Pre-pregnancy drinking: how drink size affects risk assessment.

AIMS: We considered the role of drink size in determining average daily consumption among groups at risk for Fetal Alcohol Syndrome. DESIGN: In-person hour-long interviews gathered cross-sectional retrospective data about drinking before an index pregnancy. SETTING: Subjects were recruited at public clinics in Los Angeles and the San Francisco Bay area. To reach those not necessarily seeking prenatal care, community outreach in the same urban areas was undertaken. PARTICIPANTS: Three hundred and twenty-one pregnant women were interviewed: 102 Native Americans, 185 African Americans, and 34 Caucasians. MEASUREMENTS: Volume of drinking prior to pregnancy was assessed using the graduated frequency series, which asks respondents to specify their drinking in terms of standard drinks. Using vessel models and photographs, respondent-defined drink sizes were then determined, and volume was recalculated accordingly. FINDINGS: For most beverages, the difference in milliliters between self-selected drink size and a standard size drink was significant, with the mean self-selected drink sizes ranging from 49% above the standard size (for beer) to 307% above the standard size (for spirits). For women whose pre-pregnancy average daily volume (ADV) was at the risk level of > or = 1 standard drink per day, ADV increased from four to almost 10 standard drinks per day when self-defined drink sizes were instead considered. Similarly, for women having three or more standard drinks a day, their daily dose of ethanol increased from 57 g to 153 g of ethanol per day. CONCLUSIONS: If risk levels have been based on underestimates that assume women with alcohol-affected infants had standard drink sizes, then true risk levels may be higher than previously thought. Related, risk drinkers presenting at prenatal clinics may be missed if screening protocols do not ask about drink size.

"If it burns going down... ": how focus groups can shape fetal alcohol syndrome (FAS) prevention.

Despite public health campaigns and clinical interventions that encourage women to abstain from alcohol during pregnancy, some women continue to drink while pregnant. To provide a more in-depth understanding of how at-risk women regard--and emotionally react to--warnings about drinking alcohol during pregnancy, we conducted focus groups in 1997 with 11 pregnant and recent postpartum Native American and African American women in Los Angeles, California. The main objective of these groups was to uncover relevant aspects of women's beliefs and opinions about drinking during pregnancy that may not have been elicited by other research instruments. Results would then be used to shape a large survey of pregnant at-risk women. Analysis of the transcripts revealed three emergent themes, which had the greatest impact on our subsequent survey. These were women's exposure to and perceived believability of messages, their perception of risk associated with drinking, and the barriers to cutting down on alcohol consumption during pregnancy. Questions added to our survey instrument because of these findings included whether women think that some alcohol beverages are safer to drink than others; how they value cutting back alcohol use; their views on the irreversibility of fetal alcohol syndrome; and what pressures they feel from peers and family to drink during pregnancy. Given the small sample size associated with focus groups, these results cannot be generalized to larger populations; however, these women's words revealed important underlying issues and barriers that should be considered in studying and intervening with larger representative samples.

Understanding drinking during pregnancy among urban American Indians and African Americans: health messages, risk beliefs, and how we measure consumption.

BACKGROUND: Little is known about urban American Indian and African American women's drinking during pregnancy, or their beliefs about the risk of doing so. However, rates of fetal alcohol syndrome (FAS) are believed to be highest among those ethnic groups. METHODS: The Developing Effective Educational Resources (DEER) project recruited pregnant American Indian, African American, and white women from urban California areas (n = 321), to develop culturally appropriate consumption measures, to gather epidemiological data about drinking during pregnancy, and to assess exposure and reactions to health warnings intended to encourage abstinence during pregnancy. RESULTS: The study found high levels of exposure to health warnings among all ethnic groups, but many women were unclear about the actual consequences of FAS, about the risk of drinking even beer or wine or wine coolers, or about the value of reducing intake at any time during pregnancy. The majority of the women who drank malt liquor, fortified wine, wine, and spirits reported having larger than standard drinks, and daily drinkers had the highest levels of reporting error. When drink size was considered in the calculation of alcohol volume, average daily volume of consumption during pregnancy increased to the FAS risk level (average daily volume > or = 1) in the overall sample and among the African American and white subjects. CONCLUSIONS: Because some women, especially heavy drinkers, will continue drinking despite exposure to abstention-oriented health messages, it may be prudent to develop campaigns and interventions that provide factual information to help at-risk women reduce their drinking during pregnancy. Women could be advised of beverage equivalency, of standard drink sizes, and of how their own drinks compare with standard ones. Reliance on standard drink sizes in research can result in significant underreporting of consumption, especially among pregnant risk drinkers.

Methods for evaluating policy changes in alcohol services.

Policy research assesses how outside forces affect alcohol treatment services. In this primer, we examine a range of effective methods that can be brought to bear by researchers and address the issues involved in conceptualizing and conducting studies of policy formation, implementation and policy implications. Because there is no single superior methodology for studying policy change, researchers have relied on five broad methodologies for studying policy context, formation, change and implications. We provide specific examples of each approach, addressing the following issues: data sources and samples; the problems, challenges, strengths, and limitations of the approach; and whether (and how) the method has been used in the alcohol field. The five methods are archival studies; key informant studies; ethnographic and observational studies; surveys; and meta-analyses. The strongest research designs in alcohol services research often combine methods and sources to get different vantage points on questions about policy change.

An alternative to standard drinks as a measure of alcohol consumption.

Despite the field's longstanding concern with underreporting of alcohol consumption, traditional survey questions encourage error because respondents often must calculate their number of drinks based on standard drink sizes that often do not match their own drinking style. This study considered how often respondents' self-defined drink sizes matched a 'standard' drink size based on approximately 12 g of ethanol for six different beverages. We also studied whether respondents could accurately judge the size of their drinks. Subjects were recruited and interviewed at urban prenatal clinics, health clinics, and via snowball referrals and community outreach in Los Angeles and the San Francisco Bay Area. Because of the urgency of accurate measurement of consumption during pregnancy, urban pregnant women from the groups most at risk for Fetal Alcohol Syndrome, Native Americans (n = 102) and African Americans (185), were targeted. A small comparison group of urban pregnant white women (n = 34) was included. One-hour in-person interviews were conducted. Self-defined drink sizes were determined for each beverage consumed, using models and photographs of vessels. Frequent drinkers and the majority of women who reported drinking higher alcohol content beverages reported drinking larger-than-standard drink sizes. The median size of a malt liquor drink among the daily drinkers was almost three times as large as the standard, their fortified wine drinks were four times the standard, and their spirits drinks were six times the standard size. The majority of drinkers of each beverage were unable to accurately judge the size of their drinks, underestimating the number of fluid ounces by about 30%. Although the vessels methodology used here must be refined and tested further on other populations (e.g., men, nonpregnant women, and all ethnic groups), results suggest that determination of risk levels should be based on survey data that takes into consideration the beverage mix and the actual size of respondents' alcohol drinks.

Alcoholics anonymous affiliation at treatment intake among white and black Americans.

OBJECTIVE: Black Americans are overrepresented in the public alcohol treatment system, but may be less likely to use informal services such as Alcoholics Anonymous (AA). Some commentators perceive AA as a white, middle-class organization that is unlikely to appeal to blacks. This epidemiological study considers prior attendance and engagement in AA among 791 black and white men and women entering treatment in public, private and HMO substance abuse programs. METHOD: Clients were interviewed in-person within the first 3 days of inpatient treatment or the first 3 weeks of outpatient treatment. RESULTS: Black clients dominate public detoxification programs and report more drug and employment problems than whites (who report more family problems). Those with prior treatment experiences and those reporting they had gone to AA as part of treatment reported overall higher rates of AA affiliation, with blacks more likely to say they felt like a member of AA (64% vs 54% of whites), had a spiritual awakening as a result of AA (38% vs 27%) and had done service at AA meetings in the last year (48% vs 37%); whites were more likely to have had a sponsor (23% vs 14%) and to have read program literature (77% vs 67%). CONCLUSIONS: Controlling for other effects such as prior inpatient or outpatient treatment, blacks are about twice as likely as whites to report having attended AA as part of treatment (OR = 1.70). More research is needed to understand referral pathways to AA among blacks, and the differential effect this may have on sustained participation in AA and on long-term sobriety.

'When you were drinking' vs. 'in the past 12 months': the impact of using different time frames in clinical and general populations.

AIM: Different time frames have been used to ask about drinking in clinical and general populations. Surveys of clinical populations have asked about the quantity and frequency of drinking within the context of "when you were drinking". In general population surveys, the customary practice has been to ask about a period of time such as "the last 12 months". This paper compares answers to questions about drinking using both time frames. DESIGN: Bivariate chi-squares and multi-variate logistic regression analyses were used to compare consumption estimates across the two time frames for different demographic and drinking categories of respondents. SETTING AND PARTICIPANTS: In-person interviews were conducted with general population (N = 3069) and representative treatment samples (N = 381) in a northern California county. MEASUREMENTS: Respondents were asked about their drinking within the context of "the last 12 months" and only "when you were drinking". FINDINGS: There were no meaningful differences in aggregate measures of drinking based on the time frame of assessment in either sample. Drinking five or more drinks weekly was a significant predictor of consistent reporting of frequency of drinking among the clinical sample, and of reporting inconsistent frequency of drinking 12 or more drinks among the general population. Being female or being age 46 or over also was predictive of a "consistent" response in the general population for drinking 12 or more drinks; while being 46 or older, married, and white was predictive of consistent responses for drinking to intoxication in that population. CONCLUSIONS: Survey respondents do not average their drinking across a 12-month time frame that includes periods of abstinence; rather, they appear to answer only for the periods they were drinking.

The Alcoholics Anonymous Affiliation Scale: development, reliability, and norms for diverse treated and untreated populations.

Affiliation with Alcoholics Anonymous (AA) is an important variable to measure in many clinical and research activities. This paper reports on the development of an AA affiliation scale, and demonstrates its utility in a sample of 927 alcohol treatment seekers and 674 untreated problem drinkers. The scale is short (9 items), covers a range of AA experiences, and is internally consistent across diverse demographic groups, multiple health services settings, and treated and untreated populations. The validity of the scale is supported by the findings that treatment seekers report significantly higher AA affiliation than do untreated problem drinkers, and inpatients report higher affiliation than outpatients. Potential clinical and research applications of the scale are proposed.

The relationship of pre-treatment Alcoholics Anonymous affiliation with problem severity, social resources and treatment history.

Little research has examined the relationship of substance abuse patients' prior Alcoholics Anonymous (AA) affiliation to important treatment-related variables. This study of 927 individuals seeking treatment in public, health maintenance organization (HMO) and private-for-profit medical programs, found that 82.8% of patients presented at treatment with a history of AA affiliation. Degree of prior AA affiliation was significantly associated with more extensive prior utilization of formal and informal helping resources, current seeking of treatment in the public sector, having low income, being divorced/separated and having more severe alcohol, employment/support and psychiatric problems. Implications for service delivery and future research are discussed.

Didactic and experiential education in substance abuse programs.

Medical model and social model programs both include client education as part of their service mandate, although the two models may define and accomplish the task of education differently. The role of education in substance abuse recovery has not been clear in either the treatment or recovery models. This paper therefore begins with a debate of the value of "educating" substance abuse clients, using several possible definitions of education and drawing upon a variety of theories from health education and community psychology. We divide these types of education into two broad definitional categories: knowledge acquisition and life skills development. Using data collected during a process evaluation at one medical and two social model programs, we provide examples of how knowledge acquisition and life skills development are accomplished at these sites. Analysis of the observational data pointed to two approaches to education, one didactic, the other experiential. All three sites used a didactic approach to knowledge about addiction. Only the social model sites used an experiential approach to convey knowledge and skills about recovery, and the development of life skills.

An historical and developmental analysis of social model programs.

This review synthesizes the philosophy, development, history, and current status of the philosophy of social or community model of recovery and of Social Model Programs (SMPs) based on an analysis of the available literature, much of it outside traditional sources. The social-community model of recovery evolved out of Alcoholics Anonymous (AA), and has a distinctive program philosophy with different assumptions, knowledge, and practice than professionally based treatment models. SMPs began in the 1940s in California, evolving by the 1980s into a continuum of recovery services that are publicly funded, legally incorporated nonprofit organizations. The characteristics of SMPs are described and the range of services are presented, including social setting detoxification, residential recovery homes, non-residential neighborhood recovery centers and sober living houses. SMPs are staffed exclusively by recovering alcoholics and their structure is based on the 12 traditions of AA, which emphasize democratic group processes with shared and rotated leadership and a minimal hierarchy. Cost effectiveness data suggest that residential social model programs average approximately $2,700 per stay versus $4,400 for other residential approaches, yet may offer similar outcomes in terms of substance use and improvement employment or family function.

Methodology and characteristics of programs and clients in the social model process evaluation.

A process evaluation of social model residential substance abuse programs was conducted by the Alcohol Research Group (ARG) from September 1995 to April 1996. This paper first describes the qualitative protocol used in that study, including site selection, rules for observation, and the grounded theory approach taken to data analysis. Overviews of the programs offered at each study site are given, including overall philosophy, staffing approach, size of program, length of stay, funding sources and cost for average stay. Using survey data available from another ARG study, background demographic and Addiction Severity Index client level information are presented to augment the program level results of the process evaluation.

Measuring treatment philosophy: a scale for substance abuse recovery programs.

The assessment of the philosophy that guides substance abuse treatment programs has been a difficult subject to approach by those working in treatment research. Differing treatment philosophies are generally represented by multi-dimensional theoretical constructs that do not easily lend themselves to assessment by quantitative means. In the U.S., substance abuse treatment programs have been suggested as fitting into a disease (or medical) model, a social learning (or psychological) model, or a social community model in designing a treatment regime for clients. This paper presents a Social Model Philosophy Scale (SMPS) to classify the extent to which a given treatment program follows a social model approach to treatment. The final version of the SMPS (available from the first author) contains 33 questions for use in residential programs, divided into six conceptual domains: physical environment, staff role, authority base, view of substance abuse problems, governance, and community orientation. Overall internal reliability is high (alpha = .92), with subscale alphas ranging between .57 and .79. Test-retest analyses showed that the information obtained from the SMPS is consistent across time, administrators, and respondents. In addition, the SMPS is brief and easy to administer. Methodology used in item creation and final item selection is reported. Although not designed to distinguish philosophies other than social model, early results suggest that the SMPS may also be used to classify other program philosophies.

Predictors of help seeking among a longitudinal sample of the general population, 1984-1992.

OBJECTIVE: This article considers the predictors of help-seeking behavior, and the types of help sought among the general population. METHOD: Longitudinal data are used, collected during in-person interviews with 2,234 (1190 female) individuals in 1984 and again in 1992. The focus is on help seeking during the follow-up interval, with an emphasis on baseline alcohol-related problems as predictors of seeking help for one's drinking over the 8-year period. Correlates of help seeking are shown separately for respondents who at baseline had already experienced, in their lifetime, three or more dependence-related symptoms, and those who had not. RESULTS: Significant predictors of help seeking during the longitudinal follow-up period include male gender, younger age. Hispanic ethnicity, and having already (at baseline) experienced three or more alcohol-related social consequences. Alcoholics Anonymous (AA) was the most frequent treatment experience that was reported among those seeking help during the study period. CONCLUSIONS: Longstanding social consequences appear to play a key role in decisions to seek help for one's drinking, even when dependence-related symptoms are also considered. In this study Hispanics had an increased likelihood to seek help for their drinking (compared to whites), but blacks did not. AA continues to attract the largest number of help-seekers when compared to other alternatives.

The role of health consciousness in predicting attention to health warning messages.

PURPOSE: Guided by information processing theory and the health belief model, this paper considers the relationship between health consciousness among the general population and attention to environmental health warnings about alcohol consumption. Mechanisms of exposure to three dominant types of impersonal alcohol-related health messages in the environment are explored. DESIGN: Cross-sectional survey using telephone interview data. SUBJECTS: A representative nationwide sample of adults was interviewed in 1993 (n = 1026), with a response rate of 63%. MEASURES: Key variables include exposure to warning labels on alcoholic beverages, to point-of-sale posters, and to advertisements in the media, as well as respondents' alcohol consumption, health problems (indicative of salience of health warnings), and level of health consciousness assessed by items tapping concern with nutrition and seeking information on health topics. RESULTS: In the total sample, over a third had seen a warning label or poster and almost all had seen an advertisement about the risks associated with alcohol consumption in 1993. Survey respondents scored very high on five individual items that make up the health consciousness scale introduced here, with 69% endorsing all items. The scale demonstrated good internal reliability (alpha = .70) and was significantly correlated (p < .01) with not enjoying getting drunk and with usually reading product warning labels, suggesting construct validity. Yet the hypothesized strong relationships between health consciousness and attention to health warnings about drinking were not observed; nor was salience of messages a predictor of recall. Importantly, high proportions of underage drinkers and young adults at elevated risk for drinking problems are reached by container warning label messages. Mechanisms of exposure recall vary based on message source, with "container label recall" associated with heavier drinking, younger age, and purchasing patterns; "poster recall" associated with purchasing and health consciousness; and "advertisement recall" associated with heavy consumption and younger age. CONCLUSIONS: These results are contrary to predictions from skeptics of broad-based informational interventions, who argue that only the already-health conscious are attentive to health warnings about the risks of alcohol consumption. These data suggest that the label is reaching intended target audiences, especially younger people, males, and heavier alcohol consumers. Future research in predicting attention to impersonal health warnings in the environment should continue to improve the assessment of constructs such as salience and health consciousness, and should further test the applicability of available theoretical models. Subsequent research should also consider additional measures to tap mechanisms of exposure to impersonal health messages to enable a better understanding of the population that is not being reached by such public health interventions.

Changes in drinking problems among whites, blacks, and Hispanics: 1984-1992.

This paper reports changes in drinking problems among Whites, Blacks, and Hispanics between 1984 and 1992. A probability sample including 1,777 Whites. 1,947 Blacks, and 1,453 Hispanics in the United States adult household population was interviewed in 1984. In 1992 a subsample consisting of 788 Whites, 723 Blacks, and 703 Hispanics was reinterviewed. Results show a decrease in problem prevalence among Whites, stability among Blacks, and an increase among Hispanics. Problem incidence was higher among Hispanics than among Whites and Blacks, put problem remission was higher among Whites. Women had a lower problem incidence but a higher problem remission than men, independent of ethnicity. The two best predictors of problem status in 1992 were reporting a problem in 1984 and reporting a high level of consumption in 1984.

Pathways to self-help among women for sobriety.

Women for Sobriety represents a self-help option oriented toward positive thinking and behavior modification. Formed in 1975, there are now approximately 125 active WFS groups holding weekly meetings in the United States and Canada. Using data collected from a 1991 membership survey (n = 600, response rate = 73%), this paper chronicles WFS members' pathways to recovery. We describe turning points in seeking help, things women tried at first to contain their drinking, exposure to other treatment approaches, and referrals to WFS from formal treatment programs. Only 15% of the respondents sought treatment because they had been confronted about their drinking, while physical symptoms or emotional problems represented the turning point for over half the women. Another fifth said their life had gotten out of control, and these were the ones to achieve sobriety most quickly. Almost all WFS members had sought professional help for their drinking, and three-fourths have undergone individual therapy-suggesting that WFS members are fairly open to a psychological approach such as WFS offers. WFS philosophy is based on the belief that behavior is predicated on thoughts, so the program teaches members that maintaining sobriety must involve the realization that negative emotions are destructive-and that members can control how much they allow problems to bother them. Goals of membership include abstinence, improved self-esteem, and spiritual and emotional growth. About a third of the respondents currently attend AA, and no differences in length of sobriety associated with current AA attendance were found within the WFS membership. However, women who sought professional help in response to the turning point experience but who also attended AA that year were most likely to have achieved sobriety within a year of the turning point.

Changes in drinking patterns among whites, blacks and Hispanics, 1984-1992.

OBJECTIVE: This article reports a longitudinal study of drinking patterns among whites, blacks and Hispanics between 1984 and 1992. METHOD: A probability sample including 1,777 whites, 1,947 blacks and 1,453 Hispanics in the U.S. adult household population was interviewed in 1984. In 1992 a subsample consisting of 788 whites, 723 blacks and 703 Hispanics was reinterviewed. Interviews averaging 1 hour in length were conducted in respondents' home by trained interviewers. RESULTS: Abstention increased in all groups with the exception of Hispanic women, among whom it remained stable. Heavy drinking decreased only among white men (from 19% to 12%). Among men, the incidence of heavy drinking was 7% among whites, 10% among blacks and 17% among Hispanics. The stability of heavy drinking was greater among black (51%) and Hispanic men (43%) than among white men (32%). The best predictor of drinking in 1992 was drinking in 1984. CONCLUSIONS: Reductions in heavy drinking observed among whites were not observed among blacks and Hispanics. The greater stability of heavy drinking in the minority groups helps to explain higher rates of problems reported in the literature for these two groups. Prevention efforts targeting drinking and heavy drinking among blacks and Hispanics must be renewed and intensified.

Interpretations of risk: the use of scientific information in the development of the alcohol warning label policy.

In 1988 the US Congress passed a law requiring a health warning label on alcoholic beverage containers, to include the message that pregnant women should not drink alcohol. This paper addresses the role that scientific knowledge played in the formation and passage of the alcohol warning label policy. The constellation of birth defects implicated in the fetal alcohol syndrome (FAS) (including fetal alcohol effects) is sketched, and the FAS-related legislative events leading to the law's passage are described. A synopsis of the state of knowledge in 1988 regarding the effects of alcohol on the fetus is presented, and a snapshot of the social climate at that time is offered. The paper concludes with an update of relevant FAS research since the legislation was passed, and considers implications for future research and policy in the prevention of FAS.