Validation of a self-administered questionnaire to screen for prenatal alcohol use in Northern Plains Indian women

doi:10.1016/S0749-3797(98)00158-5

American Journal of Preventive Medicine

Volume 16, Issue 3, April 1999, Pages 240-243

https://doi.org/10.1016/S0749-3797(98)00158-5 Get rights and content

Abstract

Objective: This study among American Indian prenatal patients was conducted to validate a self-administered questionnaire (SAQ) designed to (1) identify women who had consumed alcohol during pregnancy, (2) identify women who may be at risk of drinking during pregnancy, and (3) determine the quantity and frequency of alcohol and other substance use just before and during pregnancy.

Methods: The validation involved three components: (1) review of the SAQ responses by a public health nurse; (2) structured patient interview with the research nurse; and (3) medical record abstraction postpartum.

Results: Compared to extensive interview and medical record data, the SAQ is sensitive (76.6%) and specific (92.8%) in detecting pregnant women who had consumed alcohol during pregnancy.

Conclusion: The SAQ is a useful screening tool for alcohol use in this population.

Introduction

F etal alcohol syndrome (FAS) is the leading cause of preventable mental retardation in the United States.1 The prevalence of FAS was estimated to be 8.5 per 1000 live births in the Northern Plains Indians.2 Rates of alcohol use during pregnancy in the Northern Plains Indians were reported to be 36% in an urban area and 14% on reservations.3

The Surgeon General has stated that there is no known safe level of alcohol consumption during pregnancy.4 Screening women for alcohol use during pregnancy is an essential component of programs to achieve the Year 2000 national objective of reducing the incidence of FAS among American Indians and Alaska Natives to no more than 2.0 per 1000 live births.5 Several screening instruments are available, but none has been validated in an American Indian prenatal population.6

Self-administered questionnaires have generally been found to be more sensitive in identifying alcohol use than interviewer-administered questionnaires.7 An innovative patient-interactive computer program for screening American Indian prenatal patients has been developed.8 It is not widely utilized because of lack of supporting hardware and software in facilities serving Indian patients. A simple paper-and-pencil instrument such as that developed for this study is needed for non-computerized facilities. This study was conducted to validate a self-administered questionnaire (SAQ) for alcohol use among American Indian prenatal patients.

Section snippets

Method

The study protocol was reviewed and approved by the Aberdeen Area Indian Health Service (IHS) and National IHS Institutional Review Boards and by the local Indian Health Board. This study had two main components: development of and validation of the SAQ.

Sociodemographic characteristics of participants

Of 208 prenatal patients who participated in the study, 85% were American Indian and 15% were Caucasians or African Americans carrying an American Indian baby. Eight women refused to participate in the study. All 208 participants completed the SAQ, were interviewed by the research nurse, and had their medical records reviewed during the postpartum period. The average gestational age when the SAQ was completed was 3.5 months with a standard deviation of 3.7. Ages of participants ranged from 15

Discussion

Validation of alcohol screening tools is difficult because a “gold standard” has not been established to determine alcohol consumption. Since alcohol is metabolized quickly, blood-alcohol levels are not very useful as screening tools and there are no other reliable biochemical markers available for alcohol use.12 We utilized the results of the interview and medical record review to determine the sensitivity and specificity of the SAQ to detect alcohol use during pregnancy. This study indicates

Acknowledgements

The authors acknowledge the support provided by the staff at the clinic where all the prenatal care was provided and by the Indian Health Board, without whose support this study could not have been done. The late Christopher Krogh, MD, Indian Health Service Maternal Child Health Consultant made valuable contributions to this study. Cindy Garcia, RN conducted the interviews. Kathy LaBonte, Georgia Green, and Clarice LeBrun provided public health nursing services and case management for women who

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Prenatal alcohol exposure may cause a number of health complications for the mother and developing fetus, including Fetal Alcohol Spectrum Disorders (FASD). This study aimed to estimate the pooled prevalence of i) alcohol use (any amount) and binge drinking (4 or more standard drinks on a single occasion) during pregnancy, and ii) Fetal Alcohol Syndrome (FAS) and FASD among the general and Aboriginal populations in Canada and the United States, based on the available literature. Comprehensive systematic literature searches and meta-analyses, assuming a random-effects model, were conducted. It was revealed that about 10% and 15% of pregnant women in the general population consume alcohol in Canada and the United States, respectively, and that about 3% of women engage in binge drinking during pregnancy in both countries. However, the prevalence of alcohol use during pregnancy in the Aboriginal populations of the United States and Canada were found to be approximately 3–4 times higher, respectively, compared to the general population. Even more alarmingly, it was estimated that approximately one in five women in the Aboriginal populations in both countries engage in binge drinking during pregnancy. Further, among the general population of Canada, the pooled prevalence was estimated to be about 1 per 1000 for FAS and 5 per 1000 for FASD. However, compared to the general population, the prevalence of FAS and FASD among the Aboriginal population in Canada was estimated to be 38 times and 16 times higher, respectively. With respect to the United States, the pooled prevalence of FAS and FASD was estimated to be about 2 per 1000 and 15 per 1,000, respectively, among the general population, and 4 per 1000 and 10 per 1,000, respectively, among the Aboriginal population. The FAS and FASD pooled prevalence estimates presented here should be used with caution due to the limited number of existing studies and their methodological limitations. Based on the results of the current study, it is evident that there is an urgent need for implementing more effective national prevention and surveillance strategies to monitor and lower the prevalence of alcohol consumption during pregnancy and FASD.
Analysis of qualitative data from the investigation study in pregnancy of the ASSIST Version 3.0 (the Alcohol, Smoking and Substance Involvement Screening Test)
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Recognition of the harms and the need for screening in antenatal care has led to clinical guidelines and consensus statements by both governmental and professional bodies in several Western countries (National Institute for Clinical Excellence, 2008; National Health and Medical Research Council, 2009; The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2013; The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2014; Royal College of Obstetricians & Gynaecologists, 2015). A number of screening tools have been trialled in clinical studies (Russell, 1994; Chang et al. 1998; Bad Heart Bull et al., 1999; Kharrazi et al., 1999; Budd et al., 2000; Karoll, 2002; Hotham et al., 2013) and subsequently used by maternity care providers in attempts to accurately determine a pregnant woman׳s substance use pattern (World Health Organization, 2014) with consequent instigation of supportive interventions to support cessation or, less ideally, restriction of use (O׳Neill et al., 1996; Corse and Smith, 1998; Jones et al., 2004). The World Health Organization׳s The ASSIST (the Alcohol, Smoking, and Substance Involvement Screening Test) Version 3.0 (Humeniuk and Ali, 2005; Newcombe et al., 2005; World Health Organization, 2014) is one such screening tool (see Appendix 1).
to utilise qualitative data from investigation of the screening tool ASSIST Version 3.0 with pregnant women to help determine its appropriateness for this cohort, thus informing potential innovations to enhance the questionnaire׳s utility.
pregnant women were co-administered the ASSIST Version 3.0 and three established substance use questionnaires (the T-ACE for alcohol, the Timeline FollowBack for cannabis and the Revised Fagerstrom Questionnaire for tobacco).
antenatal clinics and the antenatal ward of the Women׳s and Children׳s Hospital, Adelaide, South Australia.
104 pregnant substance-users.
as well as the quantitative date (reported elsewhere), rich qualitative data documenting participants’ perspectives and experiences in antenatal care were thematically analysed. Women constantly reported friends and family urging them to stop use. Although care providers also advocated cessation or curtailment of use, this advice was reported as unpredictable, with only some providers strongly attuned to such recommendations. Some women voiced suggestions for the appropriate level of provider advice. While pregnancy was often reported as a motivator for changing substance-using behaviour, others reported continued attachment to use which was clearly linked to dependence. Those who reported successful control of use were in contrast to others who were more pragmatic, sceptical in relation to attributable harms, and disinterested in change. There were limited reports of experiences of discrimination directed to pregnant substance users. However, those instances were clearly linked with subsequent lack of honest discussions with care providers, resulting in an absence of appropriate support.
current absence of universal screening for substance use has the potential for less than optimal consequences for both mother and baby.
appropriate screening accompanied by honest, non-judgmental dialogue can guide the necessary interventions to achieve better outcomes. The recent development of the more concise and easier to administer ASSIST-LITE was partly informed by this investigation.
Maternal risk factors predicting child physical characteristics and dysmorphology in fetal alcohol syndrome and partial fetal alcohol syndrome
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So it is important that studies of human maternal risk factors for FASD include multiple measures of drinking styles that capture the pattern of consumption: how much is consumed, how often, and at what time during the pregnancy? But obtaining accurate measures from maternal reports is fraught with challenges (Jacobson et al., 1991; Alvik et al., 2006a,b,c; Hankin, 2002; Malet et al., 2006; Bad Heart Bull et al., 1999; Floyd et al., 1999; Kristjanson et al., 2007; Whaley and O’Connor, 2003; Primatesta et al., 1993; Robles and Day, 1990; Serdula et al., 1991; Waterson and Murray-Lyon, 1989; Hannigan et al., 2010). In essence, the more often a woman drinks during pregnancy, the greater amounts that she drinks (especially over short periods of time), and if drinking continues throughout the gestation of the child, the more likely a child is to have an FASD, especially the more severely dysmorphic forms of FAS and partial fetal alcohol syndrome (PFAS) (Pierce and West, 1986; Abel, 1998; Stratton et al., 1996; Ernhart et al., 1987; Flynn and Chermack, 2008).
Previous research in South Africa revealed very high rates of fetal alcohol syndrome (FAS), of 46–89 per 1000 among young children. Maternal and child data from studies in this community summarize the multiple predictors of FAS and partial fetal alcohol syndrome (PFAS).
Sequential regression was employed to examine influences on child physical characteristics and dysmorphology from four categories of maternal traits: physical, demographic, childbearing, and drinking. Then, a structural equation model (SEM) was constructed to predict influences on child physical characteristics.
Individual sequential regressions revealed that maternal drinking measures were the most powerful predictors of a child's physical anomalies (R² = .30, p < .001), followed by maternal demographics (R² = .24, p < .001), maternal physical characteristics (R² = .15, p < .001), and childbearing variables (R² = .06, p < .001). The SEM utilized both individual variables and the four composite categories of maternal traits to predict a set of child physical characteristics, including a total dysmorphology score. As predicted, drinking behavior is a relatively strong predictor of child physical characteristics (β = 0.61, p < .001), even when all other maternal risk variables are included; higher levels of drinking predict child physical anomalies.
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View full text

Brief ReportsValidation of a self-administered questionnaire to screen for prenatal alcohol use in Northern Plains Indian women

Abstract

Introduction

Section snippets

Method

Sociodemographic characteristics of participants

Discussion

Acknowledgements

The T-ACE questionspractical prenatal detection of risk-drinking

Am J Obstet Gynecol

A fetal alcohol syndrome surveillance pilot project in American Indian communities in the northern plains

Public Health Rep March-April

Assessing reproductive behavior of on- and off-reservation American Indian femalescharacteristics of two groups in Montana

Soc Biol

Surgeon General’s advisory on alcohol and pregnancy

FDA Drug Bulletin

Healthy People 2000: National Health Promotion and Disease Prevention Objectives

New assessment tools for risk drinking during pregnancy

Alcohol Health Res World

Agreement in alcohol consumption levels as measured by two different questionnaires

J Stud Alcohol

Prenatal behavioral risk screening by computer among Native Americans

Fam Med

Brief Reports
Validation of a self-administered questionnaire to screen for prenatal alcohol use in Northern Plains Indian women