When Care is Uncaring: Homelessness Stigma in Healthcare Environments and Mobile Medicine as a Model for Healing

Context: The CommuniCare Mobile Medicine team is a medical team in Northern California delivering primary care services to people experiencing homelessness (PEH). This team has worked to increase uptake of sexually transmitted infection (STI) testing.

Objective: To examine the factors contributing to the decision of PEH to engage with STI testing.

Study Design and Analysis: Qualitative study using semi-structured interviews with 50 PEH, each compensated with a $50 gift card. Interviews were audio-recorded, transcribed, and analyzed using a thorough memoing process and matrix-based analysis.

Setting: Yolo County, CA (pop. approx. 220,000 people)

Population: English-speaking adults 18 and over, currently experiencing homelessness.

Instrument: Interview guide focused on barriers and facilitators to STI testing, and survey including housing and healthcare utilization questions.

Outcome Measures: Themes identified through qualitative analysis focusing on barriers and facilitators to STI testing.

Results: Participants revealed a common tendency to avoid seeking healthcare until extremely urgent, and to de-prioritize routine health services like STI testing. Most reported negative prior experiences in health care environments including judgment from medical staff, dismissal of patient medical concerns, and denial of appropriate treatment as significant deterrents from entering health care spaces. These negatively impact self-worth and self-identity beyond the walls of the medical establishment.

Participants observed that medical staff lacked understanding of the complex factors leading to homelessness and substance use, deepening the experience of feeling unseen, unheard, and insignificant. In contrast, participants described experiences of validation and restoration of self-worth with the Mobile Medicine team.

Conclusions: Participants often avoid seeking health care until urgent and deprioritize preventive services such as STI screening. Many reported past negative experiences of judgment and dehumanization in medical environments. This contributes to emotional trauma among PEH, negatively impacting self-worth, decreasing engagement in care, and perpetuating the power structures deeming poor communities “underserved.” Reflecting on these power dynamics is critical to developing more equitable care systems. The Mobile Medicine team exemplifies features of structural competency that may be implemented in other settings to work towards this.