Exploring gendered differences among polish migrants in the UK in problematic drinking and pathways into and through alcohol treatment

Abstract

Few studies have focused on the gendered differences amongst Polish migrants in their use of alcohol or access to treatment services. This study explored the divergent pathways through alcohol use, misuse and treatment access in a group of Polish migrants in London. Using an intersectionality framework we examine the ways that social attitudes toward gender in both communities and access to services related to migrant status and class are experienced. With a view to informing treatment services we discuss how a better understanding of these pathways, and the factors likely to influence them, can be used to address challenges experienced by Polish migrant women with problematic alcohol use.

Keywords:

• Alcohol treatment
• Polish migrants
• UK
• gender differences
• intersectionality theory

Introduction

The most recent statistics published by the Office for National Statistics (ONS), 2019) show an overall decrease in immigration and an increased rate of migration out of the UK for those from EU8 countries (newer EU members from Central and Eastern Europe who joined the EU in 2004). Those from Poland have remained the largest migrant group from the EU currently living in the UK. In light of this, a considerable body of research has been conducted on the experiences of Polish migrants in the UK. This research, however, has tended to focus on labor markets with some investigating social relationships or connections, and others on the use of health services. To date, there has been little focus on the use of alcohol treatment services, and less still on gendered experiences of accessing and using these services. This paper reports on a qualitative study exploring experiences of Polish migrant women and men living in London and their use of alcohol treatment support services.

In the UK it is estimated that more than 10 million people currently drink alcohol at rates that have the potential to cause physical or long-term harm (Public Health England, 2018). The latest statistics available for England (2017) show that those drinking above weekly recommended limits, were men and women aged 55-64 years (36% and 20% respectively) (NHS Digital, 2019). Alcohol use increased with income for both genders but experienced harms from alcohol were most acute for those living in the three most socio-economically deprived deciles, while binge drinking was highest in men and women aged 25 to 34 years (PHE, 2016).

Differences between men and women in rates of drinking alcohol, problematic alcohol use and alcohol related harms have been steadily decreasing in recent years (Slade et al., 2016). This is most pronounced amongst younger cohorts and is reflected internationally. The most likely reason behind the trend is an increased rate of alcohol use amongst women and a corresponding decrease in any alcohol use amongst younger men (Slade et al., 2016). Higher income countries see smaller gender differences in alcohol use and problematic use between genders (WHO, 2018).

Globally, men are three times more likely to die through alcohol related disease or injury when compared to women (WHO, 2018), a factor that is reflected in both the research literature and service provision that tends to focus on the harms caused to men to a greater extent than those to women. While global surveys can give an indication of differences in consumption and related consequences between countries, exploring patterns of alcohol use across communities within countries is more challenging.

Current data collection and reporting across UK government and local alcohol, and other drug, services does not record either migrant status of individuals or country of birth. This makes estimating the levels of service need amongst most minority communities impossible to state with any accuracy, an issue that has been highlighted in previous research (e.g. Gleeson et al., 2019; Herring et al., 2019; Mills & Knight, 2010).

Likewise, it is difficult to estimate the extent, and experiences, of problematic drinking amongst women from migrant backgrounds when most research including migrant communities conclude that women drink at much lower rates compared to men (Mansson & Bogren, 2014; Slade et al., 2016). There is, however, some evidence that women from various minority communities are more likely to hide their alcohol use and that we may be vastly under-estimating the level of need for support services amongst women within migrant communities (e.g. Erol & Karpyak, 2015; Rolfe et al., 2009).

Research within the substance use field that has looked at migrant and/or minority communities to date has focused primarily on factors influencing male migrant’s drinking behaviors and problematic drinking. Looking specifically at Polish, or other Eastern European, communities research has investigated the experiences of homeless men and the juxtaposition of alcohol and expressions of masculinities (e.g. Garapich, 2010). Little is known about the experiences of women from a Polish background living in the UK, or other Western EU countries, and how social attitudes relating to gender, drinking and acceptable behavior affect their drinking or help-seeking.

This paper is drawn from a broader study exploring the pathways of Polish women and men in London into, through and beyond alcohol treatment services. Our aims for the initial study were to understand how, when and why Polish migrants in London access alcohol services and to better understand their journeys through treatment. An understanding of these journeys could help to inform services of ways to ensure Polish migrants access treatment support when needed and have better outcomes.

During the course of our interviews with service users and professionals for this study, it became apparent that the pathways into problematic alcohol use, treatment and beyond treatment were strikingly different for men and women. Our data suggest that Polish migrant women are at greater risk of under-identification of problematic alcohol use. They may be reluctant to seek help when a problem is acknowledged and due to their dependence on men (financially and socially) and through social sanctions, may keep their drinking behavior hidden for longer. It is these differences that we focus on in the current paper¹.

Research on gender and alcohol use

Across cultures there are differences in men and women’s drinking patterns, in rates of problematic drinking and in how society views their drinking. Research from the UK suggests that within minority ethnic communities there are often stark contrasts in the frequency and amounts of alcohol consumed between men and women, with only Irish women reporting relatively high rates of problematic alcohol use (Gleeson et al., 2019). International evidence also suggests that men’s alcohol use is likely to be more public and social compared to women who tend to drink at home or with a friend or partner (Erol & Karpyak, 2015).

Research from Poland suggests that while it is still more permissible for men to drink to intoxication than women, there has been some shift in gendered social attitudes regarding alcohol use since EU accession (Podstawski et al., 2019). The Podstawski et al study was conducted with university students showing trends over a 16 year period that documented increasingly liberal attitudes toward women and alcohol use but also found that there are still some social sanctions against women drinking to the same extent, or frequency, as men.

When gender is considered a relevant factor of interest in the research literature on alcohol use, it has tended to view women’s drinking through a ‘risk’ framework in terms of their health, sexual behavior, moral standing, or vulnerability to violence, while neglecting to consider the potential enjoyment women may experience through drinking (Mansson & Bogren, 2014; Rolfe et al., 2009). This contrasts sharply with the ways that alcohol is portrayed in magazines targeted at women, where it is associated with empowerment, sociability and self-reward (Mansson & Bogren, 2014). How women balance these opposing messages about alcohol and what impact it has on either their drinking or help-seeking if it becomes problematic is not yet fully understood.

In the field of research around drug use and policy particular barriers have been identified for women regarding entering treatment including, childcare responsibilities, gendered stigmatization and, treatment models that are inappropriate for women’s needs (Thomas & Bull, 2018). There is evidence to suggest that women are more likely to drink heavily when they are also experiencing psychological and/or emotional distress when compared to men (Erol & Karpyak, 2015), suggesting a need for a more psychologically focused approaches to treatment for women. Coupled with the acknowledgement that a large proportion of women who use substances (40-70%) have experienced some form of interpersonal abuse (including physical, sexual, psychological and emotional abuse) there is a need for alcohol treatment services to be able to provide holistic support to women that takes account of these additional needs (Bailey et al., 2020; Thomas & Bull, 2018).

Research on alcohol use and migrant communities

While there is evidence to show that recent Polish migrants to the UK tend to be young and in good health compared to the majority population, there is also concern that, for a sub-group of these migrants, rates of problematic drinking are high and often go untreated. Street drinking amongst Polish men, for example, has long been identified in local health needs assessments as a particular problem for many regions across the UK (see Herring et al., 2019; Thom et al., 2010). A report from 2007 also noted a low proportion of women accessing homeless services in London (10% of presentations to homeless services when 44% of homeless migrants were women). The authors suggest this indicates a possible vulnerability of homeless women using substances to being coerced into the sex industry rather than accessing treatment or other support services (Mills et al., 2007).

A qualitative study with Polish women who had migrated to Australia reported distinct differences in attitudes toward women drinking within their sample that were influenced by; the age at which women migrated; their relationship status and; level of engagement with Australian social events. Women who were younger, unattached and without children and who had more Australian friends were more likely to view women drinking as positive and normalized and a sign of greater freedom and empowerment compared to their lives in Poland (Wolska et al., 2004). No comparable research with Polish women now living in the UK has been conducted to date.

It was acknowledged in the years immediately following EU8 accession that key issues for newly arrived migrants included access to alcohol use services, homelessness and entitlements to health and social care (Mills & Knight, 2010). Arguments for better services in this regard, however, tend to view migrants as a homogenous group and do not consider the impacts of within community social attitudes that can influence decisions to access health and/or social care services.

All migrant populations face a number of challenges to accessing appropriate healthcare and support on arrival in a new country, including restrictions on the services that can be accessed, lack of knowledge about systems and language barriers (Madden et al., 2014; Sime & Fox, 2015; Thom et al., 2010). In addition, it is thought that social attitudes toward alcohol amongst Polish migrants hinders the recognition of problematic drinking and prevents some from seeking help until very late stages for both women and men (Thom et al., 2010).

Theoretical framework

Intersectionality is central to much feminist theory although it has been used in multiple ways by different researchers over the past four decades (Davis, 2008). First described by Kimberle Crenshaw in 1989 ( the concept had been in use for some time before this; Davis, 2008; Denis, 2008 ), it was developed in response to ‘…the need to account for multiple grounds of identity when considering how the social world is constructed’ (2004, p. 483). In Crenshaw’s view, feminist theory had failed to address the intersections between gender and race by focusing only on one or the other and argued that such analysis of one denied the validity of the other. Feminist theory had also been criticized for prioritizing the views and experiences of White, middle-class, heterosexual women at the expense of ignoring those of women from other marginalized groups.

An intersectional analysis of narrative data allows for an investigation into the ways that multiple structural inequalities are produced, re-produced and resisted through social action (Crenshaw, 2004; Davis, 2008; Miller & Carbone-Lopez, 2015). Within our sample participants were socially positioned through their gender, both within and outside of migrant communities, their standing as Polish migrants within the UK, their class (often influenced largely by their migrant positions) and their alcohol use. Our analysis has attempted to incorporate the experiences of migration, gender, alcohol use and social class to give a broad (but by no means comprehensive) understanding of pathways into, through and beyond alcohol treatment.

The flexibility provided by an intersectional framework for analysis indicates there is no single ‘correct’ way to use this approach. However, we acknowledge that our participant’s experiences are framed by both their individual characteristics and by how wider society interacts with them because of these characteristics. As Miller and Carbone-Lopez have argued “It is not simply that individuals practice gender, but that they are held accountable for their gendered performances in light of the gender order in which patterns of social life are arranged, largely unequally, on the basis of gender” (2015, p. 695).

Methods

This was a qualitative exploratory study focused on understanding the pathways into, through and beyond alcohol treatment services for Polish women and men living in a London borough. The research was designed and conducted in collaboration with a local third sector alcohol treatment service that had a dedicated Polish key worker on staff for this community. Unforeseeable circumstances meant that we could only recruit five participants for interview through this service, so the research team contacted other local charities and service providers to help expand the sample for the project. One local charity that provided advice and advocacy for Eastern European individuals in the area supported the project by helping us to recruit a further eight participants for interview.

Subsequently, interviews were conducted with four women and nine men (three with the help of an interpreter) and four interviews with professionals providing support to Polish migrants with alcohol use problems. To supplement these data we conducted a narrative review of peer reviewed and gray literature reporting on the experiences of Polish migrants with alcohol service needs in the UK and a practitioner workshop (N = 8) to further discuss and explore emergent themes from the research work. Ethical approval for both data collection exercises was granted by (removed for anonymous peer review) University Social Work and Mental Health Research Ethics Committee. All interviews were recorded and later transcribed for analysis and lasted between 40 minutes to over one hour.

Service user participants were given a £20 supermarket voucher for their time in taking part in an interview. The interviews all took place in either the charity premises or in a room in the alcohol treatment provider. We did not record additional demographic data from service user participants, but all had been living in the UK for more than five years and ranged in age from late 20 s to early 60 s. At the time of interview seven participants had experienced homelessness at some point in addition to a range of negative life experiences including relationship breakdown, loss of access to children, social services intervention and unemployment as well as substance use difficulties.

The professionals we interviewed included the Polish key worker based in the alcohol treatment service, the director of the support charity, a local Polish priest and support worker both involved in providing a Polish speaking Alcoholics Anonymous service in addition to a soup kitchen and other homelessness support services to the Polish community.

The practitioner workshop included those working within drug and alcohol treatment services, homelessness services and, the local Clinical Commissioning Group (CCG). At the workshop the research team delivered a presentation on the emerging themes from interviews, posed a number of questions for discussion around the issues thought to be important to this group and asked practitioners to highlight the most important factors that needed to be in place in order to create an ‘ideal’ treatment service specifically for Polish migrants.

Data from these three strands of the project were combined and analyzed thematically, and for the purposes of this paper, we focused on the experiences of Polish migrant women and how they diverged from those of Polish migrant men with a view to understanding underlying differences and similarities.

Findings

Alcohol and social connections

Differences in the drinking behaviors of men and women in Poland have been well documented, for example there are reports that women, at least until recent years, were less likely to drink vodka compared to men and would rarely drink to intoxication (Mills & Knight, 2010; Podstawski et al., 2019; Wolska et al., 2004). Moving to a country where gender differences are less pronounced in terms of the acceptability of alcohol use can influence a change in these patterns of drinking for some women, as was reported by Wolska et al. (2004) in their Polish-Australian sample.

However, in our interviews a clear continuation of a more traditional Polish drinking culture was seen from male participants and was indicated as one of the reasons they found it difficult to identify a problem with alcohol or to successfully stop drinking when they wanted to. For example, in the quotes below, drinking is described as an everyday behavior by men, as a way of being sociable or of relaxing after work;

…because of the Polish culture and the drink, like between Polish people it’s all the time. There is some alcohol on the table all the time…I know my friends…know I have a problem, they can talk about it behind my back, but they still have been asking me to drink with them. (Male, Interview 2, Service 1)

But first few years [living in the UK] I’m working, just very hard job on the building sites. After job I finished at 5 O’clock, all free time just drinking alcohol really. No family here. Yeah the friends which one I know at this time, a couple of years ago, just everyone drinking. This is how we spent the free time and all money. (Male, Interview 10, Service 2)

It can be seen how admitting to having a problem with alcohol could be resisted by those who associate it with social connection and friendship. Our interviews with service users and professionals suggest that those from Polish migrant backgrounds tended to only seek help when alcohol had caused physical health issues, including liver cirrhosis and physical dependence requiring medical detoxification. Overall, those who had wider social circles and had better English language skills, seemed to find it easier to cope with abstinence from alcohol compared to those who relied almost entirely on other Polish migrants for social interaction. Earlier research has also reported that a lack of integration into local social networks served to increase the risk of substance misuse in newly arrived migrants in the UK (Mills et al., 2006). Rather than men using alcohol as primarily a means of expressing masculinity as reported elsewhere (Garapich, 2010), our participants described drinking alcohol as a way of maintaining social contact, friendship and of avoiding isolation and loneliness that can be part of the migrant experience.

The experiences of women in our study were markedly different to those of men when talking about the ways their problems with alcohol developed. Women were more likely to drink alone, at home and make considerable efforts to keep their drinking hidden from those around them. In this way, women with alcohol problems were more likely to be socially isolated as a result of their drinking, rather than through stopping drinking as was the case for men. Instead, for our female participants drinking was used as a way of coping with loneliness, poor relationships or isolation;

I didn’t even realize that I was doing…that I started drinking. So whenever I was still working as a waitress, whenever I was going back, coming back home, so let’s say night bus, 2 or 3 in the morning, buying a bottle of wine. But then no one saw it was happening and everyone was asleep, so I was sitting on my own with some cigarettes and that was it. (Female, Interview 3, Service 1)

I was drinking first at home, by my own. I was drinking like very little, like two or three beers, but every time, overnight, just night time, to relax me, I got depressed. I was feeling a little bit lonely, the kids were upstairs you know. (Female, Interview 6, Service 2)

In Poland I am married,…my husband go to another woman who have very nice home,…very nice. I have two kids, I don’t work, I stay home because the kids is small. Working only my husband, drinking after the other woman. I remember one day my husband not, at night not coming to home, I buy wine. I do for kids’ dinner, my kids go to sleep, I sit and drink. I drink all the bottle. (Female, Interview 12, Service 2)

For this woman, drinking eventually became her means of coping with mental health difficulties that developed later. She still drank alone and deliberately cut herself off from those around her for a number of days while drinking. Her alcohol use, that started as a way to deal with her feelings about her husband’s affair, became her way to work through bouts of depression without seeking outside help for either alcohol use or depression;

Now I have a lot of problem now because I have depression. I have depression I stay inside, I not go outside, I not see nobody, no one speak with nobody. I am all alone. I think everything, I think, I think, I think, I drink two or three days. (Female, Interview 12, Service 2)

Social withdrawal and isolation has been reported to be a factor in contributing to mental health difficulties for Polish mothers living in Scotland which was attributed to experiences of discrimination and negative social interactions with the local population (Sime & Fox, 2015). If Polish women have little social support from their local community they will likely have a need to rely more on their Polish community as their primary means of social connection. However, attitudes toward women with problematic alcohol use amongst this social group can lead to further isolation if drinking is hidden or seen to be unacceptable within that community (Gleeson et al., 2019).

The practitioners interviewed for this study also identified additional barriers for women in seeking help with problematic drinking. These included a financial and practical dependence on men they were in relationships with, especially for women who do not speak much English, or who do not work outside the home. It was suggested that many women who come to services have experienced domestic violence which was linked to either a partner’s substance use or one of the factors leading to their own problematic drinking;

But the problem with women I think it’s, often they are very dependent on the man here as like in our group of people the same happens, usually man is working and all the benefits and agreements is on him and she’s kind of attached. So it kind of, we have some ladies come and when, at some point when the relationship is broken and he left her, she’s alone and she has, she doesn’t know how to live even here. She doesn’t have for example even bank account…so she needs to start her life from scratch. So we kind of help her with, or even instruct some ladies who live with a kind of risky partner sometime. It could be violence, but we try to help them to be more independent, maybe register for self-employment so you know okay so trying to find some part time work, sometimes advice to survive kind of if everything bad happens. (Eastern European migrant support service)

It appears that women and men from Polish migrant backgrounds present to alcohol treatment services having had different experiences of developing problematic alcohol use and may face differing additional needs. All professionals that we spoke to (from a range of different organizations) suggested that women are under-represented in alcohol treatment services and each felt that this was at least somewhat explained by the hidden nature of Polish women’s drinking patterns and community attitudes toward women who have drinking problems. The keyworker from the alcohol treatment service also suggested that women were less likely to return to services after a relapse because of negative experiences with other organizations, such as social services or probation services, and would continue to try to hide their drinking rather than seek help;

Yeah but women wouldn’t often reoffend through substance. But I’m certain they still drink in secret, in general women still drink in secret a lot and would not be in treatment as frequently as men. (Alcohol treatment services, keyworker)

Gendered consequences of alcohol use/misuse

When discussing the consequences of long-term and problematic alcohol use, women and men in our interviews focused on different aspects of their lives. Overall, the men we interviewed talked about the impact drinking had on their employment, family relationships and housing, with many having experienced homelessness as a consequence of their alcohol use. For the women we spoke to their alcohol use was closely tied to their physical appearance, in a negative way when it affected their attractiveness, or as a way of further hiding their drinking;

…because I have a problem. I know myself, I see myself in the mirror. I see myself how pretty I am, how I damage myself because of alcohol and how alcoholic I am. (Female, Interview 13, Service 1)

Sometimes alone, sometimes I drink alone even. I drink often alone, no. Not in the street, no, because people watch. (Speaking Polish.) I have to look good if I come to nice place, I have to look good, not like homeless. I come to pretty woman, to pretty woman, pretty place…(Female, Interview 13, Service 1)

The Polish key worker that we interviewed also discussed the way that women coming to alcohol services focused on the effects of alcohol on their appearance and suggested this was one way that they could be encouraged to enter treatment and stop drinking. It was seen to be a factor that encouraged women to maintain abstinence and engage with treatment;

Well…my women will mention sometimes the, for example the effect of alcohol on what they look like, or what they feel like and especially late twenties and early thirties and around forty they would say look at what my skin looks like and how nice I look, can you tell, can you tell, because I can tell – oh yeah. So maybe there is still maybe more concern with that as well, just the quality of life and that. (Alcohol treatment service, keyworker)

The notion of the Matka Polka (Polish Mother) as a self-sacrificing, patriotic carer of sons who are raised to fight for the motherland has been the subject of much debate within Polish feminist and sociological debate (Graff, 2003; Imbierowicz, 2012). This image of women as focused exclusively on their role of motherhood fits with the ideal of women who do not drink to excess or have need of outside help and support for psychological problems. Whether it is still as strongly held a view as it may have been in the past was the subject of some discussion during our practitioner workshop. How it fits with current UK conceptions of gender equality is unclear from our data, or from the existing research literature. The image of the Matka Polka has been described as a ‘national myth’ that, while its influence appears to be waning in Poland, still has some power over how women view themselves through the motherhood perspective and how Polish society judges their choices and behavior (Imbierowicz, 2012).

As noted in the previous section, shame and stigma played a part in influencing whether women accessed services for problematic alcohol use. For women who have children this can be especially relevant if they feel their behavior is potentially embarrassing to their children and for one woman we interviewed this prevented her from accessing treatment services;

I live just near there [alcohol services building], five minute away from my house, but I think more embarrassing for me was going after when, because my girls to go to that school just near…two daughters and there was meetings… when the kids come from school. And I feel like my girls feel embarrassed as well. My daughter come once and say mummy please don’t let my friends see you coming out from [alcohol service] or going there. So I feel like they feel embarrassed as well. (Female, Interview 6, Service 2)

All of the professionals we spoke to, in interviews and the practitioner workshop, were aware of women in their services who had experienced intervention from social services and had children removed from them. The Polish keyworker also talked about how women’s pathways into alcohol services were frequently influenced by their involvement with probation and/or social services which was noted as being different to men who most often self-referred into treatment services;

But women maybe are a little bit more likely to be referred by health professionals, social services or dual diagnosis, whereas men can also just come because they just know they drink too much, or something, somewhere got out of hand, whereas women would usually be referred. (Alcohol treatment service, keyworker)

Additional challenges to working with women in alcohol treatment services were noted by other professionals and practitioners in the workshop. Partly due to the shame of ‘failing’ in their role as mothers and the stigma attached to having problematic alcohol use as a woman, professionals can find it difficult to fully understand the support needs of some women if they are reluctant to share details of their experiences, as noted by one professional;

But communication is a bit different with ladies, so they’re maybe not …

Yes in what kind of sense, how do you experience that?

To find out more, all details sometimes, they don’t tell me everything or something. So there is sometimes if they even have children or if their children are in foster cares or something, so they still struggle, struggle with addiction…But also I see a lot of breakdowns of relationships because of alcohol. So very worrying relationship with a partner who is more sober, or couldn’t stand that she was kind of drinking, she was drinking part time or something, so they separated and so she end up in the street, or I don’t know, were involved in other partners or other people and it makes a mess. (Eastern European migrant support service)

Workshop participants also noted this reluctance on the part of some women to discuss their situations fully and it was suggested that at times this may be due to fear of social services being alerted to their alcohol use when there were children in the home. The impact of having social services intervene in their family life was thought to be a factor in influencing some women to seek help but also created further negative psychological effects as it brought into question their role as ‘good’ mothers;

There’s an acceptance among some women that you can’t be a good mum while your kids are in social care. These are the consequences of your drinking. It’s a hard process to get women to accept this (Workshop participant 3)

It can be a trigger to go downhill because of the loss of the children and can lead to depression. For some it’s an engagement to go into treatment (Workshop participant 5)

For male interviewees perceptions of masculinity also influenced their motivation to stop drinking, in particular when it affected their ability to work and provide for their families. For the participant below, who was awaiting a medicated detox appointment, the sense of shame about his situation arose through having to depend on his girlfriend’s income to survive as he was unemployed due to his alcohol use and the physical effects of this;

My girlfriend is helping. I cannot live like this, you know I’m, yes, I’m a man, I’m supposed to be, I must go to job, I must do the working, I must get the money, not girlfriend. It’s not good. It’s not good. (Male, Interview 8, Service 2)

In contrast, for some men the fact that they were providing for their families gave them justification to drink which in turn led to increased use and the development of a problematic relationship with alcohol;

I’m thinking when I bring money to the house, I’m alright yeah. I buy the food, I pay the rent, I can drinking, why not? (Male, Interview 10, Service 2)

Different pathways to acknowledging a problem with alcohol and the consequences of seeking treatment were seen for men and women across our participants. The perception of how women, and especially mothers, should behave influenced both women’s drinking patterns and their engagement with support services. For men, the route to treatment appeared more straight forward and were influenced by ideals of masculinity, in being a provider and the ability to work hard. Divergent routes into treatment for the men and women in our study reflected differences in their motivations to seek help and their experiences of treatment services and ability to maintain abstinence over the longer term. This issue is discussed in more detail in the following section.

UK systems and challenges of access

Previous research has consistently highlighted barriers to accessing UK healthcare for migrant populations, including those from the European Union. Language barriers, difficulty navigating a complex system, confusion regarding entitlements to care and poverty related issues, such as access to affordable transport, have all been identified as factors in low uptake of primary healthcare for both recent and more established migrants (Jayaweera, 2014; Johnson, 2006; Madden et al., 2014). Additional cultural barriers that affect Eastern European migrants have also been suggested including; fatalism about personal health (Thom et al., 2010); stigma relating to accessing certain types of healthcare (Madden et al., 2014) and; mistrust of UK health systems (Osipvoič, 2013).

Practitioners working within UK systems of substance use treatment are most likely to reject a medical model of addiction/treatment and tend to work from a strengths-based model (e.g. Bailey et al., 2020). This contrasts with the predominance of the medical model of substance use treatment that informs services based in Poland and has been described as ‘homogenous and abstinence-oriented’ (Klingemann, 2016, p. 437). Attitudes toward treatment from our participants reflected these differences where professionals discussed a focus on abstinence as the goal of treatment for Polish migrants in their services and harm reduction approaches were largely rejected by these service users. For example, one service we spoke to hosted Polish speaking AA meetings which was focused on abstinence only as the goal as it was felt it would be impossible to have some members still drinking while others had stopped. In other services intervention based on the goal of abstinence is led by what professionals believe service users would expect from treatment;

It’s interesting for me because we don’t have that kind of approach [harm reduction] over there [in Poland], and yes my clients would actually be perhaps amused partly to know that there is that kind of reduction option. I don’t even, I just skip that altogether, I don’t tell clients because they will die from that. So I just do, that’s what they would expect too, they would probably be quite puzzled if I say would you like to be abstinent or would you like to reduce, but they are shaking and sweating and have epileptic fits, so I don’t know about reducing. (Alcohol treatment services, keyworker)

None of our service user participants had future goals of being able to regulate their drinking or reduce the amount of alcohol they drank to a safer level. The general aim, for both men and women, was to become abstinent, although some struggled at times, mainly because they were not accessing additional support for psychological needs;

If everything okay I not drink. My life is normal, it’s normal…If it’s one problem, it’s for me no problem, I not drink. But if it’s one, two, three it’s, for me it’s a lot of problem, because I not sleep, I can’t eating, nothing. My depression I not, I don’t have friend, no, if you have problem, you will speak with somebody it’s better…If you take everything inside on you…it’s not as good. (Female, Interview 12, Service 2)

This quote highlights that for Polish migrant women there is often a lack of additional social support available to them to help cope with everyday struggles. While the male participants we interviewed did not access psychological support either, they appeared to have greater support through friends and family when they stopped drinking by comparison. A focus on work, moving from homelessness to secure housing and, for some, reconnecting with children and family were key factors in maintaining abstinence for men. Women were less likely to be street homeless, so had less obvious need for these types of services, and their pathways beyond treatment differed to those of men especially in their efforts to return to what was frequently referred to as a ‘normal life’;

So it was the street life and homelessness that was driving it and made it rather impossible to consider a new change and so now that I’m housed it’s almost easy, but before that it’s not. It was park benches and streets and all the connections were drink related, social connections whereas now a lot of those friends have disappeared or have been asked to disappear with the relapse prevention. (Male, Interview 7, Service 1)

…three and a half years ago, I start building something, my new life, new relationship with the people. I start building relation with my son…and with his mother, with my mother, with my family you know. Now if I start drinking, I can lose everything again, everything again. (Male, Interview 10, Service 2)

Also, for women there seemed to be a less defined plan for how they would achieve a more ‘normal’ life, with more vague references to how they would fill their time once they had stopped drinking;

INT: Go on so what’s going to help you?

I’m not sure really to be honest. Maybe starting to working, to do something, not thinking about you know the problems and just sort of okay I’ve got problem I go and drink. (Female, Interview 6, Service 2)

Many of the participants we interviewed were still on the journey toward becoming fully abstinent from alcohol so a full picture of how they cope with life beyond treatment could not be explored in greater depth. However, issues that led to differences in developing alcohol problems and seeking help, such as social isolation and attitudes toward drinking, that were evident for men and women were raised in discussion about experiences after attending treatment services. Reductions in add-on services were also noted to have particular impacts on women who come to treatment services. In the practitioner workshop, for example, discussion of the removal of specific child and family interventions was linked to seeing fewer women come to, or staying engaged with, treatment services.

Male Polish migrants are still predominantly employed in the construction sector in the UK (McGhee et al., 2012) and changes to regulations and attitudes toward drinking were raised by practitioners as one potential protective factor for those who have stopped drinking. It appears that it has become easier for men to avoid situations where they might previously have been pressured to drink alcohol, although similar experiences for women working in other industries were not apparent;

But I think there is, the working culture in manual labor jobs has changed, because also people that I see outside of the service, again they do say that, there’s no drinking at work anymore, those times have long gone. So that seems like another protective factor. But some of my current clients do say that there is a breathalyzer floating randomly around the construction site, so nobody would come drunk. (Alcohol treatment services, keyworker)

Eriksen (1999) has argued that increasing gender equality, and how women view their social roles in modern Western societies has changed the gendered identity previously associated with alcohol. Drinking alcohol as part of the ‘new female role’ toward the end of the last century is seen to symbolize self-confidence, independence and autonomy. In contrast, sobriety is associated with outdated, traditional perceptions of women as self-sacrificing and subservient. However, the argument that ‘old’ roles based on gender are entirely replaced by new ones has been criticized as being too simplistic when research suggests a complex interweaving of both perspectives that can perpetuate binary gender identities when discussing alcohol use (Mansson & Bogren, 2014).

The intersecting role of ethnic identity is often not considered in discussions around the gendered nature of acceptable behavior in relation to alcohol use, however it has been argued that for many migrant, and ethnic minority, groups women are seen to be responsible for maintaining ethnic identity and honor through their behavior in host countries (Ryan, 2010). In Ryan’s study (2010) with Polish migrants in the UK this was articulated by other women when discussing Polish (usually younger) women’s behavior in relation to their drinking and implied sexual promiscuity. From our data, it can be seen that such social attitudes toward women from their own, and other, communities can impact their decisions to engage with alcohol treatment services and how they maintain abstinence beyond this.

Discussion

Polish migration remains a significant feature of UK population diversity and current research with Polish migrants within work spaces, and to some extent their use of healthcare systems in the UK, has contributed to an understanding of the experiences of this group. Much of this research however, has explored the experiences of Polish men and little has investigated the use or experiences of alcohol treatment services. This study sought to address these gaps in the literature by exploring the pathways of Polish women and men into, through and beyond alcohol treatment services in London.

Our findings suggest a need for services to address the unique service needs of Polish (and potentially other migrant) women including, additional social stigma, social attitudes toward women within minority communities surrounding substance use and challenges to engaging with treatment. Our findings demonstrate that such issues can have an effect on women’s patterns of drinking and developing problematic use of alcohol as well as their help seeking and engagement with treatment services. In particular, social isolation experienced by Polish women seems to play a significant part in their relationship with alcohol. The professionals we spoke to highlighted Polish migrant women’s likelihood of being dependent on a male partner both in terms of financial security and access to social networks. The multiple references from professionals relating to the interaction between alcohol use and domestic violence for this group of women also suggests a need for treatment services to be aware of the additional negative experiences of women and seek ways to ensure they are addressed within treatment programmes.

Frequent references to wanting to live a ‘normal’ life in the context of home, employment, and social interactions has been highlighted by previous researchers when discussing Polish migrants in the UK (e.g. McGhee et al., 2012). To date, it has been viewed only through the perspective of financial security when migrants compared their lives in Poland to their more recent experiences living in the UK. Nonetheless, there are parallels between what has been described by participants in McGhee et al. (2012) and those in our study, a normal life consists of having stable housing, employment and a secure family life. For those who see their alcohol use as the factor preventing them from having this, it is understandable that they may view dealing with this problem enables a more ‘normal life’ to be achieved. However, as highlighted by our data, women may find achieving this ‘normal life’ more difficult as they navigate social attitudes toward their gender, migrant status and alcohol use across communities.

Using an intersectional theoretical framework allowed us to examine the data from multiple perspectives and to analyze the ways that migrant status, gender, class and substance use influence women’s and men’s drinking patterns and attitudes toward help-seeking for problematic drinking. While intersectionality has illuminated previously marginalized perspectives on women’s experiences, we found little in the extant literature that has investigated alcohol use alongside gender and migration. Further development of the intersectionality framework including these perspectives, and the ways that gendered attitudes can impact at these different levels, would contribute to a more comprehensive understanding of the experiences of migrant women who are drinking problematically. This, in turn, could contribute to current knowledge amongst alcohol treatment providers, and other organizations, about the nuanced needs of migrant women who may have difficulty accessing and engaging fully with their services.

Also, there is a need for empirical research to better interrogate gender differences between migrant, and other minority, groups in terms of health, substance use and service provision and access if we hope to inform service provision in a meaningful way. Research from Australia (Wolska et al., 2004) suggests that younger women who migrate from Poland may be more likely to adopt local attitudes toward alcohol and gender roles. There is a need for comparable research with Polish migrant women now living in the UK to understand if, and how, these factors may impact on drinking behavior and treatment access.

This was a small qualitative study based in a single borough in London and as such there are limitations to how the findings from this research can be interpreted. The aim of the study was to explore the experiences of those had identified problems with alcohol and had sought (or been referred to) treatment services. As the findings have highlighted, it is common for Polish migrants to only seek help with alcohol problems when it has had a significant impact on their physical health or has contributed to loss of work. Therefore, it is likely that we have missed many who may be experiencing problematic alcohol use but have yet to seek out support to stop. In addition there may be differences in experiences for those who do not have entitlement to secondary care services due to the No Recourse to Public Funds (NRPF) system in the UK. Access through this system is primarily based on employment (and National Insurance payment) history and is likely to have greater impact on Polish migrant women than men, leaving a higher proportion of women in need of, for example residential treatment, unable to avail of appropriate services compared to men.

The potential consequences of Britain leaving the EU (Brexit) were raised by professionals in interviews and the practitioner workshop, although not by service users. Currently, it is not known how Brexit will affect access to primary and/or secondary healthcare services for EU migrants living in the UK and there were concerns that it would become more restrictive over time. Official statistics suggest a reduction in the numbers of EU migrants moving to the UK since the Brexit referendum (ONS, 2019) but services did not report any notable reduction in demand for treatment, homelessness or related support. Within the context of already reduced budgets for substance misuse services and local authority funding, practitioners in our study felt that the implications of Brexit would likely have further negative impacts on their ability to provide adequate services for migrant groups in need.

Finally, it is important to acknowledge that Polish migrants who develop problematic alcohol use are a minority of those who come to live in the UK. Within the literature there has tended to be a focus on the potential negative impacts of migration on Polish, and other, groups, but there are also multiple positive and protective impacts that can be experienced through moving to a different country especially for those who are relatively young, well-educated and have a social support structure in their new home (Maciagowska & Hanley, 2018).

Additional information

Funding

This work was supported by Alcohol Change UK under Grant number R2107/01.

Notes

1 Throughout this paper we have framed gender as a binary construct reflective of that used by our participants in this study, rather than as a way of excluding non-binary individuals.