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.

ObjectivesPrevious qualitative research investigating the experiences of women diagnosed with gestational diabetes (GD) has provided important insights into the development of behaviour change interventions. However, these studies often lack a theoretical underpinning. This study explored the use of the capability, opportunity, motivation and behaviour (COM-B) framework (which proposes that individuals need the capability, opportunity and motivation to perform a particular behaviour) to code and the socioecological model to contextualise participant responses to better inform intervention development.DesignQualitative semistructured interviews are using purposive sampling. Interviews were audio-recorded, transcribed and coded using the COM-B framework. A socioecological approach was adopted to understand the context of intervention facets.SettingInterviews were conducted in a secondary care setting in South Yorkshire.ParticipantsTwenty-seven postnatal women with a previous diagnosis of GD were interviewed.ResultsApplying the COM-B framework to code participant, responses identified 16 key subthemes which reflected either: capability, opportunity or motivation components of the model. Four domains adapted from the socioecological model: individual, family life, community and healthcare provision; contextualised factors are important for these women in terms of behaviour change. Emotional response at the individual level was highly motivating or demotivating. Factors related to family life and community were particularly dominant and had the potential to either facilitate or impede change. We found many participants relied on healthcare provision during the prenatal and postnatal periods with timing and positive relationships being key to good care.ConclusionsOur study provides further insight into the factors crucial for behaviour change in women diagnosed with GD. By innovatively applying the COM-B framework in a socioecological context, it is clear intervention facets need to target microlevel through the macrolevel to engage this population in behaviour change. Future work should consider family-level intervention as this could allow for sustained behaviour change and consequently prevent the development of type 2 diabetes mellitus.

Objective We aimed to systematically review and synthesise evidence on the clustering of a broad range of health-related behaviours amongst 11–16 year olds. Method A literature search was conducted in September 2019. Studies were included if they used cluster analysis, latent class analysis, prevalence odds ratios, principal component analysis or factor analysis, and considered at least three health-related behaviours of interest among 11–16 year olds in high-income countries. Health-related behaviours of interest were substance use (alcohol, cigarettes and other drug use) and other behavioural risk indicators (diet, physical activity, gambling and sexual activity). Results The review identified 41 studies, which reported 198 clusters of health-related behaviours of interest. The behaviours of interest reported within clusters were used to define eight behavioural archetypes. Some included studies only explored substance use, while others considered substance use and/or other health-related behaviours. Consequently, three archetypes were comprised by clusters reporting substance use behaviours alone. The archetypes were: (1) Poly-Substance Users, (2) Single Substance Users, (3) Substance Abstainers, (4) Substance Users with No/Low Behavioural Risk Indicators, (5) Substance Abstainers with Behavioural Risk Indicators, (6) Complex Configurations, (7) Overall Unhealthy and (8) Overall Healthy. Conclusion Studies of youth health behavioural clustering typically find both a ‘healthy’ cluster and an ‘unhealthy’ cluster. Unhealthy clusters are often characterised by poly-substance use. Our approach to synthesising cluster analyses may offer a means of navigating the heterogeneity of method, measures and behaviours of interest in this literature.

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.

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