A study of appropriate methods of drug abuse education for use in the WIC program : final report

              United States
Department of A Study of
Appropriate Methods
of Drug Abuse
Education for Use
in the WIC Program
FINAL REPORT:
A STUDY OF APPROPRIATE
METHODS OF DRUG ABUSE EDUCATION
FOR USE IN THE WIC PROGRAM
CONTRACT NUMBER 53-3198-9-010
SUBMITTED TO:
U.S. DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE
OFFICE OF ANALYSIS AND EVALUATION
3101 PARK CENTER DRIVE, ROOM 210
ALEXANDRIA, VA 22302
SUBMITTED BY:
THE AMERICAN COUNCIL FOR DRUG EDUCATION
204 MONROE STREET, SUITE 110
ROCKVILLE, MD 20850
PREPARED BY:
MR. LEE I. DOGOLOFF - AMERICAN COUNCIL FOR DRUG EDUCATION
MS. LYNN SPECTOR - AMERICAN COUNCIL FOR DRUG EDUCATION
MR. MICHAEL PUMA - ABT, ASSOCIATES, INC.
MS. BONNIE RANDALL - ABT, ASSOCIATES, INC.
JANUARY 1990
Opinions expressed in this report are those of the authors and do
not necessarily reflect the opinions or official policy of the
Food and Nutrition Service or the U.S. Department of Agriculture.
ACKNOWLEDGEMENTS
This report was prepared by the American Council for Drug
Education with substantial assistance from Michael Puma and
Bonnie Randall of Abt Associates, Inc. This project has been
conducted under the overall direction of Jill Randell, Office of
Analysis and Evaluation, Food and Nutrition Service, U.S.
Department of Agriculture with significant assistance from Sandra
Bastone and Paula Carney of the Special Supplemental Food Program
for Women, Infants and Children.
Lee I. Dogoloff Lynn Spector
Project Director Program Manager
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS i
TABLE OF CONTENTS ii
EXECUTIVE SUMMARY V
CHAPTER 1: INTRODUCTION 1-1
THE CONGRESSIONAL MANDATE , 1-1
OVERVIEW OF WIC 1-3
Eligibility for WIC 1-3
Local Agencies 1-4
WIC Services . .. , 1-4
Certification 1-5
Referrals 1-5
Nutrition Education 1-6
Current Drug Abuse Information
and Referral Activities 1-8
CHAPTER 2: DRUG ABUSE AMONG PREGNANT WOMEN:
PREVALENCE AND CONSEQUENCES 2-1
PREVALENCE AND PATTERNS OF DRUG ABUSE 2-1
THE CONSEQUENCES OF ALCOHOL AND OTHER
DRUG USE DURING PREGNANCY 2-4
Alcohol 2-4
Tobacco 2-5
Marijuana 2-6
Sedatives, Hypnotics and Tranquilizers 2-7
Cocaine and Other Stimulants 2-8
Opiates and Synthetic Narcotics 2-11
Phencyclidine (PCP) 2-12
Inhalants and Solvents 2-13
Other Concerns 2-13
CHAPTER 3: EFFECTIVE APPROACHES TO DRUG
ABUSE PREVENTION 3-1
THE PUBLIC HEALTH MODEL OF DRUG ABUSE
PREVENTION 3-1
SUCCESSFUL APPROACHES TO DISSEMINATION 3-2
Targeting High-Risk Individuals 3-3
ii
ES
Targeting Points of Increased
Receptivity. 3-4
A Positive Manner of Presentation 3-4
Sufficient Duration of Effort 3-4
Linkages Among Services 3-5
Appropriate Staffing 3-5
Reducing Barriers to Participation 3-5
Methods to Increase Appeal and
Comprehension 3-5
A Variety of Methods of
Communication 3-6
Individual Counseling 3-6
Group Discussions 3-7
Print Materials 3-7
Graphics 3-8
Audiovisuals 3-9
Examples of Programs 3-10
Programs for Nonusers and
Nondependent Users 3-10
Programs for Chemically
Dependent Users < 3-13
APPROACHES TO SCREENING AND REFERRAL 3-15
Screening Techniques 3-15
Types of Screening Instruments
Used 3-16
How Questions are Posed 3-18
Location and Timing of Screening 3-19
Format of the Screening Instrument 3-19
Characteristics of the Questioner 3-20
Referral 3-21
Identifying Referral Sources 3-21
Defining a Protocol for Referral 3-22
Handling Refusals 3-23
Establishing Linkages Among
Programs 3-24
Training Staff in the Referral
Process 3-2 5
Availability of Treatment 3-26
Exemplary Treatment Programs
for Pregnant Women 3-28
CHAPTER 4: RECOMMENDATIONS 4-1
WIC Program Responsibility Should Be
Limited to Information and Referral 4-1
Drug Abuse Prevention Activities Should
Be Nonthreatening 4-1
in
f
Information and Referral Efforts Should
Reflect the Characteristics of WIC
Participants 4~2
Information Efforts Should Be Tailored
to the Types of Drug Abuse Problems
Typically Found in the Community 4-3
Drug Abuse Information Should Be Provided
Through Personal Contact 4-4
Information Activities Should Distinguish
Nonusers and Nondependent Users From
Chemically Dependent Users 4-4
Local WIC Agencies Should Establish
Linkages with Local Drug Abuse Services...4-4
Local WIC Agency Staff Should Be Trained
in Providing Drug Abuse Information and
Referral Services 4-5
WIC State Agencies Should Develop Drug
Abuse Referral Procedures for
Implementation at Local Agencies 4-6
Participants Should Be Screened for
Referral to Needed Services 4-7
USDA Should Develop a Videotape and a
Brochure on Drugs and Pregnancy for WIC
Participants and a Resource Manual and
a Videotape for WIC Professionals on
Providing Drug Abuse Information and
Conducting Referrals 4-8
EXHIBIT I E_1
REFERENCES R_1
IV
f
EXECUTIVE SUMMARY
This Report has been prepared in response to the
Congressional mandate (the Anti-drug Abuse Act of
1988 P.L. 100-690) for a study of "appropriate
methods of drug abuse education instruction" for
use in the Special Supplemental Food Program for
Women, Infants and Children (WIC). Administered
by the Food and Nutrition Service (FNS), of the
U.S. Department of Agriculture (USDA), WIC is a
federal nutrition assistance program that serves
approximately 4 million women, infants and
children nationwide. Following the completion of
this Report, the Secretary of Agriculture is
reguired to "prepare materials for the purposes of
drug education...and to distribute the
materials...to each State agency for distribution
to local agencies participating in the
program...."
Introduction
Drug Abuse
During
Pregnancy
Comprehensive national data on the prevalence of
drug abuse (including abuse of alcohol, tobacco,
and other drugs) among pregnant women are sparse
To fill this gap, the National Institute on Drug
Abuse (NIDA) has recently begun a national study
of in utero drug exposure.
Reports from various drug treatment programs,
clinical observations, and national surveys
indicate that alcohol and other drug use among
pregnant women is a serious problem that is
growing. For example, recent results from a
survey conducted by the Select Committee on
Children, Youth and Families show the incidence of
drug-exposed newborns to range between 4 and 18
percent of all live births. Moreover, the
percentage of newborns exposed to drugs in utero
increased at some hospitals by more than 200
percent from 1987 to 1988.
Although vague on the prevalence of alcohol and
other drug use, the literature is guite clear on
the effects of drug use during pregnancy. The use
of illicit as well as licit drugs (e.g., alcohol,
tobacco, over-the-counter medications) is
associated with a myriad of negative conseguences
for both the woman and her child. First, the
increased risk of obstetrical complications
exacerbates the already severe health problems
7
associated with drug and alcohol abuse. Second,
in utero exposure to alcohol and other drugs has a
powerful effect on the health of the fetus and, in
some cases, has long-term developmental
consequences as well. Third, women who abuse
drugs and alcohol place themselves and their
children at greatly increased risk for a host of
other problems, including criminal prosecution,
related dysfunctional behavior (e.g.,
prostitution), and exposure to acquired
immunodeficiency syndrome (AIDS) and a variety of
other infectious diseases. Finally, drug users
are far more likely to abuse and neglect their
children than nonusers, thereby further increasing
any developmental damage that may have resulted
from in utero exposure to drugs.
The Role The WIC Program provides supplemental foods,
of WIC nutrition education, and referrals to health and
social services for pregnant, breastfeeding, and
postpartum women and infants and children (up to
age five) who are at nutritional risk. Although
not currently required in WIC, some State and
local agencies have taken the initiative to
incorporate providing drug abuse information into
existing program operations. Nutrition education
has been deemed particularly important in this
regard since many drugs can suppress the appetite.
As described in the legislative mandate and the
accompanying floor colloquy, the role of WIC in
drug abuse education is intended to be limited to
the provision of information and, for participants
who need help, referral to providers of drug abuse
services. Specifically, the role of State and
local WIC agencies should be to:
• raise awareness of the dangers of drug abuse by
disseminating information to all adult
participants and the parents or caretakers of
infant and child participants;
• conduct screening of participants only to the
extent necessary to determine whether there is
possible alcohol and other drug use; and
• facilitate access to professional assessment
and treatment, as appropriate, by providing
referrals to available community programs.
vi
r
As intended by Congress, WIC staff are not
required to assess the extent of individual drug
abuse problems, provide counseling, or attempt to
treat chemically dependent women. These important
services should be provided by trained drug and
alcohol professionals.
Furthermore, it should be noted that many local
WIC agencies will not be able to refer their
participants to alcohol and other drug treatment
programs because of shortages in available
services, location, cost, or eligibility
requirements.
Finally, the introduction or expansion of existing
drug abuse information and referral activities
should not reduce or impair existing nutrition
education programs, or any of the other vital
aspects of current operations.
Characteristics To develop appropriate drug abuse information and
of WIC
Participants
referral methods, certain characteristics of WIC
participants must be recognized. First, in Fiscal
Year 1988, 13.9 percent of enrolled participants
were pregnant women. Evidence suggests that women
who become pregnant are often more likely than
their nonpregnant peers to change their drug-using
behavior. Few women initiate drug use during
pregnancy, and many of those who are early-stage
users quit or reduce their use of harmful
substances. Pregnancy is considered a bench mark
period in a woman's life. Research indicates that
behavior frequently changes at such a transition
time when the individual moves from one life
situation or role to another. During pregnancy,
women are thought to be more receptive to messages
urging them to adopt a range of healthy behaviors.
Although never using drugs is the ideal, quitting
or reducing use during pregnancy is of substantial
benefit to both the mother and the child. It is
also likely that WIC participants, having made the
investment to seek out and obtain WIC benefits,
are concerned about their health and that of their
children. Consequently, they may be more
motivated than their peers and more likely to
alter their behavior if exposed to an
informational program.
Second, WIC participants are generally young,
economically disadvantaged, and poorly educated.
Substantial numbers belong to ethnic minorities
VII
and speak English as a second language. To exert
an impact on this population, any information
provided should be suitable for persons with low
literacy skills. It also should reflect the
diversity of ethnic and cultural backgrounds
represented in the WIC Program and should be
available in the foreign languages used by
participants.
Finally, for many participants, WIC provides an
opportunity to receive not only necessary
supplemental foods, but also appropriate referral
to prenatal care. In the absence of WIC, these
women might forgo such care or seek services only
at the very end of their pregnancies. Consequently,
drug abuse prevention efforts must not deter women
from entering the WIC Program, a result that would
clearly undermine the intended benefits of the
mandated drug education activities.
Study This study of appropriate methods of information
Scope dissemination and referral is based on a number
of sources:
• a wide-ranging manual and computerized review
of the literature on drugs and pregnancy and
approaches to drug abuse prevention and
treatment;
• a review of Federally-supported research and
program demonstration grants on drug abuse
related to prevention, women, high-risk youth,
and ethnic-minority populations;
• descriptive program materials and evaluations
supplied by FNS and selected local WIC
programs, community-based drug and alcohol
abuse treatment programs, AIDS prevention
programs, providers of prenatal services, and
teen pregnancy programs;
• consultation with representatives from the
Office of Maternal and Child Health (who
discussed their own projects and a cooperative
initiative on pregnant substance abusers
conducted jointly by Maternal and Child Health
and the Office of Substance Abuse Prevention);
the National Healthy Mothers, Healthy Babies
Coalition; the national office of the March of
Dimes; and the Office of the General Counsel of
the Alcohol, Drug Abuse and Mental Health
Administration; and
viii
10
Characteristics
of Information
Provided
• a review of health education materials related
to providing information to populations with
low literacy skills.
The rest of this summary describes the results of
this study and recommendations for the WIC
Program.
Information Dissemination
Person-to-person communication is the most
effective way to convey information, especially on
such a sensitive subject as drug abuse. But, to
work properly, the person providing the
information must be trusted by the client, able to
communicate in the client's native language, and
capable of establishing the necessary rapport with
the client. Personal contact should also be
supplemented and reinforced by print or
audiovisual materials, or both, geared
specifically to the interests of WIC participants.
Information must be presented in a positive,
nonthreatening manner. Research has shown that
fear- or guilt-inducing messages can have little
effect on the intended target audience. Negative
information can confirm the hopelessness of a
person's current situation and convince her of the
futility of change. Although information provided
to WIC participants should state that abstinence
from illegal drugs, tobacco and alcohol is the
best course for pregnant women to follow, reducing
levels of use yields substantial benefits to
mother and child and should be strongly
encouraged.
Information should also be relevant to the culture
and life situations of the intended audience. The
more an individual can identify with the
information being conveyed, the more likely she is
to receive the intended message. An attempt
should be made to involve participants in setting
agendas for group educational sessions, evaluating
the relevance of the information provided and
identifying areas of unmet need. Information
efforts should reflect the specific drug abuse
problems that are most likely to be affecting a
local WIC agency's clients. In addition, since
nonusers and nondependent users respond
differently to information than chemically
dependent users, both audiences should be
considered when selecting and developing
ix
//
information materials. Once the characteristics
of the target audience are known (i.e. the number
of users vs. nonusers), the program should be
directed to the majority.
Finally, information should be easily understood
by the recipients. This may mean using languages
other than English and materials at a low reading
level. When possible, materials should also use
common jargon and slang rather than clinical
terminology.
Methods of Research has shown that the use of a variety of
Communication communication methods is preferable because
individuals differ in their learning styles.
However, for many WIC agencies, a multimedia
approach may be prohibitively expensive. This
section reviews each of the major approaches, with
recommendations for each.
Print. Although currently available print
materials have not proven effective with low-income
persons having low literacy skills, print
materials do afford a number of important
advantages. Printed documents are relatively
inexpensive, portable, capable of being shared
(especially among family members), available for
use at any time by the client, and can provide
lists of resources that can be contacted for help.
If print materials are used, they should be
visually appealing; use short, conversational
sentences, an active voice, and familiar
vocabulary; and employ simple, clear illustrations
to increase visual appeal and reinforce important
concepts and messages.
Graphics. As used in posters and other print
materials, graphics can be appealing and can help
clarify and reinforce important messages.
However, such items tend to be more expensive than
simple printed materials. Their appeal is also
subjective: what might work with one individual
may be rejected by another. Consequently, care
should be taken when selecting graphics for use in
an informational activity. Viewers should be able
to identify with the visual images. Images and
captions should be simple, clear, and direct.
These materials should be pretested with the
target audience.
Audioviauals. Although expensive, films and
videotapes can be very effective with persons with
12^
Screening
Questions
Making
Referrals
low literacy skills. Visual images and the spoken
word are excellent substitutes for reading, which
may be very difficult for some clients.
Unfortunately, many currently available films are
not appropriate for WIC participants. In
selecting audiovisuals, WIC should ensure that the
messages, language, and situations portrayed are
relevant so that participants can relate their own
life experiences to those depicted.
Screening and Referral
It is important to identify persons who may be
using drugs and to refer them for assessment and
specialized assistance. Identification of
suspected drug and alcohol abuse has been termed
the first step in treating the problem. However,
to be effective, local WIC agencies must be
willing to ask questions about drug and alcohol
use, have adequate information about available
sources of professional assessment and assistance,
and have a viable system for making referrals and
for involving participants actively and
appropriately in the referral process. Questions
should be asked at the time of certification or
recertification to determine if the participant
may have a problem with alcohol or other drugs.
Connections with community-based service providers
should be established and participants should be
supported in their efforts to pursue referrals.
Perhaps the most important benefit derived from an
active effort to forge linkages among referring
agencies and assessment and treatment resources is
improved case management.
Screening questions for drug abuse should be
embedded where appropriate within the nutritional
history so they appear natural and nonthreatening.
Because the literature shows that personal contact
plays such an important role in conveying
information to the target population, and because
chemically dependent women tend to misreport their
drug and alcohol use, self-administered screening
questionnaires are not recommended.
If responses to screening questions indicate that
alcohol or rug abuse may be a possibility, an
immediate referral for assessment should be made.
The need for referral should be expressed in
positive terms, and the participant's involvement
in deciding on the referral agency should be
encouraged.
xi
ft
Following Up
Referrals
Referral for further assessment, even when the
referral is rejected, is a powerful method for
penetrating the denial practiced by alcohol and
drug abusers and signals that the problem is an
urgent matter and should be taken seriously.
Regardless of whether a referral is accepted or
rejected, a simple notation should be made
indicating that a referral was suggested and, if
accepted, when and to whom the referral was made.
If resources permit, local WIC agencies should
follow up on referrals. This information could
then be used by WIC staff to support participants'
efforts to control their drug and alcohol problems.
Where multiple services (including WIC) are lodged
under one roof, local WIC agencies should explore the
possibility of developing cooperative information and
referral activities. Ideally, the referral
organization should send the local WIC agency a form
or contact the agency by telephone to report that the
referral appointment has been kept.
Barriers To
Treatment
Required
Staff
Training
In some areas
make it impos
the services
language spok
of child care
income woman
issues, such
or neglect, a
dependent pre
, existing barriers to treatment will
sible for WIC participants to receive
they need. Location, hours, cost,
en, staff composition and availability
are factors influencing whether a low-can
participate in treatment. Other
as fear of prosecution for child abuse
lso pose obstacles for chemically
gnant women in some states.
Training staff in the effects of drugs and alcohol on
pregnancy and in methods of providing information,
conducting a screening, and making a referral is
essential if information and referral services are to
be effective. WIC staff may feel anxious about
asking sensitive questions about socially disapproved
or illegal behavior. Experientially based training
could alleviate much of this concern. Experientially
based training simulates "real-life" screening and
referral situations through role playing, then
applies the techniques developed in a series of
genuine interviews which are observed and/or reviewed
as case studies during weekly staff meetings.
In some communities, drug and alcohol abuse treatment
programs frequently are equipped to provide training
XII
w
services to social service organizations and to serve
as consultants and mentors to agency staff. Tapping
existing drug and alcohol programs for training
services would be cost-effective, would ensure that
the training provided covered problems specific to a
community's population, and would be the first step
in creating a link to available drug and alcohol
programs for referrals.
A local agency lacking such resources should consider
a combined training program using a self-instructional
manual along with training consultation
from a community mental health center or public
health agency. FNS is developing a manual which will
provide information about the effects of alcohol and
other drugs as well as guidelines for providing
information, conducting screenings, and making
referrals. Skilled personnel from mental health and
public health agencies could demonstrate how they
educate clients and how they screen and refer. A
training videotape, which could be developed by FNS
specifically for WIC staff, is another option that
should be considered to enhance screening and
referral skills.
General Recommendations
• WIC program responsibility should be limited to
information and referral.
• Drug abuse prevention activities should be
nonthreatening.
• Information and referral efforts should reflect
the characteristics of WIC participants.
• Information efforts should be tailored to the
types of drug abuse problems typically found in
the community.
• Drug abuse information should be provided through
personal contact.
• Information activities should distinguish nonusers
and nondependent users from chemically dependent
users.
• Local WIC agencies should establish linkages with
local drug abuse services.
xm
M
Local WIC agency staff should be trained in
providing drug abuse information and referral
services.
WIC State agencies should develop drug abuse
referral procedures for implementation at local
agencies.
Participants should be screened for referral to
needed services.
USDA should develop a videotape and a brochure on
drugs and pregnancy for WIC participants and a
resource manual and a videotape for WIC
professionals on providing drug abuse information
and conducting referrals.
xiv
\<e
1. INTRODUCTION
This chapter reviews the Congressional mandate to add
drug abuse information and referral activities to the
Special Supplemental Food Program for Women, Infants
and Children (WIC) and presents an overview of WIC
operations. Throughout this report, the term "drug
abuse" refers to the misuse of alcohol, tobacco, and
other drugs, including marijuana, sedatives,
hypnotics, tranquilizers, cocaine and other
stimulants, opiates and synthetic narcotics,
phencyclidine, inhalants and solvents.
The Congressional Mandate
The Anti-drug Abuse Act of 1988 (P.I,. 100-690),
enacted November 18, 1988, amended Section 17 of the
Child Nutrition Act of 1966 to add drug abuse
education to the existing reguirements of the WIC
Program. The key features of the amendments are as
follows:
• Drug abuse education in the WIC Program is
limited to the provision of information and
materials to WIC participants and, in the case
of suspected drug abusers, referral to drug
abuse clinics, treatment programs, counselors,
or other drug abuse professionals.
• Materials and instruction on drug abuse must be
provided in languages other than English in
areas where a substantial number of participants
speak another language.
• Drug abuse information and referrals should be
available to all pregnant, postpartum, and
breastfeeding women and the parents or
caretakers of participating infants and
children.
• States are reguired to document in their annual
plans how they intend to coordinate their drug
abuse information and referral activities with
existing education, counseling, and treatment
programs.
To support the States' efforts to enhance existing
drug abuse information and referral activities in the
WIC Program and integrate new ones, the Secretary of
Agriculture is reguired by the amendments to "conduct
a study with respect to appropriate methods of drug
abuse education instruction" within six months after
1-1
n
the enactment of the legislation. Following the
completion of this study, the Secretary is further
reguired to "prepare materials for purposes of drug
abuse education" and to "distribute the
materials...to each State agency for distribution to
local agencies participating in the program...."
The floor colloguy accompanying the legislative
changes provides additional information on
Congressional intent. First, drug abuse information
and referral efforts are not supposed to reduce or
impair existing nutrition education programs, or any
of the other vital aspects of current operations.
Further, to ensure maximum effectiveness, the
Congressional sponsors envisioned that the
development of drug abuse education materials would
not begin until after the completion of the mandated
study.
Second, the role of local WIC agency staff with
regard to drug abuse education was expected to be
relatively modest. As stated by Senator Leahy1,
providing materials to participants and making
referrals to clinics or treatment programs are
probably a part of existing operations. The largest
cost was expected to be related to the production and
distribution of materials, which, as noted, are to be
the responsibilities of the Secretary and the State
agencies. Most important, as Senator Leahy clearly
stated, "The bill does not reguire regular WIC staff
to perform drug abuse counseling. This very
important function should be provided to WIC
participants with drug or alcohol problems by drug or
alcohol clinics or treatment programs." The role of
WIC agencies, therefore, is to provide information,
and, when necessary, to facilitate the provision of
professional assistance by making referrals to
available community programs.
This report is intended to achieve four objectives:
• provide insight into drug abuse among WIC
participants and its implications for the
outcomes of pregnancy;
• review the state of the art in preventing
drug abuse and evaluate the applicability of
relevant strategies and technigues to the WIC
Program;
Congressional Record - Senate. October 21,
1988, p. S17316.
1-2
If
• provide information on the availability of
treatment programs for pregnant women; and
• recommend specific strategies for drug abuse
information and referral efforts in WIC
agencies.
The first item is the subject of Chapter 2; the
second and third objectives are addressed in Chapter
3; recommendations are provided in Chapter 4.
Overview of WIC
The WIC Program, administered by the Food and
Nutrition Service (FNS), U.S. Department of
Agriculture (USDA), is a Federal nutrition assistance
program, serving approximately 4 million women,
infants, and children nationwide. It provides
supplemental food, nutrition education, and referrals
to health and social services to pregnant,
breastfeeding, and postpartum women; infants; and
children up to age five. Participants must be from
low-income households and at nutritional risk.
The Program is operated by State Health Departments
and Indian Tribal Organizations and their local
service delivery agencies. WIC funds are distributed
by FNS to the States which, in turn, allocate monies
to local agencies. About 20 percent of all funds
appropriated to WIC are designated for nutrition
services and program administration.
Federal regulations provide guidelines on WIC
services and on qualifications for competent
professional authorities (CPAs), the health
professionals and trained paraprofessionals
responsible for determining individual eligibility
for services. However, within these Federal
guidelines, State and local program administrators
have wide latitude to design their operations to meet
State and local needs and objectives.
Eligibility Eligibility for WIC is determined along three
For WIC dimensions—categorical qualifications, nutritional
risk, and financial need. First, individuals must
fall within one of the eligible participant
categories, that is, pregnant, postpartum, or
breastfeeding women; infants; and children up to age
five. Second, individuals must meet income
eligibility standards established by the State in
which they reside. Finally, they must be determined
by a CPA to be at nutritional risk, as shown by
1-3
/3
Local
Agencies
WIC
Services
medical or nutritional assessments. As a group, WIC
participants are young (close to two-thirds of the
pregnant women are under the age of 24), have low
incomes (about two-thirds have incomes below the
poverty line), and belong disproportionately to
minority groups (more than half are nonwhite) (130).
Because WIC is not an entitlement program, in 1979
FNS established a priority system intended to guide
the distribution of benefits to persons most in need.
Each participant is assigned to one of six or seven
priority groups, which reflect the degree of
nutritional risk. Priorities I, II, and III are for
the participants at highest nutritional risk as
demonstrated by hematological or anthropometric
measurements or other documented nutritionally
related conditions. Participants with dietary risks
alone are assigned a lower priority.
State WIC agencies contract with local sponsors to
provide WIC services to eligible participants. Based
on data for 19&6, about 4 3 percent of local WIC
programs are sponsored by county health agencies, 36
percent are sponsored by State, district, community,
municipal, or Indian health agencies, and hospitals
account for another 5 percent of local sponsors.
About two-thirds of local service sites provide on-site
health care services (130).
Some local WIC programs offer services at only one
site, operating five days a week. Other WIC programs
operate several permanent sites five days a week.
Still others provide services at one or more
permanent sites and at satellite locations for a few
days or a few hours each month (these satellite
clinics are generally not co-located with public
health services).
WIC service delivery at the local agencies can be
grouped into five operational functions:
• Certification, which includes taking
applications and screening applicants,
determining eligibility based on income and
nutritional risk, and terminating eligibility.
• Nutrition educationf which encompasses
counseling individuals, conducting group
sessions, preparing nutrition education
materials and plans, and conducting staff
training in the provision of nutrition
education.
1-4
JUO
• Referrals to health and social service agencies,
which include assisting WIC participants in
gaining access to health care and related
services as well as helping WIC participants
obtain other social services.
• Food delivery, which includes tasks associated
with delivering food or food instruments to
participants as well as assigning and tailoring
food packages. Supplemental food is provided to
WIC participants through retail, home, or direct
delivery systems. Most States operate retail
delivery systems in which participants receive
food instruments (vouchers, coupons, or checks),
which they redeem at authorized retail vendors.
In home delivery systems food is delivered to
participants' homes, usually through contracts
with dairies. Where direct delivery systems are
used, food is distributed to participants at
central pickup sites.
• Outreach, which encompasses providing publicity
about WIC benefits and the WIC Program to
potential participants, food vendors, health
care providers, and social service agencies.
The three WIC functions that deal most directly with
drug information and referral are certification,
referrals and nutrition education.
Certification. Federal regulations specify the
general guidelines for certifying applicants or
recertifying participants for the WIC Program. Local
WIC staff known as competent professional authorities
(CPAs) determine eligibility based on income and
nutritional risk. Much of this information is
obtained through individual interviews conducted by
the CPA with applicants/participants. As part of the
interview, the CPA collects basic health information,
conducts a dietary assessment, and explains the WIC
program. In some WIC agencies, staff perform health
status assessments—usually fingersticks for
hematocrits—at this stage. In others, data is
obtained from outside health care providers.
Supplemental food packages also are prescribed as
part of the certification process.
Referrals. Local WIC agencies provide referrals to a
range of other services, such as child immunizations,
well-baby and well-child care, and obstetric health
care. For the most part, however, such referrals are
informal and there is little, if any, follow-up or
1-5
documentation of referral activities2. In some local
agencies, lists of sources of locally available
health and social services are given to WIC
participants or are made available in waiting rooms.
In local agencies that are co-located with health
service providers, WIC staff sometimes help
participants make appointments for other services or
even take participants to other clinics. But even in
these instances, there is limited follow-up and
documentation of referrals.
Nutrition Education. State WIC agencies are reguired
to spend at least one-sixth of their administrative
funds for nutrition education. Most funds are spent
on labor wages and fringe benefits for staff in local
WIC agencies. Nationwide, State WIC Programs spend
about 12 percent of their nutrition education budgets
on informational materials (54).
Each WIC participant must be offered a minimum of two
nutrition education contacts during each
certification period; about one-fourth of all local
services sites exceed this minimum reguirement (62).
WIC regulations specify that "nutrition education
shall be designed to be easily understood by
participants..., bear a practical relationship to
participant nutritional needs, household situations,
and cultural preferences..., be thoroughly integrated
into participant health care plans..., and is to be
taught in the context of the ethnic, cultural, and
geographic preferences of the participants and with
consideration for educational...limitations
experienced by the participants."
State WIC agencies are responsible for providing
ongoing staff training and identifying or developing
nutrition education resources. A number of States
have procured and prepared materials aimed at
specific categories or subcategories of WIC
participants (pregnant teenagers, e.g.); some even
provide audiovisual materials and eguipment (62).
2Little data currently exist on the nature
and extent of referrals in the WIC Program. This
discussion is based on unpublished information
obtained as part of a national study of the use of
WIC funds for nutrition education and administration,
Abt Associates, Inc., conducted this study in 1987.
1-6
Local agencies are responsible for providing
nutrition education services directly to
participants. A variety of staff provide nutrition
education: about half are nutritionists, dietitians,
or home economists; more than 20 percent are nurses,
public health workers, or social workers; and the
remaining 25 percent are paraprofessionals (8% are
clerical staff). About 11 percent are high school
graduates, 27 percent have gone beyond high school
but not received college degrees, 45 percent have
bachelor's degrees, and about 18 percent have
graduate degrees (62).
Nutrition education is provided through either
individual counseling or group classes. Although
individual sessions sometimes focus on general topics
(prenatal diet, e.g.), these sessions often involve
nutritional counseling directed toward the
individual's specific needs and risks. Group
sessions, in contrast, are often organized for
participants with common needs. There may be one
class for prenatal participants and another class for
mothers of infants, for example. Some agencies
prepare monthly or bimonthly classes on specific
topics.
About two-thirds of WIC service sites use individual
counseling, about two-thirds use displays or
distribute print material, and about one-fifth use
group sessions. When nutrition education is provided
through a group session, the class is most likely to
be small (two to nine participants). During
individual sessions, participants are most likely to
be given pamphlets and watch demonstrations with food
models; at group sessions, slides, films, and flip
charts are occasionally used (62).
An individual session usually lasts about 15 minutes;
the typical group session lasts about 20 minutes. A
participant who receives the two required contacts
per certification period receives an average of 32 to
52 minutes of nutrition education (62). Agency staff
cover a range of topics in these sessions, including
general program administration; obstetric health
care; dietary needs during pregnancy and lactation;
meal planning; and, for caregivers, dietary needs of
infants and children (62) .
Most (93%) WIC service sites provide nutrition
education at the time of certification, about 52
percent coordinate nutrition education with food
instrument pick-up or food delivery, and about 21
1-7
Current
Drug Abuse
Information
and Referral
percent coordinate sessions with scheduled medical
visits (62). Because nutrition education is not
compulsory, clients must be allowed to obtain their
WIC food packages even if they refuse to participate
in nutrition education. Therefore, the only sure
points of access to WIC participants are at
certification, recertification, and food instrument
pickup.
The most frequently used locations for nutrition
education are the office (79%) and the waiting room
(55%); about 30 percent of the service sites use
classrooms or conference rooms. When nutrition
education is provided during waiting periods, it
usually involves the use of audiovisuals—often
continuous loop films or videotapes.
There are no data that measure the extent of
current drug abuse information and referral
activities in local WIC agencies. However, in
mid-1988, State agencies provided information to FNS
about policies and practices regarding alcohol and
other drug referrals and information. In general, it
appears that:
• Most agencies include the use of alcohol,
tobacco, or other drugs as a risk criterion for
program eligibility.
• Many agencies currently make referrals to an
alcohol or drug counseling program if an
individual is identified as being in need of
assistance.
• Printed materials (pamphlets, fact sheets, and
posters) on drug abuse are available in some
agencies. These materials are often obtained
from alcohol and drug abuse agencies or private
organizations such as the March of Dimes.
• A few agencies have begun to use audiovisuals
related to alcohol and other drug use.
• Some States have implemented training programs
on alcohol and other drug use for local agency
staff.
Although providing drug abuse information was not
previously required in WIC, many State and local
agencies have taken the initiative to incorporate
this activity into program operations.
1-8
Zq
2. DRUG ABUSE AMONG PREGNANT WOMEN: PREVALENCE AND
CONSEQUENCES
This chapter consists of two parts: a discussion of
the prevalence and patterns of drug abuse among
pregnant women and a discussion of the conseguences
of such dysfunctional behavior for both the
individual woman and her developing child.
Prevalence and Patterns of Drug Abuse
Reliable estimates of the prevalence of alcohol and
other drug use among pregnant women are not currently
available. Because of this lack of information and
increased public concern, the National Institute on
Drug Abuse has begun a national study of drug abuse
by pregnant women and its effect on in utero
development. Until this study is completed, data
available from various clinical observations can
provide some indication of the nature and scope of
this problem:
• In a 1989 survey of 18 hospitals in 15 major
cities across the country, the Senate Select
Committee on Children, Youth and Families (136)
found significant increases in the use of
illicit drugs during pregnancy at 15 of the
surveyed institutions. For example, the
Committee found the following increases in the
percentage of newborns exposed to drugs in
utero:
— An increase from 1.9 percent to 5.7 percent,
of live births at a Dallas hospital between
1987 and 1988.
— An increase from 1.1 percent to 3.9 percent
at a Denver hospital between 198 *> and 1988.
— An increase from 12 percent of live births in
1985 to 15 percent in 1988 at a New York City
hospital.
— An increase from 4 percent to 15 percent
between 1987 and 1988 at a Philadelphia
hospital.
The 1988 reported incidence of drug exposed
newborns ranged from a low of 4 percent in
Denver to 18 percent in Washington, D.C., and
Oakland, California.
2-1
if
In a recent study of New York City's Harlem
Hospital, 10 percent of 3,300 newborns tested
positive for cocaine (23). A similar estimate
was reported at Parkland Hospital, a large
public facility in Texas, where 9.8 percent of
pregnant women admitted using cocaine (90).
In a study of 679 urban women enrolled for
prenatal care at the Boston City Hospital, 17
percent were found to have used cocaine during
pregnancy, 28 percent used marijuana, 44 percent
used tobacco (11% smoked more than one pack per
day), 59 percent consumed alcohol (3% drank an
average of two or more drinks per day), 4
percent used opiates, and 3 percent used other
illicit drugs, including barbiturates, LSD,
mescaline, phencyclidine, and amphetamines (55).
A study of all women admitted to Chicago's
Prentice Women's Hospital and Maternity Center
of Northwestern Memorial Hospital during a six
month period found that 3 percent were using
sedative-hypnotic drugs such as marijuana,
benzodiazepine, and alcohol (26).
One in four women smoke during pregnancy (155).
Recent estimates of cigarette smoking from the
National Health Interview Survey (a national
survey of more than 31,000 individuals) indicate
declines for all race-gender groups from 1974
through 1985, but the rate of decline has been
significantly slower for women than for men
(52).
The Baltimore-Washington Infant Study with a
sample of 1,336 women, reported that 10 percent
used alcohol and cigarettes during pregnancy,
and about 2.5 percent used alcohol, cigarettes,
and some type of illicit drug (125).
A study of 12,440 pregnant women at Boston's
Brigham and Women's Hospital found that almost 3
percent consumed, on average, one or more
alcoholic drinks per day (98). This same level
of drinking was also found in a larger study of
32,000 pregnancies (104).
2-2
H>
• A study of 245 pregnant women at Detroit's
Women's Hospital and the Wayne County General
Hospital found 13 percent reported using
marijuana during pregnancy; 2 percent reported
using cocaine, heroin, or methadone; and 4
percent reported using benzodiazepines (125).
Although these data cannot be used to determine the
national prevalence of drug abuse among pregnant
women, reports such as these do indicate that the use
of alcohol, tobacco, and other drugs during pregnancy
is likely to be a significant problem in many areas
of the country. Moreover, users do not seem to
confine themselves to one drug but typically abuse
multiple substances. This polydrug use increases the
health risks during the perinatal period.
A synthesis of data from various sources (116, 147,
60, 59, 40, 151, 17) provides an anecdotal picture of
the female drug user as an unemployed, poorly
educated 25 to 34-year-old with multiple drug
problems. Blacks and Hispanics tend to be over
represented among this population, and certain drugs
(e.g., crack, phencyclidine) are linked to specific
ethnic groups in particular geographic locations.
The pregnant women participating in WIC have
similarities with this profile. According to the
National WIC Evaluation (130), most of these women
are:
• young (the average pregnant WIC participant is
22 years old; about 15 percent are teenagers);
• poor (average yearly income is $7,360, and only
about 10% are employed; almost two-thirds
receive Food Stamps, and about one-third receive
Aid to Families with Dependent Children);
• members of minority groups (almost one-third are
Black and nearly one-fifth are Hispanic); and
• poorly educated (on average, these women have
attained only a 10th grade education; for many,
English is a second language).
Although no data on the prevalence of drug abuse
among WIC participants are presently available, the
similarity between the WIC profile and that of the
typical female drug abuser suggests that alcohol and
other drug use may be a problem for members of WIC's
target population.
2-3
17
The Consequences of Alcohol and Other Drug Use During
Pregnancy
The following summary is intended to highlight the
known—or strongly implicated—social and
biological effects of alcohol, tobacco, and other
drug use during pregnancy. Any use of alcohol,
tobacco or other drugs during pregnancy is considered
abuse because of the potential for harmful effects.
Because drug users often use combinations of drugs,
determining the independent effects of each drug is
often difficult.
Alcohol Beverage alcohol (ethanol) is a central nervous
system depressant. It slows down bodily functions
such as heart rate, pulse, and respiration. When
drunk in small quantities, alcohol can induce
feelings of well-being and relaxation. Taken in
larger quantities, it progressively causes
intoxication, sedation, and unconsciousness (even
death, if consumed in large amounts). These effects
are similar to those produced by other sedative-hypnotic
drugs, such as barbiturates and narcotics.
Other alcohols, such as methyl and isopropyl
(rubbing) alcohol, are toxic to the human body and
can be deadly.
For women, heavy drinking can interfere with
fertility by altering the menstrual cycle (128) and
increasing the risk of obstetrical complications,
particularly vaginal bleeding, premature separation
of the placenta, and fetal distress (71, 128). The
risk of spontaneous abortion is more than three times
greater for heavy drinkers (three or more drinks a
day) than for nondrinking women (71, 128) . Heavy
drinking can also triple the likelihood of a
premature delivery (128).
Intrauterine growth retardation is the most frequent
effect of fetal exposure to alcohol, and it appears
to be more severe among women who drink heavily in
the third trimester of pregnancy than those who do
not. Pregnant women consuming between one and two
drinks per day are twice as likely as nondrinking
mothers to bear a growth retarded infant weighing
under 2,500 grams (104). Further, there is now
evidence that even very modest levels of drinking
(about one drink a week) just prior to the start of
pregnancy is also associated with decreased
birthweight (94).
2-4
2?
Fetal Alcohol Syndrome (FAS) occurs in about 2 of
every 1,000 live births (2). FAS entails growth
deficiencies before and after birth, abnormal
features of the face and head, and central nervous
system disorders. In fact, FAS is estimated to be
the leading cause of mental retardation (2).
Children whose mothers drank heavily during pregnancy
may also exhibit a number of developmental problems,
including hyperactivity, short attention spans,
language dysfunctions, and delayed maturation (3,
122, 128).
A study of a group of mothers who drank heavily
during pregnancy (an average of five drinks per day)
found that they had newborn infants showing such
L»JAJIIS of alcohol withdrawal as tremors, hypertonia,
i/estlessness, inconsolable crying and reflex
abnormalities (33). Infants of heavy drinkers,
particularly of mothers who drank heavily during the
last trimester, are often irritable and restless
sleepers (134). Because alcohol is transmitted in
breast milk, these effects may also continue after
birth (128).
Tobacco Tobacco's active ingredient, the stimulant nicotine,
is one of the most popular drugs in this country.
Nicotine is believed to be responsible for most of
the mood-altering effects and the addictive nature of
smoking. It has no medical or therapeutic use. Tar,
another substance found in cigarette smoke, is known
to cause lung cancer and bronchial disorders.
As with alcohol, use of tobacco can lead to impaired
fertility. Women who smoke heavily (more than 30
cigarettes per day) have a 43 percent lower fertility
rate than nonsmoking women (123). Pregnant women who
smoke also have significant increases in abruptio
placentae, vaginal bleeding, placenta previa,
ruptured membranes, and early delivery (123).
There is a direct correlation between the amount of
smoking during pregnancy and the incidence of
spontaneous abortion, fetal death, and neonatal
mortality from respiratory difficulties and Sudden
Infant Death Syndrome (71, 140). A recent four-year
comprehensive study of infant mortality (83) found
that women who smoked a pack a day or more had a 56
percent higher incidence of infant mortality among
their firstborn than nonsmokers. For later children,
mothers, regardless of the amount smoked, had a 30
percent higher incidence of infant mortality than
nonsmoking mothers.
2-5
2?
Maternal smoking has been blamed for as much as 14
percent of preterm deliveries in the United States.
Prematurity significantly increases the risks of
infant mortality and of respiratory illness (123). A
recent large-scale study of more than 30,000 pregnant
women in northern California found that preterm
births were 20 percent more common in women who
smoked a pack or more during pregnancy than among
nonsmokers (137).
Cigarette smoking also reduces a baby's birthweight
in proportion to the amount consumed—an average of
about seven ounces per infant. However, the earlier
in pregnancy that a woman stops smoking, the better
her chances for delivering a baby of normal weight
(123). Based on a nationwide study of natality (84),
if all women stopped smoking during pregnancy, the
incidence of low-birthweight infants would decrease
by amounts ranging from 35 percent for the least
educated mothers (less than 12 years of education) to
11 percent for college-educated mothers.
The consequences of maternal smoking do not end at
birth. Smoking is also a concern for nursing mothers
as nicotine is transmitted in breast milk. Children
of mothers who smoked while pregnant are at increased
risk for impaired intellectual and physical growth
and behavioral problems such as lack of self-control,
irritability, and hyperactivity (123).
Passive smoking can also have negative consequences
during pregnancy. Passive smoking has been found to
lead to infant weight reduction only about a third
less than if the mothers themselves smoked (63, 129).
Marijuana Marijuana is the common name for the Indian hemp
plant (Cannabis sativa L.) that is smoked for its
intoxicating effects. Hashish ("hash") is made by
removing the strong-smelling, dark brown resin in the
leaves and pressing it into cakes or slabs. It is
usually more potent than marijuana, containing up to
12 percent tetrahydrocannabinol (THC) which is the
primary mood altering chemical in marijuana. Hash
oil, a highly refined distillate of marijuana, may
contain up to 50 percent THC.
Although the effects of marijuana use during
pregnancy are less well documented than the effects
of alcohol, it does appear that such use may be
associated with low birthweight and height and with
shortened gestation (56). For example, a 1986 study
(66) found that among White, but not Black, women,
2-6
30
Sedatives,
Hypnotics and
Tranquilizers
regular marijuana use was associated with increased
risk of having a low-birthweight infant. Other risk
factors related to race may be more significant than
marijuana use in affecting reproduction in the Black
population.
Features compatible with FAS have been found among
infants of mothers who smoked marijuana heavily (73).
The bulk of evidence, however, now suggests that
marijuana does not characteristically produce
physical anomalies in humans, although gross
malformations (and fetal deaths) occur in animals
using larger doses than are typical of human use.
But marijuana use, particularly when combined with
use of other drugs, may increase the likelihood of
adverse consequences in such high-risk groups as
malnourished mothers, and those receiving inadequate
prenatal care (122, 14, 49, 76).
Increased tremulousness, altered visual response
patterns, and some "withdrawal-like" crying have been
found in the babies of women who smoked marijuana
heavily. These effects usually disappear within 30
days after birth, although this does not rule out
more subtle long-term consequences (56, 122). A
recent study of neonatal sleep found that maternal
marijuana use during pregnancy affected sleep and
arousal patterns in the newborn, although the long-range
implications of this are not known (134) .
Subtle abnormalities of the nervous system and
impaired learning capacity may also occur among
children whose mothers used marijuana heavily (14,
122) .
Barbiturates are among the most commonly used drugs
classified as sedative-hypnotics. They act as
central nervous system (CNS) depressants, slowing
down many body functions. Barbiturates are
prescribed for a variety of therapeutic purposes,
most commonly for managing sleep disorders, and are
among the most potentially lethal of the CNS
depressants. Although more than 2,500 barbiturate
compounds exist, about 50 have been approved for
clinical use and only 12 of these are widely used.
Heavy users of alcohol and other drugs often take
barbiturates if their drug of choice is not
available, or to counteract the negative effects,
such as anxiety and sleeplessness, of their drug of
choice.
All the diazepines (minor tranquilizers) have been
associated with increased fetal malformations if used
2-7
31
Cocaine and
Other
stimulants
during the first trimester of pregnancy (74, 71, 72).
A 1989 case study of eight offspring of mothers whose
excessive use of diazepines during pregnancy was
confirmed by blood tests reported birth anomalies
resembling those of FAS, and almost all the infants
were significantly below average in birthweight (88).
Benzodiazepines in particular can depress infants'
respirations (51, 71) .
Diazepam (ValiumR) consumed in the first trimester
has been linked to a fourfold increase in cleft
palates, lip anomalies, and malformations of the
heart, arteries, and joints. The risk of these
congenital anomalies seems to increase when diazepam
is combined with smoking and alcohol use. When used
daily for the last two to four months of pregnancy,
even in low dosages (10 to 15 milligrams), diazepam
has been found to result in tremulousness and other
symptoms of withdrawal in the newborn. Flurazepam
(Dalmane*) given in 30-milligram doses for 10 days
has been associated with lethargy and hypertonia
(reduced muscle tone) in newborn infants, lasting
several days after birth (74, 71, 51, 72).
Use of barbiturates as antiseizure medication has
also been associated with congenital birth defects
resembling FAS. Even short-acting barbiturates have
been associated with increases in birth anomalies
(74, 128, 4). Chronic use of barbiturates in the
last months of pregnancy, at doses of 60 to 100
milligrams per day, has been associated with infant
withdrawal symptoms that appear four to seven days
after birth and typically include high-pitched
crying, irritability, tremulousness, and sleep
disturbances that can persist for months (4, 51, 72).
Chronic use of barbiturates during pregnancy also may
alter infants' and children's patterns of normal
behavior, responses to the environment, and growth.
Cocaine hydrochloride is a short-acting, powerful
CNS stimulant. Cocaine also acts as a local
anesthetic. In low doses, cocaine produces a short-lived
sense of euphoria accompanied by feelings of
increased energy, enhanced mental alertness and self-esteem,
and greater sensory awareness. Larger doses
intensify these effects and sometimes cause bizarre
or violent behavior. Psychological dependence on
cocaine can occur rapidly. In fact, studies show
that cocaine may be the most powerful of all illicit
drugs in producing psychological dependence.
Physical dependence (and withdrawal symptoms) may
occur also among chronic users.
2-8
3^
Crack is the street name for a form of freebase
cocaine that has been processed into crystals, or
"rocks" and is smoked. Crack's quick action and low
cost have made it popular, especially among young
urban drug users, and its use has spread alarmingly
throughout U.S. cities. An acute overdose could
result in a coronary attack or respiratory arrest.
Amphetamines, also stimulants, produce effects
similar to those of cocaine. Chronic users can
become physically dependent and can also develop
"amphetamine psychosis," which resembles paranoid
schizophrenia. Amphetamines are generally taken
orally in tablet or capsule form, but in some
instances (especially methamphetamin<2) are injected
into the veins. Abusers often take marijuana and
depressant drugs such as barbiturates, alcohol, and
opiates to combat the negative side effects of
amphetamines.
Chronic cocaine use has been associated with an
increased incidence of spontaneous abortion (158,
159) and placental separation (5) due to reduced
blood and oxygen flow to the fetus (hypoxia).
Women who use cocaine during pregnancy are at
increased risk of preterm delivery (96). A recent
study of the newborn infants of 75 cocaine-abusing
mothers found significantly lower birthweights and a
greater frequency of heart defects than among infants
of mothers who did not use the drug (90). Another
study of 343 pregnant women whose cocaine use was
confirmed by urinalysis also found lower birthweights
in their newborn infants (32). However, even among
infants who are not born prematurely, the mother's
use of cocaine is associated with reduced
birthweight, length, and head circumference.
Mothers who use cocaine during the first three months
of pregnancy, as well as those who use it throughout
pregnancy, have been found to have infants who show
significant impairment in their ability to orient and
their muscular control (20, 23, 28). In recent
years, there has been a dramatic increase in the use
of crack. A New York study of 55 low-income Black
and Hispanic female crack users found a much higher
incidence of premature delivery than among a matched
sample of nonusers (50.9% vs. 16.4%). The newborn
infants of the users were also more than three and a
half times more likely to be retarded in growth and
nearly three times more likely to have a reduced head
circumference (31).
2-9
3i5
In another study, fetuses of 67 women, most of whom
were addicted to cocaine, were studied during
pregnancy using ultrasound technigues (a noninvasive
way of measuring the development of the unborn
infant). Several measures showed asymmetric growth
retardation suggesting abnormal development (105).
Another study of 39 infants of cocaine-abusing
mothers found that neurological abnormalities may be
present in the newborn even though other gross
developmental abnormalities are not apparent (44).
Cocaine use by nursing mothers can also pose a threat
to their infants. In one recent study, marked
tremulousness, irritability, marked startle response,
and other neurological abnormalities in a two-week-old
infant girl were traced to cocaine ingested from
her mother's milk (24). A still more recent report
describes an 11-day-old nursing infant's convulsions
resulting from the mother's topical use of cocaine to
relieve her nipples' soreness (19).
Two recent case reports also indicate that cocaine
use during pregnancy can have fatal circulatory
effects on the mother and pose great risks to her
infant. A cocaine-using mother died three weeks
after delivery as a result of a cerebral aneurysm
linked to her drug use. Although her newborn infant
was tremulous at birth and had a poor sucking reflex,
he subseguently recovered (69). In a second case
report, a newborn suffered a cerebral blood blockage
(a cerebral infarction) related to his mother's
cocaine use during pregnancy and on the day of
delivery (27).
Other stimulants, primarily amphetamines, may
increase the risk of heart malformations and brain
defects (4). Fcr example, phenmetrazine (Preludin")
has been implicated in abnormal skeletal and organ
development; research on 104 infants born to mothers
who had used cocaine, methamphetamine ("speed"), or
both during pregnancy found the infants had altered
behavior patterns characterized by abnormal sleep,
poor feeding, tremors, and hypertonia. These infants
also had significantly higher rates of prematurity,
growth retardation, and smaller head circumferences
at birth (120) compared to infants whose mothers had
not used either drug. Another more recent study
compared the offspring of 52 methamphetamine-abusing
mothers with those of a similar non-drug-abusing
group and found body weight, length, and head
circumference were all significantly lower in the
infants born of drug-abusing mothers (91).
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3V
Opiates and
Synthetic
Narcotics
Opiates (classified as narcotics) are natural and
synthetic drugs that act primarily on the central
nervous system. Opiates are effective pain killers
but are also highly addictive. Although numerous
chemical derivatives of opiates are available,
roughly 25 separate compounds are used in medical
practice today—among them, morphine, opium, codeine,
methadone (Dolophine), meperidine (Demerol") ,
oxcycodone (Percodan ) , and hydromorphone
(Dilaudid") . Heroin, an opium derivative, is one of
the most popular narcotics used by drug addicts.
Methadone, a synthetic narcotic, is now most
frequently used to treat heroin addiction. Physical
and psychological dependence on opiates develops
along with tolerance and is characterized by craving
for the drug and withdrawal symptoms.
Heroin use during pregnancy increases the likelihood
of stillbirth and neonatal death and is thought to be
associated with Sudden Infant Death Syndrome because
of the alternating toxic and withdrawal states in the
expectant mother (149, 122, 35, 4, 51).
Pediatric cases of acquired immunodeficiency syndrome
(AIDS) are one of the most rapidly increasing
categories of AIDS patients. Intravenous use of
heroin by the mother or her sexual partner is
associated with four out of five of these cases (42).
In New York City three out of four children with AIDS
have died, most by the age of three (80).
Pregnancy complications of heroin addicts include
increased risks of abruptio placentae, eclampsia,
placental insufficiency, breech presentation,
premature labor and ruptured membranes, and Caesarean
section. Ten to fifteen percent of women addicted to
heroin develop toxemia during pregnancy (35, 121,
51). Nearly half of heroin-dependent women who
receive no prenatal care deliver prematurely, often
because of infections. About 80 percent of their
offspring have serious medical problems, such as
hyaline membrane disease, intracranial hemorrhages,
and respiratory distress syndrome (35, 51).
Bacterial endocarditis, a life-threatening bacterial
infection of the lining of the heart, is another
potential complication associated with intravenous
drug use. A recently published case study of seven
pregnant women with bacterial endocarditis reported
two died shortly after giving birth. Two of the
neonates also died as a result of preterm delivery,
which may have been related to the disease (36).
2-11
3&
Heroin may also cause intrauterine growth retardation
as well as suppressing maternal appetite and
interfering with the absorption of nutrients from
foods because of its effects on intestinal, liver,
and pancreatic functioning (122, 35, 4, 51).
Withdrawal symptoms have been observed in hundreds of
infants born to opiate-addicted mothers.
Restlessness, tremulousness, disturbed sleep,
sweating, vomiting, stuffy nose, diarrhea, a
high-pitched cry, increased rooting, or seizures
usually start within 72 hours after birth and may
continue for six days to eight weeks. Irritability
can persist for three months or more after birth (7,
64, 85, 122, 35, 4, 51). Additionally, growth
disturbances and other behavioral effects, such as
hyperactivity, shortened attention spans, temper
tantrums, and slowed psychomotor development, have
been noted in children born to opiate-dependent
mothers (122, 35). Babies born to methadone-maintained
women also have been found to have poorer
visual and auditory responses and slower motor
development than matched controls. However, the
babies of methadone-maintained women who received
adeguate and consistent prenatal care seem to thrive
better and have fewer neurological complications than
those whose mothers continued heroin use or who took
methadone in an uncontrolled manner during pregnancy
(35, 122).
Methadone and other opiates also are transmitted in
the breast milk of nursing mothers (35).
Phencvclidine PCP, also commonly known as "angel dust," is a
(PCP) synthetic anesthetic that acts as a stimulant,
depressant and hallucinogen. It is often the mood-altering
chemical in street drugs represented as
other hallucinogens, for example, mescaline or THC
(the active chemical in marijuana). Its effects vary
greatly, depending on the guantity and manner in
which it is taken and the person taking the drug. It
can be swallowed, smoked, snorted, or injected. PCP
is sometimes sprinkled on marijuana, tobacco, mint,
or parsley and smoked. PCP's mood-altering effects
can sometimes cause hostile or bizarre behavior and
even severe psychosis.
PCP is known to cross the placental barrier readily
as well as to be transmitted through breast milk
(114). Although evidence of effects on pregnancy is
limited, a study of nine infants whose mothers had
smoked PCP found these neonates showed more
2-12
.3£
Inhalants and
Solvents
Other
Concerns
instability and were less consclable than other
groups of drug-exposed infants (29).
Inhalants are chemicals—usually gases or volatile
liquids—that cause intoxication when their vapors
are inhaled in sufficient quantities. People usually
do not think of inhalants as drugs because most of
them were never meant to be used that way. Most
inhalants are CNS depressants that produce an
intoxication similar to that of alcohol. Inhalants
fall into four main categories: solvents, such as
model airplane glue, typewriter correction fluid,
lacquer thinners, nail polish remover, cleaning
fluid, and gasoline; aerosol sprays, such as hair
sprays, insecticides, medications, and paint;
anesthetics, including ether, nitrous oxide, and
chloroform; and other chemicals, such as amyl nitrite
and butyl nitrite (these are stimulants). Inhalants
cause short-term mood-altering effects but have also
been implicated in many fatalities following heavy
usage.
Industrial solvents can be highly toxic to the brain,
lungs, liver, kidneys, and other organ systems and
can sometimes cause accidental death in users. Abuse
of such substances also poses obvious—and
potentially serious—reproductive risks, including
abnormal facial features and severe mental
retardation. These FAS-type symptoms are more
prevalent when inhalants or solvents are combined
with alcohol (128). A case study of toluene abuse
resulting from paint sniffiri by five pregnant women
reported growth retardation _or three of the newborns
and birth anomalies for the two others (63).
Beyond the immediate obstetric effects of drug use,
women who abuse licit and illicit substances place
themselves and their children at greatly increased
risk for a host of other problems. Use of illicit
drugs carries serious risk of criminal prosecution as
well as other types of dysfunctional behavior (e.g.,
prostitution) (21). Drug abusers also tend to have
an increased risk of other health problems associated
with their drug use, such as anemia, inadequate
nutrition, and infection. For intravenous drug users
there is the added risk of AIDS for both themselves
and their fetuses (21). Finally, the risk that
maternal drug use poses for the child does not end at
birth. Drug-involved women tend to be far more
likely to abuse and neglect their children than
nonusers, further increasing the developmental damage
that results from drug use (21).
2-13
37
3. EFFECTIVE APPROACHES TO DRUG ABUSE PREVENTION
This chapter reviews the current state of knowledge
regarding effective approaches to preventing drug
abuse. This review forms the basis of
recommendations for providing drug abuse information
and referrals in the WIC Program. The chapter begins
with a conceptual discussion of drug abuse prevention
and the role of information and referral activities.
Next, successful approaches to disseminating drug
abuse information are reviewed, followed by a summary
of the literature on drug abuse screening and
referrals. Finally, a discussion of exemplary
programs for pregnant women is presented.
The Public Health Model of Drug Abuse Prevention
The public health model commonly used when describing
drug abuse prevention programs refers to three
responses to drug abuse (72, 124). The first, called
primary prevention, responds to individuals who have
never used drugs. Efforts focus on providing
information about the effects of drug abuse,
technigues for refusing drugs should they be offered,
and activities that foster life skills and serve as
alternatives to drug abuse (70) .
Secondary prevention responds to individuals who are
using drugs but are not yet chemically dependent.
Secondary prevention contains many of the components
of primary prevention, but includes methods for
identifying and referring suspected users for
assessment so that treatment can be obtained. In
secondary prevention, information efforts focus on
discontinuing use and fostering healthful behaviors
(70).
Tertiary prevention usually takes place within a
treatment program. It is aimed at reducing the
dysfunctional behaviors of chemically dependent
persons who have lost control over their ability to
stop using drugs even in the face of the obvious
problems drugs cause. Informational efforts focus on
the negative impact of chemical dependence on health,
family functioning, and the attainment of such
personal goals as finding employment, completing
education, and developing positive interpersonal
relationships (70).
Individuals targeted by these three categories have
different needs for information and ancillary
services. Nonusers need basic information that will
3-1
3<r
support them in their decision to remain drug-free.
They also frequently need materials to share with
partners and with children. Likewise, they may need
information about referral services to deal with
problems among partners, children, and other family
members.
Nondependent users require basic facts about drugs'
effects as well as self-help and motivational
materials and recommendations for involvement in
specific counseling programs.
Dependent users require specific referrals to
treatment. Basic information about drugs is of
little use to these people because, by definition,
they cannot stop using drugs without help. In fact,
until sobriety is achieved, ancillary services have
little effect.
Successful Approaches to Dissemination
The extant literature on effective methods for
disseminating information on drug abuse has been
dominated by school-based studies (132, 156) using
outcome measures such ar increased knowledge about
drugs, improved family relationships, enhanced self-concept,
changes in drug use, and changes in
attitudes toward use (132, 124). For the most part,
these studies have focused on primary prevention
among White middle-class adolescents (132).
A small but extremely important number of studies
have explored the impact of prevention information on
alcohol use among pregnant women (93, 95, 106, 128).
One notable series of studies focused on the Seattle
Health and Pregnancy Program, which serves a middle-class
population. A second landmark study is based
on Boston City Hospital's experiences in providing
services to low-income, ini.er-city women. The
Seattle and Boston programs respond to their clients'
needs for primary, secondary, and tertiary
prevention. Through close monitoring, both programs
have found that effectiveness of information and
referral services depends on how they are provided
and whether their recipients were nonusers,
nondependent users, or chemically dependent users.
Another body of studies has focused more narrowly on
developing and applying screening instruments for
drug and alcohol use among pregnant women and
obstetric-gynecologic patients. Findings from these
efforts are relevant to the screening and referral
3-2
38
Targeting
Hiqh-RisK
Individuals
activities described later in this chapter (37, 38,
138) .
Given the relatively small number of studies
concerned directly with the provision of prevention
information to women, clinical observations and focus
group results from drug and alcohol treatment
programs serving pregnant women assume a special
importance. Although focused primarily on chemically
dependent women, many of these reports discuss issues
of particular relevance to low-income women, minority
women, and women with low literacy skills. These
issues include barriers to service, confidentiality
and reporting, staff roles and training, and linkages
to other agencies (68, 20-29, 41, 50, 51, 117, 118,
119, 41, 126, 128, 141, 153).
Findings from more than 20 years of studies
evaluating prevention efforts aimed at reducing
cigarette smoking have guided the development of the
majority of effective prevention programs in place
today (124, 156). Approaches such as targeting
messages to defined audiences, reinforcing
information consistently and over an extended period
of time, and using multiple media are now commonplace
among prevention programs. Smoking prevention
experts borrowed these ideas from the field of
advertising and skillfully adapted them to
antismoking public service campaigns. These
approaches continue to have relevance for prevention
programs and are both directly and indirectly
referenced throughout this chapter.
The health education literature offers another useful
source of ideas for providing information to minority
women and women with low literacy or low income
levels (43, 81). Although it does not discuss the
needs of pregnant drug- and alcohol-using women
specifically, it does provide guidance in developing
applicable print and audiovisual materials and in
using them effectively.
Prevention programs are most effective when they are
targeted directly at populations at high risk for
drug abuse (156). The group to be targeted,
likewise, should be defined narrowly by age, life
situation, and role (156). Moreover, education
efforts should spring from programs that already
reach the target group (e.g., health clinics) and
should be designed specifically for that group (109,
81, 156).
3-3
QO
Targeting
Points of
Increased
Receptivity
A Positive
Manner of
Presentation
Sufficient
Duration of
Effort
Information efforts should be designed to reach the
target group during bench mark periods when they make
the transition from one life situation or role to
another (e.g., puberty, college entrance, parenthood)
(156). It is at these times that behavior frequently
changes. During pregnancy, for example, women are
receptive to messages urging them to adopt a range of
healthy behaviors (93, 95). Although there is a
physiological explanation for this receptivity (e.g.,
tobacco and alcohol cause discomfort for substantial
numbers of pregnant women), researchers also believe
that women are psychologically more responsive to
information at this time, especially when they learn
of the positive effect on the developing fetus (93,
95).
The way information is presented can significantly
affect the response it receives. Positive, accurate
information that is directly relevant to the
recipient's life situation and is couched in language
she understands elicits the most favorable response
(43, 81, 138).
In contrast, presentations arousing fear or inducing
guilt have little effect and, in some instances, are
counterproductive. Fear-based informational programs
have been implicated in fostering drug use (124) . By
confirming the hopelessness of the situation through
emphasis on damage and guilt, negative information
efforts convince some recipients of the futility of
change (138) .
Face-to-face, nonjudgemental presentation of
information is deemed the most effective method of
communication with high-risk women (43, 138, 128,
109). The interest displayed by the information
provider seems to play as important a role in
effective communication as the content of the
conversation. Positive interpersonal interaction
between information provider and recipient plays a
similar prominent role in drug and alcohol screening
and referral (138, 128, 93, 95).
The duration of the information effort also appears
to be a major factor in predicting a program's
success (132). Results from antismoking, child
neglect, alcohol abuse, and teen pregnancy prevention
initiatives (68, 41, 93, 95) indicate that the more
frequently information is repeated, the more
effective it is. Thus, programs lasting six months,
for example, have better results than those lasting a
week (132).
3-4
a/
Linkages
Among
Services
Appropriate
Staffing
Reducing
Barriers to
Participation
Methods to
Increase
Appeal and
Comprehension
Programs that are effective in reaching low-income
women are characterized by strong linkages to other
services within the community (68, 109). These
relationships facilitate referrals, expedite the
exchange of programmatic information, expand
resources for staff training and technical
consultation, and improve allocation of
responsibilities within the larger network of
community services (68, 109).
Skilled staff are another ingredient of successful
prevention programs. Many programs employ the
services of highly trained professionals with
substantial experience in the drug and alcohol fields
and in providing screening and referral services
(109, 93, 95, 128, 68, 138). These professionals not
only coordinate the drug and alcohol education
programs, but also train staff.
Effective drug education programs are further
distinguished by their capacity to understand and
meet the needs of the people they serve.
Cultural sensitivities are observed, practical
services that eliminate barriers to full
participation are instituted (e.g., babysitting, bi-lingual
staff and informational materials), and
participants are actively and appropriately involved
in the services offered (e.g., helping to decide on a
referral, setting the agenda for group educational
sessions, evaluating the relevance of the information
provided, identifying areas of unmet need) (109, 126,
61, 68, 81).
An estimated 23 million Americans, or almost 10
percent of the population, may not understand what a
health professional says to them, and 20 percent
of adult Americans have reading skills below
the fifth-grade level (43) . Valuable information—
whether spoken, printed, or portrayed visually—may
not be comprehensible to the intended audience
because the vocabulary or context is inappropriate
(43).
For conveyed information to be received, the material
or conversation must make sense in terms of the
individual's life situation (43, 81, 109). Literacy
experts suggest using concrete terms (e.g., "eating
bread" instead of "ingesting carbohydrates") and
avoiding categories or lists (43). Results from
interviews with low-income minority women also show
the importance of emphasizing everyday life and
3-5
ui*
A Variety of
Methods of
Communication
immediate concerns that can be seen or felt directly
(43, 81).
In addition, information must be presented in
language close to the vernacular used by the target
audience (43). Sometimes this means using a language
other than English (81). Printed drug abuse
materials seldom use jargon and slang (e.g., "booze"
for liguor, "bam" for amphetamine) because they are
seen as limiting or offensive. Literacy experts,
however, disagree with this strategy and recommend,
instead, developing very specific materials using
common language (43). To overcome cost problems,
they suggest fabricating homemade materials, arguing
that relevance compensates for limited eye appeal
(43).
Finally, to maximize comprehension, information
should be cloaked in experiences similar to those of
the target audience (43, 81). People with low
literacy skills tend to accept only what is
meaningful to them because they have difficulty
transferring from the experience of others (43). An
early review of drug-oriented informational materials
conducted by the Substance Abuse Subcommittee of the
Healthy Mothers, Healthy Babies Coalition found that
pamphlets recommending "alternatives to drug abuse,"
in particular tended to cite irrelevant examples.
Women were advised to join fitness clubs, meditate,
listen to Pachabel's Canon, and take a vacation.
These suggestions were deemed to have little or no
meaning to the low-income target group.3
Even when a target group is narrowly defined,
different learning styles abound. For this reason,,
learning is achieved more readily when a variety of
stimuli are used (43). An information program
combining one-on-one conversations, group
discussions, pamphlets, posters, and audio and video
tapes is more likely to be effective than a program
relying on a single form of communication (43, 81,
109) .
Individual Counseling. Experts in both counseling
and teaching agree about the importance of
establishing personal relationships to foster the
learning process (43, 93, 95, 68, 109). Engaging a
From Notes from the Healthy Mothers, Healthy
Babies Substance Abuse Subcommittee recorded by the
American Council for Drug Education, 1984.
3-6
c/3
patient, client, or student through a one-on-one
relationship is the most effective means of conveying
information and ensuring that it is understood (43,
138, 33).
One method for providing this contact is to use a
printed or audiovisual aid as the centerpiece.
Individual participation is reserved for two points:
an introduction highlighting important points and
telling the individual why she is to read, view, or
listen to the material; and a conclusion, during
which she is asked what the material meant and its
basic message is reinforced (43).
Group Discussions. Although groups can be difficult
to arrange because of resistance to participation and
the logistical problems involved (time, space,
transportation, child care, scheduling conflicts),
they can be a useful element of an information
program (68). They enable one staff member to
establish several personal relationships at the same
time, and they provide an opportunity to repeat
information in a variety of different forms to
increase the likelihood that it will be understood by
participants (43).
Print Materials. Although print materials have been
deemed the least successful means of providing
information, new efforts are now underway to develop
materials specifically targeted at pregnant low-income
women and adolescents. An ambitious
information project planned for a health center in
Illinois also contains a strong evaluation component
that, ultimately, may provide needed insight on the
value of print materials as informational tools for
this target group (6).
Until such evaluations are available, recommendations
from literacy experts can provide some guidance.
Print materials should use short sentences, the
active voice, and familiar vocabulary (43). The tone
should be conversational and direct, and pronouns
(e.g., "you should" instead of "women should")
should be used throughout (43). Each paragraph
should be limited to one idea, which is introduced in
the topic sentence and reiterated in the concluding
sentence (43). Illustrations are highly desirable
but should be clear and simple (43). If possible, an
illustration should appear on the same page as, or on
the page immediately following the idea being
depicted. Headings should be plentiful; lists should
be avoided (43). Print should be large and clear,
3-7
UCI
upper- and lower-case print should be used to
expedite decoding of words, and the layout should
include ample white space to facilitate ease in
focusing and following (43).
Despite their limitations for people with poor
reading skills, print materials offer several
advantages to informational programs (43). The
message provided is consistent, and the cost is
relatively low. Also, the material is portable and
can be shared, can be reread for reinforcement, and
can provide a directory of resources for the reader
to use in the future (43).
Graphics. Graphics can enhance the eye appeal of
printed materials, clarify a concept through
illustration, personalize a message for particular
target groups through illustrations reflecting their
appearance or environment, or lend emotional impact
to a message (42, 25). Posters, postcards, comic
books, and activity sheets have been used by diverse
organizations to convey and re:nforce messages about
health, safety, and drug abuse, among other issues
(43, 109, 68). The annual Fetal Alcohol Syndrome
awareness program conducted by the National Council
on Alcoholism, the Department of Health and Human
Services' Anti-Smoking campaign targeted toward
pregnant women, and the Healthy Mothers, Healthy
Babies effort aimed at low-income, pregnant women all
used posters to convey their messages. Although
comic books and activity sheets have been used in the
drug and alcohol fields primarily to educate
children, a new demonstration project geared toward
pregnant adolescents will test the use of these
formats with young adults (6).
Unlike print materials, however, about which there
seems to be consensus on how to reach various groups,
opinions about graphics are more controversial and
subjective (43, 81, 109). For example, the fantasy
posters released by the Healthy Mothers, Healthy
Babies Coalition were criticized by literacy experts
as too confusing and complicated (43). Nonetheless,
the response to the posters among low-income women
(many of whom were likely to have limited reading
skills) was overwhelmingly positive. It may be that
the emotional appeal in this instance compensated for
the lack of clarity (81, 109). Differing opinions on
the merits of graphics and the relatively high cost
of their production underscore the importance of
pretesting these materials with the potential target
group (43) .
3-8
In general, literacy experts favor simple line
drawings or lifelike sketches or photographs that
focus the eye on one activity (43) . Viewers should
be able to identify with the sketches and
photographs, and the people portrayed should have
pleasant expressions on their faces (43). If
captions are used, they should be clear, directly
relevant to the illustrations, and in large print
(43). Because people with limited reading skills
tend to be very literal in their interpretation of
visual materials, humor, clever allusions, and
pictorial metaphors should be avoided (43).
Similarly, if cartoon characters are used, they
should be humanized so the viewer relates the message
depicted to herself (43).
Within a clinical setting, posters are freguently
welcomed as a way of decorating the waiting room.
However, they can also serve an informational purpose
if they are used appropriately (43) . Staff, for
example, can call attention to them and incorporate
their message in contacts with participants (43).
Some posters have a blank space that can be
personalized by the user. Typically, this includes a
line where a telephone number or name of a contact
person for more information can be printed (43).
Posters also come in a variety of sizes, including
8 1/2" by 11". Many are designed so that they can be
reproduced and distributed as handouts (43). The
Healthy Mothers poster series featured a mini-postcard
that was distributed to reinforce basic
health messages among low-income women.
Audiovisuals. Films and videotapes can aid
comprehension by adding another dimension to the
written word, can be substituted for reading, and can
extend or demonstrate the application of printed
concepts (43, 81, 109).
Videotapes and films are also dramatic media; they
can make concepts more vivid and memorable. Because
they are pictorial, they can show characters and
settings relevant to the viewer (43). However,
interviews with low-income women and the observations
of literacy experts indicate that many available
films and videotapes are not meaningful or helpful.
They are often too difficult to understand and do not
reflect situations with which the intended viewers
can identify (81, 109). Techniques for overcoming
these problems include the following:
3-9
q<s
• From initial conceptualization, develop the film
with a specific target group in mind (43, 81).
• Use characteristics of the target group to
develop and cast characters, to create
situations, and to suggest settings (43, 81,
109) .
• Simplify vocabulary. Even though film has
tremendous pictorial power, this cannot
compensate for language that is too difficult
(43).
• Avoid condescension. Although language should
be simple, situations should be adult in concept
(43).
• Avoid stereotypes. For example, where serapes,
Mexican hats, and Indian blankets can be
offensive, background shots including trailers,
hogans, and inner-city apartments can lend
credibility (43, 81, 109).
• Design film or video in segments so that the
presentation can be stopped and questions asked
(43).
• Use circles, arrows, and other graphic cues to
highlight important information or behavior
(43).
• Pace films for optimal understanding. Fast
action may gain attention at the expense of
comprehension (43).
• Define a few central concepts and repeat them
frequently. Resist the temptation to "pack" the
film or videotape; viewers can absorb only so
many ideas at one time (43).
This perspective on materials was reinforced by Ms.
Yolanda Cleffi, a parent participant of the National
Advisory Council on Maternal, Infant and Fetal
Nutrition (NAC) in her August 15, 1989 letter to the
Council. (See Exhibit I).
Examples of Programs for Nonusers and Nondependent Users. The
Programs Seattle Pregnancy and Health Program (PHP), an
initiative aimed at stopping women from drinking
during pregnancy, has found that women who abstained
from alcohol or rarely drank responded favorably and
positively to public health messages provided through
3-10
<V7
brochures and posters (93, 95). PHP staff encouraged
and supported this group of women to continue their
abstinent behavior and used clients' questions as
opportunities to provide additional information.
Moderate drinkers generally changed their behavior as
recommended by the information they received,
particularly if the information was conveyed face to
face (93).
Researchers who evaluated the Seattle experience also
believe that the program's emphasis on a positive
message (e.g., having healthy babies rather than the
potential damage that might be caused; stressing
reduction in use as a health goal rather than a
source of guilt) was instrumental in fostering
behavioral change. Of the 62 percent of the
population seen who had a slight problem, 36 percent
decreased their drinking during pregnancy (93).
ASPEN, the Substance Abuse Prevention Education
Network of the Shawnee Adolescent Health Center in
Illinois (which also includes a WIC Program) is
developing a more formalized approach to providing
information to nonusers (6). A curriculum consisting
of eight self-instructional modules will be used with
each pregnant adolescent in conjunction with her
weekly visits for prenatal care. The patient will be
introduced to the program during her initial
pregnancy work-up, then at each succeeding visit will
work independently on a module while in the waiting
room. Specially trained Prevention Specialists will
be available in the waiting room to assist patients
with each ASPEN module and to answer questions. Each
module contains basic information on drugs and
pregnancy, a cartoon illustration, and an activity
requiring the patient to process and apply the
learned information (6). The outcome of this
project, which is currently in the developmental
phase, may provide interesting insights on methods
for reaching WIC participants with basic information.
Health Start, a prenatal care program of the St.
Paul-Ramsey Medical Center in Minnesota, adapts many
existing materials for its clients and, in addition,
provides them with one-page information sheets on
specific drugs (68). Health Start conducted
interviews with its patients to determine the kinds
of materials and approaches they wanted. Results
indicated preferences for:
• More information on the effects of drugs and
alcohol. In particular, patients wanted to
3-11
uf
receive such information early, before damage to
the fetus was likely.
• Someone to sit down with them, to talk about the
drug problem, and to describe how drugs could
hurt them and their babies.
• Written materials, including posters, handouts,
and films.
Health Start patients particularly liked posters and
films because they thought such materials made a
strong impression and were easy to remember (68).
Another approach to providing information to nonusers
and users who are not yet chemically dependent is the
interactive video. The University of Cincinnati is
currently developing a series of four videos on
alcohol, tobacco, inhalants, and drugs and pregnancy
(118). The videos are aimed primarily at teenagers
and use the interactive format to model and practice
resistance. Although the effectiveness and
practicality of this approach have not been assessed
yet (118), the interactive aspect holds promise,
particularly in settings where staff resources are
limited.
In its booklet on "Program Strategies for Preventing
Fetal Alcohol Syndrome and Alcohol-Related Birth
Defects," the National Institute on Alcohol Abuse and
Alcoholism (NIAAA) notes that myths about alcohol and
drugs are rampant (109). Prior to beginning an
informational effort with clients and staff, NIAAA
suggests conducting an assessment of practices and
beliefs (109). Operation PAR in St. Petersburg,
Florida, offers an interesting example of why this
kind of assessment is useful (119). This large-scale,
comprehensive prevention and treatment program
launched an information initiative among pregnant
clients and could not understand the disappointing
response. Alert staff quickly surmised that the
pregnant women they were trying to reach believed
that the developing fetus was protected by what they
referred to as a "bubble." Because Operation PAR'S
information did not talk about drugs or alcohol
"piercing the bubble," patients felt they had nothing
to worry about and dismissed the alcohol and drug
information as irrelevant (119) .
Another approach to providing information is
currently being used at Booth Memorial Center in
Oakland, California (118). Although targeted at low-
3-12
M
income, pregnant Black teens, Booth Memorial's
strategy of using "peer educators" to provide
information has application to other settings and age
groups (118). At Health Start in St. Paul,
Minnesota, pregnant women who have changed their
health habits volunteer as information providers,
role models, and sources of support (68). Project
Safe in Illinois uses skilled, recovering counselors
to conduct outreach and screening, to provide
information, and to perform case management (for
clients identified as having problems) (41). In Tuba
City, Arizona, the Fetal Alcohol Syndrome Prevention
Program uses "natural helpers," Native Americans
fluent in Navajo, to reach its target population with
information (117).
Accurate information provided by a credible source
clearly seems to be effective in heightening
awareness and changing behavior among nonusers and
users not yet chemically dependent, even when they
are members of a high-risk group (93, 95, 138).
However, information seems to have a much less potent
impact among chemically dependent users, a factor
that bears consideration when designing programs for
this group (128, 93).
Programs for Chemically Dependent Users. Written
materials and audiovisuals appear to be less
effective in curbing drug and alcohol consumption by
heavy users than among less frequent users or
nonustiS. In commenting on the results of their
pioneering Seattle-based Pregnancy and Health
Program, Little and Streissguth observed that
informationally oriented prevention efforts are "most
beneficial to lighter drinkers and those with less
severe problems" (93). They also voiced their
opinion that the greatest effort in a prevention
program should be directed to the majority, who in
the case of this particular program, had no
appreciable problems (93, 95).
Elaborating on this idea, Weiner noted that in a
focus group conducted with drug- and alcohol-using
pregnant women at Boston City Hospital, most reported
that they were familiar with the general guidelines
for prenatal health, but did not comply with them
(106). Although their chemical dependency was
largely responsible for their noncompliance (as is
discussed in more detail in the next section), other
factors connected with the information itself also
may have a negative influence (106, 138, 115). For
example, researchers speculate that the chemically
3-13
TO
dependent woman's inability to change her behavior on
the basis of information provided in pamphlets and
posters may be a source of frustration and may
contribute to an overwhelming sense of failure (106).
The chemically dependent woman usually has multiple
problems and needs substantial assistance in
understanding which behaviors pose the greatest risk
and should be addressed first (107). Information
cannot perform this function and, again, may even
make the woman who cannot tackle her problem
forthrightly feel even more inadequate (106). To
counter these feelings of powerlessness and guilt,
the Public Health Foundation suggests that
information directed toward this group of women
strive to enhance their perception of control in
order to build self-esteem (115). The most effective
delivery of this information is in the context of a
treatment program.
Clinicians who treat drug-using women also emphasize
the importance of providing information privately, so
that there is an opportunity to discuss concerns and
raise questions out of the hearing of other patients
and staff in the waiting room (25) . Persons
providing information to users also must be ready to
supply them immediately with resources for further
assistance (25, 41).
After comparing results achieved by trained
volunteers and skilled counseling professionals in
providing information to female problem drinkers,
Seattle's Pregnancy and Health Program opted to
replace its volunteers with skilled professionals
(93). Skilled professionals are deemed better able
to provide positive, hopeful messages that emphasize
building self-esteem (115, 106, 41, 117). As with
nonusing women, information provided through personal
contact seems also to have greater impact on drug-using
women than impersonally conveyed information
(93, 95).
Although there is an undisputed need for sensitively
produced, positive information for drug-using women,
intervention, in the form of well-conducted screening
and referral, is the most important service that can
be provided to this group (128, 106, 41). This is
the subject of the next section of this chapter.
3-14
J7
Screening
Techniques
Approaches to Screening and Referral
By its very definition, screening is an activity
that applies to all participants in a particular
program. The goal of screening for drug use is to
identify all persons among a specific population, who
may have a problem (138, 34). Referral is the
follow-up to a positive screening (138, 34). If the
results of the screening questionnaire, interview, or
test indicate that a person may have a problem, the
next step is to put that person in contact with a
specialist who can diagnose the problem and treat it
(138, 34).
Screening and referral are therapeutic as well as
mechanical processes (93, 128, 106). Trained staff
are needed to perform this function effectively, and
ongoing efforts to ensure the responsiveness of
referral resources are essential. Otherwise, the
reputation and credibility of the referring
organization are in jeopardy (41, 61).
Because chemically dependent women, for the most
part, will not voluntarily report their drug use, two
methods commonly are used to identify possible
problems, namely, questions and laboratory tests
(e.g., urinalysis) (128, 38). Laboratory tests are
more definitive, but can measure only relatively
recent use (38). Cocaine, for example, appears in
the urine for only a few days after use. As a
result, it is possible for a current cocaine user to
"pass" a urine test (45) .
When properly posed, screening questions for drug use
can "differentiate patterns of use, and can ascertain
use over longer time periods" than laboratory tests
(37). The discussion of screening in this report is
limited to the use of questionnaires because
laboratory tests are intrusive and expensive and
require specialized training to administer properly.
Questionnaires can be self-administered or
administered by skilled interviewers. However, self-administered
questionnaires are not recommended for
the WIC population because the literature shows that
personal contact plays an important role in conveying
information to people with low literacy skills (43).
Also, chemically dependent women tend to misreport
their drug and alcohol use. A skilled interviewer
can often elicit truthful answers by posing questions
in a certain way. This flexibility is not possible
with a self-administered instrument (37, 38, 128).
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<*?-
Types of screening Instruments Used. For several
years, clinicians and researchers have been grappling
with how to design screening instruments to elicit
truthful responses about drug and alcohol use (38,
93, 95, 106, 109, 68). A sampling of the better
known instruments in use today includes the Michigan
Alcohol Screening Test, the New York Screening Self
Test, the Cahalan volume-variability scale, the
Khavari KAT scale, Case-Western Reserve's
questionnaire for identifying the alcohol-abusing
obstetric-gynecologic patient, Ten Questions:
Drinking History, and the Day and Robles
questionnaire (109, 18, 82, 138, 128, 37). The
Healthy Mothers, Healthy Babies Substance Abuse
Prevention Packet for Health Care Providers also
contained a screening instrument that incorporated
elements from the Day and Robles questionnaire,
Rosett and Weiner's Ten Questions, and several intake
questionnaires used by large-scale narcotics
treatment programs. Although the complete packet is
currently unavailable, the screening instrument is
included in a booklet entitled "Drugs and Pregnancy:
It's Not Worth the Risk" (34).
Although the number of questions asked and their
phrasing differs from instrument to instrument, the
majority of screening questionnaires for alcohol and
other drug use seek information about the following
(38):
• the quantity of a drug used;
• the frequency with which it is used; and
• the duration of use.
Answers to questions about quantity describe how much
a person uses per occasion and thereby give a measure
of exposure to the drug (37, 38). Quantity also
reveals something about "style of use," for example,
whether the person drinks until drunk or smokes
cocaine or injects heroin until the supply is
exhausted (37).
Information on how often a drug is used, teamed with
responses to quantity questions, can reveal if the
respondent is a regular user, daily user, binge user,
or moderate user (37, 38).
Information on duration of use helps to separate
long-term users from the more recently involved (37,
38). Depending on the drug and the age of the
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respondent, questions on duration of use can be used
to assess potential risk for abusing other drugs, to
determine treatment modality, and to predict the
prospects for recovery, among other concerns (37, 38,
128).
In addition to these core questions, clinicians pose
a variety of other questions that their experience
has shown to be productive in identifying abusers.
For example, Project Safe believes that a question on
parental alcohol use is essential, a view that is
shared by several clinicians (68, 93, 106, 128, 138).
This screening question is deemed important because
substantial numbers of patients receiving treatment
for dependence on drugs and alcohol (in many
programs, the majority of patients) have a family
history of alcoholism (138).
Persons with histories of psychiatric treatment also
constitute a substantial proportion of the population
in some programs. Therefore, a question about
psychiatric problems is often included in screening
instruments (41) .
The Seattle Health and Pregnancy Project reported
that positive answers to two screening questions
identified 80 percent of the pregnant women who were
later assessed as problem drinkers (93):
• Do you ever have five or more drinks on any one
occasion?
• Do you have the feeling that you should decrease
your alcohol use?
The New York Screening Self Test also uses variations
on these two questions ("If you drink wine, beer or
beverages containing alcohol, how often do you have
four or more drinks?" and "Does your drinking
sometimes lead to problems between you and your
family, that is, wife, husband, children, parent, or
close relatives?"). Furthermore, it asks whether
parents had problems with alcohol and whether the
respondent has "gone to a doctor, psychologist,
social worker, counselor, or clergyman for help with
an emotional problem" (109).
As concerns about new patterns of drug use emerge,
screening instruments are adjusted (68). At Boston
City Hospital, for example, women who reply
affirmatively to questions probing for heavy use of
3-17
JV
cigarettes, alcohol, or marijuana are now queried
about cocaine (160).
Day and Robles have done substantial work in the
construction of screening instruments. They have
found that women tend to remember quantity better
than frequency, so they advise placing questions
about amount used first (37).
To relieve anxiety about sensitive drug and alcohol
questions on the part of both interviewer and
respondent, many health programs (but not
specifically drug or alcohol treatment programs)
embed these questions in the normal intake interview,
in sections addressing health history, dietary
practices, and lifestyle (61). Similarly, the order
of questioning proceeds from prescribed to over-the-counter
medications, to the legal drugs—tobacco and
alcohol—and then on to the illicit drugs. This
progression from medically and socially approved
drugs to illicit drugs is deemed both more natural
and less threatening than other possible orders (34,
138) .
Some screening models combine screening for use (to
discover if a person may have a problem) with a
fairly detailed drug and alcohol history (91, 93,
68). This approach saves time in settings where an
assessment of drug use is made immediately following
screening and the patient subsequently is referred
for treatment (68) . Programs offering prenatal
health services or drug and alcohol treatment
services frequently use this combined approach (68).
How Questions Are Posed. Questions asked during
screening must be nonjudgemental (138). In Rosett
and Weiner's Ten Questions, for example, the
questions about beer ask (128):
• How many times per week?
• How many cans each time?
• Ever drink more?4
4Day and Robles's work on sequencing (37)
suggests that a better order for these questions
would be to put: "How many cans each time?" first.
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S5
Another technique for eliminating judgmental
overtones and promoting honest answers is to ask
about alcohol and other drug use in the past month,
rather than about present use (37) . Many women are
ashamed to admit their current use because of its
possible ill effects on the developing fetus and are
reluctant to report current involvement in illegal
behavior. Asking about use in the past month seems
to promote more honest responses (38, 138).
Despite the increased length of the questionnaire,
some researchers believe that asking separate
questions for each substance used elicits more
accurate responses (e.g., ask about cocaine, heroin,
and marijuana separately rather than about drugs; ask
about beer, wine, and liquor separately rather than
about alcohol) (18, 128, 106).
Accurate answers can also be obtained by suggesting a
relatively large amount when posing questions about
quantity (138, 34). At Cleveland Metropolitan
General Hospital-Case Western Reserve University,
pregnant patients who drink beer are asked, in a
matter-of-fact tone of voice, "One or two six packs
at a time?" Respondents who do not abuse alcohol
usually laugh and specify an amount. Women with
problems frequently agree with the amount suggested
or provide a slightly lower one (138). Regardless of
the response to any question, the interviewer's
reactions should be accepting and nonjudgemental (93,
128, 138).
Location and Timing of Screening. Experts warn
against setting up screening and referral programs as
a separate function for pregnant women (138, 109).
Instead, they suggest including screening within
ongoing programs that already provide services to
this population (109). Prenatal services are singled
out most often as ideal sites for screening, but WIC
Programs also are mentioned as possibilities (138,
106, 93, 68, 109).
Optimally, screening for use of drugs and alcohol
should occur during the participant's first visit to
the program. Some clinicians believe screening in
some form should be repeated at subsequent visits
because use is misreported by so many women with
problems (1^8, 38).
Format of the Screening Instrument. The format of
the screening instrument used should be compatible
with the screening agency's and the assessment
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sh
agency's record-keeping systems. The instrument
should not only be convenient for the screener to
use, but it should mesh with the data reguirements of
other records maintained by both agencies (41).
The instrument should minimize writing to lessen the
time reguired for completion and to maximize the
clarity of responses. Also, the instrument should be
printed in multiple-part form to expedite the
referral for assessment. Instruments used in some
programs, for example, are color coded so that the
blue copy goes into the program's record and the
yellow copy is sent to the assessment agency (68).
The screening instrument should include a flagging
method, scoring system, or some other device to
separate persons who should be referred for
assessment from those who should not (68). Criteria
used in existing instruments may be viable for many
programs; others may find that they need to adjust
criteria to reflect the problems uncovered among
their participants (34).
Characteristics of the Questioner. Experts in the
treatment of chemically dependent women believe that
skilled professionals should conduct both screening
and referral (93, 117, 128, 138). Some recommend
hiring drug and alcohol specialists to carry out this
function; others recommend intensive training in drug
and alcohol abuse screening and referral for every
front-line worker in a program so that all can share
in screening tasks and engage in informed observation
of participants' behavior and physical status, even
in the waiting room and rest room (117, 93, 138,
109). Still other experts believe that health
educators and nutritionists should be trained to
conduct screening (68).
The consensus is that proper screening reguires
substantial skill and that screeners need both
didactic and experiential training in recognizing
symptoms, establishing rapport, and posing and
rephrasing guestions (109). Operation PAR, a
comprehensive drug abuse treatment and prevention
program, provides training to social service programs
in how to screen for drug and alcohol abuse (119).
Screening is intended to uncover possible problems.
It is not definitive, and the numbers of possible
users identified are probably underestimates of the
true prevalence of drug and alcohol problems (38,
128, 138). To have an effect, screening must be
3-20
S7
accompanied by an assessment or followed immediately
by a referral for an assessment (138, 37, 68).
Referral Identification of suspected drug and alcohol abuse
has been termed the first step in treating the
problem (138). Referral for further assessment, even
when the referral is rejected, is a powerful method
for penetrating the denial practiced by drug and
alcohol abusers and signals that the problem is an
urgent matter and should be taken seriously (138).
Prior to developing and implementing a referral
system, it is essential to investigate and assess the
existing infrastructure of services. This ensures
that an appropriate role for the new system can be
clearly defined and that the system can function
viably within an interlocking network that seeks to
move a person suspected of alcohol or other drug
involvement from identification (i.e., to determine
possible drug abuse) to assessment (i.e.,
confirmation or diagnosis of drug abuse), through
treatment, and on to recovery (152, 41).
In some settings, the service infrastructure may be
minimal. If assessment and treatment services exist,
they may not be suited to the special needs of the
pregnant woman, or they may not be readily accessible
because of their location, their hours, their cost, a
language barrier, or absence of child care services
(152). Appropriate programs may be filled to
capacity (16, 152). In other settings, specialized
assessment and treatment services may simply be
unavailable (152).
Identifying Referral Resources. The first task is to
identify and characterize services that may be
available (126). In some communities, directories of
services have already been compiled and can be
updated and expanded easily. In others, a directory
of resources may have to be developed (138, 131).
The minimum information needed for referral purposes
includes the program's name and location, services
provided, hours, cost, eligibility reguirements,
admissions procedure, and contact person.
When a community offers a selection of services for
assessment and treatment, site visits can be used to
evaluate the appropriateness of services for the
intended individuals. In some settings, there is no
choice. Nonetheless, a site visit still gives the
referring agency some understanding of what the
referred person will encounter (126, 152).
3-21 sr
Programs such as Shawnee, Health Start, Project Safe,
and the Public Health Foundation, among others,
strongly recommend using a skilled community resource
and referral specialist to identify and evaluate
available community resources and compile the
directory (6, 68, 41, 115). They also suggest using
this person to define a protocol for making
referrals, develop an implementation plan for the
referral service, function as a liaison with referral
resources, train intake workers in the referral
process, and direct the program's referral component
on a daily basis (6, 68, 41, 115, 109).
Defining a Protocol for Referral. Information
gathered for the directory of services can be used in
defining a program's protocol for referral. Ideally,
a referral for assessment should be made immediately
after screening is completed, and, if possible, the
screening and referral should be conducted by the
same person (68, 128). It should be noted, however,
that in some medically oriented programs (e.g.,
Cleveland Metropolitan General Hospital), a nurse
does the screening and a physician handles the
referral (138). The greater stature and credibility
of the physician as perceived by low-income women,
overcomes the disadvantages of changing the contact
person midstream and interrupting the relationship
established through the screening process (34, 81,
138) .
The referral process generally begins by affirming
any positive items from the screening (e.g., "you
seem to be eating right, that's good for you and the
baby) (34). The idea is to ease discomfort, foster
rapport, and open up a dialogue with the participant
(34). In keeping with this approach, throughout the
referral process, a supportive, accepting, and
interested tone of voice should be used (109, 138).
Next, the problem area is singled out for attention,
but again, the tone should not indicate disapproval:
"You seem to be concerned about your drinking," "Your
use of cocaine seems to be giving you problems" (34,
68). Then, the suggestion for additional help is
made: "More help with this would be good for you and
your baby," "I would like a specialist to talk to
you some more about this" (68).
If the participant agrees, or at least does not
disagree, the next step is to initiate the referral
(138). In some programs, particularly those that are
co-located with health clinics providing assessment
or treatment services, it may be possible to
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sq
establish a system whereby a participant simply walks
over for an assessment on the spot, preceded only by
a quick call to notify the assessment provider that
she is on the way (68, 41). Where staff resources
permit, the woman may be accompanied to the
assessment site to ensure that she follows through
with the referral and to allay her anxiety (68, 41).
In many settings, however, an appointment is
necessary. If circumstances permit, the referring
program should call during the referral session to
arrange a day, time, and contact person (138). The
remainder of the referral time should be used in
encouraging the participant to keep the appointment
and in completing any forms needed to facilitate the
assessment (138).
Some programs send copies of the screening form to
the assessment or treatment agency by messenger;
others mail them (138, 41). Some programs do not
send a copy of the screening form at all. If any
information on the screening form is released to
another agency, a consent form should be signed by
the participant prior to the release of information.
Signed releases help ensure that the referring agency
is in compliance with Federal regulations concerning
confidentiality.
The participant should be given a referral form that
contains the details about the referral (day, time,
program name and address) and includes the name of a
specific contact person and his or her phone number
(41, 138). Personalizing the referral is important
in overcoming the participant's reluctance to follow
through (138). For both efficiency and purposes of
documentation, some programs use multipart forms that
contain the screening instrument, the consent form,
and the participant's referral form all in one (41).
Handling Refusals. Experience at Cleveland General
Metropolitan Hospital shows that although some women
follow through on their appointments, many others
refuse to accept a referral (138). Refusal is
frequently due to a woman's denial of her chemical
dependency as well as her fear of legal
repercussions. If a woman fails to keep the
5Personal communication with General Counsel,
Alcohol, Drug Abuse and Mental Health Administration,
May, 1989.
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60
appointment, it is important to maintain contact with
her, to hold open the possibility of her keeping an
appointment at another time, and to continue
providing positive support and acceptance (138) .
Clinicians at the Public Health Foundation observed
through focus groups that many low-income Black women
believe they are "exchanging control" over their own
lives for "government assistance" every time they
participate in a referral (115). To combat such
feelings, it is helpful to point out areas in which
the participant is succeeding to enhance her sense of
empowerment, and to describe the referral as a
positive opportunity for her to regain more control
over her own life (115).
A woman who refuses to accept a referral should be
asked to keep an "open mind" and, in the course of
future contacts, the offer of referral should be
reiterated in a positive way (138). Programs that
have motivated women to become actively involved in
working out the details of referrals have had some
success with such second attempts, as have programs
that use recovering pregnant women as role models to
show the benefits of referral (115, 68).
Even if a woman refuses a referral, it is essential
that the attempt to refer be documented (68). Some
programs use a referral instructional sheet as a
reminder (68). This sheet covers the range of
possibilities for referral and serves as a check on
actions taken and documentation completed (68). A
copy of every form completed (e.g., screening,
referral appointment, informed consent to release
information, and referral instructional sheet) should
be maintained in the participant's file (138, 68,
41). Maintaining copies of all forms allows the WIC
agency to have a complete record of the referral.
This avoids problems caused by staff changes and
misplaced forms, and documents that a referral was
made in case there is a question.
Establishing Linkages Among Programs. Linkages with
other organizations must be established to ensure
that procedures used in the referring organization
are compatible with those in the referral resource;
mechanisms are established to resolve problems or
handle unusual cases; regular contact among services
is maintained so that an individual's progress
through the referral system can be tracked; and
agreements are reached about which organization bears
responsibility for a particular individual (61, 41).
3-24
61
Linkages also can be used to help train staff. In
St. Petersburg, Florida, for example, Operation PAR
trains staff from other programs in screening and
referral (119).
Other programs identified as referral resources also
can provide useful technical consultation on such
matters as design of forms, documentation,
maintaining confidentiality, and procedures for
obtaining informed consent (61). Not only is
assistance obtained from partners in the referral
network specifically applicable to the reguesting
program and its participants, but sharing information
also promotes consistency in approach and fosters
interaction and cooperation among community-based
health and social services organizations (118, 61).
Perhaps the most important benefit derived from an
active effort to forge linkages among referring
agencies and assessment and treatment resources is
improved case management (41) . Individual services
become components of a total system, which, when
functioning at its best, provides a person with
genuine continuity of care (41).
Although affiliated with individual programs, staff
who are linked to one another within a network also
form a team capable of responding comprehensively to
an identified participant's multiple needs (41, 61).
A strong network of services allows each individual
service to concentrate on what it does best, with the
confidence that a competent organization in another
field will provide additional needed services (61).
Training Staff in the Referral Process. Well-trained
staff are the key to good referrals. Not only do
staff need to be conversant with the procedures or
mechanics involved in making a referral, but they
must be able to establish a therapeutic relationship
that will lead an individual to accept and follow
through on the referral (68, 93, 138, 41, 128).
Furthermore, they need specific instruction about
chemical dependence so they can unders