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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