Toolkit for health visitors

How can you talk about alcohol

This section offers some help in the seemingly difficult task of asking about alcohol, and identifying alcohol problems in families, in the course of health visitors’ routine visits.

The primary visit
Before the visit
Firstly it would be worth checking to see if anything is known about the family history before the visit. If there is a history of problem drinking by either parent this might make it easier to ask about it:

‘I noted that you mentioned your partner’s/husband’s drinking when we saw you with your first baby. How are things now?’

Or it may be that something came up when the mother was assessed on becoming pregnant when a nurse or doctor will have recorded the amount of alcohol drunk per week, together with smoking, etc. If it was high, it is worth knowing this in advance. It might be easier to ask what the situation is now.

Finally the midwife will have been calling regularly since the birth of the baby. In gathering information from her/him, health visitors should ask if they noticed anything about the mother’s or father’s alcohol consumption.

During the visit
Health visitors are required to ask about alcohol use as part of the primary visit. This may be easier to do if there is prior knowledge:

‘When you were pregnant you mentioned drinking x drinks per week – how are things now?’

Or if there is specific concern that alcohol misuse is a significant problem it might be worth trying to get a more detailed picture by asking how much they drink each week and then probing gently:

‘Is that less that you would have drunk before getting pregnant?’

‘Are you worried at all about the amount you drink?’

Apart from building up a general picture of the family situation to assess whether or not alcohol misuse is an issue, there is some basic advice a health visitor can communicate to a new mother who drinks even a small amount, or whose partner drinks:

About breast feeding – it’s best not to drink, next best thing is to limit drinking to one or two drinks, once or twice a week
To avoid having the baby sleeping in the parents’ bed if either parent has had a drink
About risk of fire from cigarettes if they smoke and drink
About storing drink and empty bottles and cans if there are young children about
About the need for one parent to be able to wake during the night if the baby cries

General advice such as this, which can refer to what most people would consider ‘normal’ drinking, given around the time of having a new baby may offer opportunities to gently probe and get an impression of whether alcohol misuse might be a concern.

However many women cut down their drinking substantially when they are pregnant and for a period after having a baby. The focus of assessment should therefore remain on the wider issues covered at the primary visit, establishing whether there is general concern warranting extra visits at which more information can be gathered. This could include the potential or otherwise for parental alcohol misuse as a relationship between the health visitor and the family builds up.

As far more men than women misuse alcohol it makes sense to find a way to ask about the father’s drinking. Linking this to advice about things like safety - sleeping with a baby for example when the father has been out for a drink - offers a way in. But unless there are immediate serious concerns it is perhaps best to focus on trying to get an overall picture of the family and build up a relationship with the mother. This would also allow time for a health visitor to ‘gen up’ on alcohol misuse if they think this could be a problem area.

Generally health visitors will be concerned about the family if:

The house is in serious disarray and hygiene is very poor
There are empty cans and bottles left lying about
Either of the parents smells of drink or is obviously drunk
The mother is very distracted, evasive, looking unwell.

People with alcohol problems can go to great lengths to hide them and so it should not be assumed that a spotless middle class household is automatically immune. Alcohol problems occur in all social classes, ages and in different cultures. Although there are some minority ethnic groups, which traditionally do not drink alcohol, alcohol problems can be more serious if they do occur in these groups because of the increased stigma. People from such groups can find it really difficult to admit that they, or their partner, have a problem.

Six-week check
The six-week check will be the next time the health visitor routinely sees the mother and child unless there were concerns noted at the primary visit prompting the health visitor to visit again in the interim.

Before the check the health visitor will review their notes to remind themselves of any concerns. If there was a vague concern about alcohol that it was not possible or appropriate to investigate at the primary visit, it might be possible to check it out at this meeting.

It is unlikely that a mother who misused alcohol prior to pregnancy and birth but stopped during this time will have resumed drinking at the same level as before at this stage. It might however be possible to ask about her drinking now and offer encouragement if she has kept her drinking down.

The main opportunity now is to:

Continue to develop relationship with the mother
Follow up/check up on previous vague concerns and illicit more information
Pick up on an emerging alcohol issue
Continue assessment of parenting capacity in parents already identified with an alcohol problem
Monitor and support a mother whose partner was identified at the primary visit as having an alcohol problem

However the obviously difficulty at this point is that the health visitor is not seeing the mother and baby in their home.

If there are no concerns about the child based on the health check, the focus can shift to the well being of the main carer (usually the mother) and what she is willing to report about her family life.

If it is either known or suspected that there is an alcohol misusing partner a point should be made to ask about this and offer the opportunity for the main carer to discuss their concerns.

Information on offering support to a person whose partner misuses alcohol can be found at Advice for affected others

Finding out what other services the family accesses and gaining permission to talk to staff in them to see what extra help could be offered should be considered.

Twelve week check
The additional main point to look for at this stage is parents who may have been misusing alcohol prior to the pregnancy but had stopped drinking during and after the birth of their child. Have they gone back to their previous normal drinking?

Mentioning the risk of drinking and unplanned pregnancy might be a way into the issue.

Seven-month check
As above, asking about pre-pregnancy drinking patterns and whether the parents have gone back to these might be possible.

As time goes on it is increasingly difficult to mention alcohol with a family where it has not been mentioned before. Hence the advice to raise it as early as possible, even in the context of advice regarding so-called ‘normal drinking’.

At the 7-month check it might be easier to identify concerns that were not apparent at the start. Concern should trigger an additional home visit where the points raised above under the primary visit apply.

Two-year check
This is an important check for a number of reasons:

Previous alcohol problems (pre birth etc), if they are going to reappear, will have done so by now, although not present in previous visits
A lot could have changed in the time between the last visit – parents not misusing alcohol could have started to do so and families where this had been hidden might be experiencing a worsening of the situation

For families with whom there has been no contact since the last visit at 7 months, the most the health visitor is likely to be able to do is check child development and ascertain whether there are concerns about the child or the health and wellbeing of the mother. Concerns should prompt additional visits where the points made at the start will apply.

Where alcohol misuse is known or suspected, an assessment of how well the family is meeting the child’s needs should be carried out.