Agile DSM

Following the pilot study, the final questionnaires (Appendix C and D) included the following measures.

Socio-demographic questions

Both parents were asked about their age, level of education, employment status, household income, and relationship status. These questions were included to assess relationships between socio-demographic factors and alcohol use during pregnancy. Due to the cross- cultural nature of the study, ethnicity was excluded as a variable. National surveys in Sweden do not include ethnicity; the national survey on living conditions and public health instead includes the variable ‘country of origin’ (PHA, 2014b). Although the English version of the questionnaire included ethnicity as a standard socio-demographic question, as these items would not be comparable they were excluded from the analysis. Background data was also collected relating to parent experience (first-time parent or more than one child), time since birth, and whether the pregnancy was planned. Women were asked how many weeks pregnant they were at pregnancy recognition. Household income was collected in both samples but due to difficulties with accurately comparing wealth between the two countries household income was not included in any analyses.

Pregnancy-related lifestyle changes

Women were asked whether they had made any changes to their diet in regards to healthy eating, intake of supplements, and avoidance of certain foods. Women were subsequently asked about changes in lifestyle once they realised they were pregnant relating to smoking, illicit drug use, and alcohol consumption. All these questions were drawn from an unpublished maternal health survey designed by Centre for Public Health (Morleo, unpublished data).

Alcohol consumption

Participants were asked about frequency of drinking, with the options of ‘never’, ‘once per month or less’, ‘two to four times per month’, ‘two to three times per week’, or ‘daily or almost daily’. Participants were asked to provide number of drinks as defined in commonly used standard measures in the UK (Morleo, Cook & Bellis 2011) and Sweden (SNIPH, n.d) (Table 4). Each category of alcohol reported was converted into grams of pure alcohol by using each country’s definition of a standard drink (England 8g and Sweden 12g). Women

were asked about their consumption during four time periods; in the three months before finding out they were pregnant, first trimester, second trimester, and third trimester. Partners were asked about their consumption in the three months before they found out the woman was pregnant and while the woman was pregnant. The choice to only include the partner’s alcohol habits over the course of the entire pregnancy was a pragmatic decision to shorten the items for the partners and comparing the trimesters for women are of importance in relation to biological effects on the foetus. It was therefore regarded as beyond the scope of this study to elucidate detailed drinking data from the partner within each trimester.

Table 4. Drinks measures included in the questionnaires, divided by country Beverage type Drink size, England Drink size, Sweden

Wine Regular glass, 12% (175ml) Large glass, 12% (250ml) Regular glass, 13%a (150ml) Beer/lager/cider Can/bottle, 5% (330ml) Pint, 5% (568ml) Can/bottle, light/medium/strongb (330ml) Can/bottle, light/medium/strong (500ml) Alcopop Small bottle, 5% (275ml)

Large bottle, 5% (750ml)

Bottle, 5% (275ml)

Spirits Shot, 40% (40ml) Shot, 40% (40ml) Fortified wine Glass, 18% (50ml) Glass, (80ml) Cocktails Glass (undefined)c Glass (undefined)d

a

ABV for wine as standard is 12–14% (SNIPH, n.d) and 13% was chosen as an average

b

Light beer approximately 2.2% ABV, medium beer 3.5% ABV, and strong beer 5.0% ABV

c

Calculated as one measure of 40ml spirits (8g alcohol)

d

60ml of spirits (SNIPH, n.d)

In addition to typical drinking, participants were asked if they had consumed alcohol at any special occasions (e.g. wedding, funeral) during the given time period with the options yes or no, and the number of such occasions. Under-reporting is a consistent issue in alcohol research and previous research has indicated that using a different set of questions, asking more details around non-typical drinking, can produce more accurate data (Bellis et al., 2015). In other populations the use of context-specific questions have been found to account for some of the difference observed in survey data as compared with alcohol sales data (Casswell et al., 2002; Morleo, Cook & Bellis, 2011). Most women who continue to drink report consuming small amounts of alcohol infrequently (Alvik et al., 2006; McAndrew et al., 2012; Skagerström et al., 2013), and considering the potential benefit

with accounting for under-reporting using context-specific questions, the study included the additional question of context specific drinking during pregnancy.

Relationship satisfaction scale

Participants were asked about the relationship with their partner, if they had one, including to happiness in relationship and experience of problems in the relationship with their partner. The relationship satisfaction scale is made up from three questions measured on a five point likert scale; ‘how happy are you in your relationship’, ‘how easy do you find it to talk about problems with your partner’, and ‘how often do you quarrel with your partner. The scale is a modified version of the Conflict Tactics Scale, which has been used in research on women’s health in relation to for example alcohol use and suicidal behaviour (Wilsnack et al., 2004), but also specifically in research on alcohol use during pregnancy and influence from the partner (Bakhireva et al., 2011).

Information and advice

Participants were asked what kind of information they had received in antenatal care on alcohol, smoking, illicit drug use, and nutrition. Subsequently, parents were also asked about what they were recommended in terms of alcohol use during pregnancy, to further investigate how the drinking guidelines were communicated in antenatal care. Parents were also asked whether their partner had been included in the discussion on alcohol use by being recommended to also abstain and whether they had obtained information about alcohol and pregnancy from sources other than antenatal care.

Attitudes towards lifestyle during pregnancy

Parents were asked a series of questions relating to their attitudes towards the four health behaviours (diet, smoking, alcohol, and illicit drugs) during pregnancy and their perceptions of risks. Attitudes were measured on a five-point likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. In relation to the attitude questions parents were also asked if they believed there to be a safe limit of alcohol consumption during pregnancy (‘yes’, ‘no’, or ‘I don’t know’). For the ‘yes’ response, a follow-up question was included of what amount they believed to be safe. Women were also asked about the reasons to why they changed their alcohol habits when they found out they were pregnant. This question were used in the 2010 IFS (McAndrew et al., 2012). Whilst previous research has used validated scales or measures from behavioural models such as Theory of Planned Behaviour (Duncan, Forbes-McKay & Henderson, 2012), the current study was

designed based on several behaviour change theories and models. As no there was no existing scale based on teachable moments, HBM, and the socioecological model of health, non-validated items were used for this part of the questionnaire.