Two screening instruments for collecting alcohol- related information from expectant mothers and fathers: Testing the reliability of the Parent Alcohol Screening Questionnaire and the Social Support for an Alcohol- Free Pregnancy Questionnaire

The aim is to test the reliability of two alcohol screening instruments: (1) The Parent Alcohol Screening Questionnaire (PASQ5), and (2) the Social Support for an Alcohol-free Pregnancy (SSAFP) questionnaire. This is a cohort study from the south of Sweden using repeated surveys during pregnancy. To examine if responses differed according to different data collection methods, two cohorts consisting of 289 expectant mothers and 141 fathers completed the PASQ5 both verbally (weeks 6– 7) and in writing (week 12) within regular antenatal visits. One of the cohorts ( n = 137/64) also completed the SSAFP in week 12 and later in week 33. The third cohort, consisting of


| INTRODUC TI ON
Alcohol use is a leading cause of health loss (Griswold et al., 2018).
European research shows that a mean of 16% (Mardby et al., 2017), and in Sweden, 6%-18% (Bortes et al., 2015;Comasco et al., 2012;Skagerström et al., 2013) of women consume alcohol during pregnancy. Consuming alcohol during pregnancy increases the risk for miscarriage, stillbirth, birth defects and cognitive defects (Ceccanti et al., 2014;Jones & Smith, 1973;May et al., 2004). In addition, infants may be born with congenital malformations, or develop behavioural and learning disorders . In addition, a growing body of literature suggests that paternal preconception alcohol exposure can also negatively affect the child (Andreasson et al., 2020;Ceccanti et al., 2014Ceccanti et al., , 2016Hollander et al., 2019;Jensen et al., 2014;. Therefore, finding ways to encourage a discussion around both expectant parents' alcohol consumption may be beneficial for the expectant mother's, father's and the child's health. In Sweden, expectant mothers, but not expectant fathers, are routinely screened for prenatal alcohol consumption (Wells, 2016).
However, fathers should be routinely screened, as previous studies have demonstrated that the expectant mothers' alcohol consumption is associated with the fathers' alcohol consumption (Bakhireva et al., 2011;May et al., 2014;. In addition, an expectant father may benefit from an alcohol screening for his own general and reproductive health (Jensen et al., 2014;La Vignera et al., 2013). Furthermore, when a midwife's dialogue included screening and supporting expectant fathers in relation to their alcohol consumption, the father was more satisfied with their visit (Högberg et al., 2016;Högberg et al., 2015;Saunders et al., 1993).
Lastly, both expectant mothers and fathers generally want both parents to be included in screenings and to receive professional support when needed (Deave et al., 2008;Wells, 2016;Wells & Lang, 2016).

| Social support
Social support can be defined as an individual providing assistance and protection to other individuals (Langford et al., 1997).
There are four main types of social support: emotional, instrumental, informational and appraisal (House, 1981), and family, friends and clinical professionals often provide these supports.
Emotional support involves providing another with love, trust and empathy, as well as with safety and inclusion. When expectant fathers provide emotional support to their partners, expectant mothers are more likely to abstain from drinking (Abela, 2000;Chang et al., 2005;Ockene et al., 2002;van der Wulp et al., 2015).
Instrumental support involves practically helping someone with a problem. A type of tangible aid is when expectant fathers also reduce or abstain from drinking alcohol during pregnancy (Högberg et al., 2016;Hyssälä et al., 1992). Informative support involves giving someone information to help solve a problem. For example, expectant mothers are less likely to consume alcohol at their registration visit if they receive information about having an alcohol-free pregnancy compared to those who did not receive that information (Bortes et al., 2015). Finally, appraisal support focuses on empowering a person through self-evaluation and encouragement of their ability and competence. This is shown, for example, when clinicians have the expectant mother self-evaluate her alcohol consumption (e.g. if she would like to reduce or abstain from consuming alcohol during pregnancy) and to brainstorm with her to identify alternatives to alcoholic consumption during pregnancy (Chang et al., 2000).

| Swedish prenatal clinics
In Sweden, nearly all expectant parents visit a midwife at the prenatal clinics, and all visits are free of charge (SFOG, 2016). At the initial registration visit, the midwife routinely asks about: medication usage, healthy lifestyle habits, smoking/snuff (oral tobacco) and alcohol habits. Depending on the results of these screenings, midwives offer referrals to specialists. The Alcohol Use Disorders Identification Test (AUDIT) is routinely used to screen for alcohol consumption (SFOG, 2016). However, the routine AUDIT screening is limited to expectant mothers' alcohol consumption and therefore does not include questions regarding their received social support for an alcohol-free pregnancy. In Högberg et al., 2015). However, an investigation of their reliability and usefulness in clinical practice is warranted.
In addition, since midwives currently screen expectant mothers about their alcohol intake face-to face, some expectant mothers may feel reluctant to provide truthful answers. Therefore, we wondered if responses would be similar or different when responding to the midwife verbally compared to in writing regarding alcohol consumption during pregnancy. To our knowledge, no studies have assessed if expectant mothers (or fathers) respond differently, depending on whether the screening is provided verbally or in writing, when screened for alcohol consumption during pregnancy. Previous studies on depression show that people can be screened verbally in addition to being screened in writing (Arroll et al., 2003). Similarly, when looking at an anorexia-nervosa screening tool, Perry et al. (2002) found that while both verbal and written screenings were reliable, more participants were found to potentially have an eating disorder when completing the written version. Since there are mixed results depending on the type of screening instrument, it is important to understand if there are differences regarding alcohol screenings during pregnancy.
The primary aim of the current study was to test the reliability of using the alcohol screening instrument, PASQ5, using test-retest reliability and internal consistency for expectant mothers and fathers respectively. A second aim was to test the correlation between written and verbal responses from expectant mothers and fathers. A third aim was to test the stability of responses to the SSAFP in late pregnancy for expectant mothers and fathers.

| MATERIAL S AND ME THODS
The study consisted of participants from three cohorts receiving a questionnaire in early pregnancy and a test-retest in late pregnancy, within the regular prenatal activities. All data were collected from December 2013 to April 2016 (see Table 1). It took about 10-15 min to complete both PASQ5 and SSAFP, and midwives scheduled an extra 15 min into their routine meetings with expectant parents to conduct those screenings. All midwives had previous training and experience using the AUDIT screening with expectant mothers and some had previously screened expectant fathers.
In the current intervention, all participating midwives received a half-day training for implementing the PASQ5 immediately after the AUDIT screening. This training included informing midwives of the PASQ5, how to score the instrument, as well as how to and what types of dialogues midwives could engage parents in afterward. Midwives should provide a referral to a prenatal clinical psychologist or to an addiction unit to the expectant mother and/or father if they (a) had a family history of alcohol addiction or other addiction issues or (b) if they personally had an alcohol addiction or other addiction issues. Furthermore, all midwives had access to group supervision by the prenatal clinical psychologist, or the unit manager, who would give extended support. Additionally, the research project leader could also be reached for support, as she was an experienced midwife, trained supervisor and had worked with the method earlier. The research project leader, as well as one other researcher, met with the midwives and picked up questionnaires twice a month. The project leader met all of the midwives after the study to listen to their experiences of working with the new screening tools. No problems were reported except that more time was needed.

| Setting
All 33 midwives working at five prenatal clinics in the south of Sweden helped recruit participants for the current study. All but one public prenatal clinic in Malmö participated. In addition, one suburban prenatal clinic in Lund participated. In Malmö, 52% of expectant parents used a public prenatal clinic. Expectant mothers and fathers completed the PASQ5 and SSAFP questionnaires at regular antenatal visits in early and late pregnancy. All questionnaires were in Swedish (see Tables 2a-3b; Figure 1).

| Sample
The midwives were instructed to invite all Swedish-speaking expectant mothers and fathers to participate. However, the expectant father was only asked to participate if the expectant mother agreed to participate first. If the expectant father was not present, the expectant mother was asked to take home an information packet and the questionnaire for the expectant father. When expectant mothers and fathers could not complete the forms at the visit, they were instructed to complete them at home and mail them back to the researchers, or hand them back to the midwife at the next visit.
The recruitment process of the different cohorts is shown in Figure 1 and demographic characteristics of the participants are shown in Table 4. A total of 516 expectant mothers and 327 expectant fathers were invited to participate, where 417 expectant mothers and 205 expectant fathers participated.

| Instrument/measures
The PASQ5 consisted of five questions focusing on respondents' alcohol experiences, and changes made regarding alcohol consumption during pregnancy. The five questions were: (1) Who do you drink with? with response alternatives: workmates, partner, alone, friends, other family, not drinking.
(2) Is there any alcoholism/addiction/dependence in your family or within your extended family?
with response alternatives: yes, no, I do not know and if yes, who?
(3) Has your drinking changed over the last year before pregnancy?

| Procedure
In gestational weeks 6-7, 289 expectant mothers and 141 fathers responded to the PASQ5 questionnaire verbally, where the midwife filled in the questionnaire (Cohort 1 + 2). In week 12, the same expectant mothers (n = 271) and fathers (n = 98) completed the PASQ5 in writing, as well as a demographics form (see Figure 2; Table 4).
Using another sample of parents in late pregnancy (Cohort 2), 179 expectant mothers and 133 fathers completed the PASQ5 in gestational week 31. At week 33, 146 of these expectant mothers and 107 fathers re-completed the PASQ5 (see Figure 2).
Social Support for an Alcohol-free Pregnancy was completed in week 12 and in week 33 (see Figure 2). In gestational week

| Ethics
The Regional Ethics Committee for Medical Research in Uppsala approved the study (2013/365). All expectant parents who were invited to participate at the participating clinics were given oral and written information about the study. They were informed that participation was voluntary, that they could withdraw at any time, that questionnaires were stored in a locked cabinet and that only the researchers had access to the data. Furthermore, they were informed about their F I G U R E 1 Parent Alcohol Screening Questionnaire (PASQ5) items legal rights to their own data, and that their data would be coded, so that no other personal identification would be listed in the data.
After agreeing to participate, participants signed a consent form, along with completing their first round of questionnaires, and sealed these forms in an envelope at the midwives' office. Follow-up questionnaires were also completed by the participants and sealed in an envelope at the midwives' office. Two researchers collected the envelopes twice a month. None of the researchers were involved in the care of the participants.

| Parent Alcohol Screening Questionnaire
The results showed that most questions in the PASQ5 revealed similar responses when questions were posed verbally versus in writ-

ing in early pregnancy. McNemar Test and Marginal Homogeneity
Test showed that eight of 10 questions were stable at p < .05 level in early pregnancy for expecting mothers and eight of 10 questions TA B L E 4 Characteristics of the respondents in gestational weeks 12 (Cohort 1 + 2) and 31 (Cohort 3). Expectant mothers and expectant fathers for expecting fathers (see Table 3a)

. McNemar Test and Marginal
Homogeneity Test showed that eight of 10 questions were stable at p < .05 level in late pregnancy for expectant mothers and nine of 10 questions for expectant fathers (see Table 3b). Of the questions not stable between the groups, only one was the same (the question for expecting father: 'drinking with partner').

| Social Support for an Alcohol-free Pregnancy
The showed less support (answering 'yes' on the question) in late pregnancy compared to early pregnancy (see Tables 2b and 2c).
Of the expectant mothers, 12.5% in gestational week 12 and 14.0% in gestational week 31, and of the expectant fathers, 28.4% in gestational week 12 and 30.8% in gestational week 31 reported ever having tried illegal drugs. The most commonly reported drug was cannabis, while a few reported using cocaine, amphetamines or 'mushrooms' (see Table 4). Therefore, using the PASQ5 and SSAFP can be reliable new instruments for collecting information on alcohol-related issues during pregnancy in conjunction with routine AUDIT screenings.

| D ISCUSS I ON
By using the PASQ5 and SSAFP screening instruments, clinicians will have more information from patients so they can provide more targeted support. Appraisal support (House, 1981) is given when using the PASQ5, as it can aid clinicians in their alcohol dialogue by giving both expectant parents the possibility to narrate their experiences and reflect together with the midwife how they want their children to be brought up in relation to their alcohol consumption. The SSAFP screening tool can aid clinicians in further promoting an alcohol-free pregnancy by better understanding an expectant parents' social support network and then providing advice based on those responses.
Working towards an alcohol-free pregnancy is a political priority (Socialstyrelsen, 2018). All alcohol exposure is potentially toxic to the foetus, since there is no consensus whether there is a threshold level for harmful exposure (Griswold et al., 2018). While an AUDIT screening measures alcohol intake and dependence (Gache et al., 2005) (Högberg et al., 2015). These new instruments may therefore improve paternal satisfaction with care, while potentially supporting them to reduce or eliminate their alcohol consumption during pregnancy (Hyssälä et al., 1992;Mellingen et al., 2013;Widarsson et al., 2013).
The question on drug usage was included to give both expectant parents the possibility to talk about drug experiences and to receive support from dependence outpatient care, if needed, before the child was born. The results showed that both expectant parents were willing to respond to these sensitive questions. Our results on drug usage are similar to a Swedish population study (15-64 years of age), showing that around 23% of men and 12% of women had ever used illegal drugs (Folkhälsoinstitut, 2010). The results of this study showed that the PASQ5 is reliable whether responding verbally or in writing, including whether or not the participants used drugs. Therefore, the PASQ5 is appropriate to implement together with AUDIT questions when screening clinically for alcohol during the prenatal period.

| Strengths and limitations
A strength to the current study was that it includes a relatively large number of participants during different time points throughout pregnancy, allowing for both instruments to build on previous studies (Högberg et al., 2015(Högberg et al., , 2016. Furthermore, responses were also given orally and in writing, allowing a better understanding of variation in methods clinicians might use. We also considered it a strength that some items were sensitive to change over time as the pregnancy proceeds, as this would be expected.
A limitation was that participation of expectant fathers only occurred if the expectant mothers accepted to participate first, which limited the possibility for expectant fathers to be invited. Future research should directly invite expectant fathers to participate in research directly. In addition, we do not know why some expectant parents chose to drop out of the study. However, the overall participation rates were relatively high.
The generalisability of the findings might also be limited, since all of the participants came from the south of Sweden; therefore, future research should seek to replicate the current study's findings, as well as expand on the extent to which using these screening tools can help redirect clinicians' conversations with expectant parents regarding their alcohol consumption during pregnancy.

| Further research
Future studies in different settings, before and after the child is born, are needed to confirm the suggested usefulness of the two instruments. It would also be interesting to interview expectant parents about their own reflections regarding alcohol during pregnancy, and reasons for decreasing or not decreasing their alcohol consumption before and during pregnancy (Stern et al., 2016). Future research should also strive to incorporate more complex data, such as heredity issues related to alcohol disorders (Sullivan et al., 2012) and the effects of alcohol exposure on sperm quality (Jensen et al., 2014), for better understanding diagnoses such as foetal alcohol syndrome and alcohol disorders.
Three items in the test-retest were not stable among expectant mothers, and this may depend on chance, or systematic change, such as new consciousness or changed support between measuring times.
These SSAFP questions include: 'refrains himself from drinking when I am present', 'talks with me about the harmful effects of alcohol on the foetus during pregnancy' and 'talks with others about the harmful effects of alcohol on the foetus during pregnancy'. Two items in the test-retest were not stable among expectant fathers, and this may depend on chance, systematic change such as new consciousness or changed support between measuring times. These SSAFP questions include: 'Support for decreased alcohol before parenthood from the pregnant mother', and 'Support for decreased alcohol before parenthood from others?' (See Table 2c). Further studies can support if any of those or other questions may be removed from the questionnaire in the future. In addition, the research project leader spoke with the participating midwives after the project ended, and one prenatal clinic suggested that a sixth question regarding violence and drinking be added to the PASQ5. The question could be phrased 'How do you react when you drink alcohol?' with response options: I get relaxed, I get stressed, I get happy, I get angry, I get annoyed, I get tired, I become verbally violent, I become physically violent, I get less anxious and other.

| Recommendations
We recommend that prenatal clinicians integrate using both the PASQ5 and the SSAFP along with an AUDIT screening. This will allow the clinician to better understand their clients' situation, as well as received social support. From there, the clinician can provide more personalised support towards reducing or eliminating alcohol consumption during pregnancy. It should be noted, however, that in many countries, women will not go to a prenatal clinic to see a midwife as early as gestational weeks 6-7. We encourage these tools (AUDIT, PASQ5 and SSAFP) to be implemented at registration until it is possible for midwives to have a dialogue about alcohol and other lifestyle questions early in pregnancy. Other clinicians may need training in interpreting the responses, and experienced midwives may be available to help with this.

| CON CLUS ION
Both the PASQ5 and the SSAFP were developed to be used in conjunction with an AUDIT screening to aid discussions around having an alcohol-free pregnancy with expectant mothers and fathers.
Reliability testing indicated that both the PASQ5 and SSAFP are reliable tools and may be helpful for clinicians who aim to have a deeper dialogue about alcohol consumption during pregnancy than currently possible using AUDIT alone. However, further research is needed to test if these instruments can reduce alcohol consumption during pregnancy for both expectant parents.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.