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Health and social care access for people experiencing homelessness and lessons for primary care

guest blogger3 November 2021

This blog is written by Caroline Shulman and Megan Armstrong. Caroline has worked as a GP for people experiencing homelessness in primary care and as a clinical lead in a hospital homeless team. Caroline is principal investigator (PI) on a range of projects on palliative care, frailty and homelessness. Megan was the senior research fellow on this project and currently is the Programme Manager of PD-Care and the PI of exploring self-management in those experiencing low socioeconomic deprivation. 

Though everyone’s circumstances are different, to support people experiencing homelessness, it helps to understand some of the underlying causes of homelessness. Systemic factors such as austerity, increase in poverty and inequality, regressive changes to welfare systems, increased job insecurity with more zero hours contracts, lack of affordable housing and a hostile environment for migrants have contributed to significant increases over the last decade. However, in addition, there are individual vulnerabilities that increase the likelihood of becoming homeless. It is estimated 90% of people who are homeless have experienced adverse childhood experiences with 54% experiencing four or more (1). Adverse childhood experiences include abuse (emotional, physical, sexual or neglect) and household dysfunction such as living with domestic violence, or with a family member who has an addiction, is suicidal, mentally ill or in prison. Lack of having needs met and being soothed as a child impacts on cognitive, emotional, and social development and unresolved trauma is associated with an overdevelopment of the emotional and reactive parts of the brain (2).

People experiencing homelessness have some of the worst health outcomes of any group in society with the average age of death being in their early 50s  (see here). They have a much higher rate of most long terms conditions, including heart disease, respiratory disease than even populations in the most deprived sectors of society. Conditions usually found in older populations, such as cognitive impairment, incontinence, poor mobility, and frailty are highly prevalent at a young age in this population. Many people, with a history of sleeping on the streets in London, end up on homeless hostels. Homeless hostels are staffed by support workers who have no training in health or social care. In one hostel (for adults aged 35+), where residents average age was 55, frailty scores were equivalent to a population of people in their late 80s. All had multimorbidity with the average number of conditions per person being seven. Older age conditions such as cognitive impairment, falls and poor mobility were highly prevalent, though only 9% had any form of social services package of care (3).

One reason for the young age of death of people experiencing homelessness is the barriers they often face in accessing health and social care. Our study aimed to explore these barriers and potential facilitators from the perspectives of hostel residents and staff (4). We interviewed 18 homeless hostel managers/support staff and 15 people experiencing homelessness from six homeless hostels in London and Kent.

We found there were service barriers to health and social care access due to:

Stigma of both the residents and the hostel staff (often reporting not being believed):

“We have got one of the local GPs around here, they will not accept our residents unless a keyworker is with them, and they have to attend all appointments with them and register with them. They won’t accept them on their own.” Support worker

Lack of communication and information sharing from services with the hostel:

“I was that upset and annoyed that she’s [social worker] not speaking to anyone else that I’m working with [in the hostel]. I said, “It’s not keeping you up to date.” I speak to you once every three weeks, you don’t know what’s happening. So I could be going through a really difficult time and you’re not aware of it….” Resident

A lack of trust from the residents and a struggle to build relationships beyond the hostel staff:

“I’m still finding I’m having to learn to trust people. I don’t always trust people now, and my confidence is not brilliant. Once I know someone [this is different]…., but I’m not very good coming forward at the beginning.” Resident

Incorrect assumptions around capacity and the role of the hostel:

“I think because a lot of people presume because it’s [the hostel] a 24-hour manned project, they’ve got staff. They [external services] don’t really realise that our job isn’t to be carers…It’s not always practical to see everybody every single day. What people see from the outside is 24-hour staff” Support worker

The impact of lack of health and social care support led to staff going beyond their job role, continuous support needed by the residents, and burnout:

“We also have to go and collect people’s medications. We don’t have to but we’re doing that as well and liaising with GPs to put [medication] in dosette boxes and things like that.” Hostel staff

Overall, the hostel staff and residents had a great, trusting relationship. However, due to the lack of external service support, this can become a huge responsibility for the hostel staff. The quote below highlights the trust in the hostel staff.

“I think she [hostel staff member] cares about me. I’ve never actually asked her, does she care? The staff here are alright, I like them. I like the staff here. I ain’t got a bad word to say about them.”

An example of the causes of burnout for hostel staff include the trauma when a resident dies:

“When he was standing along the walls and he was saying, “I’m feeling pain,” and he just slid into the floor. It was during the night, early morning so there were only two staff. Staff were running up and down. It was quite a traumatic experience.”

See our recent paper and blog on palliative care for people experiencing homelessness.

What does this mean for primary care?

  • Everyone needs to be able to register with a GP. Groundswell have developed ‘My Right to Healthcare’ cards that can be posted for free.
  • Training is available for reception staff including a short 6 minute video: resources here
  • Primary Care Networks should consider having an inequalities lead to explore local solutions. They could also undertake a self-assessment to support improved engagement with inclusion health groups (see here).
  • Services should be person-centred, and trauma informed so that people feel safe, welcome, listened to and understood. Here is a video on trauma informed communication skills and an overview of training available here.
  • Services need to recognise the importance of developing trust and trusting relationships, as these are at the heart of healing and recovery. Ideally with the continuity of care with the same provider.
  • Services should  proactively support people with literacy, language, and cognition difficulties.
  • Primary care services should consider how they can take care to people with the highest need to enable trust to be developed. For example, enhanced services undertaking in-reach into hostels can be highly successful in increasing engagement. Reaching out to frontline staff in homeless services, who often feel stigmatised, can be a first step in acknowledging the support they are providing and explore how they can be better supported.

It is our duty to find and care for those in our community who are excluded and marginalised and advocate for their needs. We need to embed inclusive care and assertive advocacy as core to our work.

References

  1. Liu, M., Luong, L., Lachaud, J., Edalati, H., Reeves, A., & Hwang, S. W. (2021). Adverse childhood experiences and related outcomes among adults experiencing homelessness: a systematic review and meta-analysis. The Lancet Public Health.
  2. Bennet, M.S. (2017), ‘Connecting Paradigms: A Trauma-Informed & Neurobiological Framework for Motivational Interviewing Implementation’, Bennett Innovation Group, Denver.
  3. Rogans-Watson, R., Shulman, C., Lewer, D., Armstrong, M., & Hudson, B. (2020). Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Housing, Care and Support.
  4. Armstrong, M., Shulman, C., Hudson, B., Stone, P., & Hewett, N. (2021). Barriers and facilitators to accessing health and social care services for people living in homeless hostels: a qualitative study of the experiences of hostel staff and residents in UK hostels. BMJ open11(10), e053185.

Taking the me out of social media

guest blogger9 October 2019

Emma Walker, second year BBSRC-ESRC funded Centre for Doctoral Training in Biosocial Research PhD student at University College London’s Institute for Epidemiology and Health Care, describes how getting involved with research on social media helped her to reflect on her own usage. 

It’s 00.23 and I should be in bed. I’ve got lots on tomorrow but I’ve spent the last 45 minutes scrolling. Scrolling through the profiles of Instagram “life style coaches”, yogis, models; each collection of photos perfectly curated to appeal to my desire for millennial aesthetic.

Everything feels so much better than anything I have. And actually, in the world of Instagram, I know that everything is much better than what I have. Number of followers or number of likes on each post has conveniently quantified this for me.

The next evening, as part of my public health PhD work, I’m reading Professor Yvonne Kelly’s paper laying out the effects of social media use on the mental health of girls. I diligently make notes “.. greater social media use related to online harassment, poor sleep, low self-esteem and poor body image .. ” “..girls affected more than boys..” and pause periodically to check my phone.

All my friends are at the pub having a great time, another friend just put up a post where she looks amazing, it already has 50 likes. I get to the methods section of the paper “how many times in the last 2 weeks have you felt miserable or unhappy; found it hard to think properly or concentrate; felt lonely; thought you could never be as good as other kids…”.

Then the penny drops. Why do I think I’m immune? I’m like the lifelong smoker who’s confused by their cancer diagnosis: “I never thought it would happen to me.” The idea starts to filter in: I don’t need this in my life. In fact, I need this to not be a part of my life.

The next day I deactivate my Instagram account. That day I meet a friend for coffee in a hipster café and don’t take a picture of my coffee. That night I get to sleep by 11pm. The next day I work more productively than I’ve worked in weeks.

An opportunity to get involved comes up: the National Literacy Trust are really interested in Yvonne’s work and are keen to put together an event for young people. A great group of undergraduates and I devise a series of activities to find out what young people think about the research.

The first section would involve 4 zones at the front of the Renaissance Learning centre room for Strongly Disagree, Disagree, Agree and Strongly Disagree we put a series of statements on the board and ask the pupils to move to a zone and explain why. We include statements on a range of topics including cyber bullying, sleep deprivation, self-esteem and body image and parents and social media.

On the day, the 50 enthusiastic 11-14 year olds from 3 schools across London jostle about, keen to share their opinions and to hear one another’s. I’m amazed at the diversity of ideas, overall willingness to get involved and the mental health literacy of many of the students.

Some responses are predictable; the boys happy to appear less concerned about body image, many keen to state in front of their teachers that social media does not in any way disrupt their studies. Some are surprising; only a handful of pupils had been on social media before arriving at the event that day (a significantly lower proportion than the adults running it!) Other responses are hard to read; were the gaggle of girls laughing at the very idea of social media posts making you feel left out, honest or desperate to seem not to care?

A clear feeling was the young people’s frustration at their parents use of phones and social media. Many expressed irritation at the rules their parents have established – no phones at the table, in bedrooms, after 8pm – that they, themselves constantly break.

One boy described having to ask the same question 3 times before his dad will look up from his phone. The idea that our event should be run for parents was cheered.

Next we presented them with the evidence base for the possible impact of social media and mental health then asked them to make public health campaign like posters with top tips that could go up in their schools. We were presented with a beautiful collection of posters with thoughtful advice, carefully put together information, clever slogans and eye catching drawings. Audio recordings from the day gave further insights from the young who readily offered tips and advice for younger children.

Overall, I think the event was a success. My main impression was that these young people are actually very well equipped to protect themselves from the potential mental health impact of social media. That in fact it may be people in their 20s, who have grown up in the full glare of social media and its pressures, who are at the greatest risk.

It was a real privilege being able to discuss this topic with young people and the message that stood out the most from them is the opportunity parents have to make a difference by practicing what they preach.  Chances are they’ll benefit from switching off!

As for me, it’s now been 6 months since I deleted Instagram and whilst it hasn’t been plain sailing – I have got this itch for the buzz of an influx of likes –  for the time being I’m happy and I would wholeheartedly recommend it!

Anti-social working hours: Are they making women depressed?

guest blogger12 March 2019

The rise of globalisation and the 24/7 economy are fuelling demands for people to work long hours and weekends.  But what’s the evidence about how these ways of working link with depression? Gill Weston and colleagues from the International Centre for Lifecourse Studies in Society and Health at UCL and Queen Mary University of London found such working conditions are linked to poorer mental health in women.

Across the globe, the effects of overwork are becoming apparent.  In eastern Asian countries the risk of death due to overwork has increased.  In the UK, work-related stress accounts for millions of lost working days every year.

Within the EU, a significant proportion of people have to work unsociable hours – with nearly a quarter working most Saturdays and a third working at least one Sunday a month.  But despite this, there isn’t much clear evidence about the links between work patterns and mental health.

Some studies have found a connection between unsociable work patterns and depression.  But many of the studies only focused on men, some only looked at specific types of worker or workplaces and few took account of work conditions such as whether workers had any control over how fast they worked.

To address these gaps, we set out to look for links between long or irregular hours and depression using a large nationally representative sample of working men and women in the UK.  We particularly wanted to look at whether there were differences between men and women because research has shown that work is organised, experienced and rewarded differently for men and women, and because men and women react differently to overwork and time pressure.

We used data from Understanding Society, which surveys people living in 40,000 households across the UK.  In particular we focused on information about working hours, weekend working and working conditions collected from 11,215 working men and 12,188 working women between 2010 and 2012.  They had completed a questionnaire designed to study levels of psychological distress.

Who works the most?

We found men tended to work longer hours in paid work than women, and having children affected men’s and women’s work patterns in different ways: while mothers tended to work fewer hours than women without children, fathers tended to work more hours than men without children.

Two thirds of all men worked weekends, compared with half of all women.  Those who worked all or most weekends were more likely to be in low skilled work and to be less satisfied with their job and their earnings than those who only worked Monday to Friday or some weekends

Which workers have the most depressive symptoms?

Women, in general, are more likely to be depressed than men, and this was no different in our study.

Independent of their working patterns, we also found that workers with the most depressive symptoms were older, smokers, on lower incomes, in physically demanding jobs, and who were dissatisfied at work.

Are long and irregular hours linked to depression?

Taking these findings and other factors into account, when we looked at the mental health effects of work patterns on men and on women, the results were striking: while there was little or no difference in depressive symptoms between men who worked long hours and those who did not, this was not the case for women.

Those women who worked 55 hours or more per week had a higher risk of depression than women working a standard 35-40 hour week.

Similarly, weekend working showed differences for men and women.  Compared to workers who only worked on weekdays, men who worked weekends also had a greater number of depressive symptoms, but only if they had little control at work or were dissatisfied with work.  Whereas for women,  regardless of their control or satisfaction, working most or all weekends was linked to more depressive symptoms.

Why might women suffer more than men while working these antisocial hours?

There might be a number of reasons why women might be more affected than men:

  • Women who work long hours are in a minority – just four per cent of them in our sample worked 55 hours or more per week. This may place them under additional pressure.
  • Women working longer hours tend to be in male-dominated occupations, and this may also contribute to stress.
  • Women working weekends tend to be concentrated in low-paid service sector jobs, which have been linked to higher levels of depression.
  • Many women face the additional burden of doing a larger share of domestic labour than men, leading to extensive total work hours, added time pressures or overwhelming responsibilities.

What should be done about these risks?

Our findings should encourage employers and policy-makers to think about how to reduce the burdens and increase support for women who work long or irregular hours – without restricting their ability to work when they wish to.  More sympathetic working practices could bring benefits both for workers and for employers – of both sexes.

Long work hours, weekend working and depressive symptoms in men and women: Findings from a UK population-based study by Gill Weston, Afshin Zilanawala, Elizabeth Webb, Livia Carvalho, and Anne McMunn is published in the  Journal of Epidemiology and Community Health, which is published by the BMJ.

Taking time out to scroll free

guest blogger29 August 2018

As the Royal Society for Public Health launches its #ScrollFreeSeptember campaign, encouraging people to take a break from social media, Professor Yvonne Kelly from the ESRC International Centre for Lifecourse Studies at UCL, discusses new research on the negative impacts of social media use on young people’s health. She explains how the findings point to the need to limit the time that young people, especially girls, spend on social media.

The ScrollFreeSeptember campaign accompanies the launch of a second parliamentary inquiryin less than 12 months into the impact of social media use on young people’s mental health and well-being. Our Centre will be submitting a range of important new findings to that inquiry which seeks to grow the evidence base in an area where there is a great deal of hot debate, but where little is really known and understood.

For our team of researchers, the first indication that all was not well in the world of social media and young people’s mental health came in 2015 when we found that children who were heavy users of screen-based media were less happy and had more social and emotional problems than their peers who used it moderately. Children who used social media sites for chatting were also less likely to be happy and more likely to have problems than their peers who did not.

In March this year, our widely covered work on the trends for boys’ and girls’ social media use added weight to recent calls from the Children’s Commissioner for England to, as she put it, call time on a “life of likes”. In her report, Anne Longfield argued that there was clear evidence of children finding it hard to manage the impact of online life. She said children as young as eight were becoming anxious about their identity as they craved social media likes and comments for validation.

Social media and girls

Our research, based on the experiences of 10,000 children aged 10-15 who took part in the Understanding Society study, showed that this seemed to be the case particularly for girls who used social media for more than an hour a day. 10 year-old girls in the study who spent an hour or more on a school day chatting online had considerably more social and emotional problems later on – by age 15 – than girls of the same age who spent less or no time on social media. The number of problems they faced also increased as they got older, which was not the case for boys.

It was interesting to note that more girls than boys were using social media and for greater periods of time. At age 15, 43 percent of girls and 31 per cent of boys were using it for between one and three hours per day, with 16 and 10 per cent using it for more than four hours.

We think this tells us something important about the different ways that girls and boys interact with social media. For example, girls may be more likely than boys to compare their lives with those of friends and peers – whether those are ‘filtered’ selfies or positive posts about friendships, relationships or material possessions – these could lead to feelings of inadequacy, lower levels of satisfaction and poorer wellbeing.

The pressures associated with having peers like or ‘approve’ status updates and a perceived fall in or lack of popularity could add further pressure at, what for many teenagers is a tricky time in their lives.

Boys are more likely to be gaming than interacting online in the way just described and that wasn’t covered in this research, so it’s possible that for boys, changes in well-being may be more related to gaming success or skill.

But one of the key takeaways of this research is how social media use as a very young person is linked to lower levels of happiness later on – the effects are not short term – they have longer term consequences and

Social media and depression

More recently, we have turned our attention to the social media experiences of the children in the Millennium Cohort Study (MCS), using information on 11,000 14 year-olds to look at how social media use is linked with depression. We’ve also been asking ourselves what the pathways between these two things might look like, something that’s not really been done before. So, for example, are heavier users of social media getting too little sleep or having trouble getting to sleep because they are checking accounts at bedtime; are they experiencing cyberbullying either as victims or perpetrators; do they appear to have low self-esteem or a negative view of how they look? All these questions can help us better understand what’s at play and come up with better approaches to tackling these problems.

Preliminary findings reinforce the message that girls are particularly vulnerable to the negative effects of social media. Once again we see more girls than boys in this study using social media and for longer periods of time.

Does using social media affect literacy?

A follow up piece of research looks at whether there are links between the amount of time young people spend on social media and their levels of literacy. Findings suggest a link and that this is the same for boys and girls.

In this research we look at whether the more time young people spend on social media, the less time they have for the things that might improve their literacy such as reading for enjoyment and doing homework.

There are some clear messages from our research so far:

  1. Heavy users of social media are less happy and have more problems at school and at home – interventions to help them limit and manage their social media use better are likely to be important
  2. Girls are particularly vulnerable to the negative effects of social media and may be an important group to focus on among those looking to mitigate thse effects
  3. More hours spent on social media appear to impact negatively on young people’s wellbeing and could have knock on effects for their longer term prospects at school and work

Social media companies have been accused by the former Health Secretary Jeremy Hunt among others of turning a blind eye to the problem and the chief medical officer Dame Sally Davies has been asked to recommend healthy limits for screen time.

Our research indicates that it may indeed be time for recommended healthy and safe limits of social media use, that a focus on girls, especially initiatives to boost their mental health could help mitigate some of the negative effects.

The RSPH is hoping that going scroll free this September might give us all a chance to get our social media use a little more balanced, to think about the benefits to be enjoyed and the negatives to be avoided.

As well as pausing to think about our social media use and how it affects us, it will be an opportunity to examine the facts of the matter, a time to digest new, solid evidence that these large scale studies can help us with and consider the potential longer term costs and consequences of doing nothing.

The forthcoming inquiry hopes to inform “progressive and practical solutions”, including a proposed industry Code of Practice and tools for educators, parents and young people themselves to help them enjoy the benefits and eliminate the negative effects of their social media. We wholly support those efforts and hope they result in positive changes that will make campaigns like ScrollFreeSeptember unnecessary in the future.

This blog article is courtesy of the Child of our Time blog, which is a blog about the health and happiness of children living in the UK. led by the ESRC International Centre for Lifecourse Studies, University College London,