Causal mechanisms proposed for the alcohol harm paradox—a systematic review

Abstract

Background and Aims The alcohol harm paradox (AHP) posits that disadvantaged groups suffer from higher rates of alcohol‐related harm compared with advantaged groups, despite reporting similar or lower levels of consumption on average. The causes of this relationship remain unclear. This study aimed to identify explanations proposed for the AHP. Secondary aims were to review the existing evidence for those explanations and investigate whether authors linked explanations to one another. Methods This was a systematic review. We searched MEDLINE (1946–January 2021), EMBASE (1974–January 2021) and PsycINFO (1967–January 2021), supplemented with manual searching of grey literature. Included papers either explored the causes of the AHP or investigated the relationship between alcohol consumption, alcohol‐related harm and socio‐economic position. Papers were set in Organization for Economic Cooperation and Development high‐income countries. Explanations extracted for analysis could be evidenced in the empirical results or suggested by researchers in their narrative. Inductive thematic analysis was applied to group explanations. Results Seventy‐nine papers met the inclusion criteria and initial coding revealed that these papers contained 41 distinct explanations for the AHP. Following inductive thematic analysis, these explanations were grouped into 16 themes within six broad domains: individual, life‐style, contextual, disadvantage, upstream and artefactual. Explanations related to risk behaviours, which fitted within the life‐style domain, were the most frequently proposed (n = 51) and analysed (n = 21). Conclusions While there are many potential explanations for the alcohol harm paradox, most research focuses on risk behaviours while other explanations lack empirical testing.

Beyond Behaviour: How Health Inequality Theory Can Enhance Our Understanding of the ‘Alcohol-Harm Paradox’

“…Most have a common focus: to shift attention away from the individual-level and behavioural factors, and instead take a multi-level approach. In this section we outline four main theoretical approaches: the SDH, FCT, the political economy approach and the eco-social model (see Table 1 for descriptions of each theory), and referring to a recent review [9], discuss how these approaches fit with explanations for the AHP used within scientific literature. The review highlighted which explanations had remained hypothetical, and which were present in the empirical research.…”

“…Explicitly using the psychosocial approach would reframe the discussion of psychological and social mechanisms to consider how people feel compared to others and the psychological and biological consequences of those feelings which may contribute to the inequalities expressed within the AHP. This concept of relative deprivation is particularly important given the presence of the AHP in high income social welfare state countries [9] where social inequality persists. There is a vast literature on psychosocial pathways, which have been shown to contribute to health inequalities more generally [50], particularly in the form of social capital (capturing both social buffer and potential negative effects of social inequality and exclusion).…”

“…Despite socioeconomic inequalities in alcohol-related health outcomes, health behaviour has been central to research investigating the AHP [9]. This reflects wider public health trends, as for decades epidemiological research has been criticised for its emphasis on using individual-level proximal risk factors to predict population-level health [10,11].…”

“…While empirical research on the AHP has been limited in exploring other factors associated with socioeconomic circumstances [9], there is an increasing appetite to draw on explanations used to understand health inequalities. A report summarising the AHP discusses access to healthcare and material resources as potential explanations [15].…”

“…In Section 2 we introduce prominent theories including the social determinants of health (SDH), fundamental cause theory (FCT), the political economy approach and the eco-social model and discuss the extent to which these approaches are present in the existing AHP literature. We do so by explicitly drawing on a recent systematic review which presents an overview of the explanations for the AHP [9]. We then examine how these theories could be used to explicitly frame research on the AHP.…”