Fetal alcohol spectrum disorders are neurodevelopmental disorders associated with substantial personal and social costs (May et al., 2018; Tan et al., 2015; Velasquez et al., 2015). These disorders represent a serious public health concern, with rates ranging from 1.1% to 5.0% (May et al., 2018; Tan et al., 2015). Research to address these disorders indicates the need for early intervention in the preconception period, thus preventing an alcohol-exposed pregnancy (AEP). Women are at risk of an AEP when they consume alcohol and are at risk of pregnancy due to ineffective contraception (Velasquez et al., 2015). Treatment for risky alcohol use may be particularly challenging for groups such as Latinas, who experience more negative outcomes related to alcohol use and treatment (Pinedo et al., 2020; Zemore et al., 2014). Latinas experience multiple stressors and cultural barriers to alcohol prevention and treatment seeking, access, and care, so early intervention is critical.

Data from the 2019 U.S. National Survey on Drug Use and Health indicate that Latina adults aged 21 years or older have a lifetime alcohol use of 74.9%, past-year use of 59.3%, and past-month use of 42.1% (Substance Abuse and Mental Health Services Administration, 2020). Although Latinas consume less alcohol than their male counterparts, their alcohol use and misuse presents with numerous individual and contextual challenges related to factors such as stigma and structural and logistical barriers. Latinas with alcohol use disorder also access substance use treatment at a lower rate than Latino men (2.5% vs. 6.8%, respectively; Zemore et al., 2014). The documented disparities are evidence of the great health burden experienced by Latinas. A clear need exists for rigorous and culturally informed research that examines barriers to and facilitators of behavior change for Latinas to address disparities in care.

Cultural norms and values may not only shape alcohol consumption practices, but also affect individual change processes. Sociocultural values can also influence women’s reasons for and obstacles to change. Learning what matters to Latinas, therefore, provides the opportunity to address these women’s unique needs and improve treatment receptivity. For instance, a study examining drinking patterns and motives among Native American women at risk of an AEP found that social networks played an important role in their drinking behavior (Shrestha et al., 2018). As noted by the authors, these findings highlight the need to focus on these women’s social support networks as a possible vehicle to address their risky drinking, particularly given the salience of social networks in their daily lives. Dupree and colleagues (2016) examined the pros and cons of drinking among young adults and found that social skills training could benefit this group, given that their motives for drinking centered on interpersonal factors. Taken together, findings from these studies suggest improving our knowledge about underserved groups such as Latinas is critical because it can inform early intervention efforts and treatment that may address disparities in care. In particular, little is known about Latinas’ reasons for and obstacles to alcohol behavior change. The current study aimed to increase our understanding of these important behavior change processes and the role of sociocultural context.

One particularly important factor to consider for individuals in a bicultural context is acculturation. Acculturation is a multifaceted process by which people selectively adopt elements (e.g., practices, values, and self-identifications) of a mainstream culture while selectively maintaining elements of their heritage culture (Schwartz et al., 2010). Level of acculturation may be a factor for risky alcohol use due to its potential to increase stress and expose individuals, particularly Latinas, to more permissive mainstream (i.e., U.S.) norms regarding substance use (Rote & Brown, 2013). For example, although Latinas have lower levels of alcohol use disorders compared to White and Black women, more acculturated Latinas are more likely to consume alcohol and consume at higher levels (Vaeth et al., 2012).

Behavioral interventions with motivational interviewing components, such as the CHOICES intervention, have been successful at decreasing the risk of an AEP by decreasing alcohol consumption and increasing the use of effective contraception (Floyd et al., 2007; Project CHOICES Intervention Research Group, 2003; Velasquez et al., 2017). CHOICES Plus is a two-session intervention provided by trained master’s-level behavioral health specialists at primary care clinics (Velasquez et al., 2017). It uses motivational interviewing to help motivate women to change their AEP risk behavior through changing their risky alcohol use, contraception practices, or both (Velasquez et al., 2017). Given the perinatal risks associated with tobacco use, CHOICES Plus included tobacco use as a target behavior.

Motivational interviewing is patient centered and uses nonconfrontational techniques to help women examine their risky behavior, which can be beneficial during the early process of change (Velasquez et al., 2017). Another CHOICES intervention, Project Healthy CHOICES, which was designed as a mail-based intervention, found differences in outcomes for Latinas. Specifically, those who preferred Spanish language intervention materials were less likely to reduce their risk of an AEP compared to the English language group (Letourneau et al., 2017). This finding suggests that sociocultural factors such as preferred language, which can be associated with acculturation, is important to AEP outcomes among Latinas. Overall, individual motives for and obstacles to behavior change operate in a larger social context that may shape how women perceive and address risky drinking behaviors. Examining motives for and obstacles to alcohol behavior change among Latinas can lead to better understanding of these women’s treatment needs and may result in improved outcomes.

The current study aimed to (a) examine reasons for and obstacles to changing risky alcohol use behavior in the process of early behavior change among Latina adults at risk of an AEP; and (b) given the noted relationship between acculturation and alcohol use among Latinas, examine the role of acculturation in Latinas’ barriers to and facilitators of change.

The study used data from a randomized controlled trial testing the efficacy of CHOICES Plus, an intervention targeting risky alcohol and tobacco use among women at risk of an AEP in primary care settings (Velasquez et al., 2017). The intervention was manualized and delivered by trained master’s-level behavioral health specialists in two sessions lasting an average of 40 minutes. The intervention goals included tailored feedback related to each woman’s readiness to change, decisional balance exercises in which the women were asked to consider the pros and cons of their risky behaviors, and delivery of educational materials about each risk behavior using an “elicit-provide-elicit” approach consistent with motivational interviewing (Rollnick et al., 2008). Additional components included personalized feedback on each woman’s levels of temptation and self-efficacy related to her risky behaviors, and development of a goal statement and change plan when appropriate. The sessions were tailored to a women’s readiness and interest in changing one or more target behaviors (Velasquez et al., 2017). In the parent study, 261 women were recruited from primary care clinics operated by a large urban safety-net health care system in Houston, Texas. There were 131 women in the CHOICES Plus intervention group (59 Latinas, 59 non-Latina Blacks, and 13 non-Latina Whites). The current study focused on the 59 Latinas who were part of the CHOICES Plus intervention. Data were collected by trained research assistants in the participants’ preferred language (i.e., English or Spanish) at 12 participating primary care clinics. Further information on data collection procedures in the parent study can be found elsewhere (Velasquez et al., 2017). Inclusion criteria for the parent study were: (a) aged 18–44; (b) not sterile; (c) not pregnant or planning to become pregnant in the next 9 months; (d) had vaginal intercourse with a man with no known fertility problems during the past 3 months without using effective contraception; and (e) drank at risky levels (more than three drinks per day on any day or more than seven drinks per week on average) in the previous 3 months.

All participants provided written informed consent under protocols approved by the institutional review boards of the University of Texas at Austin, Baylor College of Medicine, and Harris Health System.

Participant demographic information is available in Table 1. Participants had an average age of 28 years (SD = 7.13) and education of 11 years (SD = 3.22). Most (n = 39, 68%) had an annual income of less than $20,000. On average, participants fell in the high-acculturation group (M = 3.31, SD = 0.73). When examining participant characteristics by acculturation group, a significant difference was found in having ever been pregnant (p = .04), with more low-acculturated participants (n = 13, 93%) having been pregnant compared to high-acculturated participants (n = 28, 63%). In addition, a significant difference in foreign-born status (p < .01) was found between low-acculturated participants (n = 10, 71%) and high-acculturated participants (n = 7, 16%). Differences were also found in number of heavy drinking days between low-acculturated (M = 2.64, SD = 5.03) and high-acculturated (M = 5.93, SD = 6.58) participants (p = .05). However, there were no significant differences in number of drinking days; that is, frequency of drinking between low-acculturated (M = 5.50, SD = 6.16) and high-acculturated (M = 7.24, SD = 6.39) participants (p = .37). In addition, there was no significant difference in number of drinks per drinking day between low-acculturated (M = 4.31, SD = 2.87) and high-acculturated (M = 6.03, SD = 4.18) participants (p = .08). No other statistically significant differences were found in demographic characteristics between the two acculturation groups.

Several themes depicted reasons for and obstacles to risky alcohol behavior change among all participants. Reasons included: (a) health, (b) parenting role, (c) interpersonal conflict, (d) control, and (e) risk of harm. Themes related to obstacles included: (a) social obstacles, (b) belief that drinking is not risky, and (c) drinking to manage mood. Table 2 compares themes based on level of acculturation. Representative quotes are provided in Table 3.

Our findings reveal that most Latina participants endorsed health-related concerns as their reason for wanting to change their risky alcohol use. However, low-acculturated Latinas noted their parenting role as most important when considering changing their alcohol use behavior. Participants reported facing challenges related to social pressure and drinking to become more comfortable when socializing. More than half of the low-acculturated participants also stated that they believed that their drinking was not problematic. Given the paucity of research on the unique processes of change among Latinas at risk of an AEP, learning about this population’s reasons for and obstacles to change and how they may vary by acculturation may lead to improved knowledge of Latinas’ needs, which can contribute to improved treatment for this underserved group.

Most participants were aware that drinking could create health-related problems and cited their physical health as an important reason for change. Some experienced health challenges and wanted to prevent any further problems, whereas others had witnessed health issues among loved ones and did not want that for themselves. The intervention sessions took place at a community health clinic, which may have contributed to participants’ health-related focus.

Notably, low-acculturated Latinas strongly endorsed the value of parenting and being a role model for their children. This finding may be due to the difference in number of pregnancies between low- and high-acculturated women, with more low-acculturated participants reporting having ever been pregnant. Nonetheless, although more than half of high-acculturated participants (63%) had been pregnant, only 27% mentioned parenting as an important reason for changing their alcohol behavior. It is possible that for low-acculturated women, motherhood may be tied to cultural perceptions of traditional gender role beliefs about mothering behaviors, which influence their view of parenting. Familism, the emotional and behavioral manifestation of commitment to family life and well-being, may also be a factor for these participants, in that low-acculturated Latinx generally have a strong family orientation (Vega, 1995). A study by Shrestha and colleagues (2018) also found that among Native American women at risk of an AEP, parenting was cited as an important reason for change. The negative impact of drinking on family life was a source of concern for these Native American women. Other studies have also cited parental status as a protective factor contributing to reduced drinking among women when compared to men (Kuntsche et al., 2012).

In this study of Latinas, all participants reported experiencing social obstacles. In particular, pressure to drink and drinking to socialize were common themes. Similar to other studies with minority women, drinking was seen as a way to engage with others and in some cases, described as a typical way for family to come together (Shrestha et al., 2018). This being the case, however, many participants expressed concern that they often drank or drank more than they intended because they felt obligated to comply with requests from friends and family. Additional research is needed to examine how social pressure manifests and is addressed among Latina adults and the potential cultural obligation that Latinas may feel to concede to pressure from others. For instance, Latinx culture features a characteristic termed simpatía, which refers to a pattern of interaction that favors positive social relationships (Rodríguez-Arauz et al., 2018; Triandis et al., 1984). As such, Latinx people may conform to social situations and consider the feelings of others, at times even above their own needs, to maintain harmony. This cultural script is tied to the collectivist orientation found in the Latinx population (Triandis et al., 1984). A study examining substance use among Latinx found that simpatía was associated with lower substance use (Ma et al., 2017). The authors suggested that participants may have wanted to avoid negative family interactions and therefore, having higher levels of simpatía would help them conform with their family’s desire for them not to engage in substance use. However, in our study, social networks of friends and family members encouraged Latinas to engage in drinking behavior and may have made it difficult for Latinas to abstain from or limit their drinking due to their interest in maintaining pleasant and respectful interpersonal relationships. Future studies should examine this cultural characteristic among Latina adults in the context of gender norms, acculturation, social interactions, and alcohol use behavior (Perrotte & Zamboanga, 2021).

Perceiving their drinking as nonproblematic was another obstacle to change. Although they had agreed to participate in the intervention, these women had initially presented for a primary care visit and were not seeking treatment for their drinking or risk of AEP. Low-acculturated Latinas may not have encountered problematic experiences that may propel them to make changes to their risky drinking behavior. Moreover, some participants did not see a problem with their drinking because it did not conform to their perceptions of risky drinking and therefore, they did not consider their drinking as needing attention. For instance, because they had lower levels of heavy drinking and may not have physical problems such as daily hangovers or more serious medical conditions such as cirrhosis, they did not see their drinking as problematic. They seemed to have a higher threshold for what they considered risky alcohol use. Although all women in the study were drinking at risky levels and when combined with their ineffective contraception practices, were at risk of an AEP, those who were drinking less may have had a different perception of risky drinking that may influence their willingness to consider change.

Similar to other studies (Lee et al., 2019; Shrestha et al., 2018), participants endorsed drinking as a way to cope with stressors and manage their mood. Drinking provided relief from emotional distress and helped them relax. Emotional distress as an obstacle was found among half of low-acculturated Latinas. It manifested in their relationships with others and often acted as feedback loop that brought on additional problems.

The Latinx population is heterogeneous; therefore, our findings may not be generalizable to all Latinas. In addition, the majority of participants fell in the high-acculturation group. Future studies should consider including Latinas with varying levels of acculturation, which may lead to additional findings on unique sociocultural factors related to reasons for and obstacles to change.

Findings underscore the importance of examining salient factors associated with change and within-group variability based on acculturation among Latinas at risk of an AEP. Building on the noted strengths and reasons for change may help to offset some of the challenges experienced by Latinas. Overall, understanding these women’s perspectives and values, and incorporating culturally relevant components based on this knowledge, may help tailor treatment approaches to better address the needs of Latinas and reduce treatment disparities.