Exploring pathways through and beyond alcohol treatment among Polish women and men in a London Borough

Concerns have been repeatedly raised about high alcohol use and alcohol-related harm among Polish migrants (e.g. Byrne, et al., 2008; Kreft and Ritchie, 2009; Garapich, 2010; Thom, et al., 2010). In 2018 the Polish born population living in the UK stood at 889,000 (ONS 2018a). In the most recent statistics there was a decrease in the number of all EU citizens immigrating to the UK and for the first time the number of A8 migrants leaving the UK is slightly higher than the number entering the country (ONS, 2018b). However, Poland remains the most common non-UK country of birth, taking over from India in 2015 and Polish has been the most common non-British nationality in the UK since 2007 (ONS, 2018a). Studies on access to health care amongst migrants have identified a number of barriers including, confusion over entitlement to NHS services, lack of understanding on the NHS structures, problems registering with primary care services, language and interpretation problems and limited access to reliable transport due to poverty and poor services in areas of deprivation where many recent migrants live (Johnson, 2006). Some of the barriers such as information, language and transport, seem to cut across length of residence, affecting longer established migrants as well as newly arrived ones (Jayaweera, 2014). Our understanding of drinking patterns, help seeking behaviour and experience of treatment services amongst this minority group of Polish migrants remains limited.

The primary aim of this research study was to further understanding of the pathways into, through and out of treatment, with a focus on sustaining recovery to inform the design and delivery of services for this minority group.

We used three methods of data collection for this study:

1. A scoping review of the literature to better understand current knowledge of prevalence of problematic alcohol use and treatment availability and pathways for Polish migrants in the UK.
2. A qualitative study consisting of interviews with 13 Polish migrants (9 male; 4 female) with experience of alcohol treatment services and four professionals working across support services for Polish migrants in North London.
3. A practitioners workshop that brought together a range of professionals (N = 8) working with Eastern European migrants living in London through alcohol (and related) support services to discuss our qualitative research findings and to help develop recommendations for future service provision.

Literature review

• Prevalence data on problematic drinking among Polish (and other) migrants is not routinely collected. Definitions of problematic drinking may differ across British and Polish cultures and many Polish migrants may not recognise a problem with alcohol until it has caused serious physical or social consequences.
• There is little published literature on specific treatment interventions targeting Polish migrants although Polish speaking AA groups have been in place for some time, statutory or community services are less well known and there is some suggestion that services are reluctant to offer services to migrants due to restrictions on access to healthcare and welfare (Mills and Knight, 2010).
• Common barriers to accessing treatment reported in the literature include; normalisation of heavy drinking in Polish culture making identifying a problem less likely to happen; a belief that the individual should be able to control their own drinking without outside help; perceived poor cultural competence in services; language barriers; lack of understanding of British healthcare and treatment service pathways and; ‘no recourse to public funds (NRPF) leading to restricted access to services.
• Some evidence suggests that there is generalised mistrust of UK healthcare services amongst Polish migrants (Osipovič, 2013) which can extend to alcohol treatment services meaning that many migrants are reluctant to access treatment even through medical referrals via their GP.

Interviews

• Participants in this study tended to only seek help for their alcohol use once it had led to serious physical health complications or they had experienced negative social consequences such as unemployment or homelessness.
• Differences in the development of problematic drinking for women and men were seen where women were more likely to drink alone and to keep their drinking hidden. For men, drinking large amounts was often a social experience and was not seen to be problematic until it interfered with work for example.
• Women were more likely to come to services through GP or social services referral compared to men who tended to self-refer into services.
• Cultural influences could lead to delays in seeking treatment. For men it took longer to recognise a problem with alcohol as it was deeply embedded in everyday life. For women with children a fear of being seen as a ‘bad’ mother or the possibility of social services becoming involved acted as barriers to seeking help.
• Other factors that affected the likelihood of accessing treatment included having a Polish key worker in a service, shifting attitudes towards alcohol that was partly influenced by changing work rules on alcohol use and, being unable to work due to drinking either because of a health issue or losing accommodation.
• Two main options were taken by our participants to get help to stop drinking, HAGA-Blenheim services which offer a one-to-one therapeutic intervention or, AA meetings offered through the local Catholic church in the Polish language. Choice of which service to attend appeared to be based on personal preference rather than any access issues.
• Just two of the service users we interviewed had maintained stable housing and employment. The remaining eleven participants had experienced multiple negative life events, such as the breakup of relationships, estrangement from children, loss of employment and homelessness. It was thought by both service users and professionals that these issues needed to be dealt with in the first instance if they were to fully engage with alcohol treatment, however for some, this was not sufficient in itself to prevent relapse.
• Two key factors were reported by participants to have influence over their pathways through treatment, their relationship with a key worker, which helped them maintain sobriety and their family which could be a negative or positive influence.
• Participants stated that their ultimate goal was to achieve abstinence as opposed to reduce their drinking to safer levels. This was echoed by professionals who made distinctions between the ways that alcohol problems are treated in Poland and in the UK. It was reported by professionals that Polish service users would not expect to be given the option of either reducing or stopping drinking and this would seem puzzling to them if they were offered these choices.
• The concept of a ‘normal’ life was a common feature of participant interviews as a goal to work towards. This included regaining, or maintaining, employment, being able to provide for their family, or entering a new relationship and having stable and secure housing.
• Ongoing support after treatment was not always available to Polish service users, although the existence of Polish language AA meetings offered recovery support to those who accessed it. Alongside attending AA meetings, or if they were not used, some participants made dramatic changes to their lives in order to avoid drinking again such as moving home or changing their friendship groups.

Workshop

• From the perspectives of the professionals attending the workshop the main challenge being faced by services centred around changes to their own funding and resources and entitlements of migrants in the UK. The impact of reduced funding to community and alcohol treatment services can be seen in increased waiting time for people to access treatment and in some cases, people being turned away from services that are at capacity and cannot meet service user’s needs when they are required.
• An important factor that impacts on treatment providers is the shame and stigma that is attached to admitting to having problems with alcohol. Women in particular face challenges in this respect as there is still pressure on them to be ‘good’ mothers and look after their children. The phrase ‘Matka Polka’ refers to an idealised version of a woman/motherhood that still persists in Polish culture but may be starting to shift both in the UK and in Poland but there are still entrenched opinions about how a woman should behave.
• One of the main factors that needed to be considered was that many Polish women with drinking problems were experiencing domestic violence and there is a need to address this in the first place. Many Polish women were dependent on their partners financially and socially and this creates difficulties for them if they wish to leave a relationship. It was suggested that some women used alcohol as a way of coping with these situations. It can take many attempts to leave an abusive relationship so services need to be open to women seeking help multiple times.
• Issues associated with Brexit were thought to be creating uncertainty for Polish and other Eastern European people who have made the UK their home and for services themselves in how it may affect their funding and commissioning priorities.
• In the local area an increase in the number of people from Lithuania was noted and that they are presenting to services with similar needs to Polish people such as having wider and complex intervention needs. However, it was less likely that services would have a native Lithuanian speaker or access to an interpreter compared to Polish and this was creating problems in providing care.
• All professionals stated that the goal for this group was likely to be abstinence as this was how alcohol treatment is generally approached in Poland (and potentially other Eastern European countries also). The ‘medical model’ of treatment was discussed as being the predominant approach within Poland and most migrants would anticipate a similar approach to treatment in the UK based on their own experiences and understandings.
• We asked professionals what initiatives they used to help to encourage more people into alcohol treatment services and the things they felt were important to have in place to facilitate this. Three factors were discussed; culturally competent staff; ensuring people are aware of the options available to them and; being able to provide practical activities or employment opportunities to service users.

In line with previous research the importance of cultural competence within services was highlighted by service users and professionals, however Polish migrants may have difficulties navigating the treatment system to get to the point of service intervention and there is a need to ensure individuals are aware of what is available to them.

Polish community organisations are well placed to offer signposting to appropriate services and to work towards shifting cultural attitudes to drinking and help seeking. Public health policy needs to consider prevention approaches in consultation with the Polish community and a broad range of professionals.

On the whole, problematic drinking is only one of a myriad of problems experienced by Polish drinkers and this necessitates a person centred and multi-agency approach as currently offered by HAGA-Blenheim. Moreover, service users and professionals noted that steps need to be taken to address other needs, for example, mental health as well as practical needs (e.g. housing, money) before individuals are able to engage effectively with alcohol treatment. There is also a need to consider different means of support for women and men given the apparent gender differences in drinking patterns and pathways into treatment.

Denial of problem drinking and delay in help seeking was evident for both men and women in this study and this impacts on individuals, families, communities and services. The desire for a ‘normal life’, underpinned by a strong work ethic seems to provides a foundation for recovery. Work is valued and routes into employment and other meaningful occupation (e.g. voluntary work, study) should be an integral part of treatment. Professionals raised significant concerns about the limited help available for those with NRPF, most of whom were reluctant to return to Poland and without appropriate treatment were likely to experience a deterioration in health and even die. This presents a profound challenge not only for practitioners and service providers, but also needs to be a policy consideration for society more broadly.

We would like to thank all those contributed to the study, in particular, the participants who shared their thoughts and experiences and the professionals/volunteers who gave us their time and insights. We are grateful to HAGA-Blenheim (from 01/04/2019) Humankind and PEEC (Polish and East European Christian Family Centre) for facilitating access to potential participants.