Health and wellbeing needs of the homeless, the physiotherapist's role

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Introduction

Throughout this Physiopedia resource we will be discussing and exploring the health and wellbeing problems associated with the homeless population in order to give you a better understanding of what they are dealing with. We will also give an introduction into the management of these issues and the impact they can have on physiotherapy. The resource should take approximately 10 hours to complete on a self-study basis. The resource is aimed at final year physiotherapy students and recently qualified physiotherapists. We will discuss five main topics which are physical health, mental health, substance abuse, accessibility of health care and the implications to physiotherapy.

Aims and Learning Outcomes

Aims: 

To provide a resource for final year physiotherapy students and newly qualified physiotherapists regarding the health and wellbeing problems faced by the homeless population in the United Kingdom and consideration of the physiotherapists role in management of this population.

Learning outcomes:

By the end of this resource you will be able to:
1. Debate the issue surrounding homelessness within the United Kingdom.
2. Critically discuss the main/key health problems experienced by the homeless population in the UK.
3. Evaluate some of the challenges that the homeless population face when accessing physiotherapy.
4. Critically reflect on the physiotherapist’s role in assessing and managing the health and well-being needs of the homeless population.

Learning Styles

This resource will aim to suit everyone’s learning styles. A learning style is the way in which we learn best. Figure 1 below shows the different ways in which one learns or you can find out by taking the VARK test which is a free online resource (external link). By engaging every reader (undertaking the resource) in different activities that suits their learning style they will get more out of the resource.

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Homelessness in the UK  

By the end of this section you should be able to debate the issues surrounding homelessness in the United Kingdom, meeting learning outcome 1. This section should take 30/40 minutes to complete.

It is widely thought that homelessness is just about those ‘sleeping rough’ and on the streets, however that is just a minority of the problem. A person can be classified as homeless if they do not have a permanent home (Crisis 2005). This can be anyone who is staying with a friend, in a B&B, a hostel or a temporary home (Shelter 2014). It is believed that the homeless population are some of the most vulnerable people in our society including those of ill health, low income, unemployment, isolation and relationship breakdown (Crisis 2005).

The 2014-2015 audit results estimated there was 28,615 homeless people in Scotland, a number which has significantly decreased since 2009-2010 when 43,371 were estimated to be homeless. Figure 2 demonstrates the time-line of homeless in Scotland over the past 23 years (Shelter Scotland 2015a). Single men make up a large proportion of the homeless population at 45% compared to single females at 21% (Shelter Scotland 2015b).

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Figure 2: Applications and Assessment made by the homeless population

There are several different reasons why a person can become homeless. In 2014-2015 over half of homelessness applications made were due to relationship breakdown or being asked to leave their permanent address (Shelter Scotland 2015c). Below, figure 3 expresses the reasons behind homelessness in Scotland.

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Figure 3: Reasons for homelessness

Crisis (2014) found that most often males who were homeless, became homeless due to relationship breakdown, substance abuse or leaving an institute for example; hospital, prison or care. More specifically they found that 18% were ex-prisoners, 8% were care leavers and 3% were ex-armed forces. Additionally, 32% of ‘rough sleepers’ in London were previously in prison.
The homeless health audit results from 2014 (Homeless link 2010) highlights the health and well-being problems faced by the homeless population. It was found that 73% of homeless people report some form of physical problem, 80% suffer from a mental health problem, 39% explained they have suffered from a drug problem and 27% from an alcohol problem. In addition, 35% had been admitted to A&E in the past, with 26% having been admitted in the last 6 months.
Below, figure 4 highlights just a few of the homeless populations problems they can be faced on a day to day basis (Health EducationAuthority 1999).
Figure 4: Factors perpetuating the homeless lifestyle

The Crisis (2011a) report ended with the chilling quote “ultimately homelessness kills” putting an emphasis on the NHS services to deliver the best patient centred, compassionate care to this very vulnerable population. Additionally, Crisis (2011b) believes new laws need to be enforced to give the homeless population emergency accommodation, written advice and real assistance for their medical needs.
In 2013 it was estimated that 70% of homeless people being discharged from hospital did not have their health or housing needs met. After that it was released that £10million funding was given to the NHS and voluntary run homeless centres to help tackle health and housing needs after discharge from hospital (Department of Health 2013a). Annually the government provides £470 million in trying to prevent homelessness, aiming to ensure the safety of those who are vulnerable (Department of Health 2013b). It is believed that a homeless person is 6 times more likely to visit A&E than someone with a permanent address and the cost of treating them is 8 times higher than due to their complex physical, social and psychological needs which costs the NHS £85 million every year.

Maslow's Hierarcy of Needs

Maslow’s hierarchy of needs explains that people are motivated to achieve certain goals. In this hierarchy, there are five stages. The lower level basic needs have to be achieved before it is progressed to the next level. It was explained that self-actualisation is desired in every person. However, due to various life situations, progression from the lower level needs are often hindered.

Majority of the homeless people are still seeking to achieve their physiological needs, such as food, water, shelter, warmth and sleep. When such needs are not met, they tend to overlook health issues, thus prioritising other issues such as employment and the search for food above seeking medical attention. As such, contributing to the lack of usage of medical services in this population.

Mental Health

In this section you will learn about common mental health conditions experienced by homeless people and how these affect them, helping to achieve outcome 2. This section should take 45mins-1hr to complete.

Accesibility of Health Care

Barriers to Accessing Healthcare

There are various factors that can contribute to the lack of access to healthcare services in the homeless population. Some intrinsic factors include their fear and denial of poor health, problems communicating their health needs, self-esteem issues and lack of understanding of the health care system. A study done by Geber (1997) shows that 31% of the homeless respondents thought that their medical conditions are not serious enough to see a GP, 11% of them claims that they will “tough it out” by themselves and 8% of them do not think that they are ready to handle their health issues. Some of them felt that they are neglected from the healthcare system and a group of them felt that they were “labelled” (Martin, 2008). Patients who are homeless often describe their experience to the GP as “humiliating” due to insensitive comments made by the GPs and being judged by the practice staffs and by other patients (Pfeil and Howe, 2004). It was also noted that some of the homeless people felt that they are being discharged prematurely even though their medical needs are not resolved (Martins, 2008). Therefore, the homeless population does not have a positive impression of health care services and that the quality of care for them are discriminatory and compromised. As such, many homeless people rather not seek for health care services. A study done by Nickasch and Marnocha (2009) mentioned that the great majority of homeless people have an external locus of control, which means that they attribute their experiences to external circumstances that is beyond their control, such as luck and fate. Having an external locus of control can be one of a major factor that leads to their negative perceptions of the health care services, and therefore deter them from using the services available.

There are also extrinsic factors such as rejection upon visiting the local GP and also the inability to attend consultation during daytime (Lamb & Joels, 2014. BBC, 2001). Healthlink (2004) undertook a survey within the homeless population and asked the participants to describe their experiences within the healthcare system. A number of themes arose within the group including; lack of training and understanding about homelessness, no continuity of care, experiences of stereotyping and discrimination, GP’s not having long enough to look at the patient holistically and a constant feeling of being stigmatised.

However, it is important to note that different countries have different health policies. Due to the limited number of UK research done on the topic of homelessness, some articles from other countries such as Canada and US were referenced above. There will be differences in the perceptions and experiences of the homeless population in regards to health services due to the health policies differences in each countries.

Implications for lack of access

Limited health care accessibility for the homeless population can lead to significant social and economic impact on the society. Poor access to health care often lead to delayed clinical presentation and diagnosis (Gelberg, 1990) As a result, many of the medical conditions deteriorate and requires secondary care intervention (Melvin, 2012). This figure contributes to the high estimated cost of £85 million spent on health care for the homeless people annually, which is equivalent to £2,100 per homeless person compared to £525 per person from the general population (Taylor et al., 2012).

Another pertinent issue caused by the lack of accessible health care services for the homeless population is the usage of emergency services. Firstly, people who are homeless do not have a proper housing, putting them at higher risk of being involved in violence, getting victimised on the streets and also predisposes them to contracting diseases such as Hepatitis. (Kushel et al., 2002. Watton and Gallivan, 2013). On top of that, many of the homeless people used the Emergency Department as their only source of health care (Kushel et al., 2002). Those who are not registered to a GP turn up in the Emergency Department for non-emergency complaints (BBC, 2001). One attributing factor to such tendency is that the emergency department provides services all day and it does not require an appointment. Another reason for frequent admissions to the Emergency Department is due to inadequate discharge from health care during the previous hospital visit. This lead to readmission to the hospital shortly after as patients who are homeless find managing their health needs unmanageable on the streets (Homeless Link, St Mungo’s, 2012).

Example

Accessibility of health services is a problem faced by the homeless population throughout the UK. An annual service such as Crisis at Christmas (http://www.crisis.org.uk/) offer services for the homeless including physiotherapy. This is a volunteer run service with includes meals, shelter, entertainment and health services over the festive period. In Edinburgh, the Salvation Army provides a weekly service called StreetSmart that provides physiotherapy for the homeless population. (http://streetsmartphysio.org/about-us/) As physiotherapy students and newly qualified physiotherapists this is potentially an area of practice that can be expanded on however we may be treating the homeless population in hospitals.

Key Points and Reflections

Based on what was mentioned above, discuss the role of health care professionals in improving the accessibility of health services to the homeless people (20 mins).

Taking into consideration that a great majority of homeless people have external locus of control (e.g. Extracted from Nickasch and Mamocha (2009): “I am totally a victim of my circumstances...right now I lack complete free will...life is dictating me”), recommend ways in which health care professionals can improve on to improve the comfort levels of the homeless people during treatment sessions (20 mins).

References

References will automatically be added here, see adding references tutorial.