Access to self-care interventions can improve health outcomes for people experiencing homelessness

Homelessness is bad for health

Although the specific causes of homelessness vary across and within countries,4 it is ultimately the result of the convergence of individual vulnerabilities and structural factors leading to a broken social support network and lack of income.6 Health related factors, particularly mental ill health and substance use disorders are key drivers of homelessness467 and are also made worse through episodes of homelessness.2 For example, mental ill health may lead to a person being asked to leave a home, but being homeless itself may contribute to anxiety and depressive disorders.4

Homelessness has been shown to be bad for people’s health. It is associated with increased morbidity and increased incidence of serious chronic conditions such as hepatitis C, heart disease, epilepsy, HIV infection, and tuberculosis.248910 Death rates can be up to eight times higher than in the general population11 because of high exposure to often inter-related risk factors, including drug use, unsafe sex, mental health disorders, and high levels of violence.24 Women, young people, and gender diverse people living on the street also experience an increased incidence of sexual violence and forced or coerced sexual activity.1213

The longer someone is homeless, the more complex their mental and physical health conditions are likely to be, thereby increasing the likelihood of requiring and using emergency health services.914 This is unsurprising given that three of the five leading determinants of health—social circumstances, environmental conditions, and behavioural choices—are adversely affected by experiencing homelessness.15

Importance of self-care interventions for people who have no home

Self-care is the ability to maintain health, prevent disease, and cope with illness and disability with or without a health worker.1617 Self-care encompasses a broad range of activities such as eating a healthier diet or managing stress that all people do to varying degrees. However, it is far more challenging for people experiencing homelessness.

Self-care interventions support a person’s ability to care for themselves. They include evidence based and good quality drugs, devices, diagnostics, and digital technologies which can be provided fully or partially outside formal health services and used with or without a health worker. Examples of self-care interventions include self-administered injectable contraception, self-collection of vaginal samples for human papillomavirus (HPV) screening, and self-monitoring of blood glucose for diabetes and self-tests for HIV and pregnancy.18

Self-care interventions are not a replacement for sustainable and high quality health services, and there is a clear and important difference between empowering and supporting people to manage their health and simply passing on the healthcare burdens of cost and service delivery to individuals. People experiencing homelessness are at acute risk of not being able to access and use quality self-care interventions, denying them the possibility of greater self-determination, self-efficacy, autonomy, and engagement in their health should they wish it.19

Guidance from the World Health Organization outlines how self-care interventions can contribute to improved health outcomes. For instance, self-sampling for HPV to improve screening can increase the number of new cases detected annually and reduce mortality from cervical cancer.20 It also highlights the role of the health system in supporting a person to self-care and to access and use self-care interventions.20 However, health system challenges often impede people’s access to and use of healthcare, which can in turn hinder their ability to access and use tools for self-care (table 1).20

Health system challenges impeding access and use

People experiencing homelessness face individual, structural, and institutional barriers to accessing health services, including self-care interventions.20 Not having an address can make it difficult to register with a primary healthcare provider, and health services can be located in places that people experiencing homelessness find difficult to access such as far from public transport links.21 This is compounded by poor quality of care because of stigma and discriminatory attitudes of health workers.822 A lack of access means that chronic health conditions such as hypertension or diabetes may not be diagnosed, reducing the ability to self-manage the condition. These barriers to primary healthcare manifest in high rates of use of acute healthcare, such as emergency department visits, for health problems that could potentially have been avoided if earlier access to care were possible.223 Similarly, improving access to self-care diagnostics such as HIV tests can lead to earlier diagnosis and faster treatment and management of health conditions, as long as structural barriers to accessing physical health services and a lack of trust in health workers can also be overcome.

The majority of reliable health information on self-care comes through health workers, online, or published media sources. All of these are often inaccessible to people experiencing homelessness, who tend to depend on word of mouth. When reliable information is sourced—for example, through a drop-in centre, shelter, or training programme—people experiencing homelessness often do not have the means to follow the guidance received.24 A good example is the WHO covid-19 advice for the public, which suggests self-care interventions such as frequent hand washing and isolating at home25 that are difficult for someone living on the street.

Another challenge to self-care for people without a home is lack of privacy or safe storage for prescribed drugs such as HIV antiretroviral treatment. In Cape Town, clients who attend one of the drop-in centres at U-turn, a non-profit homelessness service provider, tell of their antiviral drugs being stolen along with the rest of their belongings and health workers refusing to replace them because they assume that the drugs have been sold. Others talk of finding out they were pregnant late as they didn’t have access to pregnancy tests. Social support for self-care is also a challenge, especially as people often have no one to assist during recuperation from illness or injury, and living on the street is not conducive to recovery.26

Cost related barriers also impede the ability of people experiencing homelessness to access self-care interventions. Preventive or curative medicines and products that are available over the counter from pharmacies are unaffordable. In some instances, cost barriers for self-care commodities can be overcome. For example, people experiencing homelessness in South Africa reported free and easy access to condoms because they are available in health centres in cities, as well as in shelters and some local bars.4 Yet, intersectional barriers of stigma and trust continue to be faced by people experiencing homelessness. In Canada, although some shelters provide menstrual pads, clients are permitted to take only a couple at a time, leading to repeated trips to the shelter.27

What should be done differently?

Health for all will not be achieved if the current estimated 100 million people experiencing homelessness continue to be underserved. Actions by support workers, health workers, health administrators and health policy makers, legislators, and regulators is needed to improve access to self-care interventions among people experiencing homelessness.20

People experiencing homelessness must be engaged as part of the solution to improve access to quality health services and the uptake of self-care interventions. Support organisations working with people experiencing homelessness should involve people who have been homeless as peer educators to provide one-to-one support, reliable information on self-care interventions, and facilitate access to quality health services. For instance, the use of peer support has been shown to reduce drug and alcohol use and increase healthy behaviours.28 Additionally, support organisations, in partnership with health workers, need to engage directly with people experiencing homelessness, such as through group dialogues and individual support sessions to rebuild their trust, dignity, and self-esteem—both to overcome previous negative experiences of accessing healthcare and to prioritise self-care.

Health workers have a specific role in supporting people experiencing homelessness and their ability to self-care. Increasing the skills and competencies of health workers to provide non-stigmatising, trauma informed care for people experiencing homelessness is essential.22 A good model is the health worker training developed by Pathway, a UK charity that enhances care coordination for people experiencing homelessness admitted to hospital.29

A strong case management approach is another way in which health workers can improve health outcomes, including for chronic conditions such as diabetes or heart disease, among people experiencing homelessness.30 Coupled with this is simplifying medicine regimens to help treatment adherence and establishing outreach services for follow-up appointments.303132 Flexibility, adaptability, and responsiveness of the broader health system is also required to meet the needs and uphold rights of all people experiencing homelessness. For instance, not requiring an address to receive health information, facility based care, or self-care interventions improves accessibility for people without a home.

As people experiencing homelessness have a plethora of needs across multiple spheres in addition to health, such as in housing, education, and employment, strong linkages are also needed beyond the health system. Partnerships should be built with homeless service providers and outreach health services provided in drop-in centres or temporary shelters. For example, the Homeless Health Service is a partnership between the UK NHS and non-profit organisations in Bristol, providing access to general practitioner services, mental health support, and substance misuse support at safe spaces across the city, such as drop-in centres.33 Focusing on non-health needs such as housing can also support better health outcomes34 and increase a person’s ability to self-care.35 The multisectoral approach used by the UK government to rapidly house people experiencing homelessness during the covid-19 pandemic in 2020 was described as transformative to people’s physical and mental health.36

Healthcare practice is guided by legislation, regulation, and policy. Including people experiencing homelessness as a vulnerable population within national health guidelines and health policies increases the focus on health system changes needed to improve their access to healthcare, including self-care interventions.37 There also needs to be adequate budget for the implementation of supportive policy changes.