In our latest blog, Chloe Farmer talks about her experience as a nurse working with vulnerable women, the importance of inclusion health services and how she hopes her PhD work will help reduce stigma.
Stigma is one of many influences contributing to the marginalisation experienced by the individuals I support within my nursing role in an NHS inclusion health service. However, the impact of stigma should not be underestimated as a barrier to both health-seeking behaviour and engagement in treatment/care that leads to significantly poor health outcomes.
Stigma and inclusion health
Inclusion health as an agenda seeks to improve the health inequity of the most socially excluded populations. These include, though not limited to, individuals experiencing homelessness, problem substance use (PSU), vulnerable migrants, those who engage in sex work or those in contact with community justice services.
Many of the individuals I work with face intersectional stigma, resulting from the overlapping of multiple stigmatised identities. Facing intersectional stigma is associated with extremely poor health and social outcomes, and quality of life. Women experiencing co-occurring homelessness and PSU are one example of a population impacted by intersectional stigma.
Women’s experiences of stigma
Working closely alongside these women, it is apparent that stigma can permeate new or existing relationships to the detriment of their wellbeing. The fear of judgement from family and friends can breakdown personal relationships, reducing woman’s social capital and resulting in their disempowerment.
Of significant concern to me as a nurse, are the stories I hear from women experiencing prejudice from staff, and associated challenges in accessing resources within health and social care settings. Findings in research support these experiences, highlighting the inflexibility of healthcare systems and negative staff attitudes to be two major factors limiting healthcare access for inclusion health populations. As health professionals, it is fundamental that we do not gatekeep health and instead adopt an inclusive and equitable approach to healthcare delivery. We must use our clinical decision-making skills to promote healthcare that is both trauma-informed and centred around the needs of the individual.
It is known that the relative effects of intersectional stigma upon health inequity are greater for women than men. For women experiencing co-occurring homelessness and PSU, this heightened experience of stigma may be seen to derive from their perceived deviation from gender norms and societal expectations. However, it is women’s conventional absence from societal discourse, public policy and funding opportunities that has minimised the breadth of reporting of woman’s experiences, which worsens stigma. To address this, gender responsive research is crucial.
Limitations upon health
Although women comprise fewer homeless-, alcohol- and drug-related deaths in Scotland compared to men, the observed gender gaps have narrowed over time. There are different pathways to homelessness and PSU between genders, with women frequently becoming homeless at a point of heightened vulnerability compared to men. Women’s experiences of both homelessness and PSU indicate greater physical, psychological and social harms related to both. Men experiencing homelessness have an average age of death of 47 years, whereas for women this is even lower at just 43 years. Despite such extreme vulnerability, the influence of stigma results in women more often experiencing discrimination and difficulties engaging with support.
These challenges are reflected in low attendance rates within primary care and preventative services, alongside the high attendance rates (around 3.5 times that of the general population) within emergency settings. With around one in three deaths amidst individuals experiencing homelessness being amenable to good healthcare, development within community services is critical.
Inclusion health services use a flexible, person-centred approach to redress the health inequities of socially excluded populations. Services are usually delivered out with traditional healthcare settings via community outreach, which helps to reduce power imbalance and increases patient engagement. There is currently a limited body of evidence relating to inclusion health service delivery for women experiencing co-occurring homelessness and PSU, that is restricting opportunities in policy and practice.
My work
Last year, I began my PhD fellowship at the University of Stirling. Using my observations in practice alongside the support of my supervisors, I have developed a project that aims to (1) provide an understanding of the health of women with experience of co-occurring homelessness and PSU, (2) gain an understanding of available inclusion health services and (3) explore what optimal inclusion health services should look like to best support these women.
To meet these aims, my project will consist of five linked work packages:
- A comprehensive ‘state of the art’ review of international evidence exploring the health of women with co-occurring homelessness and PSU
- A mapping exercise of existent services that supports the needs of women with co-occurring homelessness and PSU
- Survey research of professionals within Scottish Alcohol and Drug Partnerships and the Faculty for Homeless and Inclusion Health
- In-depth qualitative exploration of women with co-occurring homelessness and PSU
- The development of a Theory of Change for optimal inclusion health services
I hope that my PhD project will provide a voice to a group of significantly vulnerable and socially excluded women who are commonly not heard within society and contribute towards improving their experiences of equitable health and social care. I also want to highlight the benefits of inclusion health service provision in addressing the unmet health needs within this population.
SHAAP Blogposts are published with the permission of the authors. The views expressed are solely the authors’ own and do not necessarily represent the views of Scottish Health Action on Alcohol Problems (SHAAP).
Chloe Farmer
Health Inclusion Nurse Practitioner, NHS Lothian, 1st Year PhD student at SACASR/ The University of Stirling, CSO Clinical Academic Fellowship.