Background
Excessive alcohol use has been associated with a large variety of health, social, and legal problems [
1]. Individuals with a family history of alcoholism are at greater risk of developing alcoholism than those without such a history [
2]. Moreover, the link between parental problem drinking and children’s maladjustment is well established [
3]. Thus, alcoholism and its effects on family members create a vicious cycle that should be interrupted. In addition, close family members of patients with alcohol problems may suffer from stress-related physical and psychological symptoms that can be severe and long lasting [
4,
5] and are associated with high use of primary care services [
6], placing a significant burden on healthcare resources [
7]. These factors highlight the importance of screening and intervening for problem drinking in family members of patients identified as problem drinkers.
One appropriate setting suggested for detecting hazardous or harmful drinkers is general hospitals [
8]. In general hospitals in western countries, the prevalence of patients’ alcohol-drinking problems ranges from 12% to 26% due to different assessment methods and units selected [
8,
9]. However, no information is available for the prevalence of alcohol-drinking problems among family members of these patients in western countries. Moreover, current studies of alcohol-related healthcare problems in western countries have mainly focused on patients, with few studies on their family members [
10,
11].
Alcohol, which is legally accessible in Taiwan, plays an important role in Chinese culture as it is viewed as an acceptable drink to relieve stress and enhance socialization [
12]. As a result, drinking problems are easily ignored. In Taiwan’s general hospitals, where the prevalence of patients’ alcohol-drinking problems ranges from 5.7% to 19.2% due to different units selected [
13,
14]. The prevalence of hazardous alcohol-drinking problems among family members of patients with alcohol-drinking problems in Taiwan was 13.3% [
15]. As in western countries, alcohol-drinking problems in Taiwan have mainly been studied in problem-drinker patients, with few studies on their family members [
15‐
18]. Among these studies, the focus was couple relationships and alcohol use [
16,
17]. Only one study also explored spouses of alcoholic patients for their stressors, coping behaviours, and mental health status [
18].
In the only study found on family members of Chinese problem-drinker patients, their risk factors for hazardous alcohol-drinking problems were explored, along with previous assessments and interventions for alcohol-drinking problems [
15]. That study found that these family members’ risk factors for hazardous drinking were male gender, low education level, heart disease, smoking, and chewing betel quid. Only 11.8% of participants had been assessed for drinking problems in the previous year, and only 37.7% of participants with drinking problems had received a drinking intervention in the previous year. The authors concluded that alcohol problems among family members of problem-drinker patients in Taiwanese general hospitals are insufficiently assessed and targeted with interventions [
15]. That study was limited by assessing only demographic data and illness-related variables, which are not changeable. Thus, the only modifiable risk factors identified were smoking and chewing betel quid.
Detecting and intervening with hazardous or harmful drinkers is important because these drinkers’ behaviours negatively affect family members, highlighting the need to design suitable interventions to prevent them from hazardous drinking. Modifiable risk factors must be targeted for interventions to effectively reduce hazardous alcohol-drinking behaviours among family members of problem-drinker patients. Important mediators of behaviour, identified from cognitive [
19] and cognitive-behavioural [
20] approaches are cognitive patterns, e.g. beliefs, expectations, styles, or capabilities. For example, one’s beliefs and hopeless expectancies are related to whether one attempts or completes suicide [
19,
21]. Since the beliefs and expectations of hazardous alcohol drinkers about hazardous alcohol-drinking behaviours may be considered risk factors for hazardous alcohol-drinking behaviours, they are important to understand. Understanding these factors can help nurses and clinicians prevent hazardous alcohol-drinking behaviours in family members of problem-drinker patients by designing interventions to decrease risk factors for hazardous alcohol-drinking behaviours. Therefore, the purpose of this study was to explore the perceptions of family members of problem-drinker patients about their own hazardous or harmful alcohol-drinking behaviours.
Method
Design
This qualitative descriptive study was part of a large series of studies to establish a model of hazardous-drinking behaviours among family members of hazardous-drinker patients in Taiwan. This paper follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) [
22].
Sample and setting
A representative sample of family members of hazardous-drinker patients was ensured by recruiting these patients from psychiatric, gastrointestinal medical-surgical, trauma, and rehabilitation clinics and wards where most patients with alcohol problems are seen in Taiwan [
23]. Since our research team is working in northern and central Taiwan, we chose these two areas to conduct our study. Northern and central Taiwan have 127 and 105 accredited medical centres, regional, and district hospitals, respectively [
24]. Therefore, three hospitals were randomly selected from northern and central Taiwan in a 2:1 ratio. All hazardous-drinker patients at the selected hospitals were referred by physicians or nurses. Patients were asked to refer their family members to participate in this study if patients met these criteria: AUDIT score ≥ 8, > 20 years old, and able to speak Chinese/Taiwanese. Family members were included in the original study if they met these criteria: 1) > 20 years old, 2) parent, sibling, child, or partner of a hazardous-drinker patient, and 3) able to speak Chinese/Taiwanese. Family members were divided into two groups (AUDIT score < 8 and ≥8). Only data of family members with AUDIT scores ≥8 were used in this study. Participants were recruited until analysis of interview data revealed no new findings (data saturation).
Data collection
Quantitative data on hazardous-drinker patients’ and their family members’ alcohol drinking-related behaviours were collected using the Chinese-version Alcohol Use Disorders Identification Test (AUDIT) [
23]. The 10-item AUDIT measures alcohol consumption level (3 items), symptoms of alcohol dependence (3 items), and problems associated with alcohol use (4 items) in the previous year. Higher AUDIT scores indicate more severe level of risk; scores ≥8 indicate a tendency to hazardous drinking.
Quantitative data on hazardous-drinker patients’ demographic information were collected using a researcher-designed form. A similar form was used to collect the same data from these patients’ family members plus two added items: ‘Relationship to the hazardous-drinker patient’ and ‘Are you living with the patient?’
Qualitative data were collected in individual in-depth interviews using an interview guide. Sample questions for all family members of hazardous-drinker patients were ‘What is your lived experience with your relative who has drinking problems? Can you describe the most memorable event regarding your relative’s alcohol drinking? How did his/her drinking behaviours interfere with your life?’ Family members with AUDIT scores ≥8 were further asked ‘Why have you chosen to use alcohol? Have you tried to use other substances?’ Interviews were audiotaped with participants’ permission. This paper focuses on participants’ responses to the question, ‘Why have you chosen to use alcohol?’
The content validities of the interview guide and researcher-designed demographic information form were explored by a panel of 10 experts in psychiatric care: five physicians with expertise in treating hazardous-drinker patients and five clinical nurses with extensive experience caring for hazardous-drinker patients. All members of the panel agreed that both forms were suitable to use in this population.
Procedure
This study was carried out in accordance with the Code of Ethics of the World Medical Association. Each selected hospital was approached individually. After the hospitals’ institutional review boards approved the study, physicians or nurses in psychiatric, gastrointestinal medical-surgical, trauma, and rehabilitation clinics and wards were asked to refer hazardous-drinker patients. A research assistant (RA) approached referred cases, described the study, screened them for the inclusion criteria, obtained their written consent to participate, and asked them to refer their family members to participate in this study. These patients were also asked to fill out the researcher-designed form for demographics. The RA then approached family members, described the study, screened them for inclusion criteria, obtained written consent to participate, and collected data.
Data analysis
All audiotapes were transcribed verbatim as soon as possible after interviews. Transcripts were analysed following Van Manen’s [
25] steps of thematic analysis, i.e. turning to the nature of the experience, formulating the phenomenological questions, explicating assumptions and preunderstandings, exploring the phenomenon-generating data, consulting the phenomenological literature, conducting thematic analysis, determining essential themes, attending to how language is spoken, varying examples and writing. To help make sense of the large amount of qualitative information, we also used ATLAS.ti, version WIN 7.0, a programme for text analysis and model building (Atlas.ti Scientific Software Development GmbH, Germany). Participants’ demographic information was analysed by descriptive statistics (frequencies, percentages, means, and standard deviations).
Discussion
This study is the first to explore the perceptions of family members of problem-drinker patients about their own hazardous or harmful alcohol-drinking behaviours. Our results revealed that these family members’ perceptions of their own alcohol-drinking behaviours were related to six major patterns: family habits, leisure activities with friends, work pressures, personal taste, a way to forget one’s problems and to express happiness. We would like to emphasize that our patients already had physical problems for which they came to hospital for treatment. Furthermore, none of these patients were referred by their family members for problems related to drinking behaviours nor did families consider it necessary to decrease the patients’ drinking. This lack of awareness about the dangers of patients’ hazardous drinking is consistent with findings that people in the UK lacked knowledge about the long-term harmful effects of alcohol drinking [
26]. These findings suggest the need to highlight knowledge of the long-term negative effects of alcohol drinking in programmes to prevent harmful or hazardous drinking.
Family habits as a pattern of drinking alcohol were described as ways to promote family cohesion and communication as well as to relax. This finding is unique; we could not find any published report of family habits as a type of drinking behaviour. Moreover, the participants who described this pattern did not report the amount of alcohol consumed or number of drinks, but monitored their drinking by stopping before they felt drunk. Using drunkenness as a guideline, all of them perceived that their drinking behaviours were under their control.
Since drinking alcohol is a learned behaviour [
26], children can learn from their parents, husbands can learn from their wives, and vice versa. These findings highlight the importance of family environment in influencing their members’ behaviours. Changing a drinking pattern as a family habit may not be easy because the pattern is associated with many positive feelings and interactions. However, it is important to inform family members about standard amounts of alcohol in drinks (one standard drink contains about 14 g of ethanol [
27] and the recommended amounts for males and females. For men, low-risk drinking is defined as no more than 4 (standard) drinks on any single day and no more than 14 drinks per week; for women, low-risk drinking is no more than 3 drinks on any single day and no more than 7 drinks per week [
27]. Without understanding hazardous or harmful alcohol drinking, it is impossible for people to grasp the risks associated with their drinking behaviours.
Our participants also described drinking alcohol as connected to leisure activities with friends, as consistently reported in the literature. For example, peer pressure was described by Dutch adolescents (12–17 years old) as playing a role in their alcohol drinking [
28]. However, drinking alcohol was described by mid-life adults in the US (24–54 years old) [
29] and UK (35–50 years old) [
30] as a more controlled social behaviour but still an issue at times. Our participants who described this pattern of drinking could be taught to have fun with friends by pursuing other leisure activities besides drinking with friends, such as walking or hiking, cycling, or camping. Another approach to decreasing their drinking behaviours would be to teach them more positive coping strategies.
Another pattern in our participants’ drinking behaviours was work pressures, consistent with 1172 US adults’ drinking behaviours being correlated with social pressures to drink [
31]. Our participants with this pattern of drinking could be taught strategies to resist social and work pressures, which may help to change their drinking behaviours.
Personal taste was another drinking pattern related to tasting wine, which has recently become fashionable in Taiwan. People feel that it is a gracious habit that expresses a sophisticated and cosmopolitan lifestyle. Red wine in small amounts has also been reported as good for health [
32]. Unfortunately, these participants did not report the amount of wine they drank, but monitored their alcohol consumption by not feeling drunk, as reported by participants who described the family habits pattern. Therefore, prevention programme s for these participants should also consider including the standard amounts of alcohol in different kinds of drinks, e.g. one standard drink equals 12 oz of beer, 5 oz of wine, or 1.5 oz of spirits [
27], the recommended alcohol amounts for males and females, and knowledge about the long-term effects of hazardous or harmful alcohol drinking.
Drinking alcohol was also considered by our participants as helping them to forget their problems, which may demonstrate a maladaptive pattern. Like the family-habit pattern, this pattern was described by our participants as a behaviour learned from the family environment. These findings highlight the importance of family education about drinking alcohol and helping people with this drinking pattern to build positive coping strategies to deal with their problems. In contrast, one group of our participants described drinking alcohol when they felt happy. Drinking for these participants was related to celebration and happiness. Programmes for these participants should focus on educating them about the standard measures of alcoholic beverages, the recommended alcohol amounts for males and females, and the long-term effects of hazardous or harmful alcohol drinking.
Limitations
Although this study provides important information about the perceptions of family members of problem-drinker patients about their own hazardous or harmful alcohol-drinking behaviours, it had two limitations. The sample was recruited by convenience from three randomly selected hospitals in northern and central Taiwan. Thus, participants’ opinions may not represent the perceptions of family members of problem-drinker patients from other parts of Taiwan or a randomly chosen sample. Future studies should use random sampling and expand data collection settings.
Acknowledgements
Not applicable