Mixed-methods evaluation of national virtual healthcare team training on fetal alcohol spectrum disorders using Normalization Process Theory

Abstract Information: Prenatal alcohol exposure (PAE) resulting in fetal alcohol spectrum disorders (FASDs) is the most common preventable cause of permanent intellectual and developmental disabilities in the U.S. Healthcare teams play a critical role in preventing PAE, and caring for individuals with suspected or diagnosed FASD, however, they are often unprepared. Participants (n=58) were trained to prevent, identify, and manage FASDs over one year (10 sessions all virtual) using the evidence-based Extension for Community Health Outcomes (ECHO)® model from June of 2021 through April 2022. The curriculum included an FASD foundational science webinar, core content modules, and case discussions. Enrolled community health centers (n=15) received a modest stipend; participants received continuing education credits. The mixed-methods evaluation used the Normalization Process Theory (NPT) to measure knowledge, skill, and self-efficacy outcomes. Pre- (n=58), mid- (n=39), post- (n=36) and 6-month follow-up (n=35) surveys assessed shifts in outcomes along with provider burnout, training satisfaction, and sense of community. At post-test, a high proportion of participants reported: increased knowledge about screening for PAE both during pregnancy (100%) and among children with possible FASD (92%). From pre to post-test, of the 24 matched surveys, there were significant increases in self-efficacy, confidence, and self-reported practice change in FASD indicators compared to baseline. Data suggests that this mode of learning – training providers virtually using a combination of didactic instruction and case-based discussion – increases provider FASD knowledge and self-efficacy and promotes improvements in clinical practice. Quantitative findings informed qualitative data collection (i.e., interviews/focus groups, n=10) for practice-based application. Results of the virtual year-long training showed increases in outcomes and identifies facilitators/barriers to making practice change. NPT forces consideration of clinician practice and clinic protocols with a framework to guide actionable recommendations.

Relevance Statement: This proposal aligns with the theme of this year’s annual conference “The Power of Story” as our mixed-methods evaluation provides context to the implementation facilitators and barriers of screening for risky alcohol use and assessing and diagnosing FASDs, using qualitative data to support the quantitative findings. This proposal 1) ensures that mixed-methods evaluations are designed with a thorough understanding of context, priorities, resources, and protocols within which the intervention is delivered, 2) engages stakeholders in the evaluation design process ensuring varied perspectives and voices are considered when designing mixed-method evaluation that are flexible yet appropriately focused, and, 3) integrates quantitative and qualitative data using the implementation framework Normalization Process Theory (NPT) to produce recommendations that can be immediately applied in practice. This proposal has relevance to the field of evaluation for three reasons. First, use of mixed methodology to evaluate a virtual training program allowed for extraction of rich and relevant data about individual-level and clinic-level practice. We administered four surveys (pre-test, mid-point, post-test, and follow-up) throughout the 12-month training. Results were used to tailor training content and inform subsequent data collection efforts as well as to guide the program team on additional areas for technical assistance. Quantitative survey results and the NPT were used to synthesize a semi-structured interview guide, yielding information that are integral in issuing and disseminating pragmatic recommendations. Second, the proposal focuses specifically on designing and conducting a mixed-methods evaluation that must consider the nuanced implementation of alcohol screening and FASD identification and diagnosis protocols within multiple community health centers in various settings across the United States. The protocols for prenatal alcohol screening and FASD identification and diagnosis are implemented differently at each clinic. However, providers were able to gain an in-depth understanding of their own individual and clinic-level protocols through case studies and discussions with the training cohort and expert program faculty. Third, the proposal focuses on a mixed-methods evaluation of a training that is critically needed within the prenatal and pediatric community to reduce prenatal alcohol exposure and improve FASD diagnosis and managing capacities. The demand for developmental evaluation has far exceeded the workforce available to perform them. Currently, FASDs are severely underdiagnosed and a huge gap in resources to support diagnosis exists, specifically in more rural areas where barriers are even more present. Additionally, during COVID we have seen 1) a dramatic rise in alcohol consumption, especially in people of childbearing age, which puts individuals at a higher risk of prenatal alcohol exposure, and 2) a decline in universal screening for alcohol use in adult patients. Healthcare teams can play a critical role in preventing, diagnosing, and managing FASD; however, they are unprepared to do so. Summarizing mixed methods results into practical application can be challenging but when guided by a framework such as NPT yields actionable recommendations that are crucial and invaluable to enhance the practice of healthcare teams in screening their prenatal patients for risky alcohol use and pediatric patients for prenatal alcohol exposure.