"It's My Secret": Shame as a Barrier to Care in Individuals With Opioid Use Disorder

BACKGROUND

Substance use disorder (SUD) is a chronic illness impacting more than 59 million Americans last year. Opioid use disorder (OUD) is a subset of SUD. The literature supports that healthcare providers frequently stigmatize patients with OUD. Individuals with OUD often feel shame associated with their disorder. Shame has been associated with maladaptive and avoidant behaviors.

AIM

The aim of this qualitative descriptive study was to examine and describe the experiences of shame and health-seeking behaviors in individuals with OUD.

METHODS

A qualitative exploratory design using focus groups with individuals in treatment for OUD was used to identify the issue of shame and its relationship to health-seeking behaviors.

RESULTS

A systematic content analysis of discussions with 11 participants in four focus groups revealed four major themes and associated subthemes: Avoidance of Preventive Care (belief providers are judgmental); the Hidden Disorder (keeping secrets); Constraints of Shame (justification for the continuation of drug usage); and Trust in MOUD (Medication for Opioid Use Disorder) Providers. The feeling of shame leads to a reluctance to engage in health-promoting actions, such as scheduling appointments with primary care providers and dentists.

CONCLUSION

Healthcare practitioners must prioritize providing a safe, nonstigmatizing environment for patients with SUD/OUD. This includes establishing trust and rapport, providing education, collaboration with psychiatric mental health specialists and other healthcare providers, and the offering support and resources to help patients manage their condition to achieve optimal health outcomes.

Describing the development and implementation of a novel collaborative multidisciplinary approach to deliver foot health supports for individuals experiencing homelessness and its outcomes

Basic foot care is a real need of people experiencing homelessness. To improve access to foot health for this group, three services structured to provide healthcare support for people experiencing homelessness collaborated in metropolitan Melbourne, Australia: an established nurse-led Homeless Persons Program (HPP), a specialty community health podiatry clinic servicing people experiencing homelessness, and a charity supporting disadvantaged communities providing free socks, foot first aid kits and second-hand footwear for distribution by nurses and podiatrists of participating services. This paper outlines the implementation and evaluation of this collaboration. A four stage implementation approach was used, addressing: 1. Who needs to do what differently? 2. What are the barriers and enablers that need to be addressed? 3. Which intervention components could overcome the modifiable barriers and enhance the enablers? 4. How can the changes be measured? The evaluation prospectively collected information about how HPP nurses referred adults to podiatry, and whether the referred individuals accessed the podiatry clinic, the outcomes of the podiatry visit, and how many received footwear, socks and foot first aid kits provided by the non-profit organisation. Over 1st June 2019 and 31st December 2020, 52 individuals were identified as adults who could potentially benefit from podiatry by the HPP nurses, of which 33 accessed podiatry. Those who did not visit the podiatry clinic were more likely to be born outside of Australia, live in more precarious housing (crisis accommodation and rough sleeping), have slightly more predisposing factors for homelessness, but have fewer medical, psychological and cognitive conditions. A structured approach including processes, education, regular, outreach to youth refuges and formal outcome monitoring enabled foot health care access in people experiencing homelessness. Further research is needed to ascertain how to support participants at risk of foot problems to access podiatry before their foot health issue reaches crisis point.

A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare

BACKGROUND

Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort.

METHODS

A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman's multidimensional quality model. People with lived experience of homelessness were employed as part of the research team.

RESULTS

Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America (n = 17), United Kingdom (n = 5), Australia (n = 5) and Canada (n = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of 'accessible and timely', 'person-centred', and values of 'dignity and respect' and 'kindness with compassion' were most prevalent. Among the three patient experience surveys identified, 'accessible and timely' and 'person-centred' were the most frequent domains. The least frequently highlighted domains and values were 'equitable' and 'holistic'. No questions addressed the 'safety' domain.

CONCLUSIONS

The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of 'Kindness and compassion' require further emphasis when seeking feedback on healthcare experiences and the domains of 'safety', 'equitable', and 'efficiency' are not adequately represented in existing patient experience surveys.

A scoping review of psychiatric conditions associated with chronic pain in the homeless and marginally housed population

The present review sought to examine and summarise the unique experience of concurrent pain and psychiatric conditions, that is often neglected, within the population of homeless individuals. Furthermore, the review examined factors that work to aggravate pain and those that have been shown to improve pain management. Electronic databases (MEDLINE, EMBASE, psycINFO, and Web of Science) and the grey literature (Google Scholar) were searched. Two reviewers independently screened and assessed all literature. The PHO MetaQAT was used to appraise quality of all studies included. Fifty-seven studies were included in this scoping review, with most of the research being based in the United States of America. Several interacting factors were found to exacerbate reported pain, as well as severely affect other crucial aspects of life that correlate directly with health, within the homeless population. Notable factors included drug use as a coping mechanism for pain, as well as opioid use preceding pain; financial issues; transportation problems; stigma; and various psychiatric disorders, such as post-traumatic stress disorder, depression, and anxiety. Important pain management strategies included cannabis use, Accelerated Resolution Therapy for treating trauma, and acupuncture. The homeless population experiences multiple barriers which work to further impact their experience with pain and psychiatric conditions. Psychiatric conditions impact pain experience and can work to intensify already adverse health circumstances of homeless individuals.

Moderating Effect of Help-Seeking in the Relationship between Religiosity and Dispositional Gratitude among Polish Homeless Adults: A Brief Report

Although empirical reports draw attention to the pathological aspects of the functioning of the homeless, recent studies show the benefits related to the elevating roles of different positive phenomena in coping with difficulties for this group of people. The main goal was to verify whether there is a direct relationship between religiosity and gratitude among the homeless, and whether this association is moderated by the reported help-seeking since both religiosity and gratitude seem to play an important role in homeless people’s lives. In total, 189 homeless persons participated in the study. Their mean age was M = 56.55 (SD = 12.39; range = 27–86). Most respondents were men (n = 119; 63%). The Scale of Religious Attitude Intensity and the Gratitude Questionnaire were used. The outcomes presented a statistically significant positive correlation between religious attitude and gratitude (r = 0.326***, p = 0.001). Help-seeking played a moderatory role in this relationship. Therefore, it can be assumed that the relationship between religiosity attitude intensity and dispositional gratitude is stronger when homeless persons seek specific help from other people or institutions compared to when they do not look for assistance. Homeless people, overcoming their limitations by actively asking for help, can strengthen their bonds with God (faith, religiosity) and with others (dispositional gratitude).

Fostering Trust With a Young Man Experiencing Homelessness and Advanced Cancer

Persons experiencing homelessness (PEH) face countless barriers to equitable health, social, and palliative care across all settings. Brandon was a 23-year-old male, well-spoken, groomed, and polite despite difficult circumstances. He was severely abused then abandoned as a child, living in multiple foster homes until 18. With no consistent caring adult figure, he predictably fell into a chaotic lifestyle, had 3 children by different mothers, and became homeless in New York City. He presented with newly diagnosed renal cell carcinoma metastatic to lung, lymph nodes, and bone. Spine and pelvic metastases caused paralyzing somatic pain that interfered with walking and sitting and prevented Brandon from performing the activities of daily living essential for his survival on the streets and safekeeping of opioids. Lack of basic social support and a history of multiple abandonments made a care plan for this young, homeless, and truly isolated man very challenging. The inpatient and outpatient interdisciplinary team members partnering with Brandon each earned his trust with time. A "safe place" opened hearts on all sides of the therapeutic relationship and led to a plan that was acceptable for both the patient and the palliative care team. Clinicians are often challenged to provide sustained and pragmatic palliative care services for PEH due to complex barriers. Continued advocacy for equitable and tailored services that ensure high-quality palliative care for PEH is critical at individual, institutional, and system levels to promote health equity and dignified care.

'Genuine doctor care': Perspectives on general practice and community-based care of Australian men experiencing homelessness

People with complex health and social needs, including tri-morbidity and homelessness, are challenging for modern healthcare systems. These clients have poor health and social outcomes. They tend to use available health resources inefficiently, with fragmented, uncoordinated use of multiple health and social care services. Increasing access for these clients to well-supported general practice care may be an effective response to these challenges. The aim of this study was to explore client experiences of, and attitudes to, community-based healthcare, and general practice in particular, to identify opportunities to improve healthcare provision. Five focus groups with a total of 20 men currently experiencing homelessness were facilitated by the corresponding author in an inner-city homeless hostel. Discussions were transcribed, coded and analysed thematically. The analysis was informed by earlier focus group discussions with community-based homeless healthcare providers. Participants reported reluctance to engage with healthcare providers outside times of perceived crisis, and experiences of stigma and dismissive care. Some participants were sceptical of the motivations of health and social care providers, including general practitioners. Presentations with physical and psychological pain featured prominently in participant accounts. Three key themes identified important aspects of client experiences of community-based healthcare which indicate potential areas for improvement. These themes were as follows: the relative invisibility and low salience of general practice compared to hospital-based emergency and inpatient services; discontinuity within community-based healthcare and across transitions between community-based and other healthcare; and inconsistent and unsatisfactory general practitioner responses to physical and psychological pain. These responses included apparent over-prescribing, under-prescribing and short-term 'band-aid' responses. Generalist medical expertise was valued in general practitioners, but not consistently experienced. A number of challenges and opportunities exist, at both individual and system levels, for general practice to realise its potential to deliver effective, compassionate and efficient care to clients experiencing homelessness.