The socioeconomic profile of alcohol-attributable mortality in South Africa: a modelling study

Abstract

Background: Globally, illness and life expectancy follow a social gradient that puts people of lower socioeconomic status (SES) at higher risk of dying prematurely. Alcohol consumption has been shown to be a factor contributing to socioeconomic differences in mortality. However, little evidence is available from low- and middle-income countries. The objective of this study was to quantify mortality attributable to alcohol consumption in the adult (15+ years) general population of South Africa in 2015 by SES, age, and sex.

Methods: A comparative risk assessment was performed using individual and aggregate data from South Africa and risk relations reported in the literature. Alcohol-attributable fractions (AAFs) and alcohol-attributable mortality rates were estimated for cause-specific mortality by SES, sex, and age. Monte Carlo simulation techniques were used to calculate 95% uncertainty intervals (UI).

Results: Overall, approximately 62,300 (95% UI 27,000-103,000) adults died from alcohol-attributable causes in South Africa in 2015, with 60% of deaths occurring in people in the low and 15% in the high SES groups. Age-standardized, alcohol-attributable mortality rates per 100,000 adults were highest for the low SES group (727 deaths, 95% UI 354-1208 deaths) followed by the middle (377 deaths, 95% UI 165-687 deaths) and high SES groups (163 deaths, 95% UI 71-289 deaths). The socioeconomic differences were highest for mortality from infectious diseases. People of low SES had a lower prevalence of current alcohol use but heavier drinking patterns among current drinkers. Among men, AAFs were elevated at low and middle SES, particularly for the middle and higher age groups (35+). Among women, AAFs differed less across SES groups and, in the youngest age group (15-34), women of high SES had elevated AAFs.

Conclusions: Alcohol use contributed to vast socioeconomic differences in mortality. Where observed, elevated AAFs for people of low and middle SES arose from higher levels of consumption among current drinkers and not from the prevalence of current alcohol use per se. The findings can direct preventive measures and interventions on those at highest risk. Future research is needed to investigate socioeconomic differences in the risk functions relating alcohol use to cause-specific mortality.

Keywords: Alcohol consumption; Burden of disease; Inequalities; Mortality; Socioeconomic status; South Africa.

Fig. 1

Schematic overview of the data sources and relative risks used in the calculation steps. A subgroup was defined by socioeconomic status, age, and sex. DSA Demographic Surveillance Area, GISHA Global Information System on Alcohol and Health, IHME Institute for Health Metrics and Evaluation, NIDS National Income Dynamics Study, SES socioeconomic status, WHO World Health Organization

Fig. 2

Alcohol-attributable fractions (AAFs) among women (top) and men (bottom) by socioeconomic status (SES), age, and cause of death. Estimates for South Africa in 2015

Fig. 3

Stacked age distribution of all alcohol-attributable deaths attributable by socioeconomic status (SES) and sex. Estimates for South Africa in 2015. Age was truncated at 70 years

Fig. 4

Age-standardized mortality rates per 100,000 attributable to alcohol consumption. Estimates for South Africa in 2015 by socioeconomic status (SES), cause of death, and sex. LRI lower respiratory infections