Why are so few women given public assistance to relocate away from violence? This article will try to answer this question using findings from a study co-created by women with lived experiences and academic researchers. Public assistance for this group is, in Sweden, a right granted by the national Social Services Act, but a significant proportion of women in need of it do not receive it. A survey of local social services reveals a pattern of chance, low priorities, and lack of awareness of this group within the public administration. The pattern is the same for women with children, in spite of their additional legal protection.

BACKGROUND: People experiencing homelessness are at increased risk of violence and abuse, however, there is insufficient knowledge about rates of inquiry or readiness of healthcare professionals to address violence and abuse among this population. This study aimed to explore healthcare professionals' experiences and perceptions of asking about violence and abuse among patients experiencing homelessness.

METHODS: This study used a qualitative, interpretive, and exploratory design. We performed focus group discussions with healthcare professionals (n = 22) working at an integrative healthcare unit for people experiencing homelessness. Data were analysed using reflexive thematic analysis, following Braun and Clarke's six-phase approach. Findings are reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS: The overarching theme of the analysis is that addressing violence and abuse is at risk of "falling through the cracks". The theme is supported by three sub-themes: Hesitance to address violence and abuse, The complex dynamics of violence and abuse in homelessness, and Challenges in addressing violence and abuse amidst competing priorities and collaborative efforts. The normalisation of violence and abuse within the context of homelessness perpetuates a "cycle" where the severity and urgency of addressing violence and abuse are overlooked or minimised, hindering effective interventions. Moreover, healthcare professionals themselves may inadvertently contribute to this normalisation. The hesitance expressed by healthcare professionals in addressing the issue further reinforces the prevailing belief that violence and abuse are inherent aspects of homelessness. This normalisation within the healthcare system adds another layer of complexity to addressing these issues effectively.

CONCLUSIONS: The findings underscore the need for targeted interventions and coordinated efforts that not only address the immediate physical needs of people experiencing homelessness but also challenge and reshape the normalised perceptions surrounding violence and abuse. By prioritising awareness, education, and supportive interventions, we can begin to "break the cycle" and provide a safer environment where violence and abuse are not accepted or overlooked.

Interviews with individuals experiencing homelessness can be challenging for various reasons, including mental and physical health issues, substance use, and negative experiences with authority figures. Researchers have used photos to facilitate communication and empower participants during data collection. We analyzed data from a previous study to explore the use of researcher-generated photos during interviews about health with 13 women experiencing homelessness. Conversation analysis revealed clear patterns regarding the use of the photos during the interviews. The photos were referred to 118 times over the total interview length, 6 hours and 23 minutes, with the interviewer making 62% of the referrals and the women accounting for 38%. Fifty-nine percent of the referrals occurred within the first 5 minutes of the interviews. The women used the photos to trigger associations and emotions, to describe photo content, or in a minor role during the interview. Interpretations from an advisory board of six women with lived experiences of homelessness suggested that the photos did not engage participants as intended, highlighting the importance of considering participants’ perspectives when designing photo-elicitation methods. The feedback also provided valuable insights into interview locations and incentives in research that may have influenced the women’s willingness to use the photos. This study emphasizes the importance of understanding the complexity of choosing researcher-generated photos in interviews with underserved, hard-to-reach populations.

Low health literacy (HL) has been linked to low self-rated health, reduced efficacy of behaviour change, and challenges in preventing, treating, or managing health conditions. People experiencing homelessness are at risk of poor HL; however, few studies have investigated HL in relation to mental and spiritual well-being among people experiencing homelessness in general, or women experiencing homelessness specifically. This cross-sectional study of 46 women experiencing homelessness in Stockholm, Sweden, recruited during the period October 2019–December 2020, aimed to examine how HL was associated with mental and spiritual well-being among women experiencing homelessness. Participants answered questions about socio-demographic characteristics (age, length of homelessness, education) and digital technology (mobile phone/the Internet) use, in addition to Swedish language versions of three questionnaires administered through structured, face-to-face interviews: the Communicative and Critical Health Literacy Scale, the General Health Questionnaire 12 and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being. Data were analysed using linear regression, which revealed statistically significant associations between HL and mental well-being (p = .009), and between HL and spiritual well-being (p = .022). However, neither socio-demographic characteristics nor digital technology use were significantly associated with HL. In conclusion, promoting HL may improve mental and spiritual well-being in this vulnerable population. An advisory board of women with lived experiences of homelessness (n = 5) supported the interpretation of the findings and emphasised the need to consider HL in relation to basic needs such as ‘housing first’. Moreover, health information and services should be accessible to people with different degrees of HL.

Given the fact that women in homelessness face considerable health inequities, the question of how digitalization can be understood in relation to social rights and right to health surfaces. The objective of this qualitative interview study was to explore the use of mobile phones and internet for women experiencing homelessness. Women (n = 26) shared experiences of healthcare access by using a mobile phone or internet. Data were analyzed using NVivo software. The results are presented in two themes: Conditions and circumstances of having a mobile phone; and Structural and intrapersonal challenges affecting social rights. The results show that digitalization actively influenced everyday life for women experiencing homelessness. Whether women wanted it to or not, digitalization presents a line of demarcation for participation and inclusion or exclusion, in health- and social-care services.

People in homelessness face significant health inequities, with tri-morbidity, exposure to violence, substance use- and post-traumatic stress disorder. The aim of this scoping review was to describe treatments for trauma-related conditions for persons in homelessness. Systematic searches were performed in three databases: PubMed, PsycInfo and Scopus, guided by the PRISMA checklist. Nine studies fulfilled the criteria and were included in the review. Results show no randomized studies specifically focusing on treatment of trauma-related conditions for people in homelessness. Studies described interventions or programs that focused on consolidating and developing participants’ own strengths and skills to better navigate life with the challenges of homelessness, trauma, and PTSD. Treatment of trauma-related conditions may have positive effects for people in homelessness, as for others. Multimodal treatments, developing personal strengths and skills for people in homelessness, show potential to decrease trauma symptoms, however, more robust studies are needed for inferences and recommendations. 

What is known on the subject?

• This paper acknowledges the profound and lasting impact of childhood abuse on substance use and homelessness.

What this paper adds to existing knowledge?

• It underscores the inherent value and humanity of every individual, regardless of their struggles.
• That a comprehensive approach to mental health care, encompassing medication, therapy and a secure environment, is imperative.

What are the implications for mental health nursing?

• Early intervention and recognising individuals who suffer in silence are paramount. Mental health nurses must have the courage to ask uncomfortable questions and truly hear the unspoken words.
• Mental health nurses should never underestimate the power of simply being present with someone during their darkest moments. This simple act can wield significant influence.

BACKGROUND: The population of women in homelessness in Europe is increasing and women in homelessness experience multiple healthcare needs. However, there is insufficient understanding about how perceptions of caring behaviours compare between women in homelessness as patients and nurses in their clinical practice.

AIM: This study aimed to investigate perceptions of caring behaviours among women in homelessness, Registered Nurses and nursing students.

METHODS: A cross-sectional design was used with convenience sampling to recruit groups of women in homelessness (n = 37), Registered Nurses (n = 92) and nursing students (n = 142) in Stockholm, Sweden. Between August 2019 and December 2020, data were collected through face-to-face interviews or online, using the Caring Behaviours Inventory-24 instrument. Data were analysed using descriptive statistics and group-comparing hypothesis tests.

RESULTS: Overall, women in homelessness' perceptions of caring behaviours were significantly lower than nursing students (p < 0.001), who in turn scored significantly lower than Registered Nurses (p < 0.001). The Knowledge and Skill domain had the highest score, and the Connectedness domain had the lowest score in all three groups. The ranking of the individual items according to score varied between the groups. However, all three groups had the highest score for the Knowing how to give shots, IVs, etc., item and the lowest score for the Helping the patient to grow item.

CONCLUSION: Healthcare providers and nurse educators should consider incongruences and congruences in caring behaviours to better prepare Registered Nurses and nursing students to contribute to increased health equity, and more targeted clinical practice for women in homelessness.

Det övergripande syftet för projektet är att öka möjligheten för våldsutsatta kvinnor i hemlöshet att kunna erbjudas traumavård vilket förutsätter att våldet identifieras och fungerande samverkan inom och mellan ett antal välfärdsinstitutioner. För kvinnor är våld både en orsak till, och en konsekvens av hemlöshet, där kvinnan sällan erbjuds traumavård och behandling pga. drogmissbruk, samsjuklighet och avsaknad av stabila levnadsförhållanden. Att kvinnan lämnas ensam att hantera sina trauman bidrar till psykisk och fysisk ohälsa, ökad droganvändning och begränsade möjligheter att ta sig ur hemlösheten. Fungerande samverkan mellan och inom socialtjänsten – samt med hälso-och sjukvården är avgörande för att kvinnas komplexa behov ska tillgodoses och för att våldet inte ska förbises eller normaliseras.

Strukturella, organisatoriska och individuella hinder för samverkan utmanar en fungerande samordning där kvinnas möjlighet och förmåga att vara delaktig och beslutskompetent är begränsad. Krav på hälsosjukvård och socialtjänstpersonal att skapa förutsättningar för delaktig är omfattande men svåruppnåeliga. Kvinnor i hemlöshet har länge betraktats som passiva, beroendet av andras agerande, stöd och omsorg dära utonomi, värdighet eller integritet är hotad. Utan att förbise denna utsatthet behöver kvinnan även ses som aktiv, kompetenta och ansvarstagande med möjlighet att påverka sin situation. Planerat projekt har en explorativ och samskapande design där våldsutsatta kvinnor i hemlöshet och olika personalkategorier medverkar i forskningsprocessen. Data utgörs främst av kvalitativt material. Ingående studier belyser både professions- och brukar/patientperspektiv och rör identifiering av våldsutsatthet, samspel och handlingsutrymme vid samordnad individuell plan samt utveckling av intervention för ökad samverkan.

Vårdprogram, journalsystem och arbetsrutiner bör ändras för att öka säkerheten för kvinnor med skyddade personuppgifter.