Re-imagining e-SBIRT to reduce stigma and strengthen FASD prevention

About This Grant

Fetal Alcohol Spectrum Disorder (FASD) is a lifelong and highly consequential condition affecting up to 1 in 20 children in the U.S. Despite the availability of evidence-based treatment options, only a very small minority of pregnant women meeting criteria for an alcohol use disorder receives treatment; and of those not receiving treatment, 95% do not feel that they need it. Screening and brief intervention approaches (SBIRT) are designed to reach this non-treatment seeking majority and are widely recommended for use in pregnancy. However, although SBIRT is predicated on small effects that have a meaningful public health impact when delivered at scale, decades of research have shown that (1) its effects are smaller than once hoped, and (2) it is challenging to implement in busy healthcare settings. In response, we have extensively studied digital SBIRT approaches (e-SBIRT), with promising results regarding efficacy—particularly when pairing e-SBIRT with digital “dose” enhancers such as text messages and booster sessions. Unfortunately, implementation challenges have persisted despite the greatly reduced effort needed to implement e-SBIRT in prenatal care settings. Continued innovation is urgently needed. We propose two enhancements designed to increase e- SBIRT scalability and impact. First, we will improve scalability by testing e-SBIRT delivery within a whole- health pregnancy checkup and feedback model addressing a range of protective and risk factors, such as sleep, prenatal care adherence, mental health, and nutrition, in addition to alcohol. This adaptation will reduce stigma and increase perceived relevance among patients as well as clinic staff. Although allocating disproportionate time to alcohol, this approach will also allow delivery of content addressing factors known to contribute to alcohol use, such as depression. Second, we will improve impact by augmenting individual-level e-SBIRT with an engaging intervention to help family members, friends, and/or partners—selected by the pregnant participant—to effectively support the pregnant participant’s health in all areas, including alcohol. In the R61 phase, Aim 1 will use mixed methods to develop e-SBIRT multi, a user-centered, multi-level, and multi-target screening and brief intervention for pregnant participants and their key support network. R61 phase Aim 2 will evaluate e-SBIRT multi feasibility and acceptability in a single-arm trial. If e-SBIRT multi meets a priori benchmarks/milestones, R33 phase Aim 3 will test it against enhanced treatment as usual in a confirmatory two-arm randomized clinical trial (N = 326 pregnant women plus support participants). R33 phase Aim 4 of this hybrid type 1 trial will evaluate implementation outcomes among healthcare professionals, clinic staff, pregnant participants, and support network participants. This project will develop and rigorously evaluate two enhancements with the potential to increase brief intervention acceptability and impact while retaining the high-reach advantages of e-SBIRT. It represents an important step toward re-imagining SBIRT to achieve the goal of a true public health impact on FASD.