Alcohol and Ethnicity reporting- still a long way to go?
By Stacey Jennings, PhD student from Wolfson Institute of Population Health, Queen Mary University of London (QMUL). Stacey is working on the Alcohol and Ethnicity study as part of her PhD (www.alcoholandethnicity.com).
In this blog post, Stacey Jennings discusses the need to properly assess and address ethnicity in alcohol research, highlighting that we must improve representation of ethnic minorities across inclusion, reporting, and analysis. This is part one of the two-part SHAAP blog series on alcohol and ethnicity (read part two).
Ethnicity consideration in alcohol research
Our approach to ethnicity in research has been a longstanding topic of discussion. However, recent global events have coincided to drastically intensify the spotlight on health inequalities across ethnic groups. In particular, the observed differential impact of COVID-19 on ethnic groups across multiple outcomes has underlined the need to properly assess and address ethnicity in our research. But how do we best do this? Several recent publications have focused on the importance of both inclusivity and disaggregating ethnic data as approaches to meaningfully tackle health inequalities.
These calls are also increasing in prominence within the alcohol research field. Gaps in knowledge raised in the Ethnic Minorities and Alcohol briefing published by the Institute of Alcohol Studies (IAS) in October 2020 highlight that clinical trials of alcohol interventions have not regularly reported on recruitment of people from ethnic minorities or the outcomes across different ethnic groups. These gaps in the alcohol intervention evidence base have not only been flagged in the UK but internationally. For example, a US systematic review focused specifically on ethnic and sex reporting in pharmacological trials for Alcohol Use Disorder found that only 12% of trials reported full characteristics and only 6% conducted subgroup analyses. This is problematic given subgroup analyses are a ‘gold standard’ statistical method that allow us to examine differential treatment effects. Echoing previous recommendations, this paper also served as a call to action for alcohol research to improve standards.
This matters as ethnicity is significantly associated with alcohol-related outcomes and engagement with health services. For example, British South Asian groups demonstrate the alcohol harm paradox, whereby despite reporting low alcohol consumption, they are overrepresented in certain alcohol-related disorders in complex ways. Asian groups are overrepresented in hypertensive disorders, Sikh men are overrepresented in liver cirrhosis, and despite having lower than average mortality rates, men and women born in Bangladesh and Pakistan have higher mortality rates from liver cancer. Possible explanations for the paradox include self-report bias due to stigma, increased physiological susceptibility to harm, or that factors beyond alcohol use are influencing prevalence of alcohol-related disorders. Barriers to treatment seeking and reduced engagement with alcohol services could also contribute to increased severity of illness. To better understand the causes of these health inequalities and inform optimal alcohol intervention strategies that capture diversity between and within ethnic groups, proper representation is a necessity.
Despite recent attention, how we consider ethnicity in UK alcohol literature appears to remain starkly suboptimal across all three levels of inclusion, reporting, and analysis. A report and systematic review (to be published) carried out by our team on the Alcohol and Ethnicity project looking specifically at British South Asian groups has also examined this in depth. Whilst the subject of recent focus, recommendations of improving standards in ethnicity consideration are not a new phenomenon- they have been highlighted for decades, yet we still do not seem to be reaching the required standard. This raises two fundamental questions:
- How generalisable is our alcohol research to the diverse British population (i.e., are studies transparent about who is included and who the treatment is effective for)?
- What are the specific barriers to achieving higher standards of ethnicity consideration in terms of inclusion, reporting and analysis?
Alcohol research and cultural competence
With alcohol intervention research demonstrating such patchy and variable levels of ethnicity consideration, it follows that this can be reflected in clinical practice. Of course, ethnicity is not the only factor impacting upon service use and provision. Many of the people I’ve interviewed dealing with alcohol-related problems, regardless of background or level of service use, seem to share some key barriers and facilitators to engagement. At the forefront is the fact that it is rarely alcohol in isolation, but a myriad of co-existing difficulties (physical, mental, emotional, relationship, financial, practical, spiritual to name a few) that serve to maintain the cycle of addiction. It is unsurprising that these difficulties can also directly and indirectly impact on access to services. Many people (and their loved ones) felt frustrated and let down by services they perceived as ill-equipped to hear their voices or acknowledge their full range of needs. The operational characteristics of some alcohol services often inadvertently compounded the issues of the very people they seek to help. Many service users felt that the reality of the numerous hurdles they face to even get to the waiting room each week were not understood; often finding themselves discharged from support after missing a small number of appointments and then stuck on a ‘hamster wheel’ of reinitiating contact.
However, even less understood were specific barriers for ethnic minorities, and how these further diversify according to other intersecting characteristics such as gender and age. Those from South Asian backgrounds often raised cultural barriers to engagement, like heightened confidentiality concerns surrounding stigma. Crucially, however, framing of all problems as being religio-cultural in nature could be a major source of frustration and service users felt they were being viewed through a reductive lens. Cultural competence- put simply, our skills in effectively working with people from different cultures- is a widely used term and explicit criterion of most services. Matching of service user and staff ethno-cultural characteristics still appeared to be a default service approach to cultural competence, yet this was certainly not a blanket preference shared by all service users, as has been well documented in research. We must be able to incorporate nuances in both individual and collective identities to effectively tailor approaches to people’s needs. To do this, we must better define and exercise cultural competence and a crucial component of this is surely developing the evidence base. It follows that if the evidence underpinning practice is suboptimal in its consideration of ethnicity, how can we expect cultural competency and literacy to be at the required standard?
Alcohol research must improve its representation of ethnic minorities across inclusion, reporting, and analysis. To tackle these barriers and enhance our standards in alcohol research, we need to appreciate that there may be complex factors operating and interacting at participant, researcher, and structural levels (nicely illustrated in the UK context by Hussein-Gambles, Atkin and Leese). Increased inclusion seems like a reasonable starting point, which will likely facilitate and enable enhanced reporting and disaggregated analysis of ethnicity data in research and national surveys. We need to ensure mainstream literature represents ethnic minorities not just by inclusion in alcohol studies, but also by undertaking comprehensive research that specifically focuses on minorities and marginalised groups. Presently, it appears that there is an overreliance on already under resourced and stretched third sector alcohol agencies and charities to fulfil this role. In the context of anticipated addiction crises from COVID-19, it is imperative that we finally give these issues their proper attention to ensure both alcohol research and interventions are inclusive and effective for all.
Stacey Jennings would like to acknowledge QMUL, Barts Health Charity and her supervisory team on the Alcohol and Ethnicity project: Dr Georgina Hosang1, Professor Simon Dein1, Professor Graham Foster2, and Professor Kamaldeep Bhui3.
1 Centre for Psychiatry & Mental Health, Wolfson Institute of Population Health, QMUL
2 Blizard Institute, QMUL
3 Department of Psychiatry & Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford
SHAAP 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 Scottish Health Action on Alcohol Problems.