FASD Prevention Project

1. FASD Prevention Project Tracey Waller, MBA, RD/LD, IBCLC WIC Program Director 937-225-5814 or twaller@phdmc.org May 13, 2009

2. FASD Prevention Project • OBJECTIVES • Provide an overview of the Public Health—Dayton and Montgomery County WIC Program • Describe the FASD Screening and Brief Intervention project and its processes • Discuss the preliminary findings and success/challenges of the project to date

3. FASD Prevention Project • OUTLINE • Overview of Public Health—Dayton and Montgomery County WIC Program • Overview of: • Screening • Brief Intervention • Follow Up Appointments • Findings/Case Studies • Challenges/Successes • Conclusions • Looking ahead

4. FASD Prevention Project

5. FASD Prevention Project THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC): • Federally funded and income-based • Nutrition Education • Breastfeeding Support • Supplemental Foods • Referrals for Health Care and Social Service Agencies

6. FASD Prevention Project MONTGOMERY COUNTY WIC PROGRAM: • 6th largest WIC project in Ohio • Ohio is 7th largest WIC program in nation (300,000+ participant caseload) (correction) • Average monthly caseload of 13,586 for FY09 • Approximately 250 new pregnant women per month • All new pregnant women screened with TWEAK tool • 5 clinic sites • All sites participating in FASD initiative • Each site with unique demographics

7. FASD Prevention Project MONTGOMERY COUNTY WIC PROGRAM: • Income breakdown: • Must be at or below 185% of poverty level • Locally: • 78% are at or under 100% of poverty level • Predominantly urban/suburban, some rural • Racial breakdown: • 57% Caucasian 3% Hispanic • 38% African American 2% other

8. FASD Prevention Project MONTGOMERY COUNTY WIC PROGRAM: • Nationally: • About half of all US born infants will receive WIC at some point during their first year of life • Locally: • Approx. 7,000-8,000 births annually • WIC serves approx. 3,700 of these infants per year • Potentially 35-40 infants born with FASD enrolled in WIC each year Mission: find the mothers at risk and educate them to reduce prevalence of alcohol use during pregnancy

9. FASD Prevention Project THE PREVENTION PROJECT GOALS: • Screen all pregnant women enrolling in the WIC Program in Montgomery County • Provide Brief Intervention to all who screen positive • Follow women receiving Brief Intervention during her pregnancy • Develop a process for referral to treatment services • Incorporate maternal alcohol history in infant’s pediatric file

10. FASD Prevention Project SCREENING TOOL: • Screen all pregnant women at initial WIC visit • Distribute screening form attached to a routine piece of the paperwork puzzle • Copy onto pink paper to match rest of WIC paperwork • Laminated and placed “What is a Standard Drink” onto the clipboard for multiple use • In color • Decrease copying Eliminate perception of being singled out to complete “special” paperwork

11. FASD Prevention Project • CURRENT OHIO WIC FORM:  Check all alcoholic beverages you drink. ____Wine ____Beer ____Coolers ____Liquor Now ________a day _______a week ____ None Anytime during this pregnancy ________a day _______a week ____ None Three months before this pregnancy ________a day _______a week ____None • SCREENING TOOL: 4. How often did you have 4 or more drinks in one day in the past 30 days? 10 or more 9 8 7 6 5 4 3 2 1 0 5. How many drinks did you have on a typical day when you were drinking alcohol in the past 30 days? 10 or more 9 8 7 6 5 4 3 2 1 0 6. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage? Write one number between 0 and 30 days as your answer: ________

12. FASD Prevention Project TWEAK QUESTIONS How many drinks does it take until you feel the effects of alcohol? 10 or more 9 8 7 6 5 4 3 2 1 Do close friends or relatives worry or complain about your drinking? Do you sometimes take a drink in the morning when you first get up? Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? Do you sometimes feel the need to cut down on your drinking?

13. FASD Prevention Project BRIEF INTERVENTION (BI): • Triggered by scoring Screening tool • Given to all participants who score 2 or more on TWEAK questions and/or have had alcohol in last 30 days • Given at initial appointment as a part of “routine” nutrition counseling • Often goal set for BI becomes nutrition goal for WIC services • Referral to treatment if appropriate • Participant given just enough WIC coupons to last until follow up visit • usually 1 month- standard issuance is 3 months

14. FASD Prevention Project REFERRALS TO TREATMENT: • Samaritan CrisisCare • We have created a reciprocal participant consent to share information between WIC and CrisisCare • No “completed” referrals to date • 1 participant refused referral but took the info to think about • 1 participant was referred, but for drug use, not alcohol • Not counted in our data • 1 participant qualified for treatment after the loss of her infant and refused referral, but took the info to think about

15. FASD Prevention Project PRENATAL FOLLOW UP: • Approx. 1 month follow up after Brief Intervention • Assess if drinking goal was met • Refer to treatment if appropriate • Second (or more) follow up if necessary POST PARTUM: • Request consent to share maternal prenatal history with infant’s pediatrician

16. FASD Prevention Project September 9, 2008 (International FASD Awareness Day) Through March 31, 2009

17. FASD Prevention Project FINDINGS: Screening • 1779 total screened (100%) • Very little resistance to completing screening form • Those who completely abstain from alcohol likely to articulate themselves loudly on the form, but still complete it • Challenges: • Is self-reporting very accurate? • Low literacy issues uncovered • Language barriers • What about participants who bring their own mothers to their appointment and can’t/won’t be candid?

18. FASD Prevention Project • FINDINGS: Brief Intervention • 105 Brief Interventions given (6%) • 25 years old : Average age of participant receiving BI • 24 years old:- average age of pregnant WIC participant • 26% (n=27) reported drinking during 30 days prior to screen • 63% (n=17) in first trimester • 26% (n=7) in second trimester • 11% (n=3) in third trimester • 74% received BI because of TWEAK score only- no current use • Most troublesome: • “How many drinks does it take until you feel the effects of alcohol?”

19. FASD Prevention Project FINDINGS: Brief Intervention Racial/Ethnic breakdown 97% non-Hispanic 3% unknown 48% Black/ African American 45% White 5% White/Black/ African American 2% other

20. FASD Prevention Project FINDINGS: Brief Intervention BI Participants: (n=105) 19% less than high school 41% just high school 39% at least some college All Pregnant Participants: (n=1311) 30% less than high school 47% just high school 23% at least some college

21. FASD Prevention Project FINDINGS: Brief Intervention BI marital status comparable to general WIC population 89% unmarried 11% married

22. FASD Prevention Project FINDINGS: BriefIntervention (BI) • Counseling techniques are critical • Many women have taken the BI information with interest • A few have become defensive while reviewing the book • Many women who have received BI state they had already stopped drinking and won’t drink during pregnancy • Wide variance in time it takes to complete BI • Tailor education to participant's willingness to learn

23. FASD Prevention Project FINDINGS: Follow Up Appointments • 93% return rate! • 77 follow-up visits completed • 77 abstained from further alcohol use • 1 participant has had 2 f/u visits-- did not abstain at first follow up but was successful by second- receiving outpatient services for both drugs and alcohol (kicked the drugs prior to pregnancy) • 7 participants missed follow up appt and no current contact info • 1 participant had still birth before follow up appt due • 1 participant moved out of county

24. FASD Prevention Project FINDINGS: Post Partum Visit • 28 postpartum visits completed • Challenge: • Only 2 maternal alcohol histories sent to infant’s pediatrician • Participants refused to give consent and/or never actually drank during pregnancy- the TWEAK score qualified them for the BI • Working on solutions to decrease stigma of sharing alcohol history • Education needed for pediatricians to make info useful

25. FASD Prevention Project • Cases in Point: • “I lied on my screening form. Sorry. I didn’t want you to know I am an alcoholic” • “Are you sure drinking is bad?” • “I couldn’t stop myself. Please let me try another month. I know I can quit this time”. • Why are you asking me these questions over and over? Who would be stupid enough to drink when they are pregnant?

26. FASD Prevention Project CHALLENGES: Paperwork is daunting! • A color for every form • All “originals” stay at clinic in participant chart for anyone who received a BI • Staff faxes each form throughout BI process to central office as they occur. Master file is kept on white paper • Coloredforms are kept in plain view on the left (unused) side of the participant chart – reminds staff what should be there • Forms are matched up by ID number as they are received at central office and kept together • All negative screens stored at central office

27. FASD Prevention Project CHALLENGES: Paperwork is daunting! • Staying Organized • Master file- • Negative screens separate from Brief Interventions • BI file in order by screening date • Each visit/new form attached to older forms • Once participant delivers baby, BI file pulled to “completed” file • Log book at each clinic site • Clinic staff keeps track of their BI participants

28. FASD Prevention Project CHALLENGES: Maintaining the database • One central database • Clinics send all forms to central office for input • Consistency in data entry important • Limited access to database • Remove burden to very busy clinic staff to maintain their own databases • Hand counting necessary each month to sort info by clinic for monthly reporting- looking for trend by clinic • Many changes in database after issued

29. FASD Prevention Project CHALLENGES: As with most projects, the paperwork to support the project is more laborious than the actual work done for the project

30. FASD Prevention Project • CONCLUSIONS: • Enhanced screening identifies more alcohol use than standard WIC questions • Self reporting bias exists, but not as big of a barrier as thought • Brief Intervention halts alcohol use during pregnancy • Misinformation about alcohol use during pregnancy rampant • Alcohol use during pregnancy not limited to one demographic • Mothers reluctant to share alcohol use history with infant’s pediatrician • Social change takes time, is happening

31. FASD Prevention Project • Looking Ahead: • Implement revised forms • Wait to see if disclaimer affects participation • Continue to screen all pregnant women • Continue to give Brief Intervention to all who qualify • Follow BI participants through pregnancy • Devise better system for sending maternal alcohol history to pediatricians • Keep database up to date and “tidy” • Continual improvement of health professionals’ counseling skills • FASD Task force to create societal change

32. Montgomery County WIC Staff

33. FASD Prevention Project • Looking Ahead: Make enhanced screening and Brief Intervention a universal and permanent part of WIC (and beyond)?

34. Thank you!