'Why would I go somewhere where I'm not welcome?' Dehumanisation of people experiencing homelessness in medical settings and the healing potential of a structurally competent model: a qualitative study.

Abstract

Introduction: People experiencing homelessness (PEH) face myriad barriers to healthcare, including preventative sexual health services. A street medicine team in one Northern California county observed low uptake of sexually transmitted infection (STI) screening among PEH. We conducted this study to understand the factors contributing to PEH's decision to seek or accept STI screening.

Methods: This is a qualitative study using semistructured interviews and demographics surveys among PEH. The interviews focused on understanding facilitators and barriers to STI screening and experiences in healthcare settings more broadly. Interviews were audio-recorded, transcribed and analysed using a thorough memoing process and matrix-based analysis.

Results: We enrolled a total of 50 adult, English-speaking PEH: 24 men, 26 women; 52% white, 28% Black/African American, 22% Native American, 4% Asian, 22% Hispanic/Latino. Qualitative analysis revealed a theme of 'dehumanising' prior experiences in healthcare environments including judgement, dismissal of medical concerns, and denial of treatment. Participants reported similar experiences outside of medical settings, which together shaped their self-worth and factored into their decision to delay seeking routine and urgent forms of care, including STI screening. Approximately half of the participants had received medical services from the street medicine team. PEH perceived the street medicine team to foster trust by physically, emotionally and structurally 'meeting patients where they are'.

Conclusion: Prior experiences of exclusion within and outside of healthcare settings informed PEH's decision to avoid seeking healthcare until extremely urgent, and to deprioritise services like STI screening. In order to develop interventions to increase STI screening and other preventative health services, it is critical to understand the structural elements underlying relationships between PEH and healthcare systems, and the relevance of social exclusion beyond medicine. This street medicine team exemplifies features of structural competency, a model that may be integrated in other settings and in medical education to promote more equitable and inclusive healthcare.