Use of Focus Groups in Developing FAS/FASD Prevention in Russia

Abstract

Fetal alcohol syndrome is a severe outcome of alcohol use during pregnancy, and the rates may be higher in countries with greater use of alcohol. To obtain information from Russian physicians (N = 23), women (N = 23), and male partners (N = 5), focus groups were conducted with 51 participants in St. Petersburg, Russia. The main objective was to determine the participants’ knowledge, attitudes, and behavior related to drinking during pregnancy. Data were analyzed using ATLAS-ti 5.0. The results will be used to develop a survey of Russian professionals and women leading to FAS prevention programming. The study’s limitations are described.

Introduction

For 30 years, alcohol use during pregnancy has been recognized as an important public health issue. Alcohol was first identified as a teratogen in the 1970s (Jones, Smith, Ulleland, and Streissguth, 1973), and in 1981 the U.S. Surgeon General recommended that women refrain from drinking alcoholic beverages during pregnancy or when planning a pregnancy. In many developed countries, including the United States, public health campaigns, medical programs, and clinical interventions have helped raise awareness about the negative effects of alcohol consumption during pregnancy. However, the importance of this public health issue has not been addressed in many developing countries, including Russia, leaving medical professionals, pregnant women, and the public uninformed about the potential harm posed by alcohol use during pregnancy.

The use of alcohol during pregnancy is one of the leading preventable causes of birth defects, mental retardation, and developmental disabilities. Of all substances, including heroin, cocaine, and nicotine, alcohol use during fetal development causes the most serious neurodevelopmental effects (Stratton, Howe, and Battaglia, 1996). Depending on various factors, alcohol use during pregnancy can result in fetal alcohol syndrome (FAS). FAS includes abnormalities in three different areas: (a) disorders of the brain associated with central nervous system involvement, including neurological abnormalities, developmental delays, behavioral dysfunction, intellectual impairment, and/or brain structure abnormalities; (b) prenatal and/or postnatal growth retardation; and (c) facial malformations, qualitatively described as including short palpebral fissures, an elongated midface, a long and flattened philtrum, thin upper lip, and flattened maxilla (Sokol and Clarren, 1989).

Not all children exposed in utero to alcohol will exhibit FAS; however, many can show significant neurobehavioral problems, which may be diagnosed as fetal alcohol spectrum disorders (FASD) or alcohol-related neurodevelopmental disorder (ARND) (Jacobson and Jacobson, 1994; Sood et al., 2001). In ARND, central nervous system dysfunction caused by prenatal alcohol exposure is associated with a range of functional or mental impairments. These can include cognitive abnormalities as evidenced by low intellectual functioning, learning difficulties, poor school performance, poor impulse control, and problems with mathematical skills, memory, attention, and/or judgment (Roebuck, Mattson, and Riley, 1999; Sood et al., 2001). Children with ARND can also exhibit hyperactivity, behavior problems, and difficulty in social situations (Roebuck, Mattson, and Riley, 1999; Streissguth and O’Malley, 2000). As these children reach adolescence and adulthood, they are more likely than non-affected individuals to be involved with the legal system or have problems with substance use, interpersonal relationships, and employment (Olson, Feldman, Streissguth, Sampson, and Bookstein, 1998; Streissguth et al., 1991).

The worldwide incidence rate of FAS is estimated to be 1.9 per 1,000 live births (Abel and Sokol, 1987). However, this rate is likely much higher as many cases are undiagnosed through the commonly used surveillance method (May and Gossage, 2001). FAS rates may be higher in countries with greater use of alcohol and with limited education about the effects of alcohol during pregnancy. The rate does not take into account the incidence of FASD/ARND, which can be quite debilitating to affected individuals and their families. Although FASD/ARND can be difficult and complex to diagnose and consequently its exact prevalence is not easily estimated, the etiology of the disorder, alcohol use during pregnancy, is straightforward and far more easily assessed.

As in many developing countries, the rates of FAS and ARND in Russia are not precisely known. Anecdotally, international adoption agencies frequently warn potential adoptive parents about the risk of FAS or alcohol-related problems in children adopted from Russia (see Aronson). Screening evaluations for FASD in baby homes in the Murmansk region of Russia found that 13% of children had high and 45% of children had intermediate phenotypic expression scores, suggesting prenatal exposure to alcohol (Miller et al., 2006). In another study, a group of Russian pediatricians trained by U.S. dysmorphologists assessed children for FAS in orphanages and boarding schools for children with mental retardation and other mental health problems in Moscow. Of the 1,637 children assessed, the rate of FAS was higher in orphanages (14.5%) than in the boarding schools (5.3%) (Robinson, Jones, Marintcheva, Matveeva, and Riley, 2001). These findings indicate that the rate of full FAS may be as high as 53 to 145 per 1,000 children in such institutions in Russia. The researchers concluded that prenatal alcohol exposure accounted for neuropsychological deficits above and beyond those associated with the living environment. The findings from these unique samples should not be applied to the larger Russian population of children; however, the data do not include FASD/ARND cases and it is expected that a larger proportion of children may be affected by prenatal alcohol consumption. Taking into consideration that 174,432 children lived in Russian children’s homes and boarding schools for the disabled in 2002, and many more younger children were living in baby homes (Innocenti Insight, 2005), it is clear that alcohol exposure can have serious effects for a large number of children in institutionalized care in Russia.

There is a strong tradition of holiday drinking in Russia for both men and women that has deep historical roots (Herlihy, 2002). In the late 1990s, alcohol consumption in Russia ranged from 11 to 14.5 liters of pure alcohol per person per year (World Health Organization [WHO], 1999). This alcohol consumption rate is one of the highest in the world and is well above the upper limit of 8 liters annually, an amount associated with severe health risks. A study of alcohol consumption in a national sample of the Russian population found that while the overall levels of reported alcohol use appeared low, possibly because of underreporting, 31% of men reported binge drinking at least once a month (Bobak, McKee, Rose, and Marmot, 1999). In March 2006, 2,369,000, 15% more than in 2000, were registered by the Russian public health system as alcohol dependent (Onishenko, 2006). The number of alcoholics in Russia is actually thought to be six to seven times higher than the number of registered patients, resulting in an estimated 15 million alcohol dependents (Erishev, personal communication, February 28, 2003). Despite the Russian perception of drinking as unfeminine (Herlihy, 2002) and survey findings about gender differences in alcohol consumption in Russia (Bobak et al., 1999), recent research has indicated that the number of women who are alcohol dependent in Russia rose during the 1990s (WHO, 1999). These estimations do not take into account the undoubtedly large number of people who use alcohol but may not be dependent.

In summary, the problem of alcohol use and dependence is widespread in Russia and likely affects a large number of pregnant women and their fetuses. As the initial step of preventing FAS/ARND in Russia, the goal of this study was to utilize focus groups to obtain information from Russian women who were pregnant and male partners, non-pregnant women, and physicians about their attitudes, beliefs, and knowledge about alcohol use during pregnancy. The problem of alcohol use and dependence is widespread in Russia and likely affects a large number of pregnant women and their fetuses.

Method

Sample

Focus group participants were recruited using a snowball sampling technique and seven focus groups were conducted in St. Petersburg, Russia. Groups of non-pregnant women of childbearing age, pregnant women, and women with alcohol dependency were selected to represent the population who would be targeted in an FAS prevention program, and a group of partners of pregnant women was recruited to obtain information from women’s significant others. Groups of pediatricians and obstetricians/gynecologists (OBGs) participated to represent the two branches of the medical profession that have the most access to childbearing age women, an important factor for preventing alcohol exposed pregnancies. Additionally, a group of physicians providing substance abuse treatment to women was selected as these women may be at greater risk for alcohol exposed pregnancies. The potential participants were told that the study was to assess opinions of different groups of people about healthy pregnancy as an initial step in developing interventions to prevent problems in children caused by drinking alcohol during pregnancy. The data collectors were Russia female graduate students in psychology at St. Petersburg State University (SPSU) and were approximately the same age as the targeted population, i.e., child-bearing age. They were trained and supervised in conducting focus groups by an experienced Ph.D.-level psychologist at SPSU.

The focus groups included the following participants: 12 non-pregnant women recruited from a college adult education class, 6 pregnant women recruited from a public women’s clinic, 5 women with alcohol dependency from an inpatient substance abuse treatment center, 6 pediatricians and 11 OBGs at continuing education courses at St. Petersburg Pediatric Academy, and 6 physicians providing services at a substance abuse treatment clinic. Efforts were made to recruit a group of partners of pregnant women in public clinics but were not successful due to time constraints and the typical lack of male participation in their partners’ health care. In order to conduct a group of male partners, a convenience sample was recruited through personal contacts of the project staff. Five men whose partners were pregnant were recruited for the group.

A total of 51 participants were in the focus groups and the majority were primarily of Russian origin. American-based definitions of minority groups/ethnicity status are not applicable to the population groups in Russia. In addition to the Russian participants, other groups were represented by minorities specific to the Russian population (Ukrainian, Belarusian, Tatar, Jewish). The age range was from 20 to 50, with the majority being under age 40. The non-medical participants had high levels of education with most having the equivalent of a master’s or University degree. Eight of the women and one of the partners had one or more children, and 15 women and 3 men did not have children at the time of the study. The majority of the 23 physicians who participated were female, a representative figure for medical professionals in Russia, and had from 2 to 30 years of clinical experience. (See Table 1)

Table 1.

Selected demographic characteristics

Demographic characteristics	Women (pregnant, non-pregnant, and women with alcohol dependency)	Pregnant women’s partners	Physicians
N	23	5	23
Gender
Female	23		18
Male	0	5	5
Nationality
Russian	21	5	19
Other (Ukrainian, Belarusian, Tatar, Jewish)	2	0	4
Age
20–29	14	3	3
30–39	7	2	6
40–49	2 (40–44)	0	9
50 +	0	0	5
Education
Some college or technical training (3–4 years)	4	2	—
University degree	19	3	—
Medical degree			23
Parental status
No children	15	4	N/A
One and more children	8	1
Years in medical practice
Less than 5	N/A	N/A	0
6–10			2
11–20			3
21–30			10

An ethical committee/behavioral institutional review board (IRB) for the protection of human subjects had recently been established at SPSU through a research collaboration with the Oklahoma University Health Science Center (OUHSC). The SPSU IRB process was initiated as a result of the collaboration between SPSU and OUHSC in order to meet the requirements of human subjects protection for the current study. This research project was approved by the ethical committee/behavioral IRB at SPSU and the institutional review board at OUHSC. All participants were informed about the study and signed consent to participate. The participants were informed that while there may not be a direct benefit to them from participating, their information could help to develop effective programs to benefit women’s and infants’ health in the future.

Procedures

A research team from OUHSC and SPSU developed the focus group questions for women and their partners to address empirically based factors relevant to the prevention of alcohol use during pregnancy. The focus group protocol was not pretested; however, it was based on a previous study utilizing focus groups to develop an FAS prevention program in the United States (Branco and Kaskutas, 2001). The questions covered topics such as important things to do to have a healthy baby, attitudes toward drinking during pregnancy, effects of alcohol on a fetus, what would increase/decrease women’s drinking during pregnancy, advice they received from physicians about drinking during pregnancy, public messages or warnings about drinking, and general knowledge of FAS. The women were not asked directly about their own alcohol use during pregnancy. A set of questions was developed for physicians to assess their knowledge about FAS, attitudes toward alcohol consumption during pregnancy, and if they had participated in formal training on FAS. The focus group leaders facilitated the groups by asking questions and interjecting comments primarily to encourage participation and to maintain focus. Each group lasted from 1.5 to 2 hours. At the end of each group, the group leaders reviewed and summarized the key points covered in the discussion and the participants received a small gift, i.e., a pen, to compensate for their time.

The participants were approached in the different settings, i.e., women’s clinics, a college adult education program, a substance abuse treatment center, and continuing medical education programs, and asked to participate in a research study being conducted by SPSU and OUHSC. After introductions and a review of study goals and confidentiality procedures, the participants read and signed a consent form, which included permission for the session to be audiotaped; the audiotape would be erased after the tape was transcribed. The participants were told that the information they provided would be confidential and would only be used for research purposes. The participants completed a brief demographic questionnaire and then discussed the focus group questions. The groups were conducted in Russian by two female Ph.D.- or master’s-level Russian psychologists in private rooms at women’s clinics, SPSU, the St. Petersburg Pediatric Academy, and an inpatient substance abuse treatment center in St. Petersburg.

Data Analysis

The focus group sessions were audiotaped and then transcribed by the project staff. The transcripts were analyzed using ATLAS-ti 5.0, a software program designed to analyze textual and other types of qualitative data (Muhr and Friese, 2004). The analysis examines the relationships and patterns of responses and organizes code clusters according to overarching themes. The focus group transcripts were entered into ATLAS and were coded by two project investigators who are fluent in both Russian and English to condense the data into analyzable units. Segments of the transcripts ranging from a part of a phrase to a paragraph were assigned codes (in English) based on the identified points or themes. The codes were discussed and agreement in the assignment of codes was determined through discussion among the project faculty at SPSU and OUHSC. A catalog or response to each initial probe was developed and the number of individuals raising each point was recorded. For each of the initial points identified, qualitative responses, representing variability on the same point, were saved, discussed by the project faculty, and used for a decision on the final coding process. The final list consisted of a numbered list of codes and related phrases. Based on these codes, a series of themes arranged in a treelike structure connecting transcript segments organized into separate groups or themes were generated.

Results

The transcript segments were grouped into six theme structures that reflected the women, the partners, and physician participants’ responses that were identified from the data. The first theme was “Pregnant should not drink.” This theme had the highest frequency of responses and was linked to other themes in all of the focus groups. However, this theme was not raised spontaneously by any of the participants and the majority of the comments were in response to direct questions by the group facilitators about alcohol effects and women’s alcohol consumption during pregnancy. Three major groups of codes were identified in the first theme. The first group included the general effects on the mother or child of drinking during pregnancy, such as medical consequences, memory problems, or mental retardation. The second group included a few reports by women about abstinence during pregnancy. Alcohol-dependent women were more negative about alcohol in general and most of them said that women should be abstinent during pregnancy. The third and largest group in this theme reflected the participants’ ambivalence about consuming alcohol during pregnancy and the acceptability of drinking small amounts of alcohol during pregnancy. The responses ranged from “Pregnant women should not drink; however, to drink a little is OK,” to “The doctor said that you might drink, but not too much or too often,” to “Red wine is beneficial for a baby’s health.”

The next theme, “For baby’s health,” represented the second most frequent theme in all of the focus groups and reflected the high value placed on a baby’s health in Russia. The theme included a number of health beliefs existing in the Russian population, such as pregnant women should get enough sleep and exercise, experience positive emotions, avoid chemical hazards, receive prenatal care, and follow doctors’ recommendations. All these beliefs reflected a general attitude toward a healthy lifestyle during pregnancy. Despite the positive attitudes toward health during pregnancy, these descriptions lacked any attention to alcohol abstinence. “Pregnant women should avoid all bad habits such as smoking and drinking” was one of the few statements specific to alcohol consumption statements included in this theme.

The third theme centered on the “Effects of prenatal alcohol consumption on the fetus” and consisted of four groups. The first group included a number of negative effects of alcohol that were not specific to FAS/FASD but reflected a general idea about the “bad influence” of alcohol, such as, “Alcohol is harmful for the fetus,” “Alcohol can cause school problems,” and “Alcohol can result in a baby being weak.” A smaller group consisted of FAS-related problems such as birth defects and mental retardation. These items were mentioned by fewer respondents and did not include FAS specific signs, such as facial features or growth deficits. The third group represented incorrect statements such as, “Alcohol may cause a baby being an alcoholic.” Finally, the last group represented uncertainty or disbelief about the effects reflected in statements such as, “Alcohol influence on a baby may make it different,” “I don’t know what the alcohol effect is,” and “I think it may not cause any harm.”

Similarly, physicians had limited knowledge about FAS or the effects of drinking during pregnancy. OBGs and substance abuse physicians did not mention FAS spontaneously, did not know FAS symptoms, were not aware of the specific risks of alcohol use during pregnancy, and thought FAS was curable. They thought that FAS was an “alcohol dependent” newborn or the “withdrawal” process in newborns. They reported that newborn withdrawal was the most serious problem related to alcohol consumption. In the group of six pediatricians, one mentioned FAS spontaneously and described the facial signs correctly. Three other pediatricians mentioned a range of symptoms, including birth defects and behavior problems, but had limited knowledge about other FAS features such as growth deficits and mental retardation. It should be noted that Russia medical school curricula do not include information and instruction on FAS symptoms, diagnosis, or treatment.

The remaining themes were related to FAS prevention and the receptivity to different prevention approaches. All groups reported a lack of information and printed materials. Women, men, and physicians were not aware of any prevention programs on drinking during pregnancy in Russia. The first theme, “Current Sources of Information,” consisted of sources for information about alcohol and pregnancy and three groups were identified in this theme. The largest group included comments that were related to “societal” knowledge. For example, women “just know” how to behave during pregnancy and rely on their “own knowledge.” Women might get information “from childhood,” which has been passed “from generation to generation.” Another group indicated that women receive information from family members and friends. Women and partners identified mothers and grandmothers as major existing sources of information. There were fewer responses related to books or labels on alcohol beverages. Women reported seeing such labels and a few recalled the label, but they indicated that the label is written in very small, hard-to-read font and is too general: “Alcohol is harmful for pregnant women and drivers.”

The last group included in this theme reflected the lack of information women received from physicians and in women’s clinics. The majority of the women and partners reported seeing posters with information on HIV but did not report seeing any printed educational materials that included information about the risks of alcohol consumption during pregnancy. The women stated that doctors “Do not talk, they measure and take analysis, but do not talk.” They reported that physicians give health advice but such advice does not refer to alcohol consumption. One participant reported, “My doctor said that the most important thing that a women could do for her baby’s health would be to visit the doctor regularly and bring my urine for a general health testing every time.” Members of the project staff reported that there were no posters on the specific consequences of alcohol use during pregnancy in hospitals, clinics, or medical school departments. Further, verified FAS has not been addressed in the Russian media or in publications from medical or other professional organizations.

OBG doctors indicated that the lack of time, information, and resources were barriers in addressing alcohol problems in their practice. Misconceptions that could affect the physicians’ practice were also indicated such as, “Normal women know about the harm of alcohol and do not drink, and alcoholic women would drink anyway” or “It is impossible to maintain complete abstinence.” Pediatricians appeared to have the most knowledge about drinking during pregnancy. They indicated that most pregnancies were not planned, contraception was expensive and not easily accessible, and women did not know about the risks of drinking during pregnancy. One strongly recommended abstinence and another pediatrician suggested the following message: “Women should get a message: Want a baby? Do not drink; if you drink—do not have a baby.” However, one stated that drinking in the last trimester may be a preventive measure for premature birth.

The last two themes, “What can convince?” and “What can be influential?” clearly indicated that women considered physicians (OBGs) as the most influential source of information about health and pregnancy that women would listen to and believe. Additionally, “self-knowledge,” books, research data, and evidence-based recommendations were listed as potentially influential sources for information.

When asked what influences women’s health behaviors/lifestyle and why some women do not stop drinking during pregnancy, women emphasized family relationships, social support, desire to have a baby, and responsibility; doctors spoke about social attitudes that support drinking and economical problems; and alcoholic women pointed out the importance of medical control/treatment.

Conclusions

Data from the seven focus groups showed that the physicians, women, and their spouses/partners had limited knowledge about the effects of alcohol on a fetus and some participants were uncertain that there might be negative effects. Only a few knew the term fetal alcohol syndrome, while the majority were not aware of its symptoms and demonstrated misconceptions, i.e., if father was drunk at the time of conception, that could affect the fetus; the most severe effect of alcohol on a fetus was alcohol withdrawal in a newborn or the baby being an alcoholic. However, despite the lack of knowledge, the consensus in all seven groups was that women should not drink during pregnancy. Interestingly, despite the overall opinion that drinking during pregnancy was unacceptable, most participants reported that consumption of a small amount of wine was acceptable and might even be beneficial for a woman and her baby’s health.

Not only did women and partners have minimal information about FAS, the OBGs and substance abuse professionals who participated also demonstrated a lack of information. For example, when asked about FAS, they related the term to withdrawal type symptoms in newborns and were unable to provide specific examples of FAS symptoms. Pediatricians were more aware of FAS, correctly describing facial features indicative of FAS; however, a broad list of symptoms was cited, indicating limited knowledge about the specific effects of FAS, such as growth abnormalities and mental retardation.

The group discussions indicated that a pregnancy is valuable in Russian society and pregnant women’s health behaviors such as proper nutrition, exercise, and stress management are considered important for children’s health. Alcohol abstinence/reduction of drinking is considered to be a part of a general “healthy lifestyle.” However, women and their partners paid disproportionately little attention to alcohol abstinence, and the need to stop drinking during pregnancy was not spontaneously mentioned as important “for a baby’s health” in any of the groups. Upon direct questioning, participants stated that “Women should stop or limit drinking during pregnancy.” Physicians treating women with substance abuse were the only professionals who consistently recommended complete abstinence during pregnancy.

Pregnant women reported that their OBG would be the most important source of information about their pregnancy. However, only one out of five pregnant women, and none of the non-pregnant women, reported ever receiving information about alcohol and its effects on the fetus from an OBG in a women’s clinic. OBGs indicated that a lack of time, information, and resources as barriers to addressing alcohol problems in their practice. Pediatricians appeared to have the most knowledge about the effects of alcohol on a fetus and indicated that women do not know about the risks of drinking during pregnancy.

Both women and professionals emphasized the need for specific information on drinking during pregnancy and the lack of print materials for women that would provide research-based, clear, and understandable information on the effects of prenatal alcohol exposure. Women emphasized that beliefs based on their “own knowledge” would be the most important for their drinking decision. This indicated an important role for information that could be processed by women and integrated into their belief systems. Information from health professionals and women indicated that materials that would “scare” women would be the most effective with women who drink and would convince pregnant women to abstain from alcohol. In addition, there are traditional beliefs in Russia that play an essential role in defining the acceptable amount of alcohol allowed during pregnancy. While excessive drinking is not acceptable, to “drink a little” is acceptable and certain alcohols, such as wine, are thought to be beneficial during pregnancy.

This study is limited by the small numbers and high education level of the participants. However, the results indicate the lack of knowledge about the effects of alcohol use during pregnancy, even in highly educated individuals in Russia. The focus groups clearly indicated that FAS awareness and prevention resources, training for professionals, media campaigns, and printed materials do not exist in Russia and should be developed for pregnant and non-pregnant women, their partners, and health professionals.

Data obtained in this study will be used to develop a more extended survey utilizing a broader, more representative sample of Russian women and physicians to identify prevention strategies and make policy recommendations.

Glossary

Alcohol Exposed Pregnancy

a term used to describe a pregnancy in which the fetus was exposed to alcohol.

Alcohol Related Neurodevelopmental Disorders (ARND)

alcohol-related neurodevelopmental disorder is a term that describes the functional or mental impairments linked to prenatal alcohol exposure, such as behavioral and cognitive abnormalities including learning difficulties, poor school performance, poor impulse control, and problems with mathematical skills, memory, attention, and/or judgment.

Fetal Alcohol Syndrome (FAS)

fetal alcohol syndrome is a disorder resulting from maternal prenatal use of alcohol. It includes abnormalities in three domains—growth retardation, neurobehavioral abnormalities, and facial abnormalities.

Fetal Alcohol Spectrum Disorders (FASD)

fetal alcohol spectrum disorders (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications.

Focus Group

a form of qualitative research in which a small group of people () is recruited from a broader population to explore their opinions and emotional responses about a particular topic. Focus groups typically have 6 to 12 members. The groups are led by a facilitator and questions are asked in an interactive group setting where participants are free to speak with other group members.

Biographies

Tatiana N. Balachova, Ph.D., a clinical psychologist, is an assistant professor in the Department of Pediatrics at the University of Oklahoma Health Sciences Center (OUHSC). She has 20 years of experience working in alcohol research and treatment programs in Russia. She graduated from Leningrad State University, Russia, and received her Ph.D. in Clinical Psychology. In the United States, Dr. Balachova completed a post-doctoral fellowship in pediatrics psychology and child abuse and neglect at OUHSC. She was quickly recognized as having expertise in child maltreatment and was selected to speak at international conferences, train professionals in other Eastern European countries, and served as an advisor for the World Health Organization and as a faculty member for the Mental Health Alliance/Open Society Eastern European project on Child Abuse and Neglect. She has gained extensive experience in research in the areas of child maltreatment and substance abuse and joined the OUHSC faculty in 2003.

She is co-director of the Interdisciplinary Training Program in Child Abuse and Neglect at OUHSC. Dr. Balachova has extensive experiences in establishing international partnerships in research, training, and clinical services in the area of child maltreatment prevention and has served as co-PI on USAID-, NIH-, and CDC-funded international projects.

Barbara L. Bonner, Ph.D., a clinical child psychologist, is a professor and the CMRI/Jean Gumerson endowed chair in clinical psychology, director of the Center on Child Abuse and Neglect (CCAN), and associate director of the Child Study Center (CSC) in the Department of Pediatrics at the University of Oklahoma Health Sciences Center.

Her clinical and research interests include the assessment and treatment of abused children, treatment outcome and program effectiveness, prevention of child fatalities, treatment of children and adolescents with inappropriate or illegal sexual behavior, dissemination of empirically validated treatment approaches for maltreated children, and the evaluation of approaches toward prevention and intervention. Dr. Bonner has received numerous state and federal grants to conduct research and to evaluate programs serving maltreated children and their families. Over the past 10 years, she has provided education and training to professionals in 13 countries internationally.

Dr. Bonner is president of the Board of Councilors of the International Society to Prevent Child Abuse (ISPCAN) and past president of the American Professional Society on the Abuse of Children (APSAC). She has presented her research throughout the United States and internationally. Her work on behalf of children has been recognized by the United States Department of Justice, the Oklahoma Psychological Association, and the Division of Children, Youth, and Families of the American Psychological Association.

Larissa A. Tsvetkova, Ph.D., a psychologist, is the dean of the College (Faculty) of Psychology at St. Petersburg State University (SPSU). She is chair of the Scientific and Methodological Council on Psychology at SPSU and chair of the Scientific and Methodological Council on Psychology and Pedagogy at the Russian Ministry of Education. Dr. Tsvetkova received short-term training in public health at Yale University in Public Health, provided leadership in developing the MPH training program at SPSU, and has served on the board of the program. Dr. Tsvetkova is chair of the first SPSU behavioral IRB (ethical) committee. Dr. Tsvetkova has a wide range of research experiences. She has conducted a number of projects including a research project aimed at developing primary prevention of substance abuse in college students. She has also been involved in research projects with pediatricians, medical patients, and adults. Dr. Tsvetkova is a co-investigator on SPSU/OUHSC collaborative projects focused on developing FAS prevention in Russia.

Larissa Tsvetkova, Ph.D. and Galina Isurina, Ph.D.

Galina L. Isurina, Ph.D., a clinical psychologist, is associate professor at SPSU. Dr. Isurina is a vice-chair of the Commission on Medical Psychology at the Academy of Medical Science of Russian Federation and has been involved in research and teaching for 30 years. She has served as co-investigator and faculty supervisor on the SPSU/OUHSC collaborative projects. Dr. Isurina has participated in a number of research projects and has focused her own research interests on treatment and preventive aspects of mental health and substance use.

From left to right: Galina L. Isurina, Ph.D., Larissa A. Tsvetkova, Ph.D., Barbara L. Bonner, Ph.D., and Tatiana N. Balachova, Ph.D.