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Intervention Summary

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CHOICES: A Program for Women About Choosing Healthy Behaviors

CHOICES: A Program for Women About Choosing Healthy Behaviors is a brief intervention designed to help women lower their risk of alcohol-exposed pregnancy (AEP) by reducing risky drinking, using effective contraception, or both. The primary audience for CHOICES is nonpregnant women of childbearing age who are at risk for AEP because they are sexually active with a male partner, do not use contraception consistently or effectively, and drink at levels known to carry an increased risk for reproductive and fetal outcomes.

CHOICES is based on motivational interviewing (a directive but client-centered counseling style intended to reduce resistance to change) and the Transtheoretical Model of Change (an incremental, stage-based approach to conceptualizing behavioral change). The intervention consists of four 45-minute motivational interviewing sessions with a counselor/interventionist and one contraception counseling visit with a health care provider over a 12- to 14-week period. Program participants receive:

  • In-depth assessment of alcohol use and contraceptive use patterns;
  • Counseling about the consequences of alcohol use during pregnancy;
  • Brief advice and counseling for moderate-to-heavy drinkers to reduce intake levels, or referral to community treatment services for alcohol-dependent drinkers;
  • Reproductive health education about contraceptive methods; and
  • Provision of contraceptive services.

Descriptive Information

Areas of Interest Substance abuse treatment
Outcomes Review Date: August 2013
1: Risky drinking
2: Contraception use
3: Risk for alcohol-exposed pregnancy
Outcome Categories Alcohol
Ages 18-25 (Young adult)
26-55 (Adult)
Genders Female
Races/Ethnicities American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Residential
Outpatient
Correctional
Other community settings
Geographic Locations Urban
Suburban
Implementation History CHOICES has been implemented in approximately 30 sites in California, Colorado, Florida, Maryland, New York, Texas, and Virginia. Nearly 3,000 women have enrolled in the program as of 2013. Outside the United States, CHOICES has been implemented in Canada, Russia, and South Africa. The initial randomized controlled trial, conducted in 2002–2005, included participants recruited from six diverse settings in three large cities. A second evaluation was conducted with six sites funded by SAMHSA's FASD Center for Excellence, and a third evaluation is currently underway with four sites funded by the Centers for Disease Control and Prevention.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations Several adaptations of CHOICES have been evaluated in controlled trials or pilot studies. These include a single-session version of the program retaining all of the original program elements; an abbreviated version omitting the medical consultation; remote-delivered versions using telephone interviews and mailed materials; and a self-guided, Web-based version. One remote-delivered version of CHOICES was adapted specifically for American Indian women in the Northern Plains region.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Selective
Indicated

Quality of Research
Review Date: August 2013

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Floyd, R. L., Sobell, M., Velasquez, M. M., Ingersoll, K., Nettleman, M., Sobell, L., et al. (2007). Preventing alcohol-exposed pregnancies: A randomized controlled trial. American Journal of Preventive Medicine, 32(1), 1-10.  Pub Med icon

Supplementary Materials

Agrawal, S., Sobell, M. B., & Sobell, L. C. (2008). The Timeline Followback: A scientifically and clinically useful tool for assessing substance abuse. In R. F. Belli, F. P. Stafford, & D. F. Alwin (Eds.), Calendar and time diary: Methods in life course research (pp. 57-68). Beverly Hills, CA: Sage.

Ingersoll, K. S., Wagner, H., Hettema, J. E., Ceperich, S. D., von Sternberg, K., Velasquez, M. M., et al. (n.d.). Evidence of CHOICES fidelity. Manuscript in preparation.

Velasquez, M. M., Ingersoll, K. S., Sobell, M. B., Floyd, R. L., Sobell, L. C., & von Sternberg, K. (2010). A dual-focus motivational intervention to reduce the risk of alcohol-exposed pregnancy. Cognitive and Behavioral Practice, 17(2), 203-212.  Pub Med icon

Outcomes

Outcome 1: Risky drinking
Description of Measures The Timeline Followback (TLFB) method was used to obtain a continuous record of daily drinking practices from 90 days before enrollment to 9 months after enrollment. At baseline and 3-, 6-, and 9-month follow-up, participants provided TLFB reports for the past 90 days. For analysis of outcomes, data were subdivided into 30-day segments. Women were categorized as risky drinkers for a given 30-day period if they drank five or more standard drinks (containing 0.6 ounces of ethanol) on 1 or more days and/or drank eight or more drinks in a week during that period.
Key Findings Participants in the study were nonpregnant women who were currently at risk for AEP, based on self-reported risky drinking and ineffective contraception use at baseline. Participants were randomized into intervention and control groups. The intervention group participated in CHOICES and received a packet of informational materials (brochures on alcohol use and women's health and a referral guide to local resources). The control group received the informational materials only.

Women who received the intervention were more likely than those in the control group to have reduced their risky drinking behavior at each follow-up (p < .05). Effect sizes for this finding were small at 3 months (OR = 1.79; CI 1.28, 2.51), 6 months (OR = 1.64; CI: 1.15, 2.33), and 9 months (OR = 1.54; CI 1.09, 2.18).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 2: Contraception use
Description of Measures The Timeline Followback (TLFB) method was used to obtain a continuous record of vaginal intercourse and contraceptive practices from 90 days before enrollment to 9 months after enrollment. At baseline and 3-, 6-, and 9-month follow-up, participants provided TLFB reports for the past 90 days. For analysis of outcomes, data were subdivided into 30-day segments. Women were categorized as using effective contraception for a given 30-day period if they reported no occurrences of vaginal intercourse without effective contraception use during that period.
Key Findings Participants in the study were nonpregnant women who were currently at risk for AEP, based on self-reported risky drinking and ineffective contraception use at baseline. Participants were randomized into intervention and control groups. The intervention group participated in CHOICES and received a packet of informational materials (brochures on alcohol use and women's health and a referral guide to local resources). The control group received the informational materials only.

Women who received the intervention were more likely than those in the control group to report effective contraception use at each follow-up (p < .05). Effect sizes for this finding were medium at 3 months (OR = 2.40; CI 1.72, 3.34), small at 6 months (OR = 2.05; CI 1.45, 2.89), and small at 9 months (OR = 2.39; CI 1.69, 3.39).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 3: Risk for alcohol-exposed pregnancy
Description of Measures The Timeline Followback (TLFB) method was used to obtain a continuous record of daily drinking, vaginal intercourse, and contraceptive practices from 90 days before enrollment to 9 months after enrollment. At baseline and 3-, 6-, and 9-month follow-up, participants provided TLFB reports for the past 90 days. For analysis of outcomes, data were subdivided into 30-day segments. Women were categorized as being at risk for AEP for a given 30-day period if they reported engaging in risky drinking, using ineffective contraception, or both during that period.
Key Findings

Participants in the study were nonpregnant women who were currently at risk for AEP, based on self-reported risky drinking and ineffective contraception use at baseline. Participants were randomized into intervention and control groups. The intervention group participated in CHOICES and received a packet of informational materials (brochures on alcohol use and women's health and a referral guide to local resources). The control group received the informational materials only.

Women who received the intervention were more likely than those in the control group to have a reduced risk for AEP at each follow-up (p < .05). Effect sizes for this finding were small at 3 months (OR = 2.32; CI 1.69, 3.20), 6 months (OR = 2.15; CI 1.52, 3.06), and 9 months (OR = 2.11; CI 1.47, 3.03).

Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult)
26-55 (Adult)
100% Female 48% Black or African American
36% White
10.4% Hispanic or Latino
3.5% American Indian or Alaska Native
1.2% Asian
0.9% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Risky drinking 3.3 3.3 3.8 3.8 3.3 3.8 3.5
2: Contraception use 3.3 3.3 3.8 3.8 3.3 3.8 3.5
3: Risk for alcohol-exposed pregnancy 3.3 3.3 3.8 3.8 3.3 3.8 3.5

Study Strengths

Timeline Followback (TLFB) is a well-researched method and was shown to have acceptable levels of reliability and validity in the study reviewed. Sessions were audiotaped, and biweekly supervision was provided. The review of audiotapes revealed a high degree of adherence to the protocol (82% of key elements). Fidelity was assessed using a tested instrument with a high degree of interrater agreement. The use of random assignment addresses many potential confounds, and a number of baseline variables were taken into account. An intent-to-treat analysis showed minimal bias due to attrition. Missing data were handled appropriately. The analyses used were appropriate for the study.

Study Weaknesses

The self-report data obtained by TLFB were not validated using other, more objective measures and were the only data used in the study to measure outcomes. There may have been experimenter desirability bias, and, as the investigators acknowledge, mere contact with a professional could have contributed to the effects, since the control group received no such contact.

Readiness for Dissemination
Review Date: August 2013

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

CHOICES Capacity Assessment Survey

ICF MACRO. (2012). CHOICES Tracking System: System documentation. Atlanta, GA: Author.

ICF MACRO. (2013). CHOICES Tracking System: User manual. Atlanta, GA: Author.

Preparing To Implement CHOICES: Examples of Questions To Ask

Sample Timeline for the CHOICES Program

Technical assistance materials:

  • Assessment Form for Technical Assistance
  • CHOICES Coaching Assessment 2012
  • CHOICES Coaching Assessment 2012—Facilitator Copy
  • CHOICES Components: Free, Online Resources (handout)
  • Module 9: 2-Session CHOICES Option [PowerPoint slides]
  • Request Form for Technical Assistance

Training-of-trainer materials:

  • CHOICES Participant's Guide: For CHOICES Training of Trainers. (2013).
  • CHOICES Pre-Work Booklet: For CHOICES Training of Trainers. (2013).
  • CHOICES Trainer Preparation Guide: For CHOICES Training of Trainers. (2013).
  • Ingersoll, K. (2013). CHOICES Training of Trainers [PowerPoint slides]. Denver, CO.
  • Performance Checklist for CHOICES Trainer Candidates
  • Self-Assessment for CHOICES Trainer Candidates

Training materials:

  • Budget Worksheet: CHOICES Training
  • CHOICES Video Reference Guide
  • Facilitator Feedback Form: CHOICES Training
  • Facilities Checklist
  • Observation Form: CHOICES Training
  • Sample Training Agenda: CHOICES Training
  • Telephone Debrief Form: CHOICES Training

Velasquez, M. M., Ingersoll, K., Sobell, M. B., Floyd, R. L., Sobell, L. C., & Ceperich, S. (2012). CHOICES: A Program for Women About Choosing Healthy Behaviors [4-disc curriculum kit including counselor manual, client workbook, and facilitator guide CD-ROMs and training DVD]. Atlanta, GA: Centers for Disease Control and Prevention.

Project CHOICES Web site, http://www.cdc.gov/ncbddd/fasd/research-preventing.html

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 4.0 3.9 4.0

Dissemination Strengths

Extensive, high-quality materials are provided to support all aspects of implementation and service delivery in a user-friendly, easy-to-access electronic format. Comprehensive organizational readiness tools are available for new sites. Training materials, including standardized facilitator manuals, are comprehensive and available in multiple formats. Training is well developed, with exercises that are illustrated through high-quality video presentations and training activities that include interactive processes with role play and skill practice. A training-of-trainers option is available. Comprehensive and sophisticated quality assurance supports and procedures are available to track client participation and outcomes, along with training and implementation quality. One of these quality assurance supports is the Data Tracking and Monitoring System, which can be used to easily generate reports for stakeholders on outcomes and quality indicators.

Dissemination Weaknesses

Implementers are not required to use the Data Tracking and Monitoring System, which may result in inconsistent implementation quality across new program sites.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Curriculum kit (4-disc set, including counselor manual, client workbook, and training facilitator manual CD-ROMs and a training DVD) Free Yes
2.5-day training for counselors Varies depending on trainer selected and location No
Training of trainers Varies depending on site needs No
Online support resources Free No
Phone or email technical assistance Free No
On-site consultation Varies depending on consultant selected and location No
Data Tracking and Monitoring System (includes user manual and system documentation) Free No
Contact Information

To learn more about implementation, contact:
Catherine A. Hutsell, M.P.H.
(404) 498-3825
chutsell@cdc.gov

To learn more about research, contact:
R. Louise Floyd, RN, DSN, MSN
(404) 498-3923
rlf3@cdc.gov

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.