# Presentation: 017580

## FASD Prevention: Implementing Project Choices Building FASD State Systems (BFSS) San Antonio, TexasJune, 2005Kirk von Sternberg, Ph.D.Department of Family and Community MedicineThe University of Texas Health Science Center at HoustonSchool of Medicine

##           PROJECT CHOICES 

**          ****PROJECT CHOICES **

**A PRECONCEPTIONAL APPROACH **

## EPIDEMIOLOGIC SURVEY

- Project CHOICES Research Group*. **** ***Alcohol-exposed pregnancy: characteristics 	associated with risk*. American Journal of Preventive Medicine. 2002 23(3):166-173.*_* *_
- Writing Team:* Mary Nettleman (chair), Joseph Carbonai, R.Louise Floyd, *
*	**	**Patricia Dolan Mullen, Jasjeet Sidhu*
- Analytic Team:* J. Carbonari (chair), K. vonSternberg, J. Baio, J. Sidhu*

## Centers for Disease Control and Prevention
R. Louise Floyd, DSN

University of Texas Health Science Center at Houston
Mary Marden Velasquez, PhD
Patricia Dolan Mullen, DrPH

Virginia Commonwealth University
Mary Nettleman, MD
Karen Ingersoll, PhD

NOVA Southeastern-Florida
Mark Sobell, PhD
Linda Sobell, PhD

- R. Louise Floyd, DSN
*University of Texas Health Science Center at Houston*
- Mary Marden Velasquez, PhD
- Patricia Dolan Mullen, DrPH
*Virginia Commonwealth University*
- Mary Nettleman, MD
- Karen Ingersoll, PhD
*NOVA Southeastern-Florida*
- Mark Sobell, PhD
- Linda Sobell, PhD

## EPIDEMIOLOGIC SURVEY

- Characterize the population including level of risk for AEP
- Identify variables correlated with risk
- Identify independent predictors of risk

## SETTINGS

**Jail**
**Treatment Center**
- 	**University of Texas Health Science Center**
**Inner City Primary Care**
**Inner City GYN**
- 	**Virginia Commonwealth University**
**Primary Care Clinics in an HMO**
**Media Recruits**
- 	**NOVA Southeastern-Florida**

## OVERVIEW

**Women, aged 18-44 years**
**Survey designed by Study Team**
**Administered by trained interviewer on site with each survey taking about 30 minutes**
**Over 18 months**

## DEFINITION OF “AT RISK”

_**LAST 90 DAYS**_
**FERTILE **
**UNPROTECTED SEX**
**8 OR MORE DRINKS PER WEEK **_**OR**_
_**>**_** 5 DRINKS IN ONE DAY MORE THAN ONCE IN LAST 6 MONTHS**

## 2672 RESPONDENTS

- 62%     African American
- 21%     White
-    8%     Hispanic
-   6%      Native American
-    3%     Other

## Community-based Settings with High Proportion Of  Women at-Risk  for an Alcohol Exposed Pregnancy

**Notes:**
Risk for alcohol-exposed pregnancy was defined by:
Fertile and had unprotected intercourse in past 6 months
Risk-level alcohol consumption (average 8 or more drinks per week or binged twice or more n past 6 months)
Risk was higher in settings where women were expected to engage in higher risk-taking behavior
All settings showed higher proportion of risk than we estimated from national population estimates
Jail & recovery sites categorized as higher risk, health clinic and media samples categorized as lower risk

## DEMOGRAPHICS

- 17 % were legally married
- 51% were employed
- 68% were high school grads or equivalent

## DEMOGRAPHICS: AGE

## INCOME

## FERTILITY

- 32% infertile, 9% abstain
- 13% pregnant or trying
- 25% contracepting correctly
- 12% not contracepting correctly
- 8% not using contraception

## ALCOHOL USE

- 71% of respondents drank
- 31% were binge drinkers
- (5 or more drinks on a day)
- 25% were frequent drinkers
- (8 or more drinks per week)

## AT RISK FOR AEP

- 333 Respondents (12.5%)
- National estimates for the general population suggest a 1% to 2% risk
- Respondents were 6.9 times more likely to be at risk for AEP (95% CL 5.2-9.3, p=0.0001) than general population
- All sites were at increased risk (p<0.05)

## % AT RISK FOR AEP

## At-Risk Women vs Not At Risk

|  | Odds Ratio | C.I. |
| --- | --- | --- |
| Ever used drugs | 8.3 | 5.1-13.6 |
| Current drug use | 7.2 | 5.3-9.8 |
| Hx of Tx for Et/drugs | 5.1 | 3.9-6.6 |
| Ever smoked | 5.1 | 3.5-7.6 |
| Ever homeless | 3.9 | 3.0-5.1 |
| Hx of Mental Tx | 3.1 | 2.3-4.3 |

- Univariate

## Other significant univariate correlates (p<0.001) included:

- At-Risk Women vs Not At Risk

**Age > 30****	**
**White race**
**Less Education**
**Started Drinking         <age 16**
**Hx of Inpt Tx for Drug/Et/Mental**

**Hx of Physical Abuse**
**Unemployed**
**Current Smoker**
**No Health Ins**
**Perceived Poor Health**

## Comparison group was women who were not at risk but who were sexually active and fertile
Univariate and Multivariate Analysis

- Univariate and Multivariate Analysis

- AT-RISK WOMEN: FACTORS ASSOCIATED WITH RISK

## MULTIVARIATE ANALYSIS CURRENT BEHAVIORS (p<0.0001)

|  | Odds Ratio |  C.I. |
| --- | --- | --- |
| Current Drug Use | 5.1 | 3.6-7.1 |
| Current Smoker | 2.3 | 1.7-3.1 |

## MULTIVARIATE ANALYSISHISTORICAL VARIABLES (p<0.0001)

- MULTIVARIATE ANALYSISHISTORICAL VARIABLES (p<0.0001)

|  | Odds Ratio |     C.I. |
| --- | --- | --- |
| Ever Used Drugs | 3.1 | 1.8-5.4 |
| Inpt Tx for Drug/Et | 2.3 | 1.8-3.1 |
| Physical Abuse | 1.9 | 1.4-2.5 |
| Ever smoke 100 cigs | 1.9 | 1.3-2.7 |
| Inpt Tx for Mental Health | 1.6 | 1.1-2.3 |

## SUMMARY

**12.5% of women were at risk for an alcohol-exposed pregnancy**
**Risk for AEP was associated with a history of multiple problems, many of which persisted into the present**

## CONCLUSIONS TO DATE

**ALL Project CHOICES SETTINGS HAVE HIGHER PROPORTIONS OF WOMEN AT RISK FOR AN AEP THAN THE ESTIMATED RATE FOR WOMEN AGED 18-45 YRS. OVERALL (<2%)**
**SETTINGS  REPRESENT IDEAL LOCALES FOR DESIGNING AND TESTING INTERVENTIONS TO REDUCE THE RATE OF AEP**

## Project CHOICES Feasibility StudyReducing the Risk of Alcohol-Exposed Pregnancies:  A Study of a Motivational Intervention in Community Settings

*Project CHOICES Intervention Research Group, Pediatrics, 2003;111*
*Writing Team, M. Velasquez (chair), K. Ingersoll, L. Floyd, M. Sobell*
*Analytic Team, J. Carbonari (chair), K. von Sternberg, J. Baio, J. Sidhu*

## Slide 26

## Objective: Prevent Alcohol-Exposed Pregnancies

-  **Reduce Drinking**
**or**
** ****Contracept Effectively**
**or**
** ****Both**

## Can we develop and implement an intervention to target BOTH behaviors that place women at risk for alcohol-exposed pregnancy?

The first study to address improving contraception and reducing drinking in a single intervention

- The first study to address improving contraception and reducing drinking in a single intervention

**Notes:**
One of the most interesting but also a challenging aspect of the pilot intervention study of Project CHOICES was its uniqueness in addressing dual issues in a single intervention.

## Definition of “Not at Risk”

- Drinks ≤ 7 drinks/week & no days ≥ 5 drinks
- or
- Contracepts Effectively
- or
- Both

## TimeLine Follow-Back

| Sunday | Monday | Tuesday | Wednesday | Thursday | Friday |  | Saturday |
| --- | --- | --- | --- | --- | --- | --- | --- |
| 1 | 2 | 3 | 4 | 5 | 6 |  | 7 |
| A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: |  | A:
VI:     Y   N
BC:    Y   N
T: |
| 8 | 9 | 10 | 11 | 12 | 13 |  | 14 |
| A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: | A:
VI:     Y   N
BC:    Y   N
T: |  | A:
VI:     Y   N
BC:    Y   N
T: |
| CODES: |  |  |  |  |  |  |  |
| 	A:     Alcohol Use
	VI:   Vaginal Intercourse
	BC:  Birth Control
	T:     Type of birth control |  |  |  | C:  Condom
P:   Birth Control Pill
D:  Diaphragm
I:    IUD |  | S:   Spermicide
N:  Norplant
E:  Depo-Provera
Other:  (write in) |  |

## Eligibility Criteria for Intervention			

- 18-44 years old
- Fertile
- Not contracepting effectively in past 3 months
- Drinking 8 drinks per week on average or 5 per occasion
- Available for 9 months
- Signed informed consent

**Notes:**
Now that you have a good understanding of the content of the Project CHOICES intervention, let me turn to some of the other aspects of the study design.  Women were eligible for the study if they were:...

## Intervention Study

- Conducted in same 6 settings
- Targeted same population groups as CHOICES Epidemiology survey
- 2,384 women screened
- 230 eligible
- 190 consented and enrolled
- Conceptualized as a “feasibility study” or pilot study

## Intervention Design Considerations

- Women would be drawn from a range of settings with different reasons for risk
- Many women would NOT be presenting for treatment but were recruited for study
- Readiness for change would vary
- Intervention must address **readiness for change and motivation**
- Intervention should have evidence of efficacy

**Notes:**
As a multisite team, we considered several important factors in designing the intervention.

## Effectiveness of Brief Interventions

- Three major factors contribute to a patient’s long-term compliance with treatment:

**The patient feels that behavior change is a personal choice**
**The encounter between the patient and the provider is positive**
**The patient has adequate self-confidence about his or her ability to make recommended behavior changes**

## Motivational Interviewing

- Motivational Interviewing is an empathic, client-centered, yet directive counseling style.  **Its goal is ****to explore and resolve ambivalence about changing behaviors**

**Notes:**
I’ve mentioned Motivational Interviewing, so let me be more specific.  MI was developed by Miller and Rollnick in the early 90’s, building on 20 years of social and clinical psychology research that emphasized certain factors related to successfully making a planned change.  MI is a counseling style....

## Readiness: Stages of Change 

- Readiness: Stages of Change

**Notes:**
I’ve mentioned readiness several times, and I’m referring to the stages of change from the well known Transtheoretical Model of Change of Prochaska and Diclemente.  Here you see a diagram depicting the stages, from precontemplation at the bottom, where the woman is not yet considering change, to contemplation, when she is considering change but is equally motivated to remain the same, to preparation, in which she plans to make changes within a month, on to action, in which change is occurring currently, and then possibly to maintenance, in which changes that were made in the action stage are maintained and solidified.  Lastly, at any point beyond preparation, the woman may relapse and recycle through the stages, with 85% re-entering the circle at contemplation or higher.

## Why Motivational Interviewing?

- Those in earlier stages of change (precontemplation, contemplation) require motivation
- We anticipated that many study participants would be in early stages of readiness given they were not presenting for treatment
- Good evidence of efficacy, at least to reduce drinking

**Notes:**
We selected a motivational intervention for several reasons, as alluded to before.  

## Motivational Interventions

**Motivational Interventions**

**  ****Motivation is a state of readiness to change, **
**    ****which may fluctuate from one time or situation **
**    ****to another. This state can be influenced.**

**  ****Motivation for change does not reside **
**    ****solely within the client.**

**  ****The counselor’s style is a powerful determinant **
**    ****of client resistance and change. An empathic **
**    ****style is more likely to bring out self-motivational**
**    ****responses and less resistance from the client**

## Motivational Interventions

**Motivational Interventions**

**  ****People struggling with behavioral problems **
**   ****often have fluctuating and conflicting motivations **
**   ****for change, also known as ambivalence. **
**   ****Ambivalence is a normal part of considering and **
**   ****making change and is NOT pathological**

**  ****Each person has powerful potential for change.  **
**   ****The task of the counselor is to release that potential**
**   ****and facilitate the natural change process that is**
**   ****already inherent in the individual.**

## Considerations in training practitioners in brief interventions

**	****Highlight differences between motivational interventions and educational or advice-giving approaches**
**	****Interventions must be brief and ‘do-able’**
**	****Beware of the “I already do this” belief**
**	****Providers need to have high levels of confidence in the effectiveness of the strategies AND their ability to use them**
**	**

## Considerations in training practitioners in brief interventions

**	**Encourage the practitioner to use each of the strategies whenever possible, but not to feel as though they have to stick to a ‘script.’ It is much more important to establish rapport and *listen* to the woman
- 	Encourage the practitioner to integrate the strategies into the session in a natural manner rather than moving from one exercise to the next
**	****Discuss differences between the ‘trait’ and ‘state’ models**
**	**

## Assumptions of a Trait Model

**Defense mechanisms (e.g. denial) are stable personality characteristics **
**Unless a client is motivated, there is little one can do **
**Treatment failure, refusal, & drop-out are due to denial**
**People are inherently motivated to resist change**
**Accepting/admitting one’s disease (diagnosis) is essential**
**Denial can be dealt with only through direct confrontation**

## Problems with the Trait Model

- Attributional handicapping: Internal locus of failures
- Self-fulfilling prophecy with people judged unmotivated
- Encourages counter-therapeutic behaviors in counselors (suspiciousness, hostility, moralizing, power struggles)

## Problems with the Trait Model

- Substance abusers show no unique personality
- Show no higher level of denial than normal population
- Measures of denial are not clearly related to treatment, outcome**  **

## Problems with the Trait Model

- Client drop-out, compliance, and outcome are powerfully influenced by counselor characteristics and environment
- Direct confrontation yields poorer compliance, outcomes

## Counselors Influence Client Motivation 

**Expectations influence outcomes**
**Differences in drop-out rates**
**Differences in outcome rates**
**Simple actions decrease drop-out**
**Empathic counselors have better outcomes**

## Qualities of a Good Motivational Counselor

**Respect for individual differences**
**Tolerance for disagreement and ambivalence**
**Patience with gradual approximations**
**Genuine caring and interest in **
**	****clients served**

## Motivation and Counseling

- Persuasion and education alone don’t create behavior change
- Empathic interpersonal counseling styles increase willingness to consider change and avoid resistance

**Notes:**
We also know from social psychology that persuasion as a tactic, and education alone, are not enough to help people change habitual behavior.  Rather, we use a counseling style in motivational interviewing that increases a woman’s readiness to consider change.  

## Underlying the Spirit of Motivational Interviewing is: 

Collaboration - In motivational interviewing, the counselor does not assume an authoritarian role.  The interviewer seeks to create a positive atmosphere that is conducive to change.

Evocation – Consistent with a collaborative role, the counselor’s tone is not one of imparting things, such as wisdom or insight, but rather eliciting – finding these things within and drawing them out from the person. 

- Collaboration - In motivational interviewing, the counselor does not assume an authoritarian role.  The interviewer seeks to create a positive atmosphere that is conducive to change.
- Evocation **– **Consistent with a collaborative role, the counselor’s tone is not one of imparting things, such as wisdom or insight, but rather *eliciting* – finding these things within and drawing them out from the person.

## Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-efficacy

- Develop Discrepancy
- Roll with Resistance
- Support Self-efficacy

**Motivational Interviewing Principles**

**Notes:**
MI techniques stem from these 5 basic principles.  First, express an empathic understanding and interest in the woman.  Second, help her perceive a discrepancy between where she is and where she wants to be.  Third, be approachable, flexible, and avoid arguing or persuading tactics.  Fourth, if you perceive resistance, use this as a cue to change strategies and move in a more productive direction.  Fifth, encourage optimism for change and support her when she makes statements of confidence in her ability to change.  

## Motivational Interviewing: Client-centered techniques

- Ask Open-ended questions
- Listen reflectively
- Affirm her participation and honesty
- Summarize frequently
- Emphasize her personal choice and control

**Notes:**
Here are some of the counseling techniques used in MI and in Project CHOICES that are fundamental, client-centered techniques.  

## Motivational Interviewing:  Directive Techniques 

- Selectively reflect “change talk”
- Explore discrepancies between goals and behavior
- Elicit reasons for change from the woman
- Assist in goal setting

**Notes:**
These are the techniques that make MI a directive approach.  For example,....

## A Person Is Likely to Change When:

- She believes change is important
- She is confident in her ability to make recommended changes

- Change

**Notes:**
MI counselors know that in order to a woman to be motivated or ready for change, she must both believe that change is important, and feel confident that she can make the needed change.

## Project CHOICES Intervention

**Counseling Session 1**

**Counseling Session 2**

**Gyn/ family**
** ****planning **
**visit**

**Counseling Session 3**

**Counseling Session 4**

**3 month follow up**

**6 month follow up**

**Notes:**
Now I’ll review the flow of the Project CHOICES intervention.

## Counseling Session 1

- Orientation to study
- Informed consent
- Rapport building
- Assessment

- Provide fact sheets
- Make gyn appointment
- HW: Decisional balance for alcohol and contraception and self monitoring

**Notes:**
In her first session, 

## Thinking About Drinking

**Not so good things about my drinking: **

**Good things about my drinking:**

**More relaxed**
**Will not have to think about my**
**      ****problems for a while**
**More comfortable with drinking friends**

**Disapproval from family and friends**
**Increased chance of legal and job**
**     ****trouble**
**Costs too much money**

**Not so good things about changing my drinking:**

**Good things about changing my drinking:**

**More control over my life**
**Support from family and friends**
**Less legal trouble & Better health**

**More stress or anxiety**
**Feel more depressed**
**Increased boredom**

**Notes:**
This is a sample of a decisional balance completed by a woman in Project CHOICES.  You can see that she identified..... 

## Counseling Session 2

- Personalized Risk Feedback
- Debriefing of feedback
- Review self-monitoring log and
- 	decisional balance homework
- Initial goal setting

**Notes:**
In session 2, the woman receives feedback on a variety of measures she completed during the first session.  She hears about how her drinking compares to national averages, how many calories she drank, and how much she spent on alcohol in the past year.  She also learns about risks related to drinking at her level, and the risk of pregnancy and why she is at risk.  

## Your Personalized Feedback - I

**You also said that on occasions you may drink ______  drinks in a single day.**

**Moderate Drinking:**
**	****Drinking Level:**** *****No more***** than 7 drinks per week AND **
**	****	****	****	*****no more***** than 3 drinks in any one day.**
**	****Risks:**

**Risky Drinking:**
**	****Drinking Level:**** *****More***** than 7 drinks per week or **
**	****	****	****	*****more***** than 3 drinks in any one day.**
**	****Risks:**

**Your Personalized Feedback - I**

## Your Personalized Feedback - II

**How does your drinking compare with other women?   Your current drinking level falls into the __________ risk group. You are drinking more than _______________ % of women aged 18-44.**

**20**

**30**

**50**

**Moderate Drinking**
**  ****(3 out of 10)**

**No Drinking **
**(5 out of 10)**

**Risky Drinking **
**(2 out of 10)**

## Your Personalized Feedback - III

_**How many calories did you consume from alcohol per drinking day?**_

-  Based on what you told us, you drank around __________ drinks in the past
-        3 months.
-  If you usually drink at home, and an average drink at home costs $1.25, then
-       you spent about $___________ on alcohol last year.
-  If you usually drink at a bar or restaurant, and an average drink there costs
-       $3.50, then you spent about $__________________ on alcohol last year.

-  Alcohol has calories which have no nutritional value.  Sometimes women gain
-      weight because of the extra calories they get from alcohol.
-  Based on what you told us, you drank around ___________ drinks per
-      drinking day.
-  If an average drink has 100 calories, you consumed about ____________
-      calories per drinking day from alcohol.

_**How much money did you spend on alcohol last year?**_

## Your Personalized Feedback - IV

**[    ]   Low -- You use birth control correctly every **
**                       ****time you have vaginal intercourse .**
**[    ]    Risky -- You never use birth control or you**
**                         ****sometimes have vaginal intercourse                      **
**                         ****without using birth control correctly.**
**You are at risk because**** ___________________________**
**________________________________________________**
**_________________________________________________**

**Your Personalized Feedback - IV**

## Self-Evaluation Ruler - Alcohol

**On the following scale, which point best reflects how ready you are at the present time to change your drinking? **

**Not at all ready to change my**
**drinking**

**Thinking**** **
**about**** ****changing**** ****my**** ****drinking**

**Actively **
**changing **
**my drinking**
** **

**Planning and**
**making a **
**commitment to change my drinking**** **

**Notes:**
Here’s an example of a readiness ruler we use several times over the course of the sessions on which she can indicate her readiness to change one of the target behaviors.

## Gyn Visit

- History
- Contraception education and counseling
- Physical exam (if desired by woman)
- Provision of contraception

**Notes:**
After the second visit, she visits the gyn clinic practitioner associated with Project CHOICES.  

## Counseling Session 3

- Review self monitoring homework
- Debrief gyn visit
- Readiness rulers
- Decisional balance update
- Goal statement update: how well is it fitting?

**Notes:**
In session 3, she .....

## Goal Statement & Change Plan 

**[   ]   Choice 2: I plan to have vaginal intercourse and **
**	****not to use *****any***** birth  control.****	**** **
**[   ]   Choice 3: I plan to use birth control every time **
**	****I have vaginal intercourse;  *****(specify method(s))  *****_____________________________**
**[   ]   Choice 4: I plan to use birth control sometimes, but not with every  vaginal intercourse;**
***(specify method(s))_______________________________***** **

**Goal Statement & Change Plan **
**for Birth Control - I**

## Counseling Session 4

- Review prior sessions
- Develop final goal statement and change plan for alcohol and or contraception
- Discuss current decisional balance
- Discuss self-efficacy
- Schedule follow-up
- Certificate of completion

**Notes:**
In the last session, we.....

## Intervention Summary

- Used a motivational interviewing intervention to help women examine their risky drinking and ineffective contraceptive behaviors (dual focus).
- Women attended 4 counseling sessions, a session with a gynecologist, and follow-up.
- Changing either behavior (or both) results in no risk for an alcohol-exposed pregnancy.

**Notes:**
We’re eagerly anticipating the results of the intervention.  Since we’ve recently completed our 6 month followups, we have anecdotal evidence (not yet analyzed) that we should expect a positive impact from the study.  So to summarize, we.....

## Counselor Training

**M.A. and Ph.D. Level with Counseling or Clinical Psychology Background**
**On-site training in Motivational Interviewing**
**Centralized training in Study Protocol**
**Weekly Supervision **
**“****Pilot” clients **

## Intervention Quality Control

**Audiotaped Sessions**
**Session Checklists**
**MI Rating Scale**
**Supervisor Rating Scale**
**Weekly Supervision**

## What Happened?

## Completion Rates

**Counseling Session 1****	****100.0%**
**Counseling Session 2****	****92.0%**
**Counseling Session 3****	****67.2%**
**Counseling Session 4****	****58.7%**
**Ob/Gyn Session****	****62.2%**
**3-Month Follow-Up****	****74.6%**
**6-Month Follow-Up****	****75.3%**

## Pre-Intervention100% At Risk

**6 Months Post-Intervention**
** ****68.2% Not At Risk**
** ****31.8% At Risk**

## Routes to “Not At Risk”

**18.4% Reduced Drinking**
**34.0% Contracepted****	****	****	****	**** ****	****	****	****	****	****Effectively**
**47.6% Did Both**

## Completion And Success

**Mean (SD) No. Sessions Completed**
** ****Not At Risk****	****4.33 (1.17)**
** ****Still At Risk****	****3.96 (1.37)**
**	****	****n.s.**

## “Not At Risk” X Setting

**	****Setting****	****% Not At Risk**
**Jail****	****	****66.7%**
**Treatment Center****	****57.1%**
**Inner City Primary Care****	****57.1%**
**Inner City Gyn****	****66.7%**
**Media Recruits****	****79.5%**
**Broward Co. Prim. Care****	****60.0%**

## Conclusions

**Findings suggested the intervention was effective**
**More women chose to effectively contracept than chose to reduce drinking**
**Problem severity may predict outcome**
**Shows enough promise to move on to a randomized control trial (Efficacy Study)**

## Project CHOICES		        Efficacy Study

*A multi-site collaborative project between the Centers for Disease Control and Prevention, Nova Southeastern University, the University of Texas Health Science Center-Houston, and the Virginia Commonwealth University.*

**†**

**BATTELLE**

## Demographicsn = 827

- Education
- 	Less than 12 years		28%
- 	High school or equivalent	38%
- 	Some college			26%
- 	4 year degree or beyond	  8%

## Demographics

- Total Family Income
- 	< $20,000/yr			57.5%
- 	_>_ $20,000/yr			42.5%
- Mean A.U.D.I.T. Score:	17.61

## Demographics

- Marital Status
- 	Single/never married		51%
- 	Legally married			11%
- 	Living w/ partner			17%
- 	Separated				9.5%
- 	Divorced				9.5%
- 	Widowed				   2%

## Demographics

- Race
- 	American Indian/Alaska Native	  	  4%
- 	Asian						  1%
- 	African-American				52%
- 	Native Hawaiian/Pacific Islander	  1%
- 	White						42%
- 	Other					            7%
- Ethnicity
- 	Hispanic						11%

## Demographics

- Employment Status
- 	Employed full time		40%
- 	Self-employed			11%
- 	Out of work for >1 year	17%
- 	Out of work for <1 year	24%
- 	Homemaker				18%
- 	Student				17%
- 	Retired					<1%
- 	Unable to work			  7%

## Demographics

- Received previous **outpatient** alcohol/ drug treatment				28%
- 	*Median number of times treated:* 	  2
- Received previous **inpatient** alcohol/
- 	drug treatment				34%
- 	*Median number of times treated:*   1

## Demographics

- Received previous **outpatient** treatment
- 	for psychological problems:		37%
- 	*Median number of times:*		  1
- Received previous **inpatient **treatment
- 	for psychological problems:		20%
- 	*Median number of times:*		  1

## Retention Rates: Assessments

|  |  | Baseline | 3 Month | 6 Month | 9 Month |
| --- | --- | --- | --- | --- | --- |
| 
Florida | NOVA – Broward Co. Media | 149 | 107
71.8% | 106
71.1% | 112
75.2% |
|  | NOVA – Primary Care | 99 | 66
66.6% | 63
63.6% | 66
66.6% |
|  |  | 248 | 172
69.4% | 169
68.1% | 178
71.8% |
| 
Texas | UT - Jails | 223 | 139
62.3% | 148
66.6% | 149
66.8% |
|  | UT – Treatment Centers | 121 | 91
75.2% | 99
81.8% | 103
85.1% |
|  |  | 344 | 230
66.9% | 247
71.8% | 252
73.3% |
| 
Virginia | VCU - Gyn Clinic | 114 | 81
71.1% | 68
59.6% | 72
63.2% |
|  | VCU – Medicaid HMO | 126 | 103
81.7% | 91
72.2% | 95
75.4% |
|  |  | 240 | 184
76.7% | 159
66.3% | 167
69.6% |

## Outcome Variables

- Ineffective Contraception
- Risky Drinking:
- > 4 drinks on any one day _*or*_
- > 7 drinks per week

## Ineffective Contraception

- In the past 3 months, how many different men did you have intercourse with?
- When you had intercourse during the past 3 months, what were you and your partner(s) using to keep you from getting pregnant?
- During the past 3 months, did you have intercourse and not use (method) as described in this card?

## Effective Contraceptive Methods

- Condoms
- Diaphram, Cervical Cap
- Pill
- Lunelle
- Patch
- Morning-After Pill
- Depo-Provera
- IUD
- Norplant
- Sponge
- 1 partner only and partner had Vasectomy
- Had no partners

## Risky Drinking

- (*Frequency)*
- 	During the past 3 months, how many alcoholic drinks, if any, would you estimate that you consumed per week?
- (*Binge)*
- 	Considering all types of alcoholic beverages, how many times during the past 3 months did you have five or more drinks in one day?

## Risk of Alcohol Exposed Pregnancy

| 
At Risk | 
Not at Risk |
| --- | --- |
| 
Not at Risk | 
Not at Risk |

- Yes

- Yes

- No

- No

**Risk Drinking**

**Unsafe Sex**

- Yes =** **≥1 occurrence of vaginal sex without effective birth control

- Yes = ≥1 occurrence
- of > 4 drinks in a day
- or >7 drinks per week

## Conclusions