Screening, Brief Intervention, and Referral to Treatment

The IHR 5P’S

Behavioral Health Risk Screening for Pregnant Women and Women of Childbearing Age

Women’s health can be affected by emotional problems, alcohol, tobacco, other drug use, and violence.  Women’s health may also be affected when those same problems are present in people close to them. Women often find it difficult to discuss the subject of alcohol and other drug use with prenatal/primary care care staff  because of stigma, shame, and fear of legal repercussions.  However, prenatal/primary care staff have a window of opportunity to reduce alcohol use during pregnancy by discussing the risks associated with use in a non-judgmental, non-confrontational manner. By talking openly and comfortably with their pregnant or preconceptional patients about the risks associated with prenatal substance use, medical staff can normalize conversations about alcohol and the use of other substances through a universal, routine and open process. Pregnant women will receive the support, information and referral to prevention and treatment resources that will contribute to healthy birth outcomes. Preconceptional women will have information about the risks of alcohol and other drugs in pregnancy. Although the largest sub-population of alcohol and other drug dependent women are women of childbearing age, not all women who use alcohol and/or illicit drugs are drug dependent. Early identification of risky substance use and appropriate intervention is often effective in preventing problem or dependent use.

The 5 P’S
The Institute for Health and Recovery’s 5 P'S Screening Tool is based on Dr. Hope Ewing's 4 P's (Parents, Partner, Past and Pregnancy)1, and although designed specifically for pregnant women, may be used for women of childbearing age. The 4 P's have been adapted by IHR, and, in another iteration, by Dr. Ira Chasnoff of the Children's Research Triangle (see below). IHR has utilized the 5 P'S successfully in six years of the Alcohol Screening Assessment in Pregnancy  Projects, in 18 months of the Fetal Alcohol Screening for Today Project, in 32 community health centers across the Commonwealth of Massachusetts, as well as in New York, California, and other states. An article describing our utilization of the 5 P'S in prenatal settings has been published in the Maternal and Child Health Journal 1.2  The IHR 5 P'S was developed through funding by the Maternal and Child Health Bureau for the ASAP Project and is in the public domain.

We have chosen the 5P'S for its simple structure and its relational base. It is a quick, easy, non-threatening, and effective tool for use in busy, resource-challenged prenatal care offices, though it is also utilized with women of childbearing age in primary care settings. It effectively asks a pregnant woman about her own use of alcohol in a nonjudgmental manner. For women at risk for use or not yet ready to report their own use, the 5P'S asks about alcohol and other drugs by people who are most likely to be important in a woman’s life: her Partner and her Parents3. Research has shown that women who are in relationships with partners or have parents who have alcohol/drug problems are more likely to use themselves and are also at risk for other medical concerns, such as infectious disease. The 5P’S also encourages a woman to report a Past or Present problem with alcohol. The instrument opens the door to a possible conversation about a patient’s current alcohol or drug use, her past use, or use among people in close relationship to her. Each "P" and/or Smoking represents a documented risk for substance use during pregnancy. The 5 P'S can be embedded into existing office forms, used as part of a fuller pregnancy needs assessment as a self-administered written questionnaire (SAQ), or included in electronic medical records.

In ASAP1, the 5P’s were asked in a specific order that started with a question about someone else’s alcohol use (Parents). Each subsequent question brought the issue of alcohol use closer to the pregnant women (Peers, Partner) until the last two questions asked about the patient’s Past and use during this Pregnancy (present). This sequence was established to be as non-threatening as possible. Each of the risk assessment tools utilized in ASAP1 asked an additional question about tobacco use because of the documented link between pregnant women’s tobacco and alcohol use.4, 5 Using the 5P’S, including the tobacco use question, 35.5% of the pregnant women screened in ASAP1 over the first three years had at least one risk factor; the percentage has increased to 47% in more recent years. Most of those patients who screened in responded positively to the questions regarding tobacco use (ASAP1:58% in community health centers, 45% in private practices) and parental alcohol problem (31% in community health centers, 12% in private practices). In accordance with the ASAP protocol, if a pregnant woman responded positively to any of the 5P’S or the tobacco use question, she would also receive a brief intervention. Implementation protocols for the 5 P’S may be found in Alcohol Screening Assessment in Pregnancy: The ASAP Curriculum6, written and edited by the Institute for Health and Recovery. ASAP2 increased the number of screenings per pregnancy to three. Project FAST reduced the number of questions that would result in a positive screen at the request of prenatal care staff from ASAP sites. Prenatal staff felt that "parental" and "peer" use was less indicative of risk than "partner," "past," "present," or "tobacco," and that fewer positive responses resulted in the time savings of a few brief interventions. Since time is of paramount importance to medical staff, ASAP flexibility was an important factor in keeping busy prenatal sites engaged in the project.  Screenings per pregnancy were reduced from three to two times, and quantity/frequency questions were included. Positive responses to "parental" and "peer" indicate that a woman is at risk of alcohol use and prenatal staff use this opportunity to discuss risk with them. Screening outcomes from these three projects may be found at the end of this document.

In ASAP 1, a consultant conducted interviews with both patients who had completed the risk assessment with the 5P's embedded, and with prenatal care staff at participating sites. Patient interviews found that when patients were asked about the 5P’S, they reported that they felt the set of questions was appropriate and understood them to be health related. Fifty per cent reported that they found themselves thinking about issues raised in the questionnaire after the screening process had been completed. The following comments from the prenatal care staff offer their views on the choice of embedding the 5P’S within a Pregnancy Risk Assessment at the initial visit:

“We liked the alcohol screening questions. It was easier for the patients to answer questions about other people as opposed to themselves.”   (Lynn Community Health Center)

“Clients may deny use throughout pregnancy, but they are open to discussion about other people’s use.”  (Great Brook Valley Community Health Center, Worcester)

“We considered it a guide for talking to patients about sensitive issues.  We liked it because it looked at all aspects of a women’s life, the whole person and issues.”  (Lynn Community Health Center)

“It is always a plus to have a tool that helps you look at risk behaviors.” (Great Brook Valley Community Health Center, Worcester)

In addition to healthcare sites, IHR has successfully utilized the 5P’S screening/engagement tool in different settings:

1. A Substance Abuse and Mental Health Services Administration-funded IHR project (Project RISE) provided intensive clinical case management services to homeless pregnant and parenting women with substance abuse problems living in motel rooms and shelters funded by the Massachusetts Department of Transitional Assistance. Although this project ended, the Massachusetts Department of Transitional Assistance has funded a similar program through IHR, utilizing the 5 P'S (RISE II).
2. A Massachusetts Department of Transitional Assistance-funded FOR Families program, a home visiting program serving families leaving public assistance or living in “welfare motels.”
3. A Center for Substance Abuse Treatment-funded project (Project WAVE) serving women and families in domestic violence shelters who are affected by mental illness, substance abuse and/or trauma.

Trainings on the IHR 5 P’S have been offered nationally and across Massachusetts, as well as at a variety of national conferences.  

The 5 P’S Behavioral Health Risk Screening Tool expands on the original ASAP 5 P’S through reformatting the questions and providing visible pathways for provider utilization, and including Quantity/Frequency of use. Although questions regarding depression and domestic violence have always been included in the ASAP 5 P’S, this new formatting embeds these risk factors directly into the screening tool.  Harvard Pilgrim Health Plan was the first to utilize this tool in their innovative, telephonic case management program for women with high-risk pregnancies. The 5 P’S Behavioral Health Risk Screening Tool has been modified for primary care for utilization with women of childbearing in 32 community health centers across the Commonwealth of Massachusetts. Data from this Screening, Brief Intervention and Referral to Treatment (SBIRT) project are currently being collected.

For more information, please contact:
Enid Watson, M. Div.
Director, Screening and Early Identification Projects
enidwatson@healthrecovery.org
617-661-3991