It is evident that a range of factors affect long-term alcohol consumption behaviour in older adults. Interviewees described a number of reasons for making or resisting drinking change including health, social and financial factors that exerted an upward, downward or stabilising pressure on their drinking. Examining how these reasons for change or stability interacted within each individual improved understanding of the mechanisms that lead to drinking change or stability in older adults. It is proposed that long-term drinking behaviour can be understood within an information-motivation-behaviour (IMB) framework (Fisher &
Fisher 1992). This framework, described below, aids an understanding of the processes through which an individual might progress when considering a change in their drinking behaviour. Sections 8.3 to 8.7 highlighted the complexities of drinking behaviour change (such as maintenance of consumption despite knowledge of potential risks) and this framework is helpful for exploring what influenced the decisions taken around long-term alcohol consumption behaviour.
Information is the combination of knowledge and understanding in this context.
Knowledge is information acquired externally, for example imparted by a healthcare professional or through education. Each individual possessed some knowledge about the consequences of drinking alcohol for health and/or prescribed medications. The accuracy and depth of this knowledge varied across the sample, with some participants reporting inaccurate knowledge whilst others provided a detailed description of the potential health implications of drinking alcohol. Understanding developed when knowledge was internalised and an individual could judge how information was applicable to their personal circumstances. Knowledge was internalised and understood differently depending on perceptions of alcohol, personal beliefs about drinking consequences and prior experience that could translate abstract knowledge into tangible consequences. Motivation describes the internal process of balancing the
emotional and social benefits of drinking with potential health, financial and other costs.
Understanding was linked to motivation through a bi-directional relationship. An individual who had an understanding that alcohol could affect their long-term condition evaluated whether the risk of alcohol influencing their health outweighed the enjoyable aspects of drinking. This balancing process may have been subconscious. Where there were costs of drinking, older adults may have bartered internally to counter the increase in risk from drinking by changing a different lifestyle behaviour. The result was a reduction of cognitive dissonance through the adaptation of understanding about the negative impacts of alcohol on health and the maintenance of stable drinking behaviour. This information motivation behaviour process is illustrated using Composite Case Studies8 1 to 4. These case studies illustrate how knowledge and/or personal experiences situated within personal belief systems can influence motivation to modify or maintain behaviour resulting in different long-term alcohol consumption patterns.
The balance of costs and benefits of drinking that drive motivation to maintain or change differed according to the direction of alcohol consumption change. Increasing drinkers universally described more benefits of drinking alcohol and emphasised the value of one or more of these benefits whilst stating few, vague or seemingly less urgent reasons to decrease or stop drinking. For example, reasons for drinking included stress relief, relief of depression and sociability, whilst the costs of drinking were ‘I think it don’t do me any good’ (F1) or ‘it might impact on me health in the end’ (F4). Increasing drinkers described a process of gradual change over time. Decreasing drinkers who reported a gradual change identified more costs of drinking and accentuated the importance of one or more of these costs whilst describing fewer benefits. In contrast, decreasing drinkers who suddenly changed their alcohol consumption described a balance of advantages and disadvantages but reported a tangible event that had affected their drinking behaviour. This type of change is illustrated in Composite Case Study 1.
This type of event motivated change through providing older adults with first hand experience of the potential consequences of drinking or changing their circumstances so that drinking was no longer a natural part of their routine. Stable drinkers described a number of costs and benefits to drinking, but the benefits usually outnumbered the costs. The key difference between increasing and stable drinkers was that whilst increasing drinkers emphasised the importance of some of the benefits of drinking, stable drinkers were generally ambivalent
8 These composite case studies are portraits compiled using details from two or more participants who together illustrate a drinking behaviour change. Composite case studies are used as the detail provided within each case study might have made it possible to identify individual participants, breaching anonymity (Creswell 2012).
about the benefits and costs of drinking, resulting in a situation where routine drinking prevailed because there was no motivation to change behaviour.
In addition to the importance of the IMB framework for recognising the value of disseminating medical knowledge and the subsequent process of internalisation that this knowledge must undergo to encourage reflection on the costs and benefits of changing drinking behaviour, physical and social opportunities for drinking independently influenced changes in alcohol consumption behaviour. As illustrated in Composite Case Study 3, social and physical opportunities to drink may change over time with knock-on influences on personal consumption. Changes in opportunities for drinking may have coincided with changes in health that also precipitated a drinking change, or may have occurred independently of changes in health. Changes in the physical and social opportunity to drink were often reported by older adults to have been more influential on their drinking change than changes that occurred to their health, perhaps because drinking habits are harder to break whilst past drinking
‘infrastructure’ remains in place. For example, it is easier to stop drinking if you only drink whilst out dancing and you stop dancing, rather than continuing to dance but trying to resist alcohol whilst in a social situation where historically you have habitually drunk alcohol.
Composite Case Study 1: Sudden decreasing drinker
Ray is 68 and lives with his wife in a council flat in an area of high-level deprivation. He is a routine social drinker who drinks in the club three or four times a week. He is mid-level drinker who usually has a couple of pints of lager on each drinking occasion. This has been his drinking routine for over a year, before which time he would meet with friends just as regularly but drink five pints of lager. Ray has arthritis, osteoporosis, diabetes and chronic obstructive pulmonary disease. He is currently taking 19 prescription medications for his conditions. His knowledge of the health implications of alcohol consumption is very limited but he did make the generic statement that drinking too much is bad for health. He does not consider his own health and drinking to be related. When he was diagnosed with arthritis and osteoporosis two years ago he did not change his drinking habits. After a period of time he was prescribed morphine for back pain but his drinking remained stable at five pints per occasion until he experienced a dizzy spell, which he reasoned was drinking too much whilst taking morphine. Since that time he has limited his drinking to a maximum of two and a half pints. This experience illustrates how a tangible consequence of drinking can affect understanding of the relationship between alcohol and health. He did not want to experience the dizziness again so he elected to change his drinking behaviour.
Composite Case Study 2: Gradual decreasing drinker
Tom is aged 79 and lives with his partner in their own home in an area of mid-level deprivation. He is a routine social drinker and alcohol is an integral part of his social life, which centres on sharing meals with friends. Tom enjoys drinking alcohol because it complements a meal and makes an evening more relaxed. Whilst he suffers from arthritis and heart disease for which he takes medication, he does not believe drinking will affect his medication because he takes his tablets in the morning and only drinks alcohol in the evening. Tom is aware of some health risks of drinking alcohol including damage to the liver and kidneys, weight gain and gout. Over the past five years his drinking has gradually decreased from two or three drinks a day to one or two drinks three or four times a week.
Tom described a number of reasons for his drinking change: 1) his partner had decreased her drinking over time with knock on effects on his drinking, 2) he was diagnosed with gout and so cut down on his drinking, 3) he started to wake during the night after drinking alcohol to visit the toilet and so he now tries to limit his drinking to control this need, and 4) his favourite pub closed down a couple of years ago and he does not enjoy the other local pubs. These factors had combined to result in a gradual decrease in drinking over time, despite the reported social benefits. The process of drinking change for Tom is clear:
he had some knowledge about the affects of drinking on health and he understood that knowledge to be relevant to his situation, for example he knew gout was linked to alcohol and he was diagnosed with gout so he reduced his drinking. In choosing to reduce his drinking he balanced the costs of drinking, for example pain from gout and needing to visit the toilet during the night, with the social benefits. As his partner had reduced her drinking the social benefits of drinking had also diminished over time. His motivation to change was adequate resulting in decreased drinking.
Composite Case Study 3: Stable drinker
Marcus is 63 and lives alone in an area of low-level deprivation. He is a routine social drinker who goes to the pub every day to drink beer and ‘banter with the lads’. He is a higher-level drinker, often consuming three or four pints of beer in one sitting. He also enjoys drinking alcohol when out for a meal with friends. His current drinking behaviour has been routine for over 20 years. Marcus was recently diagnosed with arthritis for which he takes anti-inflammatory tablets. He exhibited awareness of some of the health risks of drinking alcohol including weight gain and the negative impact carrying extra weight will have on arthritic joints. Despite being overweight and acknowledging the potential impact of weight on his arthritis, he has not changed his drinking. Furthermore, in the past he has taken measures in other lifestyle areas to prevent having to change his drinking. A few years ago he was diagnosed with gout. His initial symptoms were treated but when the problem kept recurring he was advised to change his lifestyle to reduce the risk. Friends suggested that he should reduce his drinking but he did not want to so he sought an alternative solution. Through research he found that dietary changes might be sufficient to prevent recurrence of gout, so he modified his diet whilst maintaining his level of drinking.
He had no further problems with gout after making dietary changes. Marcus demonstrates that even having the knowledge and understanding regarding the risks of drinking alcohol, individuals may find alternative solutions to enable maintenance of habitual behaviour where drinking change does not fit within existing belief systems.
Composite Case Study 4: Increasing drinker
Michelle is 60 and lives with her husband in an area of low-level deprivation. She is a routine social drinker who enjoys drinking alcohol when socialising with friends, but also uses alcohol to relax after a stressful day at work. Michelle has had a heart attack and as a result takes prescription medications. She also suffers from osteoarthritis and occasionally takes pain relief medication. Over the past ten years her alcohol consumption has gradually increased and she reports a number of reasons for this increase including increasing levels of stress at work, changes in social activity resulting from changes in maturity and reduced childcare responsibilities, and the increased affordability of alcohol. Michelle describes how she usually drinks alcohol on two or three nights a week, but does not drink when taking painkillers because analgesics and alcohol should not be mixed. She believes that it would be better for her health if she did not drink so every now and again she stops drinking, for example when on holiday, but over time she gradually starts drinking again at social events and as the stresses of work grow. This illustrates that even when individuals have the motivation to change their alcohol consumption behaviour, the habitual nature of alcohol consumption and the perceived benefits of drinking can hinder long-term change.
8.9 Summary
This chapter has described and analysed the factors that this sample of older adults perceived to be important in determining their long-term alcohol consumption patterns within a COM-B framework. Sections 8.3 to 8.7 presented evidence to support the relevance of difference components of the COM-B for drinking change in older adulthood. The key findings are that:
1. Knowledge is a crucial first step in the process of drinking behaviour change after a change in health and is gained through various media. Some older adults actively seek medical knowledge whilst others avoid medical knowledge as a way to prevent challenges to existing behaviour.
2. Reflection on medical knowledge and how well it fits into individual belief systems around health and alcohol consumption influences long-term consumption behaviour.
3. Personal experiences (both positive and negative) promote behaviour change through turning abstract risks into tangible consequences.
4. Habit exerts a strong stabilising influence on alcohol consumption behaviour, but can be broken by emotional drivers (such as fear) and associative learning.
5. Physical limitations and changes in social opportunity to drink are strong, direct influences on drinking behaviour change.
The risk of negative health consequences generated action following a balance of the benefits of change against the costs, informed by possession of and reflection on medical knowledge.
Where the benefits equalled or outweighed the costs of drinking stable consumption prevailed because alcohol was a highly habitual and enjoyable behaviour.