Preconception interventions to reduce the risk of alcohol-exposed pregnancies: A systematic review.

BACKGROUND: The preconception period provides a unique opportunity to optimize the health of women and children. High rates of alcohol use and unintended pregnancies are common across many Western societies, and alcohol-exposed pregnancies (AEPs) are a possible unintended outcome. The aim of the current study was to evaluate preconception interventions for the prevention of AEPs. METHODS: A systematic search of four electronic databases (PubMed, Embase, CINAHL, and PsycINFO) was undertaken for relevant peer-reviewed articles published from 1970 onward. Studies were included if they enrolled women and/or their support networks during the preconception period. RESULTS: Nineteen studies met the inclusion criteria. The majority of studies (n = 14) evaluated CHOICES-based interventions, which incorporate motivational interviewing approaches to change alcohol and/or contraceptive behavior. The other five interventions included a range of different approaches and modes of delivery. The majority of interventions were successful in reducing AEP risk. Changes in AEP risk were more often driven by changes in contraceptive behavior, although some approaches led to changes in both alcohol and contraceptive behavior. CONCLUSIONS: The review indicated that many interventions were efficacious at reducing AEP risk during the preconception period through preventing unplanned pregnancy. The effectiveness estimated from these clinical trials may be greater than that seen in interventions when implemented in practice where there is a lack of blinding and greater attrition of participants during follow-up. Further research investigating the real-world effectiveness of these intervention approaches implemented across a wide range of clinical settings would be beneficial.

Acceptability of an eHealth Intervention to Prevent Alcohol-Exposed Pregnancy Among American Indian/Alaska Native Teens.

BACKGROUND: A tribally led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) Program has successfully decreased the risk of alcohol-exposed pregnancies (AEPs) among adult American Indian/Alaska Native (AI/AN) women by either reducing risky drinking or increasing contraception use. However, a community needs assessment revealed a need to implement a similar intervention with AI/AN teens. The goal of the project was to develop and establish the acceptability of CHOICES for AI/AN teens. METHODS: Key informant interviews were conducted to review the existing OST CHOICES intervention. After modifications to the existing program, focus groups with AI/AN teens were conducted to ensure validity and to finalize the OST CHAT (CHOICES for American Indian Teens) intervention. RESULTS: Key informant (N = 15) participants suggested that a Web-based intervention may increase teen engagement by making the intervention more interactive and visually stimulating. Based on this formative research, CHAT was developed via Research Electronic Data Capture (REDCap). Feedback on the online CHAT curriculum was given by focus groups comprised of AI/AN adolescents, and participants felt that this type of intervention would be both acceptable and able to implement with a community of reservation-based teens. CONCLUSIONS: This study outlines the development of a Web-based intervention for an AEP intervention for AI/AN teens and will inform future prevention efforts. Implications include an expansion of the evidence-based CHOICES intervention for AI/AN teens and also development of a Web-based intervention for rural, reservation-based AI/AN communities.

"But Problems Dwell so the Urge Is Constant " Qualitative Data Analysis of the OST CHOICES Program.

BACKGROUND: Fetal alcohol spectrum disorders are a major public health concern including among American Indian (AI)/Alaska Native (AN) communities. Various studies have demonstrated higher alcohol consumption among AI/AN women during pregnancy compared with other groups. This study intends to understand the milieu within which such consumption patterns flourish. The study utilizes qualitative and quantitative data from the Oglala Sioux Tribe (OST) CHOICES Program, a tribally run public health program that aims to reduce alcohol-exposed pregnancy preconceptually in AI women. METHODS: Alcohol consumption pattern (n = 264) is analyzed using descriptive statistics. Consumption patterns included average drinks consumed daily, their choice of drinks (beer, whiskey, wine, etc.), how much money participants were spending on alcohol and amount of calories consumed from alcohol. Qualitative data analysis included open coding of data from decisional balance exercise of the CHOICES program that looked at good things and not so good things about participants' drinking. RESULTS: Women reported drinking an average of 12 drinks daily, ranging between 1 and 86. Women drinking at home spent a median of $4,320 and $12,960 if drinking at a bar. A median of 1,200 calories per day from alcohol was reported. More women reported drinking beer compared with other types of alcohol within a domestic setting. Qualitative data analysis identified positive and negative aspects of drinking among the participants of OST CHOICES Program. Positive aspects included escaping from problems, socializing, and relaxation. Negative aspects included impact on families and domestic violence. CONCLUSIONS: While understanding their milieu, our study also unraveled different struggles (such as violence, peer pressure, financial burden, and depression) encountered by Native women in their daily lives. According to the participants, positive aspects of drinking outweigh the negative aspects and they viewed their drinking as a solution and not a problem.

Reach, Acceptability, and Sustainability of the Native Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) Intervention: A Qualitative Evaluation of an Alcohol-Exposed Pregnancy Prevention Program.

American Indian (AI) women are at risk of alcohol-exposed pregnancy (AEP) due to the higher prevalence of alcohol use disorders (AUDs) and risky drinking. The Native Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (Native CHOICES) was implemented in partnership with a Northern Plains Tribal community to address the effectiveness of a brief, motivational interviewing-based intervention to reduce AEP risk among adult AI women. A subgroup of the participants shared their perspectives in a qualitative interview conducted following the completion of the six-month post-baseline data collection. These interviews solicited participant perspectives on the Native CHOICES intervention and its satisfaction, reach, acceptability, and sustainability. The participants were delighted with Native CHOICES, felt the intervention helped them learn about AEP prevention and goal setting, learned valuable lessons, and believed Native CHOICES would be well-received by other women in their community and should be continued. The participants also shared how the COVID-19 pandemic affected their choices about drinking and birth control. The findings showed the receptivity to and acceptance of Native CHOICES among AI women. The interview findings offered a glimpse into the effectiveness of Native CHOICES and how it contributed to participants making healthier choices surrounding drinking and sexual health.

A culturally tailored intervention to reduce risk of alcohol-exposed pregnancies in American Indian communities: Rationale, design, and methods.

INTRODUCTION: Prenatal exposure to alcohol can cause lifelong physical and cognitive challenges in the form of fetal alcohol syndrome and other fetal alcohol spectrum disorders (FASDs). The prevention of prenatal alcohol exposure is thus a public health priority - and one that should account for the particular needs of subpopulations, including in American Indian/Alaska Native (AI/AN) communities. Prior to conception, alcohol-exposed pregnancy prevention is accomplished by encouraging the reduction or elimination of risky alcohol use and/or promoting effective contraceptive use among risky drinkers who could become pregnant. The current study builds on promising findings about the impact of the Centers for Disease Control and Prevention CHOICES intervention with AI/AN communities by implementing a randomized control trial of Native CHOICES, a cultural adaptation of CHOICES, with AI/AN women in a rural reservation community. METHODS: AI/AN women aged 18-44 who are at-risk for an alcohol-exposed pregnancy are being recruited. Participants are randomized in 1:1 proportion to the intervention and a services-as-usual, waitlist control condition. The Native CHOICES intervention consists of 2 motivational interviewing (MI) sessions, an elective contraception counseling session, and electronic messaging to boost the effects of MI. Data are collected at baseline and at 6 weeks, 3 months, and 6 months post-baseline. Those assigned to the control group are eligible to enroll in Native CHOICES following the completion of the 6 months post-baseline data collection. In addition to testing intervention effectiveness, the study is designed to yield a comprehensive economic evaluation, which will provide important information regarding the financial feasibility and sustainability of Native CHOICES for healthcare systems serving AI/ANs.

Utilization of the Transtheoretical Model to Determine the Qualitative Impact of a Tribal FASD Prevention Program.

Alcohol consumption during pregnancy can lead to damaging effects on an infant's health, including fetal alcohol spectrum disorders. Project Changing High-risk alcOhol use and Increasing Contraception Effectiveness Study (CHOICES), a program developed to reduce alcohol-exposed pregnancies through decreased alcohol consumption and increased birth control use, has been implemented with success in a variety of populations. The CHOICES program was structured to align with the transtheoretical model (Stages of Change), a popular public health model. Although studies have described the Stages of Change in the context of a variety of health behaviors, none have addressed the qualitatively distinct characteristics of each stage in the context of American Indian (AI) women's alcohol and birth control use. A framework analysis of 203 participants' written responses during their experience in the Oglala Sioux Tribe (OST) CHOICES Program was conducted. As a conceptual framework, the transtheoretical model of behavior change was applied to the participants' experiences, with two staff reading the open-ended responses and coding based on the stage of change. Participants' responses suggest qualitatively distinct stages as well as a progression through the stages for both behaviors during the course of the program. Many participants mentioned their children, education, and work as inspiration to decrease their unhealthy behaviors. Common barriers to behavior change were found across both behaviors. The open-ended responses uncover common themes in the experiences of the participants. These results can help inform future programs which hope to address the needs of AI communities.

The Oglala Sioux Tribe CHOICES Program: Modifying an Existing Alcohol-Exposed Pregnancy Intervention for Use in an American Indian Community.

Alcohol-exposed pregnancies are a health issue for many American Indian communities. The goal of this manuscript is to outline how an existing alcohol-exposed pregnancy prevention program with non-pregnant women (Project CHOICES) was modified to fit the needs and norms of an American Indian community. The Oglala Sioux Tribe CHOICES Program was developed and implemented using community feedback through initial meetings, reviewing materials, gathering input into recruitment and intervention logistics, and conducting interviews to evaluate the program. The intervention was implemented and has been enrolling non-pregnant American Indian women for the past several years. While data collection is ongoing, it has shown preliminary success in changing behaviors and in impacting how the community views the prevention of alcohol-exposed pregnancies. Overall, this study highlights the potential to expand this prevention program to other sites and with other populations, such as adolescents. By the end of this article, readers will comprehend the steps necessary to replicate such a program at other tribal and rural sites.

Development and Implementation of CHOICES Group to Reduce Drinking, Improve Contraception, and Prevent Alcohol-Exposed Pregnancies in American Indian Women.

Public health officials assert that prevention of alcohol-exposed pregnancies (AEP) should begin before conception, by reducing alcohol consumption in women at-risk for or planning pregnancy, and/or preventing pregnancy in women who are drinking at risky levels. One such effort is the Oglala Sioux Tribe (OST) CHOICES Program. While the OST CHOICES Program has been successfully implemented, a community-based needs assessment determined that the OST CHOICES intervention should expand and be delivered in a group setting using group motivational interviewing (MI) techniques. After extensive group MI and CHOICES group trainings, recruitment for CHOICES Group began and within a ten month period, a total of twelve groups with non-pregnant American Indian women were held for this pilot intervention. Evaluations completed by participants indicated that CHOICES Group sessions positively engaged members, had low levels of anger or tension, and had average levels of avoidance of personal responsibility. An evaluation of the CHOICES Group leaders indicated strengths in certain MI skills, although improvement is needed in some core MI and group leadership skills. This is an important expansion of a successful AEP prevention program (CHOICES), as well as a novel application of MI, and recommendations and future plans for this intervention are outlined.

Teen Pregnancy Prevention Program Recommendations from Urban and Reservation Northern Plains American Indian Community Members.

Despite declines over the past few decades, the United States has one of the highest rates of teen pregnancy compared to other industrialized nations. American Indian youth have experienced higher rates of teen pregnancy compared to the overall population for decades. Although it's known that community and cultural adaptation enhance program effectiveness, few teen pregnancy prevention programs have published on recommendations for adapting these programs to address the specific needs of Northern Plains American Indian youth. We employed a mixed-methods analysis of 24 focus groups and 20 interviews with a combined total of 185 urban and reservation-based American Indian youth and elders, local health care providers, and local school personnel to detail recommendations for the cultural adaptation, content, and implementation of a teen pregnancy prevention program specific to this population. Gender differences and urban /reservation site differences in the types of recommendations offered and the potential reasons for these differences are discussed.

Understanding gender roles in teen pregnancy prevention among American Indian youth.

OBJECTIVES: To examine the impact of gender norms on American Indian (AI) adolescents' sexual health behavior. METHODS: The project collected qualitative data at a reservation site and an urban site through 24 focus groups and 20 key informant interviews. RESULTS: The reasons that AI youth choose to abstain or engage in sexual intercourse and utilize contraception vary based on gender ideologies defined by the adolescent's environment. These include social expectations from family and peers, defined roles within relationships, and gender empowerment gaps. CONCLUSIONS: Gender ideology plays a large role in decisions about contraception and sexual activity for AI adolescents, and it is vital to include redefinitions of gender norms within AI teen pregnancy prevention program.

Preventive Dental Care Utilization For Preschool-Aged Children in Medicaid: Parents' Perceptions and Experiences With Medicaid Dentists.

Background: Studies on the barriers to preventive dental care for preschool-aged children in Medicaid often focus on whether parents understand the importance of preventive dental care. Fewer studies have examined the perceptions and experiences of parents once their child begins utilizing dental care. This qualitative study of parents who are using preventive dental care for their preschool-aged, Medicaid enrolled children uses parental perceptions and experiences to help us understand the barriers to preventive dental care. Methods: This qualitative study focused on 41 parents who participated in focus groups designed to uncover barriers and facilitators to preventive dental care use for young children in Medicaid. Results: Parents of preschool-aged children enrolled in Medicaid face a number of barriers when trying to utilize preventive dental care, even when the parents are experienced with accessing care for their young children. These barriers can be broadly categorized into system-level barriers and provider-level barriers. System-level barriers are related to the low number of dentists who accept Medicaid and/or young children. Provider-level barriers are centered on dentist behavior or clinic environment. Conclusion: Families of preschool-aged children in Medicaid continue to encounter barriers to preventive care even after the child initially utilizes care, which suggests that access to dental care is an ongoing problem for young Medicaid-enrolled children. Interventions that address system-level and provider-level barriers to care can help to ensure continual access to preventive dental care through childhood for Medicaid-enrolled children.