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 open, 11(10), e053185.

by Katie Gilchrist

I am an MSc Health Psychology student at UCL. As part of the programme, we are required to attend a clinic for observation. As a brain tumour survivor, a natural choice for me was the Neurosurgery clinic at The Unit of Functional Neurosurgery at The National Hospital for Neurology and Neurosurgery, London.

My sense of tumour

In December 2017 I was diagnosed with a benign brain tumour called acoustic neuroma and in February 2019 I underwent surgery at The Royal Randwick hospital in Sydney, Australia to have the tumour removed. A consequence of the surgery was being left with grade 6 House-Brackman facial paralysis, single sided deafness and one less vestibular nerve. I spent the first month recuperating from the surgery, practicing walking with one balance nerve and adjusting to losing the hearing in one ear and the loss of facial movement on one side of my face. Seven months after the surgery my husband and I packed up our lives after spending seven years in Australia and moved back to the UK where I started my MSc in Health Psychology at UCL. Following my experience, naturally, I was really excited about spending a morning in a hospital clinic (a mandatory part of the course) and even more excited when I saw there was a neuro clinic!

Feeling empathy for patients

So, recently I attended the clinic at The Unit of Functional Neurosurgery at The National Hospital for Neurology and Neurosurgery, London with Prof Ludvic Zrinzo. The clinic specialises in cranial nerve disorders such as hemifacial spasm (involuntary facial twitch) and trigeminal neuralgia (chronic facial pain). What I didn’t realise, when I made my selection, was that the conditions Prof Ludvic Zrinzo works with can present with facial droop or weakness and that for some of the conditions the surgical approach, risks and recovery are very similar to what I had. There were a lot of patients with facial movement issues and their faces looked like mine, asymmetrical smiles and one eye looking frozen open, foreheads not able to move and I felt such empathy for them. It was difficult not to run after them and comfort them but at the same time it was like hearing my own diagnosis over and over again. There were several moments where my eye (only one produces tears) glazed over and I had to concentrate not to show too much emotion as that would have been unprofessional. While it may help the patient to see we are human, it is not good for them to feel our burden which may accidentally transfer to them if we overshare.

Learning from the best

Having met a few surgeons through my own health experience, I was really blown away by Prof Ludvic Zrinzo’s approach to patient care. It was great to see a surgeon putting into practice all the psychology aspects we have learned in class this term; building rapport, explaining in clear language, allowing time for the patient to ask questions as well as all the additional points he covered like asking who was at home to help with care, reminding them to bring partners into appointments and explaining all the options available to them and really emphasising that it was the patients decision. Before each consultation, he explained to the patient who we were (there were three students observing) and he asked if it was ok if we stayed and listened. Only one patient decided at that time it was not ok for us to stay for that appointment and Prof Zrinzo kindly asked us to wait outside. On our return we didn’t ask about the patient and nor did he offer any information. The appointment had taken longer than some and we were playing catch up. I also felt there was an understanding between us that in this instance any discussion was to stay between patient and health professional.

What will I take from this into my future roles?

1. The importance of asking the patient what they want
   • Did they mind having students in the room?
   • What were their thoughts on which treatment?

2. The benefits of open dialog
   • Encouraging patients to include family and friends in the conversation
   • Explaining risks and benefits in layman’s terms without provoking fear
   • Asking about family, other health issues, home/work environment
   • Having open discussion with empathy and patience, even if it has been discussed several times previously

Overall, Prof Ludvic Zrinzo had such a great approach and I am so grateful to be able to have observed this. While it was emotional for me it really reaffirmed my desire to help people with health issues and I just wanted to say thank you to UCL and The National Hospital for Neurology and Neurosurgery for arranging such a great experience.

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!

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.

This blog article is courtesy of the Work Life blog, which is a blog about the relationship between work and  health and well-being of people, whether they are preparing for  working life, managing their work / life balance or preparing for retirement and life beyond retirement. Led by the ESRC International Centre for Lifecourse Studies, University College London