), implements MI principles, focuses on both contraception and alcohol use, and is designed to be deliverable routinely by OB/GYN physicians at women’s clinics. The intervention targets childbearing age non-pregnant women who are at risk for AEP, i.e., risky drinkers who are using contraception inconsistently. The DFBPI protocol and materials were prepared in consultation with Russian project consultants, obstetricians and behavioral health experts, including Russian women. The CHOICES and Healthy Moms intervention materials (e.g. workbooks) were translated and modified in accordance with DFBPI. Materials were translated and back translated by bi-lingual behavioral health experts in order to ensure that the materials were culturally congruent, accurate, and would be correctly comprehended by Russian women. A physician training protocol was developed and pre-tested by the study research group in a small randomized educational trial using a two-arm, pre/posttest design [45]. The results of this study showed that Russian OB/GYN physicians randomized to the training condition demonstrated significantly improved skills after the training.

The DFBPI, with the translated title, Baby’s Health is Your Choice, consisting of two face-to-face structured brief 5–10 min intervention sessions was incorporated in OB/GYN clinic visits scheduled approximately one month apart. Because of the lack of informational materials about contraception in Russia, an educational brochure [46] about contraception methods was also developed for the study. The DFBPI physician algorithm or steps to be taken by physicians are included in Figure 1.

In the intervention condition during the first visit, a woman’s contraception practices and alcohol use were assessed and feedback about AEP risk was provided. The woman received informational materials about the effects of alcohol on a fetus and FASD, risky levels of alcohol use, and contraception methods; was provided an opportunity to discuss her options and possible barriers; was assisted in setting up her AEP reduction goal (if she chose AEP reduction); received a workbook with exercises; and was scheduled for a follow-up visit. (Key structural elements of the first intervention session protocol are included in Figure 2).

The workbook consisted of condensed intervention messages that included 1) self-determination/feedback about the woman’s risk for AEP; 2) defining safe alcohol use during pregnancy, if attempting to become pregnant or if at-risk of unintended pregnancy; 3) recommended drinking limits if using contraception; 4) family planning/appropriate contraception use; 5) how to reduce AEP risk; 6) worksheets for self-evaluation of importance, confidence, and readiness to use alcohol safely; 7) plans for pregnancy or contraception, 8) decisional balance regarding alcohol and contraception use; 9) goal setting, and 10) a diary to record intercourse, contraception use, and alcohol use during the subsequent four weeks. The participant was asked to read information in the workbook and educational brochures about FASD and contraception, complete exercises and the diary between visits, and bring the book to the next clinic visit to discuss with the OB/GYN. The second session protocol is tailored to the woman’s choice of pregnancy planning or contraception. (The key structural elements of the second intervention session are included in Figure 3). The two DFBPI sessions were incorporated into routine OB/GYN clinic visits and could include taking a medical history, conducting a physical exam, and providing prescriptions or contraceptives if indicated. The estimated total time required for physicians to deliver the DFBPI was 5–10 min per session.

Physicians were trained in the intervention by the study supervisors who were PhD level psychologists and a senior MD/PhD OB/GYN physician. The training included a three-hour FASD education module on the effects of alcohol consumption during pregnancy, FASD, prevention, and screening and brief interventions followed by a four-hour instructional and practice workshop. The physicians learned the DFBPI protocol, application of basic MI principles, and practiced conducting the intervention in a nonjudgmental and empathic manner. The intervention protocol was presented in a step-by-step format with instructions, and skill training techniques such as scenarios, video demonstration, and role plays, which were employed to train physicians to the behavioral competency criteria by demonstrating their delivery of all components of the 5–10 min DFBPI protocol. Feasibility and deliverability data for the DFBPI protocol were drawn from project quality control efforts. Physicians delivering DFBPI were monitored in four ways. Monitoring included reviews of the intervention fidelity check lists (see Measures section) completed by physicians and by patients after each intervention session, direct observations of physician’s intervention interactions with patients conducted by the study supervisors (at least one session was observed for each physician at the beginning of the study), and reviews of audio recordings of clinic intervention visits. The OB/GYN intervention fidelity plan required completing 80% of the components of the protocol with 90% of patient contacts. The project supervising faculty, which included PhD psychologists, an OB/GYN, and a substance abuse physician, were available to provide feedback, consult about cases, problem-solve, and provide coaching as necessary.

Categorical variables were summarized as proportions. Categorical contingency tables were analyzed with McNemar’s test if the data were paired and through a chi-square test if they were not. Continuous variables were summarized with means, standard deviations, and ranges. An alpha of 0.05 was considered statistically significant.

The overall pattern of results supports the feasibility and deliverability of a brief dual-focus AEP prevention model by OB/GYN physicians in Russia. The results are consistent with results of prior studies of alcohol reduction BPI and MI outside of Russia, namely that physicians will counsel their patients if they are provided skill training and quality control support [49, 50]. Recruitment and participation agreement rates were high, and the majority of physicians who attended the training met skill criteria. Physicians trained in DFBPI and provided with support, individual feedback about their performance, coaching, and consultation during the clinical trial demonstrated high rates of delivery of all DFBPI components. They were able to implement the intervention and integrate it into routine women’s clinic visits. Based on reports from physicians, patients, and audiotapes, physicians outperformed the study intervention fidelity plan requirement that was set initially at 80% of the components of the intervention with 90% of patient contacts. Similarly to Babor et al. [49], both physicians’ and women’s reports indicated high performance in delivery of the intervention components. However, a discrepancy between women’s and physicians’ reports was significant with women more likely reporting omission of specific intervention components compared to physicians’ self-reports. Although there may be several explanations for the discrepancy, a review of audiotapes indicated that providers may have thought that a patient had already understood a point so they did not need to cover it much when in fact the patient did not. That was observed particularly when physicians discussed with patients contraception options and possible barriers to reducing alcohol use or utilizing contraception consistently.

Discussing difficulties/barriers that may prevent a woman from achieving her AEP prevention goal appeared to be the most difficult component for physicians to implement (or for women to grasp) and was more likely to be omitted than other components of DFBPI. In Russia, family planning and contraception counseling are conducted by OB/GYN physicians as a part of routine women’s health care. Therefore, the DFBPI training was focused more on intervention components related to alcohol consumption, which is not typically a part of OB/GYN services. The assumption was that if a woman selected delaying pregnancy/contraception as her AEP reduction goal, the OB/GYN would be equipped with skills to address her goal of improving contraception use. Unexpectedly, physicians were more likely to omit discussing methods of achieving goals and possible barriers when a woman chose delaying pregnancy. The physicians trained in DFBPI and MI basic principles to address alcohol consumption appeared to be comfortable delivering alcohol reduction intervention components of the intervention; however, they demonstrated difficulty in implementing basic MI principles to address inconsistent contraception, e.g., providing information about contraception methods and discussing options and possible barriers to improve consistent contraception use. OB/GYN physicians may benefit from expanding the contraception component of the training and developing skills to better address their patients’ contraception practices.

Strengths of this study include a relatively large sample size of 374 women and a combination of different methods that included physician and women’s self-reports completed shortly after sessions and live or audiotaped intervention observations were important for cross-validation of the results. Monitoring was conducted systematically and patient and provider FCL were obtained for all intervention sessions. Although audio recording was completed for a subset of interventions only, results indicated agreement between the audiotape and FCL data about completion of specific intervention components. Study limitations also should be considered. The intervention was a part of a clinical trial, and physicians and patients were provided with a level of quality control support that may be higher than what is found in routine clinical practice, which may limit generalization. The study was limited to physicians in public OB/GYN clinics and to the patients attending these clinics, so generalization to other service systems should be made cautiously. It is possible that some women with high AEP risk, such as alcohol-dependent women, do not seek OB/GYN or prenatal care, and it is not clear how well this AEP prevention model would serve these women. However, Russian government statistics indicate that 96.4% of women receive prenatal services from public women’s clinics [51], and therefore, the study sample represents the major OB/GYN service delivery system in Russia.