Without the Shelter of a Home: Inclusion Health in Collaboration With Homeless Women

Homelessness is an increasing problem worldwide and a growing sub-group within the homeless population is women (Hwang et al., 2010). In high income countries, more homeless women die from potentially treatable illness than women in the general population (Teruya et al., 2010). The mortality rate is nearly 12 times higher among unhoused compared to housed women, and victimization among homeless persons is associated with female gender, where domestic violence is an important explanatory factor for women’s homelessness (Roy, Crocker, Nicholls, Latimer, & Ayllon, 2014; Wilson, 2005). Adding further to health inequities, homeless women are disproportionally affected by physical illness, mental health disorders, sexual violence, and unplanned pregnancies (Aldridge et al., 2018; Fazel, Geddes, & Kushel, 2014). Remarkably, 36 percent of children to mothers with a history of homelessness have been diagnosed with a psychiatric disorder by the age of 15 (Nilsson, Laursen, Hjorthoj, Thorup, & Nordentoft, 2017).

Reducing homelessness globally is part of the human rights labor as well as a focus for the United Nations Agenda for Sustainable Development 2030. Actions include eradicating poverty, ensuring healthy living and fostering well-being, thus reducing inequality within and between countries. Efforts have been made to reduce homelessness, but the positive effects have been limited. As a mean towards more effective interventions, inclusion health, defined as a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations, has been advocated (Aldridge et al., 2018; Luchenski et al., 2018). However, inclusion health is problematic since marginalized groups avoid and delay seeking health care and thus, their use of Accident and Emergency Departments (A&E) is vast, far exceeding the use from the general population (Rae & Rees, 2015; Vuillermoz, Vandentorren, Brondeel, & Chauvin, 2017). Interactions with health care providers have been pointed out as a substantial barrier to homeless women’s engagement (Bungay, 2013).

Caring is often highlighted as the core of nursing and the health focus within caring science makes helping, trusting, caring relationships between nurses and recipients of care possible (Meleis, 2012; Watson & Smith, 2002). However, nurses and patients regard caring behaviors differently and if basic needs are not met, then instrumental care overrides patients’ need for relational caring (Papastavrou, Efstathiou, & Charalambous, 2011). Still professional encounters and relationships play an important role during times of homelessness and isolation. Several studies describe how the experience of being cared for and meet with respect may be of outmost importance (Biederman, Nichols, & Lindsey, 2013; Rae & Rees, 2015). However, nurses are socialized with the same stereotypes as the general population and their attitudes influence the delivery of appropriate care. Consequently, identifying preconceptions to develop compassion and authentic presence when caring for homeless persons is crucial (Maze, 2006; Watson & Smith, 2002). As homelessness is a compelling public health issue, nurse educators and health care providers are challenged to better prepare graduates/nurses to serve this population’s health care needs. Nurses have a responsibility to advocate for social justice and promote health policies that ensure adequate care resources for the homeless (International Council for Nurses, 2012; Turkel, Watson, & Giovannoni, 2018).

The overarching goal of this project is to promote inclusion health among homeless women by developing interventions to address health care inequities. This will be achieved in close collaboration with women with lived experience of homelessness, health care providers, and nurse educators. The following aims will form the start of developing future interventions to promote care for homeless women in alignment with health care needs and inclusion health:

1. To investigate perceptions of caring behaviors as rated by homeless women and its associations with clinical- and demographic variables, existential and general health, health literacy, and use of IT.
2. To investigate perceptions of caring behaviors as rated by nurses, nurse students, and homeless women, and its associations with attitudes to homelessness and sociodemographic variables.

Recruitment of homeless women will commence from Capio Maria and Capio Pelarbacken, Stockholm. Capio Maria is a ward that offers 24-hour care to homeless persons in need of qualified medical and/or end-of-life care. The ward has ten hospital beds and homeless persons, registered in Stockholm County or by referral, can be admitted either via planned or acute services. Capio Pelarbacken is a walk-in unit for homeless persons that treats 14000 patients yearly. The unit is open on weekdays and has close collaborations with social services, primary care, psychiatric care, and services for treatment of substance use disorders. The units are staffed by physicians, nurses, nurse assistants, and a case manager. If a consent to participate is given, quantitative data will be collected via paper-and-pencil administrated questionnaires including clinical- and sociodemographic variables (e.g., age, educational level, reasons for seeking care, diagnosis, employed/unemployed, and length of homelessness) and data regarding perceptions of caring behaviors and self-perceived health, health literacy, attitudes towards homelessness, and access to and use of IT.

The nurses/nurse students will receive oral and written information about the study by one of the researchers in the project. If the person consents to participate, quantitative data will be collected via paper-and-pencil administrated questionnaires including sociodemographic variables (e.g., age, educational level and year, gender, and length of employment at A&E) and questions regarding self-perceived perceptions of caring behaviors towards a fictive written case, i.e., a homeless woman with a chronic medical illness, and attitudes towards homelessness.

Five validated questionnaires will be used to answer the aims: The Caring Behaviors Inventory (CBI-24), the General Health Questionnaire (GHQ-12), the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being (Facit-SP-12), the Communicative and Critical Health Literacy Scale, and the Attitudes Toward Homelessness Inventory (ATHI). A research assistant will be present during data collection among homeless women and, if needed, answer questions related to the questionnaires and/or read the questions for the woman. A time for an interview will be scheduled, and subsequently performed by member(s) of the project group: a researcher trained in interviewing and/or a woman with lived experience of homelessness. The interviews will be held at the unit or a place preferred by the woman. We will strive to collect quantitative data from at least 35 women and qualitative data from at least 25. For nurses or nurse students, data will be collected in conjunction with work or after a lecture. We will strive to collect data from at least 35 nurses and 70 nurse students.

An extreme health inequity exists within high-income countries, such as Sweden, resulting in social exclusion and considerably shortened lives among homeless women. This unparalleled inequity calls for prompt action in health care services working with this population. Patient and public involvement has been advocated by representatives of inclusion health, however, so far initiatives to accomplish this are absent. With this project, we aim to make inclusion health a reality for homeless women.