Impacts on practice
-
Community pharmacists can benefit from appropriate training and guidelines in offering proactive support and advice to homeless patients.
-
Establishing appropriate guidelines will enable community pharmacists to be aware of their remit in advising homeless patients on wider aspects of health and social care.
-
Incorporating homelessness in undergraduate education and professional development training can improve pharmacists’ knowledge and confidence in caring for the people who are homeless.
Introduction
Aim of the study
Ethics approval
Method
Data management and analysis
Demographic characteristics | Number of respondents, n (%) |
---|---|
Sex (n = 317) | |
Female | 157 (49.5) |
Male | 155 (48.9) |
Prefer not to say | 5 (1.6) |
Experience of work as a pharmacist (years) (n = 317) | |
5 or less | 94 (29.7) |
6–10 | 50 (15.8) |
11–15 | 41 (12.9) |
16–20 | 34 (10.7) |
21–25 | 19 (6.0) |
26–30 | 27 (8.5) |
31 or more | 51 (16.1) |
Multiple deprivation index quintile (England) (n = 186) | |
1 (least deprived) | 29 (15.6) |
2 | 33 (17.7) |
3 | 36 (19.4) |
4 | 34 (18.3) |
5 (most deprived) | 54 (29.0) |
Multiple deprivation index quintile (Scotland) (n = 34) | |
1 (most deprived) | 12 (35.3) |
2 | 7 (20.6) |
3 | 6 (17.6) |
4 | 7 (20.6) |
5 (least deprived) | 2 (5.9) |
Is community pharmacy your main practice setting? (n = 317) | |
Yes | 311 (98.1) |
No | 6 (1.9) |
Are you an independent prescriber? (n = 315) | |
Yes | 17 (5.4) |
No | 298 (94.6) |
Do you have a postgraduate qualification? (n = 315) | |
Yes | 111 (35.2) |
No | 204 (64.8) |
Services offered to the homelessa | |
Dispensing or prescribing of medicines (n = 266) | 166 (62.4) |
Chronic medication service (n = 265) | 3 (1.1) |
Medicines use reviews (n = 266) | 30 (11.3) |
Minor ailments service (n = 265) | 64 (24.2) |
Opioid replacement therapy (n = 322) | 155 (58.3) |
Social support (n = 265) | 21 (7.9) |
Alcohol misuse (n = 266) | 46 (17.3) |
Promoting self-care (n = 265) | 62 (23.4) |
Other (n = 263) | 39 (14.8) |
Results
Experiences of managing homeless patients
TDF domains | Description (24) | Statements in the survey (n) | Responses n(%) | Cronbach’s Alphaa | Scale mean | Scale variance | SD | ||||
---|---|---|---|---|---|---|---|---|---|---|---|
Strongly disagree | Disagree | Neither agree nor disagree | Agree | Strongly agree | |||||||
Knowledge- self | An awareness of the existence of something | I know how homelessness affects patient health and wellbeing (315) | 13 (4.1) | 20 (6.3) | 32 (10.2) | 159 (50.5) | 91 (28.9) | 0.80 | 13.33 | 10.66 | 3.27 |
I know how homelessness affects patient adherence to their medicines (315) | 11 (3.5) | 27 (8.6) | 39 (12.4) | 146 (46.3) | 92 (29.2) | ||||||
I know how to advise homeless patients about minimising the impact of homelessness on their use of medicines (314) | 25 (8.0) | 125 (39.8) | 92 (29.3) | 56 (17.8) | 16 (5.1) | ||||||
I know where to refer to if a homeless patient asks me about social support (314) | 40 (12.7) | 116 (36.9) | 56 (17.8) | 82 (26.1) | 19 (6.1) | ||||||
Knowledge- patients | An awareness of the existence of something | Patients who are homeless know more than I do about coping with homelessness (314) | 5 (1.6) | 20 (6.4) | 71 (22.6) | 144 (45.9) | 74 (23.6) | 0.40 | 6.61 | 1.91 | 1.40 |
Patients who are homeless know more than I do about general services available to them (315) | 9 (2.9) | 63 (20.0) | 124 (39.4) | 95 (30.2) | 24 (7.6) | ||||||
Social/professional role and identity | A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting | It is part of my role to ask homeless patients about their housing status (314) | 46 (14.6) | 112 (35.7) | 115 (36.6) | 36 (11.5) | 5 (1.6) | 0.60 | 14.79 | 9.46 | 3.08 |
I should only initiate a conversation about homelessness if raised by the patient (314) | 14 (4.5) | 72 (22.9) | 90 (28.7) | 116 (36.9) | 22 (7.0) | ||||||
Only GPs or social care professionals should initiate a conversation about homelessness (314) | 45 (14.3) | 137 (43.6) | 97 (30.9) | 26 (8.3) | 9 (2.9) | ||||||
If I discuss aspects of homelessness with patients, I believe that I will be outside my own comfort zone (314) | 20 (6.4) | 71 (22.6) | 84 (26.8) | 119 (37.9) | 20 (6.4) | ||||||
Managing a homeless patient is compatible with my daily practice (311) | 25 (8.0) | 60 (19.3) | 114 (36.7) | 95 (30.5) | 17 (5.5) | ||||||
Skills/belief about capabilities | An ability or proficiency acquired through practice | I am confident in my ability to advise appropriate medicines management strategies for homeless patients (315) | 27 (8.6) | 114 (36.2) | 70 (22.2) | 86 (27.3) | 18 (5.7) | 0.80 | 11.7 | 11.07 | 3.32 |
I am confident in approaching social care services on behalf of homeless patients (314) | 48 (15.3) | 105 (33.4) | 61 (19.4) | 83 (26.4) | 17 (5.4) | ||||||
I am confident in my ability to advise homeless patients on aspects of self-care (314) | 20 (6.4) | 56 (17.8) | 60 (19.1) | 153 (48.7) | 25 (8.0) | ||||||
I am confident in my ability to identify patients who do not have a fixed abode (313) | 30 (9.6) | 105 (33.5) | 85 (27.2) | 77 (24.6) | 16 (5.1) | ||||||
Optimism/pessimism | The confidence that things will happen for the best, or that desired goals will be attained | The NHS can do little to alleviate homelessness (314) | 27 (8.6) | 83 (26.4) | 108 (34.4) | 77 (24.5) | 19 (6.1) | 0.70 | 14.1 | 9.40 | 3.07 |
Pharmacists can do little to alleviate the effects of homelessness (315) | 16 (5.1) | 101 (32.1) | 97 (30.8) | 81 (25.7) | 20 (6.3) | ||||||
Pharmacists can do little to alleviate the health impact of homelessness (314) | 33 (10.5) | 176 (56.1) | 58 (18.5) | 40 (12.7) | 7 (2.2) | ||||||
Patients who are homeless may not want my advice about housing or social support (314) | 3 (1.0) | 41 (13.1) | 111 (35.4) | 141 (44.9) | 18 (5.7) | ||||||
Managing homeless patients in pharmacy is pointless because they do not follow-up with their own care (315) | 36 (11.4) | 144 (45.7) | 99 (31.4) | 32 (10.2) | 4 (1.3) | ||||||
Beliefs about consequences | Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation | If I discuss aspects of homelessness with a patient, I believe that the patient may be reluctant to use my pharmacy again (313) | 27 (8.4) | 133 (42.5) | 106 (33.9) | 43 (13.7) | 4 (1.3) | 0.30 | 12.60 | 4.55 | 2.13 |
Homeless patients will continue to have poor health outcomes regardless of pharmacy management (312) | 15 (4.8) | 129 (41.3) | 67 (21.5) | 86 (27.6) | 15 (4.8) | ||||||
Goals | Mental representations of outcomes or end states that an individual wants to achieve | I would feel rewarded if I felt that a homeless patients’ health improved after I had provided advice to them (314) | 2 (0.6) | 3 (1.0) | 24 (7.6) | 156 (49.7) | 129 (41.1) | 0.43 | 7.98 | 1.90 | 1.38 |
Pharmacy is not the right place to treat homeless patients (315) | 66 (21.0) | 133 (42.2) | 76 (24.1) | 31 (9.8) | 9 (2.9) | ||||||
Intentions | A conscious decision to perform a behaviour or resolve to act or perform in a certain way | I would ask patients who are homeless whether they have access to food (314) | 9 (2.9) | 90 (28.7) | 87 (27.7) | 112 (35.7) | 16 (5.1) | 0.37 | 5.68 | 2.32 | 1.52 |
Pharmacists should address medication needs and, not social circumstances of a patient (314) | 18 (5.7) | 119 (37.9) | 98 (31.2) | 65 (20.7) | 14 (4.5) | ||||||
Environmental context and resources | Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour | I have guidelines on advising homeless patients with no fixed abode (312) | 117 (37.5) | 135 (43.3) | 47 (15.1) | 11 (3.5) | 2 (0.6) | 0.70 | 16.7 | 15.71 | 3.96 |
I have clear guidelines on how to advise homeless patients on their medicines use (313) | 97 (31.0) | 150 (47.9) | 48 (15.3) | 17 (5.4) | 1 (0.3) | ||||||
I have clear guidelines on how to advise homeless patients on accessing housing information (313) | 121 (38.7) | 141 (45.0) | 39 (12.5) | 11 (3.5) | 1 (0.3) | ||||||
Availability of guidelines on managing homeless patients in a community pharmacy will positively impact patient care (312) | 14 (4.5) | 20 (6.4) | 57 (18.3) | 163 (52.2) | 58 (18.6) | ||||||
I have had homeless patients complaining to me of stolen medicines (309) | 80 (25.9) | 95 (30.7) | 60 (19.4) | 55 (17.8) | 19 (6.1) | ||||||
I have had homeless patients complaining to me about lack of appropriate place to store their medicines (309) | 80 (25.9) | 109 (35.3) | 72 (23.3) | 37 (12.0) | 11 (3.6) | ||||||
I have sufficient time to discuss aspects of homelessness with my patients (314) | 60 (19.1) | 107 (34.1) | 73 (23.2) | 67 (21.3) | 7 (2.2) | ||||||
Social influences | Those interpersonal processes that can cause an individual to change their thoughts, feelings, or behaviours | I have sufficient support from my colleagues in my pharmacy in managing homeless patients (313) | 58 (18.5) | 97 (31.0) | 85 (27.2) | 62 (19.8) | 11 (3.5) | 0.52 | 13.50 | 8.93 | 3.0 |
Homeless patients often experience stigma from pharmacy staff (315) | 26 (8.3) | 80 (25.4) | 105 (33.3) | 80 (25.4) | 24 (7.6) | ||||||
Homeless patients often experience discrimination from pharmacy staff (314) | 44 (14.0) | 102 (32.5) | 105 (33.4) | 48 (15.3) | 15 (4.8) | ||||||
My organisation discourages me from discussing homelessness with a patient (311) | 102 (32.8) | 96 (30.9) | 103 (33.1) | 10 (3.2) | 0 (0) | ||||||
Individuals are responsible for their homelessness (313) | 69 (22.0) | 106 (33.9) | 103 (32.9) | 29 (9.3) | 6 (1.9) | ||||||
Emotion | A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event | I become too emotional when I discuss aspects of homelessness with patients (315) | 54 (17.1) | 141 (44.8) | 94 (29.8) | 21 (6.7) | 5 (1.6) | N/A | N/A | N/A | N/A |
Perceived behavioural determinants in managing homeless patients
Knowledge, skills and resources in managing homeless patients
Intentions
Beliefs about consequences
Social and professional role and identity
Social influences
Optimism
Objective knowledge assessment
Knowledge assessment questions | Number of respondents (n) |
---|---|
What is the average years of deathb of a homeless individual in the UK? (n = 314) | |
37 years | 31 (9.9) |
47 years |
159 (50.6)
|
57 years | 89 (28.3) |
58 years | 35 (11.1) |
Which of the below approximate number of rough sleeps in Scotland and England combined on any given night? (n = 312) | |
4000 |
42 (13.5)
|
8000 | 85 (27.2) |
10,000 | 125 (40.1) |
12,000 | 60 (19.2) |
An individual is only considered ‘homeless’ if he/she loses their home AND is living in a hostel? (n = 315) | |
Yes |
209 (66.3)
|
No | 106 (33.7) |
An individual is only considered ‘homeless’ if he/she loses their home AND is living in a bedroom at a friend’s house? (n = 315) | |
Yes |
177 (56.2)
|
No | 138 (43.8) |
An individual is only considered ‘homeless’ if he/she loses their home AND is living in a bedroom at a relative’s house? (n = 315) | |
Yes |
171 (54.3)
|
No | 144 (45.7) |
An individual is only considered ‘homeless’ if he/she loses their home AND is sleeping rough? (n = 315) | |
Yes |
305 (96.8)
|
No | 10 (3.2) |
An individual is only considered ‘homeless’ if he/she loses their home AND is sofa surfing with family and friends? (n = 315) | |
Yes |
211 (67.0)
|
No | 104 (33.0) |
An individual is only considered ‘homeless’ if he/she loses their home AND is all of above (315) | |
Yes |
170 (54.0)
|
No | 145 (46.0) |
Which group makes up the majority of the homeless population? (n = 310) | |
Families with children | 18 (5.8) |
Single men |
286 (92.3)
|
Single women | 6 (1.9) |
The number of homeless individuals in the UK is … (n = 313) | |
Rising in number but very gradually | 67 (21.4) |
About the same for the last 10 years | 19 (6.1) |
Rising in number abruptly | 57 (18.2) |
On the rise |
170 (54.3)
|
Positive and negative experiences of managing a homeless patient
‘Positive experiences’
Others described offering storage facilities for patient medicines and tailoring the dispensing services as per their needs.A homeless patient came in the pharmacy for his weekly medication pick up. He was pale and tired looking. He felt much better after we’ve given some snacks and water and he was grateful!27 year old male pharmacist
Respondents also provided accounts of having seen the outcomes of the services they had offered to people who are homeless.Diabetic patient of NFA prescribed insulin - nowhere safe to store pens, constantly mislaid/stolen. Got Rx changed to weekly dispense supply kept in pharmacy fridge.46 year old female pharmacist
Discussing coming off both opioids and ‘‘legal highs’’ with a patient who had a lot of success in doing so alongside my support and is now in work.28 year old male pharmacist
Negative experiences
Some respondents related such experiences to the wider social circumstances that homeless patients were facing.Being shouted at and threatened numerous times usually by non-regular patients asking for a needle exchange. On one particular occasion, physical violence was threatened and police were called.28 year old male pharmacist
Understandably many homeless patients feel threatened in their situation and often take their anger out on staff in pharmacies trying to help. I found on a regular basis the shouting from the patients was aggressive, rude and unnecessary.46 year old female pharmacist