Normalisation of alcohol misuse and alcohol-related harms: a mixed methods analysis exploring alcohol misuse, morbidity and healthcare engagement in people experiencing homelessness

Aim: to understand the views and experiences of homeless adults who drink hazardously around alcohol use, alcohol harms and access to liver healthcare, and to quantify the prevalence of alcohol-related morbidity in this population. <br/> <br/>Methods: a sample of homeless adults (aged 18+) who drink hazardously (AUDIT score ≥8) were recruited to complete a health and alcohol use survey. From this sample, a smaller sample was purposively selected for semi-structured interview. Participants were recruited via liver outreach clinics held in five homeless hostels/day-centres in Southampton. Using a critical realist approach, qualitative data were analysed using reflexive thematic analysis and descriptive statistics produced for survey responses.<br/>Results: 56 survey participants were recruited, 84% of whom had probable alcohol dependence and 18% a diagnosis of advanced liver fibrosis/cirrhosis. Themes identified from ten interviews described the ubiquity of alcohol misuse and harms in the life-histories of people experiencing homelessness (PEH), the differing levels of understanding and risk recognition of alcohol-related harms, and how PEH rationalise hazardous drinking, despite the risks. Normalisation of alcohol misuse and harms underlies these themes and likely contributes to feelings of fatalism and powerlessness to prevent these harms. <br/><br/>Conclusions: normalisation of alcohol-related harms may represent a barrier to timely engagement with healthcare and a mechanism driving greater likelihood of alcohol-related harms in PEH. Improving knowledge around alcohol-related harms and healthcare may help to counter the misperceptions of risk and fatalistic attitudes that normalisation fosters. Such intervention may be particularly effective for PEH if targeted towards those accessing hostels and day-centres.<br/>