Patterns and Perceptions of Maternal Alcohol Use among Women with Pre-School Aged Children: A Qualitative Exploration of Focus Group Data Journal of Addiction Research & Therapy

Background: Quantitative studies of women’s alcohol use suggest that social advantage is associated with increased frequency of alcohol use and disadvantage with increased quantities. Very few studies have examined patterns among mothers; even fewer have explored mothers’ perceptions and understandings of their alcohol use. We examine how mothers describe and make sense of their patterns of alcohol use in the context of advantaged and disadvantaged circumstances. Methods: Four focus groups were conducted with mothers from advantaged (n=9) and disadvantaged (n=9) backgrounds. To facilitate discussion, mothers were invited to comment on a number of images and diary extracts that depicted varying patterns of maternal alcohol use (from abstinence to ‘risky’). The focus groups discussions were audio recorded and transcribed verbatim. Qualitative data was analysed thematically and framed within an interpretivist paradigm. Results: Mothers recalled how their social circumstances influenced their alcohol use. Emerging themes related to where (drinking location) and why (reasons for drinking) individuals drank alcohol, they included: Drinking in the home, drinking outside the home, identity and individuality, portrayal of age and emotional well-being. Conclusion: Our research suggests that social circumstances influence mothers’ drinking locations, and reasons for consuming alcohol. Our qualitative study points to the social patterning of alcohol use and begins to explore the ways alcohol is integrated into the daily lives of women with children. The results have the potential to inform future alcohol intervention strategies in this population group.


Introduction
There is evidence that problematic alcohol use (DSM-III-R, CAGE criteria) and binge drinking (>4 drinks, >60 g alcohol per occasion) among women is negatively associated with age [1][2][3][4][5][6][7][8][9][10]. Social gradients in alcohol use have also been identified amongst women [11] and young adults [12]. Research suggests that social advantage (as measured by income) is associated with increased frequency of alcohol use and disadvantage (as measured by educational attainment and income) is associated with increased quantities of alcohol consumption. The exact mechanism by which social disadvantage exerts an effect remains unclear. However, one suggestion is that living in deprived circumstances (as measured by occupation, income, and unemployment) leads to psychological distress [13,14], which is in turn linked to problematic alcohol use [15][16][17][18]. Much less is known about patterns among mothers with children.
Disadvantage (as measured by single motherhood) has been linked to a greater mean number of drinking days during the previous 28 days in comparison with mothers residing in two-parent households [19]. Studies suggest that alcohol was seen by disadvantaged mothers as a means of escapism, a way to cope with life stress and general negativity [20][21][22]. However, qualitative research has also linked negative childhood experiences to abstinence and strict regulations on drinking in the home among disadvantaged mothers [23]. Qualitative and multi-methods research conducted in England and Sweden has shown how advantaged mothers used alcohol as a symbolic marker of their time free from childcare responsibilities, for pleasure and relaxation, and as a reward for coping with the demands of motherhood [21,24].
The aim of this study is to begin explore how mothers from different social backgrounds describe and make sense of their patterns of alcohol use.

Methods
We conducted four focus groups with mothers of pre-school aged children to obtain qualitative data and begin to explore how mothers described and made sense of their patterns of alcohol use. Nonmothers and mothers of older children were excluded.
Mothers who took part were purposively sampled by their postcode (IMD score) in an attempt to include mothers from both advantaged and disadvantaged social backgrounds. Service managers made initial contact with mothers recruited from a childcare provider in a nondeprived area (IMD score: 3.05) and a charity organisation in a deprived area (IMD score: 41.14). Mothers were provided with an information sheet detailing the purpose of the study with sufficient time to ask questions before written consent was obtained. Written

Consent for publication
All participants provided written consent for publication.

Data generation
Focus groups lasted 1-2 hours using pictorial representations and diary extracts of previously ascertained patterns of maternal alcohol use [25] as prompts to facilitate discussion. The focus group discussions were audio recorded and all data pseudonymised to maintain participants' anonymity.

Analysis
The qualitative analysis was framed within a research paradigm known as interpretivism, characterised by the ontological belief that reality only exists as a result of an individual's subjective experience of that reality [26].
Thematic analysis was used to identify recurrent themes and as a preliminary exploration of similarities and differences between mothers that could be expanded to include a larger sample. This was an iterative process whereby, the themes both emerged from, and helped make sense of, the data, following a process of refinement with several iterations of themes and sub-themes [27]. This process continued until it appeared that no new data was emerging. In addition, "deviant" cases were sought from within the data that provided alternative explanations for mothers' patterns and perceptions of maternal alcohol use [28].

Results
In total, 18 mothers took part in the four exploratory focus groups.  Mothers recalled how motherhood had altered their own alcohol use and how socio-economic and domestic circumstances affected the ways in which they integrated alcohol consumption into their mother role. It was evident that social position was a major influence on how mothers incorporated routine alcohol use into their daily lives. Emerging themes included: Drinking in the home, drinking outside the home, identity and individuality, portrayal of age, and emotional well-being. The themes relate to where and why individuals drink alcohol and are organised under two headings: Drinking location and reasons for drinking.

Drinking location
Drinking in the home: The location in which mothers' drinking took place varied and suggests that social circumstances might be influential. Several mothers described drinking at home more often and did not associate motherhood with decreased alcohol use, rather a change in their drinking venue.
Vivienne: I think it's interesting, it's not that we're saying that we drink any less, I'm not gonna make that claim it's: I find that I'm drinking in my friend's houses and my house, I'm having a lot more dinner parties…That's one of the very biggest changes for me is where I'm drinking as a parent I think.
(Vivienne, an employed married mother of 2 who had her first child aged 30+, describing her own alcohol use).
These mothers' propensity to drink at home appeared to be related to their belief that it was acceptable to consume alcohol in front of their children. Mothers believed that children should witness parental alcohol use in order for them to understand that alcohol is to be enjoyed in moderation rather than a forbidden substance that children may become inquisitive about and drink in excess.
Helen: You're showing the children that yeah, it can be enjoyable to have a drink, there's nothing wrong with having a drink but it's being sensible how you do it so you're not making it a forbidden thing, hopefully the plan being they maybe won't drink to excess themselves when they get to an older age, they just see nice happy times with it you know?
(Helen, an employed married mother of 2 who had her first child aged 30+, describing her perception of other people's alcohol use) In contrast, there were a number of mothers who stated that they were much less likely to drink at home especially when children were present. Reasons for their avoidance of home drinking stemmed from their own negative childhood experiences of parental alcohol misuse and their desire to break free from negative intergenerational patterns of alcohol use.
Cathryn: I don't know really. My childhood consisted of an alcoholic father and domestic violence. He used to go around beating up my step mum, to cut a long story short, so from a very, very young age my visions were my father laid out on the sofa after vomiting on the floor and then snoring his head off with sick on the floor and I remember this vividly from being about five or six year old erm, growing up in a pub later on…He still managed to work in a pub even though he was alcoholic so, but anyhow later on growing up in the pub and smelling the beer on all the people that used to come in the pub, a lot of that put me off. I mean yeah I can sup like a goldfish do you know what I mean? I really can but, but actually having a drink on a night I certainly won't go home and crack open a can. It wouldn't enter my head, I wouldn't sit in front of the tele on a night and have a beer. It just doesn't happen.
(Cathryn, an employed cohabiting mother of 1 who had her first child between the ages of 14 and 19, describing her own alcohol use).
Drinking outside the home: Several mothers commented that they were more likely to drink outside the home and their children more likely to be exposed to pub drinking cultures. Drinking in this type of environment was considered more acceptable by these mothers because it had a 'social' component to it. Nevertheless, they were keen to assert that they drank in a controlled manner when their children were present.
Cathryn: Yeah, I mean I don't drink around them, I mean I will take them to the pub now and again but their now very, very aware of what I'm drinking. I don't let myself go for want of a better word.
(Cathryn, an employed cohabiting mother of 1 who had her first child between the ages of 14 and 19, describing her own alcohol use).
In contrast, those mothers who drank at home felt that drinking outside the home was associated with more "relaxed" drinking behaviours that subsequently increased alcohol consumption.
The decision by some mothers to drink alcohol in front of their children outside the home may have reflected their lack of choice with regards to childcare, particularly among single mothers. Drinking companions may have also influenced mothers' drinking locations. Several mothers spoke of drinking with their partner; however, this was not the case among cohabiting and single mothers who more often drank with their female friends.

Reasons for drinking
Identity and individuality: The majority of mothers who took part in the focus groups acknowledged that their perceptions of what was acceptable behaviour among mothers and fear of disapproval from others influenced their actions-including their alcohol use.
Fiona: A lot of the time I do think, like even down to things like what I wear, I think should I be wearing that now I'm a mum, do you know what I mean? I feel like I need to dress older and be more respectable and I can't wear a low cut top, because people think "well she's a parent she shouldn't be wearing that", you know. But I am one of those people that worry about what people think, my partner says "don't worry about what other people think. As long as you know you're all right don't worry", but yeah I do. I think people have expectations of parents, like we said that's unacceptable for parents to be like that [binge drinking]…you know it does change when you're a parent don't it?
(Fiona, an unemployed cohabiting mother of 1 who had her first child between the ages of 14 and 19).
Nevertheless, alcohol remained a tool with which mothers were able to denote time free from childcare responsibilities. A number of mothers recalled using alcohol as a symbolic marker of their child-free time.
Vivienne: Kids have just gone off to bed and this is her little transition from mummy time to grown up time just to have that little glass of wine and enjoy. (Laughter) Similarly, alcohol enabled mothers to maintain their own identity separate from their mother role.
Cathryn: Alcohol turns you back into a person again, like if you go back into a pub you're suddenly, I'm back to being [Cathryn] again I'm no longer [X's] mummy. (laughs) (Cathryn, an employed cohabiting mother of 1 who had her first child between the ages of 14 and 19, describing her own alcohol use) Furthermore, mothers were able to reaffirm their identity within their social group by participating in normative drinking behaviours (binge drinking at weekends).
Fiona: Yeah nobody looks at you and thinks "oh you're getting drunk on a Saturday night". If this was midweek like a Wednesday night [and] you were that drunk and you' d drank that much, people would think "what are you doing on a Wednesday night outside of a pub that drunk?" do you know what I mean?
(Fiona, an unemployed cohabiting mother of 1 who had her first child between the ages of 14 and 19, describing her own alcohol use).
Mothers who binged at the weekend were able to maintain their position as a 'good' mother by rationalising their behaviour in the context of what others within the same social network did.

Emma: Yeah, everybody's [binge drinking].
Kirsty: Yeah, it's not dirty, it's not frowned upon to go out on a Saturday night to go out and get drunk.
(Emma, an unemployed single mother of 1 who had her first child between the ages of 14 and 19 and Kirsty, an employed cohabiting mother of 1 who had her first child between the ages of 20 and 24 describing their own alcohol use).
Portrayal of age: Age was identified by mothers as important in terms of patterns of alcohol use. Mothers spoke of young age as a key factor for binge drinking Marsha: Ok, [I associate binge drinking with] young mums, a younger mum who potentially, and maybe not totally, missing some of her, maybe she's got friends that haven't got kids and they still do the big Saturday nights and everything and she's keeping in with that kind of, her friends and her gang… (Marsha, an employed married mother of 2 who had her first child aged 30+, describing her perception of other people's alcohol use).
Mothers associated drinking little and often with older age groups. They described how this pattern of alcohol use was more controlled in comparison to patterns among younger age groups whereby the focus was on the physiological effects of alcohol.
Emma: To me this [Diary showing the consumption of alcohol as little and often] is a single or typical middle aged couple, getting home on a night time and having a glass of wine.
(Emma, an unemployed single mother of 1 who had her first child between the ages of 14 and 19, describing her perception of other people's alcohol use).
Marsha: [I would associate frequent drinking of small quantities with] someone older, and…are you looking for class? I would probably say they were more like your, towards middle class type drinking pattern...Partly to do with, I guess, it's got an air of kind of being sophisticated, and to relax drinking a glass of wine and having a bit of leisure time, and I guess there's a bit of a cost element in it as well erm...and it's not for the purpose of getting drunk, it's for relaxation, measured as opposed to getting drunk.
(Marsha, an employed married mother of 2 who had her first child aged 30+, describing her perception of other people's alcohol use).
Emotional well-being: Mothers referred to alcohol use in terms of their emotions. The majority of mothers described alcohol in terms of pleasure and relaxation, something that they "deserved". They discussed using alcohol as a means of congratulating themselves for having made it through the day or week. This was not the case among some mothers who described using alcohol to cope with stress.
Ann-Marie: Again if she's a working mum, she's under stress at work, as well she's trying to cope with the stress and her loneliness if her partners not there obviously, it's a wind down 'cause that's exactly what it is with me.
(Ann-Marie, an unemployed single mother of 3 who had her first child between the ages of 25 and 29, describing her own alcohol use).
Several of these mothers also added that alcohol was a tool with which individuals were able to escape unfavourable circumstances.
Elaine: [You drink in excess] To de-stress, cause once you're intoxicated, you don't have no worries, you don't have to think of things, it's just gone. (Laughs) (general agreement) (Elaine, an unemployed cohabiting mother of 1 who had her first child between the ages of 20 and 24, describing their own alcohol use).

Discussion
Our qualitative data has provided some explanation as to why the circumstances in which motherhood is experienced may shape mothers' alcohol use patterns through drinking locations, drinking opportunities and reasons for drinking.

Previous qualitative research conducted in Australia and South West
England has shown that the location in which drinking takes place dictates drinking patterns [29,30]. Mothers in our study who had experienced negativity as a result of their parent's alcohol use reported abstaining from alcohol and imposing strict rules surrounding alcohol use in the home and around children. Our research shows that some mothers may prefer to drink outside the home, thus making themselves more vulnerable to the negative social consequences associated with alcohol use. Mothers' propensity to drink in front of their children whilst outside the home environment also meant that their children were exposed to public drinking cultures of infrequent excess. In contrast, mothers who more often drank at home were more likely to drink in front of their children, thus exposing them to private drinking cultures of reportedly frequent controlled quantities of alcohol use. Nevertheless, the implication of regularly consuming alcohol at home with children present is a contentious issue and one that remains little studied.
We found that mothers used alcohol to shape their identity and individuality. Mothers used alcohol as a marker of their time free from childcare responsibilities and mothers felt able to maintain their identity and individuality through their drinking behaviour. Mothers described how they were able to maintain friendship groups and reaffirm their social position by participating in normative binge drinking behaviours at the weekend, a finding echoed in previous research [31][32][33].
Mothers' often linked their alcohol use to their emotional state. Consistent with previous research [20][21][22], several mothers described their alcohol consumption in relation to stressful life events and used alcohol as a mechanism to cope and as a means of escapism. In comparison, a number of mothers described their alcohol use as a reward for having coped with the difficulties they faced bringing up children and were more inclined to refer to the pleasurable aspects of alcohol use.

Strengths and Limitations
The standards appropriate for qualitative research have been and remain a focus of considerable debate [34]. A limitation of our study is the small number of research participants and limited geographical scope. Nevertheless, our research provides insight into the patterns and perceptions of maternal alcohol use among mothers themselves. Using images and diary extracts to portray different patterns of alcohol use proved particularly useful, allowing us to delve deeper into memories and feelings in comparison to more conventional interviewing techniques [35][36][37]. Participants were empowered to interpret the images and develop the discussion on that basis, thus limiting the extent to which they were influenced by the researcher [37]. Furthermore, images provided a reference point with which mothers were able to articulate their arguments and reduce misunderstanding.

Implications for Future Research, Policy and Practice
Research to date has led to a skewed knowledge of alcohol use as a result of researchers' tendency to focus on the minority of individuals who lie at the problematic end of the alcohol use spectrum. In future there needs to be greater consideration given to the examination of majority patterns of habitual alcohol use.
Our research suggests that patterns of alcohol use may be influenced by wider social factors. Research needs to consider social background, and current socio-economic and domestic circumstances. Interventions and future research may also want to consider some of the common misconceptions evident in our research. For example, socially accepted patterns of alcohol consumption and types of alcoholic beverage are not necessarily exempt from adverse health implications. For instance, frequent consumption without alcohol free days and the commonly held belief that wine is inherently beneficial to health irrespective of its high alcohol content. The focus of health interventions need to shift public attitudes away from the choice of alcoholic beverage and onto alcohol content. In addition, we need to address the social norm that it is acceptable to binge at weekends and point out the dangers of problematic alcohol use.
Early motherhood can be a difficult time, particularly for those women who find themselves in disadvantaged circumstances. In terms of problematic alcohol use, mothers who use alcohol to cope may be particularly vulnerable and since the majority consume alcohol in private, we may be underestimating the problem.

Conclusion
Health messages aimed at reducing individual and societal consequences of alcohol misuse are largely individualistic and fail to acknowledge the wider social influences behind individual patterns of alcohol use. Our research points to social background, and current socio-economic and domestic circumstances as influential in shaping mothers' alcohol use patterns. Addressing some of the wider social issues faced by mothers may prove successful in encouraging a healthier relationship with alcohol. Likewise, mothers need to be made aware that, although their patterns of alcohol use may be deemed more socially acceptable, they too may be vulnerable to the negative effects of excessive alcohol consumption, particularly if they underestimate their alcohol use.

Declaration Ethical approval and consent to participate
Ethical approval was obtained from the Department of Health Sciences Research Governance Committee at the University of York. Written consent to take part in the study was obtained from all participants prior to commencement of the study.

Consent to Publish
Written consent to publish was obtained from all participants prior to publication.