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

Jennifer Boyd,Clare Bambra,John Holmes,Robin C Purshouse

doi:10.3390/ijerph18116025

Abstract

There are large socioeconomic inequalities in alcohol-related harm. The alcohol harm paradox (AHP) is the consistent finding that lower socioeconomic groups consume the same or less as higher socioeconomic groups yet experience greater rates of harm. To date, alcohol researchers have predominantly taken an individualised behavioural approach to understand the AHP. This paper calls for a new approach which draws on theories of health inequality, specifically the social determinants of health, fundamental cause theory, political economy of health and eco-social models. These theories consist of several interwoven causal mechanisms, including genetic inheritance, the role of social networks, the unequal availability of wealth and other resources, the psychosocial experience of lower socioeconomic position, and the accumulation of these experiences over time. To date, research exploring the causes of the AHP has often lacked clear theoretical underpinning. Drawing on these theoretical approaches in alcohol research would not only address this gap but would also result in a structured effort to identify the causes of the AHP. Given the present lack of clear evidence in favour of any specific theory, it is difficult to conclude whether one theory should take primacy in future research efforts. However, drawing on any of these theories would shift how we think about the causes of the paradox, from health behaviour in isolation to the wider context of complex interacting mechanisms between individuals and their environment. Meanwhile, computer simulations have the potential to test the competing theoretical perspectives, both in the abstract and empirically via synthesis of the disparate existing evidence base. Overall, making greater use of existing theoretical frameworks in alcohol epidemiology would offer novel insights into the AHP and generate knowledge of how to intervene to mitigate inequalities in alcohol-related harm.

Highlights

Systematic socioeconomic inequalities in health persist and continue to widen across the globe, including in countries ranked highly on indices of economic prosperity and human development [1,2]
There is a large body of evidence to suggest that, those of lower socioeconomic position (SEP) tend to drink the same or less on average as those in higher SEPs, they still experience greater rates of alcohol-related harm [4]
The aim of this paper is to address this gap by identifying alternative approaches rooted in health inequality theory which could be used to design future research on the alcohol-harm paradox (AHP)

Summary

Introduction

Systematic socioeconomic inequalities in health persist and continue to widen across the globe, including in countries ranked highly on indices of economic prosperity and human development [1,2]. Alcohol-related health outcomes are an example of health inequality and contribute to inequalities in both life expectancy and death age between socioeconomic groups [3]. One record linkage study found that, despite controlling for alcohol consumption and other risk behaviours, the most deprived group still maintain a three-fold higher risk of alcohol-related harm [5]. This phenomenon, termed the alcohol-harm paradox (AHP), treats alcohol use as a risk factor for health-related harm, when alcohol use crosses into alcohol dependence the social/health state of dependence that arises is.

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