Background
Methods
Study design and sample
Job/profession at time of implementation | Role (strategic and/or clinical) | Health board area | SBI performance |
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ADP Coordinator | Strategic | A | High |
ADP Coordinator | Strategic | B | Low |
Specialist Nurse (Addictions) | Clinical and strategic | C | Low |
Specialist Midwife | Clinical and strategic | D | High |
Specialist Nurse (Addictions) | Strategic | E | Low |
Senior Medical Doctor (Public Health) | Strategic | F | Low |
Specialist Midwife | Clinical and strategic | G | Low |
Senior NHS Officer | Strategic | H | Low |
Data collection
Data analysis
Results
Health board area | PRISM domain | |||
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Recipients | Program (intervention) | Implementation infrastructure and sustainability | External environment | |
A | • Difficult to arrange training due to midwives’ workloads | • TWEAK used as screening tool, as midwives were comfortable with it – needed support on how to develop the system around it • BI delivered for positive screen, referral for “higher levels of drinking” | • High performing SBI deliverya • SBI delivery and reporting worked well • Antenatal perceived as an easier place to deliver SBIs – pregnant women have an appointment | • Growing knowledge of FAS facilitated implementation as midwives perceived SBIs as a good preventive strategy |
B | • Midwives believed women who already have a problem would be known, others would say they do not drink • No “buy-in” from senior management | • Low performing SBI deliverya | • Alcohol competed with other risk factors –not joined up | |
C | • A lot of information leaflets were handed out – some work was being done to inform about risks • The relationship and links between implementation lead and antenatal and alcohol liaison services and antenatal were not strong • Support from Head of Midwifery, some lead midwives felt it was added work • ALNs observed that midwives did not have problems asking the question | • No agreement to include new screening instrument – used SWHMR as TWEAK was “too much” • Pathway was accepted, but adopting and recording was difficult • Pathways: i) BI and leaflet if women reported any alcohol use; ii) > 2 units per week, ≥1 score on CAGE, or alcohol or drug misuse in last 12 months by woman or partner women were referred to specialist services • All women being asked, < 1% reported drinking which led to: i) looking at how the question was asked, and ii) if information could target non-pregnant women | • Low performing SBI deliverya • Incorporating into IT system facilitated recording. Initially poor uptake – made the question mandatory. • Implementation in antenatal not as successful as in A&E | • Drinking culture and hazardous alcohol use among women in general suggested < 1% reporting drinking in pregnancy was not true • The GIRFEC and Early Years Collaborative agendas directed maternity services’ work– felt SBIs needed to link up better and better links with ALNs is needed |
D | • Support from Head of Midwifery, work was led forward by three midwives with free reign to implement • The programme was seen as supporting existing practice • Midwives became comfortable with asking question and referring, but found it difficult to assess when to involve social services • Apart from a few strong characters, general good receptiveness – main point to raise awareness of why it is important | • Alcohol was already part of SWHMR –the HEAT target more about how to ask the question and how to best record it • Developed new screening tool adapted from FAST, to fit the “local language”, including pre-pregnancy drinking and encouraged midwives to focus on the conversation about how and when alcohol was consumed (see Case Study 1 in Table 3) • SBIs recorded if woman had drunk since conception to address behaviour change also for unintended exposure | • High performing SBI deliverya • HEAT target provided structure to the setup and emphasized that it was a governmental priority • Piloting and tweaking with a small number of midwives key to get screening tool and pathway right | • Local culture and knowledge of the local population part of developing the system • ADP funding was essential to get the work “off the ground” |
E | • All midwives were trained through the national training programme • Trained each local team • Generally midwives were supportive | • SWHMR, but the alcohol questions were considered unsuitable for SBIs and were therefore adapted • Following screening; BI or referral to services • Question was repeated at 32 weeks and discussed throughout with women reporting drinking | • Low performing SBI deliverya | |
F | • Midwives supported complete abstinence; NHS information at the time said limit to 1–2 units once or twice per week • Senior midwives were signed up for trainings but releasing frontline staff was difficult • Budget did not allow covering backfill in practices | • TWEAK was chosen as suitable screening tool • Poor coverage of routine screening • BIs were offered based on any alcohol use, in line with midwives’ views rather than positive screen | • Low performing SBI deliverya | • The public health agenda for midwives was perceived as too big and booking appointments long and information dense • No linking between agendas or acknowledgement of cross-over skills to address these issues • Conflicting messages of lower drinking limits influenced discussion on how to deliver SBIs |
G | • Training was not adapted for maternity, took time tweak the materials • Managers were supportive to get staff trained quickly • Maternity managers gave “free reign” with input from ADP and SBI trainers | • Added screening and SBI delivery onto existing checklist • Used SWHMR (see Case Study 2 in Table 3) –FAST seen as inappropriate– and added whether woman been given information about risks • SBIs were delivered if a woman had consumed alcohol since conception, or drank ≤14 units or regular binge drank before getting pregnant | • Low performing SBI deliverya | • Conflicting messages with lower drinking limits influenced discussion on how to deliver SBIs • ADP supported financially to cover training costs |
H | • Employed a person dedicated to deliver the SBI training | • Lack of scoping nationally into the feasibility of recording on existing systems • Felt it was more important to talk to women before they get pregnant | • Low performing SBI deliverya • Midwifes felt uncomfortable asking about alcohol because it might jeopardize their relationship with women | • Other national work around recorded information about pregnancy and maternal health was not linked up with SBIs – missed opportunity |
Integrating SBI into routine practice
It is true that I was starting from a lower base in terms of relationships. I didn’t have a strong link into antenatal settings [ … ] but there were good links with Head of Midwifery and it was made clear to midwives they had to do it. We needed to use that strategy to influence delivery in maternity so it was more of a top-down approach (Health Board C)
A lot of time (was) spent debating about exactly which women would we actually be delivering a BI [brief intervention] to, would it be women who were drinking above the 14 units limit [ … ] Was it women drinking more than the ‘Ready Steady Baby’ limits? Or was it actually what midwives felt strongly professionally, which was women who were actually drinking any alcohol at all in pregnancy? (Health Board F)
The national packs were useful after we had done the training for trainers but on the back of the work that was done, the initial antenatal packs said that women didn’t need an ABI [alcohol brief intervention] if drinking small amounts, but now anybody drinking in-pregnancy gets an ABI (Health Board D)
Screening in the antenatal setting
Several other health boards also decided to limit change in current practice by using questions from existing standard forms. In health boards where standardized tools were used, considerations to their application to the local context was considered important (see Table 2).People felt that TWEAK was too much and they were trying to incorporate it into the initial booking appointment where there are a lot of questions to work through in an hour. So we thought the simplest thing to do was to stick with questions that were already there in the SWHMR [Scottish Women’s Handheld Maternity Record] (Health Board C)
When you look at the [local] culture of drinking and hazardous drinking among women and in the population in general, we don’t think that less than 1% of women are drinking in pregnancy (Health Board C)
Case Study 2 indicated an increase in reported pre-pregnancy abstinence over time, felt likely due to a change in the accuracy and honesty of women’s reporting, rather than a genuine fall in consumption. One interpretation was that women were ‘coming prepared’ to answer the questions. Another was that a recent focus by midwives on asking about parenting capacity and home circumstances may have made women fearful about disclosing heavy drinking (see Case Study 2). In this case, midwives were encouraged to probe further if women reported no alcohol use pre-pregnancy, resulted in higher levels of disclosure.We had a lot of discussion about it being more important to ask about alcohol consumption before pregnancy, because pregnant women are less likely to disclose when they are drinking in pregnancy because they know they are not supposed to (Health Board H)
Title | Health Board | Case study text |
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Case study 1: a conversational approach to screening |
Area D
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We designed a new screening tool because we felt that some of the tools for the antenatal session weren’t [in the kind of] language [used locally], midwives fed back that they weren’t comfortable with that.
Initially we looked at how we approached the alcohol questions. We found that women tell us that they don’t drink, they will always say they don’t drink, but we know that is not true. So we had to look at a way that it was more of a conversation than about asking women about normal drinking behaviour. We asked the midwives not to ask about units, [but instead] ask when they drink, how often, what they drink, how much … so asking a young girl what her normal pattern was of drinking, she said ‘at weekends’, I asked when that started, what she drank in the house before going out, when she goes out. It’s about knowing about normal patterns of drinking, it was asking specific questions rather than asking how much you would drink. At the time I found out that she was drinking over 100 units at the weekend but initially she said she was only drinking socially at the weekend … [emphasis added]
I think what I tended to find was that women were very defensive. They say I’m not going to drink and I’m going to stop now and it’s about reassuring them that that’s great. But also asking if it’s okay if we discuss that a bit more. Saying that we know that sometimes there are special occasions and they might say ‘I plan to have x, y, z’ or ‘I drank in my last pregnancy’ and the child is OK, then that’s more of an opening. But I would say those women are the ones that are less likely to want to have the conversation. I would ask them then about the effects of drinking to find out their knowledge then ask their permission ‘can we move on?’ and discuss other parts. Talk about their normal behaviour and ask ‘how easy is it going to be to make a change from that? How are you going to manage? What will you do to make that change?’ …
I think the big thing for us is the local culture and the local language that we use. I was trying to get away from the midwives using the initial screening tool as a parrot fashion and questions. I felt that the problem was that people don’t want to talk about it, taboo around asking questions about alcohol. We had an FAS event day locally and one speaker put up some research saying that women are drinking 2 units and so they don’t drink what we think they are, using the initial screening tool we were finding they were drinking 2 units or 1 unit less than once a month. But from what we see locally and especially the post I do, people tell me that they know somebody that drank in pregnancy. So we knew that those figures weren’t right. So [we thought about] what do we do to get the correct information?...
It’s also about reassuring them that they’re not being judged or there’s going to be some form of social work input. It’s about putting them at ease and having a different kind of conversation that was beneficial for us.
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Case study 2: addressing changes in reporting over time | Area G | Screening focused on current, previous and pre-pregnancy drinking.
“Obviously the generic training we got was using the FAST [Fast Alcohol Screening Test] screening tool and it was quite clear from the word go that it wasn’t appropriate when we were going down the route of abstinence in pregnancy. That was a big issue for us initially, was the abstinence message, when there was the mixed message still going on about whether it was safe enough to use the 1–2 units once or twice a week or should we go the abstinence. However we got a lot of support locally, through the ADP and through our consultants and obstetricians as well, we were very supported in the abstinence message in [our health board]. So we decided to go with the direct questions that were already existing in the SWHMR notes, of how many units of alcohol are you drinking in the pre-pregnancy and how many units of alcohol you were drinking currently, but elaborating by asking about their pattern of drinking and establishing how many units they were drinking on their heaviest drinking day to capture the binge culture.”
Over a 9 month period, disclosures of pre-pregnancy drinking fell by over 20%.
“One of the key things that we’ve found in [this health board] bearing in mind that we’ve been screening [for almost 5 years]. Over the last 6–9 months, we were noticing when our pre-pregnancy drinking data was coming in that we were actually seeing a great increase in the number of people who were actually saying that they weren’t drinking any alcohol at all outwith pregnancy, even in their pre-pregnant drinking, it was around about 50–52% throughout all localities that women were now saying that they weren’t drinking any alcohol at all...We’ve only seen within the last 6–9 months that we are finding that 50% on average are saying they don’t drink any alcohol, prior to that, when we introduced the training and the screening … you would probably be sitting at over 75% who were describing their pattern of pre-pregnancy drinking. They were quite happy to describe their pre-pregnant drinking...”
This fall was not thought to reflect an actual fall in drinking. “We know within [this area] that we do have a problem with problematic binge drinking … we know that it’s an ongoing social factor here, so actually to look at the stats coming through of young women of childbearing age saying that they actually didn’t drink at all was questionable. So we approached the community midwives and got a feeling of their perception. We were a bit worried that it was the midwives who were losing the agenda, now that they were taking on other stuff, the GIRFEC agenda and other things going on, had this priority dropped?” Women were thought to be ‘coming prepared’ to say they didn’t drink. “So we approached midwives, and obviously working within this field for years, I know midwives who are really good at specific agendas and really good at their screening, and even midwives like that were actually coming forward to myself and saying “its actually surprising ourselves, we feel the message is out there now [the screening] has actually been embedded for several years that women actually come prepared to say that they don’t drink any more.” A greater focus on parenting and home circumstances may have contributed to the change.
“There was no kind of follow on about why they weren’t admitting it. I think there has been such a big shift with the GIRFEC agenda [a national early years child wellbeing initiative] and the total booking appointment and how many questions – how in-depth midwifes now go in their whole circumstances, whereas before we did the key screening on things, like domestic abuse, we now look really into their whole lifestyle, where they’re living, what benefits they’re getting, what their partners do, if there has been any criminal past – we actually go very, very in-depth on their parenting capacity and any concerns that might rise from that now, so I don’t know whether with us going into this agenda, that the actual fear of actually admitting that they were drinking regular and there had maybe been instances linked to that, that they had maybe been a bit afraid to disclose that. I am not really sure where the reasons come behind that but certainly that’s what the feedback from a lot of the community midwives was, was that women were coming pre-prepared and weren’t openly discussing what they were previously drinking.”
What was done in response to the fall in disclosure? “What we’ve actually done in relation to the early years collaborative/PDSA [Plan-Do-Study-Act] cycle that’s going on nationally we decided to do a bit of work within that to get a clear picture what percentages of women were advising that they don’t drink alcohol at all [pre-pregnancy] and also doing a wee bit of training for the midwifes in the community again.
So we looked at numbers for three locality areas, so on how many women were advising that they don’t drink any alcohol at all, and it was true the numbers that came in were 49/52/50% for women drinking no alcohol pre-pregnancy. So it was reflective of the figures we were finding in [part of the health board] and what the community midwives were saying to us as well.”
Focusing on more prompts led to greater disclosure back to original levels. “So next step was to focus on one community locality, and arranged to go out to speak to community midwives to have a conversation on what were their views on these stats over that last months. And they all replicated what has already been said that they felt women were already prepared and that they’ve been surprised about how many women … they were quite adamant that it wasn’t the competing agenda that was putting the priority down on their workload. So I then did a refresher course on what our policy is on the screening and when a brief intervention should be delivered and questioning their pattern of drinking when they’re pre-pregnant as well. And a lot of the midwives were again replying that women are telling us that they are not drinking.
So I encouraged them to take the probing a wee bit further and say, ‘you’re obviously saying that you’ve never drank pre-pregnancy but have you ever drank before?’ and ‘what was your pattern of drinking then?’ and ‘when did you last drink?’. So that we’re kind of taking it that next step. So the results from that was that our screening on the pre pregnant jumped back up to 74% in that area. Now in the stage where I’m linking in with the team leaders in the other localities and they will feed this info back to their community midwives highlighting this need for further probing.”
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Contextual factors affecting implementation
There were lots of different health improvement people going to the same target staff about different things to do with [how they address] lifestyle change etc. All these different approaches are being made to midwives and practice nurses or whatever separately – it’s not joined up (Health Board B)
There was a concern that there was not really a joined-up-ness about all of this. That people were being asked to be trained for talking about breastfeeding, looking for issues of domestic abuse, issues of smoking and behaviour change, and alcohol, but where was the joined up bit about it? Where could we capitalise on the shared skills, the crossover skills? (Health Board F)
All these things were coming at the same time and setting an agenda that for midwives, and frankly for women coming for booking, was becoming too huge (Health Board F)
Perceived outcomes of the SBI programme
Midwives were not particularly happy with it, their reservation was that if somebody had a significant problem they would already be known and if they didn’t have that level of problem but were drinking, they were unlikely to tell you, the others who were happy to talk about it had already reduced or stopped drinking anyway … we had to accept what they were saying. All we could do was offer more follow-up support and refresher training, which no-one accepted (Health Board B)