Exploring How Structural Stigma Plays a Role in the Health Care Experiences of Persons of Color Who Experience Homelessness

Background and Purpose: Urgent attention is needed to promote the health equity of people experiencing homelessness. Compared to the general population, individuals who experience homelessness face significant health inequities which result in higher morbidity and mortality rates (Gordon et al., 2019; Omerov et al., 2020). Structural stigma perpetuates homelessness at multiple levels including at the individual-level (e.g., self-stigma), organizational-level (e.g., institutional practices), and systems-level (e.g., discrimination). Assessing structural stigma is one way to identify strategies for how health and community-level systems can improve the health care experiences and reduce health inequities for this population. This study explores the perceptions of individuals’ health care experiences and the drivers of stigma that perpetuate health disparities. Using grounded theory, the aim of this study is to identify strategies that may contribute to promoting housing recovery and reducing health disparities for a diverse population of adults who are homeless.

Methods: Data were analyzed from focus groups (n=76 participants) as part of the Maricopa County Community Health Needs Assessment conducted in Arizona. Purposive sampling was used to recruit participants of color from underserved communities, specifically young people, women with children, veterans and older adults who were experiencing homelessness. Participants received a $45 gift card for participating in the focus group. Participants were asked about accessing preventative and health care services, barriers to health care, and community care services. Focus groups were audio recorded and transcribed verbatim. Grounded theory guided open and axial coding of the results (Strauss & Corbin, 1998).

Results: Participant were between 18 to 64 years old, female (41%), White (35%), Black (28%), Hispanic (16%), and completed high school or some college (81%). Our findings identified several themes and sub-themes that explain the multi-level drivers of stigma that affect participants’ health care experiences while homeless. At the organizational/institutional-level, participants reported barriers to housing recovery that prevented them from accessing services such as unnecessary rules (e.g., the requirement to show identification for community services) or being “timed out” of transitional housing and returning to street homelessness despite their efforts to locate permanent housing; and receiving inadequate health care services and community resources that led to disengaging from services. At the systems-level, participants experienced systemic barriers to recovery (e.g., discrimination) that exposed a persistent lack of system accountability to people experiencing homelessness and poverty. Despite these multiple levels of stigma experienced by the participants, they also discussed community assets at the organizational-level (i.e., access to benefits, preventative care, housing and compassionate, helpful providers) that influenced their engagement in health care services.

Conclusions and Implications: These findings are unique to the lived experiences of Persons of Color who are homeless. These results suggest that despite experiencing multiple levels of stigma, participants identified community assets that may reduce stigmatization towards adults who are homeless. The implication of these findings for social work practice is to develop innovative practice and policy solutions that amplify the use of stigma reduction strategies across organizations and systems that reduce stigma and promote health equity for this population.