To the best of our knowledge, this is the first qualitative study focused on the pathways traveled into and out of homelessness among people with SMI in a rural, low-income country setting. Our findings help to characterise important pathways and inform the development of prevention and intervention strategies for this vulnerable group. Family situations and relationships were crucial for both becoming homeless and exiting from homelessness, interfacing with access to mental health care, poverty and community support.
Pathways into homelessness
People with SMI and their caregivers placed contrasting emphases on the exact mechanisms which precipitated homeless episodes. While people with SMI were more likely to describe their experiences of mental ill health, caregivers focused more on how their coping resources had been exhausted. Conflicts within families were reported by all study participants.
In this setting, the major portion of the burden of care generally falls to families [
38]; access to mental health care depends on families [
39,
40], and there is almost no formal social support. Supporting the whole family unit has been recommended as the best approach to ensure the best care and treatment for people with SMI in this context [
41]. This entails not only consistent financial support, for example from community-based health insurance schemes [
42], but also psychoeducation for family members about the nature of the illness and how to reduce stigma [
38].
Studies from HICs and India have indicated that “expressed emotion” in the family, namely criticism, hostility and emotional overinvolvement/intrusiveness [
43], contributes to the exacerbation of mental health problems in those with SMI [
44]. More needs to be understood about the precise communication patterns that are culturally salient in this Ethiopian setting. Family interventions, including a focus on expressed emotions, are recommended as an evidence-based practice in HICs [
45] and have been adapted for several LMIC contexts and shown to improve certain mental health and social outcomes [
46]. Family mediation drawing on local practices may help to resolve some of the underlying issues among family members.
Experiencing mental ill health was reported by all study participants with lived experience of homelessness. Evidence from previous studies in the area indicates that access to medication can reduce caregiver stress and burden, which could in turn help to moderate some of the conflicts which trigger people to leave their homes [
47]. However structural barriers, in particular poverty contributing to non-affordability of ongoing care, prevented people with SMI from easily engaging in ongoing care [
40]; this is likely to be pronounced among those who have been or are currently homeless. It is not possible to know how rural residence impacted on homelessness from this qualitative study, but future studies should examine any relationship between proximity to services and risk of homelessness in order to quantify risk and raise awareness of the need for locally-provided care.
Substance use was described as both alleviating and causing distress and was often involved in intermittent homelessness, wherein people left their homes to access alcohol or khat and then were lost from their homes while intoxicated. Substance use problems are heavily stigmatized in this setting, both by the community and by those who have these problems themselves [
48] and may, in conjunction with SMI, overwhelm the capacity of families to cope.
Coercive treatment of people with SMI was common and led to homelessness. Coercion was expressed in multiple forms, including physical restraint and in emotional pressure from the family to continue to take medication. Surveillance was another form of social coercion, and networks of surveillance extending to neighbors and other community members were perceived ambiguously by people with SMI, and reported to both cause and prevent homelessness. Previous studies from this area have indicated that there is little involvement of people with SMI in decision-making about their care [
49] and human rights abuses in the community and at holy water treatment may drive people to run away from these settings.
Staying at holy water sites may be a form of ‘quasi-institutionalisation’ in this context, where people with SMI who cannot be managed in the home seek spiritual care and their caregivers get temporary reprieve as holy water attendants take on the burden of custodial care duties [
50]. That people with SMI escaped from both holy water and psychiatric facilities indicates that the care administered in such settings does not adequately uphold the person’s sense of liberty. In the absence of mental health legislation, there is limited protection of an individual’s desire for autonomy and protection from human rights abuses [
51].
The use of restraints was controversial, but both people with SMI and caregivers saw it as an alternative to homelessness, injury and death [
52]. There is evidence that expanding integrated care within primary health care in the district helped to lower both the use of restraint and the rates of comorbid alcohol use disorder in this population over a one-year follow-up period [
33]. Culturally-sensitive psychoeducation for people with SMI and their families should include modules related to both restraint and problematic substance use [
53] and how to manage these issues in a way which upholds human rights.
Pathways out of homelessness
While family conflict was a precipitant for homelessness, family and community intervention and support were crucial for people to return home. Families employed a flexible and wide-ranging array of measures to help family members with SMI who were homeless. The strategies used by families were adaptive and responsive to changes in the homeless person’s situation as well as factors including the ability to draw on available financial and other resources. While caregivers were motivated by a desire to help, their actions could still be coercive, particularly in regards to the use of restraint [
52].
Those with long-term homelessness required more intensive strategies to return them to housing, largely because they were more detached from their families and communities of origin. Permanent housing was secured for several of the participants. Housing is a cornerstone of interventions for people with SMI who are homeless in HICs and the provision of immediate, long-term housing is considered to be an evidence-based best practice [
22,
54]. In HICs, this housing is usually provided by the state with or without support from non-profit organizations [
22]. In our study, we found that housing was procured not through government housing or another formal housing program, but instead through the work of concerned community members who mobilized and coordinated resources from a variety of sources.
Accessing health care was a stepping stone to leaving homelessness when it could be coupled with family and community support. Once family or community members witnessed a person with SMI improving with treatment, they appeared to be more willing to support them; people with SMI were also more motivated to reunite with their families and return home after receiving treatment. Community mobilization and support activities ranged from providing housing, to the facilitation of medical care, assistance with basic needs, and offering temporary shelter, including within Orthodox church compounds.
A number of people with intermittent homelessness simply returned home unaided. “Self-return” was related to the idea that homelessness could, at times, be an extension of an individual’s personal autonomy; indeed, some study participants expressed a preference for homeless life in comparison with the “prison”-like conditions experienced in their family homes, and others saw homelessness as a “way of life” and part of their identity.
Meeting complex needs
Task-shared mental health care may not be sufficient to meet the complex needs of people who require extra support, particularly those who are the most ill and need more intensive resources [
55]. There is potential for non-governmental organisations to step into this space to help such people [
3,
56], as their work can be more intersectoral, community- and social-care based. Disability grants could alleviate some of the financial burden disproportionately experienced by families with SMI family members [
28,
57].
Community based rehabilitation (CBR) [
58] interventions have also been promoted as a way of providing more intensive, holistic support to people with SMI in the community [
59]. However, there are currently no guidelines in CBR interventions for how to deal with homelessness. These could usefully include assessing and meeting urgent needs, followed by individualized joint care planning with the person with SMI when the situation stabilizes, and they are better able to participate. Having a home one finds acceptable is an essential condition for continuity of care [
60]. Where possible, health extension workers or CBR workers could coordinate care across multiple sectors, including with government (‘
kebele’) officials.
Strengths and limitations
Strengths of the study include that we set our study in a context where a measure of trust and goodwill had been established between health workers and community members. This facilitated access to people with SMI and their caregivers and meant we were more likely to be welcomed than had our study been conducted independently of service provision. However, some people’s experiences of problems accessing care also affected their engagement with the interviews. Interviewing people with lived experience of both SMI and homelessness was a major strength of the paper and is the first time their voices have been featured so prominently in a publication from a LMIC setting (to the best of our knowledge). This is also the first study of people with SMI who have experienced homelessness in the context of the implementation of accessible integrated mental health care in a LMIC setting, highlighting its role in helping several community members to get out of homelessness. CS and KK were both outsiders to the community under study which may have impacted on the content of the interviews. Due to difficulties with accessing remote, rural areas, there was over-representation of participants who were based near the main town. Nonetheless, nesting the study within PRIME allowed us to identify people with SMI who had been homeless in the community. The availability of mental health care (delivered through the task-shared model) provides important insights on homelessness in the context of locally available mental health care but means that our findings may not be transferable to other settings.
Other issues impacting on the transferability of this study is that is was exploratory in nature and featured a relatively small number of participants. Another limitation is that we focused on pathways into and out of homelessness among people with SMI; it is likely that there are other determinants of pathways that could apply to all people and which are not listed here and could also apply to people with SMI (for example, larger migration trends or other macro-economic forces which cause uprooting from communities of origin).
Implications for policy and practice
Overall, pathways into and out of homelessness in our setting were mediated more by individual, family, and community-level factors than by the structural factors which are often emphasized in HICs (for example, access to state-subsidised medical and social care and housing). This may be due in part to the fewer structural-level assets available in this setting, as well as the stronger cultural influence of family and community.
Ending long-term homelessness in this setting will likely require transitional housing in addition to medical and social support, with family reunification and financial support as a second step [
61]. There is precedence for such a stepped approach in urban India with the work of the Banyan NGO [
62], where women with SMI are first given medical and rehabilitative care before overtures are made to reconnect women with their families of origin. A recent study from Mozambique [
63] demonstrated the proof of concept for the potential for psychiatric institutions to act as intermediate housing and rehabilitation for people with SMI in a LMIC context, however the study only had a follow-up period of 3 months and there are few psychiatric beds per capita in LMIC settings, so this is not feasible to address homelessness on the societal-level.
Intermittent homelessness might be better addressed by focusing on building up the family unit and psychoeducation [
64]. Modified, culturally appropriate “critical time interventions” [
65], wherein intensive, time-limited support is provided during the transition period back into domiciled life may be appropriate for both types of homelessness.
Ultimately, this study shows the profound contribution of the community in assisting people with SMI to get out of homelessness and this is an important finding for others planning mental health care services in low resource settings. Different types of service responses will need to address the different types of homelessness and must take into account personal needs and preferences and be sensitive to uphold the person’s sense of liberty and participation in care planning. Future work must focus on identifying and then supporting and bolstering strategies already used by those with SMI, their families and communities.