0920-1154 Provider Screener and Online Survey

Communication on Risks of Alcohol Use during Pregnancy:

Healthcare Provider Online Survey Instrument

SCREENER

1. What is your profession?

☐	Physician
☐	Nurse Practitioner
☐	Other	TERMINATE

2. What is your role in your clinic? (Check all that apply)

☐	Provide direct patient care: including treatments, counseling, self-care, patient education, and administration of medication.	MUST BE CHECKED TO CONTINUE, IN COMBINATION WITH OTHER OPTIONS OR ALONE
☐	Make administrative decisions for the clinic	IF ONLY SELECTION, TERMINATE. CONTINUE IF SELECTED IN COMBINATION WITH “PROVIDE DIRECT PATIENT CARE”
☐	Other	IF ONLY SELECTION, TERMINATE. CONTINUE IF SELECTED IN COMBINATION WITH “PROVIDE DIRECT PATIENT CARE”

3. What is your primary specialty? (Select one)

☐	Internal medicine
☐	General practice
☐	Family medicine
☐	OB/GYN
☐	Preventive medicine
☐	Pediatrics	TERMINATE
☐	Other	TERMINATE

4. Describe the county where you practice:

○	Mostly or completely urban	AIM FOR 85%
○	Mostly or completely rural	AIM FOR 15%

5) Which of the following best describes your practice?

○	Private Provider (e.g., private primary care practice)
○	Public Provider (e.g., Federally Qualified Health Center, Health Department clinic, Community Health Center, Veterans Affairs, Indian Health Service)
○	Other	TERMINATE

SURVEY

Definitions Required to Answer Survey Questions

Alcohol-Related Risky Behavior

Risky alcohol use includes binge drinking and heavy drinking.

Binge drinking is drinking five or more drinks on a single occasion for men or four or more drinks on a single occasion for women.

Heavy drinking (also considered high weekly or daily consumption) is drinking 15 or more drinks per week for men or eight or more drinks per week for women.

6) Screening for risky alcohol use is often conducted in clinical settings. If you screen for risky alcohol use, which method do you use?

○	Using a standardized screening instrument (e.g., AUDIT or AUDIT-C, CAGE, CRAFFT, T-ACE or TWEAK, etc.)	SKIP TO Q8
○	Using a single question to assess alcohol use (e.g., NIAAA single screening tool)
○	Some other screening method	SKIP TO Q8
○	I do not screen	SKIP TO Q8

7. What single screening question do you use?

○	“How many times in the past year have you had 4 (for women) / 5 (for men) or more drinks in a day?”
○	“On a typical drinking day, how many drinks do you have?”
○	“In a typical week, how many drinks do you have?”
○	Some other screening question

8) How are alcohol screening question(s) administered?

○	Interview (in person/face-to-face)
○	Patient completes a paper or electronic form	SKIP TO Q10
○	Over the telephone
○	Other, please specify _____________

9) When patients are interviewed about their alcohol use, who administers the screening?

○	I conduct the screening
○	I do not personally conduct the screening, but another physician or nurse practitioner at my practice does
○	Nurse (excluding nurse practitioner)
○	Medical assistant
○	Other

10) Among your female patients, who do you screen for risky alcohol use?

○	All female patients
○	All female patients of reproductive age
○	Only pregnant patients
○	Only female patients of reproductive age who are believed to drink
○	Only female patients of reproductive age with risk factors for alcohol use
○	Do not screen for risky alcohol use

11) Among your female patients, who do you advise and educate about the consequences of alcohol use during pregnancy?

○	All female patients
○	All female patients of reproductive age
○	Only pregnant patients
○	Only female patients of reproductive age who are believed to drink
○	Only female patients of reproductive age with risk factors for alcohol use
○	Do not provide advice or education

12) In your practice, who conducts brief interventions with patients who screen positive for risky alcohol use?

○	I conduct the brief interventions
○	I do not personally conduct the brief intervention, but another physician or nurse practitioner at my practice does
○	Nurse (excluding nurse practitioner) or physician assistant
○	No one: Brief intervention is fully computer-based	SKIP TO Q14
○	Referred to a behavioral health service agency or counsellor	SKIP TO Q14
○	Other, please specify ___________________

13) How are alcohol brief intervention(s) administered?

○	In person/face-to-face
○	Over the telephone
○	Other, please specify _____________

14) For the next few questions, consider your overall clinical experience. How often do you treat the following patients:

	Never	Sometimes	Often	Always	Not applicable
Female patients who have a child with a fetal alcohol spectrum disorder	○	○	○	○	○
Female patients who engage in drinking during pregnancy	○	○	○	○	○

Alcohol screening and brief intervention (SBI)

Alcohol SBI is used to reduce the amount of alcohol consumed by those who are drinking too much. It has two components:

1. Use of a validated set of screening questions to identify patients' drinking patterns: Examples include the Alcohol Use Disorders Identification Test (AUDIT), the abbreviated AUDIT-Consumption (AUDIT-C), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) single-question screener.

2. A short conversation with patients who are drinking too much and, for patients at severe risk, a referral to specialized treatment: Behavioral counseling interventions for alcohol misuse vary in their specific components, administration, length, and number of interactions. They may include cognitive behavioral strategies, such as action plans, drinking diaries, stress management, or problem solving. Interventions may be delivered by face-to-face sessions, written self-help materials, computer- or Web-based programs, or telephone counseling.

15) Which of the following statements most closely matches your clinical practices for alcohol SBI?

○	I have never delivered alcohol SBI at my clinic
○	I currently deliver alcohol SBI at my clinic
○	I used to deliver alcohol SBI at my clinic but do not currently deliver it

PROGRAMMER NOTE: PRESENT ONE OF THE FOLLOWING THREE SCENARIOS (A, B, OR C) TO EACH PARTICIPANT AND

THEN CONTINUE TO Q17. RANDOMIZE SCENARIOS.

SCENARIO A:

Please consider the following clinical scenario:

Ms. Johnson, aged 21, comes to your clinic for her annual check-up. She drinks socially three to four times per week, usually having two to three drinks per occasion. Ms. Johnson is sexually active and does not use any form of contraception (birth control).

16a) Please indicate how effective you think the following actions would be to assist Ms. Johnson:

	Very effective	Somewhat effective	Not very effective	Not at all effective	Not applicable
Provide education on alcohol risks in pregnancy	○	○	○	○	○
Encourage her to use contraception for every sexual encounter	○	○	○	○	○
Encourage her to reduce her alcohol use	○	○	○	○	○
Perform a standardized brief intervention	○	○	○	○	○
Refer her to alcohol treatment	○	○	○	○	○

SCENARIO B:

Please consider the following clinical scenario:

Ms. Wilkes, aged 26, comes to your clinic, pregnant in her first trimester and seeking prenatal care. This pregnancy was unintended and before she had realized that she was pregnant, she had been drinking one to three times per week, having one to two drinks per occasion. She has been drinking at these levels on a regular basis for several years and believes that having one glass of wine one to two times per month at social gatherings would not pose a threat to her pregnancy.

16b) Please indicate how effective you think the following actions would be to assist Ms. Wilkes with a healthy pregnancy:

	Very effective	Somewhat effective	Slightly effective	Not at all effective	Not applicable
Provide education on alcohol risks in pregnancy	○	○	○	○	○
Encourage her to reduce her alcohol use, but not stop	○	○	○	○	○
Emphasize the importance of stopping all alcohol use	○	○	○	○	○
Perform a brief intervention	○	○	○	○	○
Refer her to alcohol treatment	○	○	○	○	○

SCENARIO C:

Please consider the following clinical scenario:

Ms. Anderson, aged 24, comes to your clinic, pregnant in her first trimester. She was brought to the clinic by her mother to receive prenatal care. She engaged in binge drinking on a regular basis before realizing that she was pregnant. She becomes visibly annoyed when asked about her alcohol use. Ms. Anderson does not appear to be significantly concerned about the potential impact of alcohol on her pregnancy, although her mother shows much more concern.

16c) Please indicate how effective you think the following actions would be to assist Ms. Anderson with a healthy pregnancy:

	Very effective	Somewhat effective	Not very effective	Not at all effective	Not applicable
Provide education on alcohol risks in pregnancy	○	○	○	○	○
Encourage her to reduce her alcohol use, but not stop	○	○	○	○	○
Emphasize the importance of stopping all alcohol use	○	○	○	○	○
Perform a brief intervention	○	○	○	○	○
Refer her to alcohol treatment	○	○	○	○	○

17) Indicate your level of agreement with the following statements as they pertain to your female patients of reproductive age:

Statement	Strongly disagree	Somewhat disagree	Somewhat agree	Strongly agree	Not applicable
In general, I have found that my patients are open and receptive to discussing contraception methods.	○	○	○	○	○
My patients seem to understand the risks involved with consuming alcohol while not using any method to prevent pregnancy.	○	○	○	○	○
In general, patients communicate about alcohol use openly with their primary care physician.	○	○	○	○	○

18) Have you participated in any type of formal alcohol SBI educational training?

○	Yes
○	No

19) How confident do you feel about:

	Not at all confident	A little confident	Fairly confident	Very confident	Not applicable
Your ability to identify risky alcohol use?	○	○	○	○	○
Your ability to conduct brief interventions for alcohol problems?	○	○	○	○	○
Your ability to refer patients to treatment for alcohol problems?	○	○	○	○	○

20) Indicate your level of agreement with the following statements:

	Strongly disagree	Somewhatdisagree	Somewhat agree	Strongly agree	Not applicable
Alcohol screening does not offend patients	☐	☐	☐	☐	☐
Alcohol screening identifies risky alcohol use	☐	☐	☐	☐	☐
Brief interventions reduce the consequences of risky alcohol use	☐	☐	☐	☐	☐

21) Do you agree or disagree with the following statement?

“Alcoholism is not a treatable illness.”

○	Strongly disagree
○	Somewhat disagree
○	Somewhat agree
○	Strongly agree
○	Not Applicable

Now a few questions for statistical purposes:

22) In what zip code is your clinical practice?

______________

MAKE THIS FREE TEXT FIELD, EACH RESTRICTED TO A 5-DIGIT NUMBER

23) What is your age?

☐	18-24
☐	25-34
☐	35-44
☐	45-54
☐	55-64
☐	65 or Older

24) What is your gender?

☐	Male
☐	Female
☐	Other
☐	Prefer not to answer

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