Running Head: ALCOHOL CONSUMPTION DURING PREGNANCY 1

Abstract

This proposed study will use the theory of planned behaviour (TPB) to reduce alcohol

consumption of Australian pregnant women. Prenatal exposure to alcohol results in foetal

alcohol spectrum disorders, causing a range of negative outcomes. A brief intervention

administered by general practitioners using TPB principles will be utilised to promote

awareness and reduce alcohol consumption. Participants will be 200 pregnant women

between the ages of 18 and 45 years, randomly assigned to the intervention or control

conditions. Questionnaires conducted before and after the intervention will compare the

drinking behaviours of participants. It is anticipated that participants in the intervention

condition will report reduced overall alcohol consumption and less occurrences of binge

drinking than those in the control condition.

ALCOHOL CONSUMPTION DURING PREGNANCY 2

A Brief Intervention to Reduce Alcohol Consumption during Pregnancy: Research

Proposal

Background

Continued consumption of alcohol during pregnancy has been associated with many

negative outcomes, known as foetal alcohol spectrum disorders. These disorders impact

developmental processes, resulting in neurological, physical and behavioural deficits, as well

as risk of premature delivery and pregnancy complications (Floyd, O'Connor, Sokol,

Bertrand, & Cordero, 2005; France et al., 2010; Jones, Modeste, Anderson, Lee, & Lim,

2006). These outcomes may have long-lasting impacts on the health and development of the

child into adulthood. When levels of alcohol increase, the health risks to the foetus also

increase, thus binge drinking is considered to be the most dangerous of drinking behaviours.

Safe levels of alcohol use have not been established, hence abstinence is generally accepted

as being optimal, however 21% of Australian women report drinking throughout their

pregnancy. (Chang, Goetz, Wilkins-Haug, & Berman, 2000; France et al., 2010; Maloney,

Hutchinson, Burns, Mattick, & Black, 2011; Manwell, Fleming, Mundt, Stauffacher, &

Barry, 2000).

As prenatal alcohol exposure is a preventable cause of so many disabilities and birth

defects, interventions targeting alcohol use during pregnancy are vital. Clinical trials in the

United States indicate that brief interventions administered by general practitioners (GPs) are

successful in reducing alcohol consumption due to increasing women’s awareness of the

health risks (Maloney et al., 2011; Manwell et al., 2000). One such intervention involved two

15 minute appointments with GPs, scheduled for one month apart. During the appointments,

women were given a workbook and provided with information and support by GPs. Results

revealed a reduction in alcohol use by up to 48% in the intervention condition, with binge

drinking episodes decreasing from an average of five occurrences to three in the preceding 30
ALCOHOL CONSUMPTION DURING PREGNANCY 3

days (Manwell et al., 2000).

Chang et al. (2000) interviewed participants regarding their health history and goals

for pregnancy health, then had them identify situations where they may be tempted to drink

and how to avoid doing so. Participants were given a manual to take home regarding this

information. On follow up it was found that participants who set a goal of abstinence were

more likely to reduce alcohol use, particularly when the baby’s health was the motive.

Support from significant others and pressure during social occasions was found to increase

the decision to drink.

O'Connor and Whaley (2007) conducted a series of brief intervention sessions during

monthly prenatal appointments. In addition to counselling provided during these sessions,

women were given workbooks to take home. Women in the intervention were five times

more likely to report abstinence than women in the control, although both groups reduced

their drinking. Further, babies of the women in the intervention had higher birth weights and

mortality rates were three times lower than for those in the control condition.

Whilst these interventions indicate success for women in the United States, alcohol

consumption varies between countries, with Australian women reporting higher use during

pregnancy than women in the United States (Maloney et al., 2011). To date, little has been

done by way of intervention for Australian women. The theory of planned behaviour (TPB)

may be an effective method of providing such an intervention. TPB proposes that an

individual’s intention to perform a behaviour predicts the likelihood of them performing the

behaviour. Behavioural intentions are proposed to be the most important determinant of

behaviour change, and are influenced by subjective norms, or the attitudes and beliefs of

significant others; their perceived control over changing the behaviour; and specific attitudes

toward the behaviour (Ajzen, 1991). The theory has been applied to a range of health

behaviours with success, and has been of particular use in creating interventions for problem
ALCOHOL CONSUMPTION DURING PREGNANCY 4

drinking (Godin, & Kok, 1996; Jones et al., 2007). McMillan and Conner (2003) examined

alcohol consumption in university students and found a significant correlation between

intentions to drink, attitudes and perceived behavioural control. In addition, Duncan, Forbes-

McKay, and Henderson (2012) administered a questionnaire with items relating to TPB

principles to examine alcohol use by pregnant women. Results indicated that abstainers have

higher ratings of intention to stop using alcohol; greater perceived control; subjective norms

that supported abstinence; and better attitudes towards abstinence than participants who

continued to drink during pregnancy. It was concluded that TPB principles may be a highly

effective method of screening and intervention for alcohol use during pregnancy.

Aims and Hypotheses

The aim of this study is to apply TPB principles in a brief intervention to reduce

alcohol consumption by Australian women during pregnancy. It is anticipated that following

the administration of the intervention, women in the intervention condition will have less

intention to drink, more positive attitudes towards abstinence, increased perceived control in

abstaining from alcohol and feel more social support to do so, than those in the control

condition. It is anticipated that these outcomes will result in a significant reduction of self-

reported alcohol use, including less occurrences of drinking and lower amounts consumed for

participants in the intervention.

Method

Participants

Participants will consist of 200 women aged between 18 and 45 years, as previous

intervention studies have been successfully conducted with between 120-300 participants

within this age group (Chang et al., 2000; Manwell et al., 2000; O'Connor, & Whaley, 2007).

Half of the participants will be randomly assigned to either the intervention condition or the

control condition. Participants are to be recruited through invitation from trained GPs and
ALCOHOL CONSUMPTION DURING PREGNANCY 5

will receive $120 for completing all intervention sessions, including follow up.

Procedure

GPs from two Brisbane medical centres will be invited to participate in the

intervention. Those who agree to take part will attend a brief training session outlining how to

administer the three information sessions. Participants invited by the GPs to undertake the

intervention will complete the T-ACE to identify problem drinking behaviour and counteract

under-reporting of alcohol consumption (Chang et al., 1998; Chang et al., 2000). An

additional questionnaire developed by Duncan et al. (2012) will also be administered to

determine demographics and drinking behaviours in relation to TPB principles. Participants

will be informed that responses are anonymous, and encouraged to be honest and accurate.

Participants who indicate never having consumed alcohol will be excluded from the study,

whilst remaining participants will be randomly assigned to either of the conditions.

Participants will attend three information sessions over the course of three months and are to

have a partner of their choice accompany them. The first session will target attitudes towards

alcohol use during pregnancy by providing information on health risks of prenatal alcohol

exposure, with the GP advising abstinence. Participants will be given a booklet to take home

which contains more detailed information and asked to bring it to each session. Session two

will target subjective norm, with the GP initiating a discussion with the participant and

partner about their attitudes towards drinking during pregnancy. The GP will provide

information on how supporting a partner to abstain from alcohol may increase likelihood of

doing so. The GP will also assist the partner to make specific goals for how they may help the

participant to achieve abstinence and record them in the booklet to serve as a reminder. The

final session will target perceived control by having the participant and partner brainstorm

situations where drinking is a strong temptation. Through discussion with the GP, participants

will identify alternative behaviours to avoid drinking in these situations. Following the three
ALCOHOL CONSUMPTION DURING PREGNANCY 6

sessions, participants will return to complete a follow up questionnaire after delivery of the

baby. In a manner replicating that of Duncan et al. (2012), the items of the questionnaire will

be recoded to enable high scores to reflect strong agreement with the items. The mean scores

will then be calculated to compare the results of the intervention and control conditions both

before and after the intervention.

Materials/Apparatus

The T-ACE, a four item alcohol use screening measure, will be administered,

followed by a questionnaire developed by Duncan et al. (2012). This questionnaire consists

of a section for participants to indicate demographics including age, employment status, race

and number of children. An additional section consists of 14 items on a 5-point scale to

indicate level of agreement with statements concerning intention to drink (e.g., I intend to

consume alcohol in the next four weeks), subjective norm (e.g., those who are important to

me would want me to consume alcohol), attitudes towards drinking while pregnant (e.g.,

consuming alcohol would result in an enjoyable experience) and perceived control for

abstaining (e.g., it is mostly up to me whether I abstain from consuming alcohol). Participants

will complete the second section of the questionnaire again following the intervention. An

information booklet will be given to all participants in the intervention condition. This will

contain information on the health risks associated with prenatal exposure to alcohol and TPB

principles relating to each session, room to write goals and record any alcohol consumption.

Expected Outcomes and Implications

Based on previous studies, it is anticipated that participants in the intervention

condition will report significantly reduced alcohol consumption overall, including less

occurrences of drinking, and lower doses of alcohol consumed per sitting than participants in

the control condition (Chang et al., 2000; Manwell et al., 2000; O'Connor, & Whaley, 2007).

This may be achieved by increasing intentions to abstain from alcohol in relation to TPB.
ALCOHOL CONSUMPTION DURING PREGNANCY 7

Firstly, the attitudes towards abstinence during pregnancy may be more positive

following the intervention due to the increased awareness of health risks associated with

alcohol use. Chang et al. (2000) found that motivation to have a healthy baby was a strong

indicator for abstinence, thus women may be motivated to practice abstinence to promote the

health of their baby after being informed of the harm alcohol may cause.

Subjective norm may also account for a reduction in alcohol use, as having social

support and encouragement to abstain during pregnancy influences the decision to drink

(Chang et al., 2000; Duncan et al., 2012). This was targeted by having a partner accompany

the participant, so they were also aware of the health risks of drinking, as well as having them

create goals together to create a support system to achieve abstinence.

Prior research has revealed that pregnant women who identify situations where they

would be most tempted to drink, and have plans for how to avoid doing so, may effectively

reduce alcohol consumption and practise abstinence (Chang et al., 2000). These specific

plans may help to increase a woman’s perceived control over their choice to consume

alcohol, and thereby help them to resist drinking.

The implications of this extend to prevention of birth defects and other related

neurological, physical and behavioural disorders that often result from prenatal exposure to

alcohol. This will not only affect the children and their families, but also have the potential to

save costs in Government funding of health care for children suffering from negative effects

of alcohol exposure.

A potential weakness of this study is the use of self-report questionnaires to gauge

alcohol use. Such measures may not be accurate due to inability to recall, or unwillingness to

admit alcohol usage (Chang et al., 1998). The T-ACE measure will be used as the primary

screening method to counteract this, and participants will be assured that their responses are

anonymous.
ALCOHOL CONSUMPTION DURING PREGNANCY 8

An additional potential weakness is the use of local GPs to administer the

intervention. GPs have expressed that time constraints during appointments often leads to a

lack of discussion surrounding alcohol use during pregnancy (France et al., 2010). For this

reason, sessions are limited to ten minutes, enabling them to be incorporated into regular

check-ups during the course of the pregnancy. The booklets will be designed to provide

additional information that cannot be covered due to time constraints, as well as providing

reminders about participant’s goals.

Future studies may seek to conduct this intervention for pregnant adolescents with

problem drinking, particularly as this is a stage where subjective norms may be particularly

important in an individual’s life. Such interventions may not only be effective in preventing

the health risks associated with prenatal alcohol consumption, but may also reduce problem

drinking throughout the lifespan.

Thus, TPB may have the potential to inform effective brief interventions to reduce

alcohol consumption during pregnancy. This intervention may assist GPs to create awareness

of the health risks from alcohol spectrum disorders and help pregnant women to make

choices that will promote the health of their children.

ALCOHOL CONSUMPTION DURING PREGNANCY 9

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