Access to self-care interventions can improve health outcomes for people experiencing homelessnessBMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-068700 (Published 24 March 2022) Cite this as: BMJ 2022;376:e068700
- 1U-turn, Cape Town, South Africa
- 2Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/Unicef/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
- Correspondence to: J Hopkins
Many of us who have somewhere to call home can visit a health facility when we are ill, get medicine, and safely tuck ourselves up in bed to get better. When you have no fixed place to call home and no resources, these actions are often not possible.
Homelessness is a global phenomenon. An estimated 100 million people are homeless worldwide,1 and this number is rising.23 Homelessness ranges from people living in inadequate informal housing—where housing is not compliant with building regulations—to absolute homelessness, which includes people who sleep in the open, in makeshift structures such as tents, and in temporary or emergency shelters.45 We focus on the importance of expanding accessibility and availability of quality self-care interventions to improve the health of people experiencing absolute 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.
People experiencing homelessness have a higher burden of health needs than the general population, face numerous barriers to accessing healthcare, and are often underserved within health systems. Self-care is a crucial part of maintaining health and the lack of self-care intervention options available to people experiencing homelessness affects their health outcomes and increases the burden on health systems, particularly emergency healthcare services. Increasing the autonomy, self-determination, and ability of homeless people to self-care in the context of supportive health systems as well as acknowledgment of their health needs in health policy and guidance is essential to fulfil the right of health coverage for all.
The universal right to health will not be achieved if the estimated 100 million people experiencing homelessness continue to be underserved within the health system
Promoting access and use of self-care interventions for people experiencing homelessness with better linkages to health systems can improve their health
Meaningful engagement of people experiencing homelessness in policies and programmes that affect them is urgently needed
Standards of care in health systems must be improved to increase the autonomy and ability of people experiencing homelessness to manage their health needs
Adapting and updating existing health policy to include the needs and priorities of people experiencing homelessness should be a priority for health systems
Contributors and sources: JH is a programme manager and researcher with expertise in homelessness in South Africa and on sexual and reproductive health and rights. He was a member of the WHO guideline development group for self-care interventions. MN is a public health specialist with expertise in sexual and reproductive health and rights and is leading the WHO work on self-care interventions for health and wellbeing. JH and MN conceived the idea for the article. JH wrote the first draft of the paper and JH and MN developed, revised, and finalised the paper. JH is the guarantor. The views expressed are those of the authors and do not necessarily represent the decisions or the policies of WHO or the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction.
Patient and public involvement: Patient and community engagement played an important role in the qualitative evidence discussed during the development of the 2021 WHO guideline on self-care interventions for health and wellbeing. For this article, JH engaged with people experiencing homelessness in Cape Town in his capacity with U-turn.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a series proposed by the UNDP/UNFPA/Unicef/WHO/World Bank Special Programme for Human Reproduction (HRP) and commissioned by The BMJ. The BMJ retained full editorial control over external peer review, editing, and publication of these articles. Open access fees are funded by HRP.
This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (https://creativecommons.org/licenses/by-nc/3.0/igo/), which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.