Cross-sectional surveys of financial harm associated with others' drinking in 15 countries: Unequal effects on women?

A global review of the impact on women from men's alcohol drinking: the need for responding with a gendered lens

BACKGROUND

Global evidence shows that men's harmful alcohol use contributes to intimate partner violence (IPV) and other harms. Yet, interventions that target alcohol-related harms to women are scarce. Quantitative analyses demonstrate links with physical and verbal aggression; however, the specific harms to women from men's drinking have not been well articulated, particularly from an international perspective.

AIM

To document the breadth and nature of harms and impact of men's drinking on women.

METHODS

A narrative review, using inductive analysis, was conducted of peer-reviewed qualitative studies that: (a) focused on alcohol (men's drinking), (b) featured women as primary victims, (c) encompassed direct/indirect harms, and (d) explicitly featured alcohol in the qualitative results. Papers were selected following a non-time-limited systematic search of key scholarly databases.

RESULTS

Thirty papers were included in this review. The majority of studies were conducted in low- to middle-income countries. The harms in the studies were collated and organised under three main themes: (i) harmful alcohol-related actions by men (e.g. violence, sexual coercion, economic abuse), (ii) impact on women (e.g. physical and mental health harm, relationship functioning, social harm), and (iii) how partner alcohol use was framed by women in the studies.

CONCLUSION

Men's drinking results in a multitude of direct, indirect and hidden harms to women that are cumulative, intersecting and entrench women's disempowerment. An explicit gendered lens is needed in prevention efforts to target men's drinking and the impact on women, to improve health and social outcomes for women worldwide.

Can alcohol policy prevent harms to women and children from men's alcohol consumption? An overview of existing literature and suggested ways forward

The World Health Organization's list of cost-effective alcohol control policies is a widely-used resource that highlights strategies to address alcohol-related harms. However, there is more evidence on how recommended policies impact harms to people who drink alcohol-such as physical health problems caused by heavy alcohol use-than on secondhand harms inflicted on someone other than the person drinking alcohol, i.e., alcohol's harms to others. In this essay, we describe evidence of impacts of alcohol policy on harms to women and children resulting from men's alcohol consumption, as well as options for making policies more relevant for reducing intimate partner violence and child abuse. We begin with an overview of harms to women and children resulting from men's alcohol consumption and review cost-effective alcohol policies with potential to reduce these harms based on likely mechanisms of action. Next, we present a rapid review of reviews to describe existing evidence of impacts of these policies on the outcomes of physical violence, sexual violence, and child abuse and neglect. We found little evidence of systematic evaluation of impacts of these important alcohol policies on harms to women and children. Thus, we advocate for increased attention in evaluation research to the impacts of alcohol policies on harms experienced by women and children who are exposed to men who drink alcohol. We also argue for more consideration of a broader range of policies and interventions to reduce these specific types of harm. Finally, we present a conceptual model illustrating how alcohol policies may be supplemented with other interventions specifically tailored to reduce alcohol-related harms commonly experienced by women and children as a result of men's alcohol use.

Alcohol's harm to others in 2021: Who bears the burden?

BACKGROUND AND AIMS

Alcohol's harm to others (AHTO) has become a key driver of national and international alcohol policy. This study aimed to produce a contemporary, comprehensive estimate of the correlates and harms from others' drinking in 2021 in Australia.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Across Australia, 2574 adults (1380 women; 1172 men) were sampled via two cross-sectional survey modes: a random-digit dial mobile phone sample of 1000 people and 1574 people from the Life in Australia™ panel survey. In 2021 participants were asked about harms they had experienced from the drinking of family, friends, co-workers and the public in the past year. Applying combined sample weights from each mode, bivariable and adjusted multivariable logistic regressions were used to analyse differences in rates of AHTO by participant gender, age, residence in rural or metropolitan regions, country of birth, education and employment.

FINDINGS

In 2021, 23.6% reported being negatively affected by strangers' drinking and 21.3% by the drinking of someone they knew, with 34.3% reporting being negatively affected a lot or a little by either; 42.4% of respondents reported specific harms from strangers' drinking. Thus, 48.1% of respondents reported any harm (negative effects or specific harms) from others' drinking. Women, younger people, Australian-born and heavier episodic drinkers reported significantly higher rates of AHTO compared with other respondents. Smaller percentages (7.5%) of participants reported being harmed substantially by others' drinking, including by people they knew (5.8%) or strangers (2.3%). Stratified analyses showed that heavier drinking, furloughed, younger men who were born overseas in English-speaking countries were affected by others' drinking, whereas women were affected regardless of these factors (apart from age).

CONCLUSIONS

More than one-third of Australian adults appear to have been negatively affected by others' drinking in 2021, with women, younger people and heavier drinkers at greater risk. Substantial harm appears to be more likely to arise from the drinking of people Australians know than from strangers' drinking.

Social disparities in alcohol's harm to others: evidence from 32 European countries

BACKGROUND

Alcohol use can cause harm not only to the person who consumes it but also to others. Prior research has found that these alcohol-attributable harms to others differ across socioeconomic groups, though several findings have been contradictory. The aim of this contribution was to study the role of individual-level and population-level income inequalities in alcohol's harm to others among women and men.

METHODS

Logistic regression analysis of cross-sectional survey data from 2021, covering 39,629 respondents from 32 European countries. Harms from others' drinking were defined as experiences of physical harm, involvement in a serious argument, or involvement in a traffic accident, due to another person's drinking, within the past year. We examined the association of individual-level income and country-specific income inequality (Gini index) with harms from a known person's or a stranger's drinking, adjusting for the respondent's age, daily drinking levels, and at least monthly risky single-occasion drinking.

RESULTS

At the individual level, people with lower incomes had 21% to 47% increased odds of reporting harms from a known person's drinking (women and men) or stranger's drinking (men only) than their same-gender counterparts in the highest income quintile. At the national level, countries with higher income inequality showed increased risks of harms from a known person's drinking among women (OR = 1.09, 95% confidence interval [CI]: 1.05 - 1.14), while among men the risk of harm from strangers' drinking decreased with higher income inequality (OR = 0.86, 95% CI: 0.81 - 0.92). These associations with income inequality were observed among respondents from all but the lowest income groups.

CONCLUSION

Alcohol can cause harm to others, with women and people with low incomes being disproportionally exposed to these harms. Alcohol control policies targeting high consumption levels, especially among men, as well as upstream policies to reduce inequalities, are needed to lower the health burden of alcohol beyond those who consume it.

The relationship between fathers' heavy episodic drinking and fathering involvement in five Asia-Pacific countries: An individual participant data meta-analysis

BACKGROUND

This study aims to increase understanding of the relationship between heavy episodic drinking (HED) and fathers' involvement in parenting in five countries. The potential moderating effect of fathers' experiences of childhood trauma is also studied, controlling for the possible confounding of the effect of HED by father's attitudes toward gender equality, father's age and father's education.

METHOD

United Nations Multi-Country Study on Men and Violence (UNMCS) survey data from 4562 fathers aged 18-49 years from Cambodia, China, Indonesia and Papua New Guinea (PNG) and Sri Lanka were used to assess the relationship between fathering involvement (e.g., helping children with their homework) and self-reported HED of 6+ drinks in one occasion vs. non-HED and abstaining. Moderating effects of a 13-item fathers' childhood trauma (FCT) scale were tested and analyses were adjusted for gender-inequitable attitudes using the Gender-Equitable Men scale score. Bivariate and adjusted individual participant meta-analyses were used to determine effect estimates for each site and across all sites.

RESULTS

Fathers' HED was associated with less positive parental involvement after adjusting for gender-equitable attitudes, FCT, age and education. No overall interaction between HED and FCT was identified. Gender equitable attitudes were associated with fathering involvement in some countries but not overall (p = 0.07).

CONCLUSIONS

Heavy episodic drinking was associated with reduced positive fathering involvement. These findings suggest that interventions to increase fathers' involvement in parenting should include targeting reductions in fathers' HED. Structural barriers to fathers' involvement should be considered alongside HED in future studies of fathers' engagement with their children.

Al-Anon Intensive Referral to facilitate concerned others' participation in Al-Anon Family Groups: a randomized controlled trial

AIMS

To test the effectiveness of an intervention, Al-Anon Intensive Referral (AIR), to facilitate participation in Al-Anon Family Groups (Al-Anon).

DESIGN, SETTING AND PARTICIPANTS

Multi-site, randomized controlled trial of AIR versus usual care (UC), with follow-up assessments at 3, 6 and 12 months. The 12-month follow-up rate was 74%. Residential alcohol use disorder (AUD) treatment programs in three US locations. Concerned others (COs) of patients in treatment for AUD. COs were mainly women (77%) who were patients' spouses (33%) or parents (25%).

INTERVENTION AND COMPARATOR

AIR (n = 128) consisted of four sessions over 3 months with an Al-Anon coach. UC (n = 151) was the treatment program's offer of educational sessions for COs.

MEASUREMENTS

Primary outcome: COs' self-reports of any Al-Anon attendance (yes or no) at 3 months.

SECONDARY OUTCOMES

number of Al-Anon meetings and the CO-patient relationship (stressors, resources). Potential predictors of outcomes examined in generalized linear mixed models were their baseline value, time, CO-patient relationship type (marital or non-marital), treatment program and condition.

FINDINGS

There was no effect of condition for the primary outcome (28% in AIR, 21% in UC; Bayes factor = 1.86). Relationship stressors at follow-ups were more severe for COs in a marital relationship with the patient than for COs in a non-marital relationship [β = 2.19, 95% confidence interval (CI) = 1.07, 3.32]. For CO-patient relationship resources at follow-ups, the main effect for condition was significant (β = 1.33, 95% CI = 0.04, 2.61). COs assigned to the AIR condition had more resources than COs who were in the UC condition.

CONCLUSIONS

Relative to usual care, Al-Anon Intensive Referral was not associated with increases in participation of concerned others in Al-Anon, but was associated with more resources in the concerned other-patient relationship.

Improving measurement of harms from others' drinking: Using item-response theory to scale harms from others' heavy drinking in 10 countries

INTRODUCTION

The heavy drinking of others may negatively affect an individual on several dimensions of life. Until now, there is scarce research about how to judge the severity of various experiences of such harms. This study aims to empirically scale the severity of such harm items and to determine who is at most risk of these harms.

METHODS

We used population-based survey data from 10 countries of the GENAHTO project (Gender and Alcohol's Harms to Others, data collection: 2011-2016). Questions about harms from others' drinking asked about verbal and physical harm, damage of belongings, traffic accidents, harassment, threatening behaviour, family and financial problems. We used item response theory methods (IRT) to scale severity of the aforementioned items. To acknowledge culturally based variations in different countries, we assessed 'differential item functioning'.

RESULTS

The items 'family problems', 'financial problems' and 'clothes and property damage' as well as 'physical harm' were scaled as more severe in most countries compared to other items. Substantial differential item functioning was present in more than half of the country pairings. The item 'financial problems' was most often differentially scaled. Younger people who drank more, as well as women (compared to men), reported more harm.

DISCUSSION AND CONCLUSIONS

Using IRT, we were able to evaluate grades of severity in harms from others' drinking. IRT scaling yielded in similar rankings of items as reported from other studies. However, empirical scaling allows for more differentiated severity scaling than simple summary scores and is more sensitive to cultural differences.

A multi-country analysis of informal caregiving due to others' drinking

The burden of caring for drinkers is seldom articulated as a social concern, or integrated in service planning or alcohol policy. This study aims to examine prevalence and predictors of informal caregiving due to others' drinking cross-nationally by surveying 20,728 respondents (18-64 years) in 11 countries. The outcome variable was respondent-reported informal caregiving due to others' drinking, analysed by socio-demographic factors and drinking pattern using logistic regression and meta-analysis. Estimated overall prevalence of informal caregiving due to others' drinking ranged from 9% in Nigeria to 47% in Thailand. In most countries, females reported a higher rate than males of caring for children and other dependents, but males reported a higher rate of driving family or friends somewhere or picking them up. Logistic regression analysis found differences between high-income countries and low- and middle-income countries in the relationship of caregiving with employment and household composition. Respondent's own drinking was positively correlated with the prevalence of caregiving in 10 out of 11 countries. In general, younger adults and those who are themselves risky drinkers are more likely to have had caring responsibilities. Although problematic drinking is concentrated in specific subpopulations, the burden of care for others' drinking extends widely across the population.

Does drinking modify the relationship between men's gender-inequitable attitudes and their perpetration of intimate partner violence? A meta-analysis of surveys of men from seven countries in the Asia Pacific region

BACKGROUND AND AIMS

Although men's alcohol misuse and less gender-equitable attitudes have been identified as risks for perpetration of intimate partner violence (IPV), less is known about how men's gender-equitable attitudes and drinking act together to increase risk of IPV. This study aimed to assess the independent relationships of lower gender-equitable attitudes and drinking to perpetration of IPV and their interaction among men in seven countries.

DESIGN

Secondary analysis of the United Nations Multi-Country Study on Men and Violence (UNMCS) and Nabilan Study databases consisting of (1) unadjusted and adjusted logistic regression to measure the association of perpetration of IPV with gender-equitable men (GEM) scale score and regular heavy episodic drinking (RHED) and (2) meta-analyses of prevalence and effect estimates adjusted for country-level sites and countries.

SETTING AND PARTICIPANTS

A total of 9148 ever-partnered 18-49-year-old men surveyed in 2011-15 from 18 sites in Bangladesh, Cambodia, China, Indonesia, Papua New Guinea, Sri Lanka and Timor Leste.

MEASUREMENTS

The outcome variable is reported perpetration of physical or sexual IPV in the previous year.

INDEPENDENT VARIABLES

GEM scale scores; RHED, defined as six or more drinks in one session at least monthly (compared with other drinkers and abstainers).

FINDINGS

Pooled past-year prevalence of perpetration of IPV was 13% [95% confidence interval (CI) = 9-16%]. GEM scores and RHED were independently associated with perpetration of IPV overall and in most sites. Pooled odds ratios (ORs) for perpetration of IPV with less equitable GEM scores were 1.07 (95% CI = 1.04, 1.09) and with RHED were 3.42 (95% CI = 2.43, 4.81). A significant interaction between GEM score and RHED (P = 0.001) indicated that RHED increased the relationship of less gender-equitable attitudes and perpetration of IPV.

CONCLUSION

Both gender-inequitable attitudes and drinking appear to be associated with perpetration of intimate partner violence by men, with regular heavy episodic drinking increasing the likelihood of intimate partner violence among men with less equitable gender attitudes.

Harms to children from the financial effects of others' drinking

BACKGROUND

Many children live with parents who drink and experience little impact, but risky or heavy drinking by caregivers can result in a range of harms to children. Alcohol-related financial harms which directly impact children's needs in general populations have been seldom studied.

OBJECTIVE

The study aims to identify the prevalence and correlates of financial harms from others' drinking affecting children's needs in nine lower- and middle-income (LMICs) and high-income countries (HICs).

METHODS

Participants (n = 7,669) from Brazil, Chile, Ireland, Lao PDR, Nigeria, Sri Lanka, Thailand, USA and Viet Nam were aged 18-64 years and living with children. Logistic regression and meta-analyses explored differences in financial harm affecting children among LMICs and HICs, adjusting for gender, education, rurality and drinking pattern.

RESULTS

In around one-tenth to a third of households in the nine countries, children lived with people who drank riskily. Less than 1% to 8% of respondents reported that their children's needs had not been met because of financial harm from others' drinking. Women reported significantly greater harm to children due to the financial effects of others' drinking than men in the USA, Nigeria and Viet Nam. When the participant reported drinking riskily, and particularly when families included someone who drank heavily, increased odds of financial harm from others' drinking affecting children were identified.

CONCLUSION

That children's needs were not met due to financial harm from others' drinking was reported by three percent (<1 to 8%) of caregivers across the nine countries, representing a problem for large numbers of children, particularly in the low and middle-income countries studied. When a person's drinking was reported to be heavy or harmful within the family, the risk that children's needs were affected by the financial impacts of others' drinking was significantly greater.

Are Countries' Drink-Driving Policies Associated With Harms Involving Another Driver's Impairment?

INTRODUCTION

International drink-driving policy research generally focuses on aggregate outcomes (e.g., rates of crashes, fatalities) without emphasizing secondhand alcohol-related vehicular harms. In contrast, we investigate associations between drink-driving policies and harms involving another driver's impairment.

METHODS

Alcohol's harms to others (AHTO) survey data from 12 countries (analytic N = 29,616) were linked to national alcohol policy data from the World Health Organization. We examined separately associations of two 12-month driving-related AHTOs (passenger with an impaired driver; vehicular crash involving someone else's drink driving) with 3 national drinking-driving policies-legal blood alcohol concentration (BAC) limits, use of random breath testing, use of sobriety checkpoints, and comprehensive penalties for drink-driving (community service, detention, fines, ignition interlocks, license suspension/revocation, mandatory alcohol treatment, vehicle impoundment, and penalty point system), plus 2 alcohol tax variables (having excise taxes and value-added tax [VAT] rate). Multilevel logistic regression addressed clustering of individuals within countries and subnational regions, while adjusting for individuals' gender, age, marital status, risky drinking, and regional drinking culture (% male risky drinkers in sub-national region).

RESULTS

Controlling for national-, regional-, and individual-level covariates, comprehensive penalties were significantly and negatively associated with both outcomes; other vehicular policy variables were not significantly associated with either outcome. A society's VAT rate was negatively associated with riding with a drunk driver. Regional male drinking culture was positively associated with riding with an impaired driver, but was not significantly associated with being in a vehicular crash due to someone else's drinking. In both models, being male, being younger, and engaging in risky drinking oneself each were positively associated with vehicular harms due to someone else's drinking.

CONCLUSIONS

Although results are associational and not causal, comprehensive penalties may be promising policies for mitigating driving-related harms due to another drinker. Higher VAT rate might reduce riding with a drunk driver.