Beliefs underlying Women’s intentions to consume alcohol

The current study examined the extent to which women’s alcohol-related behavioral,
normative, and control beliefs predicted intentions, and subsequent engagement in
low risk drinking, frequent drinking and binge drinking across age cohorts. It was
evident that women’s intentions to drink differed as a function of their age. Specifically,
younger women were more likely to report intentions to binge drink than older women
and older women were more likely than younger women to report an intention to drink
frequently. Although the findings are consistent with women’s drinking patterns found
in Australia 31], they do highlight the need to further investigate the risks associated with frequent
drinking particularly for older women. Frequent drinking has its own set of risks
as it can: result in higher alcohol tolerance levels which can lead to increased volumes
to gain the desired effect (e.g. relaxation); be related to increased likelihood of
frequent binge drinking 32]; and even in the absence of binge drinking can still represent high volumes of alcohol
intake across a lifetime and long term harms 33]. Further, if typical quantities of alcohol consumed are often underreported 34] and alcohol is frequently present in women’s lives, such habituated drinking brings
with it greater exposure to long term harms.

Overall, a range of behavioral beliefs, control beliefs, and normative beliefs were
found to predict women’s intentions to drink, and the majority of these were also
shown to be predictive of actual alcohol consumption. Consistent with previous studies,
identification of such beliefs is significant to the extent that they may guide the
development of targeted interventions, such as public education and health promotion
messages 20], 23]. It follows then, that identifying the key beliefs underpinning women’s intentions,
and actual behaviors, to engage in drinking could inform message development. Further
specific examples will be provided in this discussion but, just as one overall example,
identifying the perceived disadvantages associated with engaging in binge or frequent
drinking would provide important insights into perceived negative aspects of drinking
that messages could emphasise to ultimately reduce alcohol related risks.

Within the final regression results, only three normative beliefs were found to significantly
predict women’s intentions to drink (i.e., low risk, Table 2 and frequent, Table 3), and two of these were also predictive of actual behavior. Normative beliefs were
found to predict intentions to frequent drink for women aged 25 to 34 years. Specifically,
the findings revealed that perceptions of having family or friends concerned about
one’s drinking reduced one’s intentions to frequent drink (Table 3). Notably, for women aged 55 and over, perceptions of their friends’ alcohol-related
expectations were positively associated with intentions to frequent drink (Table 3). For this age cohort, normative beliefs regarding spouses’ alcohol-related views
also significantly predicted women’s intentions to low risk drink (Table 2). These findings highlight age and possible generational differences in regards to
the importance of different normative referents around alcohol. Such insight highlights
how, for instance, age-based educational messages could be designed to either emphasize
those most relevant normative influences who disapprove of one’s drinking or to challenge
those normative referents perceived as positively influencing one’s drinking. The
current findings build upon previous evidence of partner influence as a risk factor
for alcohol-related harms 35] and the efficacy of normative feedback interventions 36], all of which highlight the importance in gaining an understanding of such potential
intervention targets.

Until now, the beliefs underlying intentions to engage in the specific drinking behaviors
have not been widely examined. In the discussion below, beliefs specific to age groups
are highlighted and then commonalities across age groups are discussed. These results
greatly assist in identifying specific age appropriate targets for intervention and
more general points of intervention applicable to women of varying ages.

Low risk drinking

There were no age-related differences of women’s intentions to drink on only one or
two occasions. Women’s intentions to low risk drink were influenced by beliefs that
varied somewhat according to age group, but there were some patterns evident. The
results indicated that for women in all age groups from 25 and above, family concerns
significantly affected their intentions to engage in low risk drinking. On inspection
of the behavioral beliefs influencing intentions reported by women aged between 25
and 44, the age cohort most likely associated with raising a family, it was revealed
that even having an occasional drink is perceived as interfering with family life
and therefore this aspect was a perceived disadvantage. For women aged 45 to 54, being
a mother was perceived by participants in this study as a significant barrier to their
intentions to low risk drinking (i.e. control belief – barrier).

Perceived benefits and facilitators of consuming alcohol were identified as significant
predictors of intentions for women aged between 35 and 54. In particular, these beliefs
included perceiving an advantage of drinking as being it helping one to relax (behavioral
belief) and a perceived facilitator of drinking being it reduces stress (control belief),
and were also significantly predictive of women’s reported drinking behavior. These
findings may be reflective of a time of life where family and work commitments are
high and a need to for work, life and family balance is needed 37], 38]. Although these results refer to intentions to low risk drink and thus are indicative
of a safer way to drink, there may be value in challenging perceptions that alcohol
is an appropriate and acceptable stress management technique. Across all age groups,
one of the most consistent motivations which predicted having an occasional drink
related to special occasions and celebrations (e.g. birthdays, Christmas, holidays).
It seems that the presence of special occasions and celebrations is a strong and consistent
facilitator of women’s intentions to low risk drink and engagement in such drinking
behavior, irrespective of one’s age. Interestingly, family concerns did not emerge
as significant predictors of actual drinking, indicating that these beliefs may be
more related to planning and intentions than behavior itself, while beliefs around
drinking being a source of stress relief and celebration were associated strongly
with both intention and behavior.

Frequent drinking

Older women, aged 45 years and above, were more likely to report an intention to drink
frequently compared with younger women, a finding that is consistent with other research
16], 31]. Examination of motivating beliefs underlying these women’s intentions to drink on
six or more days per week, revealed beliefs relating to: relaxation (behavioral belief—benefit)
and stress relief (control belief—facilitator); family influence (normative) and responsibility
(control belief—barrier); and health issues (control belief—barrier) (Table 3). For these older women, behavioral beliefs in terms of perceived advantages of drinking
that “made them relax” (aged 45 to 54) and control beliefs with regard to facilitating
their drinking when they are “having a stressful week” (aged 55 and above) were associated
not only with intentions to frequent drink, but also were strong predictors of actual
drinking frequency. In regards to normative beliefs, women aged 55 years and above
also reported that they expected friends to be supportive of frequent drinking. The
only two barriers to frequent drinking which were identified related to health issues
(aged 45 to 54) and family commitments (55 and above). Health and family were a concern
for other age groups too.

Being pregnant or breastfeeding was reported by women aged between 25 and 44 as a
significant control belief associated with reduced reported intentions to frequent
drink, but this belief was not a significant predictor of actual drinking frequency.
These findings are consistent with data showing that women are having children at
an older age, compared with previous generations 37], 38], and that parenthood affects the frequency of women’s drinking more so than men’s
drinking 39].

With the exception of the 35 to 44 years age cohort, all of the age groups reported
a perceived advantage of alcohol as it offering a means to relax (behavioral beliefs—benefit)
and to be used as a stress management tool (control beliefs—facilitator), both of
these beliefs were also significant predictors of frequent drinking behavior. Such
consistent findings across age cohorts indicate a need to address stressors specific
to women and promote alternative healthy stress management techniques. Although Australian
drinking guidelines do not explicitly warn against drinking on a daily basis they
indicate long term health risks associated with high frequency of drinking 7]. Further, for women, even moderate drinking levels are associated with certain health
risks such as breasts cancer 40], 41] and drinking patterns and associated beliefs can be predictive of later drinking
behaviors that may be risky 42], 43]. The current findings support the idea that women are considering alcohol as an advantage
in terms of its use as a relaxation and stress management tool. Hence, promotion of
alternative stress management tools and awareness regarding long term risk exposure
needs to be considered in future public health policy. As with the findings for low
risk, this family-oriented belief was not significantly predictive of behavior, again
highlighting the subtle effect of these beliefs on planning and intention, while stress
reduction beliefs were predictive of both intention and behavior.

Binge drinking

In line with drinking patterns in many developed nations 1], 3], 31], 44], results from this study indicated that younger women were more likely to report
intentions to binge drink compared with older women (Table 4). When investigating the beliefs predicting such intentions, the results showed that
different underlying beliefs were predictive of intentions to binge drinking compared
to the other behaviors, and for the most part, were also specific to different age
groups. In particular, the findings highlighted the important influence of a broad
range of behavioral and control beliefs.

For the women aged 18 to 24 who were most likely to binge drink, a number of control
beliefs were found to be significant predictors, specifically beliefs which would
facilitate their intentions to drink more than four drinks on any one occasion. These
facilitators related to: birthday celebrations, if their alcohol tolerance was better,
accessibility to wineries and wine clubs; and if they did not have children. Possibly,
this latter facilitator is tapping into younger mothers who are no longer able to
binge drink because of their responsibility as a mother, but further investigation
is needed to clarify this result as this suggestion is only speculative. With increasing
age, an interesting finding was the finding that the behavioral belief of “help me
to have fun” was a significant predictor of intentions to binge drink in the 25 to
34 year olds but, not for 18 to 24 year olds. Previous research has identified elements
of fun and excitement as motivating factors for young women (aged 18 to 30 years)
45] and young people (aged 18 to 24 years) 46] in their decisions to binge drink. The need to address young women’s perceptions
of binge drinking as fun, whilst negating the associated risks, is underlined.

For women aged 35 to 44, a significant control belief which would prevent binge drinking
which emerged related to health issues. In line with women’s drinking patterns 3], 31], this finding may indicate the transition from binge drinking to frequent drinking
as women’s health becomes less tolerant of binge drinking over time. The transition
away from binge drinking is evident with the 55 years and older group. This cohort
reported no significant benefits or facilitators predicting intentions to binge drink.
Instead, perceived barriers such as short term effects of alcohol and behavioral evaluations
that binge drinking “makes me feel irresponsible” were found to be significant predictors
of intentions to binge drink. Such results highlight why this cohort is less likely
to binge drink and further implies the existence of differing social norms with regard
to women and the acceptability of binge drinking.

The main consistency in regards to the significant predictors of binge drinking across
all age groups was that of the control belief of short term side effects (e.g. hangovers)
which was associated with significantly lower intentions to binge drink. Avoiding
short term side effects was also significantly associated with self-reported engagement
in binge drinking behaviors for women aged 18 to 44 years old. It would seem prudent
then to target interventions to build upon women’s perceptions about these beliefs,
especially for the younger women who tend to binge drink at higher rates. An anomaly
in the results emerged for the women aged 18 to 24 years and 35 to 44 years with regard
to accessibility of “wineries or wine clubs”. It was expected that the control belief
“If I was close to wineries or wine clubs” would be a factor that facilitated intentions
to binge drink, not the negative relationship that was actually found. One reason
for this may be that context is the important factor wherein wineries are not perceived
as venues in which to binge drink. Drinking context has been found to be an influential
factor on drinking behaviors 1], 47], 48].

Implications

Across age groups

Across behaviors and age groups it became evident that two beliefs consistently underpinned
probable targets of intervention. Firstly, although beliefs varied across age groups
and drinking behaviors, beliefs surrounding alcohol as a tonic to a stressful week
and a way to unwind and relax, were consistent across age groups and across behaviors.
Implications from this current study call upon a focus on women’s decision-making
regarding alcohol and stress-relief. The findings highlight the role that alcohol
and drinking has taken on in the lives of contemporary women as a means of relieving
stress. Furthermore, the findings suggest that there may be value in both challenging
the notion that alcohol is an important and regular means by which to reduce stress
and instead highlight healthy alternatives to stress relief including, for instance,
going for a walk or taking a bath. Secondly, the perceived short term effects of binge
drinking was found to be a barrier to engaging in this behavior across all age groups.
Alongside this finding, however, the finding that the behavioral belief of “cause
ill-health in the long term” was not a significant predictor in any of the regression
models is, arguably, most noteworthy. It is noteworthy given that it suggests that
many women are not perceiving and/or are have limited awareness of the long term health
risks associated with alcohol consumption, highlighting the need to raise awareness
in regard to this issue 21].

Frequent drinking

For the older women intending to drink more than five days in a week, behavioral and
control beliefs regarding relaxation and stress relief, respectively, and perceived
peer expectations (normative beliefs) may be of value in informing intervention content.
The belief that friends approve or expect a woman to drink frequently needs further
investigation. Previous examinations have found misperceptions regarding normative
beliefs around alcohol consumption, whereby individuals may well overestimate the
perceived peer expectations to drink 48]. Consequently, this misperception represents an important normative belief which
needs to be challenged in targeted messages.

Although the current study did not investigate drinking locations, other studies have
raised concerns about older women’s alcohol related risk because of the way in which
they drink 5]. If older women have an increased likelihood of frequent drinking in the privacy
of their homes there may be less opportunity for detection of drinking problems 5]. As such, older women are thus exposed to a different set of risks compared to their
younger counterparts, who may be more visible in public spaces where acute alcohol
risk is more pertinent 5]. Hence, reiterating the need for a different set of interventions and public health
messages for older women compared with younger women.

Binge drinking

In conjunction with other TPB research outlining the importance of beliefs in devising
and informing targeted interventions 20], 24], this current study’s results suggest, that for the younger women who engage in binge
drinking, it will likely be of value to devise messages that target the beliefs that
facilitate binge drinking. Public health promotions depicting young women as having
fun and celebrating birthdays without binge drinking could raise awareness and combat
the belief that heavy drinking is the main way to celebrate. Research has identified
cultural and normative influences on young people to celebrate birthdays, particularly
milestone birthdays (e.g. 18th and 21
^st
), with excessive alcohol consumption 49]–51]. Such notions could be challenged with increased public awareness and public health
campaigns depicting healthier fun alternatives.

As discussed above, emphasizing the short term health risks and side effects of drinking
more than four drinks on any one occasion could help to consolidate such a barrier
to binge drinking for women of all ages. In line with this suggestion, young women
reported that if their tolerance for alcohol meant that they would suffer less adverse
reactions to binge drinking, it would facilitate more binge drinking. This belief
needs to be challenged, but also outlines the presence of a desire to binge drink.
It also raises the point that if women had a high tolerance level then potentially
their consumption would increase. This was a theme that arose in the beliefs elicitation
study 26]. Hence, women’s beliefs around tolerance of alcohol and ways to negate short term
risk needs further investigation.

Strengths and limitations

This current study has a number of strengths including: the examination of women’s
drinking across a broad age range and across different drinking behaviors; having
a large sample of women; and using a well-established theoretical framework to identify
critical beliefs underlying intentions to engage in drinking behaviors. Furthermore,
this study examined differences in beliefs across age and behavior that can inform
targeted interventions. One limitation is the cross-sectional nature of the study
and hence results must be interpreted as such. Furthermore, whilst possible intervention
foci have been identified, further research is needed to assess the efficacy of interventions
targeting beliefs to reduce alcohol-related risks.

Although, the TPB is a reliable measure of the cognitive influences of intention it
is acknowledged that utilising this theory in the current research does not take into
account influences such as: potential physiological dependence 52]; or external influences such as a change of responsibility as women age that demands
a changing of drinking pattern (53]; e.g. older women adapt their consumption as a result of work and parenting demands,
so that frequent drinking is more likely than binge drinking which can impact upon
meeting responsibilities the next day). However, in line with the scope of the current
study, the TPB is a fundamental and measurable model of an individual’s intentions
to drink as a function of their alcohol-related beliefs. Furthermore, although the
TPB is a well-supported framework, future research may benefit from the investigation
of additional normative influences such as those outlined in the Integrated Behavioral
Model (IBM), an extension of the TPB 54]. The IBM defines normative beliefs as not just what an individual perceives other’s
expectations to be, but also whether or not the individual perceives others to be
engaging in the behavior as well. Previous research has incorporated both the TPB
and IBM in an attempt to capture the potential variance of descriptive norms as defined
by the IBM 55].

Overall, however, the current study has increased understanding of women’s decision-making
around intentions to drink, specifically pertaining to three drinking behaviors. It
has provided a picture of the underlying beliefs and patterns that significantly influence
women of varying ages intentions to low risk drink, frequent drink and binge drink.
Such an understanding can help target preventative measures for those women at risk
of alcohol-related harms or interventions for those who are currently partaking in
risky drinking practices.