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Pine Belt FASD Prevention Project

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									                             Pine Belt FASD Prevention Project
                                      Needs Assessment

I. Introduction

A. Purpose of the needs assessment

The purpose of the Pine Belt FASD Prevention Project Needs Assessment is twofold: 1)
to further refine the target audience of non-pregnant women of child-bearing age who
have an elevated risk of an alcohol-related pregnancy in Forrest and Jones County; and 2)
to determine what types of and levels of services are appropriate and relevant to their
needs. The needs assessment guided strategy development as well as provided a baseline
for data collection and outcome analysis. It will answer questions about the problems and
influences our targeted population encounter in using effective contraceptives, abstaining
from drinking alcohol, and utilizing support services and interventions. The needs
analysis will inform decision makers of the target population’s activities and practices;
what services they use; and what they think, know, want, and need enabling decision
makers to determine how to best meet their needs.

B. Goal of this initiative

The short-term goal of this initiative is to implement Project CHOICES in a way that
significantly decreases the amount of alcohol consumption and increases the effective use
of barriers to pregnancy in our target population. Ultimately, a reduction in alcohol-
related disabilities by decreasing the number of alcohol-exposed pregnancies is
anticipated within the target population.

C. Selected service delivery organization to integrate new practices

Pine Belt Mental Healthcare Resources (PBMHR) is a comprehensive, community
behavioral healthcare provider that serves a population of over a quarter of a million
residents in Mississippi’s Mental Health Region XII and Southeast Public Health District
VIII. All decisions and adoptions of programs are benchmarked against the mission
statement: “To excel in providing community-based behavioral healthcare services in
such an effective manner that our consumers will be empowered to pursue an optimal
quality of life.” The agency has a staff of nearly 500 serving the residents of southern
Mississippi in 43 Pine Belt Mental Healthcare Resources facilities in nine counties, and
in numerous remote facilities such as schools, hospitals, homes and jails.

PBMHR provides a continuum of care in four areas of service; adult, child and
adolescent, alcohol and drug, and developmental disability. Services include individual,
group and family therapy, psychiatric services, case management, intensive outpatient,
residential treatment, day treatment, transitional employment and transitional living
facilities. In addition to these services, PBMHR offers 24-hour emergency services.
Substance disorder and co-occurring disorder treatments are provided to pregnant and
non-pregnant women at high risk for alcohol-exposed pregnancies. The treatment



                                                                                        1
modalities are outpatient, residential, transitional, and intensive outpatient. Ninety
percent of clients are program completers with a reported relapse rates of 28 percent six
months after discharge.

Currently, PBMHR has two active HIVAIDS prevention projects. It has partnered with
the Southeast Mississippi Rural Health Initiative (SeMRHI), the local Ryan White
services provider, for many years to provide mental healthcare to the underserved
populations in southern Mississippi. The CHOICES (Choosing Health Over Infection:
Counseling, Education, and Safe Behavior) Program is an HIV prevention program
designed for ages 20 and older to decrease the number of individuals at high risk for
acquiring or transmitting HIV through counseling, education, and behavioral changes and
to increase individuals’ awareness of their HIV status. Last year, as a result of the
CHOICES project activities, 748 individuals with high-risk behaviors became aware of
their HIV status, 80 percent were enrolled in a prevention intervention, and 50 percent
reported reductions in risk behaviors.

The HIP-HOP (HIV Intervention Project-HIV Outreach and Prevention) program
provides targeted outreach, counseling, testing, referrals and prevention interventions to
African Americans residing in Mississippi Public Health District VIII who abuse
substances and are at risk for HIV and/or hepatitis infection. To date, the HIP HOP
Project has provided the evidence based practices of Spiritual Self Schema (3-S) and
Holistic Health Recovery Program (HHRP) to 61 consumers. The majority of clients
have shown a decrease in self-reported risky behaviors and an increase in self- reported
condom use. Those clients that reported no significant change had a confounding variable
in that they had been enrolled in an HIV and substance abuse prevention class prior to
this intervention.

Person Centered Planning (PCP) is a process-oriented approach to empowering people
with disability labels. It focuses on the people and their needs by putting them in charge
of defining the direction for their lives, not on the systems that may or may not be
available to serve them. It is an evidence based practice that PBMHR uses with
consumers diagnosed with a serious mental illness and co-occurring disorders. The
intervention has effectively decreased hospitalization. To date, 86 percent of participants
have remained out of the psychiatric hospital, representing a 90 percent reduction in
hospitalization and a 98 percent reduction in mental healthcare costs.

As mental and behavioral healthcare evolves from a medical model to a recovery model,
services are also evolving from specific practices to a system of care which treats the
individual, rather than the disease. PBMHR is moving towards a holistic approach to
treatment which encompasses addressing the personal causes and consequences of the
disorder rather than the disorder itself. Although PBMHR staff provides alcohol and HIV
interventions and prevention services, the services have not specifically focused upon the
prevention of FASD. A coordinated effort across the disciplines and treatment modalities
to identify women at high risk will add another dimension to the system of care; as well
exceed the expectations of consumers. By integrating FASD prevention interventions into
the treatment plans of high-risk women, PBMHR may facilitate a reduction of high-risk



                                                                                         2
pregnancies, thus lowering the number of babies born with alcohol-related disabilities in
its service area.

D. Population to be served

The Pine Belt FASD Prevention Project will target women at risk for bearing children
with FASD in Forrest and Jones Counties. These two counties are the largest counties
served by PBMHR and have the highest rate of women of child-bearing age seeking
treatment for an alcohol disorder. Variables that are associated with risk include being of
childbearing age, use of alcohol, past and current drug use, cigarette smoking,
homelessness, history of mental health treatment, past physical abuse, low achievement
of education, no health insurance, unemployment, onset of alcohol use at an early age,
and a perception of poor health (Velasquez, 2004). Being unmarried (Bertrand, et al,
2004) and cohabitation with partners who drink alcohol (Viljoen, Croxford, Gossage,
Kodituwakku, & May, 2002; Wilsnack, Wilsnack, & Hiller-Sturmhofel, 1994) are also
strongly associated, as is being 25 years or younger (Weiner & Morse, 1989).

Table 1 lists demographic point-in-time data of females age 18-44 in substance abuse
treatment that were extracted from medical records in PBMHR’s two largest counties,
Forrest and Jones, as of April 23, 2008. All are at risk for FASD due to their substance
use. The table lists other risk factors and how they are distributed.
                                                 Table 1: Demographic Profile of Population of Interest
                                              Demographic              Forrest County Jones County
All of the consumers have incomes             Characteristics
                                              (women age 18-44)
below the poverty level. Being poor in        N                          302 (54%)         261 (46%)
itself is not a risk factor; however, it is   Race
associated with many negative                   African American         142 (47%)          90 (34%)
                                                Caucasian                157 (52%)         166 (64%)
outcomes, including lack of prenatal            Hispanic                       0              4 (2%)
care and health insurance, domestic             American Indian                0             1 (.4%)
abuse, low level of education, and              Other                       3 (1%)
unemployment,         which     are     all   Marital Status
                                                Single                   265 (88%)         205 (79%)
associated with FASD.                           Married                   37 (12%)          56 (21%)
                                              Education
                                                No high school            33 (11%)          25 (10%)
A vast majority of the consumers are            Some high school          41 (14%)          48 (18%)
single (83%).       Approximately 25            High school completion   135 (45%)          99 (38%)
percent did not complete high school,           or GED
                                                Special education          19 (6%)           16 (6%)
and six percent attended special                Some college              50 (17%)          44 (17%)
education classes. Almost three of              College completion         19 (6%)           23 (9%)
four of the targeted females are                Technical/trade school         0              5(2%)
                                                Unknown                     3 (1%)               0
unemployed.        Although specific
                                              Employment status
information was not accumulated                 Unemployed               211 (70%)         198 (76%)
regarding domestic violence and sexual
abuse, anecdotally clinicians report that more are victims than not. Of all consumers with
a substance abuse disorder, 67 percent also have a co-occurring mental health disorder.
The assimilation of all of these risk factors points to a very high risk population.




                                                                                                     3
Based on this data, PBMHR consumers in Forrest and Jones counties seem to be prime
candidates for, and likely to benefit from, Project CHOICES. The integration of Project
CHOICES into the treatment of high-risk women should lower the birth rates to babies
with alcohol-related disabilities and result in other positive outcomes for the female
recipients. Since stress is a key contributor to the initiation, continuation and relapse of
alcohol abuse (Brady & Sonne, 1999), the prevention of births of children with multiple
problems to be managed will assist in the recovery process. Continued sobriety can lead
to fewer contacts with the criminal justice system, improved economic status, better
employment rates, lower rates of homelessness, enhanced relationships, better physical
health and an overall higher quality of life.

II. Methods

A. Data collection methods and sources

The focus group methodology was used to validate and expand data already gathered at
project conception regarding the prevention needs of the targeted population. This
method was chosen in order to provide information on the targeted group’s thoughts and
feelings; give insight as to why certain opinions are held; improve the project planning
process; and produce insights for outreach strategies. The advantages of using focus
groups include the ease and cost effectiveness of preparation and implementation and
their flexibility; also, they are most conducive to use with participants with lower literacy
levels. Focus groups allow participants to listen (rather than read) and verbally respond,
clarify for understanding, and take advantage of the fact that people naturally interact and
are influenced by others (high face validity). They allow the researcher to probe for
understanding and further illumination, and responses are worded in the respondents’
vocabulary and vernacular.

Three focus groups were conducted to gather information to assess the needs of the target
population and the staff. All of the contributors were obtained from a convenience
sample of the target population. The women were chosen based on age and services used
at Pine Belt Mental Healthcare Resources. Two focus groups were held in Forrest
County. The first group consisted of nine consumers of child-bearing age with serious
mental illness or co-occurring disorders, who were residents of Ivy Trace Group Home
and Forrest County Mental Health Center. The second group consisted of nine PBMHR
staff members (representing Forrest and Jones County) that will be implementing Project
CHOICES. The third focus group was conducted in Jones County Clubhouse, a
psychosocial rehabilitation program, consisted of nine women of child-bearing age who
had similar mental and behavioral health characteristics to the first group. The duration of
the group discussions were between 1 to 1.5 hours.

The focus groups were conducted during the business day, when consumers and staff
were in the midst of their normal treatment or workweek routines. Demographics were
obtained from the participants during a brief sign-in period prior to the start of the focus
group.




                                                                                           4
Each participant gave consent for the focus group to be recorded. This recording was
used to ensure that the quality of the information given in the focus group was not lost
during the transcribing process. The participants were told that the focus group’s purpose
was to assess the opinions of several people pertaining to contraceptive use and risks
associated with drinking alcohol while pregnant. The focus groups were facilitated by
Debra Long, Program Coordinator and LaNeysa Carlvin, MPH, Program Evaluator.

Consumer participants were not provided with incentives for participation; however, staff
participants were provided lunch because the discussion was held during their lunch
breaks. The moderators guided the interviews and ensured the openness of discussion.
After the discussions, the Evaluator transcribed the tapes into a written format.

B. Assessment questions

The needs assessment was developed to identify the targeted community’s needs, and to
provide a foundation for strategic planning by answering the following questions:
    How many current Pine Belt Mental Healthcare Resources clients residing in
       Forrest or Jones County are women of childbearing age?
    What are their attitudes about alcohol use and use of contraceptives?
    Will they be receptive to an evidence-based program targeted toward non-
       pregnant women of child-bearing age who have an elevated risk of having an
       alcohol-involved pregnancy?
    What are their perceptions of the benefits of and barriers to using contraceptives?
    What are the current contraceptive practices of the target population?
    What do they currently know about the risk of alcohol-involved pregnancies?
    What might influence women to participate in Project CHOICES?
    How receptive are staff to implementing Project CHOICES?
    What would hinder women of child-bearing age from participating in Project
       CHOICES?
    What are their perceptions of why women abuse alcohol and ideas about ways to
       prevent it?
    What would prevent staff from effectively implementing Project CHOICES?
    What challenges does staff think they will face when collecting data?
    How does the staff think the participants would benefit from Project CHOICES?

Focus group questions for clients were designed to learn about the participants’
perceptions of alcohol-exposed pregnancies, their willingness and ability to change, and
which support systems will facilitate the change. Focus group questions for staff were
designed to learn about the attitudes, benefits, and barriers related to the implementation
of Project CHOICES.

The questions discussed in the focus groups were:

Group 1: Forrest County Outpatient Mental Health Center and Ivy Trace (Forrest County)
    What are your feelings toward drinking alcohol while pregnant?


                                                                                         5
       Why do you think causes people to abuse alcohol and drugs?
       What comes to mind when you hear Fetal Alcohol Spectrum Disorders?
       What does it take to have a healthy baby?
       Do you currently use methods to prevent pregnancy?
       What do you think alcohol exposure can do to an unborn child?
       If there was a program to help deal with alcohol abuse, would you be willing to
        participate in it? Refer someone?

Group 2: Jones County Clubhouse (Jones County)
    How do you feel about Pine Belt Mental Healthcare Resources staff talking to you
      about contraceptive use?
    What do you think are some of the reasons why people drink?
    Do you have a support system in place to help you when needed?
    What behavior do you feel is harder to change, drinking or not using birth control
      methods?
    What are some of the benefits of having a program to help abstain from drinking
      while pregnant?
    What are some of the benefits of using birth control methods? Barriers?
    What are some things that could be done to prevent alcohol-exposed pregnancies?

Group 3: Staff Implementing Project CHOICES (Forrest and Jones County)
Prior to the start of this group, the staff implementing Project CHOICES was given a
synopsis of the program.
         How well do you think Project CHOICES will fit into the Pine Belt Mental
           Healthcare Resources service delivery system?
         What concerns do you think women who abuse alcohol may have about
           participating in Project CHOICES?
         What do you need to effectively implement Project CHOICES?
         What are some of the barriers you think you may encounter when
           implementing Project CHOICES?
         What kind of staff training do you think is needed to effectively implement
           Project CHOICES?
         How do you think women who abuse alcohol will benefit from this program?
         How do you feel about talking to your clients about contraceptive use?
         What issues do you think will arise when collecting data for this project?

III. Results

    A. Data and analysis

Data about the population was extracted from medical records and the three focus groups.
The main themes of these focus groups were alcohol use, contraceptive use, and
pregnancy.

        1. Describe and refine the population


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Medical records reflect that there were 563 women of childbearing age (18-44 years)
with a substance abuse or co-occurring disorder enrolled in PBMHR services as of April
2008 in the targeted counties. There is a strong perception among the members of the
staff focus group that a majority of the clients are in need of a FASD prevention
intervention. The analysis of medical records indicates that 47 percent of female clients
with the targeted disorders are in the age bracket of interest.
                                                                           Figure 1: PBMR Clients’ Primary Drug of Choice
Demographics and characteristics are drawn
from the entire database of female                                                   PBMHR Clients' Primary Drug of
                                                                                               Choice
consumers.      Nearly all consumers (98                                                            Sedative
percent) live at or below the poverty level.                                                          1%
                                                                                      Amphetamine      PCp     Inhalant
There is a large number of minorities served,                                             7%           0%         0%

of which the largest group is African                                           Polysubstance
                                                                                                Cannabis
                                                                                                  6%
                                                                                                                            Alcohol
                                                                                                                             30%
American (47 percent), with a small number                                           7%

                                                                                        Opoid
of Hispanics, Native Americans and people                                               19%
                                                                                                                  Cocaine
of Asian descent (1 percent). There has been                                                                       30%

significant growth of the Hispanic population
since Hurricane Katrina; however, due to
cultural barriers and fears of deportation,
there have been very few clinical encounters.

Alcohol is the primary drug abused, although in a majority of the consumers it is
consumed with another substance. The PBMHR Clients’ Primary Drug of Choice graph
portrays the breakdown of “first choices” of drugs. The majority of diagnoses of Pine
Belt clients with serious mental illness (SMI) are schizophrenia, bipolar disorder and
depression.

A large number of adults with SMI lack the family support and/or financial resources to
gain access to treatment and a good quality of life, thus making it difficult for many to
access regular treatment.         As these persons’ conditions deteriorate, concerned
stakeholders, such as family members, social workers or law enforcement, utilize the
civil commitment process in order to mandate treatment. Many consumers live in fear of
this process, and as a result, cling to social relationships (even harmful ones) and children
for security.

                                                                            Inadequate access to transportation, the
           Figure 2: Primary Dx for PBMHR Consumers                         stigma associated with obtaining
                          Psychoses
                                      Other
                                          A&D
                                                                            treatment, and a lack of insurance
                     Dementia

                    Bipolar
                                                Anxiety
                                                                            coverage and/or financial resources to
                                                 Cognitive
                                                                            pay for treatment are all barriers to the
                                                                            consumers seeking mental health
          Schizophrenic
                                                                            treatment.    Anecdotally, there is a
                                                    Depressive/Affective
                                                                            relatively high “no show” rate for
                                                                            clinical and medical appointments
                                                                            within this population.



                                                                                                                                      7
The nature of mental illness and substance abuse can contribute to a downward cycle of
positive outcomes. When clients are not compliant with their treatment regimens and
begin to deteriorate, self monitoring becomes extremely difficult, due to the nature of the
disease(s), which causes impaired include hallucinations, delusions, disordered thinking,
depressed thoughts, and/or grandiose thoughts, and it becomes very difficult for a client
to recognize the need for, and take the initiative to seek treatment for the condition.
Additionally, often individuals with SMI have damaged relationships with family
members and friends and live alone, thus they lack a support system.

Based on the analysis of the data, 90% of the female consumers of PBMHR will qualify
for participation in Project CHOICES. Ideally, the consumers who would most likely
participate in and benefit from the intervention are: 1) single women who have an alcohol
or substance dependency with a co-occurring disorder; 2) are disproportionately low
socioeconomic classification; 3) are unemployed; and 4) are at risk of having an alcohol-
exposed pregnancy.

2. Describe how the population currently uses the services

There are two primary modes of substance abuse treatment: 1) residential treatment; and
2) outpatient treatment. Residential treatment for an alcohol or drug disorder begins with
a 28 day course of treatment at Clearview Recovery Center in Moselle (Jones County).
During the 28 day period, the female consumer is housed and treated with female clients.
She will undergo a minimum of one hour of individual therapy and five hours of group
therapy per week. She will participate in psychoeducational groups. During the first
week, she will not be able to have contact with her family or friends, but after that,
significant people in her life are encouraged to participate in therapy. During her time at
Clearview she will participate in HIV prevention activities which will include
psychosocial education on negotiating contraception and HIV disease, as well as
Counseling, Testing, and Referral (CTR). If she is ready for discharge after 28 days, she
will be encouraged to participate in Aftercare groups. These groups assist in
accountability for behaviors. Individuals who are not ready to return to their home
environment because they are not stable in their sobriety may opt for another 28 days at
Clearview, or to move to transitional treatment at Oak Arbor.

Transitional treatment for females may last from one week to two years. Consumers live
in a home with five other females. They attend intensive outpatient treatment sessions,
Aftercare groups, and are required to work at a paid job or volunteer in some capacity.

Females whose substance abuse diagnoses are not severe enough to be admitted into
residential treatment receive outpatient treatment at their local mental health center.
Approximately two thirds of the targeted population participates in outpatient services.
Sixty seven percent of these consumers are diagnosed with a co-occurring mental illness.
These consumers will typically participate in weekly therapeutic sessions, which include
individual and “dual diagnosis” groups. Many of the females with serious mental illness
will also opt to participate in the Clubhouse, a psychosocial rehabilitation program which
operates on a daily basis from 9:00-2:00. Last year, 770 women of child-bearing age



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were admitted to residential treatment and 186 in outpatient treatment programs. The
completion rate for these women was not available.

3.Describe knowledge, attitudes and intentions related to the desired behaviors

The opinions of consumers related to desired behaviors are protected medical information
revealed during the course of therapy; therefore, the following description is based upon
opinions expressed in the focus groups. One hundred percent of the participants in the
focus groups believed that alcohol use during pregnancy was “bad;” however, they
believed that it was acceptable to drink during any other situations. Over half of the
participants described alcohol use as a means of getting “high” and considered it to be
harder to quit drinking than it is to effectively use birth control.

Eighteen participants had knowledge of the types of contraceptives that are available but
lacked expertise in their proper use and effectiveness. Nine of the women who had
children reported their pregnancies to be a result of failed contraceptives and perceived
contraceptives as ineffective in preventing pregnancy. Many others did not have access
to contraceptives or did not know how to properly use them. Those who did not have
access to condoms either did not use them or took extreme measures to mimic them (e.g.,
garbage bags with rubber bands).

Seven participants believed that the availability of a wide variety of contraceptives on the
market was a great benefit. They believe this provides other options to taking a pill daily.
Most believe that it was hard to remember to take a pill at the same time of day;
therefore, they were more inclined to get on the Depovera shot or more long-term
contraceptives. A prominent barrier to using birth control was peer pressure from
significant others and family members who are not currently using contraceptives. Some
of the focus group participants were concerned about the side effects associated with
contraceptives and believed that the risks of using them outweighed the benefits.

All focus group participants were unfamiliar with the term FASD; however, they
associated it with birth defects, mom drinking alcohol during pregnancy, and Fetal
Alcohol Syndrome. They also linked it with alcohol abuse and the effects it has on a
fetus. Ten of the participants believed that risks associated with alcohol-exposed
pregnancies were mainly birth defects. They believed that children exposed to alcohol
were faced with learning difficulties, social and behavioral problems, brain dysfunctions,
abnormal limbs and could possibly be stillborn. One participant had a sister who adopted
twins who were exposed to alcohol. She noted that she believed these children had
marked disabilities because of the alcohol exposure. According to the participant, the
children have been plagued with low immune systems, emotional problems, and weak
bladders. All of the participants agreed that consuming alcohol during pregnancy could
only cause harm to the baby.




                                                                                          9
All participants perceived the reasons for alcohol abuse to be stress, peer pressure, and
the high feeling after alcohol consumption. The staff believed that relationship (low self-
esteem and abuse) issues were also a contributing factor to alcohol abuse.

All of the staff believed that providing this intervention in conjunction with the other
services being rendered would influence women to participate in Project CHOICES.
They perceived that women would view this service as an added bonus. Also, providing
an incentive to the participants would help with program retention. The staff, however,
believed that lack of transportation, denial of actually having an alcohol problem, and the
lack of incentives given for program completion would hinder women of child-bearing
age from participating in Project CHOICES. They also believed that if the time lapse
between sessions is too long, it would encourage participants to miss appointments or to
completely drop out of the program.

   B. Relevant information

   1. Types of activities or service characteristics population is or is not willing to use

Participants in the focus groups did not identify specific services that they would be
unwilling to use, however this may be due to intimidation because of their client status.
Based upon past experience with engagement of clients, in general women of child-
bearing age who may be at risk of having an alcohol-exposed pregnancy can be reluctant
to seek services due to the stigma associated with mental and behavioral disorders. Other
barriers to service include being cost prohibitive, inconvenient timing, or not perceiving
the need for or benefit of the service.

Participants in the focus groups generally affirmed the treatment modality that they are
currently participating in (e.g. Clubhouse, HIP HOP, relapse prevention, etc.). The
programs were perceived as “beneficial,” and participants reported looking forward to
attending the sessions. These modalities all incorporate a psychosocial education
component in a group format. They reported learning information that was valuable to
their sobriety including: how to avoid relapse; negotiating safer sex; and avoiding other
high risk behaviors that contribute to their substance dependency.

A crucial element to service delivery is cultural competence, especially with a large
minority population. As an example, cultural beliefs may impact an African American’s
decision to accept treatment. Mistrust of the mental health profession dates back in the
United States to the 19th century when African Americans were labeled with bizarre
mental conditions. In keeping with this, many studies report that African Americans
have a preference for service providers from their own ethnic backgrounds (Nickerson,
Helms, & Terrell, 1994; Sue, Zane, & Young, 1993; Beal, Abrams & Saul, 2003).
Cultural differences influence how consumers conceptualize substance abuse and mental
illness, recognize their own distress, communicate their distress, seek help, and
participate in treatment. Combined with the continuing growth of immigrant populations,
empowerment of women, diverse ranges of socioeconomic status, open choices of sexual
orientation, and large numbers of individuals lacking literacy skills, there is a need to


                                                                                        10
ensure cultural competency within the treatment protocols. Service delivery will still
need to be tailored to meet the unique cultural experiences of different consumer groups.
Each mode of treatment must be adapted to be congruent with the target population’s
cultural beliefs and values yet maintain fidelity to the treatment model in order to achieve
desired outcomes.

   2. Referral sources and other services clients may use or that reinforce efforts

No information pertaining to referral sources was obtained during the focus groups.
However, past experience with similar programs provides valuable information regarding
networking opportunities. Two types of programs were queried for information: 1)
psychosocial education programs; and 2) substance abuse treatment programs.

The staff from the psychosocial education programs (Clubhouse, HIP- HOP, and
CHOICES) was examined for referral sources and other services that may be utilized by
clients. The Clubhouse primarily relies upon referrals from the mental health centers.
Both of the HIV prevention programs listed community health centers, public health
department, shelters, beauty and barber shops, night clubs, probation and parole offices,
and houses of worship. They also stated that social marketing through health fairs, radio
shows, and public appearances have been fruitful.

The staff from substance abuse treatment programs reported a two tier approach to
outreach for clients. The first tier involves education regarding substance abuse
treatment. This is accomplished through the website, brochures, commercials, and a
marketing representative who calls on possible referral sources. The second tier involves
contact; that is making contact with specific referral sources in order to persuade
potential clients of the benefits of services. The various referral sources that are currently
utilized are: hospitals, private physicians; health clinics; treatment centers; mental health
centers; pain clinics; D.U.I. courts; drug courts; criminal courts; probation and parole
officers; prisons; industries; veteran serving organizations; homeless shelters; domestic
abuse shelters; and college campuses.

Case management is integral to reinforcing and supporting behaviors and positive
attitudes gained during the therapeutic process. The case manager provides social
services linkages, emergency and crisis intervention, advocacy, consultation and
educational services to assist the participants in the recovery process. The case
management service plan will address the clients’ bio-psycho-social needs. It is the case
manager’s responsibility to locate and broker for other services that will reinforce efforts
including: primary healthcare; housing; educational assistance; workforce assistance;
transportation; medications; childcare; and financial assistance. PBMHR, through its
thirty-plus years of experience, has an extensive list of sources to call upon for client
assistance.

    3. People or institutions that influence the population
The act of seeking treatment is often influenced by cultural beliefs, including the stigma
associated with disclosure, biases elicited from previous encounters with the system of



                                                                                           11
treatment, and cultural identification with treatment providers (Hines-Martin, Malone,
Kim, & Brown-Piper, 2003). Family members, local faith-based organizations, and
mentors can potentially influence the target population by being a positive influence and
providing a support system that is vital to successfully completing their treatment and
abstaining from those unhealthy behaviors (Geronimus, 2000).

.

Peers who are, or who have, participated in the recovery process are also strong
influences upon consumers. A majority of the treatment clinicians are in recovery
themselves, and serve as positive models for the consumers. Through contact with a
clinician at the treatment facility, plans are formulated based upon the work
accomplished and knowledge gained during treatment to prepare for the transition back to
day-to-day life. Concurrently, time is spent educating the family and/or workplace on
how to support the consumer's recovery. As a group, the consumer and stakeholders
identify resources in the recovering person's local community that will support and
reinforce the prescribed continuing-care plan; and identify resources that would be of
benefit to the family, such as therapists, family programs, and organizations such as Al-
Anon.

    4. Existing data related to FASD prevalence and consumption of alcohol by
       women of childbearing age and pregnant women.)

It is very difficult to find prevalence statistics on FASD. Mississippi has one of the
highest rates of children with developmental disabilities in the United States. According
to the Mississippi State Department of Health’s FY2007 State Health Plan, the MDH uses
birth weight and gestational age obtained from birth certificates to monitor fetal
development. Low birth weight—less than 5.5 pounds (2,500 grams) at birth, and
prematurely—gestation age less than 37 weeks, are factors relating to inadequate prenatal
care, poor nutrition, lack of formal education, abject socioeconomic status, smoking,
alcohol or drug abuse, and age of the mother. In 2004, 21.9 percent of births were either
low birth weight or premature. These indicators differ markedly by race of the mother.
Low birth weight was 74.7 percent higher among nonwhite mothers: 8.7 for whites,
against 15.2 percent for nonwhites. The rate of births that were either low birth weight or
premature were 42.7 percent higher among non-white mothers (14.3 percent for whites
versus 20.4 percent for non-whites). In addition, the plan indicated that the state would
target alcohol consumption among teenagers as an attempt to decrease infant mortality
and increase health.

In 1994, (the most recent publication that could be found) the CDC reported Mississippi
to have the lowest rate of pregnant women consuming alcohol in the country (3.9
percent). However, in 2004, ten years later, the National Organization on Fetal Alcohol
Syndrome noted Mississippi to have one of the highest rates of female binge drinking
(9.9 percent). These contradictions make it difficult to draw accurate conclusions
regarding the severity of the problem. Suffice it to say that PBMHR treated 742 women




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of childbearing age for substance abuse last year within its nine county service area, and
this was a small portion of those who probably required a treatment intervention.

IV. Implications and Recommendations

   A. Refinement of the target audience

The target population is ideal for the intervention. In addition to having a substance
abuse disorder, participants in the focus groups indicated that the target population either
did not use contraceptives or used them ineffectively, had little or no support system, and
identified stress and peer pressure as a precursor to drinking. In addition to the chosen
target population, including women of childbearing age with SMI for the intervention is
indicated for several reasons: 1) the nature of their mental illness causes erratic and
undisciplined behaviors such as binge drinking, promiscuity, and unprotected sex; 2)
national statistics, chart reviews, and anecdotal interviews suggest that a large portion of
this population is not properly diagnosed with a co-occurring substance disorder; and 3) a
large portion of this population may not admit to drinking and go undiagnosed.

   B. Factors that influence the audience

All of the focus group staff believed that providing this intervention in conjunction with
the other services being rendered would influence women to make better choices. They
perceived that women would view this service as an added bonus. They also stated that
the target audience may be influenced to complete the program by the use of incentives.
Offering this in conjunction with current services would overcome the barrier of
transportation by not adding another time to travel. Family members, local faith-based
organizations, and mentors can potentially influence the target population by being a
positive influence and providing an unequivocal support network that is vital to
successfully completing their treatment programs and abstaining from risky behaviors.


Consumers must perceive that the intervention is relevant to their needs. For this reason,
it will be important for interventionists to engage participants at their particular stage of
readiness to change (Prochaska & DiClemente, 1983). Open ended questions should be
asked to solicit pertinent details about problem areas, support systems, and the cultural
context of the consumer’s world. Detailed information about mental health and
substance abuse symptoms such as duration, content, control, perception of cause,
exacerbating and tempering factors, and management skills should be solicited in order to
determine the consumer’s level of motivation. The consumer should be asked to give in-
depth information about factors that contribute to and inhibit their recovery and their
efforts to manage the disease. The clinician should determine treatment goals utilizing
motivational interviewing. Motivational interviewing can be used to assist the reluctant
participant with resolving ambivalence and committing to change.




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Lastly, consumer trust in the practitioner will be important. Development of a
therapeutic alliance is crucial to behavioral changes. A critical element in the therapeutic
alliance is the consumer’s perception of the service provider’s cultural competency.

C. Potential opportunities, obstacles, strengths and weaknesses relevant to program
development

Training will be crucial to the successful implementation of the project. Although the
staff of Pine Belt Mental Healthcare Resources has extensive experience working with
the targeted population, maximum success will be dependent upon training in the
evidence based practice. Since FASD prevention has not been specifically screened for in
the past, this will require some minor organizational changes to take place. This should
be accomplished by: 1) developing an internal social marketing campaign; 2) training in
the evidence based practice; 3) implementing the evidence based practice; 4) closely
supervising the implementation for fidelity; 5) providing a forum for two way feedback;
and 6) monitoring the outcomes.

A potential barrier to success will be overcoming the nature of addiction and dependence
upon substances. Relapse rates universally range from 50-70 percent. In order to prevent
relapse and promote healthy babies, familial and social support will be crucial to
successful treatment, particularly for participants in outpatient treatment. Negative
reinforcement of problematic behaviors must be identified and eradicated. The case
manager and others in supportive relationships should collaboratively work to identify
and address such influences.

A strength of this project is the agency’s long history of service delivery. There is a
target audience that is easily accessible. Using existing clients eliminates the barrier of
developing trust, although outreach for new participants should be fostered. The agency’s
experience in the delivery of HIV prevention interventions has already provided
important lessons in targeted outreach and cultural competency.

Another strength is the agency’s extensive infrastructure. With a large staff already in
place, recruitment for project personnel is not an obstacle. Support services are readily
available including case management, Management Information System (MIS),
accounting, clerical, and supervisory services. The physical plants are established and
easily located. All are accredited by the Commission on Accreditation of Rehabilitation
Facilities (CARF), certified by the Mississippi Department of Mental Health, and ADA
accessible.

 Sharing positive outcomes with the various referral sources will create opportunities to
network and promote the availability of the intervention within our service area. It is
expected that outreach will become self sustaining as positive outcomes for clients are
shared with other members of the targeted population. Costs to serve clients that access
preventive interventions and prevent pregnancies or have healthy babies will be
compared to the costs of serving and providing medical care to those with alcohol
exposed pregnancies. This savings will be presented to a variety of funding sources,



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which may include boards of supervisors, Department of Corrections, Department of
Health, Department of Mental Health, etc., to sustain funding. Pine Belt Mental
Healthcare Resources will also access other third payer sources such as insurance and
Medicaid, when appropriate, and will continue to pursue foundation and federal grant
sources.

Another strength of PBMHR is their practice of treatment using the recovery model.
Interested stakeholders in the recovery process usually involve a close family member or
friend. Treatment at PBMHR is person centered in that it places primacy of the
consumers and their interested stakeholders at the center of participation in all aspects of
the care delivery process. When PBMHR staff interact with consumers, they are aware
that cultural heritage, ethnicity, age, and sexual orientation may impact beliefs, values
and preferences for care. Communication is framed in understandable language, carefully
avoiding subtle messages that professional language and diagnostic labels may convey.

PBMHR provides culturally competent services by assessing the needs of each
participant in terms of how each person’s heritage has been adapted to the current
environment in order to form a world view. Clinicians and other service providers
investigate how the individual’s recovery issues and drug issues are influenced by his/her
cultural views of drug and alcohol use, life problems, help seeking, relapse and recovery.
Clinicians recognize the multiple aspects in each consumer’s identity that affect recovery;
individualize the counseling approach; avoid assumptions; and grow the therapeutic
relationship through the accommodation of cultural values and responding to cultural
verbal and non-verbal communication styles.

The Hispanic population has grown tremendously since Hurricane Katrina; however the
agency has little evidence of engagement in services. Little health data exist about
Hispanic/Latina women's knowledge of the effects of alcohol during pregnancy on the
fetus. If the project sees an increase in Hispanic women accessing services, it may be
beneficial to conduct an additional needs assessment specific to this subgroup.

Currently, Project CHOICES is being implemented in three of the nine counties in
PBMHR’s service area. The success in these counties could potentially lead to an
opportunity to offer this intervention in all of the counties serviced by Pine Belt Mental
Healthcare Resources.

   D: Insights relevant to developing the intervention and integrating it into the
   current service delivery organization

The proposed activities will enhance and expand upon the services that are already
provided by PBMHR. Clinical services will be provided by clinicians already employed
by the agency. Likewise, psychiatric, case management, and residential services will be
provided at the same locations with existing staff. Supportive services required to
accommodate project activities, such as MIS system, office equipment, office space,
accounting services, janitorial, telephones, internet, transportation, human resources and
clerical assistance are already in place. Other federally funded projects will be linked to



                                                                                         15
in order to broaden service offerings. Project funding will be primarily used to improve
upon treatment to a population already targeted for services through the additional
offering of a full system of care for co-occurring disorders.

Project CHOICES is the practice that will be implemented to facilitate the prevention of
alcohol involved pregnancies. All of PBMHR clinicians are already trained in
motivational interviewing; therefore it is expected that acceptance and utilization of the
intervention will be relatively easy. The intervention can easily be integrated into the
treatment plan by incorporating the sessions into the therapy sessions. Clinicians will
initially receive training in the intervention, and will practice through behavior modeling.
Supervisors will perform monthly fidelity checks the first six months of implementation,
and will provide feedback to the clinicians. Once fidelity checks score highly on a
consistent basis (three months in a row), fidelity checks for the clinician will be scaled
back to quarterly checks.

Administrative staff will need to carefully monitor each clinician’s caseload in order to
avoid overloading him/her due to the extra intervention. “Buy in” by the clinicians is
integral to the intervention’s success; therefore, it will be important to ensure that
clinicians do not perceive it as “extra work” and, as a result, punitive. If the intervention
is effectively integrated into their current caseloads, it can be viewed by clinicians and
consumers alike to be a seamless, natural extension of therapy delivered to match
individual needs.

Administrative staff should consider the possibility of providing incentives for
participation and/or project completion. The staff felt strongly that this would facilitate
consumer acceptance, and similar programs (e.g. HIP HOP and CHOICES) have had
success with this practice.

If the agency decides to additionally target women with SMI, the timing of the sessions
should be reviewed and adjusted for more frequency and shorter time spans between
appointments. Most of these consumers have monthly sessions, which staff feels may
contribute to dropping out and/or missing appointments. If transportation is a problem,
the agency may either consider providing transportation or conducting group sessions in a
closer community-based setting.

In order to objectively determine the best interventions and whom they may benefit, it is
crucial that PBMHR dedicate resources to data collection and assessment. Time must be
invested into the development of a comprehensive data collection plan, training front-line
staff in its utilization, and timely collation and dissemination of the results. The data
collection efforts could be easily embedded into the current processes by the insertion of
an additional form at the intake. This form should be set up for the new electronic
medical records system at the beginning of its use. If the data specific to this project is
determined to be reliable and valid, then decision makers will be able to make informed
decisions on project progress, processes, and effectiveness.

   E:Reasons FASD prevention is needed in the organization



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PBMHR has established access to a population at high risk to have alcohol involved
pregnancies. This places the agency in an excellent strategic position to conduct targeted
preventive interventions. The integration of evidence based prevention interventions for
alcohol involved pregnancies will add another component to PBMHR’s composite
system of care and will target a priority population of the state of Mississippi.

PBMHR has experience with similar interventions and can draw upon their experiences
in their implementation. It has an extensive referral base and a broad network of
collaborators to provide supportive services. The similar programs that have been
initiated for high risk populations (HIV, homeless) have had very good consumer
outcomes.

PBMHR’s solid infrastructure not only enhances its ability to initiate and implement the
intervention, but increases the possibility of its sustainability. Grant funding will provide
seed money to initiate the practice and assess preliminary outcomes, but the agency will
be able to successfully sustain it by integrating it into its continuum of care. Once the
program is established and outcomes documented, the project could feasibly be expanded
into the rest of PBMHR’s service area.




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