Journal of Midwifery & Women’s Health
www.jmwh.org
Original Research
Screening and Brief Interventions for Alcohol and Other Drug Use Among Pregnant Women Attending Midwife Obstetric Units in Cape Town, South Africa: A Qualitative Study of the Views of Health Care Professionals Petal Petersen Williams, PhD, Zaino Petersen, PhD, Katherine Sorsdahl, PhD, Catherine Mathews, PhD, Katherine Everett-Murphy, PhD, Charles DH Parry, PhD
Introduction: Despite the negative consequences of alcohol and other drug use during pregnancy, few interventions for pregnant women are implemented, and little is known about their feasibility and acceptability in primary health care settings in South Africa. As part of the formative phase of screening, brief intervention, and referral to treatment for substance use among women presenting for antenatal care, the present study explored health care workers’ attitudes and perceptions about screening, brief intervention, and referral to treatment among this population. Methods: Forty-three health care providers at 2 public sector midwife obstetric units in Cape Town, South Africa, were interviewed using an openended, semistructured interview schedule designed to identify factors that hinder or support the implementation of screening, brief intervention, and referral to treatment for substance use in these settings. Transcribed interviews were analyzed using the framework approach. Results: Health care providers agreed that there is a substantial need for screening, brief intervention, and referral to treatment for substance use among pregnant women and believe such services potentially could be integrated into routine care. Several women-, staff-, and clinic-level barriers were identified that could hinder the successful implementation in antenatal services. These barriers included the nondisclosure of alcohol and other drug use, the intervention being considered as an add-on service or additional work, negative staff attitudes toward implementation of an intervention, poor staff communication styles such as berating women for their behavior, lack of interest from staff, time constraints, staff shortages, overburdened workloads, and language barriers. Discussion: The utility of screening, brief intervention, and referral to treatment for addressing substance use among pregnant women in public health midwife obstetric units was supported, but consideration will need to be given to addressing a variety of barriers that have been identified. c 2015 by the American College of Nurse-Midwives. J Midwifery Womens Health 2015;00:1–9 Keywords: alcohol and other drug use, health care providers, pregnant women, SBIRT
Address correspondence to Petal Petersen Williams, PhD, Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa. E-mail:
[email protected]
regarding the potential impact of these 3 substances on pregnancy outcomes, highlighting the importance of identifying effective strategies for identification of and interventions for pregnant women using substances in the Western Cape. One effective strategy for preventing the negative outcomes associated with alcohol and other drug use is screening women for risky patterns of substance use, providing at-risk women with a brief intervention to reduce risks, and referring those who need more extensive treatment to specialty treatment.5–9 Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. The majority of studies that have investigated SBIRT in antenatal care have been conducted in high-income countries, and there has been little research on whether SBIRT can be successfully implemented in low- and middle-income countries such as South Africa. One exception is a quasi-experimental study by Everett-Murphy et al10 that evaluated the impact of a brief smoking cessation intervention integrated into routine care for pregnant women in Cape Town. This intervention was based on the 5As (ask, advise, assess, assist, arrange) best practice clinical guideline for smoking cessation among pregnant women11 and was found to significantly improve cotinine-validated quit rates
1526-9523/09/$36.00 doi:10.1111/jmwh.12328
c 2015 by the American College of Nurse-Midwives
INTRODUCTION
Alcohol and other drug use has been found to be highly prevalent among pregnant women attending antenatal services in the Western Cape Province of South Africa, with one study reporting a biologically verified drug prevalence of 8.8% (3.6% self-reported) and a biologically verified alcohol prevalence of 19.6% (36.9% self-reported),1 potentially resulting in a variety of negative consequences for both maternal and child health. The most severe risk of alcohol use during pregnancy is the fetal alcohol spectrum disorders (FASDs). Rates of FASDs in the Western Cape are among the highest reported in the world, where the overall rate of FASDs among first-grade children in a wine-growing region in the Western Cape was 135.1 to 207.5 per 1000 children (13.6% to 20.9%),2 whereas methamphetamine use in particular is increasing among women of childbearing age.3 Furthermore, among one subgroup of disadvantaged pregnant women in the province, tobacco rates are as high as 46%.4 There is growing concern
1
✦ Health care providers agree that there is a great need for screening, brief intervention, and referral to treatment (SBIRT) for substance use among the pregnant women they care for. ✦ There is a lack of a formal protocol in dealing with alcohol and other drug use and related risks within antenatal facilities in the Cape Metropole. ✦ Women-, staff-, and facility-level barriers exist, and careful consideration needs to be given to these barriers prior to implementing SBIRT services to address substance use among pregnant women attending antenatal services in public health care facilities in South Africa. and reduce smoking. The guideline recommends that a 10- to 15-minute counseling session by a trained provider and the provision of pregnancy-specific, self-help education materials become a standard component of routine antenatal care. The guideline also outlines the 5As approach in which the health care provider should ask about risk behavior; advise to change behavior; assess willingness to change behavior; assist to attempt to change behavior; and arrange follow up. The intervention was well accepted by clinic staff and women regarded the provision of social support from peer counselors as very helpful.10 Although the brief 5As intervention was originally developed for smoking cessation, it has since been recommended as a general approach to engaging women in the self-management practices needed to change health-risk behaviors.12,13 In order to ensure sustainability of SBIRT in low- and middle-income countries, it is important that task shifting occurs so that nonsubstance use specialists such as peer or lay counselors, nurses, and midwives can play a role in implementing services. Understanding and addressing the attitudes of the health care professionals responsible for the implementation of programs is crucial for the delivery and uptake of services.14 Evidence shows that the views of the medical staff toward SBIRT affect the success of its implementation.15–19 However, little is known about the opinions of South African health care professionals in terms of implementing brief interventions in midwife obstetric units. The aim of the present study is to investigate the health care providers’ perceptions of the acceptability and feasibility of providing SBIRT to address substance use among pregnant women attending antenatal care in South Africa. METHODS Study Setting
We conducted qualitative interviews with midwife obstetric units’ personnel to identify barriers and facilitators to the implementation of SBIRT. In an attempt to redress social and economic injustices, the South African government has implemented a district health system based on a primary health care approach. In the Western Cape area around Cape Town, a system of midwife obstetric units has made obstetric services geographically accessible.20 These units provide outpatient primary obstetric care to women within defined areas and refer those who have high-risk pregnancies to secondary or tertiary hospitals according to defined protocols. They are birthing units run by midwives in the community for 2
women with primary health care needs. Physicians visit these facilities once a week. Postnatal care also takes place at these clinics. There are 11 midwife obstetric units in greater Cape Town that fall under the Western Cape Department of Health. All are found in areas that were classified as black African or colored under the apartheid regime. Given their location, the clientele visiting these clinics are mainly from these ethnic backgrounds. The terms white, black, and colored refer to demographic markers and do not signify inherent characteristics. They refer to people of European, African, or mixed (African, European, and/or Asian) ancestry, respectively. The continued use of these terms in South Africa is important for monitoring improvements in health and socioeconomic disparities, identifying vulnerable sections of the population, and planning effective prevention and intervention programs. Furthermore, the midwife obstetric units can be considered as serving previously disadvantaged communities, and the majority of women accessing these services continue to be disadvantaged. Two midwife obstetric units located within public health clinics offering free primary health care to large urban township communities were purposively selected by the Western Cape Department of Health as research sites.
Theoretical Framework
We used the consolidated framework for implementation research21 as the theoretical framework for this study. The consolidated framework for implementation research identifies 5 domains, each made up of several constructs that affect the implementation of evidence-based practices into routine care. These 5 domains include: 1) characteristics of the intervention such as strength of evidence for the intervention; 2) the outer setting, which refers to the economic, political, and social context of the facility or service; 3) the inner setting, which refers to the structural, political, and cultural contexts of the facility or service; 4) characteristics of individuals providing the intervention, for example, individuals’ attitudes toward and value placed on addressing substance use by the medical personnel; and 5) the process of implementation, for example, support needed to deliver services.21 An open-ended, semistructured interview schedule guided the interviews (Supporting Information: Appendix S1). Specific open-ended questions relating to each of the 5 consolidated framework for implementation research domains are summarized in Table 1. Volume 00, No. 00, March 2015
Table 1. Description of Questions and Related Consolidated Framework for Implementation Research Domains
Characteristics of the
Participants’ knowledge and beliefs about a possible intervention and their perception of the extent of
intervention
AOD use among pregnant women, as well as the issue of self-efficacy and their beliefs about their capabilities to execute an intervention aimed at pregnant women using AOD was explored.
Outer setting
The construct dealing with women’s needs and resources was explored with questions that specifically asked about barriers and facilitators to implementation of an intervention to meet these needs.
Inner setting
Questions relating to the organizational culture, structural characteristics, networks and communication mechanisms, and implementation climate were explored in order to understand the organizational setting in which interventions are likely to take place.
Characteristics of individuals
Participants’ perceptions of the quality and strength of an intervention aimed at women using AOD, their perception of the relative advantage of implementation, perception of the complexity or difficulty of implementation, and perception of how well the proposed intervention is put together, packaged, and presented was explored.
Process
Participants were asked about the support they thought would be needed for the successful implementation of the intervention dealing with the construct of reflecting and evaluating where the importance of dedicating time for providing feedback and debriefing is thought to be relevant for implementation activities.
Abbreviation: AOD, alcohol and other drug.
Participants
Table 2. Demographic Characteristics of Staff
We invited all nursing and counseling staff working at the 2 midwife obstetric units, and those who would potentially be involved in or affected by the implementation of an intervention, to participate in the research.
Variable
Procedures
Ethical approval for this study was granted by the University of Cape Town’s Research Ethics Committee in the Health Sciences Faculty. Interviews were conducted by the first author (p.p.w.), with a second interviewer acting as a moderator or an observer for some of the interviews. Prior to the interviews, participants were asked to provide informed consent. Interviews were conducted at the clinic in a secure and private room. All interviews were conducted within a space of 2 months from August to September 2011. Interviews lasted from 40 minutes to an hour and were conducted in English, but Afrikaans-speaking participants were allowed to express themselves in their native language, a language understood and spoken by the principal investigator. All interviews were audio-recorded. Data Analysis
Interviews were transcribed verbatim. The interviews were qualitatively analyzed using the framework approach (ie, familiarization, identifying a thematic framework, indexing, charting, mapping, and interpretation).22 Although this approach reflects the actual accounts of the participants, it starts deductively with the aims of the project and the known requirements for the successful implementation of an intervention.23 The 2 researchers involved in the analysis of the data did so independently and then came to an agreement on the coding list. The analysis was concluded when they reached an agreement on the interpretation of the data. Journal of Midwifery & Women’s Health r www.jmwh.org
Participant Age, mean, (SD), y
Characteristics (N = ) 41.9 (9.3)
Job description, n (%) Nurse
12 (27.9)
Midwife
18 (41.9)
Health promoter
2 (4.7)
HIV counselor
8 (18.6)
Mental health nurse
1 (2.3)
Midwife obstetric unit manager
2 (4.7)
Race,
a%
Black African
19
Colored
74
White Years experience in profession,
7 13.6 (10.8)
mean (SD) Abbreviation: SD, standard deviation. a The terms white, black, and colored refer to demographic markers and do not signify inherent characteristics. They refer to people of European, African, or mixed (African, European, and/or Asian) ancestry, respectively. The continued use of these terms in South Africa is important for monitoring improvements in health and socioeconomic disparities, identifying vulnerable sections of the population, and planning effective prevention and intervention programs.
RESULTS
A total of 43 female health care providers consented and were interviewed. Table 2 outlines the demographic characteristics of the providers interviewed. During analysis, the saturation of themes was met after the 20th participant. Therefore, the data described here is based on the accounts of these participants, although the remaining interviews were read to ensure that saturation had been reached. The main findings 3
are presented by highlighting the constructs within the consolidated framework for implementation research that were emphasized by participants as the crucial elements influencing implementation. These are: 1) perceived severity of alcohol and other drug use in the community among pregnant women; 2) health care providers’ knowledge about the effects of alcohol and other drug use and reasons for use; 3) midwife obstetric units’ current response to alcohol and other drug use; and 4) barriers and facilitators to implementation. Perceived Severity of Alcohol and Other Drug Use in the Community Among Pregnant Women
The majority of participants described the outer setting as conducive to drug abuse, whereas substance use in the community is seen as being both commonplace and widespread and alcohol and other drugs are easily accessible. Not only were tobacco and alcohol use described as a regular part of growing up in these disadvantaged townships, but illicit drugs such as methamphetamine are similarly becoming a part of everyday life, and there seems to be little shame or stigma associated with having a newborn addicted to methamphetamine:
I was quite shocked asking her, “Are you still tikking? [using methamphetamine] seeing that you were pregnant before and you were on tik [methamphetamine]?” Her response was, “Yes, I have a tik [methamphetamine] baby [previous pregnancy], I just need to get the baby tested and everything like that. I’m still tikking [using methamphetamine], I will never stop.” Health Care Providers’ Knowledge About the Effects of and Reasons for Alcohol and Other Drug Use
Most participants were very confident that they have sufficient knowledge to identify alcohol and other drug use in the women to whom they provide services, suggesting a favorable inner setting. They were also able to discuss a range of consequences for the fetus and reproductive health. Additionally, coupled with their view that they are able to identify the signs of alcohol and other drug use, such as certain physical characteristics (namely poor dentition) or unusual behavior during antenatal visits and during labor or birth, participants also reported being aware of what is happening in the outer setting and of the social dilemmas that women face daily and how this relates to substance abuse. Participants thus felt that they could empathize with the needs of their clients:
I’ve seen it a few times . . . you will see mommies getting pregnant and then you know they didn’t plan it, and that will cause them to become depressed and develop anxiety because they can’t afford it in the first place. Some of them have been raped, that you can also see, that’s also increasing now. I’ve had 2 cases where mommies actually started to use substances like tik [methamphetamine] and dagga [cannabis] . . . because they wanted to get rid of the baby. 4
Midwife Obstetric Units’ Current Response to Alcohol and Other Drug Use
This finding relates to the inner-setting domain of the consolidated framework for implementation research. Despite the need to address alcohol and other drug use among pregnant women, there currently does not appear to be a formal protocol to address the issue in the midwife obstetric unit. Conflicting pathways of care were described highlighting the structural organization of the midwife obstetric unit and the communication networks that require some adaptation prior to the implementation of an intervention. Referral to mental health care within the community health care center in which the midwife obstetric unit is located also occurs. According to the respondents’ descriptions of what is done when women report alcohol and other drug use, the current response in the midwife obstetric unit to pregnant women who use alcohol and other drugs consists of a variety of actions. These include providing support, motivation, education, health advice, information, and awareness. However, some reported that currently nothing gets done and no programs are in place. Importantly, what emerged from 2 respondents was a fear of interfering too much in women’s personal problems or delving too deep into substance use problems if one does not know how to handle the information. A directive style of counseling was also referred to by 4 participants who were specifically critical of this approach in which the staff tells people that they must quit or change their behavior, as opposed to motivating them for change: Some of them are very harsh to patients. . . . “You are smoking! And you know you mustn’t do this!” And some of us will tell the patient that, “You know it’s wrong, you mustn’t do that.” All participants reported not having received any formal training on alcohol and other drug use, and most expressed a strong desire to learn more about effective ways of responding to the problem. They felt that their knowledge on alcohol and other drug use in pregnancy was inadequate, considering the extent of the problem among pregnant women: I don’t think it (knowledge of alcohol and other drug use and how to respond) is adequate because sometimes I ask myself, “What do I say now?”. . . sometimes you realize you don’t even understand yourself, so how are these people going to understand me? The participants, therefore, perceived themselves as not being capable of fully supporting women who needed help in this regard. Participants felt there was a need to receive training and that everyone in the midwife obstetric unit should be trained in order to strengthen the organization of the clinic to better respond to the problem: I think it’s better if everyone gets trained so then you don’t have to run around if you have a problem. Sometimes when it’s so busy I think, “It is so busy that I need the sister [who is more qualified than a nurse] now because I can’t deal with this problem,” then I tell myself, “Why didn’t you study further?” Volume 00, No. 00, March 2015
All of the participants agreed that there is a great need to address alcohol and other drug use in pregnancy by means of interventions and training for health care personnel to deliver such interventions. Although it was acknowledged that some women would require specialized services, many could receive interventions by the health care providers already working in the midwife obstetric units. Ongoing support for pregnant women through education and reading materials, continued care, follow-up, and support groups are thought to be necessary, and it is considered feasible to provide such interventions in antenatal services. A few participants also emphasized that careful attention should be paid to how alcohol and other drug use by women is dealt with in the clinic and the strategies most likely to lead to ongoing behavior change. One respondent said, “I think there is a need to provide interventions, but I think it’s how we are going to address it because it’s difficult if you [are] just in here and there’s no follow up afterwards.” Barriers and Facilitating Factors to Implementation
Health care providers identified several women-, staff-, and facility-level barriers that would need to be addressed prior to the implementation of a screening and brief intervention in these facilities. In addition to identifying barriers, participants similarly discussed factors that they believed would help or enable implementation of intervention activities. Table 3 outlines these barriers and potential solutions, which relate to characteristics of individuals (particularly individual stage of change and other attributes), the inner setting and implementation climate, and readiness for implementation to occur, as well as process issues such as the execution of activities.
Table 3. Identified Barriers and Potential Solutions
Identified Barrier Women’s lack of honesty about alcohol and other
Potential Solution Staff to alter their communication style and build better rapport
drug use Women regarding the intervention as an add-on service
Integrate the intervention into routine care. Advertise intervention services on posters in the facility.
Negative staff attitude
Staff to alter communication style
toward substance-using
and adopt nonjudgemental
pregnant women using
attitude
substances Relief staff not grasping
Appoint a dedicated person to
the importance of the
address substance use in
intervention when staff
pregnant women seen at the
rotate or go on leave
facility. Provide ongoing training and adequate support, guidance, and mentoring.
Staff regarding the intervention as additional work
Integrate the intervention into routine care and include all staff. Appoint a dedicated person to address substance use in pregnant women seen at the facility. Provide clear guidelines on the
Barriers Related to Pregnant Women
procedures to follow and clear
The main women-level barrier that was articulated by providers related to women’s lack of honesty and not being open with midwife obstetric unit staff about their alcohol and other drug use, making it difficult to gain information and offer appropriate women-specific assistance. Another concern expressed by many was the fact that women may regard the intervention as another add-on to services that will require them to stay in the clinic even longer than they already do, which causes frustration:
referral pathways for pregnant
[B]ecause of the visit being time consuming, they get tired of sitting and waiting, and they will say: “So now you are going to take a little bit longer to talk to me.” [T]hen we tell them, “But you are not done yet, after me you have to take your folder, you have to go around the corner, you are still going to be examined.” Barriers Related to Staff
Many participants suggested that the health care providers within the facility would need to alter their attitude toward women who are using alcohol and other drugs if they were to help them. Although they were not directly critical of their colleagues, some believed that health care providers who take a directive style of counseling (ie, berating the women for their behavior) would need to alter their communication style. Journal of Midwifery & Women’s Health r www.jmwh.org
women using substances. Limited space, overcrowded facilities
Provision of additional space in the facility to implement intervention activities
They felt that the women’s response to the intervention would depend on the approach adopted by the staff and that pregnant women would only disclose their use of alcohol and other drugs if the staff have an attitude that is nonjudgemental and if there is better rapport between the women and caregivers. One respondent shared, “[T]he thing is the mothers are lying because they know if they tell the sisters they are using tik [methamphatemine] then the sisters are going to scold them.” Importantly, concern was raised by few health care providers over the fact that staff rotate or go on leave and that relief staff might not grasp the importance of the intervention. More than half of the respondents also thought that staff would see the intervention as simply adding more work (including more paperwork) to their already busy schedules. Participants were concerned about the current workload of staff in general and the capacity to do more. However, if these 5
problems are overcome, staff may be more excited about the intervention: Staff are very overburdened, and we always have a shortage of staff. Any new thing makes them a bit reluctant, not because they don’t want to do it, but because they’re thinking “Will I have time to do this?” . . . but I think once it is implemented they will also get excited because I think it will make a difference. Barriers Related to the Facility
A few participants felt that language barriers will pose a threat to the success of implementation. The majority of women seen at the midwife obstetric units speak Afrikaans, English, and/or Xhosa. Staff who are employed in the facilities speak either English and Afrikaans or English and Xhosa, and often staff members need to ask for assistance if they cannot speak the native language of the women. Additionally, these facilities are increasingly seeing more and more foreign women with little or no understanding of the local languages. Participants discussed several ideas for what an intervention to address alcohol and other drug use among pregnant women should include. Importantly, the majority of staff felt that any intervention offered should include all staff in the clinic and that the intervention should be integrated into routine service provision: Because sometimes a patient is not going to tell me she is using drugs but maybe she is going to tell the health promoter or maybe the sister, and that’s why everyone must be involved. Maybe the reason for not telling me is because they trust another staff member more. Despite the belief held by many that all staff should be trained and services integrated into routine care, it was suggested that a dedicated person or champion should also be appointed to address alcohol and other drug use in the clinic, or alternatively, hiring another health promoter or social worker or someone dedicated to a substance use intervention program for pregnant women: I think they do need it [training to deal with alcohol and other drug use], but I just think that we won’t be able to do it. I would love to do this but then that must be my post, that is what I should get paid for . . . so I think there’s a very big need but as midwives we don’t have time. Facilitating Factors
Various support systems were described as necessary in order for staff to implement the intervention and for it to be a success. The majority of participants felt that ongoing training, adequate support, guidance, and mentoring were all essential. They felt that additional staff would help, as well as having additional space made available in the clinic to implement intervention activities. They thought that the intervention services should be advertised by posters in the facility and that they needed adequate materials and resources to give to pregnant women who needed them. Finally, clear guidelines on procedures to follow and clear referral pathways were seen as paramount to the success of the intervention. 6
DISCUSSION
Whereas several studies have examined health care providers’ perceptions and views regarding the feasibility (and possible barriers) to implementing SBIRT integrated into health care services in South Africa,24,25 this study is among the first to explore the views of health care professionals working in antenatal service delivery regarding SBIRT to address alcohol and other drug use. Additionally, this study made use of the consolidated framework for implementation research, which is an overarching theory and includes important constructs from several implementation theories. First, health care providers are in agreement that there is a great need for SBIRT to address substance use among pregnant women in their clinics given its high frequency of use and normalization (particularly with regard to tobacco and alcohol use). This is concerning given the implications of substance use on the fetus and maternal health outcomes, and it highlights the urgent need to address substance use during pregnancy. Secondly, study findings suggest that there is a lack of a formal protocol to assist them in dealing with alcohol and other drug use and related risks within the midwife obstetric unit setting. Conflicting pathways of care were described or understood by different staff members as the expected response to learning about a women’s alcohol and other drug use. Not understanding how to respond, who to refer to, or responding to a woman’s use in an inappropriate manner is unlikely to result in adequately addressing alcohol and other drug use among these women. These findings are consistent with a previous local study investigating these issues in which it was found that 75% of the professional and enrolled nurses participating in an evaluation of alcohol screening and brief intervention in primary health care services in a district of South Africa reported that they did not know how to handle and help patients with alcohol-related problems.24 However, these concerns can be addressed with intensive training using an evidence-based, patient-centered approach and through obtaining buy-in from all health care providers, irrespective of whether they are at the forefront of delivering the intervention. Third, participants identified certain barriers that need to be considered when implementing SBIRT for substance use in the midwife obstetric unit. To begin with, nondisclosure and length of time waiting for services were reported as potential women-level barriers to implementation. Many felt that women are not always honest when asked about their use of substances, and it was thought that nondisclosure could act as a barrier to implementation and make it difficult for staff to provide essential services to those most in need of them. High levels of underreporting of substance use by this population have been reported locally.1 In order for women to feel comfortable disclosing alcohol and other drug use, some participants noted that this may depend on the approach and communication style of the staff and that pregnant women would only disclose their use of alcohol and other drugs if the staff have a more supportive attitude, better rapport, and are nonjudgmental. Staff attitudes may also influence the degree to which health care providers implement the intervention and adequately screen pregnant women. Studies have shown that the health care professionals’ attitudes influence self-reported Volume 00, No. 00, March 2015
practices. A study conducted among 96 primary care professionals from 5 health centers in S˜ao Paulo, Brazil, explored the association between these professionals’ attitudes about people with unhealthy alcohol and other drug use and their readiness to implement clinical prevention practices. This study suggested that more stigmatizing attitudes were associated with lower readiness to implement unhealthy substancerelated preventive care.26 However, the current study did not specifically measure how staff attitudes impact the extent of the implementation of screening and brief intervention for substance use. Participants emphasized that a stigmatizing attitude impacts the quality of an intervention because it impedes disclosure by pregnant women of their alcohol and/or drug use. Addressing staff attitudes prior to implementation of an intervention is therefore crucial to successful implementation in the health care setting. The long hours that women spend in the clinics were also discussed, and some thought that this would deter women from participating in the program because they may view the intervention as another addon service, which will require more of their time. However, this barrier should be overcome by the fact that the proposed 5As intervention will be integrated into routine service delivery, and all health care providers who were interviewed felt that this could be successfully achieved. Additionally, a number of staff-level barriers were raised, including who would be the ideal interventionist, lack of training, and attitudes toward integration of care. Health care providers felt strongly that everyone should be involved and receive training on an intervention program or take some responsibility for dealing with substance use and related risks in pregnancy. Despite recognition of the importance or need for screening for substance use, as was the case in the present study, lack of training and systems that could facilitate an intervention have shown to be a barrier in other studies as well.27 Research has demonstrated that one of the factors influencing the implementation of SBIRT in routine primary care practices is the percentage of staff trained in SBIRT, with better outcomes for facilities with all staff trained.24 It is therefore essential that staff are adequately trained throughout the health care facility if SBIRT is to be successfully implemented because it has been shown that the implementation of screening and brief interventions generally increases with increased training and/or support provided.28 By training all staff, the responsibility of addressing alcohol and other drug use is shared among more staff members and in doing so minimizes the burden on a few individuals. It also means that women will receive the same standard of care and treatment, regardless of which staff members they interact with. However, previous research has demonstrated the positive impact on implementation activities when peer counselors were used for screening and brief intervention and the intervention did not add to the existing workload of clinic staff.25 A further staff-level barrier included staff attitudes about having to be involved in the intervention because it may be seen as additional work. Concern was raised about the current workloads, and it was felt that the intervention would increase the already heavy workloads. Careful consideration will thus need to be given to current staff tasks, and the impact that implementing an intervention to address alcohol and other drug Journal of Midwifery & Women’s Health r www.jmwh.org
use would have on current activities and whether staff have the capacity to intervene with women using alcohol and other drugs. A Swedish study conducted among 65 general practitioners and 141 nurses in 19 primary health care centers found that the overall attitude toward the role of primary care staff in screening and an intervention was fairly positive and that barriers to implementing screening and intervention was more related to insufficient practical skills.29 The current study also highlighted lack of skills or knowledge as another barrier to implementation given that staff mostly have not received any sort of formal training on how to respond to alcohol and other drug-use disclosure by women. A general cry for support was evident in their expression of the need for everyone in the midwife obstetric unit to receive training and take some responsibility for dealing with alcohol and other drug use. This is a finding common in other settings where factors related to a perceived lack of knowledge act as a barrier to the adoption of brief interventions, and requests for further training by health care workers are widespread.15 Research done in emergency departments in Cape Town also found peer counselors implementing screening and brief intervention, identifying the need for additional training and support.25 A systematic review found that among 26 studies (6 in the United Kingdom, 4 in Australia, 4 in Sweden, 2 in the United States, and the remaining 10 studies in other countries) using the 5As behavioral counseling framework, health professionals may not use the 5As for reasons including: a lack of confidence, knowledge about (alcohol) use and related risk factors, time, and/or training—and/or uncertainty about if and how they should raise the topic with their patients.30 The current study, therefore, identified barriers common in international settings that emphasize training (which in turn addresses confidence and knowledge) and lack of time (which is very often the primary reason for concerns regarding workload). A number of facility-level barriers were also discussed such as staff shortages and space to deliver interventions. Particularly, participants were concerned about the limited human resources and staff shortages in the clinic. This was similar to other study findings in which SBIRT was incorporated into routine care.19 The lack of time staff have to take on additional responsibilities was also considered to be a major barrier, as mentioned above. Respondents noted that employing an additional staff member dedicated to providing SBIRT for substance use should be considered for such a program to be implemented successfully. Lack of space in the facilities and the difficulties associated with finding a private space to deliver brief interventions on substance use and to discuss other sensitive and confidential information with women was seen as a barrier. The barriers associated with working in overcrowded facilities are common in the South African context, where there is limited space and high numbers of women, and finding private space to deliver brief interventions in a confidential manner remains an ongoing challenge.25 Thought will have to be given to these practical challenges in the clinics prior to the widespread roll-out of intervention services for pregnant women using substances. Despite these barriers, participants generally felt positive and displayed a supportive attitude toward the possible 7
implementation of an intervention. Although health care providers, including lay counselors, have supportive attitudes, some research shows that lay workers do not necessarily have the required skill to implement such interventions.31 However, others show that lay health workers can successfully implement interventions with sufficient training and supervision.32 The study findings are subject to the following limitations. The sample was limited to include antenatal staff at only 2 midwife obstetric units across the Cape Metropole, and the findings therefore do not necessarily represent the views of health care personnel more broadly. Secondly, participants were aware that the proposed 5As intervention was being implemented and supported by the Western Cape Department of Health, which could have resulted in responses that may not reflect the actual practice or opinions and resulted in the overreporting of opinions perceived as socially desirable. The potential for this was reduced by interviewers emphasizing their role as independent researchers who were not employed by the department of health. CONCLUSION
The findings of this study suggest that, although attitudes and feelings toward the implementation of SBIRT for substance use in pregnant women were generally positive, a number of barriers were identified and should be considered prior to implementation of widespread SBIRT in antenatal services. Several recommendations regarding screening and interventions have been made internationally. In 2013, in an update of the United States Preventive Services Task Force recommendation statement on screening and behavioral counseling interventions for the general population in primary care to reduce alcohol misuse, it was recommended that all adults aged 18 years and older be screened for alcohol misuse and those engaged in risky or hazardous drinking be provided with brief interventions.33 Similarly, among women specifically, the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice recommends routine assessments (or screening) in primary and preventive care.34 More recently, the World Health Organization developed and published guidelines for the identification and management of substance use and substance use disorders in pregnancy.35 These guidelines focus on 6 areas, the first of which is screening and brief intervention, highlighting the importance of identifying and managing substance use during pregnancy. It is recommended in these guidelines that health care providers ask all pregnant women about their use of alcohol and other substances (past and present) as early as possible in the pregnancy and at every prenatal visit and that health care providers offer a brief intervention to all pregnant women using alcohol or drugs. Given these recommendations, future research should investigate solutions to the barriers highlighted in this study and elsewhere and one way to do this would be to ask women who receive services at the midwife obstetric units for their opinions. Our findings provide insight into those contextual, staff-level, women-level, and facility-level factors that could pose a threat to the successful implementation of a much-needed service as well as important facilitating factors to enable the implementation of intervention activities. 8
AUTHORS
Petal Petersen Williams, PhD, is a Senior Scientist in the Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council. Zaino Petersen, PhD, is a Senior Scientist in the Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council. Katherine Sorsdahl, PhD, is a Senior Lecturer at the Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry, University of Cape Town, South Africa. Catherine Mathews, PhD, is the Director in the Health Systems Research Unit, South African Medical Research Council; and Honorary Associate Professor in the Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa. Katherine Everett-Murphy, PhD, is a Senior Scientist in the Chronic Disease Initiative for Africa, Department of Medicine, University of the Cape Town, South Africa. Charles Parry, PhD, is Director of the Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council; and Extraordinary Professor, Department of Psychiatry, University of Stellenbosch. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. ACKNOWLEDGMENTS
The authors would like to acknowledge the assistance of Ms. Bulelwa Mtukushe for her assistance as cointerviewer for some of the interviews. SUPPORTING INFORMATION
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