{
  "abstract": "Background Amongst people experiencing homelessness (PEH), alcohol misuse is a major driver of poor health outcomes, including alcohol-related liver disease (ARLD) and deaths. Premature deaths from ARLD are preventable with early identification; however, timely engagement with healthcare is poor amongst PEH and numerous barriers limit access to services. Despite alcohol misuse contributing significantly to health inequalities amongst PEH, the perceptions of PEH around alcohol use, alcohol harms and access to liver care is under-researched. Using a mixed methods approach, we aimed to understand the views and experiences of homeless adults who drink hazardously around alcohol use and liver healthcare, and to quantify the prevalence of alcohol-related morbidity in this population.Methods A convenience sample of homeless adults (aged 18+) who drink hazardously (AUDIT score ≥8) were recruited to complete a closed-question survey about their health and alcohol use. From this sample, a smaller sample was purposively selected to complete a semi-structured interview. Participants were recruited via liver outreach clinics held in four homeless hostels and one homeless day-centre in Southampton. Using a critical realist approach, qualitative data were analysed inductively using reflexive thematic analysis and descriptive statistics were produced for survey responses.Results 56 survey participants were recruited, 84% of whom had probable alcohol dependence and 18% a diagnosis of advanced liver fibrosis/cirrhosis. Thematic analysis of ten interviews identified four themes, describing the ubiquity of alcohol misuse and harms in the life-histories of 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 throughout the lives of PEH underlies these themes. Normalisation starts in childhood with parental alcohol misuse and continues in the social drinking environments of adulthood. Alcohol-related illnesses and deaths are similarly normalised by their prevalence in PEH’s communities and likely contribute to feelings of fatalism and powerlessness to prevent these harms.Conclusions Normalisation of alcohol-related harms may represent a barrier to timely engagement with healthcare amongst PEH and a mechanism driving greater likelihood of alcohol-related harms, because normalisation may lower this population’s perceived need or urgency to engage with healthcare. Improving knowledge and addressing misperceptions around alcohol-related harms and healthcare may help to counter the low risk perceptions and fatalistic attitudes fostered by normalisation of alcohol-related harms. Such intervention may be particularly effective for PEH if delivered via peers and targeted towards communities of homeless drinkers accessing hostels and day-centres.",
  "authors": [
    {
      "affiliations": [
        "Primary Care, Population Sciences and Medical Education, University of Southampton, UK",
        "Public Health and Social Research Unit, West Sussex County Council, UK"
      ],
      "name": "Catherine Wells"
    },
    {
      "affiliations": [
        "Primary Care, Population Sciences and Medical Education, University of Southampton, UK"
      ],
      "name": "Ryan M Buchanan"
    },
    {
      "affiliations": [
        "Primary Care, Population Sciences and Medical Education, University of Southampton, UK",
        "Nuffield Department of Primary Care Health Sciences, University of Oxford, UK"
      ],
      "name": "Rachel Dewar-Haggart"
    },
    {
      "affiliations": [
        "Primary Care, Population Sciences and Medical Education, University of Southampton, UK"
      ],
      "name": "Kate Glyn-Owen"
    },
    {
      "affiliations": [
        "Primary Care, Population Sciences and Medical Education, University of Southampton, UK"
      ],
      "name": "Yun Kim"
    },
    {
      "affiliations": [
        "University Hospital Southampton, UK"
      ],
      "name": "Hannah Stevens"
    },
    {
      "affiliations": [
        "Primary Care, Population Sciences and Medical Education, University of Southampton, UK"
      ],
      "name": "Julie Parkes"
    }
  ],
  "title": "P120 ‘Proper alcoholics’ and ‘Catch-22s’: a mixed methods analysis exploring alcohol misuse, morbidity and liver healthcare engagement in people experiencing homelessness",
  "uid": "f8d1f4fc-0eca-5540-94ef-86699bbf6876"
}