Equity-Oriented Health Care Improves Patient-Provider Relationships Within Unhoused Communities

By Nyoko Brown

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Many advocates for health equity are emphasizing Equity-Oriented Health Care (EOHC) as a standard for delivering sustainable and accessible healthcare to vulnerable communities. Individuals experiencing homelessness face physical and social barriers to care that programs with an EOHC approach could begin to mitigate. EOHC is healthcare that is tailored to the patient that is being treated with cultural sensitivity and trauma- and violence-informed care (Gilboe, 2018). Los Angeles Clinics tackling the alarming number of HCV cases within the homeless community serve as a current model for how healthcare can evolve to meet the needs of those without stable housing.​

EOHC is fulfilled by three main components, which are to be trauma-and violence-infomed, advocate for harm reduction, and cultivate an environment for cultural safety. For care to be trauma and violence informed, it must commit to an awareness and acknowledgement of trauma, establish trust and a sense of safety between the patient and the provider, dignify the patient’s choices, and provide space for patient control and collaboration. Care that advocates for harm reduction promotes programs, practices, policies, and philosophies that center mental health when discussing and treating substance use. Cultural safety in a healthcare setting acknowledges and counteracts healthcare inequities rooted in racism, discrimination, and inequitable power relations. (Purkey, 2019). Most importantly, EOHC demands that changes to the delivery of healthcare be informed by people with lived experience.

Experiences within the healthcare system impact unhoused people in ways that lead to further stigmatization of their situation, as well as their own decreased desire and ability to seek care. One account given by a participant in the study Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care provided sensitive insight into the negative impacts of stigma faced by those with substance use who are unhoused when they seek medical care [TW: SA].

"I’ll share a story that was shared with me. [This woman] had suffered a brutal rape. Horrific. Absolutely horrific. She was a woman in her late 40s. Lived on the street throughout her whole life, back and forth. She was telling me her story. She needed to share it […] and she didn’t cry. Not one tear when she talked about the abuse that she endured [..]. She wept when she talked about how she got treated at the hospital because she was bleeding so profusely and she flinched at a needle and the comment from the nurse was made to her: 'Well look at your arms, as if you have a problem with needles". That weighed so heavily and this is when the woman broke down. The abuse was horrific but she had almost been marinating in that level of violence and abuse all her life. The devastating part of it all was the shame she felt from the hospital […] because of her I.V. drug use."

Anticipated stigma from shared experiences among the unhoused population is followed by an increased noncompliance with provider recommendations, assuming the provider did not dismiss the patient altogether on account of their substance use. While it was found the health service was improved in the presence of an advocate, this fact only made it more apparent to researchers the discrimination faced by those who are unhoused, especially if they have substance use. However, it was also found that how much someone valued healthcare could be positively impacted by receiving care that did not compromise their dignity, and where providers extended compassion and established trust. One participant of the same study provided the following positive quote.

“They are really like, hey we like the atmosphere of this place. We like that people here treat us really nice and we’re people. We feel loved. There are paramedics here who are, you know, assisting us. Um we really feel safe in this space and like there’s no judgment and we want to keep coming back here.”

However, being treated fairly is not where equitable care ends. Purkey et al. points out how healthcare is fatally flawed, because it was designed for and by the middle class with the intent of making everyone conform to one standardized system. The barriers presented by the system to unhoused people include the need of a home address, penalties for late and missed appointments, and refusal to take a harm reduction approach to care. The consequences of such a system can be further analyzed in the context of HCV prevalence within homeless communities.   

Unhoused injection drug users are at a significantly higher risk for contracting and spreading HCV than stably housed injection drug users to the extent that areas with homeless shelters have been marked as “hot spots” for HCV transmission. 70% of homeless individuals can be expected to be exposed to HCV compared to only 1.7% of all Americans (Benitez, 2020). Despite HCV being rampant among this community, one of the barriers to care is an unawareness of infection. The other barrier is getting to appointments or referrals. Traditional appointments are known to pose challenges in terms of distance, complex administrative processes, and strict time constraints.

Examining how some clinics in Los Angeles have changed services to make HCV treatment more accessible is an opportunity to see EOHC applied in the context of the current American healthcare system. Project HEAL (Hepatitis C Engagement and Accessible Linkage) provided HCV screenings and care coordination from sites that were close to the community they aimed to serve. They were located at two federally qualified health centers, had 6 sites near Skid Row and 3 sites near Boyle Heights. Project HEAL coordinated further care by linking patients with the resources needed to complete a follow-up appointment. Patients who screened positive for HCV were contacted by phone, mail to home, P.O. Box, or shelter, and by in-person visit of the care coordinator to nearby shelters in order to have the patient return to the clinic for laboratory results. The study of such programs conducted by Benitez et al. showed that overall this model could ensure that 84.7% of their viremic patients return to the clinic for laboratory results. Of these participants in the study, 46.1% had no knowledge of their HCV status. This study emphasizes the importance of the relationship between local clinics and shelters, as well as the importance of setting these care centers in the communities they serve. The results are especially positive when the site is bundled with other necessities, such as primary care, mental health services, social work, and dental services. These programs have also seen greater retention amongst their patients with substance use and/or mental illness. (Benitez, 2020). 

Healthcare providers have a responsibility to all communities to be accessible and to provide sustainable solutions to improve health outcomes. Unhoused individuals, and especially those struggling with substance use, have shown and insisted upon the efficacy of  Equity-Oriented Health Care. It is their right to receive care that is dignified and care that works. ​

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References

Benitez, T. M., Fernando, S. M., Amini, C., & Saab, S. (2020, January 24). Geographically focused collocated hepatitis C screening and treatment in Los Angeles's skid row. Digestive Diseases and Sciences. Retrieved November 29, 2021, from https://link.springer.com/article/10.1007%2Fs10620-020-06073-0. 
Ford-Gilboe, M., Wathen, C. N., Varcoe, C., Herbert, C., Jackson, B. E., Lavoie, J. G., Pauly, B. B., Perrin, N. A., Smye, V., Wallace, B., Wong, S. T., & Browne For The Equip Research Program, A. J. (2018, December). How equity-oriented health care affects health: Key mechanisms and implications for Primary Health Care Practice and policy. The Milbank quarterly. Retrieved November 29, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6287068/. 

Purkey, E., & MacKenzie, M. (2019, July 1). Experience of healthcare among the homeless and vulnerably housed a qualitative study: Opportunities for equity-oriented health care. International journal for equity in health. Retrieved November 29, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604349/.