Feasibility of an Art-based Intervention to Address Clinician Stigma and Improve Care for Neonatal Opioid Withdrawal Syndrome

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Project Summary Clinician stigma toward mothers with opioid use histories adversely affects implementation of evidence-based care and, subsequently, infant outcomes. Our preliminary research found 54.5% of perinatal nurses had heightened stigmatizing attitudes toward perinatal opioid use and neonatal opioid withdrawal syndrome. This is concerning because every 15 minutes a newborn suffers from opioid withdrawal in the United States and the rate of perinatal opioid use is steadily increasing. Improving clinical care and outcomes for opioid-exposed mothers and infants is considered a top clinical and public health priority. Numerous studies recommend perinatal nurses engage and support mothers with opioid use disorders to deliver interventions (breastfeeding, skin-to-skin care, rooming-in) that improve short and long-term infant health outcomes (eg, withdrawal symptom severity, length of hospitalization). However, the implementation of these efforts is stymied by nurse stigmatizing attitudes related to perinatal opioid use. Toward the goal of improving infant health by addressing stigmatizing attitudes, PI Shuman developed DAB-RN (Drugs, Art, and Babies for Registered Nurses), an art-based intervention informed by Corrigan’s model of stigma and the Emancipatory Theory of Compassion. Art has long been used to facilitate attitudinal change and motivate behavioral change and DAB-RN applies artwork and art pedagogy to improve attitudes about perinatal opioid use and, thus improve infant care and health outcomes. In our preliminary testing, DAB-RN improved self-reported attitudes toward perinatal opioid use and all participants reported high satisfaction with the intervention. After conducting two focus groups, we found that the intervention is severely limited by its current delivery format – a synchronous, group-delivered program led by a facilitator – and must be adapted to a more scalable, sustainable, and testable platform. We use the ADAPT-ITT 8-phase model to adapt DAB-RN. We have completed phases 1-3 in our preliminary work. For this R21 proposal, we will complete phases 4-8. We will address barriers and concerns noted in our preliminary testing by adapting DAB-RN to a web-based intervention for asynchronous, remote delivery. Then, we will theater test the program with a diverse sample of 24 nurses and 4 topic experts, soliciting attitudes and feedback on the look, flow, usability, and content of the intervention. Findings will be used to modify the DAB-RN intervention (Aim 1). Then we will test the feasibility of the adapted DAB-RN intervention in a pilot cluster randomized trial with two arms: 1) experimental group receiving the adapted DAB-RN intervention (N=75) and 2) control group not receiving any intervention (N=75) (Aim 2). From the experimental group, we will examine feasibility including acceptability, adaptation, practicality, study logistics (recruitment, retention), and cost (production, site maintenance). We will conduct 10 in-depth interviews with nurses in the experimental arm to more comprehensively assess feasibility. We will measure nurse stigmatizing attitudes at baseline and 3-months following the intervention to identify direction of intervention effects to inform a future large cluster randomized control trial evaluating DAB-RN’s efficacy. The proposed research is significant and fits well with NIH priorities, including addressing maternal morbidity (IMPROVE Initiative) and substance use (HEAL Initiative). This study will lead to a scalable version of DAB-RN primed for a series of large-scale studies evaluating efficacy and effectiveness.