Reach, Acceptability, and Sustainability of the Native Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) Intervention: A Qualitative Evaluation of an Alcohol-Exposed Pregnancy Prevention Program

3.1. Reach

Within the broad theme of “reach,” participants shared their motivation to take part in Native CHOICES, how it helped them, and what they learned from participating in Native CHOICES.

Motivation to take part in Native CHOICES. The participants shared that their primary motivations for taking part in Native CHOICES were to understand their drinking habits, become empowered to make healthy choices, reduce their risk of an AEP, and learn more about themselves and their habits.

“I learned about your program through Facebook and wanted to look at myself with the alcohol choices and stuff, like, whatever options. Kind of like basically wanting to see what I was going through, I wanted to see it through your study. See what I was doing, what led my life to alcohol”.

(Amy)

Participants also shared the common theme of being motivated to join Native CHOICES out of curiosity about what the program entailed. Either they heard about Native CHOICES from a friend and wanted to participate themselves, or they were intrigued by other recruitment efforts.

“At first, one of my friends recommended me to come over here because she just got done with the study, and she said that it was a really good learning experience for her as well as research study. And it intrigued me to want to come do it, so I came this way”.

(Sarah)

How Native CHOICES helped. Several participants addressed how learning about AEP risk helped give them tools to be more health conscious, which allowed them to quit unhealthy habits and engage in new, healthier ones.

“It did. And it actually helped me to really be conscious about my health as a woman and, I guess, with contraception. And it really helped me to open up and think about other family members and how it’s not a subject that everybody talks about”.

(Angela)

What participants learned. The participants valued Native CHOICES because it provided new insights, tools, and lessons for addressing their sexual habits, learning about sexual health, setting goals to change their drinking habits, and generally becoming aware of their drinking habits. Many shared their success in this regard.

“There was a lot going on. A lot of people drink alcohol, use cigarettes, have unprotected sex because we’re not making a rational thinking. And there’s a lot more that comes from that than just HIV and STDs. There’s a lot more to it. So, we just get more information about certain things, and a lot of it pertained to women. So, it’s kind of like just a women’s program”.

(Erin)

Another participant discussed how she never thought her drinking was risky, but through Native CHOICES, she realized it was.

“I’ve also learned about risky drinking. You really don’t think about it until we talk about it. Because I didn’t think I was a risky drinker and I am. I have never thought about it. I thought alcohol is just something fun to do. But then it’s also risky for yourself as a woman and your reproduction”.

(Maria)

Another reflected how she looked at herself differently when it came to drinking following her participation in Native CHOICES.

“I started looking at myself and seeing myself through a different perspective of my alcohol use, and I was trying to slow down, but I just never really thought about (it). After I started answering the questions and stuff, I started seeing myself in a different way and it helped me want to change”.

(Amy)

One participant valued Native CHOICES for what they learned about sexual health, including how to obtain birth control, the prevalence and prevention of sexually transmitted infections, and how to prevent AEP.

“Well, I learned that I wasn’t on birth control and that I was a heavy drinker. And then it is true, you should just start being protective. And I did get on birth control after that, though. So, I’ve been on birth control, so it helped me because I can’t really handle it myself. So, I’m glad that I got on birth control because if I happen to get pregnant, I wouldn’t know how I would be able to take care of the kid”.

(Talia)

Reflecting on aspects of Native CHOICES that supported their insights and behavioral changes, participants felt that the client workbook was particularly helpful. Some shared that the workbooks and lessons they utilized in the Native CHOICES intervention guided them to become more health conscious, get on the right path, gain a new perspective, and address other health priorities, for example, quitting smoking. The participants also identified goal setting as an important aspect of Native CHOICES that led to their behavioral changes.

“I remember in CHOICES I made goals, and I said I wanted to stay sober and be sober, and that’s over 10 months ago now and I’m still sober and loving life and I’m still not pregnant. But I still don’t believe in birth control, so I’m not even using it. But I am loving the sober life and Native CHOICES help me set those goals to make me want to stay sober. And here I am, still sober 10 months later”.

(Amanda)

Along with goal-setting specific to drinking, participants also shared their appreciation for setting realistic goals to move forward in life more generally.

“I’d just like to thank your program for helping me look at myself in a different way and those questions that I answered really helped me, and I’m still pushing forward with my goals. And it’s a struggle but I’m making it”.

(Amy)

Talking to Native CHOICES staff and having permission to be vulnerable were also noted as helpful. The participants felt comfortable sharing their experiences because they knew the information was confidential, and they trusted and valued the Native CHOICES staff.

“I like the staff. You guys are all very friendly and helpful. Like I said, helped with referrals to the women hospitals and gave us pamphlets and information. And it was really nice. It was just a nice atmosphere. Nice to go in and visit with people. We don’t get to see you guys every day. So, it was nice to just go visit someone different”.

(Erin)

3.3. Sustainability

Participants shared recommendations for sustaining and expanding the intervention. They believed it would benefit younger women and recommended more advertisements and outreach in the community. They also shared that incentives were essential and should always be included.

One participant shared that her initial reason for joining was receiving an incentive to help her with life costs, but she later appreciated what she learned.

“So for me, I like that it helped me see my drinking habits and stuff. But I think for them—and the only reason why I, honestly, did participate was because of the compensation. But I think the compensation could help them with gas or whatever and make them more aware of self—Because I understand some people—but I feel like when they come in just to get the money, and then they’re like, ‘Oh, well, I actually learned something.’ You know what I mean? A little bit. So I don’t know. I feel like—Yeah, that was totally me”.

(Lucy)

One participant shared information she learned—about sexual health, birth control, the prevalence and prevention of sexually transmitted infections, and how to prevent AEP—with her nieces and pointed out the importance of continuing Native CHOICES for her younger family members.

“Yeah. I got nieces and stuff that I show those information stuff to. They would like to do stuff like that, too. They’re young and doing that stuff now too”.

(Miranda)

Participants shared recommendations for recruiting and advertising in their community. Women recommended using Facebook and more traditional venues like the radio, newspaper ads, flyers posted on bulletin boards around buildings in the community, such as the grocery store and post office, and passing out flyers to community members. They also recommended sharing information about Native CHOICES in more traditional settings, such as community Talking Circles. One participant shared the importance of recruiting participants through word of mouth and simply talking to women in the community through different mediums to foster comfortability and an environment where they can feel more open to learning and participating.

“I think I’ve heard a radio ad. I think that’s a great way to put it out there. And I also think even just talking about it. Like having a recorded session with people who are open to talk about it and advertising that, whether it’s a Facebook Live or a radio portion, I think when people see someone talking about something so comfortably, then they’re open to join in”.

(Maria)

Other suggestions were to collaborate with community-based programs serving individuals who may be interested in Native CHOICES, such as family violence programs, Community Health Representative programs, women’s clinics, and the Indian Health Service.

3.4. Impact of the Pandemic

Participants reflected on the ways in which the pandemic affected their drinking habits and access to birth control. Many drank less during the pandemic due to social distancing, travel restrictions, and fear of contracting COVID-19, which restricted socializing. However, a few women drank more, a few quit altogether, and a few reported the pandemic did not impact their drinking habits at all.

“Actually, I quit during COVID because sharing alcohol and just like transferring it from your saliva, it’s hitting the bottom of the bottle. And just, no”.

(Claire)

Among women who drank more during the pandemic, isolation, lack of structure, more free time, and travel restrictions were noted as contributors.

“It (drinking) was a lot worse. There was nothing to do, with no jobs hiring or anything. And I don’t know, all my friends are doing it, too. And I didn’t want to be alone. And I started falling with everybody else”.

(Amy)

With respect to birth control, many participants reported their use was not affected. However, a few reported poor access to birth control due to stay-at-home orders, closed clinics and hospitals, or overcrowding at clinics and hospitals.

“The clinics were closed—Yeah, there was no work. There were times I had gotten sick, but I couldn’t go to the hospital to get birth control and I know the programs weren’t open and everyone was on leave for the pandemic. Everybody got to stay home”.

(Amy)

Conversely, some women reported using birth control due to drinking behaviors during the pandemic and wanting to protect themselves.

“So for me, during COVID, personally, I noticed I’ve started drinking a lot more alcohol. I don’t know if it was freedom or time or being quarantined. It kind of felt like there was not very much structure during COVID or during quarantine. But I definitely was more aware of using birth control because I knew I was drinking more alcohol”.

(Angela)