As described in Table 1, several organizations were awarded funding to support the implementation of alcohol screening and brief intervention into healthcare systems—Boston Medical Center/Boston University School of Medicine with the Boston Sustainable Models for unhealthy Alcohol use ReducTion (B SMART) Program, Henry Ford Health, University of Connecticut Health Center (UCH), and the University of Alaska Anchorage. The approaches described in this paper, as described in Table 1, are contributed by Boston Medical Center/Boston University School of Medicine, University of Connecticut Health Center “ASPPIRE Program” in partnership with Planned Parenthood of Southern New England (PPSNE), and the University of Alaska Anchorage (UAA SBIRT) in partnership with Planned Parenthood Great Northwest, Hawai’I, Alaska, Indiana, Kentucky (PPGNHAIK).

Several nationally-focused programs were also awarded funding, including the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), the University of Nevada, Reno in partnership with the American Association of Medical Assistants, The University of Texas at Austin (UT-Austin) Steve Hicks School of Social Work in partnership with the National Association of Social Workers (NASW), and the Women’s Health Nurses and Midwives Collaborate for Alcohol-Free Pregnancy (Women’s Health Partnership), a partnership between the University of Alaska Anchorage, the National Association of Nurse Practitioners in Women’s Health (NPWH), the American College of Nurse-Midwives (ACNM), and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). The approaches described in this paper are contributed by AAFP Portland, UT-Austin, and the Women’s Health Partnership (Table 1).

Based on organizational structure and program purpose, different methods were employed for FASD education. The approaches to FASD prevention education were not mutually exclusive as different programs chose to incorporate different strategies in implementation. Some programs focused on FASD prevention through staff training and clinical intervention, specifically alcohol SBI, while others focused on broadscale professional education and awareness. Different programs utilized a champion approach to achieve success in providing and continuing education, relying on members within the organization or healthcare team to serve as a source of knowledge, ideally increasing organizational and staff buy-in through existing structures and existing rapport.^23.24 The implementation of the champion model varied by project.

Each of the clinical-based programs described utilized some form of champions model to reach their target audience, whether that audience was national professional organization members, front-line clinic staff, clinic administration, or other personnel.

While there were some minor differences in definitions of “champion” across programs, in general a champion was utilized as a person who could act as a trusted resource, promote available trainings or resources, advocate for staff or members on their need for FASD- or SBI-related education or resources, or could promote the implementation of alcohol SBI into their clinical practice setting. Within each program, champions were identified at the beginning of and throughout their respective implementation periods and offered valuable insight into their health centers’ operation. This proved vital to the ongoing quality improvement (QI) process and increasing education uptake and sustainability among staff. Some programs, such as the ASPPIRE program, put the use of champions on hold due to COVID-19 and related staffing issues, while others like B SMART’s champions were “health center liaisons” who served in a similar capacity.

For the participating national programs, there were additional approaches and variations in the champion model. AAFP utilized physician champions to lead their practices, as well as to guide the creation of FASD prevention educational tools and resources at the point of patient care for all AAFP members. These champions collaborated with experts to create micro-learnings for physicians and healthcare teams. These comprised five videos ranging from 6–12 minutes discussing alcohol SBI implementation and sustainability. Two patient scenario videos are also included which review how to initiate alcohol SBI discussions with patients and complement other trainings available for primary care physicians and their healthcare teams. Materials and resources from AAFP, CDC, and other grantees were sent to members. Being able to provide peer-led materials to family physicians across the US has been a highlight of using a champions model at the national level.

Across alcohol SBI implementation initiatives — B SMART, Connecticut ASPPIRE, Alaska SBIRT — training included FASD awareness and prevention education for whole healthcare teams, including medical assistants, administrators, support staff, providers, nursing staff, and in some systems, behavioral health providers. Trainings within healthcare systems, such as Connecticut ASPPIRE and Alaska SBIRT^a1, included raising awareness of FASDs and the importance of addressing alcohol use in primary and reproductive healthcare, and included training teams on the process of delivering alcohol SBI during a routine medical appointment. Projects such as B SMART conducted initial evaluations to better tailor training and identify holes in knowledge. As the programs developed, another aspect of the curriculum content was filling gaps in confidence around the topic, skills, and being able to engage with patients on the topic of alcohol use and FASD prevention.

In the multi-level approach, skills practice was crucial. In some cases, this allowed for role-stratified skills practice, wherein participants explored their specific role in FASD prevention. For the Alaska SBIRT program, the team facilitated case studies with staff to practice administering a standardized alcohol screener and delivering a brief intervention to individuals drinking above the recommended limits. In addition, training highlighted strategies for talking with patients about preventing AEPs.

These interdisciplinary training programs target teams of healthcare professionals–- including social workers, physicians, physician assistants, nurses and behavioral health specialists–- to ensure efficient and effective delivery of evidence-based alcohol SBI. A particular focus for these trainings has been utilizing SBI for alcohol use as a primary approach to reduce the risk of AEPs.

Motivational Interviewing (MI) employed in alcohol SBI is another evidence-based approach for supporting clients in making informed choices about their health. MI is a collaborative conversation style that develops and strengthens a client’s motivation for and commitment to change. It has a strong evidence base in health care and focuses on the client’s strengths and capacity for change. In alignment with social work ethics and standards, MI supports and honors the patient’s capacity and right to self-determination and autonomy.^25.26 This alignment between social work values and MI has been a crucial component of trainings delivered to social workers to help create buy-in among them.

The Health Behavior Research and Training Institute (HBRT) at UT-Austin’s Steve Hicks School of Social Work conducted Motivational Interviewing (MI)-based SBIRT training for alcohol and other drugs and introduced CHOICES, an intervention for the prevention of AEP, as a brief treatment for individuals who can become pregnant consuming alcohol. For example, the UT-Austin Integrated Behavioral Health Scholars program is designed to train graduate students from social work, nursing, psychology, and psychiatry fellows/residents in addressing substance misuse in healthcare settings. In addition, HBRT delivered instruction for “Transformative Teams in Healthcare,” an interprofessional elective course that reaches about 300 students in social work, medicine, nursing, and pharmacy each year.

Additionally, these national programs employed a variety of methods to train and educate interdisciplinary staff and update existing organizational practices (i.e. routine trainings, grand rounds) around FASD education.

For instance, Connecticut ASSPIRE developed a “Working Group”’ that consisted of training staff and leadership. This collaborative approach, along with backing from senior PPSNE personnel, allowed for a smooth transition and increased health center staff buy-in during education. Alaska SBIRT formed an interdisciplinary planning team that included the UAA implementation team and PPGNHAIK leadership who, in addition to refining and adapting FASD awareness and alcohol SBI training modules, adapted content to address the practice philosophy and patients served. For both projects, full participation by the health systems in modifying trainings and alcohol SBI protocols, promoted staff buy-in and acceptance of trainings and practice changes. Similarly, B SMART, worked with existing structures and staff at various health centers in the Boston HealthNet system to tailor the approach to each health center’s needs.

Strategic communications planning has been a successful way to promote awareness and discussion about FASD prevention strategies among national professional organizations across all projects. The nationally-focused programs collaborated to promote and expand their FASD awareness campaigns, reaching thousands of healthcare professionals across the organizations’ digital and print platforms. Articles created through these campaigns included NASW Social Work Blog posts on social workers’ role in reducing risky drinking, tips to make alcohol SBI part of routine care, and key facts healthcare professionals need to know about alcohol and pregnancy. Coordinated social media campaigns focused on selected national health awareness months, such as National Birth Defects Prevention Month, Alcohol Awareness Month, and FASD Awareness Month. The messages often included links to professional and client resources, and training opportunities. Given the size of these organizations’ social media following, these messages have the potential to reach several hundred thousand healthcare professionals across the U.S.

National professional organizations’ journals, magazines and newsletters have also been important platforms for promoting clinical guidelines and policies. For example, the October/November 2020 issue of NASW’s member magazine, Social Work Advocates, featured an opinion piece on Alcohol SBI and its role in addressing racial health disparities in risky drinking, written by a UT-Austin HBRT team member. In addition, ann overview of screening instruments, brief interventions and implementation issues was tailored for a social work audience and distributed through the NASW newsletter, Practice Perspectives. Presentations at organizational partners’ annual meetings or through digital platforms have also provided mechanisms for raising awareness of the importance of using alcohol screening and brief intervention strategies.

The content and curriculum for the included programs focused on a few specific areas. The first element was the foundational science around FASDs, including the impact of alcohol on the developing embryo and fetus and the life-long conditions that may result, as well as the need build trust with patients to counter the potential stigma associated with excessive alcohol use and towards families and individuals impacted by prenatal alcohol exposure. This core knowledge was an underlying aspect of the various trainings and educational materials. Skills based training also played a role in the possibility for implementation. Embedded in the multilevel approach to the core content was information and training based upon participant roles in healthcare teams. As the programs developed, another aspect of the curriculum content was filling gaps in confidence around the topic, skills, and being able to engage with patients. For instance, B SMART tailored additional content based on clinic-based needs assessments. Finally, many of the educational materials and trainings included sections that dealt directly with reducing stigma and creating clinic environments that promote open conversations about alcohol use.²⁷

One of the many adaptations that happened within clinic-based programs was a transition to a screening procedure that can occur across patient care settings. The shift to telehealth posed challenges for the healthcare setting of the different programs. This change impacted the processes adapted in the alcohol SBI models, including staff education on the use of pre-screening, mobile check-in technology, and electronic assessments adapted across different program settings based on individual needs. A concern for the education programs, as the screenings were going down in light of pandemic and telehealth shift, was the notable increase in alcohol consumption in many environments and nationwide.^28–30

Across almost all programs, technology was used as a solution for many of the risk-related issues of COVID-19, but it also posed a variety of challenges to which education-based and clinical programs alike are still adapting. For the Alaska SBIRT program, feedback from PPGNHAIK organizational leaders and local clinical staff highlights the challenges COVID-19 posed through increased staff turnover and the transition to remote trainings. Trainings that had been conducted in-person at sites were converted to online modules offered through PPGNHAIK’s Learning Management System (LMS). Skills practice in conducting brief interventions were conducted synchronously using videoconferencing. Other programs found that the new technologies aimed at easing COVID-19 adjustments required their own training for successful adaptation.

Working within the health center setting during COVID-19 and gaining access to make changes and train teams proved difficult due to new competing priorities. Due to uncertainties and the risk of transmission, the programs’ FASD and alcohol SBI education was no longer a priority, and in-person access was limited. In B SMART, many grand rounds were effectively put on hold and education efforts were appropriately focused on COVID-19 and COVID-19-related topics. Family medicine clinics endured these challenges, as some even closed for weeks during shutdowns and were navigating new procedures and COVID-19 roles. Acknowledging the priority shift and challenges, the B SMART program adapted trainings making them topically relevant and timely, such as exploring increased alcohol use during COVID-19. B SMART also developed a podcast as a form of asynchronous learning, and other programs developed and utilized online training modules and remote learning for program rollout.³¹

The COVID-19 pandemic also impacted the planned approach of the programs working with and through national professional organizations. For example, the Women’s Health Partnership had relied heavily on leveraging attendance at national and regional conferences to disseminate FASD education opportunities, materials, and resources, as well as to build its champion program. With the cancellation of these events or the re-orientation to a virtual format, the partnership re-thought the outreach plan and pivoted to other platforms. This led to the creation of an independent website²⁷ where partner organizations link to social media messaging from their own organizational websites. This new joint website houses online CDC training, videos, implementation guides, and other resources. In addition, the partnership conceived and developed an entire online, modular curriculum that could be used not only by nursing and midwifery professionals already in practice, but also by faculty seeking new ways to integrate FASD and alcohol-related content into courses suddenly moved to a virtual format. This curriculum includes introductory information about FASDs, alcohol use patterns in the US, the basics of alcohol SBI, skills-based learning, and discusses stigma and ethics related to alcohol use during pregnancy and FASDs.

UT-Austin also relied on in-person conferences to support its dissemination efforts and shifted its approach for NASW’s virtual national conferences in 2020 and 2021. In lieu of creating an exhibit for conference attendees, UT-Austin disseminated FASD education resources for social workers by participating as patrons of the 2020 conference and created a dedicated email to registrants for the 2021 conference. The dedicated email linked to CDC’s FASD training page and its page on alcohol SBI, as well as alcohol SBI resources tailored to social workers created in partnership with NASW.

Although these programs vary in setting, region, and audience, the common administration of FASD prevention education did render some core lessons learned across the programs discussed. Adaptive training models are most successful when they incorporate three methods: easily accessible online education, reinforcement booster trainings, and an emphasis on skill building, as seen in Table 2. Easily accessible online education is one key component as it can be accessed at any time rather than administered. Learners can use this resource and improve practice. This information is adaptable to clinic needs and changing circumstances, which is also helpful for issues with staff turnover.

A variety of the programs encountered provider hesitancy and reported some patient pushback. However, they utilized the strategies specified in Table 2 to address provider and patient discomfort. This was vital to both the success of patient screening through alcohol SBI and provider education and skill building. Within some of the AAFP Portland and Alaska SBIRT clinics, some providers reported that their patients appeared offended by alcohol screening questions. During repeat training sessions, emphasis was placed on research studies and patient survey data that disprove this belief. Furthermore, they stressed the importance of universal alcohol screening was incorporated into a broader annual behavioral health questionnaire including drugs, depression, and anxiety.

A recurring theme in the Alaska SBIRT implementation program and Connecticut ASPPIRE was a challenge in providing cannabis-based educational resources and integrating cannabis into screening. These clinicians were hesitant to discuss alcohol use or other substances (especially cannabis) with their patients, reporting it felt out of context, judgmental, or both. During initial and refresher trainings, clinicians were encouraged to dovetail alcohol use brief interventions with the patients’ contraception or discussions around prenatal alcohol exposure prevention, particularly if the patient was considering becoming pregnant, to ensure the conversation had additional context. Materials, such as brochures and infographics, were provided to help aid providers. Brief intervention and evidence-based information was consistently posted on the online learning platform for health center staff to access. More study is required to further understand how prenatal cannabis use might be addressed through universal screening. While multi-substance use during pregnancy is a concern, more information is needed to educate healthcare professionals and patients on the risk of polysubstance use during pregnancy or among individuals at a high risk of pregnancy.

The COVID-19 pandemic forced a re-think about how outreach to healthcare professionals is conducted at the national level. Prior to the pandemic, there was an emphasis on in-person events and training opportunities. The shift of events to online or virtual platforms created new options for self-directed learning, greater accessibility, and innovative training and education methods. The programs working with national partner organizations coordinated for national outreach campaigns such as National Birth Defects Prevention Month, National Alcohol Awareness Month and National Alcohol Screening Day, and International FASD Awareness Day/Month, leveraging each others’ strengths and communication channels to reach a broader and more interdisciplinary audience.

While these programs model a variety of methods to increase provider education around FASDs and alcohol use, results are limited due to the challenges faced on a day-to-day by providers and educational institutions alike. Adding trainings to the already heavy workload of providers and health care teams can be challenging, and this review is unable to increase the time and resources of health care workers, operating clinics, or provider-focused educational institutions. Additionally, measuring stigma is difficult, and while evidence suggests that normalization can reduce the impact of stigma on clinical practice²⁷ the numerical impact of such interventions in this study is unknown. Lastly, multiple of the programs discussed rely on self-reported measures, and even with universal screening, self-reported substance use is often an underrepresentation of the actual use rate.

Inadequate education, misinterpretation, or falsely perpetuated ideas around FASDs and alcohol use during pregnancy can lead to misinformed healthcare professionals and confused patients, making professional education about the prevention of FASDs vital to healthcare professionals and individuals within the reproductive healthcare setting. Accuracy in research and education can help ensure effective strategies for reducing alcohol use and risk of AEPs. The stigma associated with excessive alcohol use and FASDs is pervasive enough to deter conversations and awareness of the issue and patient reporting. Educational programs and interventions such as these focus on the importance of language when discussing health risks related to alcohol use, especially excessive alcohol use, binge drinking, and use during pregnancy. Skill-based trainings may also aid providers in appropriately and effectively addressing alcohol use during pregnancy.

For all FASD education, programs emphasized accessibility, understanding, and adaptability of material, with prevention and implementation-based projects also incorporating skill-building through modeling provider/patient interactions and case studies. With changing circumstances as evidenced by COVID-19, adaptability from feedback gathered during data collection and evaluation became vital to the longevity and efficacy of FASD prevention education.