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J Psychiatr Ment Health Nurs. 2022;00:1–12. wileyonlinelibrary.com/journal/jpm
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1© 2022 John Wiley & Sons Ltd.
Received: 29 November 2021
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Revised: 29 April 2022
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Accepted: 6 July 2022
DOI : 10.1111/j pm.12859
ORIGINAL ARTICLE
Reflections on health among women in homelessness:
A qualitative study
Åsa Kneck1 | Anna Klarare1,2 | Elisabet Mattsson1,2 | Martin Salzmann- Erikson3 |
in collaboration with Women Advisory Board for Inclusion Health4
1Department of Health C are Sciences,
Marie Cederschiöld University, Stockholm,
Sweden
2Department of Women's and Children's
Health, Healthcare Services and e- Health,
Uppsala University, Uppsala, Sweden
3Department of Caring Sciences, Faculty
of Health and Occupational Studies,
University of Gävle, Gävle, Sweden
4Ersta Möjlighet, Stockholm, Sweden
Correspondence
Martin Salzmann- Erikson, Department
of Health and Caring Sciences, Faculty
of Health and Occupational Studies,
University of Gävle, SE- 801 76 Gävle,
Sweden.
Email: martin.salzmann@hig.se
Funding information
Forskningsrådet om Hälsa, Arbetsliv och
Välfärd, Grant/Award Number: 2020-
00169; Vetenskapsrådet, Grant/Award
Number: 2019- 01095
Accessible Summary
What is known on the subject?
• Previous research reports that people in homelessness have poor physical and
mental health and are excluded from society with risk for loneliness and social
exclusion.
• Women in homelessness face particularly vulnerable circumstances with signifi-
cant risks of harm.
What the paper adds to existing knowledge?
• Feelings of having a home is a basis for meeting physical, psychosocial, and exis-
tential needs related to health.
• Being involved in authentic relationships and caring for others gives women in
homelessness a sense of worth.
• To be accepted by others and feeling like an equal was important for experi-
ences of preserved dignity.
What are the implications for practice?
• Nurses need to recognize and support women in homelessness for their capac-
ity to heal and to experience health.
• To regard women in homelessness as active health- seekers, instead of passive
victims, can improve women's experiences of care provided by mental health
professionals.
• Nurses can promote health by regarding women as resourceful and active, de-
spite the fact that they live in homelessness.
Abstract
Introduction: Mental health issues are common among women in homelessness,
alongside undertreated chronic physical conditions leading to serious and unneces-
sary complications. Even though homelessness and risks of impaired health have been
researched, broader perspectives of health are absent.
Aim: To describe reflections on health among women with experiences of
homelessness.
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KNECK et a l.
1 | INTRODUC TION
The association between health an d socioeconomic status is well es-
tablished in the literature, that is, health linked to social advantages
(Marmot et al., 2012). Viewed through the lens of social determi-
nants of health, homelessness is characterized both through social
exclusion and extremely poor health.
People in homelessness face multiple everyday challenges which
present considerable negative impact on their physical and mental
health, leading to increased risk of premature death (Aldridge et al., 2018;
Roncarati et al., 2018). Furthermore, complex psychiatric problems and
substance use disorders underline the urgency of addressing needs in
this underserved population (Nielsen et al., 2011). Tri- morbidity, that is,
poor physical and mental health in combination with substance use, il-
lustrates the complexity in designing and providing relevant healthcare
interventions to support people in homelessness (Vickery et al., 2021).
The significant mortality rates from suicide and unintentional injuries
also highlight important preventative factors to consider when caring
for individuals in homelessness (Nielsen et al., 2011).
There is no official definition of homelessness in Europe;
however, the European Typology of Homelessness and Housing
Exclusion (ETHOS; Edgar, 2009) is increasingly used for policy and
research purposes (Busch- Geertsema et al., 2016). According to
ETHOS, an adequate living situation is a home (Ed gar, 2009) con-
ceptualized as a legal domain, a physical domain and a social domain.
Living situations that are deficient in one or more of these domains
represent homelessness and housing exclusion. ETHOS defines four
main concepts of homelessness: roofless, public space or night shel-
ter; houseless, homeless hostel/temporary accommodation; insecure
accommodation, temporarily with family/friends; and inadequate ac-
commodation, non- conventional building.
The current prevalence of homelessness in Europe is unknown,
but data from a recent study concludes that the scope of home-
lessness is far wider than suggested by official statistics (Taylor
et al., 2019). Available data on homelessness across the European
Union suggests a steady rise over the recent decades, with an in-
creased number of migrants, families, youth and women experienc-
ing homelessness (European Commission, 2013; FEANTSA, 2018).
Also, homelessness continues to be considered a problem mainly
affecting men, and thus, the prevalence of women's homelessness
remains concealed (Bretherton, 2020; Luchenski et al., 2018), and
consequently underestimated (Mayock & Bretherton, 2016).
It has been concluded that experiences of homelessness are
gendered, thus females (and non- binary individuals; authors' note)
must be considered independently from their male counterparts
(Milaney et al., 2020). That is, women have higher rates of mental
health diagnoses, suicidal thoughts and attempts, as well as adverse
childhood trauma. A growing body of research suggests that mental
illness (Milaney et al., 2020; Montgomery et al., 2017) and domestic
violence (Clark et al., 2 019) are significant contributors to women's
homelessness, and therefore, important factors to consider in men-
tal health nursing. Moreover, homelessness poses other risks, such
as social isolation and stigma (Bower et al., 2018). Thus, women in
homelessness can be labelled as an underserved group with height-
ened vulnerability.
Promoting and restoring health as well as preventing illness and
alleviating suffering comprise the essence of nursing (International
Council for Nurses, 2021), where attention to the complexity of
needs of people in vulnerable and underserved groups is essential.
Mental health nurses can play a significant role in enhancing the
health and well- being of women in homelessness if they are sensi-
tive to the life circumstances faced by this population (De Chesnay
Method: We conducted 13 interviews with women in homelessness using researcher-
driven photograph elicitation. Together with an advisory board of women with lived
experience of homelessness, researchers were guided by the DEPICT model for col-
laborative data analysis and performed a thematic analysis.
Findings: Women with experiences of homelessness emphasized three main re-
sources for achieving health and well- being: feelings of having a home, being involved
in authentic relationships and experiences of preserved dignity.
Implication for practice: Healthcare needs to integrate the perceived resources for
health and well- being when caring for women in homelessness. It is imperative since
women will return to the healthcare setting only if they feel safe and secure, and only
if dignity is preserved or restored. The results promote utilization of an integrative
nursing approach; understanding that the health of women in homelessness is insepa-
rable from their environment and social determinants for health, such as housing and
social integration.
KEY WORDS
health, health equity, homeless persons, photograph- elicitation, women's health
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KNECK e t al.
& Anderson, 2016). The existing research highlights the correlation
between homelessness and impaired physical and mental health,
while research regarding the potential strengths and resilience that
women show in order to survive during dire circumstances are lim-
ited. Solely mirroring women in homelessness as passive victims
(Phipps et al., 2021) may conceal factors of importance for mental
health nursing in helping women managing and exiting homeless-
ness. Thus, the understanding of health with a holistic view needs to
be further explored.
Taken together, the research that addresses health among indi-
viduals in homelessness, accentuating men in general and women in
particular, focuses on acute care needs or severe medical conditions,
while the broader view of health among people in homelessness is
overlooked. In line with the World Health Organization (198 4), we
have adopted a holistic view of health, not limited to the absence of
disease or infirmity, but as a resource for living. Thus, the aim was to
describe reflections on health among women with experiences of
homelessness.
2 | METHODS
This study is part of a research program with an overarching goal
to address health inequities among women in homelessness. As a
means towards this end, we work in close collaboration with women
with lived experience of homelessness. The intent with the collabo-
ration is an active partnership in which the women can influence
and shape research priorities. The research program adheres to the
definition of public involvement in research by the National Institute
for Health Research [NIHR], UK, as “research being carried out
with or by members of the public rather than to, about or for them”
(NIHR, 2021).
In the present study, we adopted a qualitative explorative re-
search approach (Bowen, 2008), utilizing the DEPICT model to guide
a collaborative analysis process (Flicker & Nixon, 2015).
2.1 | Setting
In Sweden, with a population of about 10 million people, it is esti-
mated that more than 33,000 Swedish citizens, or individuals with
temporary or permanent residence permits, are in homelessness;
approximately 38 percent are women, with a mean age of 39 years
(National Board of Health and Welfare, 2018). The Swedish model
implies the principle of leaving no one behind and the right of ever y
person to fulfil their potential. Despite this, homelessness has in-
creased due to changes in housing policies resulting in increased
marketisation (Carlsson Stylianides et al., 2021). To meet the
standards of human rights, the principle of Housing First has been
developed, implemented and evaluated in several neighbouring
countries (Pleace et al., 2019). In contrast, Sweden has a long tradi-
tion of the Housing Readiness model in which the individual must
demonstrate compliance and motivation (Winograd et al., 2019) to
obtain housing.
The recruitment of participants took place in a primary health-
care centre in Stockholm, Sweden for individuals in homelessness
within Stockholm County (population 2.4 million). The centre offers
a broad array of healthcare services and has close collaborations
with primary and psychiatric care, social services and services for
treatment of substance use disorder. During 2019, approximately
1300 individuals, 40 percent women, were cared for in the health-
care centre (around 14,000 visits). Participants were recruited in the
waiting area of the healthcare centre using convenience sampling.
The first author (a female registered nurse and researcher) and a
female research assistant (who earlier had work at the healthcare
centre) were present in the waiting room and informed potential
participants about the study. The aim of learning more about the
experiences of health and well- being in homelessness was empha-
sized. If interest to participate was shown, more information about
the study was provided in an adjoining room. After oral and written
consent, the interviews were conducted in the same room.
Inclusion criteria were women with experience of homelessness
speaking Swedish or English. Exclusion criteria were women exhib-
iting severe distress or anxiety, manifesting as violent or abusive
behaviour. Thirteen women, Swedish (n = 12) or English speaking
(n = 1), were included in the study. The women's self- reported socio-
demographic characteristics are presented in Table 1.
The youngest woman interviewed was 30 years of age and the
oldest was 60 years. Time in homelessness varied from 13 days to
30 years; however, two women could not specify how long they
had been in homelessness. According to the ETHOS (Edgar, 2009),
most of the women (n = 10) were roofless or houseless, while three
women had been assigned own apartments through social services.
TAB LE 1 Self- reported socio- demographic characteristics of the
13 interviewed women
Characteristics n (%)
Median
(range)
Age, years 44 (30)
Length of homelessness, yearsa7 (30)
The European Typology of Homelessness and Housing Exclusion
(ETHOS)
Roofless 5 (38)
Houseless 5 (38)
Self- repor ted alcohol/drug misuse, health problems, and
psychosocial problemsb
Alcohol/drug misuse 9 (69)
Neurodevelopmental disorder 5 (38)
Mental illness 2 (15)
Chronic physical illness 2 (15)
Intimate partner violence 1 (7.5)
aMissing: n = 2.
bSix women reported more than one illness/problem.
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KNECK et a l.
Over half of the women reported drug/alcohol use (n = 9) and five
women reported more than one illness/psychosocial problem.
2.2 | Data collection
In the present study, we used researcher- driven photograph elicita-
tion (Bates et al., 2017; Harper, 2002), that is, the researcher pro-
vides the photographs for the interview and uses these as stimuli to
promote discussion. The photographs enabled the women to control
the topic of the interview by choosing the photographs that they
liked to use in the dialogue; identified as a way to give participants
a voice and a choice (Phipps et al., 2021). Twenty photographs were
selected from two yearbooks produced by a photographers' associa-
tion, each representing examples of social determinants of health
and with possibilities to read or interpret feelings like belonging,
hope and love. See Table 2 for a presentat ion of chosen photograp hs
and number of times each photograph was chosen by the women.
The women were invited to choose five photographs they as-
sociated with health or well- being and to reflect or elaborate out
loud. To deepen the dialogue, the interviewer used probing ques-
tions, such as “Could you tell me more?” or “Could you please elab-
orate?”. Data were collected from December 2019 to January 2020.
The interviews were audio- recorded, transcribed and lasted from 10
to 66 min (mean 29, median 28 min). As a token of appreciation, the
women received a gift certificate (20 euros) valid in a national chain
of grocery stores.
2.3 | The Women Advisory Board
An advisory board of women with lived experience of homelessness,
The Women Advisory Board for inclusion health, was created and con-
nected to the research program. The aim of forming the board was
threefold: to ensure and promote public involvement in the research
program, to consult with researchers on equal ground in interpreting
and presenting research findings, and to gain methodological trust-
worthiness by joint prioritization in relation to the research agenda.
The women lived in a sheltered housing that offers specialized, tai-
lored long- term support for women who struggle with substance use
disorder and have experiences severe male violence and abuse. The
shelter has eight places (beds) and meets legal requirements in line
with the highest national standards of security and confidentiality
in Sweden, for example, secret address, alarms and security doors.
Women were informed about the project and invited by shelter
staff. Women who expressed an interest in attending were invited
to weekly 2- h workshop(s), with two of the authors (ÅK, EM). Board
members were paid per hour (temporary employment at Marie
Cederschiöld University) according to guidelines for public involve-
ment (INVOLVE, 2021).
In the present study, the Women Advisory Board was involved in
the data analysis proceedings and providing feedback during report
writing.
2.4 | Ethical considerations
The study was approved by the Swedish Ethical Review Authority
[2019- 02130; 2020- 02457]. The women were given written and oral
information about the study, and written consent was provided by all
participants. All data were self- reported, and no medical files were
accessed. Audio recordings and written documentation of research
data was kept on a password- protected server, accessible only to
the research group. Documentation was consecutively organized in
folders, each folder contained: the audio file, the transcribed text
and the written consent form for the interview in question.
Women who live/have lived in homelessness have difficult ex-
periences of life, often characterized by abuse, trauma and violence.
Participating in interviews, as well as reading transcribed interviews,
may trigger memories that cause significant distress for the inter-
viewed women and women attending the Women Advisory Board
workshops. Thus, attention and concerted effort were focused on
ensuring the women psychosocial support if needed in association
with both interviews and workshops. To manage potential distress
during the interviews, the interviewer, an experienced nurse, sched-
uled one interview at the time to ensure time to debrief or manage
distress. An alarm bell to security guards was available during inter-
views, but never used.
2.5 | Data analysis
Two women attended the Women Advisory Board workshops and
participated in the present data analysis. Seven face- to- face work-
shops were held during February and April of 2021, each comprising
2 h. The analysis proce ss wa s iterative and conduct ed in close co llab-
oration between the researchers and the Board. Two of the authors
[ÅK, EM] facilitated the workshops and a modified approach of the
DEPICT model for collaborative data analysis (Flicker & Nixon, 2015)
was used to guide and structure the process. Three of six sequential
steps were used in the present analysis: Dynamic reading; Inclusive
reviewing and summarizing of categories; and Collaborative analys-
ing. See Table 3 for an overview of data analysis activities with the
Women Advisory Board.
We combined the DEPICT model with thematic analysis, fol-
lowing the six steps described by Braun and Clarke (2006); namely
(1) familiarizing with the content, (2) generating initial codes, (3)
searching for themes, (4) reviewing themes, (5) defining and nam-
ing themes and (6) producing the report. The first author listened
to the interviews and all authors read and re- read the transcriptions
to gain an overall sense of the material and facilitate familiarization
(step 1). One woman from the Board reviewed the entire transcripts
of five interviews and both women in the workshop read segments
from all interviews. We identified segments that related to the pur-
pose of the study and subsequently discussed them with the Board,
generating initial codes (step 2). As we became more immersed, we
colour- marked segments with similar content. We discussed how the
content of the interviews as a whole and the individually generated
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KNECK e t al.
initial codes related to each other, their similarities and differences,
searching for themes (step 3). During the generation of codes, we
picked excerpts that corresponded with the theme. Reviewing
themes (step 4) ensured that the themes had both external and in-
ternal homogeneity. Next themes were defined and named (step
5) and the specifics of each theme were further discussed for clear
definitions and distinguishing features. In final production of the re-
port (step 6), the Board chose key quotes related to each theme.
In producing the report, writing and reviewing the text together,
we strived to present the essence of the findings and present ar-
gumentation in relation to the research aim and questions (Braun &
Clarke, 2006).
3 | FINDINGS
The women reflected on their views of health while looking at their
chosen photographs and thinking out loud. The main themes found
were that health has connotations with feelings of having a home,
being involved in authentic relationships, and with experiencing pre-
served dignity.
3.1 | Health as feelings of having a home
The women held that health meant having a life that involved a
home. A home was related to a sense of safety, self- determination
and influence. A home would provide the ability to set one's own
pace, for example, to be able to get up and have a coffee without
stress. In this sense, stability in life was described as being able to
have an ordinary life that includes routines and structure.
Because I'll get my own apartment. That's really
something I'm looking forward to […] To be able to
sort myself out. I don't need to be so dependent on a
lot of other people, staff and such. I can just depend
TAB LE 2 Description of images (n = 20) and number of times each image was chosen
Image Description
Number of
times chosen
Women at a cafe Two women sitting outside a busy café, drinking coffee. The women each have a small
dog in their lap
8
Baby Naked baby sitting on the floor 6
A man with two children A man in bed looking at a gift. Two children joining him, one is jumping upside down and
the other is sitting next to him
6
Couple A man and a woman sitting next to each other. The woman has her arms around his neck 6
A residential area at night A residential area at night, the heaven has a green colour. A high- rise building is in the
spotlight
6
Bowling hall A boy and a woman at a bowling hall. Both throw their balls 5
Silhouette of a large tree Silhouette of a large black tree against a yellow and orange background 5
A woman in bed A woman laying on her back with closed eyes on a bed. Behind her a large window with
drawn cur tains where the light sprinkles in
4
People dancing People in different ages shaking. A young smiling boy is in the forefront followed by an
older man shaking with a couple of women
3
A woman and a parrot A woman in a sheer red dress and a red flower in her hair singing. Next to her a climbing
parrot in an ornate steel stand
3
A woman on a train platform A woman squatting on a train platform with a laptop in her lap 3
A woman reading a diar y A woman, looking into the camera, with a diary in her lap and a cup of coffee 3
An older woman with punk hairstyle An older woman with punk hairstyle wearing sunglasses, a necklace with metal rivets
and headbands
2
People sitting in front of a cottage People sitting in front of a cottage in rain with raised umbrellas. Their backs are turned
against the camera
2
A woman laying on a hospital bunk A woman laying on her back on a hospital bunk 1
Four women in a formation Four women standing in a close formation. Three women are dressed in black and one
woman is naked
1
Young woman on a skateboard A young woman sitting on a skateboard looking at her mobile 1
A woman with a helmet A woman with a yellow helmet standing in a tunnel 0
A woman looking up in the sky A woman wearing a polka dot t- shirt, looking up in the sky with arms raised touching her
own neck. She is standing against a colourful wall with dots
0
Two women in front of a pedestrian
crossing
Two women standing with their backs against the camera in front of a pedestrian
crossing
0
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KNECK et a l.
on myself […] It's like, I have to cook the food and have
to clean and that sort of stuff. You know, what I need
for the home and such like… Like, who I take home
and you know… things like that.
(Woman number 4 (W4))
A home represented stability, feeling calm and being able to enjoy
the freedom of choosing to stay at home of leaving the home to seek
social interactions; safe in knowing that there is a home to go back
to. One photograph that displayed two women sitting talking at an
outdoor café was selected by several women. They stated that such
activities are part of healthy living, being able to leave home with con-
fidence and to return again. Home was described as being essential for
psychological dimensions of health but also affected bodily health. A
home enabled caring for personal hygiene, and by extension, crucial to
the sense of qualifying as a proper woman.
Woman : Having a shower and putting on make- up and nice clothes,
it's just comfortable clothes, warm clothes, so yes, sure, you can
put on make- up sometimes and when you are in the emergency
housing, you can be like…
Interviewer: Yes, so this is like femininity then?
Woman : Yes exactly, it feels like it's … it's hiding [the femininity]
somewhere else, it's on a shelf somewhere, like no one…
(W13)
Moreover, having a home was associated with having a good
night's sleep, which referred both to feelings of physical safety and to
the peace of knowing where to spend the night.
Because a home for me, it's […] a door… when I say
a door, I mean a home, not a refuge. Not a hostel
room but my home […] I know that no one will come
and knock on the door unless it's someone who's
welcome…
(W9)
A home was expressed as a prerequisite for being able to
look for or to maintain a job, since having a permanent address
and knowing where one would wake up in the morning was cru-
cial. Having a home was also essential for enjoying hobbies, like
lis tening to music or knit ting. Wr it ing a diary was a way to feel less
lonely and to reflect:
…but putting down my thoughts and then reading
them, getting my own answers so to say…I often write
a letter to myself.
(W2)
A home was described as allowing possibilities to decide for one-
self, and ability to be in control of what, when and with whom to do
things. Health as connotated with feelings of having a home involved
influence and freedom.
The photographs of people in homes encouraged the women to
talk about their longing for a home and also their fear in relation to
a home:
My own place. I had that, I didn't feel good sitting
alone and like… I took more drugs then… I'm not
ready for that yet, but I need to get healthier first […]
Both, maybe have had a year or two with substitution
medication… and I have Subutex. They asked me if I
wanted an apartment again and I said no, no … I have
to be clean for a year at least, because I don't trust
myself you know, so that it… So, I have to live in [sup-
ported] accommodation like this, that's what you have
to do, so that… […]
(W1)
A home was associated with responsibilities which women in
homelessness longed for; however, this was simultaneously associated
with fear and uneasiness for some.
3.2 | Health as being involved in authentic
relationships
Photographs portraying people alone or together yielded associa-
tions to the women's own longing for true friendship and authentic
relationships. Moments of calm, relaxed socialization with friends,
family and pets were raised in relation to experiencing health.
Relationships that entailed ability to feel connection to another per-
son were appreciated and described:
TAB LE 3 DEPICT steps, the roles of Women Advisory Board, and guiding questions
DEPICT step Member roles Questions to answer
Dynamic reading Individually review a subset of transcripts.
Record notes on important concepts
What aspects related to women's
experiences of health and well- being
seem to be crucial in these texts?
Inclusive reviewing and summarizing of
categories
Working together to develop category
summaries
What are some key quotes?
Collaborative analysing Work together to depict main findings What are our most important findings?
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KNECK e t al.
So, it's not like … superficial, instead it's relaxed, you
know, natural.
(W8)
or:
…that you have someone you can lean on when it's
hard and so. And then it's… it's a community, then
it doesn't matter if it's raining, as long as you have a
good time together and such like.
(W5)
One woman talked about her reconnecting with her family and
how that affected her well- being:
It's friends and family, who I've regained contact with
the last 2– 3 years or so, who've become… yes, very
important again. So, it feels good, it makes me mo-
tivated and stronger to like… yes, seeing the light in
the tunnel, to be able to… yes… like there's hope you
know.
(W13)
Authentic relationships could inspire hope for a better future.
Relationships with children stood out as essential and evoked strong
emotions. Family relationships could generate not only joy and hap-
piness, but also a lot of sadness and grief. One woman expressed her
strong longing for the childre n and gr andchildren that she has not been
able to see for years. Another woman had an ongoing relationship with
her sister's children and described this as positive, giving her a chance
to feel connected to others. She looked at a photograph of a father
with children on a bed and said:
This is good for the soul. I don't have children my-
self, but I have a lot of nieces and nephews. […] This
is the best thing that I want, this makes you feel so
good, even though it's chaos, it's still good chaos,
you know, they jump on the bed and they take out
toys. […] There's nothing better than when kids
come and jump on the beds […]- even if you're tired,
you're happy anyways. It makes you want to get up
(laughs)
(W2)
One woman chose the photograph of two women sitting together
at a café and briefly addressed that kind of friendship as a meaningful
relationship. Being able to have a relaxed coffee with a friend was as-
sociated with health and something to long for. It evoked thoughts of
the impor tance of not just taking par t in such an activity but also of the
persons in their network. Staying away from persons they had valued
relationships with, in challenging times, so as to not risk losing those
persons was also described.
Structured living was expressed as a prerequisite for peaceful
socializing. Photographs displaying typical caring and authentic rela-
tionships evoked feelings. The photograph of a father with children
on the bed evoked associations of family as health:
I love children and animals. Just… joy in like… family,
though it doesn't have to be blood relatives, but some
kind of constellation of family, you know.
(W9)
Also, significant was their relationships with pets. One photograph
of dogs was chosen by several participants:
I've got two little ones like that, or I have had … I've
still got them but it's not me who takes care of them
[…] they mean a lot to me and do a lot for my health
and so on…. it's like family … a lot of love and warmth
and joy.
(W13)
Being involved in authentic relationships also meant being able to
care for others, which was expressed in different ways in relation to
health and well- being. Having a healthy pet acted to legitimize the
women's ability to care for others and was associated with pride and
accomplishment. In addition, pets were also described as being a “so-
cial bridge,” facilitating new relationships for friendships and acquain-
tances. The opportunity to help and care for others was important:
the resolve to not want to lose oneself. If you know
that you're a sensible person and can contribute to
society, and can… make others feel better or succeed
or yes, contribute, then… and you want to do it,… or I
don't give up hope that I'll be able to.
(W9)
One woman talked about her engagement with others in a similar
situation to herself:
Woman : A girl now that I really care about followed me, …every day I
make sure that I have contact with her so that she's alright.
Interviewer: Okay
Woman : Because she has brain damage and, you know, due to addic-
tion, and people have treated her really badly.
Interviewer: Okay. So, you are in contact with her?
Woman : Yes, every day. I'm like a mother. Her father is dying and
she's never had a mother.
(W10)
These excerpts denote the importance of caring for others as a
vital ele ment for fe eling pers ona l value as a huma n being ; defining one-
self as a person and providing an opportunity to give something back
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KNECK et a l.
to societ y. Another aspec t is that the women signal a longing to engage
and fulfil their social contract as a citizen.
3.3 | Health as experiencing preserved dignity
The connotations of health in the last theme relate to being able
to feel equal to housed people, being accepted by others, having a
place and a role in society. On an overarching level, health was spo-
ken about as experiencing preserved dignity. Staff in some organiza-
tions were seen as helpful, since they accepted the women and their
conditions, and signalled implicit understanding of circumstances in
the women's situation.
That the staff genuinely really want to help you and
don't seem to think that there's anything the least bit
strange or that I've done something that's my fault,
for having ended up where I am today, like…
(W6)
The feeling of being considered trustworthy was central for ex-
periences of preserved dignity, which was described as being treated
the same way as others. Being met with acceptance instead of pre-
conceived notions contributed to feelings of being accepted on terms
equal to housed people. Being able to preserve and experience feel-
ings of dignit y in encounters with social services was important for not
feeling exposed, or further accentuating the inherent vulnerability of
the situation.
However, having experiences of being deprived of dignity was
not only about exposing themselves verbally to social services
but also something that the women experienced in daily life. Life
in homelessness had negative consequences for bodily health and
singled the women out. One woman described how it was hard to
preserve dignity because of the way she looked. Her dental health
deprived her of dignity when she entered a store; the stigma was not
only limited to being singled out as a homeless person, but people
also drew conclusions that she was probably a thief.
I: Yes, I want new dental implants. I want new teeth and I want to be
able to smile again and I want to be able to go into a store without
being judged as soon as they see that I have no teeth. They fol-
low you and think you're going to steal something straight away.
Straight away, immediately, immediately, immediately. I'm judged
immediately. Open your bag!”
M: But so, teeth you think that would be important?
I: Yes, for me that woul d mean a lot right now. And to fit in, with soc iet y.
Who wants to look like this? You can't go into a bank and stuff.
(W1)
Experiences of dignity was addressed in relation to feeling in con-
trol of one own life. About it pertained to accepting conditions and
rules set by various services; having to obey and being subordinate;
as the non- trustworthy party, was often conditional to being able to
obtain resources for basic needs.
4 | DISCUSSION
Women with experiences of homelessness reflected on health as
feelings of having a home, being involved in authentic relationships
and experiencing preserved dignity. In the forthcoming discussion,
we will focus on these resources for everyday life in relation to a
mental health nursing perspective.
The women had multiple and different needs related to hous-
ing, and the meaning of a home was multi- layered. A home was
a basis for meeting physical, psychosocial and existential needs
related to health; a place to return to. In line with Edgar (2009),
Hilli and Eriksson (2019) refer to a home as a place in which one
can experience peace, quiet, freedom and privacy. A home can
be conceptualized as a physical place, a house, but the house as
a home also refers to an individual's own internal world, the self
(Hilli & Eriksson, 2019). In clinical encounters, nurses can invite
women without a shelter of a home in caring relationships by
showing openness, attentiveness to and respect for the woman
as an individual. Thus, nurses have the power to help the woman
feel metaphorically at- home, a particular aspect of well- being in
spite of illness and disease (Öhlén et al., 2014). As a means to-
wards this end, nurses can enhance at- homeness by making sure
that women feel safe, connected through caring relationship and
centred through recognition of their experiences. By using these
tenets of a holistic and integrative approach, mental health nurses
can affirm the inherent value and maintaining or preserving the
dignity of women who live in homelessness.
The women in our study needed a house to return to, a place free
from chaos and uncertainty. In line with Hilli and Eriksson (2019),
we argue that the healthcare context can be that place; a place
where women in homelessness can meet their inner selves and
reach the feeling of being at- home despite dire circumstances and
tri- morbidity. Mental health nurses can embody and offer a safe
haven. However, it is imperative to consider that the process of at-
homeness manifests itself in bi- directional ways. It is a continuum
dimension, that is, can fluctuate from being metaphorically at- home
to being metaphorically homeless (Öhlé n et al., 2014). Thus, in clinical
situations, nurses are in a position to both enhance or prevent at-
homeness (Hilli & Eriksson, 2019; Öhlén et al., 2014). Unfortunately,
there are numerous studies concluding prevailing experiences
within healthcare of the latter. People facing homelessness describe
experiences of alienation, discrimination, disrespect and stigmati-
zation during encounters with healthcare professionals (Omerov
et al., 2020), which in turn reinforce feelings of both external and in-
ternal homelessness. Against this backdrop, it is obvious that nurses
must take action to re- frame healthcare to include all citizens and
persons in need. Protecting and restoring human dignity in caring
relationships are core values in nursing and key factors when caring
for women in homelessness. Furthermore, it is well in line with the
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KNECK e t al.
updated ICN Code of Ethics, which highlights social determinants of
health and further that nurses shall advocate for equity and social
justice (ICN, 2021).
Authentic relationships and caring for others gave a sense of
mattering and worth for the women in our study. Thoits (2011)
described mattering as having someone's attention, being import-
ant for that person and knowing that someone is dependent on
one for the fulfilment of particular needs. The possibility to care
gave the possibility of defining oneself in ways other than “home-
less” or in need of the benevolence and pity from others. Caring
was associated with a sense of pride and personal value. Hilli and
Er ikss on (2019 pp. 427– 428) theoriz e th a t “t h e et hics of caring imply
an affirmation of human beings' absolute dignity and holiness” and
“to recognize ethos is to be sensitive to the voice of the heart and
to have the courage to connect to one's innermost human being.”
In other words, the women's ability to care, for self and others, is a
sign of being in contact with the self. Adding further to the creation
of authentic relationships in caring, mental health nurses need to
pay particular attention and sensitivity to the fact that many moth-
ers are separated from their children during periods of homeless-
ness (Cowal et al., 2002). The pain associate d with the mother– child
separation is devastating for the women and includes feelings of
exclusion, diminished self- esteem, psychosocial distress, shame and
self- blame related to the stigma of having failed to be good moth-
ers (Mayock & Bretherton, 2016). In society, these women become
invisible mothers, categorized as single in health- and social care
records. The identit y of bei ng a mother is denied . Recognizi ng these
experiences and the suffering as well as providing visibility to the
women's status as mothers is imperative in restoring health. Mental
health nurses can engage with women in authentic caring relation-
ships, by acknowledging them as mothers, thereby enhancing at-
homeness and providing a safe space for health recovery.
The importance of providing the interviewed women with a
home does not only correspond with human rights, access to hous-
ing is also an important determinant of health (Marmot et al., 2012),
especially for women in homelessness (Aldridge et al., 2018).
Indeed, rehousing individuals who are roofless or houseless, or in-
dividuals who experience insecure housing has been put forward
as an important health intervention (Baxter et al., 2 019). Thus, the
Housing First model, which provides rapid housing, not conditional
on abstinence from substance use, has become a core strategy in
increasing housing stability in Europe (Baxter et al., 2019; Pleace
et al., 2019). Although Housing First has been found to improve
housing stability, evidence regarding the impact on health and well-
being is scarce. In a recent review, no clear differences with regard
to self- reported mental health, quality of life and substance use
were seen between those who were housed via the Housing First
model compared with control groups (Baxter et al., 20 19). These
results underscore the complex interplay between homelessness,
poor physical and mental health and substance use disorders
(Aldridge et al., 2018; Nielsen et al., 2011; Roncarati et al., 2018), as
well as difficulties in providing healthcare interventions to support
people in homelessness (Vickery et al., 2021). Mental health nurses
need to bear in mind that there are various causes to homeless-
ness, that can seem intractable, and this too emphasizes the im-
portance of feelings of having a home, being involved in authentic
relationships and experiencing preserved dignity. Encounters and
relationships with health- and social care professionals are im-
portant during times of homelessness, since the need for personal
support is increased, while the social networks and community are
reduced (Omerov et al., 2020). Taking the time in the moment to
interact and acknowledge women in homelessness as persons of
importance and worth does not cost anything extra, yet may sig-
nificantly impact their health trajectory. Doing what we can and
doing something, however complex and multifaceted the circum-
stances, is better than doing nothing.
4.1 | Methodological considerations
This study has both strengths and limitations. The photographs
served as intended icebreakers and evoked memories, experiences
and associations (Bates et al., 2017; Harper, 2002). The interviewer
could also return to the photographs when the dialogue needed to
be fuelled. However, it is possible that data could have been richer,
or exhibited other dimensions, if the participants had taken own
photographs or if follow- up interviews had been carried out. On the
contrary, the chosen procedure for data collection gave us possi-
bilities to listen to voices that are seldom heard in research: women
without a shelter of a home.
The interviewed women reflected on health as resources for
living despite impaired physical and mental well- being as well as
challenges with substance use. However, it could be speculated that
a different location for data collection, than the healthcare centre
where the women sought care for illness, would have made it easier
for them to talk about health in an even more holistic way.
A major strength of the study was the collaboration with the
Women's Advisory Board, that included two women with lived
experience of homelessness. The women actively participated in
the data analysis by taking part in seven workshops (total 14 h).
The analysis was guided by the DEPICT model for collaborative
qualitative analysis (Flicker & Nixon, 2015) and was a valuable tool
to guide the process. However, in the present study, we only used
three of the model's six sequential steps. We did not list import-
ant ideas for categorizing data (DEPICT step: Engaged codebook
development), nor did the women individually review and code a
subset of transcripts (Participatory coding). The reason for exclu-
sion of these steps was that although the women spoke Swedish,
both had difficulties reading and writing in Swedish as they had
other first languages. In addition, we did not develop a knowl-
edge translation and exchange plan for sharing research results
(Translation). Nonetheless, we argue that the collaborative analy-
sis did contribute to enhancing the trustworthiness and reliability
of the study.
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KNECK et a l.
4.2 | What this study adds to existing research
To summarize, women with experience of homelessness under-
scored three main resources for achieving health and well- being,
namely feelings of having a home, being involved in authentic re-
lationships and experiencing preserved dignity. During dire circum-
stances, such as homelessness, healthcare services may focus on
these perceived resources and offer women, without the shelter
of a home, a safe haven. Healthcare contexts can be place where
women are met as individuals, and where their experiences and suf-
fering are acknowledged alongside their strengths. It is well known
that homelessness encompasses social isolation and marginalization,
often accompanied by extremely poor health and substance use.
Designing and building health care interventions on the identified
three resources may comprise a core intervention with potential to
promote health in line with women's needs and wishes. Women will
return to the healthcare setting only if they feel safe and secure, and
only if dignity is restored and preserved. Fulfilment of these basic
human needs may be a prerequisite for medication adherence, an-
other necessary resource for ever yday life, for women experiencing
homelessness.
5 | IMPLICATIONS FOR MENTAL HEALTH
NURSING
Mental health nurses can make a difference by considering that
women's experiences of homelessness differ from those of men,
that is, women are worse off with regards to mental health issues
and experience heightened vulnerabilities, such as stigma and social
exclusion. The women in this study emphasized the importance of
having a home; a safe place to return to. In times of hardship, nurses
have the potential to invite women without a shelter of a home to
feel at- homeness, to be involved in authentic relationships and con-
sequently, to experience preserved dignity.
Furthermore, mental health nurses must heed the ICN (2021)
call to consider social determinants of health, and to actively work
for health equity and social justice. A first step can be taking action
to prevent stigma and discrimination from being decisive factors in
and during care encounters and care provision. Leading by exam-
ple and using the expertise within mental health nursing to provide
respectful care to a population with great needs and resources. Re-
framing mental health nursing to encompass a sense of respite care
during healthcare encounters, however complex the circumstances
and however bleak the situation may seem; this is the message from
the women in this study.
6 | CONCLUSION
Women in homelessness face many challenges and much of the
focus in health research has been on risks, illness and premature
death in this population. However, given the opportunity to reflect
on their health and well- being, women expressed multiple connota-
tions of holistic health, the feelings of having a home, being involved
in authentic relationships and the importance of experiencing pre-
served dignity.
We argue that nurses should use a holistic, integrative nursing
approach caring for women in homelessness, due to the complex
interplay between women's health and life circumstances. Nurses
need to recognize and support women in homelessness in their
capacity to heal and to experience health. Regarding women as re-
sourceful, active, human beings with wishes and needs, despite the
social position of living in homelessness with heightened vulnera-
bility, is at the core of nursing. Encounters and relationships with
health- and social care professionals may be especially important
during times of homelessness, since the need for personal support
is increased, while the social networks and community are reduced.
Providing a safe haven during healthcare encounters is the least we
can do.
7 | RELEVANCE STATEMENT
Women in homelessness represent an underserved group in society
as well as in nursing research. The women face multiple everyday
challenges, such as tri- morbidity, social isolation and experiences of
stigma, which negatively impacts their mental health. Based on our
findings, we emphasize the need for using a holistic and integrated
approach in mental health nursing. Women's health, resources and
environment are inseparable and must be considered together in
working to promote health, prevent illness, restore health and allevi-
ate suffering for women in homelessness.
AUTHOR CONTRIBUTIONS
EM, AK, MS- E and ÅK involved in conception and design. ÅK and EM
involved in data collection. ÅK, EM, AK, MS- E, ÅK and WAB involved
in data analysis and interpretation. ÅK and MS- E involved in drafting
the article. EM and ÅK involved in critical revision.
FUNDING INFORMATION
The Swedish Research Council [no. 2019- 01095] and FORTE [no.
2020- 00169] funded the project. The funders had no influence on
the research process at any stage.
DATA AVA ILAB ILITY STATE MEN T
Data available on request due to privacy/ethical restrictions
ORCID
Åsa Kneck https://orcid.org/0000-0002-2135-2684
Anna Klarare https://orcid.org/0000-0001-7935-3260
Elisabet Mattsson https://orcid.org/0000-0001-5104-1281
Martin Salzmann- Erikson https://orcid.
org/0000-0002-2610-8998
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KNECK e t al.
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How to cite this article: Kneck, Å., Klarare, A., Mattsson, E.,
Salzmann- Erikson, M., & in collaboration with Women
Advisory Board for Inclusion Health (2022). Reflections on
health among women in homelessness: A qualitative study.
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https://doi.org/10.1111/jpm.12859
