Deaths resulting from alcohol are on the rise in the UK, with the highest number recorded for 20-years in England and Wales, and in over 10-years in Scotland, in 2020. However, the burden of these deaths is not felt evenly across society. Those in our most deprived communities are more likely to die from alcohol, despite often consuming less alcohol than more advantaged groups. This counter-intuitive relationship – termed the alcohol harm paradox – is undeniably an example of health inequality, yet little has been done to use what we know about health inequality to understand the causes.

In our paper published in IJERPH, we examined four key theories of health inequality. We investigated the extent to which these theories are already present in the literature on the alcohol harm paradox and their potential to understand the causes of (and therefore potential solutions to) inequalities in alcohol harm. This is important because research in this field has been dominated by studying health behaviour.

What did we find?

We examined four key theories, but this blog will focus on two of these: the social determinants of health and fundamental cause theory.

The social determinants of health consider how everything from individual characteristics, to the structure of our society, shapes health. Within this there are four underlying-interrelated-explanations:

  • Culture-behaviour: considers the role of culture and norms (the rules or expectations for behaviour when belonging to a group) in shaping health behaviour and as a result health. Behavioural explanations have dominated research on alcohol harm. However, the impact of culture and norms has only been hypothesised. Future work could look at the interplay between culture, norms and behaviour, by investigating whether the why, when, where and who of drinking occasions differs between groups.
  • Materialist: focuses on the role of wealth and resources in determining health. This explanation has not yet been tested in the context of alcohol harm. However, both individual and place-based deprivation have been proposed to have an impact. Measuring resources available in the environment and individual resources, both between and within groups, could shed light on whether materialism plays a role.
  • Psychosocial: focuses on the experience of comparing yourself to others who are better off in society and how this can negatively impact health. This explanation has not been tested in the context of alcohol harm but again the associated mechanisms have been proposed to contribute to harm. Social capital measures, which measure the extent to which your social network can protect you from stressful life events and captures the negative impacts of feeling excluded, could be used to assess whether the psychosocial pathway contributes to inequality in alcohol harm.
  • Lifecourse: takes the risk factors specified in the other explanations and situates them in time to explore critical time points and the accumulation of risks throughout life. This explanation could be assessed using event history analysis and retrospective data, however we only identified one study which had implemented these methods to investigate factors associated with the development of a comorbid alcohol and mental health condition.

Fundamental cause theory is rooted in the idea that there are fundamental resources (power, money, knowledge, social connections and prestige) which determine whether an individual will have the ability to adapt to new information or uptake new treatments.

Those with access to a flexible pool of resources can adapt and improve their health, whereas those without access cannot. This theory has been tested using a comparative case study which compared lung cancer to pancreatic cancer. This study observed a mortality advantage for those of a high socioeconomic status only for lung cancer (a preventable disease – much like liver disease) but not for pancreatic cancer.

Next steps

Our hope is that this paper will encourage alcohol researchers to use some of these theories in future research to provide structure to the research effort and get at the root causes of inequality in alcohol harm. Alcohol consumption and other behaviours do contribute to harm, that’s clear from the existing evidence, and we shouldn’t stop trying to intervene to encourage healthier behaviour.

However, we need to acknowledge that if we want to reduce inequalities in alcohol harm, we need to start to unpick the other factors and processes present in the lives of the most disadvantaged that either exacerbate the effects of their alcohol consumption, or independently contribute to their risk of harm.

Written by Jennifer Boyd, PhD student at the Wellcome Trust Doctoral Training Centre in Public Health, Economics and Decision Science, University of Sheffield

All IAS Blogposts are published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Institute of Alcohol Studies.