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 |