Health Education Research, Vol. 16, No. 5, 593-602,
October 2001
© 2001 Oxford University Press
Developing a strategy for community-based health promotion targeting homeless populations
Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, The Mortimer Market Centre, London WC1E 6AU and
1 Criminal Policy Research Unit, South Bank University, London SE1, UK
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Abstract |
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There is a need for targeted health promotion aimed at homeless populations. A survey of 100 Big Issue newspaper vendors was conducted, along with in-depth interviews and focus groups, in order to identify health promotion needs. Drug and alcohol problems, the effects of cold weather, nutritional deficiencies, and poor personal hygiene were reported as the main health concerns. However, health was not always an immediate priority for the homeless, with daily concerns predominating, such as shelter and getting money for food. A range of information needs were highlighted and a number of key health promotion topics identified. Social network and social activity data were collected from 14 Big Issue vendors to assess their penetration of groups of homeless people. Both generic and targeted health promotion activities are recommended, and the role of health advocacy and peer education should be further explored.
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Introduction |
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A recent review identified the need for focused health promotion interventions targeting homeless and vulnerably housed people (Power et al., 1999
). It also laid down the challenge to develop and deliver health promotion initiatives to a heterogeneous population of homeless people. Although there have been extensive reviews of the link between homelessness and health, little attention has been paid to the health promotion needs of this population (Connelly and Crown, 1994; Plearce and Quilgares, 1996). Partly resulting from shifts in housing policy and a contraction of the public housing sector, homeless people find themselves in a range of marginalized accommodation situations correlating with mental and physical health problems (Smith et al., 1994; Robinson, 1998). When compared with the general population, the health status of homeless people is extremely poor (Plearce and Quilgares, 1996). More specifically, this is the case concerning health issues such as diet and malnutrition (Stitt et al., 1994), sexual health, substance misuse, and mental health (George et al., 1991; Klee et al., 1991; Gill et al., 1996). A wide spectrum of physical problems have been associated with the living conditions and lifestyles of the homeless, ranging from cardiovascular disease to accidents and hypothermia (Burrows and Walentowicz, 1992; Connelly and Crown, 1994). This need to address the health concerns of homeless people resonates with the British government's call for community-level health promotion that aims to change the behaviour of socially excluded groups (Department of Health, 1998). To this end we conducted a study to assess the feasibility of using Big Issue newspaper vendors as peer-educating health advocates (Hunter and Power 2001a). The Big Issue is a newspaper sold on the streets by homeless people, thereby providing them with a source of income. The Big Issue originated in Britain, but the concept has been adopted elsewhere, including St Petersburg in Russia and Los Angeles in the US. The Big Issue Foundation strives to help vendors develop skills to enable them to move away from lifestyles associated with being homeless. One of the assumptions behind this study was that vendors would have good access to socially excluded homeless people and could prove to be a viable conduit for health promotion activity. As part of a formative evaluation for this study we collected data from homeless Big Issue newspaper vendors: (1) to identify the health promotion needs of homeless people and (2) to describe the social networks of the vendors themselves. Further components of the study, to assess the practical feasibility of involving Big Issue vendors in peer education training and delivery, and the development of relevant health promotion materials, are reported elsewhere (Hunter and Power, 2001b).
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Methods |
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The study was conducted over a 9-month period during 1999. We followed a participatory research design, working closely with Big Issue staff, especially the Drugs and Alcohol Workers, and the Jobs, Education and Training (JET) team. It was agreed that three sites would be chosen for the study to reflect the range of locations where the Big Issue operated. These were centred on Big Issue offices in London, Brighton and the West Midlands. Due to the larger numbers of vendors at the London office and the fact that they originated from many parts of the country, it was decided to develop and pilot the research instruments and to conduct the questionnaire survey at this site. Initial key themes for the questionnaire, topic-guided interviews and focus groups were derived from an ';expert panel' on homelessness and health, which was funded by the Health Education Authority and chaired by the first author (Power, 1999
). Subsequently, and in order to examine health promotion concerns of homeless people, a questionnaire survey was conducted among 100 vendors at the London office of the Big Issue, recruited by the second author. During a 3-week period vendors were asked to participate in the survey when they came to the ‘vending area’ of the office to collect their Big Issue papers, which they would then go on to sell. Interviewing continued until the target of 100 was reached. Each respondent received 10 free papers for participating in the survey, which they would then be able to sell to the general public at a profit of £6. Less than one in 10 vendors declined to participate in the survey, mainly due to lack of time and eagerness to leave the office to claim their vending pitch.
At two other Big Issue offices (Brighton on the South Coast and Birmingham in the West Midlands) 14 vendors who expressed an interest in taking part in peer education training were interviewed about their social contacts. These topic-guided interviews took approximately 1 h and recorded details of social networks, social and other activity, and contacts with relevant agencies. Additionally, five focus groups were held (four with vendors and one with vendor support staff) and 18 in-depth interviews (14 with vendors and four with staff). The qualitative data derived from the focus groups and in-depth interviews are used to illustrate the survey data, as seen in Results. It is anticipated that the multi-method approach adopted by this study and the consequent triangulation of results would counter the potential compromise to reliability and validity resulting from the largely opportunistic sampling of vendors.
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Results |
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Basic socio-demographic details were collected from survey respondents. Of the 100 respondents, 79% were male, 94% were white British, 74% were under 35 years of age (mean age 26.5 years) and 45% had been vending for 6 months or less. These general characteristics of the survey respondents were similar to the vendor profiles as described by Big Issue staff (predominantly male, white, aged in their mid-20s, vulnerably housed).
Identifying health problems and health concerns
Respondents were asked to identify key health concerns affecting the homeless. As can be seen from Table I, many health issues were identified as suitable targets for health promotion interventions.
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Most commonly mentioned were problems related to drug or alcohol use, the effects of exposure to cold weather (especially for those sleeping rough, in squats or traveller sites), the difficulty of obtaining a good diet, and of maintaining personal hygiene to avoid skin conditions and parasites. Also noted was the fact that minor health problems can deteriorate due to difficulties accessing medical care. Physical injury or mental stress as a result of violence or intimidation on the streets was also mentioned.
The extent of health problems for those who lack secure housing was perhaps best summed up by the following comment, made by a vendor in London: ‘there are just far too many to say’.
The Big Issue support staff stressed the wide range of physical and mental health problems suffered by the homeless, as highlighted in the following interview extract:
Depression, low self-esteem, a lot of chest complaints, TB is on the rise again, hepatitis C. Head lice, poor circulation, bad feet, very bad feet. There seems to be an awful lot of asthma. I couldn't really put figures on these things. They're just general impressions. People drink or take drugs. The heroin that is widely available at the moment is cheap, smokeable heroin. It's not meant for injection, so you get in drug users now who have no veins after using heroin IV [intravenously] for two to three years. We see a lot of people with citric burns, you know very deep holes. People are using their veins out that much quicker and are resorting to the groin that much quicker, with all the complications with that. [Support staff, West Midlands]
Without doubt, drug and alcohol-related harms were a major concern. Vendor support staff commonly mentioned health problems associated with drug injection, including hepatitis C.
Health problems and health-seeking behaviour
The survey also collected data on the extent and nature of vendor contact with a range of outpatient health services in the 12 months prior to interview. Over three-quarters (76%, n = 100) of respondents had contacted at least one health service in the past year. Over one-third (36%) had visited their GP (34% reported being registered with a GP in London) and over one-quarter (27%) a primary care centre (a service specifically for those without GP registration, or a satellite clinic attached to a hostel or day centre). Forty-four percent had been to a hospital Accident and Emergency Department and 20% to a drug or alcohol service. A minority had contacted a sexual health (6%) or mental health service (6%).
The reasons for contact with different health services are reported in Table II, indicating a wide range of potential targets for health promotion.
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Health in context
Despite the problems reported above, personal health was not always a priority, reflecting the complex nature of the condition of being homeless. This was confirmed by use of a basic four-point Likert scale to measure ‘worry’, which ranged from ‘often’ to ‘not at all’. Over half the sample often worried about money (53%; 52 of 98), 39% (38 of 97) often worried about their families (the majority reported limited contact with families) and 36% (35 of 96) often worried about accommodation (either getting any or because their current accommodation was temporary). This compared to 30% (29 of 97) who often worried about their health. Other issues that were often worried about included eating properly (15%), drug use (10%), alcohol use (6%), personal safety when sleeping rough (7%) and the ‘future’ (4%).
The interview extracts below continue this theme, showing how health problems may be perceived as less important than more immediate concerns:
If you're homeless and penniless, the big problems don't really matter. It's the day to day problems. Where's the next meal or where you're sleeping...basic things just add up. I mean the major problems you just put right behind ‘cause you've got to get your basic day to day things sorted. [Vendor, West Midlands]
What you're thinking about really is just food and keeping yourself warm. Living on a day to day basis. You've got so much right here, right now...to deal with. [Vendor, West Midlands]
Identifying information needs
A precursor to devising health promotion interventions is the identification of information needs. When asked to prioritize these, the more generic topics of accommodation and centralized information on homelessness services were most commonly reported. Thirty-one percent of vendors (n = 100) rated ‘information on getting housed’ as the key information priority. Twenty-one percent prioritized ‘centralized information on homelessness services’. Alongside these, and in terms of health-specific information, themes around ‘finding sympathetic doctors’, ‘dealing with drug/alcohol problems’ and ‘help with mental health problems’ were most commonly raised in the qualitative interviews.
Part of the reason few vendors specifically mentioned health information needs was the common view that information was sufficiently available, but the main difficulty was getting access to it. Vendors mentioned the need for better advertising and coordination of information about services for the homeless. This is highlighted in the following comments:
There's a lot of information already on everything you need to know [but] the main thing is that people need to know where to go to get that information. [Vendor, London]
Knowing where to go for help in a metropolis such as London was considered particularly difficult for newcomers to the city:
The information is there, but you've got to know where it's available. If someone first comes to London, it's difficult to know where to go. [Vendor, London]
For example, finding out about the availability of hostel accommodation was described as a sometimes difficult and complicated process. As one of the vendors explained:
You've got to go to day centres to find out about hostels, but there's only certain times you can go into day centres. There needs to be a central place to go. [Vendor, London]
During focus group discussions and in-depth interviews a number of ideas were forwarded as potential foci for a health promotion intervention. One priority was the need to tackle drug-related harm. A harm reduction intervention based on reducing injecting-related risk behaviour was considered one appropriate topic:
It [health promotion] needs to be about safe injecting. Perhaps an area that people don't like to touch upon is that if people are injecting and hacking themselves to bits then someone needs to show them how to do it properly. That's about harm reduction. For instance, using vitamin C and not citric acid. [Vendor, Brighton]
Hepatitis C and safer injecting, chiropody, keeping warm, cheap and healthy eating, TB, lice prevention. These are some issues to address. [Support staff, London]
Linked to safer drug use was the idea of giving vendors training in basic First Aid skills. Amongst other things, this could help provide the competence and confidence to deal with an overdose situation:
You could do with people knowing about what to do in an immediate situation. Like if you're mate goes over [overdoses]. Immediate overdose. I was there when one of my mates went over and I didn't have a clue... I didn't know whether to move them into a position or to clear the airways. You need to let people know. That's really important. [Vendor, West Midlands]
Dealing with overdose. Obviously, that doesn't just include First Aid. It's about teaching people that you don't mix your drugs and you need to do a whole campaign around ‘don't mix alcohol with heroin’, ‘don’t mix benzos [benzodiazepines] with heroin’, ‘don't use on your own’. All that sort of stuff has to be covered along with the First Aid course. [Support staff, Brighton]
Other proposals included vendors providing information to homeless people about where to find sympathetic health services:
Which doctors and dentists will deal with homeless people? Because a lot won't take people on who are on the social [benefit payments]. I had to change my doctor when I first came to the Big Issue. [Vendor, West Midlands].
Other health promotion suggestions were direct and practical. For example, dealing with common colds and sore feet. Another vendor mentioned the need to prevent ‘skin conditions like scabies and impetigo, or various things like that’.
The prevailing view, as articulated by the following comment, concerned the need for any intervention, no matter what the topic:
To re-inform people with accurate information and get rid of all the rubbish that gets passed around like Chinese whispers and old wives tales. [Vendor, Brighton]
Social networks of vendors
Having identified some key areas for health promotion amongst the homeless, we need to identify appropriate conduits to convey messages and materials to the target audience. The Big Issue vendors themselves offer one potential channel. To assess the viability of this notion we examined the social networks of a sample of vendors who expressed an interest in participating in a health promoting peer education project.
The social mapping exercise described here examined key social contacts and the social ‘arenas’ where vendors spent time in the month prior to interview. As noted in Methods, 14 regular Big Issue vendors from Big Issue offices in Brighton and the West Midlands participated in the mapping interviews.
‘Spatial’ and ‘locational’ data were collected regarding living arrangements, venues, and arenas visited, and contact with helping agencies. ‘Temporal’ data focused on proportions of time spent per week on key activities such as vending and social contacts. Data were also collected on the ‘extent and nature of contacts’ with the following: partner, friends and acquaintances, social and health professionals, and Big Issue office and staff. Social contacts were also coded according to category (e.g. ‘homeless’, ‘drug user’) as were ‘social activities’ (such as visiting friends, attending drug user groups, etc.).
All interviews were tape-recorded and transcribed.
Respondents comprised four women and 10 men, with an age range of 22–35 years and a vending career of between 8 months to 3 years. As can be seen from Table III, respondents covered a wide range of social arenas where homeless people congregate and were in contact with homeless people of varying profiles. Significantly, they also came into contact with homeless people who were new to the area.
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The interviews highlighted a number of key venues where vendors met with other homeless people. These included accommodation venues, such as hostels or traveller sites (mobile living); day centres, where vendors made visits for hot meals or, in several cases, carried out volunteer work; and also at public arenas such as the Big Issue office, drug agencies and other social services. Respondents were also involved in a wide range of social activities that brought them into regular contact with other homeless people. Notably, these activities involved Big Issue newspaper vending, but also included attending parties and gatherings at traveller sites, and visiting friends and relations.
As expected, a significant proportion of each day was spent vending the Big Issue newspaper. This activity involved between 4 and 10 h , 6 days per week. For most vendors, newspaper sales comprised the bulk of their income. It was this very activity, which took place in public and semi-public venues, which brought vendors into close contact with other homeless people. Table III
shows that vending pitches provided the opportunity for contact with a range of people, including those described by the respondents as ‘homeless drug users’, ‘beggars’ and ‘buskers’ (street entertainers).
One respondent reported that she was regularly approached whilst vending by homeless people asking for directions to the Big Issue office or to local hostels. In this context the mapping exercise shows that vendors are already viewed by other homeless people as important sources of information. They are easily recognizable and have become a common feature in many towns and cities. This has other implications that are relevant to any potential peer education intervention. Some respondents reported that they were sometimes asked if they knew about drug supplies in the town. Being approached by drug users in this way opens up a conduit for health advocacy amongst one important target group of homeless people.
Regular contact with the Big Issue office was maintained even when vending had temporarily ceased. While collection of newspapers may have been the main reason for these visits, it also allowed the chance to socialize with other vendors and provide the opportunity of a good site for informal health promotion.
Other activities identified in the interviews included attendance at a drug users' group and visits to friends, who were often identified as drug users. Health service contact was also reported. This was often, though not exclusively, related to drug use, including visits to needle exchange schemes and regular appointments to pick up methadone prescriptions. All these activities provide opportunities to meet with other homeless people and offer the potential for engaging in health promotion activities, such as peer education. Another example was where a respondent made daily visits to a specific area (a square) in the town centre, which had become a regular meeting point for vendors and other homeless people.
Temporary accommodation venues were reported as other opportunities for vendors to come into contact with the homeless and vulnerably housed. Notably, a local traveller site provided temporary accommodation for several respondents. To some extent travellers constituted one sub-group among vendors, or the homeless more generally. First, this form of mobile living is often, at least initially, a matter of personal choice; and second, it comes with a distinctive social life, including free parties and/or attendance at particular pubs, identified as accepting of travellers. Of note was that sites comprised some travellers who were using drugs (including heroin).
Day centres were also potential points of access to other homeless people. Respondents visited these, most often for food.
On the basis of these mapping interviews, it could be argued that all respondents had opportunities for peer education with the ‘homeless’, but some had greater opportunities than others. For example, one respondent's potential for peer education was limited because his vending contacts were confined to the ‘general public’. He spent very little time at the Big Issue office (twice per week for 10 min) and lived on a traveller site with only one other. Other respondents had more opportunity for peer education as they regularly attended a number of social venues (e.g. parties, town square, day centres) where homeless people congregated.
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Discussion |
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Key to creating an evidence base for health promotion is the need to illuminate and understand process in order to identify the basic and best conditions for successful implementation and replication of any intervention (Nutbeam, 1996
). The use of qualitative research methods as part of formative and process evaluation has been widely advocated in identifying the key health promotion needs of different target groups, and in ensuring that the most appropriate venues and groups are targeted (Macdonald and Tones, 1996; Speller, Learmouth et al., 1997). This paper has identified the health promotion needs of the homeless and utilized social mapping as a method of formative evaluation to assist the development of community-based health promotion interventions. This study indicates the need for both comprehensive and focused health promotion interventions for homeless people. The contemporary emphasis on social exclusion highlights the need for broad-based and inclusive interventions which go beyond the bounds of health per se. In the context of homelessness we have seen that health is not always a main priority in addressing what is often a very stressful lifestyle. Immediate issues, such as shelter and food, are often more pressing than direct health matters. Yet, a number of specific health promotion issues were identified, including first aid, drug use, overdose and podiatry. From this we can deduce the need for comprehensive health promotion which situates specific issues (such as overdose) in the broad context and lifestyles of homeless people.
From our examination of the social contacts of vendors we can conclude that they are well connected to the target group and are well positioned to act as potential health advocates. One model of health promotion intervention for those considered ‘hard to reach’, or socially marginalized (such as homeless people), is community-based peer intervention. This has been popular as a method for maximizing contacts for HIV prevention initiatives in the community (Grund et al., 1996; Wiebel, 1996). It also seeks to replace individually focused health education with efforts to change ‘community norms’ regarding health behaviour (Rhodes, 1994). For example, since the late 1980s, HIV interventions in the USA have used a variety of peer-based strategies to help change behaviour among injecting drug users (IDUs) and gay men. Initiatives involving current and former IDUs as outreach workers and peer educators have been employed to target social networks of drug users in attempts to encourage safer injecting practices and to reduce the transmission of HIV (Home Office, 1994; Kelly, et al., 1997). Similarly, ‘popular’ gay men recruited from bars and clubs have been enlisted to promote condom use and safer sex (Klee and Reid, 1995). This approach has also been promoted as a means of providing drug prevention and sexual health education to young people (Shiner and Newburn, 1996) and considered as an option for health interventions with sex workers (Barnard and McKeganey, 1996).
Despite wide advocacy of this method, there has been less clarity as to the theoretical basis for using peer-based approaches in health education. Nor has there been consensus on the actual process or the expected outcomes (Milburn, 1995; Turner and Shepherd, 1999). Turner and Shepherd provided a review of the various claims which have been made for peer education (Turner and Shepherd, 1999). These include cost-effectiveness, good access to, and credibility with, the target population, and the harnessing of existing informal information networks. Furthermore, it is argued that it is beneficial and empowering to those who participate. Yet, defining and measuring such variables has been difficult and thus such commendations are largely untested (Milburn, 1995). We therefore need to be cautious in making any substantive claims as to the evidence-base for peer education. As with other areas of health behavioural interventions and health promotion, we need systematic reviews of evidence and rigorous process and outcome evaluation.
Whilst acknowledging the cautions outlined above, in the context of ‘hard to reach groups’ in the community, peer interventions may provide a means of access that would be more difficult to achieve by way of traditional outreach approaches (i.e. by professional outreach workers). The focus of this feasibility study was to examine the potential for peer intervention amongst different homeless populations, using newspaper vendors from the Big Issue as peer workers or educators. This paper has explored the potential opportunities Big Issue vendors have to make contact with different homeless populations. Although they may not have access to all sub-groups of the homeless and vulnerably housed (e.g. families in bed and breakfast accommodation), vendors were accessing a wide range of homeless groups, as evidenced from the social network mapping exercises. Consideration needs to be given to appropriate means of contacting the whole spectrum of homeless people. The study also explored some of the practical issues of training and delivery, as well as involving vendors in the development of health promotion materials.
The next stage of our work is to put the vendors to the test as peer educators and to assess the transferability of any resulting model of health promotion. To this end we are planning an action research project based at the site of one Big Issue office. We will work intensely with a cohort of vendors, alongside the JET team, towards the dual goals of developing an appropriate intervention and a sustainable and transferable training programme. This will operate within the general framework of a peer education and a health advocacy approach to health promotion. The research findings to date will be used to assist the vendors, the Big Issue staff and other interested parties (such as the St John's Ambulance Service) to focus on priority training and health promotion topics, as well developing a framework for the most appropriate service delivery methods. It is anticipated that the resulting model of community-based and participatory health promotion will have value for other socially excluded populations.
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Acknowledgments |
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We wish to thank all the vendors and support staff at the Big Issue offices in London, Birmingham and Brighton who assisted in this research project, especially Neil Ansell, Ian Hayden, Annalise Vogiatzis and Helen Weston. The project was funded by the Health Education Authority.
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Received on January 5, 2001; accepted on March 7, 2001
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