Abstract
Alcohol is widely used in many cultures as part of everyday life and for special occasions. It is a leading cause of preventable death in the UK, with higher rates among socioeconomically disadvantaged people. Gypsies and Travellers are ethnic and cultural minorities who experience extreme social disadvantage but there is a lack of knowledge about their alcohol use. The study aim was to explore experiences of alcohol use and harm in these distinct groups. Taking a participatory research approach, peer researchers conducted semistructured interviews (n = 26) to explore experiences of alcohol use and harm within the following four Gypsy/Traveller communities: Irish Travellers, Boaters, Gypsies, and Slovakian Roma. Vignettes were used as a basis for interview questions. Data were analysed thematically following the framework model. Alcohol consumption was found to be fundamental to celebration in all groups and integrated within social norms. Among Gypsies, Irish Travellers and Roma, drinking was associated with masculinity and despite an increase in alcohol use among women, female drinking remains highly socially regulated. Gypsies and Irish Travellers reported being illegally excluded from public drinking venues, while Slovakian Roma experienced less discrimination towards their ethnic group in the UK. Knowledge of the risks of alcohol dependence was high in all groups, but there was little awareness of the health impact of regular heavy drinking. Shame was a barrier to help-seeking for Gypsy, Roma, and Irish Traveller men and women, while Boaters’ nomadism reduced access to both primary care and alcohol treatment services. These distinct ethnic and cultural groups are aware of the health and social risks of alcohol use but experience barriers to accessing healthcare. Each community has different needs in relation to prevention of alcohol dependence, highlighting the need for targeted health promotion to accompany national strategies to reduce alcohol harm.
1. Introduction
Alcohol use is highly normalised within European cultures and around 80% of the UK population consume alcohol [1]. In addition to being a commodity, alcohol causes harm, contributing to physical and mental illness (cardiovascular diseases, cancer, and mental health disorders) and injury (road traffic crashes, violence, and suicide) [2–4]. Alcohol use is not consistent within and between ethnic groups, and people from BME (Black and minority ethnic) backgrounds are more likely to abstain from alcohol [5]. Problematic alcohol use is more common among those ethnic minorities who experience multiple exclusion and reduced access to services have gendered beliefs such as drinking being associated with masculinity for men but shameful for women and are prone to shame about health problems [5]. Disadvantaged groups suffer higher rates of alcohol-related hospital admissions and deaths despite reporting similar or lower average levels of consumption [5–7]. There is a recent worldwide trend of young people being less likely to drink alcohol [8], but this trend is not observed in people from BME groups, smokers, and those with poor mental health [9].
People described as Gypsies and Travellers include English, Welsh and Scottish Gypsies, Irish Travellers, New Travellers, and Roma people who have migrated to the UK from central and eastern European countries [10]. Gypsies, Irish Travellers, and Roma are ethnic minorities who share a nomadic background, while new Travellers are cultural groups who are often highly nomadic. Liveaboard Boaters without a home mooring are among the most nomadic of travelling people [11]. All Gypsy/Travellers have high health needs and encounter barriers in accessing health services [12–14]. When providing support services, local authorities often fail to differentiate between Traveller groups, meaning that services are ill equipped to meet their distinct health and social needs [15].
There is a lack of knowledge about alcohol use and harm among Gypsies and Travellers as, despite being included as one ethnic group in the census, their ethnicity is not routinely recorded within health databases and they are difficult to trace within routinely collected data [15–17]. In Ireland, rates of problematic alcohol use are high among Travellers [18, 19] and in a recent survey, Gypsies and Travellers identified alcohol as their biggest healthcare issue [20]. Hurcombe et al. found that alcohol consumption among Traveller women, though stigmatised, is increasing and young men are more likely to engage in risky drinking behaviours [21]. Boaters are rarely included in health research but substance use concerns are evident [12]. Lidster and Cannon suggested that Gypsies and Travellers are aware of alcohol and drug problems in their communities, but experience shame in acknowledging these problems and lack knowledge of services [22]. Results from studies of alcohol consumption among Roma people are mixed overall [13], but research in Slovakia indicates alcohol consumption at a lower or equivalent rate to the majority population [23–25]. A small UK study found that professionals considered alcohol consumption was high among migrant Roma but Roma participants reported low rates of use [26].
The study aim was to explore experiences of alcohol use and harm within four distinct ethnic and cultural minorities who share a background of nomadism and social exclusion. Boaters, Gypsies, Irish Travellers, and migrant Roma people were selected to represent diversity and to identify similarities and differences between these communities who are often grouped together as Gypsies and Travellers in policy and practice.
2. Methods
2.1. Study Design and Participants
Taking a participatory research approach, university researchers formed equitable partnerships with community stakeholders to address this public health issue, with involvement extending from study design to dissemination of findings (27). Community stakeholders conducted semistructured interviews as peer researchers between December 2021 and May 2022 in England and Wales. All peer researchers had extensive experience of working as advocates for Gypsy/Traveller communities and 3/4 were themselves community members (Roma, Boater, and Gypsy). Peer researchers selected participants purposively for ethnicity, gender, and age (see Table 1), not for alcohol use or experience of harm, as the research focus was on “how people like us drink.” Participants were recruited from the following age groups: young people (16–24 years), adults (24–49 years), and older people (over 50 years) in order to observe generational differences in attitudes. Four vignettes were used as a basis for interview questions (see Supplementary materials, Table S1). Vignettes were codesigned by university and peer researchers and focused on topics identified as relevant from community knowledge and existing research (e.g., gendered drinking [19, 21, 27], mental health [28, 29], bereavement [30, 31], and domestic abuse [32, 33]); vignettes were not pilot tested. Probes were used to elicit more information from participants (e.g., “Is this the sort of thing that could happen in your community?”) after each vignette.
2.2. Data Collection
Peer researchers were recruited from the lead author’s networks, and all had previous experience of qualitative interviewing for research studies. For this study, they participated in a two-hour online study-specific training. A target of seven interviews was set for each ethnic/cultural group, which was considered sufficient to perceive differences and similarities and feasible within the project time scale and funding [34]. Peer researchers approached community members they considered open to discussion, and no potential participant declined to be interviewed. Initial contacts with participants were made via peer researchers’ social networks and third sector organisations, face-to-face or by telephone. As some COVID-19 restrictions were in place, most interviews (17/26) were conducted by telephone; otherwise, interviews took place in participants’ own homes. No field notes were taken but after each interview the second author held a debrief session with each peer researcher. No repeat interviews were carried out and no transcripts returned to participants for comment.
All interviews were audio recorded and fully transcribed. Six interviews conducted in Romanes were transcribed and then translated into English by an independent translator and checked for veracity by the Roma peer researcher. All four peer researchers were female, and as we were unable to recruit an interviewer of Irish Traveller ethnicity, and no Irish Traveller participant was interviewed by a peer of their own ethnicity.
2.3. Analysis
Data were analysed thematically following the framework model, which entails familiarisation with the data, constructing a thematic framework to apply to all interview data and mapping and interpretation of the findings [35]. Following interviews, the second author held a debrief session with each peer researcher, in which they could give their preliminary views on themes arising within and across interviews. After all transcripts had been read by the first and second authors for familiarisation, an online session was held with all authors where potential themes were discussed and the thematic framework was compiled. Interviews were coded line by line in NVivo by the second author (four transcripts were independently coded by the first author to ensure rigour) and all the transcripts put into a framework matrix [36]. This process allowed mapping and interpretation of themes and subthemes by interview, ethnic/cultural group, and age/gender, illustrated with representative quotes from participants. Additional quotes which provide corroborative detail are presented in Supplementary Materials, Table S2.
2.4. Ethics Approval and Consent
Ethics approval was obtained from a Swansea University Ethics Committee in July 2021 (reference 5216). Participants were given at least one week to consider participation, and written consent was obtained prior to interview. Participants consented to their interview data being used in publications, including anonymised direct quotations. An amendment was approved in April 2022 to include participants 16–18 years in response to community interest in young people’s drinking.
3. Findings
A total of 26 interviews were conducted between December 2021 and May 2022. Interview recordings averaged 29 minutes (ranging from 12 to 49 minutes), with one interview being a joint interview of two people. All participants self-identified as members of the communities ascribed to them by peer researchers; however, an overlap between groups was sometimes demonstrated; one Boater had an Irish Traveller and Showman (circus) heritage, some had originally been land-based Travellers (van dwellers), and Gypsies occasionally referred to themselves using the generic term Travellers.
Over half of Gypsy and Irish Traveller participants had no educational qualifications (6/11), whereas all Boaters had educational qualifications and 3/8 had a university degree. Most Roma participants were apprentices (4/7), one had no qualifications, and none had a degree. Being a carer was common among all participants, either for a child (8/26) or an adult with a disability (5/25). Employment was highest among Boaters (6/8), with fewer Gypsies (2/7), Roma (2/7), and Travellers (1/4) in paid employment. The remainder of participants was unemployed (6/26), retired (4/26), full-time parents (3/26), students (2/26), or a volunteer (1/26). All Boater participants currently lived on boats, all Roma were housed, and most Gypsies and Irish Travellers (9/11) lived in caravans.
Findings are presented under the main headings of alcohol use and harm, subdivided into subordinate themes (see Table 2). Direct quotes are attributed to participants described in a unique identifier by their ethnicity or culture, gender, and age range (e.g., Traveller1, F, 16–24 is the first Irish Traveller participant, female, and aged 16–24 years).
3.1. Alcohol Use
3.1.1. Alcohol Use Contributes to Group Identity
Participants described drinking alcohol as traditional within their ethnic or cultural group. A small number of participants (n = 4) argued that there was no characteristic way of drinking within their own community that was different from the majority population. Despite this, all participants were able to describe cultural norms within their community, which influenced who drank, when, and how.
All participants described themselves as belonging to communities of like-minded people who shared traditions and behaviours that influenced their lifestyle. Alcohol was an integral part of communal celebration, creating an atmosphere of fun and contributing to easier communication and intimacy. For Roma, Gypsy, and Travellers communal celebrations were associated with landmark family, religious and seasonal events (e.g., christenings, first communions, marriages, birthdays, Christmas, and New Year). There was a spiritual context to drinking for some Boaters (“We usually have a drink of mead on all pagan holidays and celebrations,” Boater5, F, 25–49) but celebrations were usually informal, such as impromptu mooring or “towpath” parties where drinking took place. In Roma and Boater communities, celebration was associated with creative activities such as music and dancing, which were perceived as integral to group identity.
“It is a Romani tradition; it is the most typical thing among the Roma, that they drink, celebrate, dance.” (Roma1, F, 50+)
Traditionally, Roma people drank home-brewed pal’enka (fruit spirits) at weddings, but since moving to the UK, wine was now drunk at celebrations, like the “gadže” (non-Roma). For both Roma and Irish Travellers, it was important to provide alcohol at weddings to demonstrate that they had sufficient financial means to entertain others (“When there is nothing on the table, among us Roma it would mean poverty, they would say so, well... well, poverty!” Roma4, F, 50+). In Gypsy and Irish Traveller communities, examples were given of increasing normalisation of alcohol use in daily life, e.g., seasonal drinking, a jug of alcohol at Bingo, and cocktails after shopping, which signified a change from alcohol being drunk primarily at formal celebrations. Some considered the COVID-19 pandemic had increased alcohol use as regular drinking outdoors in the evening became more prevalent. Gypsies and Irish Travellers attributed drinking more during lockdown to boredom and grief due to COVID-19 deaths in the community.
Drinking in moderation was an ideal for all but perceptions of moderate alcohol consumption differed between individuals and groups. Prolonged periods of heavy drinking at celebrations (weddings, funerals, and holidays) was identified as a problem by several Irish Traveller participants: “If you’re on holiday you could drink for a week…you wouldn’t be looked at any different if you were to drink every night until it was over…whereas if you’ve done it where there was no occasion or anything going on, obviously you’re automatically an alcoholic and nobody wants you in their company” (Traveller1, F, 16–24).
After migrating from Slovakia, Roma participants described drinking more moderately as a result of being in work and an improved quality of life: “In England everybody works, they do not have time to drink, they are employed, they go to work, they care for the children, they buy clothes.” (Roma5, M, 50+). This was contrasted to heavy drinking premigration due to discrimination, unemployment, boredom, and “sorrow.” In all four communities, men and women described their daily responsibilities as being a curb on the amount of alcohol consumed and daytime drinking was viewed as abnormal. For Boaters, living aboard required constant vigilance and hard work; Gypsies, Irish Travellers, and Roma described an all-day domestic schedule for women and men’s work taking place outside the home.
3.1.2. Gender and Age Influence Alcohol Use
Boaters described a “level playing field” in drinking between men and women, in terms of the amount drunk and types of drinks (usually beer, cider, and wine). All other communities had traditions of men drinking more alcohol and women less, with strict rules governing drinking behaviours. Traditionally, Gypsy and Traveller men drank at the pub with other men from the community, and this was a time to network, find jobs, and share news. Pride was taken in being able to manage one’s drinking without exposing the family to harm:
A Gypsy won’t put himself in the gutter for drink. You’ll see some people spend their rent money, they spend their children’s food money, anything. A Gypsy won’t do that. (Gypsy4, M, 50+)
Strong views persisted in Gypsy, Roma, and Traveller communities about the norms of women’s drinking, extending to the drinks appropriate to women (e.g., wine, spirits, and alcopops). A common view was that women should drink less than men because men were considered stronger and more able to cope with larger amounts. Abstinence was expected of young single women although some participants said they had illicitly drunk alcohol when single. Once married, Traveller and Gypsy women had more freedom to drink, and it was generally agreed that alcohol consumption had become a normal part of most social occasions: “When I was growing up, drinking wasn’t such a big thing...I drink more now as I’m older, because it is a social thing.” (Gypsy1, F, 25–49). This had changed the tradition, cited by two Gypsy participants, of keeping alcohol out of the home because of its perceived dangers. Several women observed that home drinking increases alcohol consumption as measures are larger than pub measures, and alcohol bought at a supermarket is cheaper.
In all communities, women drinking heavily were liable to be “talked about,” in contrast to general tolerance of male drinking. Young as well as older participants commented on the continuation of these judgemental and sexist attitudes: “There still is…harsher views, like if a woman’s always drinking…she shouldn’t be doing that, but if a man goes out drinking like every single day with his mates…he’s just going out with the lads.” (Roma7, F, 16–24). The high standards of behaviour expected of young unmarried women in Gypsy, Roma, and Irish Traveller communities meant that young women behaving drunkenly in public were judged harshly: “To see a young Travelling girl getting really drunk and falling across the floor, it don’t really look very good do it?” (Gypsy3, F, 25–49). One participant considered that a drunk Roma woman would not only bring shame on herself but on her partner as “it is not nice for the Romani man, that this Romani woman drinks a lot and she is drunk…that she does not know how to behave” (Roma4, F, 50+). In these communities, mothers were expected to abstain completely from alcohol while caring for children.
Many Boaters considered that drinking alcohol was declining among the young and cited young relatives who rarely or never drank. Similarly, Roma participants described many young people as engaged in educational and social activities postmigration, which reduced alcohol use. Within Gypsy and Irish Traveller communities, there was concern about levels of teenage drinking, and some older Gypsies considered national measures were needed to reduce alcohol consumption, such as reducing the range and strength of alcoholic drinks and banning drinks designed to appeal to young people (e.g., alcopops).
3.1.3. Discrimination Is a Risk When Drinking in Public Venues
In the UK, the Roma predominantly drank at home with relatives, while young people drank in public drinking places, such as bars. Roma people did not experience hostility when drinking in public venues, in contrast to their experiences in Slovakia: “In England, yes, they do not know that we are Roma…here the gadže are such people that they let everybody in.” (Roma4, F, 50+). A young Roma woman commented that people could discriminate if aware of their ethnicity but Roma were not a visible minority in the UK. All non-Roma groups had experienced being banned from public drinking places because of their culture or ethnicity. For Boaters, this was relatively minor and described as a preference among some canal-side pub landlords for holiday makers, who spent money on food as well as alcohol. One Irish woman expressed her sadness that moving to England had not reduced discrimination: “Can you imagine how we feel? We left Ireland because of discrimination, aiming for the better lives and it never changed.” (Traveller2, F, 50+). Gypsies and Irish Travellers encountered prejudice based upon their ethnicity in restaurants, pubs and bars, which led to them being asked to pay in advance for food and drinks (unlike other customers), closely watched and even turned away:
“A couple of months ago I was in London with my Mum and Dad, and there was an Irish café …we asked for a table, and the guy told us to get out, that they don’t serve Travellers. Yes, I swear to God. And me, my three children and my Mum, my Dad and my two brothers had to walk out.” (Traveller1, F, 16-24)
Two male participants described the police being called when pubs turned them away: “Sometimes you’re not let into pubs, yeah sometimes they call the police and…it’s depressing you’re not let in, and all your friends are in there.” (Traveller3, M, 25–49). Some participants were aware that such overt discrimination was illegal, but most lacked the ability to challenge exclusion. Dealing with discrimination (described as “bullying” of Travellers) was seen by one participant as a major cause of mental health problems.
3.2. Alcohol Harm
3.2.1. Perceived Health and Social Risks of Alcohol Harm
Within all communities, people dependent upon alcohol were usually referred to as alcoholics. For Gypsies, Roma, and Travellers, this meant someone who drank daily and could not manage daily life without alcohol. In the Boater community, there was less clarity about the definition of heavy drinking, and identification as a dependent drinker was a matter of personal judgement rather than linked to the amount of alcohol consumed. No participant defined problematic drinking according to the number of units of alcohol consumed on a weekly basis.
Physical and mental health impacts of alcohol dependency were widely known. Alcohol was described as harming internal organs, particularly the liver. Injury was mentioned by all groups and was a particular problem for Boaters due to the hazards of the canal environment. Not only was there a risk of falling into the water after a night out but candles used onboard for light and warmth also posed a real danger. Participants reported incidents where Boaters had died due to drowning or fire when drunk. Social effects of excessive alcohol use were described as disputes with family and friends, relationship breakdown, and violence (both domestic and in public places). Two men, Roma and Irish Traveller, cited alcohol as contributing to domestic abuse of women.
All groups were concerned about the effects of parental alcohol consumption upon children, and clear descriptions were given of how children could be neglected, dirty, and without regular meals. Witnessing arguments between parents was perceived as emotionally damaging for children, and a cause of problems in adult life, potentially including harmful drinking. Participants who had experiences of caregivers who were heavy drinkers described painful experiences: “My grandparents would drink all weekend then come back…You think Mondays are bad, but when your family have been drinking all weekend, Mondays were really bad.” (Traveller4, M, 25–49)
Despite extensive knowledge of alcohol harm within communities, no participant condemned drinking entirely. Even those with personal experience of alcohol dependence within the family and those who did not themselves drink saw alcohol as an inevitable and accepted part of life, and the general view was that the individual had a responsibility to manage their alcohol use to reduce harm to themselves and their families.
3.2.2. Barriers to Seeking Help within the Community
Gypsies as well as Irish Travellers stated that those who drank too much would be shunned and not be invited to celebrations, a major concern in communities which place a high value on sociability. Several participants stated that because of the shame of being seen as a heavy drinker, people (especially women) were likely to conceal their drinking. A common view was that people dependent on alcohol should not have “let theirself get like this” (Gypsy2, F, 25–49). Dependence was a sign of unacceptable weakness, which restricted help-seeking behaviour: “Obviously you keep it to yourself…you’d be ashamed of what you’re doing.” (Gypsy3, F, 25–49). In Gypsy, Roma, and Irish Traveller communities, the view persisted that to succumb to alcohol dependency was a sign of weakness was prevalent, as “strong-minded” man and women should be able to resist:
If you’re dependent on something there’s a bit of a stigma isn’t there, the shame of…I don’t want people to know… I should be stronger and be able to man up and get on with it. (Gypsy1, F, 25-49)
While family normally supported those with difficulties, this did not generally hold true for dependent alcohol use because it contravened community ideals of pride and resilience. One participant gave an example of a sister who was a “secret drinker” who hid her problem because of hostility from the family: “We used to row at her…so it probably was just, oh I can’t be bothered with the hassle then, just hiding it” (Gypsy5, F, 50+). Some participants stated that they would support family members with an alcohol issue, but they considered this a minority view.
In all four communities, participants mentioned having personally experienced shame about drunkenness and worry about how their behaviour had impacted on others. Boaters were tolerant of alcohol being consumed regularly as an integral part of regular socialising, which led to difficulties in identifying a problem and then seeking help from others:
“I don’t think you would find someone wanting to ask their neighbour on another boat for help about a drinking problem, because I think…it’s not taken as seriously maybe on the canal, because it’s quite a regular occurrence.” (Boater2, F, 16-24).
If alcohol use was causing a problem, particularly where there were dependent children, emotional and practical support would usually be willingly offered by the Boater community.
3.2.3. Accessing Health Services for Dependent Drinking
Seeking professional help was problematic for all the communities though some Roma people knew of people who had accessed specialist alcohol treatment services via the general practitioner (GP). Shame would need to be overcome, and a Roma participant believed that a young man seeking help for alcohol dependency would be mocked by male peers: “[They] would laugh into his eyes…so because of this he would be ashamed, he would not search for a doctor.” (Roma4, F, 50+). For reasons of shame, many Gypsies and Irish Travellers stated that would not access health services, fearing judgement from peers and health providers:
“In the Travelling community you’re taught to have…so much pride you wouldn’t know what it would be like to be judged, do you know what I mean? Like I mean if you were to reach out, you’d feel like they were going to look down on you.” Irish Traveller (P1, F, 16-24)
If an individual chose to seek help, problems were encountered in accessing care. This was partly because health services were seen as hard to access for patients, irrespective of ethnicity: “There’s no one to help them today…you can’t get a doctor, never mind help for mental.” (Gypsy6, F, 50+)
No participant mentioned self-referral to alcohol treatment services, and the general perception was that all services are accessed via the GP. Boaters mentioned two charities which offered advice and signposting for alcohol issues, but some were reluctant to engage because of concerns about privacy and wishing to remain “off-grid.” A young Roma woman also mentioned third sector services but no Gypsies or Irish Travellers. One Irish Traveller participant stated that some would choose to go to their priest for spiritual support for alcohol dependence in preference to accessing health services.
Boaters were prepared to seek help for alcohol dependence, and some study participants had done so. Seeking help could be enforced as a condition of child protection procedures, which added to the stress of accessing services. All Boaters had experienced difficulty in registering with a GP because they did not have a permanent address. One strategy was to give the address of a relative or friend who was settled:
“That’s where it does become a little more community specific. Unless you’ve taken steps to keep yourself registered somewhere and kept a GP at a registered address, being of no fixed abode theoretically shouldn’t cause problems with access to healthcare but in reality it does.” (Boater7, M, 25–49)
Some considered that GP practices were reluctant to register Boaters because their health needs could be greater than the majority population and because community health services were becoming increasingly large scale and less personal. One Boater had moved from a practice which had a large clientele of Boaters and understood their needs to a “super surgery” which they considered reluctant to register Boaters because they did not fall within existing GP targets linked to financial incentive payments. Travelling did not fit within the system and caused difficulties in accessing all health and social services:
“If you’re travelling around then you can’t really get access to that stuff that’s funded by the government to help people. Like you have to be in the same area.” (Boater6, M, 16–24).
Under Canal Regulations, people with no home mooring are required to cruise continuously in one direction, stopping for a maximum of 14 days [19], rules which apply to liveaboard Boaters. In specified emergency situations, Boaters can apply to moor for longer periods, but participants did not describe using this for alcohol treatment.
4. Discussion
This study illustrates the impact of ethnicity and culture upon alcohol use among Gypsies, Roma, Travellers, and Boaters. By illuminating the alcohol culture of each group (“how people like us drink”), a nuanced picture has been gained of alcohol use and harm. Strong group identities influence use of alcohol, in common with research into other health behaviours among Gypsies and Travellers [27]. Because culture and beliefs are not static, change occurs in relation to alcohol use [5], an example being the experiences of Roma people postmigration where improved employment and educational opportunities had served to decrease alcohol use. Recent commentators have highlighted the dangers of prioritising the impact of ethnicity upon health above societal factors such as poverty and discrimination [37, 38], and Millan and Smith have made this point in relation to Gypsies and Travellers [39]. When researching the social norms of alcohol consumption, it is important to recognise that drinking behaviours are affected by a complex mix of societal factors, including availability, affordability, and accessibility of alcohol [40, 41].
A commonality across groups was the integral use of alcohol in celebration, as a symbol and facilitator of enjoyment and high spirits. Much generational difference identified in this study reflects broader trends in the general population, for instance, Gypsies and Irish Traveller women are drinking more, and there is a shift from beer to wine and more drinking takes place at home [42]. Paradoxically, strong taboos persist about female drinking even among young people, perpetuating harsh gendered judgements for drunkenness or dependence. Boaters and Roma described lower alcohol consumption or abstention among young people, reflecting the trend in the general population [8], but older Gypsy and Traveller participants were concerned about the impact of alcohol use on young people. This study suggests that the wider societal trend for young people to abstain from alcohol or drink less is not reflected in Gypsy and Traveller communities, hence increasing the risks of alcohol harm. In view of these findings about women’s and young people’s drinking, further data are required into alcohol harm among Gypsies and Travellers in the UK, from both research and routine datasets. An important first step in the UK is to ensure that Gypsy and Traveller ethnicity is offered as a classification in all National Health Service (NHS) databases as has frequently been recommended [15].
An unanticipated finding was the alcohol‐related discrimination experienced by Gypsies and Irish Travellers. Roma participants described discrimination in Slovakia, which led to drinking outside or at home, but in the UK, they were not recognised as a visible minority. This supports the findings of Grill (2018) that “In England, they don’t call you black!” [43]. By contrast, Gypsies and Travellers are recognised as members of a stigmatised ethnicity in the UK, and this study has revealed the discrimination they experience when seeking to drink in public places. Previous studies have shown the extreme levels of discrimination and hatred experienced by Gypsies and Travellers in their everyday lives [30, 44] despite protection for their ethnicity in the UK under the Equality Act. It is likely that the racism experienced by Gypsies and Irish Travellers adds significantly to their alienation from mainstream society and health disadvantage. Alcohol-related racism has the potential to be addressed in policy and practice, for instance, in enforcing the legality of access to public places under the 2010 Equality Act. While society-wide racism against travelling people is a national problem (with even some health workers’ views reflecting negative media stereotypes [45]), education on equality and diversity could be included in mandatory training for hospitality workers. Equality training for all professions needs to include information about the specific issues faced by Gypsies and Travellers. The recent successful UK legal case against a holiday company who refused bookings from people presumed by name, accent, or address to be Travellers [46] demonstrates the determination of Travellers and their advocates to challenge racism, and the power of the law to bring about change.
Drinking moderately was an ideal for all four communities; however, norms of moderate drinking varied. Irish Travellers were shown to be at high risk of extended periods of heavy drinking at times of celebration; this finding accords with higher levels of drinking among people of Irish background [5] and problematic drinking being a health issue for Travellers in Ireland [19]. While there was awareness of the risks of alcohol dependency in all groups, there was little understanding of the impact of heavy drinking. The health impact of alcohol consumption is largely determined by the total volume and the pattern of drinking, particularly episodes of heavy drinking [3], but no participants referred to drinking guidelines or monitoring of units consumed weekly. Measures to control alcohol harm suggested by participants in our study were national restrictions on marketing alcohol to young people and control of alcohol pricing, as well as individual behaviour change, signifying readiness to support alcohol harm reduction at a macro level. Pricing policies and restrictions to alcohol availability and marketing are evidence based and cost-effective ways of reducing alcohol consumption [47, 48]. A recent review of behaviour changes in disadvantaged groups found no research that included Gypsy, Roma, and Traveller people despite their high levels of socioeconomic disadvantage, poor health, and risky lifestyles [49], indicating a need for more extensive research.
Cultural taboos among Roma, Gypsy, and Irish Travellers about who drinks, what, and when, potentially restrict alcohol use; however, these also served to increase people’s feelings of shame and reduced their ability to seek any help from peers or health services. For Boaters, the main barrier to treatment was GP registration and distance from GP, which has been identified in previous research as a barrier to service use [50]. Boaters, Gypsies, and Travellers all experience barriers to registering for GP services due to not having a permanent address, despite this not being a requirement for registration [51]. For all groups, the GP was perceived as the first point of access for alcohol treatment, therefore ensuring access to GPs is a priority. Under current contracts, most GPs are currently remunerated for providing services to the general population, with additional payments available for patients with chronic conditions [52]. In recognition of the high health needs of ethnic and cultural Travellers, a possible intervention would be to include them as targeted groups for whom GP practices are rewarded financially to provide services. No group appeared to know that UK substance use services can be accessed by self-referral, indicating a need for information about treatment services to be more widely promoted and accessible for groups at high risk of harm.
5. Limitations
This is a qualitative study which explored alcohol use and harm in depth from the perspectives of different participants and offers insights which are transferable to other socioeconomically and educationally disadvantaged groups. Study limitations relate to the sample and participatory approach. While a diverse sample was achieved overall, numbers of participants per ethnic/cultural group were small (4–8, median 7), fewer participants were aged 16–24 years compared to other age groups, and there was no Gypsy participant of this age. This is an omission as recent evidence suggests that drinking patterns among young people are changing. Fewer men participated, which may partly be due to the lack of male interviewers, and the target sample size for Irish Travellers was not reached. Gypsy and Traveller participants were representative of their ethnic groups in terms of lack of educational qualifications, high levels of caring responsibilities and low levels of paid employment [53]; however, more participants lived in caravans than in the 2011 census. Roma participants were atypical in being more highly qualified than average [54]. “Roma” encompasses a diverse group of European people, some of whom have experiences of migration; this reduces the transferability of these findings to other Roma groups.
6. Conclusions
This is the first study to explore experinces of alcohol use and harm among Gypsies, Roma, Irish Travellers, and Boaters taking a participatory approach. It has shown that alcohol consumption is influenced by ethnicity and culture in terms of the types of drinks consumed and by whom, when, and where they drank. Gypsies, Irish Travellers, and Roma are likely to be disproportionately affected by alcohol harm due to socioeconomic disadvantage, gendered attitudes to drinking, shame about health problems, and discrimination. Positives for health promotion are a desire in all communities to drink moderately and evidence of support for measures at a national level to reduce alcohol harm. For all groups, knowledge of the health and social effects of alcohol dependence was high, but there was little awareness of the need to monitor heavy drinking. All groups experienced barriers in accessing treatment services; for Gypsies, Roma, and Travellers, this was in overcoming disabling shame and for Boaters in overcoming institutional barriers to service use relating to their nomadism. This study exemplifies the need to view these groups separately in order to address community-specific health issues in health promotion, service provision, and policy [55].
Data Availability
The datasets generated and analysed during the current study are not publicly available due to issues of confidentiality in small communities and the terms of consent obtained from participants.
Disclosure
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors’ Contributions
All the authors developed the research protocol. SW, JC, DB, and LM recruited participants and collected data. SCH, LC, MP, and FC led on data analysis, with the whole team contributing to the development of themes and overall interpretation of findings. All the authors have read and approved the final manuscript.
Acknowledgments
We thank our steering group and Dr Zuzana Bodnarova for translation and transcription from Romanes. This study was supported by Alcohol Change UK through its New Horizons grant programme. Open access funding was enabled and organized by JISC.
Supplementary Materials
Table S1: COREQ (consolidated criteria for reporting qualitative studies) checklist. Table S2: vignettes used to explore the social norms of alcohol consumption among Roma, Gypsies, Travellers, and Boaters. Table S3: additional quotations from the themes and subthemes identified from framework analysis. (Supplementary Materials)