Policy drivers and training

This theme describes what policy participants considered as the main policy drivers for implementing screening and ABI in antenatal care settings and views on perceived factors likely to enhance the delivery of the intervention.

5.4.1 Policy drivers

All policy participants unreservedly acknowledged that the HEAT target was the single most important drive for the implementation of ABI in antenatal care settings.

Participant HS1 recognised this and noted the contribution of other factors.

Well, in terms of policy, the HEAT target is obviously the main driver for ABI programme. Of course not just antenatal, but primary care and A&E as well. So to my knowledge there isn’t any other mandatory policy drivers for introducing ABI. The other kind of main policy drivers in this area are about, kind of a more general policy driver is about health improvement and reducing health inequalities (HS1).

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Participant HS2 cited the commitment of the Chief Medical Officer of Scotland to curb the surge of alcohol related health burden in Scotland as a reason.

I think the other one will be a long-standing interest at the Chief Medical Officer level in Scotland related to FAS or FASD. So, at the Chief Medical Officer level there have been concerns about that, which is translated into the need for the health service within the context of antenatal work to do more to ensure that women have accurate, up to date information and they are aware of what the potential consequences might be of drinking during pregnancy (HS2).

Whereas SG2 indicated that recent changes in antenatal care policy meant it was logical for ABI to be implemented at the time.

Also, KCND, which is Keeping Childbirth Natural and Dynamic, had a huge impact in the way antenatal services were delivered, making sure that rather than going to the GP, ensuring that pregnant women in the initial stages are directed to the midwife in the first instance. So, I think definitely that is a policy driver, more from I think how antenatal care is delivered which then has an impact on things such as ABIs being delivered in that setting. So, this is sort of the wider context (SG2).

This emphasis on KCND suggests that the midwives rather than GPs are better placed to deliver ABI to pregnant women. Previously, women had to attend their GP to confirm pregnancy before being referred to a midwife thus prolonging the time before the booking appointment¹. One of the aims of the KCND initiative was that midwives would be the first point of healthcare contact for women. It was anticipated that this would allow midwives to undertake the initial pregnancy risk assessment, including addressing the issue of alcohol use in pregnancy at an earlier stage.

HS1 said that, although the evidence base for implementation of ABI in antenatal care is not strong as compared to primary care and A&E, directives from clinical guidelines

1 The first appointment pregnant women have with midwives during which detailed assessment and medical history are recorded.

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have stressed the need for its implementation in the antenatal care setting.

Antenatal care, there is very little (evidence). There have only been a handful of controlled studies done, not just in the UK but across the world. So the evidence base is limited but it was in the SIGN guidelines as a recommended area for doing it in and recently it has been included in the NICE public health guidelines as a recommended area along with a host of other areas where the evidence base is limited. So, I think there's evidence for doing it in this settings out with primary care. Thus antenatal and A&E has generated more kind of plausible theory about this is an obvious area where alcohol misuse should be targeted and ABI as an evidence based intervention that works elsewhere, so the plausible theory is that the strength of its effectiveness elsewhere would transfer I suppose to antenatal settings to some degree to make a difference. (HS1).

The above extract implies that, whereas HS1 was convinced of ABI’s effectiveness in primary care, its use in the antenatal care setting, to some extent, was deemed to be based on theoretical assumptions but not on robust evidence.

The Scottish Government sets health targets for NHS Health Boards in Scotland. In the abstracts below, the national ABI policy lead (SG1) explained the essence of the HEAT targets and what was expected from Health Boards regarding ABI delivery:

The board as a whole had one number (of ABIs) that they had to deliver.

Whether they deliver all in primary care or all in antenatal, it was totally up to them as to how that split worked and how it was managed. Yes, you know, it may not be the best you know based on the quality outcome and things like that but what it did do was to raise the priority and raise the pressure within Boards to make sure that these services and professions got the focus they needed to actually embed this going forward (SG1).

Whereas targets may be performance indicators as highlighted by SG1 above, they also have the potential to compromise quality when practitioners are focussed on trying to reach set targets. For instance, since Health Boards are only obliged to report on the number of ABIs delivered, it is possible that less emphasis would be placed on other aspect of the ABI components. For example, putting in place appropriate mechanisms

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to measure outcomes on the number of women who reduced their alcohol intake or providing adequate follow up support.

Another important issue that participants acknowledged had facilitated the ABI policy initiative was the current media focus on issues of prenatal drinking.

I think slowly but surely, you are seeing much more communication in the media about alcohol exposed pregnancies, which you didn’t see before. Things like FAS is becoming much more commonly talked about among clinical and health staff and again women are aware of the impact of alcohol exposed pregnancies so I think these things all help cheer us on (HS1).

By the above assertion, HS1 believed that media input had helped in terms of publicity and relaxing the previous societal view of regarding alcohol intake in pregnancy as a taboo subject (Plant, 1997).

5.4.2 Training and support

It was noted that nearly all midwives, especially community midwives who provide antenatal care to women have been trained on screening and delivery of ABI in Scotland. All policy participants considered training of midwives as milestone for the ABI programme. Training and support had always been an important issue in ABI implementation in various settings (Johnson et al., 2010). ABI training has the potential to overcome practitioner barriers like inadequate knowledge and skills (Mengel et al., 2006). Overall, policy participants agreed that the ABI initiative had provided a pool of trainers with the aim of assisting midwives to improve their confidence and understanding of the ABI protocol; ensuring consistency of delivery; and that it provided them with materials to undertake the screening and referral process.

Participants highlighted that the training programme for the ABI implementation was initiated by NHS Health Scotland and the extracts below articulated what they felt to be

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its importance.

So certainly, the training programme for screening and ABI kind of trained midwives to improve on their (motivational) interviewing skills and to use screening tools appropriately; when you probe and when not to probe and kind of act on cues to have it in an non-invasive, informal conversation to glean information in that way. And obviously when we get to the ABI, we use the principles of FRAMES¹ as well and of course the other resources we produced.

We produced a specific professional pack for antenatal staff for ABI which is kind of a one stop shop which discusses the evidence base, the screening tools, it has got clip sheets in it, it has got prompt cards and that should help not just the staff but the women who receives the ABI because it can be used interactively in terms of rolling it out appropriately (HS1).

HS1 identified FRAMES as the protocol used in antenatal care. The use of a specific protocol could help midwives to follow specific framework in ABI delivery especially as it was found in the previous review (chapter three) that definitions and components of what constituted ABI varied between studies.

Interwoven with training is the issue of confidence. Policy participants felt that training of midwives was likely to promote confidence, ensuring that they were able to openly discuss alcohol issues with pregnant women. Improved confidence means with time midwives will spend less time in screening and delivering ABI, enhancing the integration of the programme into routine care. All policy participants shared this idea.

The extract below elucidates this.

So it (screening and ABI) should be able to be delivered within that 5-10 minutes window for consultation effectively. But that depends on the training and the confidence of the midwife or practitioner to deliver that. The higher the confidence the easier it fits into the conversation, possible the quicker. Certainly some anecdotal feedback is, the more you do, the quicker you get at it. Because you get more comfortable doing it so you don’t kind of necessarily follow it step by step (SG1).

1 One of the approaches for delivering ABI. The acronym FRAMES stands for Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy.

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This quote suggested that, whereas regular delivery may enhance the delivery procedure, delivering on ad-hoc basis could have the negative effect of reducing confidence and time efficiency.

To help midwives to identify the appropriate women for ABI, the ABI initiative introduced the use of screening tools. Policy participants reported that training also promoted the appropriate use of these tools. They revealed that TWEAK and T-ACE are the screening tools currently recommended and used in Scottish antenatal care settings, replacing the previous ‘yes’ or ‘no’ style of questioning women about alcohol consumption. Among prenatal population, these two screening tools are associated with high sensitivity and specificity (Russell et al., 1994). Policy participants were of the view that, as compared to the previous questions, these tools have the potential to produce robust and reliable data.

So where there have been benefit is the use of validated screening tool. So screening tool are obviously set up to kind of navigate the way round or counteract people trying to kind of, I suppose, people trying to underestimate or overestimate their alcohol consumption (HS1).

HS1 reported that in order to ensure that all who require an ABI are identified, screening in antenatal care setting has been extended to include pre-pregnancy risk drinking.

However, if she says prior to becoming pregnant she drank at levels that could be deemed hazardous or harmful, then there is an argument that you could do ABI based on pre-pregnancy drinking. Whether that goes against the ethos of what ABI should be – opportunistic based on current drinking is where the evidence base lies – is a different argument I suppose and I suppose may impact on effectiveness of the outcome you are looking at (HS1).

Although, the screening tools are only validated for prenatal drinking, it has been shown that pre-pregnancy drinking is a strong predictor of risk drinking during

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pregnancy (Russell et al., 1994; Chang et al., 2006). As a result, by screening for alcohol intake from these two perspectives ensures that there is a high probability of identifying women abusing alcohol and reduce the risk of losing pregnant women who may otherwise screen positive for ABI. In addition, finding out what women drank before pregnancy may offer midwives the context where they can slot-in alcohol advice independent of the client’s current non-drinking status.