This document proposes an intervention program to prevent Fetal Alcohol Syndrome (FAS) in South Africa. The program would use a dual approach: 1) counseling and treating women who are currently or plan to become pregnant about the dangers of drinking alcohol during pregnancy, and 2) educating younger women and girls to prevent FAS in future generations. Focus groups and surveys would assess knowledge and behaviors around drinking during pregnancy. An intervention including counseling high-risk women and educational sessions for schoolgirls would aim to decrease alcohol consumption during pregnancy and prevent FAS. The goal is to improve knowledge of FAS risks and lower rates of this preventable condition affecting children's health in South Africa.

1. Prevention of Fetal
Alcohol Syndrome in
South Africa
LINDA ZHENG AND TAWANDA MATAMBANADZO
DR. MARTHA TERRY, BCHS 2509
SUMMER 2014

2. Abstract
Fetal Alcohol Syndrome (FAS)/Fetal Alcohol Spectrum Disorder (FASD) are
serious conditions which require attention from the field of public health. In
particular, the children of South Africa have been known to be inflicted with
FAS/FASD due to their mothers consuming alcohol during their pregnancies. As
FAS/FASD is completely preventable, an intervention program which is effective
can be developed through the dual approach of: 1. treating and counseling
women currently or about to become pregnant, 2. educating younger women
and girls about FAS/FASD and the dangers of consuming alcohol during
pregnancy. Through continuous surveying and educational/counseling sessions,
this program plans to both decrease the amount of alcohol consumed during
pregnancy and prevent FAS/FASD from occurring in future generations.

3. Introduction – The Problem
WHAT?
Fetal Alcohol Syndrome (FAS) / Fetal Alcohol Spectrum Disorder (FASD)
WHO?
Pregnant women
HOW?
Consuming alcohol during pregnancy
WHERE?
Western Cape, South Africa
WHY?
To eliminate the risk of developing FAS/FASD in newborns so that they may
live healthy, high-quality lives

4. Background
Fetal Alcohol Spectrum Disorder – a collective term for the conditions which
may arise in people whose mothers drank during pregnancy1
 Completely preventable
 Symptoms may include: Abnormal and retarded growth of facial features and body
structures, central nervous system problems, heart defects, mental retardation
 No cure and lasts a lifetime, but some treatment options—early intervention may
improve development in children
Fetal Alcohol Syndrome – the category of the most severe cases of FASD, may
include fetal death1
As of 2011, the World Health Organization recognized South Africa’s Western
Cape province as having the highest reported rate of FAS in the world2
 An estimated 1 million people in South Africa have FAS and 5 million have FASD2

5. Characteristics of Fetal Alcohol Syndrome
Figure 1. Characteristic facial features in a child with fetal alcohol spectrum disorders.3

6. Social Ecological Framework
Individual
◦ Genetic predisposition for addictive behaviors
◦ Environment of alcohol use /abuse
◦ Knowledge of effects of alcohol on fetus/FAS
◦ Stressors and coping mechanisms
◦ Age/previous pregnancies
Interpersonal
◦ Role of alcohol in personal relationships/social gatherings.
◦ Parental perceptions and education on daughter's maternal health.
◦ Environment of alcohol abuse
◦ Provider interventions for FAS to pregnant mother.
Community
◦ Cultural norms related to use of alcohol
◦ Social definitions of alcoholism
◦ Norms related to alcohol and gender
◦ Norms related to alcohol use/abuse and pregnancy
Institutional
◦ Role of beverage/alcohol industry in awareness
◦ Availability of Mental health facilities/practitioners
◦ Accessibility to bars, and other locations that sell alcohol.
Policy
◦ Funding for mental health programs/services.
◦ Funding for FAS awareness programs
◦ Regulations related to selling/access of alcohol products and
definition of alcoholic beverage (taxes, availability etc.)

7. Stakeholders & Resources
Individual
 Pregnant women in Western Cape, South Africa prone to drink during their pregnancy
Interpersonal
 Families, close friends, and health care providers/caregivers of the pregnant women
Community
 “Drinking buddies,” community members/neighbors, religious groups
Institutional
 Hospitals and their expertise, Alcoholics Anonymous South Africa, Public Health Association
of South Africa (and other Public Health institutions), bars and alcohol distributors,
institutional buildings for meetings, social media/newspapers to spread information
Policy
 Local, provincial, and national government and their policies and funding

8. Theoretical Framework-Health Belief Model
Perceived Susceptibility- use /abuse of alcohol during pregnancy and risk for FAS; and/or belief
in the correlation between FAS and alcohol; belief in the dangers of consuming alcohol
Perceived Severity- related to FAS spectrum disorder; level of knowledge of the seriousness
and/or severity of FAS
Perceived Barriers- related to decreased alcohol use and prenatal care/education; anything that
may stop or hinder the women from lowering alcohol consumption (e.g. social norms)
Perceived Benefits- specifically alcohol abstinence/reduction in alcohol consumption during
pregnancy; whether or not this will help/be beneficial to the child
Cues to Action- education/awareness of FAS disorder and correlation to alcohol use, therapy for
alcohol abuse, therapeutic coping strategies, CBT
Self-Efficacy- likelihood to reduce intake/abstain from alcohol during pregnancy

9. Methodology
Mixed methods approach: Focus groups followed by 100 online surveys and 100 paper surveys.
Focus group study:
 Each focus group (total of 4) will consist of 8-10 women who are either pregnant or planning on becoming
pregnant and have resided in South Africa for at least 3 years. The women involved do not necessarily have to
actively drink alcohol, in order to broaden our understanding of the views and norms on drinking alcohol while
pregnant. The women will be recruited through local hospitals and obstetricians via surveys and flyers (e.g.
Would you like to participate in a focus group setting studying views on pregnancy and alcohol consumption?).
 Focus group questions will include: What are your views/do any social stigmas exist on consuming alcohol
during pregnancy? Do you think consuming alcohol during pregnancy is a problem that needs to be
addressed? How easily can alcohol be obtained and what role does it play in everyday lives? Have you heard of
Fetal Alcohol Syndrome/Fetal Alcohol Spectrum Disorder and what do you think it is?
 Data from the focus groups will be collected with recorded audio transcripts which will later be transcribed
into text without speaker labels and the audio files destroyed. Two analyzers will search for and label themes
in the transcription and compare results.
Online survey:
 Online surveys will be offered to 200 adult female residents of South Africa, recruited through hospital
settings and news/media associated advertisements. The survey questions will be formed by analysis of the
focus group responses but will generally involved the topics of pregnancy, alcoholism, consumption of alcohol
during pregnancy, knowledge of FAS/FASD, social norms and stigmas involving the consumption of alcohol. All
responses will be recorded anonymously and then analyzed thoroughly into a report.

10. Intervention
Based on Committee to Study Fetal Alcohol Syndrome of the
Institute of Medicine of the National Academy of Sciences model for
interventions.4
Counseling Services
◦ Targeted intervention for at risk women, whom might be pregnant or plan to
be pregnant and currently abusing alcohol.
Educational Services
◦ To increase knowledge/awareness amongst school age girls in the risks
associated with FAS; thereby deterring future alcohol use during pregnancy.

11. Goal: to decrease the amount of alcohol
consumption during pregnancy.
Target Population: Women (16-35) of child bearing age in Western Cape, South Africa
PROCESS OBJECTIVES:
By September 1st, 2014, identify 3-4 health centers and high schools to recruit for focus groups,
surveys and CAGE survey for alcoholism as well as 3-4 counselors for targeted education on FAS, via
TCAE and intention-to –abstain Likert scale evaluations for at risk women as identified by above
centers.
By November 1st, 2014, recruit/identify 26-44 women between ages 16-36 for focus groups.
Between December 2014-January 2015, recruit approximately 200 women for surveying.
By January 1st, 2015, conduct 3-4 focus group of at least 8 women per group.
By April 1st, 2015, assign counselors to identify and begin counseling session to 30-40 at-risk-
women, with TCAE and Likert scale evaluations every 3 months.
By April 1st, 2015, provide education, divided into 2 sessions, to at least 50 girls with pre-post and
6-month test on FAS.

12. Goal: to decrease the amount of alcohol
consumption during pregnancy.
IMPACT OBJECTIVES:
By the end of each counseling session, each participant will be able to provide two reasons for
why drinking alcohol during pregnancy is dangerous.
By the end of each educational session, each participant will be able to explain in basic terms
what FAS is and how it develops.
At the end of the educational sessions, 60% of girls should score >75% on the post test.
By June 1st, 2015, 80% of the counseling participants will have decreased their alcohol intake
(measured by number of alcoholic drinks per week).
By June 1st, 2015, 90% of the educational participants will have told at least two other women
about FAS and the dangers of consuming alcohol during pregnancy.

13. Goal: to decrease the amount of alcohol
consumption during pregnancy.
OUTCOME OBJECTIVES:
By February 1st, 2016, identified women should complete counseling sessions with an
improvement in TCAE & Likert scale scores of approximately 35% of women from baseline.
At the 6 months test, 40% of girls should score >75% on FAS knowledge test.
By February 1st, 2016, increased knowledge/awareness of FAS in 2 high schools for girls ages >16
years will have been achieved, as measured by surveys.

14. Ethical Issues
 Beneficence-related to the care of child and mother:
 All coordinators and researchers will be reminded to think of both the child and
mother
 No actions which harm one in benefit of the other to a significant degree will be
taken
 Informed consent/Autonomy:
 Informed consent will be obtained from all participants of the study
 Every participant may leave the program whenever desired
 Paternalism/Autonomy- related to care of fetus and ideals of
human autonomy related to mother.
 No action or lifestyle behavioral change will ever be forced upon any participant
 The program focuses on strong encouragement and not limitation of freedom

15. Conclusion
 Fetal Alcohol Syndrome (FAS)/Fetal Alcohol Spectrum Disorder (FASD) is a
serious problem affecting the children of mothers who consumed alcohol during
their pregnancy and requires attention from public health intervention
programs, particularly in South Africa.
 It is important to analyze the knowledge and beliefs of pregnant (or about to
become pregnant) women in order to create an intervention program which will
increase knowledge about FAS/FASD.
 The best way to intervene is to take a two-pronged approach: 1. counsel those
currently pregnant and/or dealing with alcoholism and 2.educate those who
may come into this situation in the future.
 This program hopes to decrease the amount of alcohol consumed during
pregnancy in pregnant mothers living in South Africa and to educate and spread
knowledge of FAS/FASD and the dangers of consuming alcohol during pregnancy.

16. Bibliography
1. Centers for Disease Control and Prevention. (2014, May 24). Facts about
FASDs. Retrieved from http://www.cdc.gov/ncbddd/fasd/facts.html#
2. Zolotova, E. (2001, June). Fetal alcohol syndrome: dashed hopes, damaged
lives. Bulletin of the World Health Organization, 89.6, 393-468. doi:
10.2471/BLT.11.020611
3. Wattendorf, D.J. & Muenke, M. (2005, Jul 15). Fetal Alcohol Spectrum
Disorders. American Family Physician, 72(2), 279-285.
4. Hankin, J.R. (2002). Fetal Alcohol Syndrome Prevention Research. Retrieved
from http://pubs.niaaa.nih.gov/publications/arh26-1/58-65.htm