ACKNOWLEDGEMENT. Kencho Zangmo

Transcription

1 THE ROLE OF PRIOR DRINKING, PERCEIVED SUSCEPTIBILITY, PERCEIVED SEVERITY, AND DRINKING REFUSAL SELF-EFFICACY IN ALCOHOL CONSUMPTION DURING PREGNANCY AMONG PREGNANT WOMEN IN BHUTAN KENCHO ZANGMO A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE MASTER DEGREE OF NURSING SCIENCE (INTERNATIONAL PROGRAM) FACULTY OF NURSING BURAPHA UNIVERSITY JULY 2015 COPYRIGHT OF BURAPHA UNIVERSITY

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3 3 ACKNOWLEDGEMENT This would not have been possible without the help and support from many people. Foremost, I would like to thank my advisors, Assoc. Prof. Dr. Wannee Deoisres and Dr. Wantana Suppaseemanont for their continuous support, patience, and immense knowledge. A very special thank you to my major advisor, Dr. Wannee, for helping me right from the beginning of my research till I came up with this thesis and for challenging me to do my best. Beside my advisors, I would like to thank the rest of my thesis committee: Dr. Tassanee Prasopkittikun and Dr. Pronnapa Homsin for their insightful comments, encouragement, and hard questions. My sincere thank you goes to Dr. Chintana Wacharassin, Ms. Kinga Pem, Dr. Sonam Gyamtsho, and Dr. Usa Chuahorm for their help in validation of the instruments. I remain highly indebted to Thai International Cooperation Agency (TICA) and Ministry of Health, Bhutan for giving me this prestigious scholarship, making it possible for me to pursue my dream of higher education and also for supporting this research study. I thank Faculty of Nursing, Burapha University for two years of great learning experience and for making my stay in Thailand comfortable and memorable one. I take back home not just the knowledge of subject matter but a lot more lived experiences of kindness, friendship, and shared culture. I am so thankful to my course mates, friends back home, and my family for their love and support. A special thank you to all the women who participated in this research study- you all are my unsung heroes and none of this would be possible without each of your kind cooperation and consideration. Lastly, I dedicate this to my mother, who means a world to me. Ama, I thank you for giving me this wonderful life and for always being there for me. Kencho Zangmo

4 : MAJOR: NURSING SCIENCE; M.N.S. KEYWORDS: ALCOHOL CONSUMPTION/ PREGNANCY/ HEALTH BELIEF MODEL/ PRIOR DRINKING. KENCHO ZANGMO: THE ROLE OF PRIOR DRINKING, PERCEIVED SUSCEPTIBILITY, PERCEIVED SEVERITY, AND DRINKING REFUSAL SELF- EFFICACY IN ALCOHOL CONSUMPTION DURING PREGNANCY AMONG PREGNANT WOMEN IN BHUTAN. ADVISORY COMMITTEE: WANNEE DEOISRES, Ph.D., WANTANA SUPPASEEMANONT, Ph.D. 92 P Alcohol consumption during pregnancy is both a global and national public health issue today. Despite health messages urging women to stay on complete alcohol abstinence during pregnancy, studies from across the globe report a high prevalence of pregnancy drinking. Literature on pregnancy drinking suggest that women s belief factors and prior drinking habits might play an important role in explaining alcohol consumption during pregnancy. Thus, this study examined alcohol consumption and the predicting factors of alcohol consumption during pregnancy among Bhutanese pregnant women. The Health Belief Model was used as the research framework. A systematic random sampling technique was employed to recruit 110 pregnant women from the antenatal clinic at Jigme Dorji Wangchuk National Referral Hospital, Bhutan. Data were collected through a face to face interview, using a well-structured questionnaire. Results showed quite a high (43.6 %) prevalence of alcohol consumption in this group of pregnant women. Multiple regression analysis revealed that prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy could together explain a statistical significance of 67 % variance in alcohol consumption during pregnancy (R 2 =.67 Adjusted R 2 =.65, F (4,105) = 52.05, p <.001). Moreover, drinking refusal self-efficacy (β = -.47, p <.001), perceived severity (β = -.24, p <.001), and perceived susceptibility (β = -.20, p <.01) showed unique role of independent predictors of alcohol consumption during pregnancy. Findings suggest that women s belief factors play an important role in alcohol consumption during pregnancy. Interventions targeted to prevent alcohol consumption during pregnancy should aim at changing women s false beliefs about pregnancy drinking.

5 5 CONTENTS Page ABSTRACT... iv CONTENTS... v LIST OF TABLES... vii LIST OF FIGURES... viii CHAPTER 1 INTRODUCTION... 9 Background and significance... 9 Research objectives Research hypotheses Scope of study Research framework Definitions of terms LITERATURE REVIEWS Alcohol consumption during pregnancy Definition of alcohol consumption and related terms Recommendations on alcohol consumption during pregnancy Pregnancy drinking and characteristics Alcohol consumption during pregnancy in Bhutan Pregnancy and fetal consequences of alcohol consumption The health belief model [HBM] Development and evolution of the HBM The HBM constructs and their relationship Application of HBM in behavioral research Factors predicting alcohol consumption during pregnancy Prior drinking Perceived susceptibility Perceived severity Drinking refusal self-efficacy... 38

6 6 CONTENTS (CONTINUED) CHAPTER Page 3 RESEARCH METHODOLOGY Research design Study setting Population and sample Research instrument Psychometric properties of instruments Protection of human subjects Data collection procedures Data analysis RESULTS Description of sample characteristics Description of study variables Factors predicting alcohol consumption during pregnancy CONCLUSION AND DISCUSSION Summary of the findings Discussion Implications Limitations Recommendations for future research Conclusion REFERENCES APPENDICES APPENDIX A APPENDIX B APPENDIX C APPENDIX D BIOGRAPHY... 98

7 7 LIST OF TABLES Tables Page 1 Demographic characteristics of sample Alcohol consumption prior to and during pregnancy Alcohol consumption mean comparison prior and during pregnancy by Wilcoxon signed rank test Perceived susceptibility Perceived severity Drinking refusal self-efficacy Pearson s correlation coefficient among study variables Standard multiple regression analysis... 61

8 8 LIST OF FIGURES Figures Page 1 Research Framework The Health Belief Model... 30

9 9 CHAPTER 1 INTRODUCTION Background and significance The direct, indirect, and intangible problems related to alcohol use and abuse is becoming a pressing public health issue today. According to the world health organization global status report on alcohol and health (2014), alcohol use and abuse is component cause of more than 200 disease and injury conditions in individuals, most notably alcohol dependence, liver cirrhosis, cancers and injuries. In the year 2012, 3.3 million deaths or 5.9 % of global deaths and 5.1 % of global burden of disease and injury were attributable to alcohol alone. The worldwide consumption of alcohol in 2010 was equal to 6.2 liters of pure alcohol consumed per person per day (World Health Organization [WHO], 2014). The universal gender difference in human social behavior leads to more men using and abusing alcohol than women. However, alcohol use and abuse among women had been increasing steadily in line with economic development and changing gender roles. World Health Organization (2005) report on gender, health, and alcohol use showed one woman with alcohol use disorder for every five men. But the gender difference gaps narrowed in recent years, as evident from reported ratios of 2:1 male and female deaths attributable to alcohol in the year 2012 (WHO, 2014). Women generally are believed to be most motivated to change their alcohol consumption and many other risky behaviors once they become pregnant. But recent research evidences on prevalence of pregnancy drinking suggest it otherwise, with many studies showing a substantial number of women drinking alcohol during pregnancy. A Cochrane collaboration review reported that more than 20 % of pregnant women worldwide consume alcohol (Stade et al., 2009). Many research studies across the globe have repeatedly reported that a concerning number of pregnant women drink alcohol throughout pregnancy (Anderson, Hure, Powers, Kay-Lambkin, & Loxton, 2012; Ethen et al., 2009; Williams, Jordaan, Mathews, Lombard, & Parry, 2014; Yamamoto et al., 2008; Yen et al., 2012). The World Health Organization [WHO], American College of Obstetricians and Gynecology [ACOG], and Center for

10 10 Disease Control and Prevention [CDC], all recommend that pregnant women, as well as women who are trying to conceive to stay on complete alcohol abstinence throughout pregnancy (American College of Obstetricians and Gynecology [ACOG], 2011; Center for Disease Control and Prevention [CDC], 2010; WHO, 2014 ). Contrary to the recommendations by these and many other health agencies, studies on prevalence of alcohol use among pregnant women showed prevalence rates of 30.3 % in the United States of America (Ethen et al., 2009), some 11.1 % in Japan (Yamamoto et al., 2008), 26.6 % among indigenous group in Taiwan (Yen et al., 2012), and as high as 72 % of pregnant women in Australia were not in compliance with their pregnancy drinking guideline of complete alcohol abstinence (Anderson et al., 2012). A recent study in a South African country showed pregnancy drinking rate still as high as some 34.6 % (Williams et al., 2014). Alcohol had been established as a teratogen and fetotoxic since 19 th century (International Center for Alcohol Policies [ICAP], 2014; Ornoy & Ergaz, 2010). According to the Center for Disease Control and Prevention, fetal exposure of alcohol is one of the largest preventable causes of birth defects and developmental problems in the United States of America. When women drink alcohol during pregnancy, so does her unborn baby; the magnitude of effects is only greater on a fetus with underdeveloped body physiology than the adult mother, especially during the period of organogenesis (Ornoy & Ergaz, 2010). Drinking endangers growing baby in many ways such as increasing the risk of miscarriage (Andersen, Andersen, Olsen, Gronbaek, & Strandberg-Larsen, 2012; Asamoah & Agardh, 2012), still birth (Aliyu et al., 2008; Bailey & Sokol, 2011), placental abruption (Aliyu et al., 2011; Yang et al., 2009), and preterm birth (Kesmodel, Wisborg, Olsen, Henriksen, & Secher, 2002; O Leary, Nassar, Kurinczuk, & Bower, 2009; Patra et al., 2011). Babies are at risk of being born low birth weight and have problems related to cognition (Lewis et al., 2012), behavior (Flak et al., 2014), and suffer from developmental delays. The most severe form of effect of prenatal alcohol exposure is Fetal Alcohol Spectrum Disorder [FASD] (Chasnoff, Wells, Telford, Schmidt, & Messer, 2010; Foundation for Alcohol Research and Education, 2012). Bhutan is a small landlocked Himalayan kingdom in South Asia sandwiched between two most populous countries of the world, China in north and India in east,

11 11 west, and south. Alcohol consumption is deeply engraved in Bhutanese culture. To a Bhutanese, alcohol has always been more of a food item used in their daily lives than an illicit drug. It is an important social and cultural commodity that has been in use for ages. It is used as medicines, for ritualistic offerings, and in various social events (Dorji, 2005; Dorji, 2012; Udon & Areesantichai, 2012). The age-old problem of alcohol use and abuse is only gaining recent recognition as a major public health issue in the country today, with the Royal Government of Bhutan placing high priority in reducing harms related to alcohol use. The national target is to reduce morbidity and mortality from harmful alcohol use by 50 % at the end of 2020 (Royal Government of Bhutan [RGOB], 2013). In line with the national health goal and policy targets, some of the most notable actions undertaken towards curbing problems related to alcohol use include alcohol taxation, restricting home brewing, discouraging alcohol use in rituals and social gatherings, and limiting easy accessibility and availability through observance of alcohol free days (RGOB, 2013). With the general belief that women will not expose her fetus to harmful effects of alcohol during pregnancy, not much has been done in the area of pregnancy drinking. The Bhutanese national health survey report showed 28 % of populations aged are currently using alcohol and 24 % of them drinking daily (Ministry of Health [MOH], 2014). Bhutan has one of the highest per capita consumptions in South Asia with 8.47 liters (Dorji, 2012), much higher than the global rate of 6.2 liters (WHO, 2010). A recent national health survey ranked alcohol liver disease among top 5 killers in the country. Report also predicted that alcohol is likely to become one of the main sources of disease burden in the country (MOH, 2014). In addition, alcohol has always been an essential part of childbirth observances in Bhutanese culture and almost every postpartum mother consume alcohol with the belief of pain relief, relaxation, gaining vigor, and enhanced milk production (Dorji, 2005; Udon & Areesantichai, 2012). It is also a Bhutanese tradition that alcohol beverage be served when friends and well-wishers gather to wish the family on arrival of the new member of the family. Thus, the tradition of fermenting an alcoholic drink is part of a childbirth preparation, which is still followed in many parts of the country. Despite these facts, very little is known about alcohol consumption among pregnant women in Bhutan. As far as the author is informed, there is only one study addressing the issue

12 12 of alcohol consumption among pregnant women in Bhutan, till date. Udon and Areesantichai (2012) assessed alcohol consumption in pregnant women visiting antenatal clinic and found out 66.7 % reporting lifetime alcohol use. The study reported that 25.3 %, 23.7 %, and 10.9 % of pregnant women in their sample had alcohol consumption in the past three months, one month, and one week respectively. Therefore, alcohol consumption during pregnancy is both a global and national public health issue today. The problem with its grave consequences on individual, family, and society needs to be addressed. Research studies done in an effort to study factors predicting alcohol consumption during pregnancy have suggested factors such as age, income, education level, etc (Li et al., 2012; Lee, Shin, Kim, & Oh, 2010; Peadon et al., 2011; Yen et al., 2012). The commonest significant predictor was prior drinking or pre-pregnancy drinking factor (Anderson, Hure, Powers, Kay-Lambkin, & Loxton, 2012; Peadon et al., 2011; Skagerstrom, Alehagen, Haggstrom-Nordin, Arestedt, & Nilsen, 2013; Yen et al., 2012). Prior drinking is an important factor inhibiting women s ability to cease alcohol consumption when they become pregnant. In fact, some 52 % of pregnant women with prior drinking continued to drink during pregnancy (Yen et al., 2012). In addition, the pattern of prepregnancy drinking also influenced pregnancy drinking. Women who drank at hazardous level prior to pregnancy were 56 times more likely to drink during pregnancy than those who drank at moderate level in pre-pregnancy state (Anderson et al., 2012). A previous study in Bhutan reported some 66.7 % of pregnant women drinking prior to pregnancy (Udon and Areesantichai, 2012). Thus, the role of prior drinking factor in alcohol consumption during pregnancy needs to be examined in this population. In addition, studies on factors influencing alcohol use and abuse among wide range of population have used Health Belief Model (HBM) to explain the drinking behavior, though only one study on alcohol consumption during pregnancy had used it. Previous studies have suggested that constructs of HBM such as perceived susceptibility, perceived severity, and self-efficacy could significantly explain and predict alcohol consumption behavior among adults, adolescents, and in pregnant population (Foster, Yeung, & Neighbors, 2014; Hang, 2011; Yeo, 1999). Perceived susceptibility refers to subjective perception of contracting a condition or

13 13 experiencing negative health outcome (Rosenstock, 1974a; Champion & Skinner, 2008). Studies have shown significant negative association between perceived susceptibility and alcohol consumption (Hang, 2011; Yeo, 1999). Pregnant women perceiving susceptibility towards fetal alcohol disorder are less likely to drink alcohol during pregnancy (Yeo, 1999). Perceived severity is known as subjective belief concerning seriousness of a given condition or a negative health outcome (Rosenstock, 1974a). Previous studies found significant negative association between perceived severity of consequences of alcohol drinking and alcohol drinking behavior (Hang, 2011). Pregnant women perceiving fetal alcohol disorders as a serious problem drank lesser alcohol during pregnancy than those who did not (Yeo, 1999). While self-efficacy is confidence in one s ability to take an action-either positive health action or inhibition of risky behavior (Carpenter, 2010; Champion & Skinner, 2008). In alcohol consumption studies, the self-efficacy variable of HBM is often referred to as drinking refusal self-efficacy (DRSE). It is individual s belief about their own capacity to refuse drinking alcohol in different situations (Foster et al., 2014). Drinking refusal self-efficacy showed significant negative association with alcohol consumption behavior (Foster et al, 2014; Oie & Jardim, 2007).Though widely used and claimed to be significantly predicting alcohol consumption behavior in other sections of population as adult and adolescents, the DRSE had not been studied in alcohol consumption among pregnant women. Individual beliefs and perceptions are the most important determinants of healthy or risky behavior in individuals (Champion & Skinner, 2008). Although previous studies have examined common factors predicting alcohol consumption during pregnancy, women s belief factors were the least explored variables and thus, the current study is expected to fill this gap of knowledge. This will allow health care providers to view the problem of alcohol consumption during pregnancy from women s point of view, through lenses of their beliefs and perceptions, ultimately broadening the scope of interventions. Moreover, the widely accepted drinking culture in Bhutan, few scientific evidences on alcohol consumption during pregnancy, and the only previous study reporting high prevalence of both prior and current drinking during pregnancy, calls for the need of this study in Bhutan. Thus, this study will investigate alcohol

14 14 consumption during pregnancy and the predicting factors of alcohol consumption among Bhutanese pregnant women. Generating research evidences in this area will not only improve the existing maternal and child health care at practice level but evidence generated is expected to be useful for development of health policies on maternal and child health. Research objectives The main objective of the study was to explore alcohol consumption and the predicting factors of alcohol consumption among pregnant women in Bhutan. Specific objectives 1. To examine alcohol consumption prior to and during current pregnancy among Bhutanese pregnant women. 2. To examine perceived susceptibility of the consequences of alcohol consumption during pregnancy among Bhutanese pregnant women. 3. To examine perceived severity of the consequences of alcohol consumption during pregnancy among Bhutanese pregnant women. 4. To examine drinking refusal self-efficacy among Bhutanese pregnant women. 5. To examine predicting factors of alcohol consumption among Bhutanese pregnant women including prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy. Research hypothesis The prior drinking, perceived susceptibility and perceived severity of pregnancy and fetal complications of alcohol consumption during pregnancy, and drinking refusal self-efficacy could predict alcohol consumption during pregnancy among Bhutanese pregnant women. Scope of study This research study was aimed at examining alcohol consumption among Bhutanese pregnant women and the predicting factors of alcohol consumption during

15 15 pregnancy. The factors included were prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy. Participants were women in their second and third trimester of pregnancy, visiting an antenatal clinic at Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu, Bhutan for their regular antenatal care from February to March Research framework The Health Belief Model (HBM) was born out of concerns about widespread failure of people to participate in the United States of America public health services (Rosenstock, 1974; Champion & Skinner, 2008). The HBM has three major constructs as: 1) modifying factors, 2) individual beliefs, and 3) action. Modifying factors consist of socio-demographic, personal, and structural factors. Individual beliefs consist of five perception variables as perceived susceptibility, perceived severity, perceived benefit, perceived barrier, and perceived self-efficacy variable. Action variable can be either healthy or risky behavior and is triggered by cues to action (Champion & Skinner, 2008). In brief, the model explains how an individuals perception as a central concept influence individuals to exhibit healthy or risky behavior. And modifying factors mediate both individuals perception and action. Thus, perception variables are core of HBM. Befitting the current study phenomena and based on previous literature (Hang, 2011; Champion, 2012; Yeo, 1999), individual belief factors such as perceived susceptibility, perceived severity, and self-efficacy were used to guide this study. According to the HBM, perceived susceptibility is individual s perception of risk of contracting a condition or experiencing a negative health outcome. Perceived severity is how serious the individual perceives a condition or experience of negative health outcome to be. Self-efficacy is individual perception of the confidence in one s ability to take an action (Champion & Skinner, 2008). The women s alcohol consumption during pregnancy is influenced mainly by her perceptions and beliefs about alcohol consumption during pregnancy. If she perceive her drinking as risk to pregnancy related complications and negative fetal consequences, she is less likely to drink. Moreover, for women to feel threatened of drinking, she has to believe that the consequences of drinking are severe or serious. Furthermore, pregnant women s

16 16 drinking refusal self-efficacy is another important construct determining alcohol consumption during pregnancy. In addition, the prior drinking factor is derived from literature review, prior drinking was reported to be the common significant factor predicting alcohol consumption among pregnant women by previous studies (Anderson et al., 2012; Peadon et al., 2011; Skagerstrom et al., 2013; Yen at al., 2012). Thus, based on literature review and the HBM as a conceptual framework, research framework for the current study is depicted in figure 1. Alcohol consumption during pregnancy was examined and investigated in relation to prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy. Prior drinking Perceived susceptibility Perceived severity Alcohol consumption during pregnancy Drinking refusal self-efficacy Figure 1 Research framework Definition of terms Pregnant woman refers to women in their second and third trimester of pregnancy (gestational age > 12 weeks) and who had come to receive their routine antenatal care in JDWNRH. Alcohol consumption during pregnancy is defined as consumption of any amount and frequency of alcohol containing drink during current pregnancy. It was measured using the standard tool, Alcohol Use Disorder Identification Test- Consumption [AUDIT-C] (Burns, Gray, & Smith, 2010). Prior drinking refers to pregnant women s alcohol consumption in past one year before the current pregnancy. It was also measured by the AUDIT-C.

17 17 Perceived susceptibility is defined as pregnant women s belief about the alcohol consumption as a risk to her pregnancy and fetus. It was measured by the Perceived Susceptibility Questionnaire (PsuQ) developed by the researcher based on literature and definition of perceived susceptibility construct of HBM. Perceived severity is defined as pregnant women s belief about the seriousness of the consequences of alcohol consumption during pregnancy. It was measured by the Perceived Severity Questionnaire (PseQ) developed by the researcher based on literature and the definition of perceived severity construct of HBM. Drinking refusal self-efficacy is defined as pregnant women s belief that she is able to resist, refuse, or turn down alcohol on different occasions such as social, emotional, and opportunistic. It was measured by the Drinking Refusal Self-efficacy Questionnaire-Revised (DRSEQ-R) developed by Oei, Hasking, and Young (2005).

18 18 CHAPTER 2 LITERATURE REVIEWS This chapter presents literature review on alcohol consumption during pregnancy, the Health Belief Model, and factors predicting alcohol consumption during pregnancy. Literature and research related to this study were reviewed as follows: 1. Alcohol consumption during pregnancy 1.1 Definition of alcohol consumption and related-terms 1.2 Recommendations on alcohol consumption during pregnancy 1.3 Pregnancy drinking and characteristics 1.4 Alcohol consumption during pregnancy in Bhutan 1.5 Pregnancy and fetal consequences of alcohol consumption 2. The health belief model [HBM] 2.1 The development and evolution of HBM 2.2 The constructs of HBM and their relationship 2.3 Application of HBM in behavioral research 3. Factors predicting alcohol consumption during pregnancy 3.1 Prior drinking 3.2 Perceived susceptibility 3.2 Perceived severity 3.4 Drinking refusal self-efficacy 4. Summary

19 19 Alcohol consumption during pregnancy Definition of alcohol consumption and related-terms Alcohol, also known as ethyl alcohol is an intoxicating ingredient found in beer, wine, and liquor (CDC, 2010). Many people across the globe enjoy alcohol for its relaxing properties and as an enhancer of sociability when taken within moderate levels. However, it can create problem when taken in excess and irresponsibly. The intoxicating properties of alcohol can cause physical, emotional, and socioeconomic harms if taken at excessive levels (ICAP, 2014). The cornerstone in defining alcohol consumption is how much alcohol is consumed and the pattern in which it is consumed because the effects of alcohol depend mainly on those two factors (ICAP, 2014). In addition, how much of the alcohol is not only about the physical measure of an alcoholic drink such as a glass of beer or wine; but more about the absolute ethyl alcohol content in those alcoholic drinks. In order to define alcohol consumption, it is important to understand the meaning of the standard drink, which is the very basic unit to measure alcohol consumption; it is the strength of an alcoholic drink expressed in terms of grams of pure ethanol content. According to ICAP (2014), there is no single accepted definition for a standard drink at international level or in scientific literature, mainly because standardization of a drink size depends greatly on local culture, customs, and type of alcoholic drink. For example, a standard drink in the United States America refers to14 g of pure ethanol but the same standard drink in Japan contains g or it is only 8 g of ethanol for United Kingdom. Bhutan does not have a drinking guideline that defines standard drink size or defines the levels of drinking, that befits our context. Standardizing a drink size is not an easy task either, especially with so many local brewed drinks available, each with different alcohol content based on how it is prepared at homes. Never the less, a previous study used one standard drink definition as a drink containing 10 g pure ethanol (Dorji, 2012), which is in line with most countries definition of standard drink at international level (ICAP, 2014). However, a more practically feasible definition of a standard drink is a definition by American dietary guideline. This definition of standard drink is equivalent to the 14 g ethanol content in a standard drink size of America and defined in terms of fluid measures as the drinks are served in that form; hence, the practical

20 20 feasibility for researchers. Therefore, one standard drink is defined as 12 fluid ounces of regular beer (5 % alcohol), 5 fluid ounces of wine (12 % alcohol), or 1.5 fluid ounces of 80 proof (40 % alcohol) distilled spirit. (The U.S. Department of Agriculture [USDA] & Health and Human Services, 2010). Thus, this definition of the standard drink with its practical feasibility was used in the current study. The 2010 dietary guidelines for Americans, defined levels of alcohol consumption for adult women as follows: 1. Moderate alcohol consumption is defined as up to one drink per day for adult women. 2. Heavy or high-risk drinking for adult women is defined as consumption of more than 3 drinks on any day or more than 7 per week. 3. Binge drinking for adult women is defined as consumption of 4 or more drink within 2 hours. A more feasible definition used by Balachova et al. (2012) in their study defines binge drinking for pregnant women as, consumption of 4 or more drinks on a single drinking occasion. The above guideline defines different levels of alcohol consumption for general population of women; so that, women who wishes to drink and whose general health allow her to enjoy a drink or two, does it sensibly and within safe levels. However, pregnant women do not share same consensus but the researchers often use these levels as references for examining pregnancy drinking. Recommendations on alcohol consumption during pregnancy Drinking guidelines can differ from one nation to another depending on their own definition of standard drinks and the drinking context; but most countries allow 1-2 drink per day as a safe level for adult women who wish to drink. However, all the recent guidelines recommend complete alcohol abstinence as the safest choice for women during pregnancy (ICAP, 2012). In addition, many health agencies advice women to stay on complete alcohol abstinence during pregnancy and as women plan for their conception (ACOG, 2011; CDC, 2010; WHO, 2014). These recommendations and guidelines are all in line with the recent research evidences suggesting that, while there is strong body of evidence linking maternal heavy drinking to various adverse health outcomes for offspring, there is none on the threshold below which the risk for harm is negligible (CDC, 2012; ICAP, 2014).

21 21 Moreover, recent research findings suggest that even lower level of alcohol is not safe at any time during pregnancy (Andersen et al., 2012). Thus, the current advice for pregnant women on alcohol consumption is to stay on complete alcohol abstinence throughout pregnancy as the safest choice. Hence, there is no safe level of drinking defined for a pregnant woman. Pregnancy drinking and characteristics Alcohol consumption during pregnancy can simply mean pregnant women drinking alcohol or described in terms of amount, frequency, and time (gestational age) of alcohol consumption. A recent survey on alcohol and other drug use during pregnancy among South African women by Williams et al. (2014), described alcohol consumption during pregnancy as, pregnant women consuming alcohol during and in three months before they knew they were pregnant. The three months before recognition of pregnancy was considered because of the risk of unintentional exposure of fetus during early months of gestation. Often pregnancies are recognized only by 4-6 weeks or later and by then organogenesis have already begun and the fetal exposure had occurred if any (Ornoy & Ergaz, 2010). Another study by Aliyu et al. (2008) described alcohol consumption during pregnancy slightly different from above, as the aim of this study was to investigate the effect of different levels of alcohol consumption during pregnancy on early stillbirth. They used three types of categories of alcohol consumption during pregnancy such as 1-2 drinks per week (moderate level drinking), 3-4 drinks per week (heavy drinking), and > 5 drinks per week (binge drinking). Thus, the concept is usually defined in terms of amount, frequency, and gestational age at exposure because the effect will depend on how much women is drinking, how frequent is her drinking, and at what time of pregnancy she is drinking (Ornoy & Ergaz, 2010). In addition, different terms such as prenatal alcohol exposure, alcohol exposed pregnancy, fetal alcohol exposure, and maternal alcohol exposure are all synonymously used to mean alcohol consumption during pregnancy. A close examination of alcohol consumption among pregnant women by many previous studies showed common characteristics of women who drink alcohol during pregnancy. These evidences shed some light on the general believe that pregnancy provides some form of motivation for women to change her drinking

22 22 behavior and health care providers can use pregnancy as an opportunity to not only prevent alcohol related pregnancy complications and fetal harms but also to curb the general alcohol problems in women. In Russia, Balachova et al. (2012) examined alcohol consumption among 648 women and reported that the overall prevalence of alcohol consumption during pregnancy was 20 %. Moreover, compared to the 81 % of them consuming alcohol in pre-pregnant, most women abstained from alcohol on recognition of pregnancy with only 20 % of the women drinking alcohol during or throughout pregnancy. For those who continued to drink during pregnancy, the amount of consumption decreased as pregnancy progressed with the average consumption of 1.1drinks per week in first trimester, decreasing to an average of 0.7 drinks per week in second trimester, and the pattern of consumption in third trimester (0.9 drinks per week) remained not much different from first or second trimester. Another population based cohort study among 4088 mothers described a different pattern of pregnancy drinking (Ethen et al., 2009). The study results showed prevalence rate of 30.3 % and the pattern of drinking seen were 22.5 % of sample using alcohol in the first month in first trimester, decreasing to 8.5 % in second month, and 5.5 % in third month; the number increased to 7.4 % of women consuming alcohol in second trimester; and 7.9 % in third trimester. The patterns of pregnancy drinking reported above showed most women reducing alcohol consumption than quitting on recognition of their pregnancies while some continued to drink throughout pregnancy. Thus, these pose a challenge for health care providers who take care of pregnant women and believe that women will modify their drinking behavior during pregnancy. This multi-factorial issue rather needs to be addressed with a more comprehensive approach, especially now as the recent research evidences suggests that there is no safe level of drinking at any time during pregnancy. Recognizing women who might be at risk or who are with the problem of alcohol consumption during pregnancy is crucial for the health care providers, in order to plan specific interventions targeted for the risk group. Often women are reluctant to talk about their substance use and abuse and the problem might go unrecognized. Scientific literatures have suggested some of the common characteristics of women who might be at risk of alcohol consumption during pregnancy. Pregnant women who are multiparous, older maternal age, belonging to

23 23 high-income group, having higher education level, having partner or friend who drink, and abusing illicit drugs and tobacco are more likely to drink alcohol during pregnancy compared to their counterparts (Anderson et al., 2012; Li et al., 2012; Peadon et al., 2011; Raymond, Beer, Glazebrook, & Sayal, 2009). In addition, women who are violence exposed and physically abused are at risk of alcohol consumption during pregnancy. Alcohol consumption during pregnancy in Bhutan In Bhutan, with alcohol use and abuse subject gaining only recent recognition, very little is known about the alcohol consumption during pregnancy. Alcohol consumption among women is not stigmatized in Bhutanese society, especially once they attain the age of adulthood (18 years) (Udon & Areesantichai, 2012); thus, easy accessibility of alcohol for women. Studies in other parts of the world have suggested easy accessibility and availability to be independent factors influencing alcohol consumption behavior (Bryden, Roberts, Mckee, & Petticrew, 2011). A descriptive survey study by Udon and Areesantichai (2012) is the only one examining alcohol consumption among pregnant women in Bhutan, till date. Three hundred and twelve pregnant women visiting antenatal care in JDWNRH took part in the survey: 20 % in first trimester, 39 % in second, and 40 % of the participants were in third trimester of gestation. Some 66.7 % of the participants reported lifetime alcohol use, 25.3 % consumed alcohol in last 3 months; 23.7 % in last one month; and 10.9 % in past one week time. The most common types of alcohol drinks preferred by pregnant women in Bhutan were Changkey, Beer, Wine, Ara, and Bangchhang. Bhutanese pregnant women drank alcohol for various reasons such as culture (17.6 %), positive psychological feeling (17.3 %), physical benefits (10.9 %), and some 13.1 % reported pressure from their partner, family, and friend as a reason for their drinking. Pregnancy and fetal consequences of alcohol consumption Alcohol consumption during pregnancy might harm both mother and the baby but literature on alcohol consumption during pregnancy had focused more on the effects of alcohol consumption during pregnancy on pregnancy and the fetal health in particular. This might be because of the change in pattern of drinking during pregnancy; as it is evident from research studies on pattern of pregnancy drinking,

24 24 both the amount and frequency of alcohol consumption is not same in pre-pregnant and pregnant state with most women drinking at moderate levels during pregnancy (Balachova et al., 2012; Ethen et al., 2009). The moderate level of drinking by pregnant women, defined as safe but not risk-free for an adult woman may not share the same safety margin for fetal health during pregnancy. Maternal alcohol consumption brings about numerous irreversible teratogenic effects on fetus (Ornoy & Ergaz, 2010), as well as negative effect on fetal development via poor maternal health and behavior. For the women who drink, her risk for pregnancy related complications such as miscarriage, placental abruption, stillbirth, and premature labor increases with drinking. Drinking endangers the growing baby in many ways such as by increasing the risk of preterm birth, low birth weight, and problems related to cognition, behavior, and developmental delays such as fetal alcohol spectrum disorder [FASD]. Thus, the literatures on the effect of alcohol consumption during pregnancy on pregnancy and fetal health were reviewed, which is also in line with the scope of the current study 1. Effects on pregnancy Spontaneous abortion and stillbirth: Spontaneous abortion defined as fetal demise prior to 20 completed weeks of gestation and stillbirth is the demise occurring after 20 weeks. The exact cause of such pregnancy complications is not known; however, alcohol exposure is one of potential risk factors for both spontaneous abortion and stillbirth (Bailey & Sokol, 2011). A result from Danish national birth cohort showed substantial increased risk of spontaneous abortion with even low levels of alcohol consumption in early pregnancy. In addition, study also reported that, the hazard ratio depended on dose of consumption and time of gestational age at consumption or exposure. The adjusted hazard ratios of spontaneous abortion reported were 1.66 (95 % CI ) for women who reported drinks per week in first trimester, increasing to 2.82 (95 % CI ) for those reporting 4 or more drinks per week. After first trimester (13-16 weeks), the hazard ratios were 1.57 (95 % CI ) for drinks per week and 1.73 (95 % CI ) for 4 or more drinks per week (Andersen et al., 2012). Thus, the risk of spontaneous abortion is not only higher with higher level of alcohol consumption but also higher when taken at smaller gestational age.

25 25 The studies on prenatal alcohol exposure and stillbirth showed significant association, In fact, it was estimated that the risk of stillbirth increased by 40 % in women who consumed any amount of alcohol compared to the abstainers (Aliyu et al., 2008). Another study reported that risk of stillbirth is dose dependent and the risk is as high as 31 % in heavy consumption, while it is about 4.2 % with mild exposure (Kesmodel et al., 2002). The risk for stillbirth was 3 times higher in women who consumed > 5 drinks per week than in women who consumed < 1 drink per week. Thus, women who drink alcohol during pregnancy are at some level of risk of pregnancy complications such as spontaneous abortion and stillbirth, depending on the amount, frequency, and time of gestational age of alcohol consumption. Therefore, there is nothing called as safe level of drinking during pregnancy. Placental abruption: defined as the premature separation of placenta, complicates about 1 % of births, accounts for up to one-third of all perinatal maternal deaths, and approximately 10 % of all preterm births are associated with placental abruption (Oyelese & Ananth, 2006). Maternal alcohol consumption during pregnancy is one of the reported risk factors of placental abruption. A population based retrospective cohort study in Missouri among singleton deliveries during 1989 to 2005 [n= 1,221,310] by Aliyu et al. (2011), reported that women who consumed alcohol during pregnancy were at 33 % greater risk of placental abruption compared to their non-drinking counterparts (OR = 1.33, 95 %, CI ). The same database was also examined by Salihu et al. (2011) and a logistic regression analysis predicted that alcohol consumption during pregnancy increased the risk of placental abruption by 29 % (p <.01). Another study analyzed the data from population-based cohort with singleton pregnancies in United Sates of America (Yang et al., 2009). The study compared risk factor for placental abruption and placenta previa among the sample. There were 5,630,854 pimiparous and 11,026,768 multiparous in the sample and placental abruption reported was 4.8 per 100 births among primiparous and 5.9 per 100 multiparous. The analysis concluded that, drinking alcohol during pregnancy increased the risk of placental abruption. Preterm birth: refers to babies born alive before completion of 37 weeks of gestation and there are different categories of preterm such as extremely preterm (< 28 weeks), very preterm (28 to < 32 weeks), and late preterm (32 to < 37 weeks).

26 26 A global action report on preterm births co-authored by March of Dimes, The Partnership for Maternal Newborn and Child Health, Save the Children, and WHO (2012), reported that annually approximately15 million babies are born preterm and this number is rising, especially in African and South Asian regions. Every year over 1 million babies die from the consequences of prematurity; preterm birth is the number one killer of newborns and the second leading cause of death after pneumonia in under-fives. While there are many causative factors of preterm birth such as maternal infections, high blood pressure, diabetes, and so on, alcohol consumption during pregnancy showed significant association with preterm births. A study by Mullally, Cleary, Barry, Fahey, and Murphy (2011) analyzed 61,241 antenatal bookings with self-reported alcohol consumption during pregnancy and the delivery records. Alcohol consumption was categorized as low (0-5 units per week), moderate (6-20 units per week), and binging (> 20 units per week). The analysis showed that high levels of alcohol consumption was associated with very preterm (< 32 weeks) births; and the result was significant even after adjusting for cofounders (OR-3.15, 95 %, CI ). Low and moderate drinking did not show statistically significant effect in the final analysis. Another study investigated the effects of maternal alcohol consumption on fetal growth and preterm birth among 4719 singleton births (O Leary et al., 2009). The results showed that, women who had exposed their fetus to binge drinking during late pregnancy had highest percentage of infants born before 37weeks (9.5 %); and women who drank heavily but stopped before second trimester (13.5 %) too did. Thus, heavy levels of alcohol consumption anytime during pregnancy resulted into increased risk of preterm birth. In addition, a meta-analysis of 14 case-control and cohort studies on association between maternal alcohol consumption and preterm birth concluded that, the risk of having preterm birth increased by 23 % for mothers who consumed more than 3 drinks (36 g per day) compared to non-drinking mothers (Patra et al., 2011). On a contrary, a systematic review by Bailey and Sokol (2011) reported that, there is no significant association between preterm and alcohol exposure during pregnancy. However, the authors of the review concluded with an opinion that, the findings are controversial as many studies reviewed suffered methodological

27 27 weakness. They stated that, two studies however, showed a reliable methodology and demonstrated an increased risk of preterm in women who consumed alcohol during pregnancy. Thus, alcohol consumption during pregnancy is a risk factor for preterm birth and the relationship is dose dependent; higher the levels of alcohol consumption at any time during pregnancy, greater the risk of having preterm birth. 2. Effects on fetal health Fetal alcohol spectrum disorder (FASD): refers to the most severe consequence of higher level of prenatal alcohol exposure, mainly the binge-drinking pattern. The FASD is an umbrella term used to describe a wide range of effects that can occur in an individual whose mother drank alcohol during pregnancy; the effects may be physical, mental, behavioral, and learning disabilities with possible lifelong implications (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2013; Ornoy & Ergaz, 2010). The criteria for FASD diagnosis are: 1) all three facial features present (smooth philtrum, thin upper lip, short distance between inner and outer corners of the eyes); 2) growth deficits (height/weight < 10 th percentile); and 3) central nervous system problems (CDC, 2010). In addition, a child meets the criteria even if there is problem with brain structure and not functional problems. The dose, pattern, and timing of exposure of alcohol during different period of development can greatly influence the pattern and severity of structural and functional abnormalities in FASD (Ornoy & Ergaz, 2010). Some of the problems associated with children born with FASD are problem solving, planning, speech, language disturbances, and fluency (Aragon et al., 2008; O Keeffe, Greene, & Kearney, 2014; O Leary et al., 2009). Children with FASD diagnosis will also have poor motor performance such as hand-eye coordination, weak grasp, tremors, and balance and gait difficulties (Chiodo et al., 2009; Mattson, Crocker, & Nguyen, 2011). A recent study showed that both fine and gross motor functions are affected and delayed skeletal maturity were seen in children with FASD (Mattson et al., 2011). In addition, children with FASD showed clinically significant sleep problems (Chen, Olson, Picciano, Starr, & Owens, 2012). The studies on FASD showed a prevalence rate of 4-12 per 1000 in Italy (May et al., 2011), 2-7 per 1000 in U.S (May et al., 2009), and as high as per 1000 in South African countries (May et al., 2007). While FASD is one of the leading

28 28 causes of mental retardation in the U.S (Chasnoff et al., 2010), a CDC (2012) statement on FASD reported that FASD is 100 % preventable if women were to stay on complete alcohol abstinence throughout pregnancy. In that case, when FASD could be prevented through simple measure such as behavior change in women, it should not be allowed to live an epidemic; especially with the grave consequences it bear on individual, family, nation, and world at large with the lifelong physical, social, and economic burdens. For example, an estimated annual cost of caring a child with FASD in a Canadian study ranged from 57.9 to million Canadian dollars (Popova, Lange, Burd, & Rehm, 2014). Neurodevelopmental disorders: Broadly refers to the disorder of brain that affects motor functions, emotion, learning ability, speech, self-control, and memory; and the manifestations unfold as individuals grow. Maternal alcohol consumption is a potential risk factor to so many neurodevelopmental disorders in children. A study by Hannigan et al. (2010) assessed maternal alcohol consumption during pregnancy, starting from antenatal period and retrospectively at the 14 years follow-up among 288 mothers. The results showed a significant association between prenatal alcohol exposure and teacher reported teen behavioral problems such as attention-deficithyperactivity-disorder, oppositional defiant disorders, aggressiveness, rule breaking behavior, and anxiousness. Another observational study to investigate whether moderate level of alcohol exposure during pregnancy influenced child s cognitive development at the age 8 found out that, there is significant (p <.001) association between children s IQ at 8 years and moderate prenatal alcohol exposure. The moderate level of alcohol consumption in the study was defined as consumption of 1-6 units per week during pregnancy (Lewis et al., 2012). In addition, a recent metaanalysis of studies on prenatal alcohol exposure and neuro-developmental problems in children concluded that, binge drinking affected child s cognition such as IQ and exposure at low to moderate levels are responsible for behavioral problems in children (Flak et al., 2014). Lastly, the impact of maternal alcohol consumption on fetus begins at the organogenesis phase affecting the growth and development inutero; then, if the baby survives spontaneous abortion and stillbirth, is either born preterm or with number of congenital anomalies. Next, as the baby grows up, the physical abnormalities remain

29 29 irreversible depending on the degree of severity. In addition, the child s cognition is affected and symptoms of neurodevelopmental disorders unfold as the child grows up. This lifelong effect on the child will in turn have physical, mental, emotional, and socio-economic implications at individual, family, community, and society levels. At present, the evidence linking the high levels of alcohol consumption with FASDS and other impacts are strong; but the evidence on harms at low level of drinking is insufficient (CDC, 2012). The health belief model [HBM] Development and evolution of the HBM The HBM dates back to early 1950s, initially developed by Hochbaum, Kegeles, Leventhal, and Rosenstock (Champion & Skinner, 2008; Rosenstock, 1974 a) as a way to explain and predict preventive health behavior. The original HBM focused on relationship of health behaviors, practices, and utilization of health services. The two important circumstances, which were largely responsible for the emergence of the then HBM are: the health care setting in those days focusing more on preventive health than curative care and the training and background of the developers of the model (Rosenstock, 1974 a). The developers of the model, who were a group of social psychologists, were confronted with problems of failing preventive medical services such as tuberculosis screening programs, offered then by U.S public health services free of cost. Thus, while exploring for answers to their practical problem, they simultaneously came up with the theory and model to explain such behavioral problem of non-acceptance of free health services offered then. The earliest model with four major perception variables was influenced by the theory of Kurt Lewin, which explained that any human behavior is detrimental to the world of perceiver; it is what the person perceives and believes that make him want to act or behave in healthy or risky way (Rosenstock, 1974 a). Since its inception in early 1950s, the model had been in use for decades, as a conceptual framework to understand and predict wide range of health behaviors and explain possible reasons for non-compliance with recommended health actions (Champion & Skinner, 2008). Thus, the model evolved rapidly and the addition of variable, self-efficacy to the older model occurred in 1988 by Rosenstock, Stretcher,

30 30 and Becker (Carpenter, 2010). Therefore, the current HBM has seven major variables such as perceived susceptibility, perceived severity, perceived benefit, perceived barrier, self-efficacy, modifying factors, and cues to action (Champion & Skinner, 2008). The HBM constructs and their relationship The health belief model as shown in Figure 2 in the next page is an updated version of model and the latest (Champion & Skinner, 2008). The model can be divided into three major components as modifying factors consisting of sociodemographic, personal, and structural factors; individual beliefs consisting of four perception variables and self-efficacy variable; and action which is the healthy or risky behavior including the cues that triggers the action. Modifying factors Individual beliefs Action Age Gender Ethnicity Personality Socioeconomic Knowledge Perceived susceptibility to and severity of disease Perceived benefits Perceived barriers Perceived Self-efficacy Perceived threat Individual behavior Cues to action Figure 2 Health belief model (Champion & Skinner, 2008) Perceived susceptibility is subjective risk of contracting a condition and individuals vary widely in their perception of susceptibility to a given condition (Rosenstock, 1974 a). This refers to individual perception of the risk of contracting a disease condition or experiencing negative health outcomes because of their risky

31 31 behavior (Champion and Skinner, 2008). This belief or perception will determine the healthy or risky behavior in an individual; if an individual perceives that he/ she is at higher risk of contracting a disease condition, he/ she is more likely to engage in healthy behavior or actions to avoid the risk. Thus, higher the perceived susceptibility of a disease condition, more likelihood to take health actions to avoid contracting that condition. Similarly, individual are likely to avoid risky behavior if individual had higher perceived susceptibility of negative health outcomes from that particular risky behavior. Perceived severity refers to the convictions concerning the seriousness of a given condition (Rosenstock, 1974 a). It is the individual s judgment of the severity of the disease or the consequences of risky behavior, mostly based on medical information/ knowledge; but it may also come from the individual s belief about the physical, emotional, social, and financial implications that the consequences of risky behavior might create in one s life (Rosenstock, 1974 b). Though perceived susceptibility is important to prompt an individual to take up heath actions, feeling susceptible alone is not enough but the person has to believe that contracting the risk or disease will create serious short and long-term consequences in his or her life (Champion, 2012). The perceived susceptibility and perceived severity, together known as perceived threat is a stronger drive to prompt an individual to take health actions or avoid risky behavior than each one alone. Perceived benefit is the individual belief in efficacy of the advised action to reduce susceptibility or seriousness of disease condition or negative health outcome (Rosenstock, 1974 a). This construct mostly applies to the positive health actions; individual are likely to take up or opt for the advised health action, only if they believe that the action will be beneficial to them (Champion and Skinner, 2008). For example, the women will go for breast cancer screening tests only if she believes that the screening can prevent her from getting a breast cancer or at least reduce the risk of it. Perceived barrier refers to the tangible and psychological costs of the advised action or treatment option that individuals perceive to be an obstacle in taking up the advised action (Rosenstock, 1974 a). Barriers are obstacles perceived by an individual and believed to be keeping him/her from attempting the advised health

32 32 action or treatment option. It can be characteristics of treatment or preventive measure such as inconvenient, expensive, unpleasant, painful, and unacceptable (Champion and Skinner, 2008). Self-efficacy is the confidence in one s ability to take an action and action refers to the positive health action or inhibition of risky behavior. This construct was added to the HBM later in 1988 and many critiques are of the view that, adding selfefficacy to HBM increased the explanatory power of the model (Carpenter, 2010; Champion and Skinner, 2008). Modifying factors are the demographic, socio-psychological, and structural variables that serve to condition individual perceptions (Champion & Skinner, 2008). These are the individual and contextual factors such as age, personality, ethnicity, knowledge, etc that has some influence on individual s perception. Cues to action refer to various stimuli or factors that serve as cues to trigger the action in an individual who is psychologically ready to act (Rosenstock, 1974 a). A cue can be any stimuli as momentary as a sneeze or the barely conscious perception of a poster; although an interesting concept, it is difficult to study in explanatory studies (Champion and Skinner, 2008). Thus, according to the HBM, there are certain personal and contextual factors known as modifying factors that might influence all the perception variables of individual belief. Firstly, people will be motivated to take up positive health actions only if they believe that they are at risk of getting a disease or negative health outcomes. Secondly, the model predicts that the stronger the perception of severity of disease or negative health outcomes, the more likely that people will work to avoid it (Rosenstock, 1974 a). Thirdly, in addition to the perceived threat- made up of perceived susceptibility and perceived severity, people must believe that the intended action will be beneficial and benefits will outweigh the perceived barriers of the action. Perceived barriers are the different forms of obstacles that people believe it to have potential to keep them from succeeding in the recommended health actions; thus, the benefits minus barrier leads to attempting positive health actions in the first place. Then, people must believe that they are competent and capable to take up the positive health actions; perceived self-efficacy is very important for successfully achieving the intended health action, especially when it is about avoiding the lifelong negative

33 33 habits such as alcohol and tobacco use (Champion & Skinner, 2008). Finally, the mocdel also includes cues to action, which are the additional factors that might trigger the person to adopt positive health actions once he/she is psychologically ready to act. Application of the HBM in behavioral research According to Becker, 1974 (cited in Rosenstock, 1974 b), the strength of HBM lies in its potential for application to a wide range of health issues. Since the development in 1950s, HBM with its potentiality to mediate, predict, and serve as a blue print strategy for behavioral change interventions had been in use for decades. Today it is one of the most widely used theoretical frameworks in behavioral research (Champion & Skinner, 2008). The model had been used as a conceptual framework in wide range of health behavioral studies such as breast self-examination (Noroozi, Jomand, & Tahmasebi, 2011), eating disorders (Akey, Rintamaki, & Kane, 2012), substance abuse (Bonar & Rosenberg, 2011), smoking during pregnancy (Katirai, 2011), and alcohol consumption in adults and adolescents (Champion, 2012; Foster et al., 2014; Hang, 2011) to list a few recent ones. However, a literature review by the researcher revealed very few evidence on application of HBM specific to alcohol consumption during pregnancy. In fact, a thesis by Yeo (1999), retrieved from online source, was only one that used the HBM as a conceptual framework to study alcohol consumption during pregnancy. Throughout the review, the author also noted that most of the literature on alcohol consumption during pregnancy and related factors did not use any theoretical frameworks to guide their studies. Never the less, a study on factors predicting alcohol consumption among adults in Vietnam used all the six major constructs of HBM as a conceptual framework (Hang, 2011) and the results showed that, the HBM constructs could significantly predict the alcohol consumption among adult male and female in Vietnam. Similarly, a study by Champion (2012) used it to explain drinking among college students, though the results did not show any statistical significance due to small sample size (n-30) as the published result was from a pilot study. In addition, Katirai (2011) used the four perception constructs of HBM to determine factors associated with tobacco use in pregnant women and found the constructs could effectively explain smoking behavior in pregnant women. Smoking and alcohol consumption are the very closely related risky behaviors in pregnant women, often

34 34 referred to as closest cousins by many researchers. Research studies have not only found close association between the two risky behaviors (Mullally et al., 2011; Namagembe et al., 2010; Walker, Al-Sahab, Islam, & Tamim, 2011) but pregnant women who smoked during pregnancy were 4 times more likely to drink alcohol during pregnancy compared to their non-smoking counterparts (Skagerstrom et al., 2013). Other related literatures reviewed on HBM as a guiding framework to explain alcohol consumption behavior suggested that, HBM is fairly a robust model, especially after being bolstered with construct self-efficacy in late 1980s, and should be used in alcohol and drug studies (Sharma, 2011). The drinking refusal selfefficacy construct of HBM is widely used to study alcohol consumption behavior among wide range of population and the role of this factor remains to be explored in pregnant population (Foster et al., 2014; Hang, 2011; Oie & Burrow, 2000; Oie & Jardim, 2007). Therefore, HBM with the key idea centered on avoidance of negative health consequences, should be a good model for addressing problem behavior such as alcohol consumption that evokes health concerns (Champion & Skinner, 2008). In addition, Carpenter (2010) in his meta-analysis concluded that, the susceptibility and severity variables relate to the individual s perception of the negative health consequences of risky behavior while benefit and barriers relates to the individual s perception of the targeted positive health behavior taken to reduce the likelihood of the negative health outcome. Thus, the HBM constructs including perceived susceptibility, perceived severity, and drinking refusal self-efficacy guided the current study with an aim to examine alcohol consumption among Bhutanese pregnant women and predict factors associated with alcohol consumption during pregnancy. Factors predicting alcohol consumption during pregnancy From the literature review on alcohol consumption in both pregnant women and in other population such as adult and adolescents using HBM as the conceptual framework, HBM variables such as perceived susceptibility, perceived severity, and drink refusal self-efficacy significantly explained the alcohol consumption. In addition, in the studies reviewed on factors predicting alcohol consumption during

35 35 pregnancy, prior drinking remained as the common significant factor closely associated with alcohol consumption during pregnancy. 1. Prior drinking Numerous research studies have suggested that, prior or pre-pregnancy drinking habit is an important factor inhibiting the ability of women to cease drinking when they become pregnant. The general belief is that pregnancy provides some form of motivation for most women to cease or at least reduce drinking. On the contrary, research evidences suggest that it has not been easy for women with prior drinking habits to change their addictive behavior suddenly on recognition of pregnancy, though most reduce the amount of consumption, which is not enough according to the health messages based on recent research evidences. A cross-sectional study by Anderson et al. (2012) among 837 pregnant women in Australia examined alcohol consumption during pregnancy through assessment of pregnant women s compliance with new drinking guideline, which says complete alcohol abstinence for all pregnant women. In specific, study examined the factors predicting women s non-compliance to the guideline and found out prepregnancy drinking to be one of the most significant factors predicting pregnancy drinking or non-compliance with the guidelines. Majority of the participants (72 %) did not comply with the new drinking guideline of complete abstinence during pregnancy and the frequency and quantity of pre-pregnancy drinking strongly predicted pregnancy drinking. Women who consumed alcohol at least once a week before pregnancy were 56 time more likely to drink during pregnancy compared to those who drank less than weekly before pregnancy. In addition, compared to women drank 1-2 drinks per drinking day before pregnancy, abstainer women were 45 times more likely to stay on abstinence during pregnancy. Another study among 1594 pregnant women in Sweden concluded that, strong pre-pregnancy alcohol consumption habits predicted drinking alcohol during pregnancy (Skagerstrom et al., 2013). The study reported that 84 % of the participants drank alcohol before pregnancy and 14 % of them were drinking at hazardous level. As women planned to become pregnant, only 19 % of hazardous drinkers reduced their alcohol consumption compared to 33 % reduction in moderate drinkers- an indication that pre-pregnancy heavy drinkers are less likely to reduce or abstain from

36 36 drinking during pregnancy compared to moderate drinkers. Moreover, four in five women with hazardous drinking prior to pregnancy continued to drink until recognition of pregnancy, exposing the fetus to alcohol during early weeks of gestation. Similarly, a finding from the study in Taiwan supported the other studies prediction on prior drinking to be the strongest predictor of pregnancy drinking (Yen et al., 2012). Twenty six percent of the 806 postpartum mothers reported that they drank alcohol at some point during pregnancy; 52.5 % of the 398 women who drank before recognition of pregnancy continued to drink throughout pregnancy. Thus, more than 50 % of women who were prior drinkers continued to drink during pregnancy. In addition, the study reported that, the frequency of pre-pregnancy drinking significantly predicted alcohol consumption during pregnancy. Another study in Australia by Peadon et al. (2011) assessed women s intentions of consuming alcohol in future pregnancy. The researchers conducted a national cross-sectional survey via computer assisted telephone interview of 1103 women aged years and that, 89.4 % consumed alcohol in last 12 months. Both the alcohol use in last pregnancy (adjusted OR = 43.9, 95 % CI ) and more frequent and higher current alcohol consumption were significantly associated with intentions to drink in future pregnancy. 2. Perceived susceptibility According to HBM, women who perceive that the alcohol consumption is a risk for pregnancy and fetal complications such as miscarriage, placental abruption, stillbirth, preterm labor, and having an abnormal baby are less likely to drink during pregnancy; and more likely to adhere to health recommendations of complete alcohol abstinence throughout pregnancy. The vice-versa could happen for women who believed that alcohol consumption during pregnancy has no such risks. A descriptive study using HBM as a conceptual framework to explore the phenomena of alcohol consumption during pregnancy among 117 pregnant women found a high level of general perceived susceptibility to fetal alcohol spectrum disorder and fetal alcohol exposure among the sample (Yeo, 1999). Women were asked to rate their perceived susceptibility of having a baby with something wrong due to alcohol consumption; the rating was done on a visual analogue of zero (no risk)

37 37 to 100 (highest risk), the scale correspond with 100 %. Eighty one percent of respondents felt that their risk was between 0-30 percent, the other 19 % felt that their risk of having baby with problem related to maternal alcohol consumption in pregnancy was %. In the sample, only 9.4 % of women consumed alcohol during pregnancy and 19 % of the sample rated their perceived susceptibility to fetal alcohol spectrum disorders between %, the remaining rated between 0-30 %; thus, we can see that the sample s perceived level of susceptibility is higher and drinking reported much lower. Therefore, women who show higher perception of susceptibility of fetal alcohol spectrum disorders are less likely to drink alcohol during pregnancy and the vice-versa for those who rate lower perceived susceptibility. In another study by Hang (2011), examined alcohol consumption among adult male and females in Vietnam and found out that perceived susceptibility of consequences of excessive alcohol drinking had negative significant correlation with moderate level of alcohol consumption, defined in the study as lowest safe level of drinking allowed for adults (r = -0.34, p <.001). In a final regression model, the perceived susceptibility was one of the four variables that could significantly predict 77.6 % of the variance in alcohol consumption among male and female adults in Vietnam. Thus, the study concluded that, those with low perceived susceptibility of consequences of excessive alcohol drinking are more likely to engage in excessive drinking behavior and those who have higher level of perceived susceptibility of consequence of excessive drinking are less likely to drink alcohol at higher levels such as heavy and binge levels of drinking. Katirai (2011) used HBM as a conceptual framework to guide the study on factors determining tobacco use among pregnant women. The study results showed that, smokers (1.34) had much higher mean score, indicating that they felt less susceptible to harms of smoking during pregnancy (p <.001). Thus, pregnant women who drink or smoke during pregnancy do so because they believe that their drinking and smoking will not cause harm to their fetus or complicate their pregnancies. Likewise, those with higher perceived susceptibility of the harm smoking or drinking will smoke or drink less.

38 38 3. Perceived severity According to the HBM definition of perceived severity, pregnant women who perceive that the effects of alcohol consumption during pregnancy on pregnancy and fetal health are very serious are less likely to drink during pregnancy. The opposite could happen if women did not belief that the effects of alcohol consumption on pregnancy and fetus are a serious problem in their life. Yeo (1999) assessed the perceived severity of fetal alcohol spectrum (FAS) or fetal alcohol exposure (FAE), resulting from alcohol consumption during pregnancy. The perceived severity of FAS/ FAE measured on a visual analogue scale of 0 to 100 with zero indication not serious at all and 100 indicating the extreme seriousness. The results of the study showed that, most participants believed FAS/FAE to be a serious with 53% of the women marking on the line between 90 and 100. The other 14 % placed their mark between 71 and 90, 5 % between 41 and 50, 3 % at 41 and 40, 2 % at 1 and 30, and 17 % placed at Overall, majority of the participants perceived that having a child with FAS/FAE was moderate to extremely serious problem. Thus, the higher perceived severity of FAS/ FAE among the sample of pregnant women with only 9.4 % of the sample drinking alcohol during pregnancy signifies that, the higher the perceived severity of FAS/ FAE, the lesser likely pregnant women are to consume alcohol. An examination of the HBM construct perceived severity in relation to excessive alcohol consumption among adults in Vietnam (Hang, 2011) showed that, perceived severity of consequences of excessive alcohol drinking had negative significant association with the low level of alcohol drinking (r = -.24, p <.01). It means that the adults who perceived that the consequence of excessive drinking is a serious problem are more likely to drink at low levels and less likely to drink at excessive levels. The result indicates that, higher the perceived severity of consequences of excessive alcohol drinking, lesser were people likely to drink alcohol at excessive levels. However, the final model did not show significant with perceived severity as a factor predicting alcohol consumption among adults in Vietnam. 4. Drinking refusal self-efficacy Self-efficacy defined as conviction that one can successfully execute the behavior required to produce the outcomes (Bandura, 1997 cited in Champion &

39 39 Skinner, 2008). The self-efficacy concept relates to individual s subjective belief in their capacity to perform a specific behavior. Perceived self-efficacy of an individual influences both the acquisition of new healthy behavior and inhibition of existing risky behavior (Strecher, DeVellis, Becker, & Rosenstock, 1986). When the concept of self-efficacy is related to a risky behavior such as alcohol consumption, it is about inhibition of the risky behavior; thus referred to as the drinking refusal self-efficacy [DRSE]. The drinking refusal self-efficacy construct measure person s belief about their own capability to refuse drinking in three different situations such as drinking for emotional relief, drinking at social setting, and drinking when an opportunity arises (Foster et al., 2014). In the current study, drinking refusal self-efficacy refers to pregnant women s beliefs that she is able to resist, refuse, or turn down alcohol on different occasions. The studies available for review on alcohol consumption during pregnancy using HBM as a conceptual framework did not use drinking refusal selfefficacy variable of HBM. Because they used the older version of HBM with only four variables of perception, self-efficacy was added to HBM only in late 1980s (Carpenter, 2010; Champion & Skinner, 2008). Never the less, drinking refusal selfefficacy concept of HBM is a very important individual differences variable that affect drinking; it had been found to be a very significant factor in explaining alcohol related behavior across other populations such as adult, college students, and in community participants (Foster et al., 2014; Hang, 2011; Oie & Burrow, 2000; Oie & Jardim, 2007). A recent study by Foster et al. (2014) used drinking refusal self-efficacy construct of HBM as a major concept in examining the drinking identity and alcohol use among college students. Participants were 1069 college students with mean age of and % of the sample were female. The study results showed that, all the three subscales of drinking refusal self-efficacy such as emotional relief (r = -.27), social (r = -.40), and opportunistic (r = -.16) scale showed significant (p < 0.01) negative association with alcohol use among college students. College students with higher score of DRSE are more likely to drink lesser number of drinks per week; and those with lower score were more likely to consider themselves as not competent to refuse an alcoholic drink in different situations.

40 40 Similarly, another study examining factors influencing alcohol consumption in adults suggested significant negative association between drinking refusal selfefficacy and alcohol consumption (Hang, 2011). In a sample of 266 adults, 55.7 % of the sample reported drinking at safe levels, 33.8 % at hazardous level, and 10.5 % likely indicated for alcohol dependence. The final model included drinking refusal self-efficacy along with three other variables significantly predicting 77.6 % (p <.001) of the alcohol consumption behavior; thus, adults with low level of DRSE were more likely to drink at excessive levels. Moreover, Oie & Burrow (2000) used drinking refusal self-efficacy as one of the major variables to explain alcohol and other drug use and abuse among 168 college students. Multiple regression analysis showed that all together four major variables including drink refusal self-efficacy showed 17 % variance in alcohol consumption among the sample. Furthermore, the DRSE was the only variable to uniquely predict a significant proportion of 8 % variance (sr 2 =.08, p <.001).Thus, the researchers concluded that DRSE could specifically predict the alcohol consumption behavior. Lastly, a very interesting study by Oie & Jardim (2007) on alcohol expectancies, drinking refusal self-efficacy and drinking behavior in 188 Asian and Australian students concluded that, DRSE variable could significantly predict drinking specifically among the Asian students. The regression analysis showed that Australian group s drinking could be explained by both alcohol expectance and DRSE; but for the Asian group, DRSE was the only significant predictor of drinking, uniquely accounting for 15 % of the variance and as expected had negative relationship (β = -.41, p <.001). Thus, those who scored lower on DRSE showed higher consumption of alcohol, which is in accordance with the HBM concept of drink refusal self-efficacy. Therefore, DRSE just as it was used to explain alcohol consumption in adolescent and adult populations; it should be used to study alcohol consumption during pregnancy. Unlike previous studies on pregnancy drinking, which have all used only other four perception variables of HBM, examining DRSE s role in pregnancy drinking in current study will only broaden the scope of interventions.

41 41 Summary During the course of rigorous literature review, the author encountered some gap in knowledge on factors predicting alcohol consumption during pregnancy in general and in specific to the population of study. Firstly, the researcher noticed that very few studies on alcohol consumption during pregnancy used any conceptual framework and even fewer used the HBM, especially the drink refusal self-efficacy construct of HBM. Many experts have suggested that, the health belief model should be used in studying risky health behaviors such as alcohol consumption, especially with the self-efficacy construct added to it later around late 1980s (Sharma, 2011). Using theory as a conceptual framework to guide research studies will not only allow the researcher to have well planned guide to examine and understand the behavior but it will also increase the explanatory and implication power of the findings from the study (Glanz, Rimer, & Viswanath, 2008). Secondly, almost all the studies reviewed on factors predicting alcohol consumption behavior studied common factors such as women s age, income, education level, parity, partner drinking, knowledge, and so on. Women s belief and perception factors, which are important factors for both women with the issue of alcohol consumption during pregnancy and the nurse taking care of her, remain to be explored in depth. Individual s belief about health and illness is a very important factor determining the healthy or risky behavior in individual (Glanz et al., 2008). For the nurse, trying to understand women s risky behavior of alcohol consumption should start from understanding the problem from women s point of view, through the lenses of her subjective beliefs and perceptions; and then, change her perceptions through well-planned interventions. Lastly, the widely accepted drinking culture in Bhutan and the age-old problem of alcohol use and abuse in the country gaining only recent recognition justifies the need to investigate alcohol consumption among the most vulnerable group of population, pregnant women. Recent health reports ranked alcohol related health problems as one of the top five killers in the country. In addition, the short and long-term burdens associated with prenatal alcohol exposure such as lifelong cost of bringing up a FASD diagnosed child will enormously burden the limited health care

42 42 resources of a developing nation like Bhutan. Despite all facts these, very little is known about the subject and thus, the gap needs to be filled for many purposes the generated evidence is expected to serve. Moreover, the only previous study on alcohol consumption among pregnant women in Bhutan showed that 66.7 % of the survey samples were lifetime drinkers. Thus, prior drinking as a predictive factor of alcohol consumption during pregnancy needs to be examined this population.

43 43 CHAPTER 3 RESEARCH METHODOLOGY This study was aimed at examining alcohol consumption during pregnancy and the predicting factors of alcohol consumption including prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy. This chapter will discuss the research methodology in detail including research design, study setting, population and sample, instrumentation, ethical considerations, data collection procedures, and the process of data analysis. Research design A predictive cross-sectional design was used to accomplish the research objectives of this study. Study setting The study was conducted at antenatal clinic in Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), a 350 bedded tertiary level healthcare center located in Thimphu, Bhutan. Thimphu is one of the most populous cities with over 100,000 of population living there. Population of Thimphu represent people from all over the country as people from different parts of the country come to live in Thimphu for different purposes such as work in public and private sectors, for better job opportunities, to have better living facilities, and for business opportunities. Jigme Dorji Wangchuk National Referral hospital is the apex national referral hospital in the country, providing free basic medical treatments as well as advanced surgeries and emergency services to the people of Thimphu and nearby districts. The hospital, equipped with most sophisticated health care system in the country, also takes care of all the referred cases from lower health care centers in the country. Antenatal clinic [ANC] in the hospital provides service to approximately pregnant women per month; that would make about women in a day. Out of those pregnant women visiting clinic, approximately more than half of them are in their second and third trimester. The clinic provides comprehensive

44 44 antenatal care to all pregnant women; it opens from 9:00 am to 3:00 pm on Monday to Friday and 9:00 am to 12:00 pm on Saturdays, they are closed on Sunday and government holidays. Pregnant women come in at any time during the working hours and receive their routine antenatal care. As the data collection was done around winter months of February to March, a clean and well ventilated warm room was arranged within the clinic for interviewing the participants. Moreover, the room assured privacy to the interviewing the participants. Population and sample Target population for this study was pregnant women visiting antenatal clinic for regular antenatal check-up at Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan. Participants meeting the following inclusion criteria were selected to be the sample of this study. Inclusion criteria: 1. Pregnant women in their second and third trimester (gestational age > 12 weeks) 2. Age > 18 years 3. Both singleton and multiple pregnancies 4. Bhutanese nationals only 5. Pregnancy without medical complications Sample size According to Green, 1991cited in Tabachnick and Fidell (2007), a simple rule of thumb for determining sample size for testing individual predictors as in case of regression analysis or for a predictive designs is: n > m (where n is the sample size and m the number of independent variables). For the current study with predictive design and regression analysis, required sample size was obtained using n > m; study involved 4 independent variables, therefore, it was calculated as n > = 108. Thus, the sample size was rounded up to be 110 pregnant women in their second and third trimester.

45 45 Sampling procedure Participants were recruited through systematic random sampling technique. A systematic random sampling technique involves selecting every k th number of individual on the list, using a starting point selected randomly (Burns & Grove, 2005). In a day, the ANC clinic gets about pregnant women in their third trimester and data were to be collected over a month s time (22 working days). Therefore, to get 110 samples in those 22 working days time available for data collection, a minimum of 5 participants had to be interviewed per day, thus, n = 5. Therefore, k = N/ n = 15/ 5 = 3, (where N is the population size, n is the required sample size, k is the sampling interval). Thus, the sampling interval was 3 and the first sample for the day was selected randomly as either women number one or two. Sampling was done on daily basis as follows: 1. On the first day at the clinic, researcher presented herself at the ANC registration counter at 8:30 am and then recruited women. 2. The first sample for the day was selected randomly as either women number one or two. This was done by writing down numbers, 1 and 2 on each two small pieces of paper; then, one of the papers was picked up randomly to be the first sample of the day. For example, if the number that was picked was 1 then the first sample for the day was the first pregnant women at the clinic. 3. The consecutive samples followed an interval of 3 (k = 3). 4. From next day on wards, the same procedure of sampling was followed as above till the required sample size of 110 was met. Research instruments The study used five types of instruments as: 1) Demographic characteristics questionnaire; 2) AUDIT-C questionnaire; 3) Perceived susceptibility questionnaire (PsuQ); 5) Perceived severity questionnaire (PseQ); and 5) Drink refusal self-efficacy questionnaire (DRSEQ-R). 1. Demographic characteristics The general information such as the pregnant women s age, education, occupation, income, parity, gestational age were asked

46 46 2. Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) The AUDIT-C was used to assess pregnant women s prior drinking and also the alcohol consumption during current pregnancy. This tool had been used in previous studies to assess both the prior drinking and alcohol consumption during pregnancy (Smith, Savory, Couves, & Burns, 2014; Skagerstrom et al., 2013). The specificity and sensitivity of AUDIT-C in identifying problem drinking in pregnancy were reported as 85 % and % respectively (Burns et al., 2010). The AUDIT-C is 3-item alcohol screening tool that was modified from the 10-item Alcohol Use Disorder Identification Test (AUDIT) tool developed by WHO and made available for public use. This questionnaire has provision for assessing alcohol consumption in terms of both dose and frequency, which are both very important characteristics in describing alcohol consumption. The AUDIT-C is scored on a scale of A total score of zero is interpreted as abstainers or who does not drink at all, a score of 1 to 2 is drinking at non-hazardous level, and a score of 3 or more is drinking at hazardous level. 3. Perceived susceptibility questionnaire (PsuQ) Perceived susceptibility, defined in this study as women s belief about the alcohol consumption as a risk to the pregnancy and fetus was measured using instrument PsuQ, developed by the researcher based on literature review (Champion, 2012; Hang, 2011; Yeo, 1999) and the perceived susceptibility concept of health belief model (Rosenstock, 1974). There are 10 items in PsuQ, each listing the pregnancy and fetal effects of alcohol consumption during pregnancy from literature review. Perceived susceptibility questionnaire began with a statement if I drink alcohol during pregnancy, followed by the list of risks women might feel as an alcohol drinker during pregnancy. Women s perceived susceptibility was rated on a 4 point likert scale as: 1= strongly disagree; 2= disagree; 3 = agree; and 4 = strongly agree. The higher mean score meant higher perceived susceptibility and it was further classified as low ( ), moderate ( ), and high ( ). 4. Perceived severity questionnaire (PseQ), Perceived severity was defined as the current study as pregnant women s belief about the seriousness of the pregnancy and fetal effects resulting from alcohol

47 47 consumption during pregnancy. It was measured using PseQ developed by the researcher based on literature review (Champion, 2012; Hang, 2011; Yeo, 1999) and the definition of perceived severity construct of the health belief model (Rosenstock, 1974). The PseQ contains 10 possible serious pregnancy and fetal effects of alcohol consumption during pregnancy based on literature. Questionnaire begins with a common statement, if you consume alcohol during pregnancy, how serious do you think the following effects of drinking are, followed by list of serious consequences of alcohol consumption during pregnancy. Perceived severity or serious about each consequence of her drinking was rated on a 4 point likert scale as: 1 = not at all serious, 2 = not serious, 3 = serious and 4 = very serious. The higher mean score was interpreted as higher perceived severity and it was further categorized as low ( ), moderate ( ), and high ( ). 5. Drink refusal self-efficacy questionnaire-revised (DRSEQ-R) The DRSEQ-R developed by Oei et al. (2005) was used. This questionnaire contains a list of 19 different situations (social, emotional, opportunistic) in which people may find themselves drinking alcohol. Five items are categorized under social and seven items each for emotional and opportunistic situation of drinking. A confirmatory analysis test of DRSEQ-R among community samples, undergraduate students, and alcohol-dependents showed alpha reliabilities range from.87 to.94 and test-retest reliabilities range from.84 to.93 (Oei et al., 2005). For the current study, original DRSEQ-R questionnaire was used with deletion of item 16 (when I have just finished playing sports) and item 17 (when I am at the pub or club). The exclusion of these two items had been done in current study as the items were found not suitable for the pregnant women in Bhutan. Pregnant women s self-efficacy to refuse an alcoholic drink at different situations was rated on a 6 point likert scale as: 1 = I am very sure I could not resist drinking, 2 = I mostly likely could not resist drinking, 3 = I most probably couldn t not resist drinking, 4 = I probably could resist drinking, 5 = I most likely could resist drinking, and 6 = I am very sure I could resist drinking. The self-efficacy to refuse drinks at different situations was interpreted as higher with high mean score and it

48 48 was further categorized as low ( ), moderate ( ), and high ( ). The instruments used in this study were all in English version. Instruments borrowed were used as it was in its original English version and those that researcher developed were also in English. The translations of these instruments were not necessary as English language is used as a formal language in Bhutan. Moreover, it is difficult to get the exact translation of terms in Dzongkha (national language), which are in English in the original questionnaire. Psychometric properties of instruments Test of validity The instruments AUDIT-C and DRSEQ-R are valid standard tools that have been widely used in previous studies for the same purpose (Foster et al., 2014; Smith et al., 2014). Content validity of the researcher developed questionnaires, PsuQ and PseQ, was done by the panel of 5 experts invited for the purpose and with a background expertise in alcohol consumption during pregnancy and nursing research. Three experts were faculty members from Faculty of Nursing, Burapha University with expertise in nursing research, maternal and child health nursing subject, and community health nursing subject. The remaining two were an Obstetrician and a nursing faculty from Bhutan, who had knowledge of study setting and population and were experts maternal and child health subject and nursing research. The Item level content validity index (I-CVI) were calculated for both the questionnaires. The average I-CVI scores of PsuQ and PseQ were.98 and.94 respectively. Test of reliability A pilot study was carried out with 30 pregnant women meeting the inclusion criteria to test the internal consistency of the instruments: PsuQ, PseQ, and DRSEQ- R. The results of the pilot study showed that the internal consistency by Cronbach s alpha coefficient of PsuQ, PseQ, and DRSEQ-R questionnaire were.96,.97, and.79 respectively. Cronbach s alpha of.8 was deemed to qualify the instruments (Polit & Beck, 2006) and all the values from pilot testing meet this standard criterion.

49 49 Protection of human subjects First, the research proposal was reviewed and approved by Institutional Review Board [IRB], Faculty of Nusing, Burapha University. Second, Research Ethics Board of Health [REBH] of ministry of health in Bhutan reviewed the proposal and approved it. Finally, after the approvals, permission for formal access to the study setting and data collection were sought for from the concerned authorities in JDWNRH. The participants meeting inclusion criteria were explained about the research purpose and what is required of them; and then, informed consents were obtained from the participants who were willing to take part in the study. Participation in this study was completely voluntary and participants were explained about their rights to withdraw their participation at any time before and during the process of data collection. Participants were assured that their anonymity would be maintained and will not be identified in any way. In order to maintain anonymity, identification codes were assigned to questionnaire sheet of each participant and participant s names were not asked. The data collected were maintained under strict confidentiality and is accessible to only researcher and will be made accessible to the principal advisor or the thesis committee if need be in future. Participants comfort measure such as privacy, a warm room, a comfortable chair to sit during interview, and not interrupting their regular antenatal care schedule were all taken care of during the data collection. The participants were assured that their participation will not expose them and their fetuses to any form of harm. They were also explained that they will not derive any form of direct benefit from the participation, except that the evidence generated will benefit maternal and child health care in long run. Data collection procedures After the IRB and REBH approvals of the study and with the formal permission for the data collection from concerned authorities at the setting, the researcher used following steps to collect the data: 1. Closed, fixed response face-to-face interview technique of data collection was used to collect the data.

50 50 2. The researcher invited a woman at a time from randomly selected sample into a private room for interview. Then, asked woman to take a sit and get settled comfortably. 3. Researcher politely introduced herself and talked to woman for about 5 minutes to make her feel comfortable and gain her confidence. Then, she was briefed about the interview and she was informed that it would take only minutes to complete the interview. 4. Research questionnaire was administered through interview and the answers from woman were written down exactly as woman had given. Researcher also assisted women by further explaining the questionnaire whenever they needed but no leading questions were asked and normal facial expression was maintained throughout the process of interview. 5. The researcher ended the interview and thanked women for her participation. The researcher then showed her off to door, while inviting the next participant in. In a day 5-8 women were interviewed depending on the numbers of women visiting ANC on each day. This was done keeping in line with the time feasibility of the study and quality of the data obtained. Data analysis The data were coded after all the samples were collected. The statistical software was used for analysis. The alpha level for significance was set at.05. Prior to data analysis, the researcher carefully cleaned data for accuracy, using descriptive commands of minimum, maximum, and frequency. The data analysis was done by performing following statistical procedures: 1. Descriptive statistics including frequency, percentage, means, and standard deviation were used to describe the demographic characteristics of the sample, alcohol consumption during pregnancy, perceived susceptibility, perceived severity, drink refusal self-efficacy, and prior drinking. 2. Wilcoxon signed rank test was used to test the difference in alcohol consumption in prior to pregnancy and during pregnancy. This non-parametric statistical procedure was used as the assumption for paired t-test was not met.

51 51 3. Pearson product moment correlation was used to test the relationship between the study variables. 4. Multiple regression analysis was used to determine factors predicting alcohol consumption during pregnancy.

52 52 CHAPTER 4 RESULTS The main objective of this study was to examine alcohol consumption and predicting factors of alcohol consumption during pregnancy. Data from 110 women in their second and third trimester of pregnancy were analyzed using standard multiple regression. This chapter presents demographic characteristics to give a general picture of the study sample, followed by description of study variables, and the results of predicting factors of alcohol consumption during pregnancy. Description of sample characteristics The demographic characteristics are presented in table 1. Age of respondents ranged from 19 to 39 years old with the mean age of years. There were 30 % with middle and 22.7 % with higher secondary education levels, while 26.4 % of the sample had never been to school. The most dominant occupation of the sample was housewife (46.4 %), followed by 23.6 % private employees, and 16.4 % civil servants. Majority of the respondents (43.6 %) had no income of their own as most of them were housewives, followed by 35.5 % of the sample with monthly income of Ngultrum less than Ngultrum 10,000 (USD 156.5). Almost everyone in the sample was in their third trimester (86.4 %). There were 44.5 % primiparous women in the sample and 35.5 % of them had one previous liable birth. Table 1 Demographic characteristics of sample (n = 110) Variables F % Range X SD Age (yrs) <

53 53 Table 1 (continued) Variables F % Range X SD Education level No education Primary (6 yrs) Lower secondary (8 yrs) Middle secondary (10 yrs) High secondary (12 yrs) Degree or higher Occupation Housewife Private employee Civil servant Business Farmer Others Monthly income (Nu.) Nu: 0-30,000 5, , USD: No income < 10, ,001-20, > 20, Gestational age weeks: Second trimester Third trimester Number of birth

54 54 Description of study variables Alcohol consumption prior to and during pregnancy As presented in table 2, in a sample of 110 pregnant women, % (n = 78) had alcohol in past one year before current pregnancy. However, 54.5 % of the sample with prior drinking drank at non-hazardous level of drinking (1-2 AUDIT-C scores). Based on AUDIT-C scoring of prior drinking, % of sample with prior drinking drank alcohol at hazardous levels of drinking as evident from the AUDIT-C scoring of > 3 scores. Almost more than half of the samples (56.4 %) were alcohol abstainers during pregnancy. Out of the women (n = 48) who had alcohol during current pregnancy, almost all of them (97.9 %) drank at non-hazardous levels. The AUDIT-C scoring of pregnancy drinking showed only.9 % of sample drinking alcohol at hazardous level during current pregnancy. Alcohol consumption prior to pregnancy and during current pregnancy was compared using Wilcoxon singed rank test as the data did not meet assumptions of the paired t-test, which was initially planned to compare the prior drinking and alcohol consumption during pregnancy. The results showed a statistically significant difference (z = -7.10, p = <.01) in alcohol consumption prior to pregnancy ( X = ) and during pregnancy ( X = ) as shown in table 3. Table 2 Alcohol consumption prior pregnancy (in the past one year before pregnancy) and during pregnancy (n = 110) Alcohol consumption Prior to pregnancy During pregnancy f % f % Never (0 score) Had non-hazardous drinking ( scores) Had hazardous drinking (> 3 scores)

55 55 Table 3 Alcohol consumption mean comparison prior and during pregnancy by Wilcoxon signed ranks test (n = 110) Alcohol consumption X SD Median Z P Prior pregnancy <.01 During pregnancy Perceived susceptibility The overall mean score of perceived susceptibility was (+ 5.04), indicating only moderate level of perceived susceptibility among the sample. Looking at each item of perceived susceptibility in the table 4, the highest mean score was for abnormal brain development ( X = 3.73) and the lowest for delivery before due date ( X = 2.66). Table 4 Perceived susceptibility No Perceived susceptibility items 1 Alcohol will reach my baby and something will go wrong 2 Alcohol will harm my baby. 3 Greater chance of Miscarriage. 4 Greater chance of baby dying inside your womb. 5 Delivery before due date. Possible scores Actual scores X SD Interpretation High High Moderate Moderate Moderate

56 56 Table 4 (continued) No Perceived Possible Actual X SD Interpretation susceptibility items scores scores 6 Baby born with High abnormal facial features. 7 Have small baby Moderate compared to friends who don t drink. 8 Greater risk of having High an abnormal baby compared to friends who don t drink 9 Greater chance of High having baby with abnormal brain development compared to women who don t drink. 10 Having an abnormal Moderate baby because of drinking habits Overall Moderate Perceived severity The study sample in general showed high perceived severity with a mean score of (+ 4.38) as seen in table 5. Perceived severity for abnormal facial feature showed highest mean score ( X = 3.83) and preterm birth and small baby had lowest mean scores of 3.29 and 3.23 respectively.

57 57 Table 5 Perceived severity No Perceived severity Possible Actual X SD Interpretation items scores scores 1 Having miscarriage High 2 Having still birth High 3 Having preterm baby High 4 Having an abnormal High baby 5 Giving birth to small High baby 6 Giving birth to baby High with abnormal facial features 7 Child not looking like High other normal children 8 Child with lower IQ High 9 Child with problem High of speaking and language fluency 10 Child with antisocial High behaviors Overall High Drinking refusal self-efficacy The overall mean score of drinking refusal self-efficacy was (+ 6.50), indicating a high self-efficacy to refuse drinking among the sample in general. As it is evident from the table 5, the highest mean scores were for items such as when I feel upset, when I feel nervous, and when I feel frustrated, an indication of high selfefficacy to refuse alcohol drink in those situations. Drinking refusal self-efficacy for when my friends are drinking ( X = 3.90) was lowest scored item, indicating sample s

58 58 perception of low self-efficacy to refuse alcohol drink while their friends were drinking. Table 6 Drinking refusal self-efficacy No Drinking refusal Possible Actual X SD Interpretation self-efficacy items scores scores 1 When someone offers Moderate me a drink 2 When my spouse or High partner is drinking. 3 when my friends are Moderate drinking 4 when I am angry Moderate 5 when I feel frustrated High 6 when I feel upset High 7 when I feel down High 8 when I feel nervous High 9 when I feel sad High 10 when I am worried High 11 when I am watching High TV 12 when I am at lunch High 13 when I am on the way High from work 14 when I am listening to High music or reading 15 when I am by myself High

59 59 Table 6 (continued) No Drinking refusal Possible Actual X SD Interpretation self-efficacy items scores scores 16 when I first arrive High home 17 when I am out at High dinner Overall High Factors predicting alcohol consumption during pregnancy Standard multiple regression analysis was conducted to predict alcohol consumption during pregnancy among pregnant women in Bhutan. Preliminary analyses were conducted to ensure no violation of the assumptions of regression analysis such as normality, linearity, and homoscedasticity, which were all examined using histogram and scatter plots. In addition, the correlation matrix showed no multicollinearity between the predicting variables. The Cook s Distance and Centered Leverage Value showed no outliers. The Durbin-Watson value was 1.9, which is a clear indication of no autocorrelation. Also, assumptions of residuals were met. Before running regression analysis, Pearson s test was performed to determine the relationship among study variables. The correlations between independent variables and dependent variable showed significant correlations as shown in table 4. Alcohol consumption during pregnancy had significant positive correlation with prior drinking (r =.57, p =.001). Perceived susceptibility, perceived severity, and drinking refusal self-efficacy showed significant negative correlations with alcohol consumption during pregnancy as (r = -.57, p =.001), (r = -.55, p=.001), and (r = -.75, p =.001) respectively. Thus, all predictor variables showed statistically significant correlation with the alcohol consumption during pregnancy, which indicated that the data was suitably correlated and can be reliably examined through multiple linear regression analysis (Tabachnick & Fidell, 2007).

60 60 Table 7 Pearson s correlation coefficients among study variables (n = 110) Variables Prior drinking 1 2. Perceived susceptibility -.27** 1 3. Perceived severity -.35***.39*** 1 4. Drinking refusal self-efficacy -.68***.53***.42*** 1 5. Alcohol consumption during.57*** -.57*** -.55*** -.75*** 1 pregnancy ** p <.01, *** p <.001. Predictors of alcohol consumption during pregnancy All the four independent variables were entered into regression model. Standard multiple regression analysis indicated that prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy, together explained a statistically significant 67 % of variance in alcohol consumption during pregnancy (R 2 =.67, Adjusted R 2 =.65, F (4,105) = 52.05, p <.001). Out of the four predictors entered, drinking refusal uniquely acted as the most significant predictor of alcohol consumption during pregnancy, showing a higher Beta value than other three variables (β = -.47, p =.00). Similarly, perceived severity (β = -.24, p =.00) and perceived susceptibility (β = -.20, p =.01) also showed statistical significance of independent predictors. However, prior drinking did not show any significance as an independent predictor of alcohol consumption during pregnancy (β =.12, p =.13) as seen in the table 8.

61 61 Table 8 Standard multiple regression analysis (n = 110) No Predictor variables B Β t P 1 Prior drinking Intercept = 6.11*** 2 Perceived susceptibility R 2 =.67 3 Perceived severity <.01 F (4,105) = 52.05*** 4 Drinking refusal selfefficacy <.01 DV = Alcohol consumption during pregnancy, *** p <.001, B = un-standardized beta coefficient, β = standardized beta coefficient, t = t-test statistics.

62 62 CHAPTER 5 CONCLUSION AND DISCUSSION This section presents the summary of study findings, interpretation and explanation of the study findings. Study findings are also discussed in relation to the theoretical framework and previous literature on pregnancy drinking. In addition, implication of the study findings to nursing practice, research, and education are discussed. The chapter will also address some of the limitations of the study. Summary of the findings Despite the messages from many health organizations and recent research evidences advising women to stay on complete alcohol abstinence during pregnancy (ACOG, 2011; CDC, 2010; WHO, 2014), studies on pregnancy drinking report a high prevalence rates of alcohol consumption during pregnancy (Anderson et al., 2012; Ethen et al., 2009; Yamamoto et al., 2008; Yen et al., 2012; Williams et al., 2014). In order to address this global public health issue of pregnancy drinking, the possible answers as to why a concerning number of women drink against health messages needed to be sought for. Many previous studies on factors predicting alcohol consumption during pregnancy have studied common factors such as age, income, education, marital status, and so on. Health Belief Model (HBM) is such theoretical framework that has guided many previous studies in explaining alcohol consumption in different sections of population. According to HBM, individual belief factors are the most important determinants of healthy or risky behavior in individuals (Rosenstock, 1974 a). In addition, previous studies on pregnancy drinking reported a strong association between prior drinking habits and alcohol consumption during pregnancy. Thus, current study guided by both theory and literature, examined alcohol consumption during pregnancy and the predicting factors of alcohol consumption during pregnancy among Bhutanese pregnant women. One hundred and ten women in their second and third trimester of pregnancy were randomly selected to be the sample of this study. Women were recruited from antenatal clinic at Jigme Dorji Wangchuk National Referral Hospital, Thimphu,

63 63 Bhutan. Data were collected through a face-to-face interview using structured interview questionnaire. Data were analyzed using the descriptive commands of frequency, percentage, mean, and standard deviation; Wilcoxon signed rank test; Pearson s product moment correlation, and standard multiple regression. In the sample of 110 pregnant women, 70.9 % had alcohol in past one year before current pregnancy. Based on AUDIT-C scoring, 16 % of the samples were drinking at hazardous level prior to pregnancy; while the remaining majority drank at non-hazardous levels of 1 or 2 standard drinks. Some 43.6 % of the sample reported drinking alcohol during their current pregnancy and majority of drinker drank at a frequency of once in a month and dose of 1 or 2 standard drinks. The AUDIT-C scoring for pregnancy drinking showed that sample did not drink at hazardous level except for one participant. Perceived susceptibility ( X = ) scores were at moderate level while the sample showed higher overall scores of perceived severity ( X = ) and drinking refusal self-efficacy ( X = ). The regression analysis results showed that drinking refusal self-efficacy, perceived susceptibility, perceived severity, and prior drinking, together could explain a statistically significant 67 % of variance in alcohol consumption during pregnancy (R 2 =.67, Adjusted R 2 =.65, F (4,105) = 52.05, p <.001). Discussion Study results suggest that alcohol consumption during pregnancy is quite high in Bhutan, with 43.6 % of sample drinking at some point of time during their pregnancy. Previous studies have reported pregnancy drinking as 30.3 % in the United States of America, 34.6 % among the South African pregnant women, 26 % among indigenous Taiwanese pregnant women, and some 72 % of pregnant women in Australia were not in compliant with their national guideline of complete alcohol abstinence during pregnancy (Anderson et al., 2012; Ethen et al., 2009; Williams et al., 2014; Yen et al., 2012). The only previous study on pregnancy drinking in Bhutan reported 25.3 %, 23.7 %, and 10.9 % of pregnant women drinking alcohol in the past three months, one month, and one week respectively (Udon & Areesantichai, 2012). Thus, the current findings revealed a relatively higher rate of alcohol consumption during pregnancy than the rates reported by most of the previous studies.

64 64 In Bhutan, despite the repeated efforts by health care agencies to curb alcohol issues in the country, alcohol consumption among Bhutanese pregnant women seems to have remained same or relatively increased from past years. This finding did not come by surprise, given a well groomed drinking culture that Bhutanese women live in. Alcohol studies from other parts of the world suggest that alcohol consumption is significantly related to easy acceptability of drinking behavior by the community. Some of the other reasons for increasing alcohol use and misuse among women in the country could be changing demographic characteristics and gender roles with socio-economic development of the country in recent years. However, alcohol consumption during pregnancy among this sample occurred at non-hazardous levels of 1 or 2 standard drinks, similar to the pregnancy drinking patterns reported by previous studies (Balachova et al., 2012, Ethen et al., 2009, Harrison & Sidebottom, 2009; Skagerstrom et al., 2013). In addition, there was a significant reduction in hazardous level of drinking from 16 % of the sample drinking at hazardous level prior to pregnancy to a minimum of.9 % of the sample drinking at hazardous level during pregnancy. This is an indication that, although many pregnant women drink alcohol, most of them understand that alcohol consumption during pregnancy is harmful, especially the hazardous level of drinking but their efforts are not so strong enough to make them stay on complete abstinence. Many health organizations and recent research evidences suggest complete alcohol abstinence as the safest choice during pregnancy; therefore, a mere reduction in hazardous level drinking may not be enough. Furthermore, the cessation of hazardous level of drinking among this sample of pregnant women signifies that women make an effort to change their drinking habits when they become pregnant. This in turn could serve as an incentive for health care providers, in planning interventions to foster women s effort to change their drinking behavior during pregnancy. Thus, alcohol interventions at antenatal clinics will not only help to prevent fetal alcohol exposure but it will also address drinking issues in women at large as women seem to be most receptive of the change in alcohol consumption when they become pregnant. Factors found to predict alcohol consumption during pregnancy were prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy. While these four factors, together explained a significant 67 % variance

65 65 in alcohol consumption during pregnancy among Bhutanese pregnant women, prior drinking did not show any unique role as an independent predictor of alcohol consumption during pregnancy. Prior drinking or pre-pregnancy drinking was quite high among the sample and based on AUDIT-C scoring of hazardous level of drinking, one-fourth of the prior drinkers had alcohol at hazardous level of drinking. Although our study results showed significant association between prior drinking and alcohol consumption during pregnancy, prior drinking factor did not show any statistical significance as an independent predictor of alcohol consumption during pregnancy in this sample. Our finding of significant association between prior drinking and alcohol consumption during pregnancy was very much in line with many previous studies. Previous studies have suggested that women with prior drinking or pre-pregnancy drinking habits were more likely to drink during pregnancy (Anderson et al., 2012; Peadon et al., 2011; Skagerstrom et al., 2013; Yen et al., 2012). In fact, Yen and colleagues (2012) asserted that as many as 52 % of Taiwanese women with prior drinking continued to drink during pregnancy. Although the prior drinking factor did not independently predict alcohol consumption during pregnancy in this sample of pregnant women, it can still be interpreted that prior drinking factor has some role in alcohol consumption during pregnancy due to its significant association with alcohol consumption during pregnancy. In our population, the high prevalence of prior drinking born in a well-accepted drinking culture will further inhibit the cessation of alcohol consumption during pregnancy. Therefore, assessing prior drinking and the characteristics of drinking prior to pregnancy will help in identifying women who may be at risk of alcohol consumption during pregnancy. In addition, women with hazardous level of prior drinking are not only at risk of alcohol consumption during pregnancy but they are also at risk of unintentionally exposing their fetus to high doses of alcohol during early months of pregnancy, when it is the most vulnerable time for fetal growth and development (Ornoy & Ergaz, 2010). Often women are not aware of their pregnancy as most pregnancies are recognized not earlier than 4-8 weeks of gestation and thus, the risk of unintentional fetal alcohol exposure for women with prior drinking. Moreover, women who drink at hazardous level prior to

66 66 pregnancy are at risk of entering into pregnancy with poor maternal health. Thus, prior drinking factor plays an important role in alcohol consumption during pregnancy and interventions targeted to prevent fetal alcohol exposure should begin with assessment and correction of prior drinking in general population of reproductive age group women such as through women s health campaigns and adolescent health education in schools and colleges. Based on the concept of health belief model (HBM), it was hypothesized that, Bhutanese pregnant women who believed alcohol consumption during pregnancy as a risk to pregnancy and fetus, who perceived that the pregnancy and fetal consequences of alcohol consumption during pregnancy were severe, and who perceived self-efficacious to refuse alcohol during pregnancy are less likely drink alcohol during pregnancy. It did not come as a surprise when the sample which showed quite a high prevalence rate of alcohol consumption during pregnancy showed only moderate level of perceived susceptibility, given the negative association between two. The mean score of perceived susceptibility was (+ 5.04), which indicates that most pregnant women in the sample did not belief that consuming alcohol during pregnancy could put them at risk of many pregnancy and fetal complications. According to HBM, perceived susceptibility is individual perception of risk of contracting a disease or experiencing negative health outcome because of their risky behavior (Champion & Skinner, 2008; Rosenstock, 1974 a). If women perceive alcohol consumption during pregnancy as a risk to pregnancy and fetal health, women are less likely to drink alcohol during pregnancy and the vice-versa if women did not believe it as a risk. The current study results (r = -.57, p = <.001) confirmed the concept definition of negative association between perceived susceptibility and alcohol consumption by HBM and was in line with results from previous studies (Hang, 2011; Yeo, 1999). Similar to the findings of Yeo (1999), which showed high perceived susceptibility among sample of pregnant women who did not drink alcohol during pregnancy, the current sample had high rate of alcohol consumption because pregnant women did not perceive alcohol consumption during pregnancy as a risk to pregnancy and fetus. Moreover, the current findings were in line the results from a study by

67 67 Hang (2011), which not only showed a negative association between perceived susceptibility and alcohol consumption among adults (r = -0.34, p <.001) but reported that the perceived susceptibility entered with three other variables showed a significant variation of alcohol consumption by 77.6 % (p <.001). In current study, perceived susceptibility along with other three variables did not only predict 67 % of variation in alcohol consumption during pregnancy but showed a unique character of independent predictor (β = -.20, p = <.01) of alcohol consumption during pregnancy. Thus, health care providers were to encourage pregnant women to stay on complete abstinence during pregnancy, women must first be made to believe that alcohol consumption during pregnancy is a risk of many pregnancy and fetal complications. Current study results confirmed findings of previous studies and perceived severity concept definition of HBM, suggesting a negative association between perceived severity and alcohol consumption behavior (Hang, 2011; Rosenstock, 1974 a; Yeo, 1999). Over all, the sample showed relatively high perceived severity, which is pregnant women s belief about the seriousness of the consequences of alcohol consumption during pregnancy. When looked into the details of each item of perceived severity, it was noted that pregnant women in the sample considered consequences related to physical symptoms more serious than the mental or emotional consequences. For example, it can be seen from the mean score difference between abnormal facial features ( X = 3.83), lower IQ ( X = 3.74), and anti-social behavior ( X = 3.59). In addition, preterm and small birth, which are both important indicators of neonate and infant mortality and morbidity on rise today, are perceived as less severe consequences with mean of 3.29 and 3.23 respectively. This might be because many women in the sample have never been to school or completed only lower levels of education and thus, the lack of knowledge or information on the severities of cognitive and emotional related consequences of fetal alcohol exposure. Perceived severity showed negative association with alcohol consumption during pregnancy and also acted as a significant independent predictor (β = -.24, p =.00) in explaining 67 % of alcohol consumption during pregnancy along with three other variables. This was different from finding of previous study by Hang (2011), which showed only significant negative association between perceived severity and alcohol consumption in adults but it did not show any statistical

68 68 significance as an independent predictor of alcohol consumption. The reason for this difference could be because pregnancy drinking involves double risk of maternal and child health, putting two lives at stake; thus, pregnant women perceived consequences of drinking more severe than non-pregnant adults do. Though drinking refusal self-efficacy (DRSE) is a very important and widely studied factor determining alcohol consumption behavior in other sections of population (Foster et al., 2014; Hang, 2011; Oie & Burrow, 2000; Oie & Jardim, 2007), studies on pregnancy drinking have not explored its role. Current study findings showed higher DRSE among sample in general but quite interesting observations were made when looked into details of each item of the DRSE questionnaire. Pregnant women perceived that they have lower self-efficacy to refuse drinking during social occasions such as when their friends were drinking ( X = 3.90), when they are at dinner ( X = 4.55), and when someone offered them a drink ( X = 4.95). Though not related to self-efficacy, previous studies have all suggested that women with a friend or partners who drank are 3 to 5 times more likely to drink during pregnancy (Namagembe et al., 2010; Yen et al., 2012). Moreover, friend s drinking was pointed out as an independent predictor of pregnancy drinking in other studies as by Raymond et al. (2009). However, Bhutanese pregnant women in the sample were not much of an emotional drinker as evident from very high perceived self-efficacy scoring on emotional items such as ability to refuse drinking when frustrated, upset, and nervous. These insights can serve as very useful information in assessing, examining, managing women with pregnancy drinking or those who could be at risk of pregnancy drinking. Moreover, the findings will assist us in modifying women s environment such as by educating women s partners and friends on the grave consequences of pregnancy drinking and how they can encourage women to stay on complete alcohol abstinence during pregnancy. According to HBM, self-efficacy is individual s belief in their capacity to perform a given task and drinking refusal self-efficacy is pregnant women s belief in their capacity to refuse drinking alcohol during pregnancy. Pregnant women with a higher self-efficacy to refuse drinking are less likely to drink during pregnancy and vice-versa for those who perceived lower drinking refusal self-efficacy. Current findings showed a negative association between DRSE and alcohol consumption

69 69 during pregnancy (r = -.75, p = <.001), which is in line with both the theory and literature based on previous studies (Foster et al., 2014; Oie & Burrow, 2000; Hang, 2011). In addition, the unique role of DRSE as the strongest independent predictor in this study was in line with previous studies. Drinking refusal self-efficacy uniquely predicted a significant 8 % of variance (sr 2 =.08, p <.001) in alcohol consumption among college students (Oie & Burrow, 2000) and significantly explained alcohol consumption among adults in Vietnam (Hang, 2011). Thus, it can be concluded that drinking refusal self-efficacy plays a very important role in pregnancy drinking just as it was claimed of its role in literatures on alcohol consumption among adolescents, college students, and adults. Therefore, if women s self-efficacies to refuse drinking were boosted, it could result into less alcohol consumption during pregnancy or even alcohol cessation. In addition, assessment of types of situations in which women were less or more likely to be efficacious to refuse drinking, will allow the health care providers to modify the situations so as to broaden the aspect of care. Thus, pregnant women who did not perceive alcohol consumption during pregnancy as a risk to fetus, who did not perceive the consequences of pregnancy drinking to be severe, and who perceived that they were less self-efficacious to refuse drinking during pregnancy were more likely to drink alcohol during pregnancy. Therefore, it is confirmed that pregnant women s perception and belief factors play an important role in explaining alcohol consumption during pregnancy, reaffirming the theory of health belief model. Out of the four variables examined to be predictors of alcohol consumption during pregnancy, drinking refusal self-efficacy, perceived susceptibility, and perceived severity of HBM showed statistical significance in independently predicting alcohol consumption during pregnancy. This confirms all the claims made for HBM as a better theoretical framework in examining alcohol behaviors by both theory and research (Champion & Skinner, 2008; Sharma, 2011). However, prior drinking, which was suggested as a commonest factor predicting alcohol consumption during pregnancy in literature, showed a strong association with alcohol consumption during pregnancy in this sample of pregnant women but no unique role as an independent predictor of alcohol consumption during pregnancy.

70 70 Implications Nursing practice Findings showed quite a high prevalence of alcohol consumption during pregnancy among Bhutanese pregnant women and this has not come by surprise, given the favorable drinking culture in Bhutan. Almost everyone in the sample had consumed alcohol in past one year and half the sample had their pregnancies exposed to alcohol. All these signify the magnitude of problem of alcohol use and abuse in Bhutan and if we are to achieve the national health goal of 50 % reduction in alcohol related mortalities and morbidities by the end of year 2020, it is time we start now. Health care providers including nurses play a vital role in addressing issues of pregnancy drinking, especially nurses at antenatal clinic. Nurse-midwives at antenatal clinics can improve their existing care related to assessment and management of pregnancy drinking by may be incorporating a better assessment tool for alcohol use during pregnancy; by coming up with innovative interventions to bring about behavioral change; and by sensitizing the general public with magnitude of the problem of pregnancy drinking. In particular, examining and understanding women s beliefs regarding pregnancy drinking will allow nurses to see the problem of pregnancy drinking from women s point of view. This will in turn help in planning specific interventions targeted to change false beliefs and boost their self-efficacious to refuse alcohol drink at different situations and occasions. Educating women and general public on pregnancy drinking and its grave consequences might help to change their false beliefs regarding pregnancy drinking. Behavioral and cognitive therapies can equip women with capacities to say no to alcohol while pregnant. Widening the care to her surroundings such as inclusion of her partner or friends in health education will modify women s environment of drinking. In addition, to broaden the aspect of care, fetal alcohol exposures need to be prevented even before women visit antenatal clinics. Interventions beginning at antenatal clinics may be little too late as most women visit the clinic on confirmation of their pregnancies. So, in order for that, education related to hazards of pregnancy drinking should actually start during preconception through health educations in colleges and universities where many young girls can be reached. Moreover, our

71 71 community health nurses can play a very vital role in developing interventions to prevent fetal alcohol exposure as they can reach women with prior drinking and the general population of women. Thus, provide a preventive care beyond our antenatal clinics and at right time. Nursing education The findings of this study might as well be used by our young nurses in learning about the problem of pregnancy drinking in our culture as they are soon going to be playing the roles of full-fledged nurse. In addition, the nursing students could learn the how to apply theoretical framework in practice and learn to develop their interventions based on theory. Limitations of the study Firstly, the data collection though done in an area where population could represent the whole country, it is still possible that it will limit generalization to women in other parts of the country where the drinking environment might differ. Secondly, data was collected during winter months in Bhutan (February and March) and around that time, it was Bhutanese New Year; thus, it is possible that the cold weather and festive mood might have altered women s alcohol consumption. Recommendations for future research 1. A retrospective study can be done in postpartum women to examine alcohol consumption starting from prior to pregnancy, to during pregnancy, and through postpartum period. 2. A longitudinal study can be planned to examine the effects alcohol consumption during pregnancy. Examining the impacts of alcohol consumption during pregnancy in the population will further support the few existing evidences on pregnancy drinking and this will in turn, lead to better interventions towards curbing problem of pregnancy drinking. 3. Interventions such as counseling women during preconception to boost their self-efficacy and educating them to change their false beliefs can be tried to reaffirm the role of belief and perceptions factors alcohol consumption during pregnancy.

72 72 Conclusion The study findings showed high rate of prior drinking and alcohol consumption during pregnancy among Bhutanese pregnant women. An indication that it is time we address pregnancy drinking along with all other measures that we have in place to achieve our national health goal of 50 % reduction in alcohol related morbidity and mortality by the end of year The antenatal clinics might incorporate alcohol assessment tools and provide services to women who are at risk of or with problem of alcohol consumption during pregnancy. Both while identifying at risk pregnant women and managing women with alcohol consumption during pregnancy, women s belief factors need to be considered. It is important that we assess her beliefs about pregnancy drinking and the innovative interventions should include changing women s false beliefs and boosting her self-efficacy to refuse alcohol during pregnancy. Moreover, monitoring and modifying prior drinking in women can be seen as an important task to broaden the aspect of care to prevent alcohol exposed pregnancy and its grave consequences.

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78 78 Namagembe, I., Jackson, L. W., Zullo, M. D., Frank, S. H., Byamugisha, J. K., & Sethi, A. K. (2010). Consumption of alcoholic beverages among pregnant urban Ugandan women. Maternal and Child Health Journal, 14(4), National Institute on Alcohol Abuse and Alcoholism [NIAAA] (2013). Fetal alcohol exposure [Factsheet]. Retrieved from FASDFactsheet/FASD.pdf Noroozi, A., Jomand, T., & Tahmasebi, R. (2011). Determinants of breast selfexamination performance among Iranian women: An application of health belief model. Journal of Cancer Education, 26(2), O keeffe, L. M., Greene, R. A., & Kearney, P. M. (2014). The effect of moderate gestational alcohol consumption during pregnancy on speech and language outcomes in children: A systematic review. Biomedical Central, 3(1), O Leary, C. M., Nassar, N., Kurinczuk, J. J., & Bower, C. (2009). The effect of maternal alcohol consumption on fetal growth and preterm birth. British Journal of Obstetrics and Gynecology, 116, Oei, T. P. S., & Burrow, T. (2000). Alcohol expectancy and drinking refusal selfefficacy: A test of specificity theory. Addictive Behaviors, 25(4), Oei, T. P. S., & Jardim, C. L. (2007). Alcohol expectancies, drinking refusal selfefficacy and drinking behavior in Asian and Australian students. Drug and Alcohol Dependence 87(3) Oei, T. P. S., Hasking, P. A., & Young, R. M. (2005). Drinking refusal self-efficacy questionnaire (DRSEQ-R): A new factor structure with confirmatory factor analysis. Drug and Alcohol Dependence, 78, doi: / j.drugalcdep Ornoy, A., & Ergaz, Z. (2010). Alcohol abuse in pregnant women: Effects on the fetus and newborn, mode of action and maternal treatments. International Journal of Environmental Research and Public Health, 7(2), Oyelese, Y., & Ananth, C. V. (2006). Placental abruption [Clinical expert series]. Obstetrics and Gynecology, 108(4),

79 79 Patra. J., Bakker, R., Irving, H. Jaddoe, V. W. V., Malini, S., & Rehm, J. (2011). Dose response relationship between alcohol consumption before and during pregnancy and the risk of low birth weight, preterm birth, and small-size-forgestational age (SGA) A systematic review and meta-analyses. British Journal of Obstetrics and Gynecology, 118(12), Peadon, E., Payne, J., Henley, N., D Antoine, H., Bartu, A., O Leary, C., Bower, C., & Elliott, E. J. (2011). Attitude and behavior predict women s intention to drink alcohol during pregnancy: The challenge for health professionals. Biomedical Central of Public Health, 11(584), Polit, F. D., & Beck, C. T. (2006). Essentials of nursing research: Method, appraisal, and utilization (6 th ed.). Philadelphia, PA: Lippincott Williams and Wilkins. Popova, S., Lange, S., Burd, L., & Rehm, J. (2014). Canadian children and youth in care: The cost of fetal alcohol spectrum disorder. Child Youth Care Forum, 43(1), doi: /s x Raymond, N., Beer, C., Glazebrook, C., & Sayal, K. (2009). Pregnant women s attitudes towards alcohol consumption. Biomedical Central, 9(175), 1-8 Rosenstock, I. M. (1974 a). Historical origins of health belief model. In M. H. Becker (Ed.), Health belief model and personal health behavior (pp. 1-8). Thorofare, NJ: Slack. Rosenstock, I. M. (1974 b). The health belief model and preventive health behavior. In M. H. Becker (Ed.), Health belief model and personal health behavior (pp ). Thorofare, NJ: Slack. Royal Government of Bhutan. [RGOB]. (2013). The national policy and strategic framework to reduce harmful use of alcohol. Thimphu, Bhutan: Author. Salihu, H. M., Kornosky, J. L., Lynch, O., Alio, A. P., August, E. M., & Matry, P. J. (2011). Impact of prenatal alcohol consumption on placental-associated syndromes. Alcohol, 45(1), doi: /j.alcohol Sharma, M. (2011). Health belief model: Need for more utilization in alcohol and drug education. Journal of Alcohol and Drug Education, 55(1), 3-6.

80 80 Skagerstrom, J., Alehagen, S., Haggstrom-Nordin, E., Arestedt, K., & Nilsen, P. (2013). Prevalence of alcohol use before and during pregnancy and predictors of drinking during pregnancy: A cross sectional study in Sweden. Biomedical Central of Public Health, 13(1), Skagerstrom, J., Chang, G., & Nilsen, P. (2011). Predictors of drinking during pregnancy: A systematic review. Journal of Women s Health, 20, Smith, L., Savory, J., Couves, J., & Burns, E. (2014). Alcohol consumption during pregnancy: Cross-sectional survey. Midwifery, 30(12), doi: /j.midw Stade, B. C., Bailey, C., Dzendoletas, D., Sgro, M., Dowswell, T., & Bennett, D. (2009). Psychological and/ or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy (review). Cochrane Database of Systematic Reviews, 15(2), Strecher, V. J., DeVellis, B. M., Becker, M. H., & Rosenstock, I. M. (1986). The role of self-efficacy in achieving health behavior change. Health Education Quarterly, 13(1), Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5 th ed.). Northridge, CA: Pearson Education. The U.S. Department of Agriculture [USDA] & Health and Human Services (2010). Dietary guideline for Americans. Washington, U.S: Government Printing. Retrieved from _guidelines_for_americans/policydoc.pdf Udon, P. & Areesantichai, C. (2012). Assessment of alcohol consumption among pregnant women in antenatal clinic (ANC) at Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu, Bhutan. Journal of Health Research, 26(2), Walker, M. J., Al-Sahab, B., Islam, F., & Tamim, H. (2011). The epidemiology of alcohol utilization during pregnancy: An analysis of the Canadian maternity experiences survey (MES). Biomedical Central Pregnancy and Childbirth, 11(52), 1-10.

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82 APPENDICES 82

83 83 APPENDIX A Questionnaire in English

84 84 QUESTIONNAIRE Study title: THE ROLE OF PRIOR DRINKING, PERCEIVED SUSCEPTIBILITY, PERCEIVED SEVERITY, AND DRINKING REFUSAL SELF-EFFICACY IN ALCOHOL CONSUMPTION AMONG PREGNANT WOMEN IN BHUTAN Identification Code... Date of interview. Start time Finish time Part I. Information about participant s demographic characteristics Instruction: Answer to the following question by filling in the blanks or marking in the box. 1. Age:. (Years) 2. What is your highest education level achieved? Never been to school Non-formal Primary level (till 6th) Lower secondary level (8th) Middle secondary (10th) Higher secondary (12th) Degree and higher 3. What is your current occupation? Housewife Farmer Civil servant Private employee Business Others (specify) 4. Your monthly income:. (Ngultrum) 5. Gestational age:.. (Weeks) 6. Parity:

85 85 Part II. Prior drinking information [Provide information based on your drinking habit before you knew you were pregnant with the current baby]. Instructions: answer the following questions by marking in the box. 1. How often do you have a drink containing alcohol? Never Once in a month 2-3 times a month 2-3 times a week 4 or more times a week 2. How many standard drinks containing alcohol do you have on the day you drink? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more 3. How often do you have a six or more drinks on one occasion? Never Less than month Monthly Weekly Daily or almost daily

86 86 Part III. Information about your drinking during current pregnancy [Provide information based on your drinking habit after you knew you were pregnant with the current baby till today] Instructions: answer the following questions by marking in the box. 1. How often do you have a drink containing alcohol during your current pregnancy? Never Once in a month 2-3 times a month 2-3 times a week 4 or more times a week 2. How many standard drinks containing alcohol do you have on day you drink? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more 3. How often do you have a six or more drinks on one occasion? Never Less than month Monthly Weekly Daily or almost daily

87 87 Part IV. Perceived susceptibility information Instruction: mark in the column appropriate with your answer of agreement or disagreement. No Statement Strongly disagree Disagree Agree Strongl y agree If I drink alcohol during pregnancy, I might be at risk of the following 1 The alcohol that I drink can reach my baby and something will go wrong with it 2 Alcohol will harm my baby 3 I have greater chances of miscarriage 4 I have greater chance of baby dying inside my womb 5 I might deliver before my due date 6 I might have baby born with abnormal facial features 7 I might have small baby compared to my friends who don t drink 8 I am be at greater risk of having abnormal baby compared to my friends who don t drink 9 Compared to pregnant women in my neighborhood, my chances of having baby with something wrong is greater 10 I worry having an abnormal baby because of my drinking habits

88 88 Part V. information on perceived severity Instruction: Instruction: mark in the column appropriate with your answer of seriousness. No Statement Not at all serious Not serious Serious Very serious If you consume alcohol during pregnancy, how serious do you think the following consequences of pregnancy drinking are? 1 Having miscarriage 2 Having stillbirth 3 Having preterm delivery 4 Baby born abnormal 5 Giving birth to a small baby 6 Baby born with abnormal facial features 7 Child not looking like other normal children 8 Child will have lower IQ later 9 Child will have problem of speaking and language fluency later 10 Child not behaving well in school later

89 89 Part VI. Drink refusal self-efficacy information [DRSEQ-R by Oie, Hasking, & Young, 2005] Instruction: Rate your capability to refuse alcohol drink at different occasions as follows, ranging from I am very sure I could NOT resist drinking = 1 to I am very sure I could resist drinking = 6 How sure are you that you could resist a drinking? I most I probably I probably I most likely could could could likely could NOT resist NOT resist resist resist drinking drinking drinking drinking I am very sure I could NOT resist drinking I am very sure I could resist drinking When I am out at dinner 2. When I am watching TV 3. When I am angry 4. When someone offers me a drink 5. When I am at lunch 6. When I feel frustrated 7. When I feel upset 8. When I feel down 9. When I feel nervous 10. When I am on the way home from work 11. When I feel sad 12. When my spouse or partner is drinking

90 When I am listening to music or reading 14. When my friends are drinking 15. When I am by myself When I first arrive home 19. When I am worried

91 91 APPENDIX B Permission to use instruments

92 92 Instrument Owner: Tian Po Oei Ph.D., FAPS Researcher: Kencho Zangmo Following is the conversation as the permission to use instrument DRSEQ was sought from the rightful owner of the instrument. 1. From researcher to the owner of instrument DRSEQ-R Sir, I am Kencho, studying master degree in nursing (midwifery major) in Burapha Univerisity, Thailand. I am doing a research thesis on 'alcohol consumption in pregnant women'. I would like to know how i can get a copy of the drinking refusal self-efficacy questionnaire in this link: P.S. please let me know if there is any formalities i need to fulfill for seeking permission to use this questionnaire. Kencho Zangmo 2. from the owner of instrument to researcher thanks for your interests in our work, here are the info requested good luck to your research Tian 3. from researcher to the owner of instrument Hello sir/madam, thank you once again for the information you provided me on DRSEQ. I did some reading on it and would like to use your tool for my master thesis titled 'factors predicting alcohol consumption among pregnant women in Bhutan'. No translation is required for my population so i would like to use your original questionnaire as it is. Please kindly permit me to use it... will be looking forward for positive reply from the owner of instrument to researcher you are more than welcome to use it good luck to your study Tian

93 93 APPENDIX C Informed consent form and participant information sheet

94 94 INFORMED CONSENT Title: The role of prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy in alcohol consumption among pregnant women in Bhutan. IRB approval number: Date of collection data Month.Years Before I give signature below, I have been informed and explained by Ms. Kencho Zangmo about the purposes, method, procedures, and benefits of this study. I understood all of that explanation and I agree to be a participant of this research project and I have received a copy of this form. I am Ms. Kencho Zangmo, as a researcher, i had explained all of about the purposes, method, procedures, and benefits of this study to the participant with honestly. I assured participants that all of data/information of the participants will only be used for purpose of this research study. Name and Signature of the Participant Date: Name and Signature of witness Date: Name and Signature of the researcher Date:

95 95 PARTICIPANT S INFORMATION SHEET Dear.. I am Kencho Zangmo, a graduate student at the Faculty of Nursing, Burapha University, Thailand. My study entitled, The role of prior drinking, perceived susceptibility, perceived severity, and drinking refusal self-efficacy in alcohol consumption among pregnant women in Bhutan. The main objective of the study is to explore alcohol consumption and the predicting factors of alcohol consumption among pregnant women in Bhutan. Hundred and ten (110) women who are in their second and third trimester of pregnancy, visiting antenatal clinic in Jigme Dorji Wangchuk National Referral hospital, Thimphu will take part in the study. This study will be a survey study. If you agree to participate in this study, you will be asked come to the room adjacent clinic registration room after you are done with your routine check-up. Once, in the room you will be offered a comfortable chair to sit on and then, the researcher will interview you. The interview will take only about minutes to the maximum. Your participation in this study is voluntary and it won t give you any direct personal benefit but the result of the study is expected to improve the maternal and child health in near future. The result is expected to guide the health care personals better in taking care of antenatal mothers. Your participation in the study will not harm you or your baby in any way. You have the right to end your participation in this study at any time without any penalty. You may refuse to answer any specific questions, remain silent, or leave this study at any time. Any information received from this study, including your identity, will be kept confidential. Findings from the study will be presented as a group of participants, no specific information from any individual participant. All data will be destroyed completely within 1 year after publishing or presenting the findings. The research will be conducted by Kencho Zangmo under supervision of my majoradvisor, Assoc. Prof. Dr. Wannee Deoisres. If you have any questions, please contact me at telephone number: or at kenchozangmo84@gmail.com and/or my advisor s address: wannee@buu.ac.th. Your cooperation is greatly appreciated. You will be given a copy of this consent form to keep.

96 96 APPENDIX D Ethical approval letters from Faculty of Nursing, Burapha University and Research ethics board of health [REBH], Ministry of health, Bhutan

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