Research Update

Alcohol Use and Pregnancy: An Important Canadian Public Health and Social Issue

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9 Training and Professional Development

What the Studies Say As new evidence of effective practices arises, there is a need to transfer the new knowledge from researchers to practitioners (researchers, in turn benefit from networking with practitioners and parents in this field). Best practice and clinical guidelines can support the uptake of new practices, as can training. There is very little scientific evaluation of the effectiveness of FASDrelated guidelines or training initiatives. At times, there are other barriers to the adoption of new practices, and a “workforce development” approach that assesses the picture from a broader perspective is necessary.

The implementation of evidence-based practices holds large implications for professional development. With respect to identifying and intervening with pregnant women with substance use issues, physicians and other health care professionals, such as nurses and midwives, hold an important position.³¹² Routine screening of pregnant women for alcohol use problems is a recommended practice, yet this has not been achieved in Canada. A recent study reporting a 41% response rate found that 94% of a national sample of Canadian health providers (pediatricians, psychiatrists, obstetricians and gynecologists, midwives and family physicians) asked pregnant women about their alcohol use, but only 62% report using a standardized screening tool.³¹³ This reinforces findings from other physician surveys that indicate that screening is not fully routine and that validated screening tools are much underused.^314,315 Authors of the national study suggested that those least likely to be identified include women over age 35, social drinkers, women who are highly educated, women with a history of sexual or emotional abuse, and women of high socio-economic status.³¹⁶

According to the findings of the Canadian physician surveys, efforts should be directed toward improving professional preparedness to care for alcohol dependent/abusing pregnant women and FAS-affected individuals, as less than 60% of respondents felt prepared to do so. Lack of specific preparation was viewed as the chief barrier with journals, medical school curricula, continuing medical education (CME) and parents of affected children, identified (in descending order) as preferred channels for learning.³¹⁷ Professional policy statements and practice guidelines are important vehicles for professional development. A landmark guide for Canadian health care professionals on this issue was the Joint Statement: Prevention of Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE)in Canada, led by the Canadian Paediatric Society, and signed by 19 organizations.³¹⁸ In 2002, the Canadian Paediatric Society also published a position statement that provides guidance on the identification, prevention and management of FASD to pediatricians. While both of these publications were widely circulated, neither has been evaluated for their impact.

Generally, practice guidelines are considered necessary but not sufficient for changing practice. Training is often required. The Ontario Best Start program has given attention to physician training with the development of a training program and planning guide for training local physicians. Handmaker et al. (1999b) used a controlled study design to test the effectiveness of a 20-minute training videotape focusing on motivational interviewing with a small sample of obstetric care physicians.³¹⁹ Those in the experimental group showed greater empathy and were more effective in minimizing patient defensiveness and supporting women's beliefs in their ability to change.

The medical, child welfare, women's services and substance abuse treatment systems tend to have differing agendas and understanding of issues (e.g. reporting requirements regarding suspected child abuse and child custody, confidentiality, expectations regarding recovery from a substance use problem, and the most effective methods for ensuring a healthy outcome for mother and child). Cross or joint training of these professionals would allow for a broader perspective and lead to critically important collaboration between the sectors. An example of a joint training approach is a program funded by Health Canada and piloted by Breaking the Cycle and the Canadian Centre on Substance Abuse, which trains prenatal and child services practitioners together, using a motivational, stages of change model for working with both pregnant women and affected children and families.³²⁰ Other practitioners, including social workers and human service workers, have important opportunities to identify women at risk. In their qualitative research concerning barriers to treatment facing women in British Columbia, Poole and Isaac found that supportive professionals from a wide range of services, including justice, violence, health and housing, proved helpful to women in obtaining treatment.³²¹

As has been discussed in this review, diagnosis of FASD is an important way to prevent future cases of FASD. Significant joint US–Canada effort has resulted in the development of the first Canadian guidelines for the diagnosis of FAS and related disabilities.³²² These guidelines reflect a harmonizing of Institute of Medicine diagnostic criteria and the Four Digit Diagnostic Code. Those involved in the preparation suggest that these form the basis of physician training.

9.1 Recommendations and Implications

Priorities for research, programming and policy arising from this review of the evidence in support of training and professional development are:

Evaluation Research

• Conduct Canadian research into the extent to which disseminating practice guidelines to health care and social service practitioners increases the adoption of recommended practices.
• Conduct Canadian research into the extent to which providing training to health care and social service practitioners on practice guidelines results in the adoption of recommended practices.
• Identify barriers (beyond awareness and training) to the adoption of recommended practices concerning prenatal alcohol use in health care and social service settings.

Policy and Program Implications

While awaiting the results of Canadian studies, priority should be given to these promising practices:

• Develop a national workforce development strategy that recognizes the range of barriers that may prevent or inhibit the adoption of recommended practices concerning use of alcohol by pregnant women in the health care and social services fields, including the substance abuse treatment sector.
• Within a national workforce development strategy on this issue, prepare a national training strategy that takes advantage of regional expertise and minimizes duplication.

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