1.BackgroundAlcohol use disorders (AUD) are characterized by impaired control of alcohol consumption, compulsion to drink, and withdrawal symptoms upon cessation.(1) The harmful use of alcohol is a causal factor in more than 200 disease and injury conditions and accounts for 5.1% of the worldwide burden of disease.(2) AUD are more prevalent in high-income countries than in low and lower-middle-income countries and Muslim-majority countries.(3) Effective treatment is available. However, fewer than 20% of people affected access alcohol-related healthcare.(4, 5) For women with AUD, this number is even lower due to socio-economic and self-esteem factors.(6)Over the past decade, female harmful alcohol use has been an emerging trend in many countries. The World Health Organization (WHO) reports that the absolute global number of currently drinking women has increased and is predicted to continue increasing, especially in North and South America. (3) It is estimated that 3.7 % of women in the United States (US), and one in every 30 women aged 16 or older in the United Kingdom (UK), have an AUD.(7, 8)In Australia, women aged 45 to 60 who consume more than two standard drinks per day have increased from 8.8% in 2001 to 11.7% in 2019.(9) Women aged 30 to 39 have increased single-occasion risky drinking from 17% in 2001 to 21% in 2016.(10) Aboriginal and Torres Strait Islander women who consume alcohol do so at a higher median rate than non-Indigenous women, up to 14 standard drinks per session.(11) The size of the gender gap in alcohol use differs between countries and their cultures. For example, in Australia, among women aged 39 to 59, parity with men’s consumption of alcohol has almost been reached.(12) A similar trend has occurred in New Zealand and Norway, whereas in India, male use of alcohol outweighs women by 12:1 suggesting that culturally prescribed gender roles shape drinking behavior.(13)Women are more likely to experience negative health consequences from alcohol yet are less likely than men to access treatment.(14) Women are more vulnerable than men to the physical effects of alcohol due to differences in body weight and metabolism and are more susceptible to liver disease.(15) Women with moderate intake (15 – 30g/day) have a 10% higher risk ratio for mortality from cardiovascular disease possibly due to higher blood ethanol levels and the risk of liver dysfunction that contributes to morbidity.(16) Alcohol is a risk factor for the incidence of breast cancer; as little as one extra standard drink a day can increases the risk of breast cancer by 5% for premenopausal women and 9% for postmenopausal women.(11)Hormonal differences between men and women can affect alcohol use, menstrual-cycle stage and estrogen levels can influence ‘drug-liking’ and craving.(17) A systematic review by Salari et al.(18) reported a significant association between alcohol intake and sexual dysfunction in women, with 55% of study respondents reporting lower libido, and 52% in difficulty reaching orgasm. Also, menopause-related stress and depression can affect alcohol consumption and result in alcohol-related disease and injury, such as falls, stroke, and osteoporosis during the menopausal years.(17)According to Guinle and Sinha,(19) women are more likely than men to experience childhood victimization or trauma, which can be a factor in drinking to cope with emotional distress and negative affect. This, in turn, increases their risk of developing AUD. Women who drink are more likely to experience neuro-behavioral consequences that increase their risk of alcohol-related cognitive impairment. For example, a study by Fama et al.(20) found that moderate alcohol consumption, defined as less than 12.5 g/day (about one standard drink), was associated with a lower risk of dementia, whereas excessive drinking (more than 23 standard drinks per week) was associated with a higher risk of dementia.Alcohol use has historically been seen as a male-dominated behavior, and treatment approaches and settings can reflect this view.(21) Women can experience barriers to treatment, such as affordability and accessibility factors, and lack of recognition that their alcohol use is a problem.(22) Other barriers may include previous negative experiences with alcohol treatment, or lack of knowledge of treatment efficacy, unsupportive family, and language and cultural barriers.(23, 24) Furthermore, women are more likely than men to experience shame, and stigma about their drinking, which can thwart help-seeking.(25)There is a lack of evidence exploring women’s experiences and perspectives on alcohol-related treatment. There are systematic reviews that focus on specific populations or interventions for women, (26-32) though none on factors facilitating treatment uptake. To address this gap, we undertook a review to synthesize the available evidence regarding women’s views of alcohol treatment to inform approaches to healthcare for women with AUD.2.MethodThis systematic review sought to determine factors that facilitate treatment access for women with an AUD in high-income countries as defined by the World Bank(33) We employed a narrative synthesis and applied a social ecological framework to the analysis to best capture organizational, individual, and societal enablers of treatment uptake for women with AUD.(34)2.2. Search strategyThe search strategy was developed in consultation with a research librarian. Examples of the search terms used were: ‘alcohol dependence’, ‘alcoholism’, ‘alcohol use disorders’, ‘alcohol-related disorders’, ‘women’, ‘female’, ‘treatment-seeking’, ‘facilitators’, enablers’, ‘barriers’, ‘stigma’, Keywords were combined with MeSH terms and truncated as appropriate and specific for each database. For this study, ‘treatment uptake’ relates to at least one occasion of an outpatient, primary care, tele-health, face to face, pharmacological, online, harm reductive, or abstinence intervention. Five databases: Medline, Cinahl, PsychiNFO, Embase and Cochrane library databases were searched. Citation chaining was used to include relevant articles in the screening process. Peer reviewed articles containing qualitative and quantitative data were included. Limits were applied to studies from high-income countries only, and a year restriction from 2000 to 2023 to ensure a comprehensive search that included recent studies.This review focuses on adult women therefore, the population of the included studies are cis-gendered females aged 18 years and over. The search included women and alcohol use only, mixed substance use studies were included only if alcohol use data could be isolated. Studies including both men and women, were only included if the results relating to women could be disaggregated. The exclusion criteria included studies with non-female samples, children, over 80-year-olds, mixed population studies and mixed substance use studies.The review was reported in accordance with the PRISMA flowchart and statement (35) Two reviewers checked all full-text articles and completed a table for excluded articles with reasons. After duplicates were removed, 2360 citations were retrieved from the database search. The initial title and abstract review indicated 244 potentially relevant articles, and of these, 17 studies met the eligibility criteria and were included in the review (see Figure 1).2.3. Study screening and quality appraisalThe retrieved publications were imported into the Covidence software platform for screening. The authors systematically applied the inclusion criteria to assess eligibility for all identified studies. For quality appraisal, the Critical Appraisal Skills Programme (CASP)(36) was used to assess qualitative studies and randomized control trials, while the Mixed Methods Appraisal Tool (MMAT)(37) was applied to mixed-methods studies. Quality assessment was initially conducted by one author (MA) and independently confirmed by two other authors (AD & JR), to ensure agreement.2.4. Data extraction and analysisData including study design, sample size, population characteristics, intervention details, and results were extracted and collated by one author (MA). The findings were summarized in tabular form according to the three key areas of the individual, societal and organizational social ecological model and independently reviewed by other authors (AD & JR).A narrative synthesis, aligned with Popay et al.(38) Guidance on narrative synthesis in systematic reviews, was applied. The synthesis was driven by the theory that women’s treatment-seeking behaviors for AUD are shaped by factors across these levels.Study results were coded and categorized as a basis for the narrative synthesis, reflecting Popay’s structured approach. Each study was reviewed to identify key elements contributing to treatment-seeking, and results were categorized based on intervention type and reported outcomes. Findings were tabulated to identify common characteristics, and thematic analysis examined emerging individual, societal, and organizational patterns across studies, examining how different interventions related to study outcomes. For instance, stigma emerged as a common societal barrier, whereas support networks facilitated access to care. Outcomes were categorized by whether the intervention increased women’s participation in treatment programs.3. ResultsSeventeen studies were included in the review. Five studies were conducted in Australia (24, 39-42),, eight studies were conducted in the United States (6, 22, 43-48), and one study each in France (49), Belgium(25), Sweden (50) and the United Kingdom.(51)Fourteen studies were conducted in outpatient and community settings,(6, 22, 24, 25, 39, 40, 42, 44-46, 48-51) two studies conducted in criminal justice settings. (43, 47) and one study in a hospital setting.(52) The sample size of the studies ranged from 12 to 2647 participants.Six studies were qualitative, (25, 39, 40, 42, 50, 52) one study was phase 1 of a qualitative co-design study of four phases.(24) One quantitative study used a longitudinal design,(22) two studies were randomized controlled trials (RCT),(43, 51) one study was phase 2 of a RCT(22) and one was a pilot RCT.(46) Five were mixed method studies (6, 44, 47-49) (see Table 1).Several key themes emerged based on individual societal and organizational factors. Individual motivators were positively associated with problem perception, alcohol use severity, age, intrapersonal relationships, and the desire to keep the family together and retain or regain child custody. Societal motivational themes centered on social norms - such as the desire to drink and act responsibly and civilly - were affected by a woman’s socioeconomic status and interpersonal relationships. Organizational themes of accessibility, acceptability and affordability were positively affected by clinicians’ knowledge of treatment options, screening and brief interventions, harm reductive and non-labelling approaches, appointment flexibility, and short wait times.3.1. Individual factorsProblem perceptionFive studies included in this review reported associations between problem perception and treatment seeking (6, 22, 39, 43, 47). Alcohol problem severity and alcohol use disorders identification test (AUDIT) symptom count was a significant predictor for women seeking treatment, with each additional AUD symptom being associated with 42% higher odds of perceiving a need for seeking alcohol treatment services.(22) Two studies of incarcerated women with AUD in the US found that a higher AUDIT score was significantly and positively related to engaging in any type of treatment upon release.(43, 47) Likewise, a study by Grosso et al.(6) reported that a greater degree of alcohol use severity and worry about increasing drinking was a motivating factor in 31% of participants.Intrapersonal consequencesNegative self-image and feelings of guilt, shame and unhappiness were found to be significant a predictor of treatment seeking in a community sample of treatment women in the US.(45) The respondents in another study expressed concern about appearance, such as ‘wrinkles and weight gain, embarrassing behavior such as ‘drunk dialing’, and risky or promiscuous behavior while drinking, secretive drinking, and cognitive impact of drinking, such as blackouts.(6) A 51-year-old participant in a study by Schamp et al.(25 p.180) described feelings of shame as a motivator to seeking treatment, ‘and often feeling bad about myself, or ashamed. All that played a role [in seeking help], the biggest role even’.Family affected by drinkingKeeping the family together was an important motivator for women to engage in alcohol treatment.(6, 25, 42) Thirty-eight per cent of women seeking treatment on the east coast of the US listed the ‘impact of drinking on spouse and children’ as a motivator.(6) Similarly, in an Australian study of sober curiosity and social class, several mothers described complexities with parenting teenagers or young adult children. Concerns about ‘increasingly anxious young people’ were described by one woman who said that reducing alcohol would allow for good role modelling and relief from the burden of worry about their older children.(42)Retaining or regaining custody of children was reported as a strong motivator to seek treatment in a study of residential and outpatient treatment-seeking women in a study by Schamp et al.(25)A 38-year-old respondent explained the loss of her daughter as help-seeking motivation, ‘they had already taken her away from me and [son] had also left home. So, it was basically to get them back, I had to do something, you know. It couldn’t go on like this’. (25 p.180)Mental health and trauma historyA study from France(49) found that rural women were more likely to self-initiate alcohol treatment if they had a family history of alcoholism (56% compared vs 35%), were twice as likely to have attempted suicide (43% compared to 23%) and have experienced physical and sexual trauma. Likewise, a study of barriers and facilitators among a community sample of rural and urban women by Small et al. (46) showed that 48.54% reported lifetime exposure to sexual or physical abuse, compared to only 2% of the men.