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Table 2 Findings organised by PRISM domains

From: The conversation matters: a qualitative study exploring the implementation of alcohol screening and brief interventions in antenatal care in Scotland

Health board area

PRISM domain

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

  1. A&E Accident and Emergency, SBI Screening and Brief Intervention, ALN Alcohol Liaison Nurse, CAGE Cut down, Annoyed, Guilt, Eye-opener, GIRFEC Getting It Right for Every Child, SWHMR Scottish Women’s Handheld Maternity Record, TWEAK Tolerance, Worried, Eye-opener, Amnesia, Cut down
  2. a Performance ranking refers to the ranking at the time of the interview; high = above median of overall SBIs delivered in antenatal care, low = below the median