Awareness of CVD within the homeless population

The groups presented a range of knowledge around causes of CVD. They had experience of parents and others having heart-related conditions, dying from heart attacks or following strokes, or unexpected deaths in those with no previous known history, and discussed hereditary factors. While most did not volunteer having a heart condition initially, the typical background and lifestyle of rough sleeping, drug usage and smoking raised concerns of the long-term cardiac impact. Smoking was common, and not all had linked this to CVD. Having a cardiologist present provided an information source for a range of questions around personal health issues. The discussions revolved around concerns with current issues such as breathlessness, high blood pressure, palpitations and arrhythmia, and understanding helpful actions.

While knowledge around diet, exercise, stress and smoking was high, participants discussed a number of direct and indirect barriers to health. The following themes explore the key concerns that relate to cardiovascular risk factors and health promoting behaviours: available facilities promote unhealthy eating habits; security and hygiene act as barriers to exercise; barriers to managing health conditions; the impact of stress and mental health, and coping mechanisms; and experience of discrimination in health services.

Available food types and lack of access to food preparation space promote unhealthy eating habits

Although a healthy diet and fitness were understood as essential for better cardiac health, conditions of living and food donations made this much harder to achieve. Food was a priority, and consisted of ‘death by sandwiches’, cakes and ‘party food’. People reported putting on two or three stone while being homeless, with companies and members of the public routinely offering carbohydrates and sugar. One man summarised his own health: ‘When I wasn’t homeless my weight say was between 71 kilos and 78. After my time on the streets and eating whatever I can I ballooned up to 120 kilos… it’s a struggle to get my weight back down again. I checked my heart rate on a monitor and my resting heart rate went up to 80–90 beats which is a lot higher than it should.’ A balance of healthier options was hampered by sugar cravings following substance abuse, tiredness or need for comfort, nowhere to cook food and the cost and availability of cheap junk food over healthier meals. Even in the hostels, people were given ‘Fatty foods—we do get a lot of that where we are living. There are so many cakes. Cause it’s there we eat it. It tastes nice and you get overweight.’

Security and hygiene concerns act as significant barriers to exercise

Exercise was identified as a necessary factor in maintaining health, with some using walking and outdoor gyms as free options usually once in hostels. The more vulnerable talked about fear of walking away from where you were when sleeping rough in case you missed the chance of help and how the need to queue for a shower and to get food took up the majority of the day and personal energy.

When you’re homeless your daily struggle is to get a shower. So it means coming to places like this and waiting hours in the morning to get inside so your chances of exercise are diminished. You spend 3 or 4 hours in a queue waiting, then a couple of hours within a place literally stationary in a chair so you can do your bits and bobs and by the time you’ve come out and got a bit of food, its already 6 or 7pm.

Loss of previous activities such as boxing, yoga or gym meant not only reduced cardiac fitness but loss of companionship, normality, encouragement and peer network, where health-related dialogue could have happened. Former exercise routines such as 5—a-side football with friends were avoided because of the shame of arriving potentially smelling and/or not having appropriate kit. Support for exercise was welcomed, but only if in conjunction with hygiene facilities: ‘But if you’re exercising, where can you get a wash or shower? It’s disgusting in the day centre.’

Barriers to managing existing health conditions

For those with a health condition, hygiene, managing appointments and taking regular medication was difficult. Medication could be stolen easily and it was difficult to store safely, keep dry, and to find private and hygienic places to take medication. Without a routine and with disturbed, fearful sleep, people become disorientated within days. They lost track of time and remembering appointments or collecting medication could be difficult. Mobile phones were seen as a solution but ‘On the street not many have usable phones or they don’t have credit or they get stolen.’ A few participants had been given a £5 disposable health phone that helped.

Impact of stress and mental health issues, and coping mechanisms are significant contributors to CVD

Stress and mental health issues contributing to CVD were a key discussion in all the groups. The conditions of insecure living, desperation and depression creating stress, stress increasing high blood pressure and smoking, created the perfect storm. Someone commented that 75% of individuals experiencing homelessness suffer mental health issues which are compounded by living on the street.

The majority smoked to alleviate stress and boredom and while giving up was discussed, the social norms in the hostels and perception of smoking as a stress reliever, meant that this was not seen as likely for most. ‘I’ve quit before but take it up again because of stress. After giving up drink and drugs, I smoke more. It’s a way of dealing with stress.’ Some pointed out that although there were public health initiatives, at this point in your life you could not action them without support. ‘There are a lot of activities going down but some people if they’ve got that far down, they’re not able to cope on their own, and they need a big support system until they can have like a normal life again … Even with the benefits people are still going to smoke.’ Those who did not smoke tended to have an explicit reason for being different and while individuals talked about reducing, there was no obvious group norm to give up. Some commented that they had not realised that smoking damaged the heart, although they knew it was bad for health and presumably saw it as a lung issue in isolation.

We did not explicitly ask about alcohol or drug usage, however, alcohol problems, marijuana, crack and cocaine came up when talking about the need to relieve stress or when asking about the effects of usage on the heart. Alternatives to stress relief were suggested by some individuals, such as meditation and mindfulness, yoga, exercise and being outside. For others, life was still too chaotic to consider softer alternatives.

The timing of interventions for CVD prevention and management was also considered crucial. When sleeping rough, people talked about becoming disorientated within days or weeks, with lack of sleep, feeling unsafe and cold all contributing. ‘The mental state of mind. You’re finding yourself homeless and in a different situation. Do you really think you’re going to be healthy? You want to drop dead. The last thing is health. They’re going to do drugs to forget what they do or get drunk and forget what’s happening to them.’ Although not all relied on substances, the sense of hopelessness was shared. Long-term health issues were irrelevant at this stage and, with the sense of disorientation, ‘responsibility and routine are not part of your life.’

Experiences of discrimination affect trust and belief in health services

Most of the participants (n=22) had a GP, but found attending on their own difficult. ‘Now I have a key worker, but I made every excuse not to go until I trusted her and slowly improved. Then I found her sitting in the GP holding my hand.” Moving address, sometimes frequently, also meant that the patient and the notes were separate ‘I had to wait 4 months. My records were in London and I was somewhere else. I could do day to day issues, but they didn’t know my history.’

Participants did not all realise you could change doctor when dissatisfied and many felt it would help to have a doctor in the day centre and more drop-in clinics: ‘You need somewhere where you can find a doctor. You’re not going to keep an appointment’. People liked having doctors who were specialised in supporting people who were homeless. This was reflected in the discussions with the health and care professionals who noted that other professionals incorrectly perceived that standard health initiatives would not work in this group.

There was a strong sense that professionals treated people experiencing homelessness differently. ‘Their attitude is different, their customer service is different. Everything is different. It’s as if they’re talking to an animal.’ They described being left until last, discriminated against and treated like ‘dirt’. People perceived themselves as less likely to be heard: ‘If you’re in a shelter, you’re not recognised for the seriousness of what you’re saying. It took me ages to get heard. To get compassion.’

Being sent away from hospital because of actual or perceived drug abuse was common. ‘In A&E, you get fobbed off because you’re homeless’. Some individuals described making an effort ‘not to look homeless’ in order to be treated better. ‘I’ve always been able to keep up my appearance so I don’t look too homeless… When I go to hospital, I need to make them like me.’

People described getting a referral as ‘impossible’, with no reply to phone calls, and lengthy waits: ‘I was at St Mary’s for an ECG for 2 hours and now I have to wait 9 weeks to see a GP.’ People talked about delays, some of which may have been specific to the homeless population. ‘If you get in with these services, they are really good. If they believe you and that you are genuine. But you can spend months on the waiting list. There’s other people in more serious situations that need it.’ There had been several workarounds with people going to a dentist or optician as a way of getting a referral. One person talked about how the new duty to refer (a duty within the Homelessness Reduction Act 2017 for public authorities to refer those at risk or experiencing homelessness to local authority teams)16 was going to make a difference, but it was taking time and most had not heard of it.

Recommendations on improving CVD care

This final theme summarises recommendations made across patient and professional focus groups in this study. CVD care has to be seen within the context of living conditions. Without shelter or support, many initiatives have no chance of being effective. The bottom line is housing. ‘Do you think someone who has got a heart condition should be on the street? Someone who has congenital heart failure should be in a hospital or a house.’ Despite the legal obligation to help get people off the streets, people reported being on the street for months. It was once people were known and had deteriorated—‘That’s when they come looking for you and start doing things for you.’ Even following this, the groups reflected hostel living as the beginning, not the end of the journey. ‘People when they come here, they don’t really care about their health. They need a push…’

Focusing on CVD care, key themes for improving services included:

• Flexibility of access to medical interventions including: A mobile service that drops off prescriptions; safe medication storage; peer support to go to appointments; better referral avenues; and having doctors present at shelters and events for those experiencing homelessness. It was identified that currently there were no health professionals there talking about heart health. A Find and Treat van linked to the current TB service was suggested as a potential avenue, but healthcare professionals raised concerns that this might also lead to the danger of overwhelming drop-ins with tests.

• Supporting healthy behaviour through improved access to hygiene facilities, exercise groups and alternatives to stress reduction.

• Educating the public, for example, getting nutritional informational to people on streets and public wanting to help.

• Informing those experiencing homelessness about their health service rights such as: eligibility for annual GP check-up for the over 40s; and telling people about duty of care and how to get access or change GPs.

• Increasing trust with the health system through non-judgemental clinical staff, who are specialised at working with those experiencing homelessness.

• Integrated substance use support.